The Added Value of WHO in the Nutrition Sector
In
Complex Emergencies
Examples from Ethiopia
Ms Albertien van der Veen
Consultant
Emergency and Humanitarian Action
December 2000
World Health Organization
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Index
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Background
Collaborative Linkages
WHO standards in the Somali Region
Emphasis on Health in the SNNPR
Improving Nutrition Surveillance
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1.
Background
During 2000, the UN estimated that approximately 13,4 million people in the Horn of Africa,
particularly in pastoral and agro-pastoral areas of Djibouti, Ethiopia, Kenya and Somalia,
were at risk of starvation. In Ethiopia alone, some 10 million people were affected.
In response to the increasing concern for the drought situation the Secretary General
appointed Ms Bertini as his Special Envoy (SE) for the drought in the Greater Horn of Africa.
During her first visit, she recommended the appointment of a Regional Humanitarian Coordinator (RHC). A RHC was appointed and an office (ORHC) established in Addis Ababa
in June 2000. WHO and FAO seconded two staff members each to the ORHC in order to
provide the office with capacity and expertise in the fields of public health, nutrition1,
agriculture and livestock.
Assessments of the food and nutrition situation were carried out in the worst affected regions
of Ethiopia, including the Somali Region, Northern Omo in the SNPPR, Wollo (Amhara
Region) and Konso Special Woreda. Separate reports were compiled on each of the
assessment mission, which are available from the UN Emergency Unit for Ethiopia web-site2.
Assessments were also carried out in drought affected areas of Somalia and the north of
Kenya. In Somalia, the north western part of southern Somalia was visited, also assessing the
health situation.
Follow-up of recommendations from these assessments, with the active support of and often
in meetings initiated and chaired by the RHC, indicates that the provision of technical support
on the spot can contribute to improved quality and effectiveness of the response in complex
emergencies. In addition, in particular in Ethiopia, the growing importance stakeholders
attached to the prevalence of malnutrition as an indicator of effectiveness of the response has
generated new interest in nutrition in post emergencies and monitoring nutritional status as
part of early warning. The added value of WHO in this respect is summarised in several
examples. Because establishing collaborative linkages at the earliest opportunity is essential
in ensuring effectiveness, this issue is addressed firstly.
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Terms of Reference of the WHO nutrition consultant, working under the responsibility of the WHO
Representative of Ethiopia, can be summarised as follows:
Assess the current nutritional status of the population in Ethiopia
Travel as needed to other countries in the Horn of Africa to assess nutritional impact of the drought and
identify possible cross-border activities
Evaluate the household food security situation and assess needs
Analyse the problems assessed and develop short and medium term plans of action
Identify patterns, which could start and sustain nutrition surveillance after the mission and identify
resources to this end.
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Address: undp-eue@telecom.net.et
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2.
Collaborative Linkages
As elsewhere in emergencies, UNICEF in Ethiopia is the lead agency for nutrition. As part of
its drought response, UNICEF had requested and ensured additional nutrition expertise from
CDC for a period of three months. Close collaboration between WHO and UNICEF was
agreed on shortly after arrival.
Recognising the need for enhanced co-ordination and a common approach, the UNICEF
spearheaded nutrition co-ordination meeting was transferred in a nutrition task force with
active support of WHO. Initiatives undertaken by the UNICEF/WHO nutritionists consisted
among others of the:
 Compilation into a data-base of information on surveys and interventions (which is
currently maintained by UNICEF)
 Dissemination of guidelines on best practices and minimum standards (copies of relevant
WHO manuals as well as brief outlines)
 Provision of technical assistance upon request
This pro-active approach resulted in a strengthened role of the nutrition task force in coordination through broader and more the regular participation of major NGOs, donors, and
UN agencies. By explicitly addressing the need for improving the quality of the response,
technical expertise within the task force increased, with the active involvement of NGOs. For
instance, Help Age conducted a short workshop focussing on assessing the nutritional status
of adults and elderly, while OXFAM and SCF USA presented findings of nutrition surveys
carried using international recommended survey methodologies.
As part of its strategy to further strengthen inter-agency co-operation in the field of nutrition,
WHO also carried out joint assessments with UNICEF (Gode) and the ORHC (Wollo). A
third mission with WFP was cancelled at the last moment due to bad weather. Strong links
with WFP in information gathering and sharing were established from the start and
maintained throughout however.
WHO was also a member of the USAID initiated North Omo (Wolayita) co-ordination group
and the RHC spearheaded task force for the Somali region. These forums served among
others to discuss (WHO and/or other) assessment findings and give effect to
recommendations.
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WHO standards in the Somali Region.
In response to the high prevalence of malnutrition, seven international and one national NGOs
commenced selective feeding programmes throughout the Somali region from during the
period April - July 2000.
Because the Government of Ethiopia (GOE) policy is not in favour of feeding centres, there
are only out-dated (pre 1990) guidelines from DPPC/MOH for selective feeding programmes.
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As a result, NGOs used their own criteria and guidelines. In response to the crisis, UNICEF
had recently posted a technical officer in Gode town to assist in nutrition training, monitoring
of selective feeding interventions and standardisation of practice.
A WHO/UNICEF food and nutrition assessment in Gode and other zones of the Somali
Region revealed, that the quality of care provided by less experienced NGOs, not always met
minimum standards. Lack of 24-hour care, high default rates, relatively poor education of
mothers and the exclusion of malnourished older children, adolescents and adults were of
particular concern. In addition admission criteria were often found to be inconsistent, variable
and not in line with international recommendations. Lack of routine medical care,
inappropriate feeding practices and insufficient attention for an adequate water supply were
noted as well. Lastly, standardised reporting of results including recovery periods, default
and mortality rates and analysis of average weight gains was often not carried out.
Findings were extensively discussed with the UNICEF co-ordinator on the spot. Guidelines
based on the WHO manual The Management of severe malnutrition: a manual for physicians
and other senior health workers were provided for further dissemination, monitoring and
improving technical guidance by UNICEF on the spot. (refer to Annex 1 for these guidelines).
Findings also served to convince the DPPC of the need for updated guidelines on selective
feeding. In principle, this task would fall to the MOH, but at present the Ministry lacks
expertise in this field. WHO Ethiopia is however interested and able to second a national
consultant to assist the MOH3.
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Emphasis on Health in the SNNPR
Following nutrition assessments, various agencies commenced selective feeding programmes
and general food distribution complimenting DPPC. A WHO assessment revealed that a
strong point of the drought response programmes implemented by NGOs was the combination
of selective feeding of malnourished children and pregnant and lactating women, and the
provision of general rations to all family members of malnourished children, thereby targeting
the most vulnerable. Also, therapeutic and supplementary feeding programmes were of
excellent quality, because nearly all agencies were using internationally accepted criteria for
admission and discharge; provided recommended medication and adhered to feeding
protocols and other standards of good practice. Moreover, response was characterised by
effective co-ordination among NGOs, resulting in even coverage of woredas, albeit late in the
case of some woredas.
A weaker point was that malnourished adolescents and/or elderly were excluded from these
feeding programs. Also, response in the health sector had been marginal, despite findings of
nutrition surveys indicating that morbidity, in particular due to malaria and diarrhoeal disease,
was a major underlying cause of malnutrition and that vaccination coverage was extremely
poor. The assessment recommended to strengthen the link between nutrition, food security
and health needs among others through better co-ordination between (national) NGOs
working in the health sector, INGOs planning to provide support in the health sector, MOH
and UN agencies. Specific recommendations included the following:
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A job-description was made, but the process is possibly on hold until the arrival of an international
nutritionist based at WHO for supervision.
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 Support the Zonal Health Department to carry out a mass measles vaccination campaign
 Boost regular EPI, vitamin A and ferrous/folic acid supplementation and ORT with
WHO/UNICEF technical support
 WHO to explore possibilities to link one or more of the above to its polio eradication campaign
 Strengthen communicable disease surveillance (WHO)
 Support the Zonal Health Department in malaria control by the provision of appropriate drugs,
means to prevent malaria and the logistics to effectively implement such a programme at woreda
level.
Findings were shared in the North Omo co-ordination group and contributed to triggering new
response in the health sector by NGOs. Although unrelated to these or other assessment, it is
also interesting to note that WHO in Ethiopia has recently linked measles vaccination and the
provision of vitamin A to its polio eradication campaign.
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Improving Nutrition Surveillance.
There is no country-wide nutrition surveillance programme in Ethiopia, but a nutrition
surveillance programme (NSP), implemented by SCF-UK in conjunction with the early
warning department of the DPPC, is in place in part of the Ethiopian highlands. The NSP is a
longitudinal monitoring system that utilises a standard set of food security, agricultural and
anthropometric indicators to track changes over time. The anthropometric indicator that has
been used by the NSP is mean weight for length (MWL) of the population. A cut-off point of
90% MWL is used by the DPPC to define population nutritional vulnerability and the need for
external food aid in its official policy.
A standard component of all assessments included a review of all nutrition information
available. Analysis of results of nutrition surveys carried out by NGOs in Wollo and
Wolayita, both covered by the NSP, clearly indicated, that mean WFL alone as reported by
the NSP was an insufficient indicator of nutritional vulnerability in an emergency situation. In
addition, results of nutrition surveys cast serious doubt on the validity of using a cut-off level
of 90% mean WFL to determine the need for emergency food assistance4. Nutrition surveys
were consequently found not only to provide useful, but also essential complementary
information. Rather than continue to use the cut-off level to determine the need for food aid,
WHO recommended to –at least for the time being– optimise information on the nutritional
status collected by the NSP through systematic reporting of the percentage of children falling
below the Weight for Height cut-off level of 80% for moderate and 70% for severe wasting,
in order to prioritise areas that warrant a comprehensive nutrition survey.
As a result, the validity of the current system of to determine the need for food aid is on the
DPPC agenda again, while nutrition surveillance now includes rates of moderate and severe
malnutrition.
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As early as 1993, analysis of the use this system revealed that child mortality is likely to increase before
area mean WFL fall to 90% of the reference, indicating that emergency interventions should be
triggered earlier. And also that (... such) nutritional status data provide confirmation of a developing
crisis rather than early warning. Lawrence M., Tayech Yimer & O’Dea J.K., Eur. J. Clinical Nutrition
(1994), 48.
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ANNEX I
UNICEF/WHO Interim Guidelines for Selective Feeding Interventions:
In a nutritional emergency, a proportion of children become moderately and severely
malnourished. While improving the general food ration remains the key intervention to
prevent the further nutritional deterioration of the population, for those children already
malnourished, a special diet is required beyond the general ration to rehabilitate them
effectively.
Therapeutic Feeding Centres:
The therapeutic feeding of children with severe malnutrition is a highly specialized area of
clinical care that should only be implemented by agencies with significant experience in this
field. Clinicians including doctors and nurses and at least one nutritionist with experience
managing a therapeutic feeding centre should be available before an agency attempts to
implement such a programme. Ideally a 30 cluster nutritional survey should have been
performed prior to designing such an intervention. Such a survey demonstrates the need for
selective feeding (i.e. high prevalence of acute wasting as defined by weight for height zscore or % median indicators) and assists in estimating the potential number of beneficiaries
for programme planning.
There are a number of guidelines that outline the specific protocols in detail to be used in
therapeutic feeding such as the WHO manual: Management of severe malnutrition: a manual
for physicians and other senior health workers and the MSF nutrition guidelines.
The major principles of treatment are:
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Admission according to strict criteria such as 70% weight for height or < -3 weight for
height Z score
Treatment in phases with the basis of feeding being therapeutic milk such as F-75 for
phase 1 and F-100 for phase 2 (these products have the macro and micro nutrient contents
required for the recovery of severely malnourished individuals)
Careful titration of volume of milk to weight of the child
Approximately 5% calories derived from protein in phase 1 and 10-12% in phase 2
6-8 meals per day with 24 hour care wherever possible
Low protein diet particularly in phase 1
Use of low sodium rehydration fluids such as Resomal if available except in the setting of
profuse watery diarrhoea
Gradual increase in calorific content of the diet
Move from phase 1 to phase 2 as appetite improves and/or oedema begins to resolve
Addition of local foods in phase 2 or 3
Discharge according to strict criteria such as 80% weight for height or < -2 weight for
height Z score
These broad principles are the key to a successful therapeutic feeding programme. The use of
commercially available milk powders in TFCs such as Nido or Coast milk is dangerous and
should be strictly prohibited. BP5 biscuits have a protein content of approximately 15% and
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should not be used in phase 1 and with extreme caution in other phases (see Document C:
Guidelines for the use of BP5 biscuits in nutritional emergencies).
A medical protocol including the following medications should always be used concurrently:
measles immunisation, folic acid, mebendazole, vitamin A, a broad spectrum antibiotic and
the addition of iron supplements after day 7.
For monitoring activities –see Document E: Reporting format for selective feeding
interventions.
Supplementary Feeding Programmes:
Just as with TFCs, the beneficiary population needs to be clearly defined. Blanket
supplementary feeding of all people under a certain age (5 for example) may be appropriate
where the general food ration is not adequate in terms of quantity or quality.
Otherwise supplementary feeding programmes based on anthropometric criteria should be
used. Appropriate criteria include children between 70 and 80 % median weight for height or
between –3 and –2 Z-scores weight for height. Pregnant and lactating women and the elderly
may also be included.
Generally dry supplementary feeding is preferred to wet feeding (feeding on site) because it is
logistically easier to manage and avoids large population concentrations and the subsequent
risk of disease transmission within the centre. Unless security is a major problem or the
general ration is so poor that the majority of the supplementary food will not get to the
targeted beneficiary, then dry feeding is preferred.
Major principles are:
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Dry ration should provide 1000-1200 kcal per day for children and/or pregnant or
lactating women with the assumption that at approximately 40-50% of the ration will be
shared
Wet ration should provide 500-700 kcal per day for children
Appropriate foods include blended foods such as CSB, Famix or local produced mixes
containing a cereal, a high protein source and a high energy source
BP5 biscuits may be used but generally only if there is not a better local alternative
Dried skim milk or other milk products should never be distributed alone
Medical screening should occur in supplementary feeding programmes and should at least
include: checking measles immunisation status, administration of vitamin A and
mebendazole and re-hydration with ORS or Resomal if necessary.
In certain situations where the general ration is not adequate and the sharing of the majority of
the ration is likely to occur, it is acceptable to increase the supplementary ration beyond this
level. This should be regarded as a temporary measure however, while advocacy to improve
the general ration continues.
For monitoring activities –see Document E, UNICEF/WHO reporting format for selective
feeding.
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