Theme VI. Community-based growth monitoring and promotion

Relevance

Community-based growth monitoring and promotion (CbGMP) activities are relevant where there is low awareness of the causes of malnutrition and where families do not have the necessary information to help them protect and promote their children's health. Growth monitoring refers to weighing a child (from birth through the first two, three or five years of life) and recording the weight on a growth chart. Because weighing and charting alone cannot improve growth, promotional activities are also needed. These include counselling and action to improve child growth. CbGMP activities can provide an entry point for households and local groups to use the information on child growth to guide activities that address the problems identified. CbGMP is a relevant complementary activity for many of the actions and interventions described in Part IV.

Feasibility

CbGMP requires a situation that is relatively stable and not an emergency. Developments need to be under way such that people have begun to improve and reconstruct their own lives. Growth promotion requires trained people at the local level with proper support, some basic guidelines and sufficient time with families. Community growth promoters (CGPs) are usually experienced and respected mothers (and occasionally fathers), or parents who have successfully managed the rehabilitation of a malnourished child. CGPs need to know how to weigh children, record data and counsel mothers.

CGPs require supervision from the local clinic nurse or health worker, or the nearest hospital nutritionist. They decide whether weight gains are adequate or not, and counsel mothers - congratulating them on healthy children or advising them on feeding and the next steps to follow. They also help facilitate and support actions at the family and community levels to address specific problems.

A suitable structure to function as a weighing post needs to be identified or built, and measuring equipment and record books provided. A sufficient number of CGPs need to be trained, so that the time volunteered by one individual does not infringe on their other responsibilities. While CGPs usually work on a voluntary basis, some recognition of their contribution may be required (e.g. t-shirts, hats, etc.). There should also be a system for referring sick children to health services.

Effectiveness

Growth promotion can be particularly useful when it is employed in decision-making about:

• recommendations for individual children's care (particularly related to illness and feeding, but also to cognitive and motor development);

• activity plans for the community that aim to make it easier for families to maintain the growth of their children, for example, by addressing problems of food shortages, lack of and/or unsafe water, and collective child care needs that affect more than a single household;

• programme activities to bolster community actions that affect households with special needs, such as income-generating or transfer schemes.

Box 41: The growth promotion package

Source: Griffiths, Dickin and Favin, 1996.

Local-level ownership and responsibility are essential. Growth monitoring data should be presented and discussed at a local-level forum so as to contribute to increasing pride and accountability for the well-being of all children in the community. Horizontal integration with other local-level initiatives will help communities to identify and implement actions that give them the highest gains in nutrition indicators. A reliable referral and supervision system needs to be in place to ensure medical treatment for children where necessary and to provide on-the-job training, supervision and encouragement to the CGPs.

In situations where the full package (see Box 41) cannot be implemented, the problem solving nature of the process should not be abandoned, because that is what makes the approach more effective. In these cases, innovation may be required in the design of the weight assessment, decision-making and action package, or in the infrastructure for its implementation. Innovations that could be considered include:

• using indicators other than weight (e.g. presence of illness, extreme thinness, recuperation from illness) to identify children of different ages for special attention and tailored advice when weight-for-age monitoring is being introduced; this will help workers to solve problems;

• restructuring workers' time or developing tools that allow for more and better counselling and community problem solving sessions;

• mobilizing community support, such as using unconventional cadres of workers (youths, teachers or others) to help the appointed worker with growth promotion activities.

Monitoring

• Under-five attendance at CbGMP sessions.
• Adequacy of growth as an indicator of state of health.
• Improvements in behaviour (e.g. child feeding).
• Presentation of results at local-level meetings.
• Local-level initiatives to address the underlying causes of poor child growth.

A farmer drying the onion harvest

FAO/22113/J. Koelen

Theme VII. Food and nutrition education

Relevance

Food and nutrition education plays a vital role in protecting and promoting household food security and nutrition. In relatively normal times, but also in situations of scarcity it is essential that people know how best to make use of limited resources to acquire a variety of safe and good-quality foods to ensure nutritional well-being. Adequate knowledge of what constitutes an appropriate diet, as well as the skills and motivation to practise good care and feeding practices, are vital for households' survival, especially during times of crisis. Learning how to make optimal use of the foods available, including local foods and unfamiliar relief rations, and practising healthy eating patterns are essential skills that can help households and individuals meet their nutritional needs.

Nutrition education involves a combination of activities, including providing information, increasing people's knowledge of why specific foods and feeding practices are beneficial (e.g. exclusive breastfeeding up to six months, the introduction of complementary foods from six months onwards, feeding young children frequently, giving young children their own cups and spoons, feeding them separately from the family and other children so that they get their fair share, feeding actively by giving children preference in feeding, etc.), which influences their attitudes and beliefs (e.g. low value placed on vegetables, high value placed on meat), helps them to develop personal skills (e.g. preparing an energy-dense complementary food, learning how to feed a child actively) and motivates and supports them to adopt healthy eating practices (e.g. forming mothers' support groups, providing information sessions for mothers on child feeding at monthly growth monitoring and promotion sessions, following up with mothers at home for individual support and counselling). Nutrition education also involves influencing public policy and promoting access to a variety of nutritious foods that are rich in macro- and micronutrients.

Once an assessment has indicated that malnutrition or nutrition-related problems might be partly attributed to lack of knowledge, traditional beliefs and/or harmful nutritional care and feeding practices, nutrition education becomes an essential element of comprehensive food security and nutrition programmes. Nutrition education is especially important if wider livelihood and food security interventions that increase food and income availability are to translate into improved nutritional well-being. An assessment will contribute to a good understanding of the factors affecting food and nutrition security, so that nutrition education interventions can be designed to be relevant to the conditions in which families find themselves. For example, in an emergency, lack of fuelwood may be a more immediate constraint than lack of food itself. In this case, the most useful information would relate to constructing fuel-efficient stoves. In crisis situations, nutrition knowledge and skills are a mobile asset that displaced individuals or families can use when they return to their areas of origin.

Feasibility

The development of a nutrition education and communication programme will need to call on the skills of adult education specialists and social communication/marketing experts, as well as nutritionists, agriculturists, etc. Prior to the development of nutrition education messages and materials, it will be necessary to prepare an inventory of already existing resources and materials, including studies on people's perceptions, knowledge, attitudes and practices.

Successful implementation of nutrition education and communication must consider the technical content and concept of the message; the target group/s, communication channels and tools; and the development of training materials and visual aids.

Message development. The messages and training material should be:

• based on an assessment of knowledge, attitudes, perceptions and practices/behaviours, and reflect the community's priority nutrition issues;^[4]

• adapted to the age, sex and status of programme participants;

• pre-tested for practicability and acceptability among proposed programme participants;

• in harmony with messages from other sources;

• appropriate to the needs of the household, and the constraints under which it operates.

Advice will rarely be put into practice if, by doing so:

• the capacity of the family to earn money would be reduced;
• it would leave less money for other basic needs.

Box 42: Common themes for nutrition and health education in relief and rehabilitation

Communication channels. People communicate best with others of their own area, age and social class. Agricultural extension and health workers, teachers, youth leaders and other interested and influential local individuals need to be trained to pass on appropriate knowledge and skills and to counsel people with specific problems. If the entire extension and health system has been disrupted, local groups should select people to receive basic training in health and nutrition and communication skills.

The communication mechanism depends on the context and cultural preferences and on how people normally receive/obtain information. Mechanisms could include group discussions, role-play, drama, demonstrations, practical sessions, newsletters, posters, radio/TV slots and videos, and songs. In refugee or IDP camps there may be more opportunities at on-site feeding sessions or central locations, such as food distribution sites or water collection areas. With more dispersed populations, social or religious spaces and events may be more appropriate opportunities for nutrition and health information to be passed on to mothers or care takers. One-to-one counselling works well during home visits or at health centres when problems of a sensitive nature (e.g. family planning, voluntary counselling and testing for HIV/AIDS) that affect a particular family or its child can be discussed, and help and advice offered. Food and nutrition education can also be included in school curricula. Non-formal education programmes (e.g. literacy classes, youth and women's groups) are also potential channels for providing nutrition and health education.

Women pounding grain

FAO/23898/D. Minkoh

Both adults and children can easily lose interest, so communication methods should be as visual, interactive and participatory as possible. Mothers, care takers, grandparents and older siblings should be actively involved in education and practical sessions on health, hygiene, food preparation and complementary feeding. This is also an opportunity for them to contribute their own knowledge and skills. They should have a chance to practise their new knowledge and skills, and exchange experiences so that they are motivated to learn and continue to practise what they have learned.

Effectiveness

It is difficult to separate the impacts of nutrition education and communication from those of other components, such as health care or supplementary feeding. However, in order to be effective, nutrition education should be linked with the means to adapt or adopt new practices; for example, nutrition advice about eating certain foods is supported by advice on how to plant, protect, store, process and prepare those foods. In urban situations, foods should be available in local markets and be affordable to the target group. Nutrition education or advocacy with decision-makers (government policy-makers, local leadership, the donor community, NGO managers) is also crucial in providing an enabling political, policy and economic environment and the cross-sector linkages that are necessary for ensuring successful interventions.

There are many opportunities for linking nutrition education to other activities, for example, in on-site feeding programmes, supplementary and general ration distributions, community-based therapeutic care programmes, growth monitoring and promotion, training in home gardening, and community poultry raising.

Although many of the themes covered by nutrition education relate to women's activities, men should be invited to join in. This raises men's nutrition knowledge and wins their enthusiasm and support for improving practices at the household level. Within schools and youth clubs, home economics and nutrition/health education should be given to boys as well as girls.

Box 43: A case study from Somalia: home gardening in an emergency context -Shabelle and Juba valleys in Bay Region

Source: Hinrichs, Maccoll and Vliegen, 2001.

Nutrition education and communication will be more effective if they are reinforced by the use of different channels and the adaptation of messages for different target groups. The exchange of information and knowledge between host and displaced populations can often result in rapid changes of positive practices.

Monitoring

• Knowledge and behaviour changes related to specific nutrition and public health topics.
• Trends in morbidity for key diseases.
• Trends in nutritional status.

Theme VIII. Training and extension

Relevance

Training of trainers and support to government extension services (where these are still functioning) are important interventions to ensure that there is technical backstopping, referral and supervision of local-level workers. Training can also play a key role in developing a common understanding of the multisectoral nature of food security and nutrition problems.

Feasibility

Activities related to the training of trainers and extension workers should be part of an overall capacity building strategy. Training needs should have been prioritized in relation to the key food and nutrition problems that were identified in the situation assessment. Training materials and training formats need to be adapted or developed to reflect the language and cultural characteristics of the situation. Training interventions need to be based on:

• a trained core of staff to train local-level workers;
• appropriate technologies and messages;
• participatory approaches.

Effectiveness

Training should provide extension workers with basic concepts related to food security and nutrition, and an understanding of the roles of different disciplines in addressing problems and improving nutritional well-being. The following are some examples:

• Training of agricultural extension workers needs to include basic nutrition issues so that farmers are aware of the nutritional importance of producing certain foods.

• The role of home agents and female community workers, which tends to focus on food preservation, cooking and home crafts, should be expanded through training to include horticultural production techniques and basic nutrition concepts.

This contributes to closer links among local-level health, education and agricultural extension work, and ensures that nutrition interventions complement and reinforce each other. Teamwork can be promoted through participation in joint problem analysis, needs assessment, etc.

In recent years, increased attention has been given to the integration of agriculture assistance, nutrition rehabilitation and nutrition education and training. Women bringing their children to the nutrition rehabilitation facilities are provided with basic training on crop production and agricultural inputs for when they return to their communities. This has resulted in decreased readmission rates of the children attending these facilities. The self-targeting modality of such projects makes them an interesting model for replication and diversification.

Extension trainers teach crop planting techniques such as plant spacing and other methods for improving crop production and nutrition to Burundian refugees in a camp in Western Tanzania

FAO/22210/E. Eliah

Box 44: A case study from Burundi: integrated nutrition and agriculture interventions

Monitoring

• Sectoral training material incorporates a holistic view of food and nutrition security.
• Sectoral extension activities incorporate both production and consumption aspects.
• There are joint multisectoral training and field activities.

Theme IX. Food aid

In acute crises, the most essential and life-saving response to a situation of existing or threatened food scarcity or malnutrition is to provide food aid in the form of general distributions and/or selective feeding programmes. However, food aid must be part of an overall response - nutritional status will not be protected without meeting other basic needs, especially shelter, clean water, sanitation and an adequate caring environment.

Food aid interventions should not be limited to addressing immediate needs, but can be designed to ensure the transition from short- to longer-term approaches to assistance. Targeted food distributions may be appropriate at an earlier stage to protect livelihoods when coping mechanisms are under stress and people are selling productive assets such as livestock in order to obtain food. In some situations, the food donor and recipient government agree that food aid be "monetized" and the proceeds used to invest in mutually agreed programmes. Figure 4 shows the possible uses of food aid in crisis situations.

Off-loading food supplies

FAO/G. Bizzarri

Figure 4: Uses of food aid in crisis situations

General and complementary food ration distribution

Relevance

A general food distribution can be part of an appropriate response to protect lives when people have suddenly been cut off from their normal means of access to food. This can happen, for example, when agricultural production has failed through drought or floods, or when people have involuntarily left their homes and become IDPs or refugees. A targeted general food distribution may be relevant when there is the danger that households begin to sell their productive assets in order to obtain food. A complementary food ration is appropriate when households have adequate access to staple foods, but have shortfalls in protein-rich, energy-dense foods and/or micronutrients.

In situations where people have very limited or no access to food, nutritional considerations are most important in deciding the size and content of the ration. In the first stages of an emergency, the priority should be to provide a sufficient supply of the basic commodities that provide an adequate subsistence diet (staples, edible oils and fats, protein-rich food such as pulses and salt). Where the population has no access to complementary foods (sugar, fresh vegetables and fruit, or blended vitamin-enriched foods) some or all of these should also be provided, as they supply additional nutrients and increase the palatability of meals. Iodized salt and culturally important condiments should be included if the population has no alternative access to these items. In the past, priority was given to supplying the minimum energy value when planning the ration. However, while energy is the first aspect to consider, it is only one of the essential nutrients. Where people (e.g. refugees and IDPs) are totally dependent on relief commodities, they may be at risk of micronutrient deficiencies (vitamin A deficiency, anaemia, iodine deficiency diseases, beriberi, pellagra, scurvy). While these nutrient deficiencies may be avoided by providing a diverse food basket, it may also be necessary to consider fortifying certain food products (e.g. cereals, blended foods).

In situations of food scarcity where people are selling productive assets, economic considerations are most important in deciding the make up and quantity of the ration. In such cases, where food aid is being provided as economic support to households, its transfer value rather than its nutritional value is important. The transfer value is how much it would cost to buy an equivalent amount of food on the market, and/or how much money it would raise if it was sold.

Pastoralists are one of the groups for whom food aid can play a valuable role in sustaining livelihoods. There is a minimum herd composition and size below which a herd cannot recover, even if pasture conditions become ideal. The provision of food aid, combined with livestock health and feed inputs, can avoid the need to sell livestock and can maintain the status of the herd to enable rapid recovery. Targeted food aid distributions can also be used to support households in their place of origin. This is preferable to waiting for a situation to deteriorate until family members are forced to adopt abnormal migration practices in search of employment, pastures, water, etc.

Feasibility

Once the content and size of the food aid ration have been determined on the basis of the affected population's situation and the available resources, other aspects need to be considered. The proposed ration should be assessed in terms of dietary quality, variety, safety and cultural acceptability. There must also be facilities for processing and cooking the food commodities.

The principle food aid donors/agencies (WFP, the United States Agency for International Development [USAID], the European Union [EU], ICRC often work with and/or through implementing partners (international and national NGOs) to distribute and monitor the use of food rations. This requires considerable financial, logistical, administrative and personnel resources to ensure that food distributions are timely and reach targeted populations, and that losses through spoilage and leakages are kept to a minimum.

Access conditions (isolation, transport and communication infrastructure, seasonal factors and the security situation) can influence the feasibility of a food distribution operation. Pressures in the awarding of transport contracts and the danger of food aid deliveries being hijacked or diverted are additional factors that may be present in conflict situations.

Effectiveness

Food aid needs to be used with caution, as it is expensive compared with other interventions and can have many drawbacks. Except in the most extreme emergencies, it is always difficult to decide whether to provide free food aid and, if so, how much to provide. If needs are underestimated, increased malnutrition and/or further loss of livelihoods may result, while if needs are overestimated, the prevailing negative consequences of food aid will be intensified. Local and regional purchases should be promoted as sources of food aid. This can act as an incentive for local production, marketing and development. The negative effects of food aid are to some extent unavoidable, even when food aid provision accurately corresponds to needs.

Box 45 gives examples of ways to avoid or minimize these effects. The important criterion for the use and continuation of free food aid distribution is that its benefits should greatly outweigh the disadvantages.

Box 45: The negative consequences of food aid and ways of minimizing them

The distribution of general food rations should be accompanied by information concerning quantities, the contents of the rations, the number of individuals and period of time that they should cover, and how best to use the commodities. There should also be discussions with local leaders and representatives (particularly women) about the expected duration of general food distributions and the overall planning, management, distribution and monitoring of food aid distributions. These discussions provide an opportunity to identify options for the transition to more sustainable forms of support.

Monitoring

• The quantities, content and timeliness of ration distributions (with special attention to groups that may be discriminated against).
• Ration use within the household (food, animal feed, production of alcohol, sale).
• Changes in the availability and prices of ration commodities in local markets.
• Changes in crisis strategies (abnormal migration, sale of assets, begging/destitution).
• Changes in child and adult malnutrition rates.

Selective feeding programmes^[5]

Relevance

Supplementary feeding programmes^[6] (SFPs) are needed if an assessment has identified the following conditions:

• People have very little or no access to food; for example, they have recently fled from their homes and become displaced in their own or a neighbouring country, and there is a malnutrition rate of 10 percent or more among children under five years.

• There is some access to food, but the home diet is not sufficient to meet the needs of all members, including the extra needs of pregnancy, lactation and child growth; the malnutrition rate is 5 to 9 percent, but there are aggravating factors such as poor food availability, inadequate shelter and the threat of disease.

The objective of SFPs is to promote growth and prevent severe malnutrition. SFPs are inappropriate if the cause of malnutrition is not lack of food. They can divert attention and resources away from pressing priorities that would have a more sustainable impact on nutrition and health, such as immunization campaigns, the establishment of clean water supplies and sanitary facilities, and local-level education and participatory training in nutrition and health practices. Figure 5 provides a matrix to help consider the need for the best type of nutritional strategy, including selective feeding programmes, for situations where people have little or no access to food other than food aid, such as following a large influx of refugees.

Figure 5: Selection of nutritional strategies

Source: MSF, 2002.

Notes:

Global acute malnutrition rate = W/H: < 80% of median or oedema.
Severe acute malnutrition rate = W/H < 70% of median or oedema.
CMD = crude mortality rate.
GFD = general food distribution.
BFP = blanket feeding programme.
TFP = therapeutic feeding programme.
SFP = supplementary feeding programme.
TFC = therapeutic feeding centre.

• There is an implicit hierarchy of importance in the specific objectives presented in the figure: all interventions aimed at famines and severe food crises must include basic access to food through GFD in order to be effective.

• Mortality rates are influenced by a variety of factors (e.g. health status, outbreaks, etc.), yet they represent the best indicator of the seriousness of a situation. Seasonally high malnutrition rates without increased mortality should be considered with caution.

• All feeding programmes should run parallel to basic public health interventions. Epidemics and primary communicable diseases should be controlled through the provision of adequate health care and sufficient water and sanitation.

• Malnutrition rates should be considered according to percentage of the median rather than z-scores.

• Food accessibility and availability must be interpreted by means of comparison with a normal situation.

• Populations are rarely homogeneous; therefore it is always necessary to consider subgroups.

• TFPs require much more intensive training, management and supervision. In general, SFPs and BFPs are easier and more rapid to implement.

Selective feeding programmes for orphans, the elderly and the disabled are appropriate in the following situations:

• There has been a severe breakdown in social support and coping mechanisms. The needs of these groups could be met through channelling support through local mechanisms (e.g. additional rations to families hosting orphans, institutionalized feeding [orphanages]), or the creation of alternative local support structures (e.g. the establishment of local group-managed kitchens, etc.).

• There is high prevalence of HIV/AIDS in the population, and people living with HIV/AIDS (PLWHA) are unlikely to be able to meet their higher nutritional requirements through a general ration or normal household food supplies.

• There are a high number of TB patients who default on their medication as their appetite begins to improve, because they are unable to afford additional food purchases.

Feasibility

The following requirements are essential for the successful implementation of SFPs:

• SFPs should always be implemented alongside the provision of an adequate general ration, or where household food availability is sufficient. Otherwise they will be of low effectiveness.

• SFP workers need to be trained and supervised in applying standard entrance and exit criteria.

• On admission, participants should be medically screened, and treated if necessary (e.g. deworming, diarrhoea management, malaria treatment, micronutrient supplementation, immunization, antenatal care).

• A system is required for referring severely malnourished children to therapeutic feeding, and for providing medical checks to determine the presence of an underlying condition such as TB or HIV/AIDS.

Locally available and marketed fortified and blended foods should be used in supplementary feeding programmes for children. Blended foods are ideal for the intended beneficiary and, in general, unfamiliar to and unappreciated by adults. This reduces the risk of supplementary foods being diverted within the family. If local blended food mixes are not available in sufficiently large quantities, imported blended foods such as corn-soya blend (CSB) could be used as an interim measure. However, the continued use of CSB as a complementary food in supplementary feeding centres, or as a take-home ration, reinforces a medical model of malnutrition as a disease that requires to be cured with special commodities.

It is harmful to distribute dry skimmed milk (DSM) powder. DSM does not supply an adequate nutrient mix, and when reconstituted with unclean water it becomes an ideal breeding ground for bacteria, especially in hot climates. A premix porridge can be made up with cereal flour, oil, sugar and DSM mixed together. The premix then has to be boiled to make it edible.

Identification of an appropriate delivery mechanism. Supplementary feeding programmes can provide cooked meals ("wet feeding") at a central site, or provide dry take-home rations. There are advantages and disadvantages of both methods, and neither has been consistently shown to be more effective than the other.

Wet feeding can be more easily targeted to malnourished children, but is more labour-intensive and costly and is more frequently used for day care or 24-hour therapeutic feeding. A physical structure with water and sanitation provision needs to be identified or built. Cross-infections are likely to increase when a large number of sickly children are cared for together. A care taker should accompany the child to the feeding centre; this can increase the pressures on women's time and disrupt family meal patterns and activities.

More recently there have been initiatives to treat severe acute malnutrition at the local level, as Box 46 explains.

Box 46: Comminity-based therapeutic care

Source: Collins, 2001.

A dry take-home ration system allows distribution to greater numbers of children, at a frequency that takes into account the local context and resource availability. A wider catchment area can be covered. These factors may be important in situations where conflict limits humanitarian access, and the general population continues to circulate between unstable and secure areas. Local health or extension workers, teachers, etc. could be involved in the implementation and monitoring of take-home ration systems. The disadvantages of this system are that unless an unfamiliar blended mix is used the food is generally placed in the "family pot" rather than given to the intended beneficiary alone. There are also fewer opportunities to implement direct nutrition and public health promotion activities.

Effectiveness

An efficient monitoring and follow-up system is needed to minimize the number of drop-outs from SFCs. If the overall situation remains food-insecure, or there is an inadequate general ration, the number of readmissions will be high. Households with children in an SFP should have priority for longer-term interventions aimed at increasing income levels and food production. The size of dry take-home rations should be calculated on the assumption that the food will be shared at least among other children in the family.

Selective feeding programmes can be designed in a way that fosters local participation, self-reliance and integration with other activities, such as community-based growth monitoring and promotion, the use of local materials to construct facilities and provide ingredients for rations, and the employment of mothers or the elderly from poor and/or vulnerable households. Selective feeding programmes should routinely provide nutrition and health education (i.e. basic hygiene, health care, HIV/AIDS sensitization/awareness, complementary/weaning food preparation) as this greatly enhances their effectiveness. Education classes with group discussions and practical demonstrations should be organized, taking into account the social and cultural preferences for timing and location. Existing health workers, teachers and extension workers could be given basic/refresher training to provide nutrition education, counselling, community-based growth monitoring and referrals in their home areas.

Monitoring

Monitoring the functioning of supplementary or therapeutic feeding centres for malnourished children should include:

• Number of admissions.
• Average weight gain per child per week.
• Numbers successfully discharged within the recommended period.
• Numbers of drop-outs and readmissions.
• Numbers of follow-up home visits.
• Changes in feeding and caring practices at home.
• Numbers of socially marginalized groups attending.

The role of food aid in shifting between short- and long-term interventions

The basic right to an adequate quantity and quality of food must be ensured and upheld at all times. The timing of when to move from one food distribution modality to another therefore depends on information on livelihood options, the security situation and nutritional surveillance. General food distribution should be phased out as soon as appropriate, but must be tied to support that strengthens and reinforces households' existing coping mechanisms and/or allows people to develop alternative means of obtaining food. The general distribution can be replaced by a targeted system following an assessment of who needs continued aid, and when adequate programmes to promote livelihoods are in place. Targeting food aid to the most vulnerable helps to prevent an oversupply of commodities on the market, which may depress prices. In such cases, food aid commodities lose their economic value and farmers have little incentive to resume or increase production.

In protracted crisis situations, when households have regained a level of self-reliance, targeted food distribution may be phased out and replaced with a safety net for the most vulnerable, as well as self-targeting mechanisms such as food for work.

Targeted food aid distributions

Part of WFP's food aid policy incorporates the concept of "food for assets". Through this modality, the food-for-work (FFW) concept has been expanded with the specific idea of creating long-lasting productive assets that result in better health, nutrition and productivity, as well as mitigating future shocks. This has implications in terms of the ability to intervene early in order to provide assistance to protect assets, contribute to good nutrition in early childhood, use food to help children attend primary school and learn, and assist the poor to use natural resources in a sustainable manner before they become irretrievably degraded.

Relevance

FFW/food-for-assets activities are appropriate if an assessment has identified the following conditions:

• People have limited access to food, or there is limited food available in the region and a pool of underemployed people.^[7]

• Contingency planning incorporates the preparation of off-the-shelf protocols and proposals for food-for-asset activities and projects that can be launched quickly and are in harmony with government rehabilitation and food security policies.

The timing and duration of potential food-for-assets activities needs to be assessed. If individuals are engaged in a local-level food-for-assets project, they cannot spend time on their own productive activities or on building up their own assets. The implications for child care provision need to be considered, especially if women are among the target group for the activity. Box 47 describes how FFW activities have been used to encourage savings among women in Burundi.

Box 47: FFW for agriculture and cash generation in Burundi

Source: Wilde, 1997, p.21.

Food-for-assets activities are not an appropriate way of addressing direct nutritional objectives, as households with malnourished individuals may not have the physical capacity to work on these projects, and rations may not be based on nutritional considerations.

Feasibility

The following conditions need to be in place for a successful FFW/food-for-assets project:

• Resources other than labour and food are needed for many kinds of work, e.g. tools, machinery and trucks for road building.

• Capable and experienced implementing partners are needed.

• Local-level management structures should be able to determine priorities, use and control the benefits of activities, and agree to take on the recurrent costs of activities in order to maintain the benefits.

In stable and secure areas, food-for-assets activities can be oriented towards establishing or rehabilitating productive infrastructure: irrigation systems, terracing lands, clearing and planting fields, planting trees, repairing roads/bridges to market towns, making drying floors, etc.

In conflict and unstable situations, food-for-assets modalities should focus on investing in skills and training that create mobile assets (e.g. marketing, business skills and caring practices for vulnerable household members).

The ration size (wage) will determine both the numbers and the alternative occupations of those who enrol. A lower wage will result in self-targeting to the poorest and most food-insecure people. High wages may have the benefit of driving up wages in the local labour market, but may draw people away from other occupations. The food rations provided may have disincentive effects on local agriculture and markets. Ideally, the ration is set to be equivalent to existing cash wages, so people are not drawn away from other types of employment, and the programme simply provides additional employment.

All food distribution modalities should be complemented by information about the reasons and criteria for any targeting mechanism, the content of food rations, and options as to how best to utilize it.

Effectiveness

The reconstruction of physical infrastructure alone is not sufficient to allow social and welfare facilities to function. Service facilities (e.g. health centres and schools) should not be reconstructed until it has been established who (government, local authorities, communities) will equip the facility, provide trained staff and guarantee a regular budget to enable the facility to operate sustainably

Wherever possible, nutrition, health and social awareness promotion should be incorporated into activities related to the construction or rehabilitation of social and welfare infrastructure. For example, public health and sanitation should be promoted in conjunction with well construction, and youth, sport and social clubs should be supported in conjunction with the construction of meeting spaces.

Food-for-assets modalities can help to provide conditions for future sustainable livelihood activities, for example, rehabilitating irrigation systems, reclaiming land, conserving land and water, conservation farming techniques, and seed multiplication. These types of projects should also incorporate agriculture and nutrition information that is related to different aspects of the food chain, i.e. from productive activities, storage, processing and marketing to consumption and utilization.

Food-for-assets interventions involving training and skill acquisition could be linked to the provision of small grants on "graduation" in order to provide start-up capital for income generation activities.

Food-for-assets programmes have high potential for supporting local decision-making capacity, organization and management. Both men and women should be involved in planning, implementing, monitoring and evaluating activities. Box 48 gives some examples of how gender and participation issues can be approached in different food aid distribution contexts.

Box 48: Focusing on gender and participation in emergency food aid distributions

Source: Wilde, 1997.

Monitoring

• Numbers of vulnerable communities and households involved in the project.
• Numbers of communities actively involved in planning and managing food, activities and assets.
• Non-food items successfully obtained and used.
• Numbers of effective implementing partners and successfully completed agreements/contracts.
• Changes in number of food-insecure households or length of hungry period.
• Numbers and types of assets created, and their impact on sustainable livelihoods.
• Gender equality in management of and benefits from the assets created.
• Existence of maintenance arrangements for assets.
• Cost-effectiveness of the activities.

Box 49 provides examples of activities where FFW or food for assets could play a role.

Box 49: Examples of activities where FFW/food for assets could play a role

Further reading and resources

FAO. 1983. Selecting interventions for nutritional improvement. A manual. Nutrition in Agriculture No. 3. Rome, Food Policy and Nutrition Division.

FAO. 1994. Social communication in nutrition: a methodology for intervention, prepared by M. Andrien. Rome.

FAO. 1995. Improving nutrition through home gardening. A training package for preparing field workers in Southeast Asia. Rome.

FAO. 1997. Agriculture, food and nutrition for Africa. A resource book for teachers of agriculture. Rome, Food and Nutrition Division.

FAO. 1997. Human nutrition in the developing world, by M. Latham. Rome.

FAO. 2001. Improving nutrition through home gardening. A training package for preparing field workers in Africa. Rome.

FAO/WHO. 2002. Living well with HIV/AIDS. A manual on nutritional care and support for people living with HIV/AIDS.

IASC. Inter-Agency Standing Committee. (no date). Guidelines for HIV/AIDS interventions in emergency settings.

MSF. 2002. Nutrition Guidelines. Revised draft. Available at www.nutritionnet.net.

WFP. 1999. A guide on food for assets. Working Document. WFP Southern Africa Cluster. WFP.

WFP. 2000. Food and nutrition handbook. Rome.

WFP/UNHCR. 1997. Memorandum of Understanding on the Joint Working Arrangements for Refugee, Returnee and Internally Displaced Persons Feeding Operations.

WFP/UNHCR. 1999. Guidelines for selective feeding programmes in emergency situations. Rome.

WHO. 1999. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva.

WHO. 2000. Caring for the nutritionally vulnerable during emergencies: an annotated bibliography. Nutrition for Health and Development. Geneva.

Technical briefs

Brief 8. Strategies and lessons for establishing home gardens
Brief 9. Estimating general ration needs per person and calculating food aid requirements
Brief 10. Issues to consider when choosing food relief commodities

Elderly woman using a hand tool to prepare land for planting in a field in front of a factory that was destroyed during the war

FAO/23329/A. Proto

Theme X. Information systems

In crisis situations, there are increased demands on information systems. These demands reflect the often unstable and insecure operational environment, multiple information needs and users, and the need for real-time information on which to base decisions. Humanitarian information systems may include the following components:

• baseline vulnerability analysis and poverty assessments;
• early warning information for food security;
• emergency needs assessment;
• programme monitoring;
• impact evaluation;
• context monitoring;
• lessons learned exercises;
• community-based food security and nutrition information systems.

All these components can contain data and information relevant to assessing, analysing and acting on food security and nutrition problems. Some of the components can operate simultaneously, others provide information that can be used in other components. Each component may have specific objectives, users and uses, and may operate at different levels. While there is a need for collaboration and coordination (to ensure standardized methodologies, coding, formats and data exchange), an integrated master system is often neither feasible nor desirable. Box 50 illustrates the experience in southern Sudan.

Box 50: Food security data in southern Sudan: access and management issues

Source: FAO. 2001. Operation Lifeline Sudan Household Food Security Programme, data needs and a management system. Office of the FAO Household Food Security Coordinator, Southern Sudan. December 2001.

Baseline vulnerability analysis and poverty assessments

These describe and analyse the risk factors to which vulnerable populations are exposed, and their capacity for dealing with risks and the impact of shocks. The information is normally used for informing long-term poverty alleviation programmes, social safety-net mechanisms and national disaster management and contingency plans. It is valuable at the national level for drawing out differences in vulnerability and poverty that are based on geographical and population groups. When they already exist, vulnerability and poverty assessments and maps can provide extremely useful background and baseline information on risks, livelihood systems and the characteristics of different population groups. This information can provide basic indicators for an early warning system to assess the changes brought about by a crisis.

Early warning systems for food security

These should be an ongoing activity to provide information for predicting and mitigating the impact of shocks before an emergency situation has emerged. Early warning systems can operate at different levels, for example, the Global Information and Early Warning System on Food and Agriculture (GIEWS), the Famine Early Warning System Network (FEWS NET) and the Food Insecurity and Vulnerability Information and Mapping System (FIVIMS) at the global level, the Southern Africa Development Community (SADC) and the Intergovernmental Authority on Development (IGAD) at regional levels, and national early warning systems at the country level. Early warning data collection activities may be based on a statistically representative sample population, or sentinel sites may be chosen to represent best- and worst-case situations or population groups of particular concern. If the objective of an early warning system is to draw national comparisons, it is necessary to collect standardized data on a key set of common variables. However, these may not be the most relevant indicators at the local level, and the interpretation of each indicator can be location-, production group- and even season-specific. Many societies (especially pastoralists) use indigenous technical knowledge (ITK) to predict climatic and pasture conditions. In some situations, it may be possible to include indicators based on ITK in a national system, in order to complement or verify other information sources.

Normally EWS includes modules on the following aspects.

Agricultural production: Monitoring activities for agricultural production are generally based on seasonal assessments that are carried out by provincial or district officials. Variables include cropping patterns, area under cultivation, input availability, crop development and yield forecast. Climatic data, together with remotely sensed data on cold cloud cover and vegetation indices, are also used to feed into early predictions of likely crop performance.

Market information: This is used to monitor supply and demand conditions at different levels for agricultural inputs, produce and food commodities. Analysis of seasonal and inter-annual price movements and shifts in terms of trade can contribute to understanding how production failures may affect food access.

Health and nutrition surveillance: This can be based on data collected from facilities (e.g. health clinics and schools) or through population-based surveys. Data on nutritional status, morbidity and mortality may be included. Care is required when interpreting facility-based data, as they reflect the situation only of those attending or with access to the facility. Household living condition surveys and expenditure and consumption surveys may be available, but only at intervals of five to ten years. Box 51 describes a nutritional surveillance system in the Sudan.

Other types of data that feed into early warning systems for food security relate to demography (e.g. population movements), food aid, macroeconomic performance and incomes. More recently, indicators relating to conflict (e.g. the build up of militia groups, clan tensions over access to water and pasture) and political conditions (e.g. border closures) are being included; however, by their nature, these are highly sensitive and may only be used to help interpret a situation, rather than being explicitly incorporated into a reporting system.

Box 51: Food security data in southern Sudan: assessment and monitoring

Source: Young and Jaspers, 1995.

Early warning information should feed into disaster preparedness and response mechanisms at the international, national and local levels. Emerging problem areas or groups should be flagged in order to activate an emergency needs assessment. Box 52 gives examples of systems that are currently operating in the Horn of Africa.

Box 52: Examples of disaster preparedness and contingency planning in the Horn of Africa

Programme monitoring

This is designed to ensure that specific inputs (food, seeds, training activities) reach their intended target groups in a timely manner and achieve the expected outputs or results (food distributions, crops cultivated, people trained). The main users of this type of information are programme managers and donors, who use it to ensure that adequate control systems are in place and that there is accountability of the funds received. Examples of programme monitoring indicators include numbers of beneficiaries reached (by gender), and quantities of items distributed. Box 53 gives an example of monitoring food ration distributions among refugees in the United Republic of Tanzania.

Box 53: Monitoring rations received by refugees in Benco camp, Ngara, United Republic of Tanzania

Source: Jaspers, 1994

Impact evaluation

Regardless of whether or not specific inputs have been supplied, it is necessary to evaluate whether the desired impact is being achieved. Examples of impact indicators include changes in the consumption of specific foods, dietary variety, infant feeding practices, levels of food insecurity and malnutrition, morbidity, levels and sources of income, and levels and types of participation. An impact evaluation provides critical feedback for the design and implementation of interventions, and can help the assessment of which particular activity is most effective in reaching the desired objective or goal.

A monitoring and evaluation plan should be prepared at the project/intervention design stage, in order to identify which data should be collected (and how they will be linked to needs assessments and baseline surveys), how they will be collected, and who will be responsible for the different steps in the monitoring and evaluation process. The plan should also identify mechanisms for linking the information generated to programme decision-makers and beneficiary communities.

Monitoring and evaluation indicators need to be selected on the basis of:

• ease of collection (especially in areas where access may be intermittent);
• ease of interpretation;
• ability to disaggregate by gender and socio-economic status;
• an understanding of the multi-causal nature of malnutrition;
• validity, i.e. how well the indicator measures what it claims to measure;
• reliability, i.e. whether the measurement is replicable across samples.

It is also important to be able to differentiate the effects of a specific intervention from those of other factors that may have influenced an outcome. For example, increased food production may not be the result of a seed distribution intervention, but rather of improved stability and security allowing more land to be cultivated, or of better than normal rainfall patterns.

Box 54 provides an example of the use of location-specific indicators to monitor the impact of a food intervention after the agency had recognized that aid provision played an additional role. This case also illustrates how, in emergency situations, objectives are modified or added to during implementation.

Box 54: Indicators to monitor the impact of food aid in Goma, eastern Democratic Republic of the Congo

Source: Adapted from van Nieuwenhuyse, 1997.

Participatory monitoring and evaluation systems

These can be used to complement the types of information described in the previous subsection, for example, to determine whether the contents of a ration were culturally acceptable and of adequate quality, the seeds distributed were agronomically suited and germinated, or the training activities were relevant and conducted at convenient times. Participatory monitoring and evaluation can be designed to show different perspectives (e.g. by age, gender, livelihood). Monitoring activities can be incorporated into schools, with children collecting market price data, surveying the number of latrines constructed, etc.

The results from monitoring and evaluation activities can be posted in public places (markets, schools, religious meeting places) or presented at public meetings. This is important because providing feedback to affected populations can assist the verification of information and stimulate discussion as to why interventions are not having their intended effects.

Context monitoring

This is similar to early warning information activities; however, the monitoring of climatic and production conditions, nutrition surveillance, the political and security situation, and institutional capacity or strength is used to judge the balance between the needs for life-saving interventions and livelihood protection or promotion. Context monitoring also makes it easier to interpret monitoring and evaluation indicators, for example, an unusual increase in market prices may be the result of a disruption to commercial and relief food distribution networks caused by deteriorated security conditions.

Lessons learned exercises

These are critical components that contribute to institutional memory. They can be internal exercises conducted by organizations with beneficiary groups, or they can be implemented on behalf of donors or public fundraising mechanisms (e.g. the Disaster Emergency Committee in the United Kingdom). Findings from lessons learned studies can provide feedback for disaster preparedness, contribute to improving agency adherence to international standards and codes of conduct, and highlight best practices.

Women with freshly ground cereals at Medeber market

FAO/19440/R. Faidutti

Community-based food security and nutrition information systems

These can be autonomous and/or complement national early warning or food security and nutrition information systems. They can be established in situations where there is sufficient time and stability to discuss the need for and use of information with local groups. Investments need to be made in training and oversight. The process of choosing indicators can stimulate discussions about local perceptions and definitions of food insecurity and malnutrition. Local-level identification and ownership of the data collected and the resulting information are crucial if community self-monitoring systems are to be self-sustaining. A combination of normative (for national comparisons) and location-specific indicators can be collected. Data collection can be incorporated into ongoing activities (e.g. a community-based growth monitoring programme).

Box 55 highlights some of the advantages of supporting the development of a local food and nutrition information system.

Box 55: Supporting the development of a local food and nutrition information system

Community-based information systems can support local problem identification, analysis and action. However, this approach needs to be able to tap both local and external resources in order to develop interventions that address the problems identified, and to provide tangible results in order to be successful

Matrix of nutrition activities in emergency situations

Reading the matrix

• This matrix (see following pages) is meant to provide guidance on nutrition actions to be implemented during different phases of a humanitarian crisis.

• It is meant to be read from left to right.

• To avoid repetition, actions are mentioned only once. In other words, if an action is mentioned in the acute phase, it should also be implemented in the post-acute and reconstruction phases.

• In any given country, different areas may be in different emergency phases at the same time, and there may be a degree of back and forth between phases (e.g. many emergencies do not follow a linear sequence from acute emergency to reconstruction).

• Phases will vary in time depending on the nature of the emergency, but acute phase interventions should be started as soon as possible after the emergency occurs. Solid emergency preparedness will help to accelerate the implementation of a successful acute phase response.

Principles

• Nutrition interventions are multisectoral and should seek to complement and add value to interventions in different sectors by paying attention to the timing and sequencing of interventions.

• Local-level participation and capacity building should be integral to all intervention, although the extent to which this is possible depends on the local context.

• It is important to establish coordination and leadership mechanisms prior to an emergency, and to leverage organizations' differential strengths, so that each can lead in their area of expertise.

• Local and national governments should be involved and may be able to allocate human and financial resources.

• These activities may be developed in the absence of national policies or programmes, such as in situations where non-State entities control territory and populations, or where government no longer has the capacity to act.

• Nutrition interventions for displaced populations should also service host populations to the maximum extent possible.

Emergency preparedness

Acute phase

Post-acute chronic

Post-emergency reconstruction

Nokia boats sunk in a pond to protect them from cracking during the heat of the dry season when drought and a water table of less than 2.5 m cause the wood to crack as the boats dry. En route from Dhaka to Fedore

FAO/19909/G. Grepin