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20131213-ECHO-En by Egg3
Transcript of 20131213-ECHO-En by Egg3
Changing the way we look at the problem of undernutrition...
And help us to move forward together in new directions...
Undernutrition in Crisis
As reflected in the EU policy document, a new perspective on nutrition has emerged – one that is multi-sectoral, focusing on both treatment and prevention and joining up the humanitarian and development agendas.
This has important implications for ECHO which needed to be clarified in order to strengthen partnerships and ensure global consistency of approach.
...but at the same time, we still need to be clear about persisting information gaps – and to ensure that these are priorities for investment.
As result of new technologies and research we know so much more than we did (e.g. CMAM, survey methods, specialised products etc).
SWD articulates the
of European Commission’s Humanitarian Assistance for Nutrition in Emergencies
The principle objective is to reduce and avoid excess mortality and morbidity caused by undernutrition in humanitarian situations.
for European Commission’s Humanitarian Assistance for Nutrition in Emergencies
All interventions should be in line with the core
humanitarian principles of humanity, neutrality, impartiality and independence and incorporating gender perspectives systematically –
thereby ensuring that the entitlements of every individual in need of nutrition support are recognised.
Interventions should also be needs based and results based.
When to Consider Engagement?
Intervention may also be justified when emergency rates of mortality or acute undernutrition have been reached, exceeded or are anticipated based on early warning indicators forecasting critical deterioration.
The Commission does not have to wait for rates of acute undernutrition to rise or for formal disaster declaration in order to provide humanitarian assistance to address nutrition related needs.
Emergency rates are defined as U5 mortality > 2/10,000/day or GAM rates > 15% or GAM rates > 10% with aggravating factors.
When to Consider Disengagement?
When indicators have stabilised at below emergency levels.
When non humanitarian players are able to respond or when needs are fully covered by other humanitarian players.
When core principles cannot be respected, particularly where the risk of doing harm outweighs the potential benefits of remaining engaged.
From Assessment of Needs to Response Analysis
Addressing Acute Undernutrition
Access to free healthcare.
To address the challenge of scaling up, and to take forward the resilience agenda, and where ever possible, the focus is often increasingly on a ‘systems strengthening approach’ where nutrition interventions in emergencies build on existing capacities e.g. package of support channelled through MoH structure.
The Commission recognises the potential effectiveness of fortified and/or nutrient dense food products with regard to the treatment and prevention of acute undernutrition but ‘exclusively supports the use of specialised nutritional products where specific conditions are deemed to be appropriate and upon close monitoring of their effectiveness and impact’.
When indicated by assessment of needs and where the most vulnerable (generally children under five years of age and pregnant and lactating women) are not covered by existing health provision.
The Commission welcomes the advances made by CMAM.
Therefore ECHO supports the implementation of the ‘CMAM’ approach wherever possible with emphasis on:
Early detection of acute undernutrition at community level and intensive case finding through community mobilisation
Provision of outpatient treatment for SAM without complications (estimated around 80-90% of total SAM caseload)
Facility based treatment of individuals suffering from SAM with medical complications (10-20%)
Supplementary feeding programmes to treat those with MAM
Micro Nutrient Deficiency (MND)
There is growing evidence that MND can impact on children’s morbidity, mortality and cognitive development. Over 10% of child deaths can be attributed to deficiencies in Vitamin A, zinc, iron and iodine (Lancet).
While MND is often a chronic problem reaching beyond ECHO’s comparative advantage as a humanitarian donor, the increased risks triggered by a crisis, together with the opportunities presented by intervention presence, may justify the following response options:
Infant and Young Child Feeding in Emergencies (IYCF-E)
It also includes other essential interventions…
Adolescents and Adults
It is also important to ensure that the special needs of other specific groups are adequately addressed
(e.g. the disabled, the elderly, the chronically ill etc.)
Gaps remain in evidence concerning the treatment of acute undernutrition in adolescents and adults although, both groups have specific nutritional needs requiring appropriate treatment and support.
Women and adolescent girls can be particularly vulnerable due to their gender roles. Undernutrition in women contributes to maternal deaths as well as higher infant morbidity and mortality.
Overarching Operational Priorities
Systematic inclusion of nutrition relevant objectives and indicators across all sectors.
Water, Sanitation and Hygiene (WASH)
Undernutrition and infection are working in tandem: 'Undernutrition increases the risk of infection while at the same time infection can aggravate undernutrition.
The existing EU Communication and SWD on Humanitarian Food Assistance, together with additional guidance of response analysis, indicators etc, also builds on the UNICEF Conceptual Framework. Food assistance is therefore presented as a potentially effective instrument for the prevention of undernutrition.
This reinforces the case for an integrated approach to assistance for food and nutrition.
The Challenge of Coordination, Capacities and Information
At Global level, the Commission seeks to support coherence and improved coordination for nutrition across all relevant sectors and international actors involved in emergency nutrition response.
Putting it all Together - From Policy to Practice:
Changes in the way we think about undernutrition have led to a new roadmap for response. The key messages for ECHO and partners include:
ECHO’s specific focus is on acute undernutrition in emergencies(and the immediate and underlying causes).
While specific groups (such as children under five, pregnant and lactating women, elderly people) can be considered most vulnerable, as a matter of humanitarian principle, ECHO supports all people suffering or at risk of undernutrition.
However, undernutrition exists globally on a massive scale and constitutes a persistent crisis. Therefore, the artificial divide between humanitarian and the development agendas for nutrition must be overcome.
In every crisis, a joint humanitarian / development framework for action, involving Government commitment to build national systems, is an essential precondition for effective response and enhanced resilience.
As our understanding of the problem has evolved, important innovations such as CMAM have paved the way for scaling up of nutrition specific response.
But at the same time, there is increased awareness of the need for a multisectoral approach, with the role of each sector in a specific context identified through robust and coordinated analysis of causes.
Ensuring a proactive approach to linking humanitarian and development agendas to address persistent vulnerability and build resilience over time.
Strengthening the evidence base regarding the most effective response options in different contexts.
Supporting free access to healthcare and promoting a healthy environment are essential components of the prevention and treatment of acute undernutrition.
It is important that health is given as much consideration in emergencies as food security and WASH.
In addition, assistance can be provided on an unconditional or conditional basis
(e.g. for a beneficiary’s activity such as cash or food for work or training)
However, it is recognised that assessing the precise impact of humanitarian food assistance transfers on changes in nutritional status, remains both a challenge – and a priority to be addressed.
Furthermore, assistance may be provided to the affected population, or as targeted assistance aimed at reaching the most food insecure households (informed by household economy analysis).
Assistance may be in the form of
depending upon careful contextual analysis.
cash, in kind or through vouchers
It also emphasises the importance of thorough analysis in the process of considering a range of possible to improve individual dietary intake. Above all, what matters most is the proactive and transparent identification of the most efficient and effective path to this end.
Mapping the Problem
What is undernutrition? Undernutrition is one form of malnutrition which also includes overweight and obesity
It includes stunting, wasting and micro-nutrient deficiencies
How bad is the situation?
26% of children under five are stunted
165 million (2011)
8% of children under five are wasted
52 million (2011)
At any given time it is estimated that up to 20 million children under five may be severely wasted
What is undernutrition?
Something had to change
Emergence and Expansion of CMAM
The Lancet Series
High-impact nutrition interventions recommended by 2008 Lancet nutrition series
In general there has been increasing international attention to the nutrition agenda over last decade. In particular three initiatives have made a significant impact:
In 2008 The Lancet Medical Journal published a landmark series of articles on child undernutrition. A follow up Lancet series has also been published in 2013.
It called on stakeholders to step up to this serious challenge by focusing actions on the 13 most efficient interventions.
It triggered a movement for scaling up nutrition and increasing political mobilisation around nutrition.
Behaviour change communication.
Rates of persistent wasting are highest in South Asia
of both stunted and wasted children live in South Asia.
Micronutrient deficiency (e.g. Vitamin A, zinc, iron and iodine) is also widespread
Undernutrition increases the risks of mortality and morbidity. It is estimated that every year undernutrition leads to over three million preventable children's deaths.
And it has irreversible consequences on the future generation, on intellectual ability, economic productivity and risks of morbidity’
Global Initiatives such as the Scaling Up Nutrition (SUN) initiative have played an important role in calling for a multi-sectoral approach. Such initiatives have focused international attention and commitment to the nutrition agenda.
Efforts to mobilise political commitment at country level (state having the primary responsibility for their population) are currently underway.
A trademark of the SUN initiative is the useful strategic distinction between two equally crucial approaches: nutrition specific and nutrition sensitive.
Therefore the framework places nutrition at the heart of the resilience agenda and necessitates that humanitarian and development actors work together to address the causes of undernutrition and save lives.
Addressing under-nutrition requires a multi-sectoral approach, with potential actions including health, water, sanitation and hygiene, food security, education and women's empowerment.
Compared to sub-Saharan Africa
While there is an urgent need to scale up treatment for those affected by undernutrition (whether during 'emergencies' or not) this must be accompanied by greater emphasis on ensuring the prevention of new cases.
The CMAM approach signals a massive breakthrough in effective treatment of children most at risk. It allows increased coverage of the nutrition programmes and improved outreach to children by moving medical uncomplicated cases from health facilities back to the communities.
Since 1999, Concern with Valid International, have pioneered the CMAM approach – initially in Ethiopia.
Treatment of acute malnutrition (SAM and MAM)
Promotion of exclusive breastfeeding for the first six months of life
Promotion of optimal complementary feeding for infants after the age of six months
Vitamin A supplementation
(two doses per year for children between 6 and 59 months)
Zinc supplementation for diarrhoea management, multiple micronutrients for children under five years
De-worming for children (two doses per year for children 12–59 months)
Iron-folic acid supplementation for pregnant mothers
Promotion of improved hygiene practices, including hand washing
Salt iodisation, Iron fortification of staple foods
The Communication on Enhancing Maternal and Child Nutrition in External Assistance is an EU Policy Framework - the result of the changes, which occurred in the past 3 decades in the nutrition sector. It was time for the EC to formalise the way it address undernutrition in external assistance.
The Policy has two main objectives: reducing stunting and reducing wasting.
The policy is focusing on maternal and child nutrition, promoting a multisector approach and joint humanitarian and development work to address the causes of undernutrition.
Strategic priorities include: enhancing political and financial commitment, scaling up actions at country level by strengthening capacities, increasing investments in nutrition specific and nutrition sensitive interventions, while continuing to invest in research, information and capacity development.
Nutrition sensitive interventions (also highlighted in the 2013 Lancet series) address more underlying determinants e.g. food security and social transfers, women’s empowerment, child protection, schooling, water, sanitation and hygiene, health and family planning service, maternal mental health etc.
Nutrition specific interventions address the immediate determinants of nutrition
(the high impact nutrition interventions).
Increased consumption of complementary fresh food items
Integration of MNs into the prevention and treatment of certain diseases through healthcare services (eg: zinc for management of diarrhoeal disease, vitamin A alongside measles vaccinations).
Special attention to complementary feeding for children 6 to 23 months of age. Distribution of micronutrient supplements, either targeted to specific groups or as population level supplementation.
Provision of fortified food assistance commodities such as fortified cereal, CSB+/++ and /or micronutrient supplements e.g. sprinkles for home fortification.
Lack of access to safe water and adequate sanitation along with poor hygiene practices, collectively contribute to the spread of infectious diseases, growth faltering, lowered immunity and increased morbidity and mortality.
The Commission therefore promotes the incorporation of nutrition specific objectives into WASH humanitarian responses in crisis contexts where undernutrition is a humanitarian concern.
At the same time the approach serves to increase the visibility of nutrition as a major – but often hidden – crisis.
Not Wasted or Stunted
Wasted and Stunted
Humanitarians must act fast in the face of need, but when the need persists, and even worsens, it is time to pause.
“If I were given one hour to save the world, I would spend 59 minutes defining the problem and one minute resolving it.”
Changing the way we look at the problem of undernutrition can redefine our response to the basic questions and take us forward in new directions.
EU Communication ‘enhancing maternal and child nutrition’ and ECHO’s Staff Working Document ‘Addressing Undernutrition in Emergencies’ (2013) aims to do just this...
The context in which humanitarians are working has changed as well as the way we look at the problem of undernutrition. The EC CoM and SWS are reflecting these changes.
The destruction and disruption of everyday life can worsen undernutrition.
Young children, pregnant and lactating women and the elderly are the most vulnerable. However, any individual in need should receive appropriate assistance.
Humanitarian assistance does not generally have a comparative advantage in situations characterized by permanently high levels of undernutrition.
However, where humanitarian risk is high, other actors are not engaged and positive impact can be expected, assistance can be considered. In such cases advocacy and coordination with development actors will play an important role.
With the broadening of response options for nutrition in emergencies, the choices that need to be made in a crisis can be complex. In addition to anthropological indicators, causal analysis is important to identify strategic priorities for response based on available evidence.
Investment in information systems, research and capacity development, while not ECHO's primary focus, can be supported when viewed as priority components to be integrated within a broader humanitarian response and linked to longer term strategies.
What is the role of Humanitarian Assistance?
What is ECHO’s Core Focus?
ECHO supports IYCF-E interventions where results are expected within the timeframe of the ECHO funded interventions e.g. supporting mothers to continue breastfeeding and promote appropriate feeding practices despite the disruption resulted bydisaster (safe place, access to appropriate products and support etc.)
Enhancing Maternal and Child nutrition in external assistance: an EU Policy Framework
In the 90s UNICEF developed a strong conceptual framework to bring everyone onto the same page. It is still regarded as a valuable guideline today.
Maternal and child
death and disability
Inadequate maternal and child-care
sanitation and inadequate health service
Quantity and quality of actual resources -
human, economic and organisational -
and the way they are controlled
environment, technology, people
Underlying causes at household/
Basic causes at societal level
Inadequate and/or inappropriate knowledge and discriminatory attitudes limit household access to access to actual resources.
Political, cultural, religious, economic and social systems, including women’s status, limit the utilisation of potential resources.