Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY

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Tech the News!
EDITO

U

undernutrition remains one the most important public health issues of our day1, with 165 million children under five years of age suffering from stunting and 52 million from wasting.

Special issue: Aligning Nutrition & Food Security and Livelihoods
You will find in this special edition key examples of work that has been done or is currently being developed as part of the ACF “Aligning FSL and Nutrition” strategy, including:

During the last decade, significant progress in finding efficient and cost effective ways to tackle undernutrition has been made: The Lancet Series on Maternal and Child Undernutrition published in early 2008 identified a series of effective nutrition (or ‘nutrition-specific’) interventions, which if implemented at scale during the window of opportunity (from pregnancy through the child’s second birthday), have the potential to reduce undernutrition-related mortality and disease burden by 25% in the short term 2. As a follow up to the Lancet Series, the global movement ‘Scaling Up Nutrition’ (SUN)3 called for the scale-up of proven nutritionspecific interventions AND the design of more nutritionsensitive strategies, including food security interventions, to tackle underlying causes of undernutrition. Indeed, long-term preventive approaches that aim at reducing the incidence of undernutrition, supporting the management of acute malnutrition and/or preventing relapse of children discharged from curative programs, represent a formidable lever. For more than two years , ACF has engaged in a process to improve synergies between food security and nutrition interventions in order to maximize its overall impact on undernutrition. The first step of this strategy led to the publication of a practical manual4 which gathers existing knowledge, evidence and experience and provides guidance to field teams on ways to practically enhance nutrition-sensitivity of programs. Another important step was achieved at the end of 2012 with the organization of the first ACF FSL-Nutrition joint technical workshop in London. The workshop brought together a large number of Nutrition and Food Security & Livelihoods specialists from most ACF missions around the same agenda: how the two sectors can improve their collaboration to enhance nutrition security.
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Research to build more evidence and identify what works
best at lowest cost possible: MAM’Out, Low Input Gardens (p. 26) and Cost Effectiveness Analysis (p. 24) projects.

Technical Development to test and develop new tools
and models: Nutritional Causal Analysis project update (p. 24), and an example of its practical application in Chad (p. 12); Listening Post pilot in Burkina Faso (p.17); Nutritional Impact Assessment Project launch (p. 24) and Cost of Diet tool piloting (p. 27).

Sharing and documenting experiences and lessons
learnt in a range of contexts: Nigeria (p. 7), Central African Republic (p. 9), Occupied Palestinian Territories (p. 11), Pakistan (p. 15), Myanmar (p. 19) and Afghanistan (p. 22); in addition to the production and dissemination of a set of brief case studies in 2012 (p. 27).

Capacity building with the development and implementation of a two-day training course based on the manual as well as the publication of a book providing key information on nutrition: The Essential – Nutrition & Health (p. 27).

Policy and advocacy in the framework of ACF Advocacy Strategy’s third pillar (p. 3) and the development of an ACF Nutrition Security Policy in 2013, encompassing all sectors. You will also read about relevant work being done externally on the topic as it gains growing international attention, as well as an interview of Anna Herforth, who has contributed extensively to moving forward the reflection on contributions of agriculture to nutrition. This special edition is longer than usual because we thought the richness and importance of the subject merited the extra space to further strengthen ACF fight against undernutrition. We hope you’ll enjoy reading and find it useful to support your daily work.
Julien Morel, Senior Food Assistance and Policy Advisor – ACFFrance (jmorel@actioncontrelafaim.org)

UNICEF-WHO-The World Bank, 2012, Joint Child Malnutrition Estimates 2 The Lancet, 2008, Maternal and Child Undernutrition, Special Series 3 Scaling Up Nutrition (SUN), 2010, Scaling Up Nutrition: A Framework for Action 4 ACF, 2011, Maximising the Nutritional Impact of FSL Interventions. A Manual for Field Workers.

©ACF International /// Newsletter N°16 /// April 2013

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **
NEWS FROM THE HEADQUARTERS DID YOU KNOW...? QUESTIONS ASKED TO COUNTRY ROADMAPS ZOOM ON A PROJECT RESEARCH AND TECHNICAL DEVELOPMENT WHAT HAPPENED? Publications, surveys, reports, meetings, fora… WHAT’S NEXT? Publications, surveys, reports, meetings, fora… WHAT CAN YOU FIND IN PREVIOUS NEWSLETTERS? 2 3 4 5 7 24 28 31 32

This newsletter was prepared in New York with the participation of all headquarters and missions. Thanks to all for your contributions!

NEWS FROM THE HEADQUARTERS
New York Nutrition Advisor Nyauma Nasani left ACF in Oct 2012; Leonie Van Mil is acting as Interim Nutrition Advisor for East Africa until a new person is recruited. Senior Nutrition Advisor Marie Sophie Whitney left ACF at the end of 2012 after over 10 years and having led the development of the technical department in ACF US HQ. Maureen Gallagher took the position of Senior Nutrition Advisor in NY in Sept 2012. A Nutrition Rapid Response Team member as well as Nutrition Advisor will be recruited by mid-2013. Lily Frey has joined ACF-US as the new half time Advocacy officer. Lily will develop US-based advocacy work and its contribution to the global ACF advocacy strategy. 1-2 Roving Tech positions will open this spring to contribute to emergency surge capacity in ACF-USA missions and serve a gap filling function. Hybrid or cross sectoral technical profiles with previous ACF field experience are sought – stay tuned. Paris Bader Mahaman has joined the technical team as Senior Sustainable Agricultural Advisor in charge of developing strategy, policies, positioning to support and reinforce this strategic axe in ACF. Contactable at: bmahaman@actioncontrelafaim.org Marie Sardier will be absent from mid-march until September for maternity leave. Her recruitment is in process. Ian Dalipagic has joined the FSL team for 6 months as the new intern to follow prices issues and support the sector in developing case studies for agricultural interventions. All related analysis and reports on price fluctuation should be sent to him : foodsec@actioncontrelafaim.org Oriane Barthélémy has also joined the team for 5 months to work with Julien Morel on nutrition security. She will be in charge of developing case studies, supporting the production of a nutrition security policy and documenting the nutrition effect of prevention interventions. She will also work on documenting cash interventions outside the FSL sector. Madrid Since the last Tech the News, there has been some movement in Madrid. Alvaro Pascual is no longer the FSL Coordinator in the Emergency Pool and this vacancy is currently open. Elena Rivero is replacing Elisa Dominguez as the Health and Nutrition Senior Adviser for Latin America, Middle East and Eurasia. The rest of the positions remain the same, with Marisa Sanchez as the Health and Nutrition Adviser for West Africa, Joaquin Cadario as the FSL Adviser for the Middle-East and Latin America, and Julien Jacob as FSL Senior Adviser for West Africa and Eurasia. ©ACF International /// Newsletter N°16 /// April 2013 2

Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

DID YOU KNOW…?
2013 Advocacy Plan on Nutrition Sensitive FEWS NET Update Laura Rossi—Senior Nutrition Policies (l.rossi@actionagainsthunger.org.uk)
Etienne du Vachat—Food Security Advocacy Officer, ACF-France (eduvachat@actioncontrelafaim.org)

Technical

Advisor,

ACF

UK

ACF’s international advocacy strategy’s 3 pillar focuses on “nutrition-sensitive policies” and the nutritional impact of policies and programmes. Our primary goal is “to ensure that food security and livelihoods policies, programmes and investments from the local to the global level are nutrition-sensitive and actually result in improved nutrition outcomes for those children under 5 at most risk of undernutrition”. Within this pillar we aim at influencing the making of food security and agricultural policies and programmes from national governments, regional institutions and donors, so that they better take account of their potential (positive or negative) impacts on nutrition and better integrate nutritional considerations. In 2013 we will produce case studies on how agricultural and food security policies of 3 countries where ACF is working are actually integrating (or not, and to what extent) nutritional considerations. On the basis of these reports we aim at influencing the decisions of the CFS (Committee on World Food Security) plenary session in September and the ICN+21 ‘International Conference on Nutrition’ jointly organized by FAO and WHO in November so that nutritional dimensions are better taken on board by decision makers in the field of agricultural and food security policies.

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ACF has been selected by FEWS NET to define an approach for use of nutritional information and data in early warning systems in West and East Africa regions. The project is coordinated by Dr. Laura Rossi (ACF-UK). At regional level the project is carried out by two ACF regional officers seconded to FEWS NET offices in Niger (Niamey) and Kenya (Nairobi). The project started in mid-2012 and will be running until the end of 2013. There are three key areas which ACF UK, in collaboration with ACF International (HQs, missions and regional offices) will focus on: Existing data: develop a harmonized data set at the region level; map malnutrition in FEWS NET covered countries; expand access of FEWS NET to nutrition surveillance data; define analysis and interpretation approach for early warning. Elaboration of new data: Operational capacity support: ACF UK/ FEWSNET team will provide operational support to FEWSNET in carrying out nutrition assessments (SMART); development of case-study (NCA). Training: Capacity development and institutional strengthening capacities: build capacity of FEWSNET staff in term of nutrition surveillance.

Food Assistance Convention: Ratified
Julien Morel—Senior Food Assistance and Policy Advisor, ACF-France (jmorel@actioncontrelafaim.org)

A new Food Assistance Convention have been re-negotiated and a text finalised early 2012. As the minimum number of signatory countries have ratified the revised text before the end of 2013, the convention has now enter into force. As a reminder, the FAC is the only international treaty with a humanitarian focus. The former version, dating 1999, previously named “Food Aid” Convention, was out-dated and ACF, in coordination with other NGOs who formed the TAFAD coalition, has pushed for years for its revision. The full new FAC text is available here: http://www.foodaidconvention.org/en/index/foodassistance.aspx

©ACF International /// Newsletter N°16 /// April 2013

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

QUESTIONS ASKED TO...
Anna Herforth is an independent consultant who has consulted for the World Bank and FAO for a number of years. Recently she has worked with USAID’s SPRING Project to review Feed the Future programs and make recommendations on how they can strengthen the link between agriculture and nutrition.
Can you briefly describe the work you’ve been doing to develop a common understanding of nutritionsensitive agriculture?
FAO supported me to do a review of nutrition-sensitive agriculture guidance¹, and is using the outcomes to inform a collaborative process of consensus-building around a common understanding of nutrition-sensitive agriculture. With the SUN movement, country governments are often interested in addressing nutrition multi-sectorally, and having a statement of basic, agreed upon principles of nutrition sensitive agriculture would be very helpful. iron supplementation for pregnant women etc. These interventions are a starting point, but they are not sufficient. The SUN movement identifies multi-sectoral action as critical, and we now need some consensus on what that means, particularly through agriculture.

Are there major gaps you think we need to address, as a community of practice?
One of the gaps is in awareness about how much evidence and knowledge we actually have on the ways agriculture can improve nutrition. And another is that we need more evidence. These two statements seem like a contradiction, but they aren’t. I am concerned that the main message communicated so far about nutrition-sensitive agriculture is: “We don’t have enough evidence.” We really know a lot; it’s just that the way we look at evidence for nutrition-sensitive actions has to be different than for direct interventions. Agriculture is very contextspecific, so the aim is not to replicate discrete proven interventions. Instead, we need to focus on evidence around principles that can be applied in diverse programs and settings. This is where more evidence is needed: if we are all acting on the principles that we think are important, then how do they work in different contexts? I believe there is a lot of existing evidence that has not seen the light of day. No one knows about some of the great work NGOs have done because there is no incentive or staff time to get it published. We need to learn more about evidence that is not public yet – we need to learn from how programs are implemented, where did they go right, wrong, what were the lessons learned? Advocacy about the major role agriculture plays in nutrition is also needed. ACF is lucky to already center their work on food security and nutrition. This is not so for the majority of funding for agriculture, which is aimed more at goals of economic growth or income growth. There is a strong need to advocate for agricultural development to take on nutrition as a core objective.

You recently co-led an FSN Forum² discussion on linking agriculture and nutrition. How does that conversation contribute to larger global discussions?
The stakeholders who attended the Forum were, for the most part, not the same group who had written the guidance documents. Reassuringly, the conversation highlighted many of the same issues as the guidance documents (for example, the importance of assessing context when developing a program; the importance of targeting vulnerable groups; women empowerment; etc.). Most of the discussion emphasized diversification and production of more nutritious foods as opposed to a focus on staple and cash crops. On certain points, the discussion went even further beyond what the guidance principles had highlighted. For example, it touched on environmental sustainability, underutilized foods and biodiversity, and the importance of addressing people’s dignity and rights. The goal is not simply to reduce hunger and undernutrition but to pay attention to the process of development work, how people participate and their ability to determine their own solutions that are sustainable.

What do you see as opportunities for agreeing on joint action and collaboration for nutrition sensitive agriculture?
Discussions that bring institutions together, like the SUN movement, are extremely positive for increasing awareness and action to improve nutrition. The biggest opportunity is to use this moment of high interest in agriculture and nutrition to get our messages straight. From what many institutions and people are saying based evidence and experience, a common set of messages is already there. So we need to recognize this harmony and use it to reshape agriculture in a better direction for nutrition. In past decades, the nutrition community has had a hard time getting its message straight and deciding on priorities. After the Lancet Series and the SUN movement, however, there was at least a common message: The first 1000 days are critical, and there are certain direct nutrition interventions that need to be scaled up: promotion of breast feeding, support of

What is your recommendation on strengthening the operational side for improved nutrition sensitive programming on the ground?
We need to find ways of adapting the principles to the programs, and sensibly measuring their effects. However we can’t simply ask the teams in the field to apply and measure them; an increase in capacity is needed. Nutritionists working with agricultural professionals or agricultural professionals themselves need to be better trained on the linkages. It may take some time to get there, but it’s possible if we have a common goal to improve livelihoods and nutrition.
¹A recent Synthesis of Guiding Principles on Agriculture Programming for Nutrition commissioned by FAO summarizes key nutrition-agriculture guidance, identifies 20 common principles and highlights a number of constraints that limit action. ²The FSN Forum is a community of practice on Food Security and Nutrition issues. See discussions on Making agriculture work for nutrition: Prioritizing country-level action, research and support.

©ACF International /// Newsletter N°16 /// April 2013

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

COUNTRY ROADMAPS
Last October, the first ACF FSL-Nutrition joint workshop took place in London aiming at having people from both sectors learn, think and work together on how to practically and systematically maximize the nutritional impact of FSL interventions. It brought together more than 80 ACF practitioners from most ACF International missions and headquarters. In order to build on the momentum gained during the two-day workshop, a call was made that each ACF mission work on specific country plans to define time-bound key actions to further strengthen integration and multi-sectoral activities within the mission strategy, interventions and daily work. While the process is still ongoing in some missions, you’ll find below two examples of these country action plans from Bangladesh and Kenya, which provide interesting insights on different priorities and areas of focus. Missions are encouraged to draw their inspiration from these two examples to build their own roadmaps towards strengthened integration for nutrition outcomes.

BANGLADESH Country Roadmap for Enhanced Coordination and Integration
ACF Bangladesh indicated, in its 2013-2015 strategy, that the integration of nutrition and food security & livelihoods (FSL) programs is a means to achieve both nutrition and food security & livelihoods goals at the household level. Similarly, ACF Bangladesh has found that the integration of projects is a way to make positive changes in the lives of Bangladeshi people who benefit from the programs implemented by ACF. The objective of ACF’s ‘roadmap’ is to have as many projects as possible that identify beneficiaries through nutrition programs and have them referred to FSL projects, which they are able to benefit from in the long run. At the same time, projects will include beneficiary profiling, which will allow future nutrition and FSL projects to identify households that are at a high risk of having malnourished children. Beneficiary profiling includes all elements of ACF’s sectors including nutrition, food security, mental health and WaSH. To date, ACF Bangladesh has started introducing the concept of integration of nutrition and FSL projects and has been presenting it to potential donors. The concept fits within most donors’ strategies in terms of long -term achievements and sustainability for beneficiaries. ACF Bangladesh will continue to strengthen programs and concepts in the upcoming year, to a point where concepts can mature, so that having parallel or project silo’s (FSL and Nutrition) will be considered outdated in terms of program planning, design, implementation and reporting.

Action 1 :
Indicator(s) of achievement (SMART) :

Integration of Food Security and Nutrition projects in Bangladesh Mission
Number of integrated projects At least 50% of the projects are integrated At least 50% the beneficiaries of integrated projects are the same.

Level of intervention (Region, mission, base, and/or project level):

Based on the needs of the area, all new projects will be integrated with nutrition and food security. This will happen at the mission level. In instances where integration cannot occur (funding etc), inroads into integration of FSL and Nutrition will be integrated in the program planning. An integrated project is a project where the area or the beneficiaries or the staff or the approach or the assessment/survey is shared.

Responsibility (who) for implementation : Timeline/deadline : Limitation/risks factors:

Country Director, Heads of Departments, Field Coordinators and Program Managers 12 Months (November 2013) Donor acceptance of Strategy. Funding for integrated projects. Expertise from Field Manager and Field Coordinator to be able to work in an integrated approach.

©ACF International /// Newsletter N°16 /// April 2013

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

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Action 2 :
Indicator(s) of achievement (SMART) : Level of intervention (Region, mission, base, and/or project level): Responsibility (who) for implementation : Timeline/deadline : Limitation/risks factors :

Capitalisation of Integrated Projects
All integrated projects are documented (OVI is the report) with a lessons learnt (or action after review) workshop Project level reporting National level reporting of integrated projects Project managers, Heads of Departments, MEAL Officer, Reporting and Communications Officers 15 Months (3 months following project conclusion) Capacity of Managers and Heads of Departments to be able to identify the lessons learnt and the best practices taken stemming from the projects

Action 3 :
Indicator(s) of achievement (SMART) : Level of intervention (Region, mission, base, and/or project level): Responsibility (who) for implementation : Timeline/deadline : Limitation/risks factors :

Field Survey (needs assessment, SMART survey, exploratory mission...)
50% of all field surveys are integrated Mission, base and project level

Project managers, Heads of Departments, MEAL Officer, Country director, Field Coordinators 1 year Joint needs assessments are decided by the HCTT in which ACF has no power

Kenya Country Roadmap for Enhanced Coordination and Integration
Planned Activity
Present the Joint FSL+NUT workshop objectives, agenda and the main findings Finalize action plans at mission level based on session 1 and engage all the mission stakeholders Present the Nutrition MultiSectoral Seasonal Calendar 2 days training session for the Maximising Manual 2 sessions to finalise the mission action plan Project workshop with all sectors - review project designs that have been developed and capture inputs from other sectors, identify potential synergies

Objective
Highlight key discussions and findings and introduce work on the action plans.

Look at the current processes at mission level with regard to integration to tackle malnutrition and do a SWOT analysis, engage the Mission Strategy Plan throughout and focus on 2-5 action points with related achievement indicators, timeline and responsible person. Strengthen knowledge of the tool by all positions in charge of coordinating strategic planning at mission or base level and circulate the Maximising Manual. Develop key action points to be implemented to enhance nutritional impact of ACF interventions and improve coordination. Build the mission’s nutritional seasonal calendar, get feedback from staff on ways to ensure better coherence between sectoral strategies and programs’ external assessments if partners could also benefit from the Maximising Manual. Get feedback from other sectors on integration, look for innovative approaches and tools implemented to enhance integration, share experiences through case studies.

©ACF International /// Newsletter N°16 /// April 2013

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

ZOOM ON A PROJECT I

Northern Nigeria: Researching the impact of social protection on nutritional outcomes
Nigeria Mission. Contact: Suzanne Ilyin—FSL Coordinator, Nigeria (fslco.ng@acf-international.org)

Action Against Hunger (ACF-USA) and Save the Children UK, through funding from the UK Department for International Development (DFID), will soon begin a large-scale social protection program to support some of the most nutritionally at-risk, food insecure households in Zamfara and Jigawa States of northern Nigeria. According to UNICEF, there are an estimated 800,000 children at risk of malnutrition¹ in northern Nigeria. Half of the children under five years old are stunted, while infant mortality is 40% higher in northern Nigeria than in the rest of the country². The CDGP aims to protect an estimated 420,000 people from hunger and extreme poverty, reduce the prevalence of stunting in 94,000 children, and reduce the under-five mortality rate in the targeted states by 3%5%³. A recent Household Economy Approach study conducted jointly by ACF and Save the Children in Jigawa State found that 50-55% of households were “very poor” and another 20-25% of households were classified as “poor” during a wealth ranking exercise.4 Food prices in northern Nigeria fluctuate significantly during the hunger season every April and May. Vulnerable households reduce food intake and sell assets as coping strategies, putting them at risk of deteriorating nutritional status and reducing their asset base for future livelihoods activities. The CDGP aims to provide timely, useful sums as a safety net for mothers so that they do not reduce food intake or quality for their families. Income generated by the household can then be used towards livelihoods activities or other basic needs. Unconditional cash grants are intended to increase access to a balanced diet, which, combined with information on Infant and Young Child Feeding Practices (IYCF) and good health and care practices, can contribute significantly to the prevention of malnutrition.

Set to kick off its inception phase in March 2013, the Child Development Grant Program (CDGP) will provide regular, unconditional cash grants of approximately 22 USD5 per month to 60,000 households over five years. Pregnant women and women with children under the age of two will be the primary beneficiaries of the grants, and they will remain in the program and receive monthly cash transfers until their youngest child reaches the age of two. This regular transfer, accompanied by a robust behavior change communication scheme comprising nutrition education and health, care and hygiene advice, will enable women to purchase an adequate quantity and quality of food to meet the nutritional requirements for their households.

¹As cited in ‘Commission Decision on the Financing of Humanitarian Actions in West Africa from the 10th European Development Fund’. European Commission, 2010. ²United Kingdom Department for International Development, Child Development Grant Programme Business Case, August 2012. ³Ibid. 4 European Commission Humanitarian Aid/Civil Protection (ECHO) Directorate General, Draft Report: Household Economy Analysis conducted by Save the Children UK and Action Against Hunger | ACF International in the Northeast Hadejia Valley Mixed Economy Zone (January 2013).

The CDGP will also include strong components of sensitization and mentoring, new technology, monitoring and evaluation, the development of an evidence base to influence policy and promote scaling up, and technical assistance for an eventual handover to state governments. Monitoring, evaluation and learning will be bolstered by a common Management Information System (MIS), a focus on nutrition, food security and livelihoods outcomes and the presence of an external evaluation team contracted directly by the donor that will remain in country from the baseline to the final evaluation stages of the program. Ultimately the program seeks to reduce the prevalence of stunting and the mortality rate of young children, improve food security and dietary diversity, and reduce distress asset sales.
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Grants have been set at 3500 Naira, approximately 14 GBP or 22 USD.

©ACF International /// Newsletter N°16 /// April 2013

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The first step in implementation will be to work with local traditional leaders to gain acceptance of the program and encourage husbands to allow their wives to participate. During the enrollment process, households will be encouraged by traditional leaders to register births with the National Population Commission and also to obtain birth certificates for all of the children within their households. Cash grants provide an excellent entry point for the establishment of women’s support groups. Group formation will take place along with basic training, immediately following enrollment and prior to disbursement of the grants. Support groups consisting of 30 women enrolled from the same communities will become a part of a peer education network that shares information using standardized behavior change and communication (BCC) tools about optimal child feeding. This will enable women to gain an understanding of the consequences of malnutrition and of adequate practices as a cluster of behaviors that includes quantity of food, quality of food, frequency of feedings, duration of attention, and care. These behaviors address challenges for the beneficiaries as well as the members of the community at large. At the same time, pregnant women and mothers will be encouraged to practice better health-seeking behavior such as promotion of attendance in ante- and post-natal care. This will provide a critical moment of opportunity to contribute to the prevention of maternal and child undernutrition. The communities mobilized through the BCC framework will be engaged in promoting other aspects of Integrated Management of Childhood Illnesses (IMCI), to align the BCC within the integrated approach in the management of pediatric illnesses caused by five preventable and treatable conditions, namely pneumonia, diarrhea, malaria, measles and malnutrition. These women’s groups will enable women living within each targeted community to support one another, share ideas and discuss new learning so as to promote the adoption of good health practices by their entire communities. In addition to providing a forum for learning about good care and nutrition practices such as complementary feeding, the women’s groups will also serve as a feedback mechanism for enrollees to express how they spend the grant. This information should also be useful in helping to tailor state and donor supported programs to meet their most pressing needs. The grants will be disbursed monthly to the enrolled women, during the same period as nutrition education sessions for women’s groups. Delivery mechanisms will likely involve mobile vehicles in the first year, as this ©ACF International /// Newsletter N°16 /// April 2013 mechanism has already been tested in northern Nigeria. Mobile phone transfers should be rolled out by the end of year one or beginning of year two, and eventually they will scale up to cover all beneficiaries, in collaboration with local mobile and financial service providers.

In addition to providing a forum for learning about best nutrition practices like complementary feeding; the women’s groups will also serve as a feedback mechanism for enrollees to express how they spend the grant. This information should also be useful in helping to tailor state and donor supported programs to meet their most pressing needs. CDGP will contribute to a growing evidence base on the nutritional impact of cash transfers. This program will provide robust research not only on the impact, but also the cost effectiveness of cash grants for nutrition. The parameters of the research component of the program will be defined by an external evaluator during the inception phase. Impact of an overlap between the Child Development Grant Program and other existing nutrition interventions versus impact of the CDGP alone will be evaluated. State governments of Jigawa and Zamfara will be encouraged to take over and gradually expand the program using their own financial and human resources, thus setting an example for the adoption of social protection policies across Nigeria.

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

ZOOM ON A PROJECT II
Central African Republic: Preventing Acute Malnutrition by Improving Food Access and Availability for at-risk Households in Nola Sub-prefecture
Clément Cazaubon—Country Director, CAR (cdm@cf.missionsacf.org); Aurélie Carmeille — FSL Coordinator, CAR (fsco@cf.missions-acf.org); Anne-Lyse Coutin—FSL Advisor, ACFFrance (alcoutin@actioncontrelafaim.org)

Humanitarian and food security issues: The south-east Central African Republic (CAR) has a rich sub-soil, and the inhabitants of the Sangha-Mbaere depend almost exclusively on mining to meet their needs (dietary and other). Male family members work in the mining industry (and to a lesser extent, in the cultivation of profitable crops such as coffee), to the detriment of subsistence farming. The region experienced a serious crisis in 2007, brought on by many different factors. This led to a large-scale nutritional crisis: The crisis in the mining and business sector (the engine of the local economy) following a new government taxation policy led to the closure of companies and sales offices, depriving households of their main source of income; Because local subsistence agriculture is very limited, market availability is highly dependent on other regions (Cameroon and the northern part of the country). This leads to significant price volatility in “normal” years (for example, the price of cassava increases by 50% during the lean season). This low supply, combined with the drop in household purchasing power (for reasons already mentioned) led to price increases which households were unable to weather. This crisis exacerbated existing structural weaknesses in the zone. More specifically: The agricultural sector lacks appropriate means of production, basic agricultural knowledge, and technical assistance. Subsistence agriculture is practiced on a family scale (0.5 hectares per household). The principal crops are cassava, plantain, taro, and corn (and to a lesser extent peanuts, squash, beans, and rice). This region also suffers from a lack of crop inputs, and ancient local crop varieties suffer from genetic erosion. Home gardening practices are under©ACF International /// Newsletter N°16 /// April 2013

developed in the zone. Food supplies from the November harvest are not sufficient to cover the period until the next harvest (July / August). At-risk groups experience a “hunger gap” during the lean season of May-June, a period of outdoor activities, and reduce their food consumption from 2-3 meals per day to 1 meal per day. During this period, malnutrition rates spike: SAM rises from 0.4% to 1.3% (source: ACF). Dietary diversity is poor: the standard dish is cassava balls, served with a “green sauce” for poor households, or “meat sauce” for the more well -off. Cassava has little nutritional value, and is often scarce when strong rains prevent it from being dried. Finally, food taboos constitute an obstacle to a balanced diet. Intervention strategy: In order to respond to this crisis and the structural conditions it revealed, ACF and local technical authorities have launched an integrated malnutrition prevention and management program. The program has two phases, the first of which was funded by CHF (Nutrition; Food Security and Livelihoods; and Water, Sanitation and Hygiene). In 2012, a second integrated phase bringing together Nutrition and Food Security and Livelihoods was funded by the CIAA (France’s Inter-ministerial Commission for Food Aid) and ACF-France. Based on lessons learned during the first phase, notably the need to better target beneficiaries of Food Security and Livelihoods initiatives in order to provide maximum nutritional benefit, the CIAA-ACF project targeted former patients, and new patients admitted in the course of the project, for ACFled NRU support (in total, 610 households received support). The project aims to achieve the following results: At-risk households are able to meet their daily nutritional requirements with food staples during the lean period and the period of intensive agricultural work (distributing protection rations of rice and beans) At-risk households having, or having had, a malnourished child under the age of 5, diversify their daily diet with vita9

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mins and mineral salts (introducing home gardening to the region; distributing crop inputs; providing technical training, etc.) At-risk agricultural households increase subsistence farming yields (distributing crop input; supervising producers, notably training in the preparation and use of bio-pesticides) At-risk households modify their food-related knowledge and practices (including food taboos). Project beneficiaries, notably women, attend informational and awareness-raising sessions to change food production and consumption habits, practices, and behaviors. Results, limitations, and potential improvements: Comparing indicators from the initial study with those in the final study shows there has been a slight improvement in terms of preventing malnutrition; however, much work remains to be done. Indeed, although there has been a marked improvement in the understanding of healthy dietary practices (the average percentage of households with knowledge of “healthy” food rose from 12% to 50% by the end of the project), and the importance of colostrum (the percentage of women who said they had breastfed their babies rose from 60.7% to 79.3% by the end of the project), more work is needed to improve understanding of the signs of malnutrition, during the period of exclusive breastfeeding. In terms of food security, results are highly varied; 65.6% of participants said Food Consumption Scores wer e ac c eptable overall (compared to 17.24% who said they were “borderline” and 17.24% who called them “poor”). There has also been an increase in the number of daily meals consumed by children (the percentage of children who had 3 meals or more per day rose from 31.7% to 59% by the end of the project) and adults (these data also reflect seasonal variations). However, dietary diversity scores are low, even decreasing (the HDDS went from 4.98 at the beginning of the project to 5.1 at the end; children’s IDDS dropped from 3.69 at the beginning of the project to 3.4 at the end). These mixed results may be explained by the following difficulties: Home gardening and subsistence farming production volumes are limited (low production -> low consumption); women are already busy with many other tasks and do not devote time to home gardening; insect attacks on home-grown crops occur; local crop varieties under-perform; our staff have difficulty tracking and assisting producers remotely; production may be damaged due to the lack of clear limits between crop and livestock zones; There are availability problems; in many villages there are no markets, and those that exist are poorly supplied and underperforming; There is a lack of technical coordination between departments (Nutrition / Food Security and Livelihoods); as a result, Food Security and Livelihoods teams may have poor retention of nutritional knowledge / treatment practices (making them less able to transmit those practices and knowledge effectively in the field) Despite these difficulties, the team is convinced that the chosen approach is the right one, and hopes to continue optimizing the nutritional outcomes of Food Security and Livelihoods operations. The following recommendations are made with this in mind: Strengthen technical assistance within ACF to better integrate the work of Nutrition / Food Security and Livelihoods Promote the “integrated agro-sylvo-pastoral” approach in family-run operations (reducing conflicts, improving food availability and diversity) Help kick-start research into new crop varieties Re-think the division of household tasks (gender-based approach) Study potential improvements in the use of local wild products

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ZOOM ON A PROJECT III

Occupied Palestinian Territory: Tackling Anemia through Gender Sensitive Cash for Work
Louise Finan—Advocacy and Communications Officer, ACF-Spain (lfinan@pt.acfspain.org); Stanislas Morau—FSL Coordinator, oPt. Additional contact: Julien Jacob—Senior FSL Advisor, ACF-Spain (jjacob@acfesp.org)

Tackling anaemia through CFW As part of a WASH and FSL intervention, ACF designed a nutrition sensitive component. Between 2011 and 2012, 153 unskilled and 7 skilled women worked on the elaboration of micronutrient rich foods. The two processed foods were maftoul, made of fortified wheat flour, and grape molasses, that were distributed to vulnerable families who had children suffering from anaemia. In total 6.600 Kg of fortified maftoul and 2.100 Kg of grape molasses were distributed to 270 food insecure households and 1 orphanage, simultaneously with awareness sessions on food utilization, nutrition and diet balance for adults as well as for children and young infants. To avoid spoiled food and hence to increase the final number of families receiving nutrient rich food, ACF's team estimated the rations per family according to the average consumption of a Palestinian family. Rations were made to last 2 to 6 months depending on the size of each beneficiary's household. Products were conditioned to optimize their shelf-life. The final food parcel included 10 Kg of grape molasses and 20 to 37 Kg of maftoul per family. The distribution of nutrient rich food together with the awareness sessions positively contributed to changes in food utilization in the community. During the first pilot of this activity the only indicator measured was the recipients' satisfaction and this has encouraged the team to renew and scale up this type of support. Within the ongoing phase of this activity, ACF is measuring the HDDS of the beneficiaries. So far a slight increase has been observed from baseline to end line study (+0.48). A more qualitative questionnaire is now being developed for the remaining phase of the program to complement this indicator and better get the impact of activity. Gender added value Apart from the positive effects on nutrition, the Cash-for-Work component designed specifically to employ women was well received in the community. ACF's experience here proved that by bringing women out of their home to work and earn an income resulted in gains in self-confidence and respect both at the community and household level. Processing food within a group of women is a culturally acceptable manner for women to get more involved in the local economy. Men not only were supportive but were proud of their work representing a step towards improving women’s social position and self esteem. This combined form of support bolstered the existing local safety nets and improved social assets of marginalized females. The activity designed as a temporary support proved to have the potential to generate incomes because of the outputs' quality and of the women's willingness to work together. In addition, women processing nutrients rich food had the satisfaction of seeing that their work supported children suffering from anaemia in their own community.

Context¹ ACF-E has been present in the Occupied Palestinian Territory (oPt) since September 2002 with the mandate of supporting the most vulnerable communities affected by conflict. In oPt food insecurity has varying causes: food price inflation, livelihood deterioration and erosion of coping mechanism. In the West Bank (WB) food insecurity is mainly a consequence of income, poverty and livelihoods erosion, while in Gaza (G) it is a result of limited economic opportunities due to the Israeli blockade. Years of conflict have forced families and communities into selling their disposable assets and now approximately half of households rely on credit to purchase food. Since 2009, 15% of households in oPt reported a decrease in expenditure, 88% of which was in relation to food, especially the quantity of meat they consumed. These factors (unemployment and negative coping mechanisms such as reducing the quantity and quality of food) have contributed towards the deterioration of the overall nutritional status in the WB and G. Micronutrient deficiency is a concern in oPt and contributes to the prevalence of stunting in the country. Iron deficiency, anaemia and vitamin A deficiencies constitute to serious public health problems, despite the fact that the MoH has protocols on management and provides supplements free of charge to pregnant women and young children. However, the noncompliance to current supplementation programmes is a critical concern regarding public health. Anaemia is a complex condition that results from the interaction between different risk factors in the oPt. Various studies on IYFP and diet nutrient adequacy have shown repeatedly that inadequate intake of iron coming from the foods consumed is one of the main reasons for anaemia, as well as tea consumption, which is very common among all age groups, and whose tannins inhibit the absorption of non-hem iron. Most surveys found anaemia levels to exceed 30%, 40% for some age groups, confirming that anaemia remains a serious public health problem for both children and women of childbearing age. ¹Extracted from: Elena Rivero (ACF-E), Nutrition situation in the occupied
Palestinian territory-Review and Nutrition Assessment, Jan 2011

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ZOOM ON A PROJECT IV

Chad: Qualitative Analysis of the Causes of Malnutrition
Boukari Biri Kassoum—FSL Coordinator, Chad (fsco@td.missionsacf.org); Carine Magen—Consultant (carinelise@hotmail.com); Anne Lyse Coutin—FSL Advisor, ACF-France (alcoutin@actioncontrelafaim.org)

ACF and the problem of malnutrition in Chad ACF has had missions in Chad for almost 30 years and has most prominently been present in the west of the country (Kanem, Barh el Gazal), since 2009, due to extremely high prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) in the region. Study and methodology objective In May 2012, ACF France conducted a qualitative analysis of the causes of malnutrition in Grand Kanem (Kanem, Barh el Gazal) in order to gain a better understanding of the causes of malnutrition and consequently to develop more effective prevention and treatment programmes. This study, financed by the Swedish International Development Agency (SIDA), is based on ACF’s conceptual framework on malnutrition (adapted from UNICEF) in order to understand the determining factors of the underlying and immediate causes of the disease. In methodological terms, the Nutrition Causal Analysis (NCA) is based on the work being carried out by Julien Chalimbaud ( NCA Coordinator, nca@actioncontrelafaim.org) and has followed these key steps: Bibliographic research Workshop for experts to define hypotheses of the investigations/surveys (16 in total) Data collection and analysis on the ground to confirm or rebute these hypotheses and for reports to experts. The team consisted of 1 expert (Carine Magen, Anthropologist), 2 investigators and 2 translators. Study Results The results of the study are broken down into 3 groups of causes for the conceptual framework. 1. Basic causes of malnutrition The Grand Kanem has a socio political system which is based on the caste system. It is an isolated Sahelien area, benefiting from little central state development, where households rely on the market for food supplies. For a long time, the economy of this area had been subsidized by money transfers from migrants in Libya or Saudi Arabia. However, due to a reduction of transfers caused by the Libyan crisis, the area is now in recession. Behaviour linked to resources and economic vulnerability ©ACF International /// Newsletter N°16 /// April 2013 12

is in large part influenced by the nobles’ caste. The rate of malnutrition in poor households is not particularly higher than in rich households¹ - in some cases, the risks during non-food crisis periods are actually less significant for the poorest people. The shame arises from the increasing poverty of the noble households which hinders the care of malnourished children, and the social division of traditional work limits the possibility of activities which could generate an income. Servants of noble families are typically the first ones to be plunged into severe poverty, with practically no means to improve their situation. Rich families that must transition into a low-income lifestyle often develop food strategies that worsen the nutritional status of their household members.

Finally, the socio cultural aspects of Grand Kanem perpetuate ancestral practices (ie. frequent pregnancies, starvation during pregnancy, removal of the uvula, sudden weaning) generally detrimental to the health of the mother and children, making them predisposed to malnutrition. 2. Underlying causes Rainfall deficit and recurrent enemy attacks in the area affect the level of farming production, leaving households exposed to food insecurity thus, increasing their risk of malnutrition. The socio economical profile study² of NCA beneficiaries led by ACF, demonstrates that the beneficiaries possess as many animals as households whose children are not sick. Nevertheless, the difficulties for some people to access milk during a crisis can constitute a nutritional risk factor for children who are weaned suddenly due to frequent pregnancies.
¹ACF-F:Economy of households and food security Kanem and Wadi Bissam, 2010

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In the dry season, mothers, afraid that their children become dehydrated, often give them unclean water which causes diarrhea, in turn contributing to malnutrition. In these cases, mothers do not often go to health centres as there are few of them and they are a long way from the villages. Mothers often cite distance as a major obstacle to the accessibility of health care. Another challenge is the fact that only husbands are allowed to decide if children need medical treatment. The analysis of the Chad Health System by the World Bank revealed that “only one in ten births benefit from public and/or private not for profit services , with around one in five in urban areas and one in 20 in rural areas. Low attendance in rural areas (6.3%) is probably due to the long distances from health centres, the absence of qualified staff outside opening hours and the presence of traditional birth attendants as well as matrons in the villages” Many studies have shown the causal link between a lack of education of a mother and the malnutrition of her children. Illiteracy affects a huge majority of women in Kanem, which causes serious problems in terms of developing knowledge and practices related to education and the care of children. 3. Immediate causes Children aged 12-23 months who are breastfed are more at risk of malnutrition than those who are weaned at the same age. This is most likely due to poor interpretation of the health messages which are given to mothers, who may think it is not necessary to supplement the food of their breastfed babies. The ACF study³ demonstrates that “deficiencies in iron and vitamin based micro nutrients could explain a risk of malnutrition for at least 37% of children who don’t have a varied nutritional diet and are exposed to a risk of deficiency of growth good based from vitamins, eggs and fruits. They could also explain to some degree the admissions and readmissions in Kanem and Wadi Bissam’s nutrional centres, the villages involved in the study. “ In Grand Kanem, the ideal birth is one which can be described as “discrete.” A woman must give birth alone. The pregnant woman aims to have the smallest baby possible for an easy birth. Given this logic, going to the hospital and giving birth in front of “strangers”, especially men, only happens in extreme cases where the mother’s or baby’s life are in danger. The World Bank’s report explains this lack of progress regarding giving birth in a hospital, by the much reduced number of trained and available midwives in some areas of the country. The number of deaths in childbirth can be explained by very late attendance at a health centre during difficult births. Similarly, knowledge of such deaths in childbirth only increases the anxiety surrounding birth and reinforces the women’s desire to have an easy and “discrete” birth. Babies born under these circumstances usually have a low birth weight and are often predisposed to being malnourished. Conclusion The lack of education has obvious effects on hygiene and nutritional practices, access to economic resources, birth control and treatment choices as well as the well-being of mothers and children. With regards to the causes of malnutrition, it is possible that women coming from Libya may play a positive role in village communities: often more educated and having experienced a more modern lifestyle, they are able to influence maternal practices in terms of hygiene, food and traditional medicine which they view as “archaic.” “Here women rarely bathe, they don’t wash their hands and don’t wash their children because there is no water. For those of us who are coming from Libya, we are introducing another way of life. But there has to be water. ” Conversely, they can also be discouraged of breastfeeding because it is said that “they don’t breastfeed their children and prefer bottles”. Strengths, weaknesses, constraints and opportunities of this study Strengths and advantages of NCA Provides extensive bibliographic research ²ACF-F:Socio economic profile of CAN beneficiaries, Kanem region
(West Chad) Sept’09-Jan’10. ³ACF-F:Economy of households and food security in Kanem and Wadi Bissam, 2010

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Brings an anthropological point of view to the problem Multi-sectoral analysis and approach Has allowed the testing, piloting and contributing to a methodology which is currently in development, in the context of a research project. Constraints and limitations Time constraints, therefore a focus on the qualitative investigation Very large geographical area to be covered within a limited timeframe. Possible bias: the investigation has been carried out during the Sahel food crisis, no immersion to overcome this bias. No means of measuring the relative importance of each cause in relation to the others (prioritisation). The ACF team was not actively involved (the results and recommendations have not been entirely integrated by the mission) Key lessons to take away Dedicate funds and resources (human and logistic ) to this study Avoid carrying out a NCA during a crisis period (risk of masking basic and underlying causes) Involve the ACF team in the analysis and the formulation of recommendations and in the response plan (adoption by the mission)

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ZOOM ON A PROJECT V

Pakistan: Nutrition Mainstreaming Strategy and Lessons Learnt of the Pakistan Emergency Food Security Alliance
Shahid Fazal—Nutrition Coordinator, Pakistan (nutco.pk@acf-international.org)

4. Hand washing 5. Safe water chain FSL staff in turn trained community volunteers who rolled out the trainings locally. Due to cultural restrictions and the short program timeline that precluded in-depth community advocacy, volunteers tended to be male. Post-distribution monitoring showed that the mainstreaming of nutrition led to the improved utility of cash transfers to be used for the diversification of food. The nutrition related trainings also led to improvement in the hygiene condition of communities, especially in the lives of women and children, who showed fewer illnesses compared to before the project. Messages from the five nutrition awareness modules managed to reach 91% of the FSL beneficiaries and reached out to an average of 3,270 other members of the households of which 80% were women. These sessions were useful because they allowed caregivers to better understand the importance of a clean environment and the time that should be invested in their child, as a means of improving the nutritious status of the family. Participants recalled water and sanitation messages more than any other message. Information retained included the importance of personal hygiene and a clean environment, of consuming clean water, and of washing hands, mainly with soap. Before intervention, most of the communities practiced open field urination and defecation, and poor hygiene conditions were found in homes, including dirty kitchens, the sharing of utensils and livestock kept inside the home. Before the program, few women knew when to initiate breastfeeding after delivery and nutritional practices were largely inadequate for at-risk groups such as infants, young children, pregnant and lactating women, mainly due 15

Since 2010, Action Against Hunger has worked to respond to some of the worst floods in Pakistan’s history. ACF and its six partners in the Pakistan Emergency Food Security Alliance (PEFSA) program aimed to save lives, protect livelihoods and increase the resilience of disaster affected households and communities in the worst flood-affected provinces. The program evolved from a stand-alone FSL alliance to an aligned FSL-nutrition treatment and awareness consortium program. Key program approaches and activities directly supported the alignment of food security activities to nutritional objectives: Mainstreaming of nutrition awareness sessions to all beneficiaries of FSL interventions Beneficiary targeting for FSL activities prioritized nutritionally at-risk households, i.e. those with children under two years and pregnant and lactating women Beneficiaries discharged from nutrition treatment were referred to FSL activities Awareness raising about the causes and consequences of malnutrition and promotion of adequate feeding practices through one-on-one counseling support and advice at the health structures and within the community – including the cash for training sessions Development and sharing of best practices and lessons learned on mainstreaming nutrition security Nutrition staff trained FSL staff in a training of trainers (ToT) on the five key messages and related modules, including guidelines for awareness session facilitators, session objectives, information, education and communication (IEC) materials, and proposed timeline for messages dissemination. The five modules focused on: 1. Awareness about malnutrition 2. Exclusive breastfeeding 3. Diet diversity ©ACF International /// Newsletter N°16 /// April 2013

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to food restrictions and taboos. Women’s knowledge of malnutrition and its consequences improved from 50% to 84% in the second phase. However, improved knowledge did not necessarily translate into shifts in practice during the short timeframe of the program, likely because behaviors are influenced by longstanding beliefs as well as by household resources and decision-making power. Lack of income and poor community infrastructure limit households’ access to a healthy diet, water, sanitation facilities, and soap. Lessons Learned: Measuring the impact of aligned nutrition and FSL interventions: Impact evaluation will be considered in future to determine exactly which components of nutrition and FSL programs contribute to improved nutritional status. Qualitative research conducted as part of the nutrition causal analysis in Sindh revealed that intrahousehold dynamics and social norms led to certain unhealthy care and feeding practices and that the emergency intervention could not adequately address these deeper issues. Delivery of the nutrition awareness sessions: More initial training and supervision of community volunteers and/or facilitation of sessions by trained ACF staff, in order to ensure the quality of session delivery, and local-level negotiation with community leaders to ensure women’s participation should be carried out in future. Visual materials, discussion and banners should continue to be used for interactive sessions. Behavior change messages must be repeated over a longer period of time to have long-term results, and their ongoing delivery can also be through radio and other communications methods as “refreshers.” Training of Trainers: Community volunteer trainers omitted several sessions in some villages. Awareness sessions also varied greatly in quality since volunteers had limited experience and prior knowledge. In future, female caretakers should be targeted by training female community volunteers and female Ministry of Health staff (lady health workers), who have some existing knowledge on the subject. Coordination between nutrition and food security teams: Direction by the nutrition team allowed for consistent oversight of the implementation strategy focused on nutrition throughout the duration of the program, and should be continued. ©ACF International /// Newsletter N°16 /// April 2013 16 Joint production of IEC materials: The nutrition team and community members worked together to adapt the material and strategy of activities to the local context, and this was a major success of the program. The materials should be modified for other project areas to include local customs of food consumption or challenges that are distinct to certain areas. FSL teams can provide context analysis and local food information, while WaSH teams can provide relevant details on hygiene. Recommendations: Align nutrition, FSL, and WaSH interventions through the Clusters: Advocate for more aligned approaches within and between Clusters, partners and line ministries. Even if the duration of an intervention is short or in response to an emergency, closer coordination and more frequent communication between these nutrition and FSL, as well as with WaSH, will prevent duplication and encourage integrated approaches within and amongst humanitarian organizations and local stakeholders to tackle the root causes of malnutrition. Train staff to “think aligned”: Staff should be trained throughout the project cycle in order to understand the conceptual framework of malnutrition, how nutrition, FSL and WaSH implementation and results overlap and together contribute to nutritional outcomes, and to ensure that staff members apply related concepts and strategies to their daily work, with follow-up by program managers. This involves continuous awareness raising and “refresher” sessions for staff particularly following staff turnover. Participatory, interactive delivery of nutrition awareness sessions: Nutrition awareness sessions should be repeated throughout the project cycle, and creative delivery mechanisms should be brainstormed and decided with the community. Beneficiaries need time to understand new ideas and apply related practices to contribute to their children’s health. Different strategies should be utilized for different groups (e.g. mothers, fathers, elders), including home-based sessions for small groups of women and care -giving, feeding, or cooking demonstrations with beneficiary participation. Women must be included as community volunteers to deliver awareness sessions to other women, which in Pakistan could require alternative training locations and methods such as female neighbors gathering in a small group in one of their compounds.

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ZOOM ON A PROJECT VI

Burkina Faso: Listening Post - a New Approach to Understanding Seasonality of Undernutrition
Julien Chalimbaud —NCA Coordinator, ACF -France (nca@actioncontrelafaim.org); Abdoulaye Ilboudo—FSL Coordinator, Burkina Faso (foodsec@bf.missions-acf.org); Theodore Kabore— Country Director, Burkina Faso (cdmadj@bf.missions-acf.org)

Presentation of project LISTENING POST (LP) is a methodology of nutritional surveillance designed with M a r k M y a t t (epidemiologist), SCF UK and ACF. The goal is to follow the seasonality of undernutrition and its main risk factors. Since September 2010, ACF’s mission in Burkina Faso has been the first mission to successfully test the methodology in the province of Tapoa (see map). Tapoa province is located in the Eastern region of Burkina Faso, at the border of Niger and Benin. The province has been subdivided into 3 Food Economy Zones where 3 LPs were established. Selection of monitored children For each LP, 6 villages and 22 children ages 6-24 months per village were randomly selected for a total of 396 children. The data presented consolidates information gathered for the 3 LPs. Indicators monitored The main indicators monitored were: prices in the markets of basic commodities, terms of trade, food diversity, weight gain, morbidity, brachial perimeter/edemas, Household Food Insecurity Access Scale (HFIAS), level of cereal stocks, proportion of food expenses, revenue, main sources of drinking water.

Results According to the analysis, the LP data shows a significant overall link between children with GAM and morbidity (especially diarrhea). Peaks of diarrhea and peaks of GAM occur at the same period of the year (February and March) while we thought the peak of GAM occurred during the lean season.

Estimated prevalence of GAM with children having been sick and children not having been sick (children with diseases in red and those without, in green):

In Tapoa, access to clean drinking water is a real problem (rate of access 38.81% in 2012, MAH data) and many people are forced to supply themselves with contaminated water points: usually shallow traditional wells and surface water. February through March is the dry season, when access to these water points becomes nearly impossible exacerbating rates of diarrheic illnesses.

Estimated prevalence of GAM in children who ate more or less than 4 food groups (children having eaten more than 4 food groups in red and those who hate less, in green)

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Hypothesis of increase of malnutrition in young children during the lean period The impact of the lean season is not felt the same way by all members of a household: children’s diets often are not lowered dramatically compared to adults and parents. This is due to the fact that during more vulnerable times of the year, children are often provided a certain “protection”. During the lean season, wild foods (fruit, leaves etc.) are available freely, therefore are often overlooked when assessing dietary diversity. This period is also marked by an increase in availability of cow’s milk and eggs. These findings have been verified through interviews and an IRD study in Burkina. The lean season, therefore, does not have a particularly negative impact on children’s nutrition and the peak of malnutrition rates appear, rather, between March and April, due to diarrhea. This is not to say that children’s diets are a factor to ignore in Tapoa, on the contrary, it is simply to say that children’s diet do not vary dramatically over the course of the year and their malnutrition rates do not follow the same rhythm as the seasonality of food security. Scientific research in Burkina has confirmed these results with evidence of poor nutritional status of mothers while having no effect on that of children less than five years old during the lean season. It is important to keep in mind that the LP monitors young children (6-24 months). Older children (24-59 months) are probably more vulnerable to food insecurity issues during the lean period since they must share meals with the family and are more resistant to the risks of diarrhea. Operational utilization of the results Monthly discussion meetings on the analyses of processed data are organized with the technical teams (Food Security and Livelihood, Nutrition and Health, WaSH). The results are utilized for quickly understanding the evolution of the nutritional context; to support the interpretation of parallel inquiries; to consolidate our contextual data. The Listening Post has had an operating cost of around 27,500 Euros with a team of 4 persons to manage 3 LPs. Missions are encouraged to put this methodology into place in their intervention zones. This means, however, ©ACF International /// Newsletter N°16 /// April 2013
Estimated prevalence of Global Acute Malnutrition (GAM) in children aged 6-24 months Scale of access determining Household Food Insecurity Assessment Score (HFIAS)

that this will depend on context, especially in terms of availability of households. There were several apprehensions regarding the methodology: the increase of malnutrition in children during the lean period, however it is interesting to conduct specific parallel and deeper studies to understand certain results/changes. It has also been difficult to change the opinions on malnutrition and food security; therefore, one must proceed slowly and know how to ask the advice of specialists. ——————————————————————— Below are additional findings from the study in Tapoa:

Prevalence of diarrheic illnesses

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ZOOM ON A PROJECT VII

Myanmar: Lifting Livelihoods with Homestead Gardens
A Smallholder Farmer Success story
Myanmar Mission. Contact: Victor Kiaya—FSL Advisor, ACF-France (vkiaya@actioncontrelafaim.org)

Project’s title: Supporting the sustainable recovery of livelihoods through Water and Sanitation-Hygiene (WASH), Food Security (FS) and Care Practices programs in Northern Rakhine State (NRS), Myanmar. Funded by: European Commission Implemented by: Action Contre la Faim (ACF) Duration: May 2009 - May 2012 Contribution: 2 553 000 € Facts and figures (May 09-May 12) 31185 people in 2 townships benefited from ACF activities. 71 villages benefited from food production and income generating activities. 150 families now earn sufficient income from fish breeding and 528 families from vocational training. The project has increased the diversity and quantity of foods available to vulnerable households supported by home gardening. The Dietary Diversity Score (HDDS) rose to an average of slightly below 6 (5.7) compared to previously an average of around 4 (3.6) before the project. 2 food security newsletters were produced and disseminated among stakeholders. Target area: Maungdaw & Buthidaung Townships

ject. The project was designed to assist chronically food insecure households. The programme provided Food Production Activities (FPA), distribution of agricultural inputs, livestock/fish, cash for Income Generating Activities (IGA), vocational training, capacity building and close follow up of the food security and livelihoods situation through a surveillance system. As of march 2012, a total of 31185 individuals participated in and benefited from the food security and livelihoods component of this intervention. Context: Myanmar is a food surplus country with significant agricultural potential, through unfavourable economic policies, impaired social cohesion and the marginalization of some sectors of the population adversely affect livelihood opportunities and the adequacy access to food requirements. Food insecurity is particularly pronounced in border areas, home to the majority of the country’s minorities. The livelihood context in NRS is that of chronic poverty and food insecurity, aggravated from time to time by transitory factors. The enforced policies in the area have a direct and major impact on the livelihoods of the population, setting clear limits on development and the efficiency and effectiveness of external responses. Objectives: Overall: To contribute to improve and reinforce livelihoods of marginalized and vulnerable uprooted groups in Rakhine State. Specific: To extend beneficiary household’s physical, financial, human and social capitals, contributing to the sustainable recovery of livelihoods of beneficiaries in Maungdaw and Buthidaung Townships. Impact (what has been achieved so far?) : This project was one of the food security and livelihoods department initiatives to move thousands of critically food insecure people in NRS areas from cyclical vulnerability into a more secure livelihood by smoothing consumption requirements, protecting, and to some extent, building assets through livelihood diversification. The project succeeded to move part of the population from passively received handouts to active involvement through self-reliance. 3 vocational trainings were developed and conducted for 528 beneficiaries/participants 6 FPA training courses were implemented for 917 beneficiaries/participants 1507 IGA kits for IGA were provided for 1839 beneficiaries/participants 767 agricultural kits for FPA were provided for 767 beneficiaries/participants 6 seed fairs were organized for 1,699 individuals participants.

Abstract: Launched in May 2009, the proposed project seeks to improve the livelihoods of marginalized and vulnerable uprooted groups in Rakhine State by reinforcing specific capital assets linked to ACF's intervention capacity. In order to evaluate the impact of the intervention on households, ACF used the sustainable livelihoods framework (SLF) for presentation and further analysis of the pro©ACF International /// Newsletter N°16 /// April 2013 19

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Voices from the field Smallholder’s experience in Ka Gya Bet Kan Pyin Village, Buthidaung centre / Township. Sahara Katu and Saynuwara are two motivated farmers, who were involved in the project since 2010 and succeeded cultivating three cropping seasons so far. Getting started was hard for us, but we are passionate about homestead garden, said Sahara & Saynuwara.

Brief success story of Sahara Katu

Seed saving mixed with ash

During this summer season I harvested 300 kg of chili. I can sell chili for 2000 MMK-kyat/kg. Vegetables also help me because they allowed me to eat well and I can sell any surplus. By selling at harvest I’m able to save. The extra money has allowed me to buy a goat for about 20,000 MMK-kyat.

I’m proud to be part of ACF’s intervention in my village. I own two distinct plots of land of approximately 0, 25 ha inherited from my family and farm them. This plot of land was not cultivated before because I did not know to cultivate. Since I started receiving support from ACF I have learned lot of useful farming methods and met lots of people in the same situation as me. Before the programme, I was not able to plant. Now I have learnt about gardening techniques, row planting, natural pesticide making, water management, seeds saving & storage in the bottle with ash and using manure on my fields. Also, I learned how to take advantage of local material that I’m able to find in my yard or surrounding area. This means I’m able to get a much better yield. I received tools/equipment such as a watering can from ACF that allowed me with the support of my family members to water my field and to extend my plot and I can grow so much more now. I grow a variety of vegetables like okra, maize, long bean, red bean, eggplant and chili as cash crops.

Goat bought by Sahara

I can afford to buy other goods and improve my livelihood. ACF helped other people in my village in the same situation as me. We are able to help each other and discuss things. Through this group we’re able to discuss and overcome our fears and start working again. With my experience, I am a respected member of the community and people consider me as a lead farmer in our village. I’m happy in providing them support at any time. Now all villagers are interested in learning. I have a lot of projects for the future. I’m planning to diversify my livelihood by breeding goats and to buy cattle. Being part of this project makes a big difference and has really helped increase the amount I’m able to grow and I can buy almost everything I need in my life. 20

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Brief success story of Saynuwara
Saynuware belongs to a minority ethnicity and is extremely poor, with a very small landholding of 200 m 2. However, the overarching challenge remains a lack of manpower due to lack of active family members.

Saynuwara with her daughter in their plot

I was just looking for a way to survive and feed my family. Before I joined the project, I did not have any knowledge of homestead gardening. Since I’ve been selected by the project, I took the chance to learn a lot. The project gave me training on good agricultural practices and sustainable agriculture. I learned about pest and disease management, water management, natural pesticide making, compost making, and seed saving in a bottle mixed with ash. Through this project I can access fresh vegetables and year round availability of food is guaranteed. Now I grow a variety of vegetables such as, okra, chili, corn, beans and sweet potato. Life is better now and I can save money. I plan to set up poultry and to manage the resource and money that I have well in order to keep my daughter healthy. Homestead gardening is a good investment providing a source of income and savings for my household. The homestead garden is considered like a bank account to cover my needs. Because of good produce I have something to sell, meaning, I can harvest any time and sell to earn money either to reimburse debt or to contribute in any ceremony organized within the community. I no longer work for others. My life has changed economically, now I can see others who are in the same situation as me or even worse. I feel supported and confident.

Vegetables also really help me because they allow me to eat well and I can sell any surplus. These days from the 200kg of chili harvested, I can sell 1 kg for 2000 MMK. The income earned helps me to rehabilitate my house and diversify my livelihood. Homestead gardening became a part of my life. ————————————In the village where women don’t normally consider themselves as farmers, Sahara and Saynuwara are role models for other women. ACF’s intervention developed their sense of ownership and encouraged them to cultivate their field. Today Sahara and Saynuwara and other women of the village plough their land on their own. These women are aware of their rights as farmers; they are respected members of the community and make all the decisions related to their agricultural land. They are now lead farmers within the community. Apart from growing vegetables for the household consumption, Sahara and Saynuwara are now using part of their land to cultivate cash crops and generate revenue. Sahara also teaches other women to plough their fields and is proud of the difference it is making in their lives. The project “Supporting the sustainable recovery of livelihoods through Water and Sanitation-Hygiene (WASH), Food Security (FS) and Care Practices programs in Northern Rakhine State” allows farmers from selected township to take care of their family and their land. So they do not rely at all on external inputs (all inputs come from within the farm). 21

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

ZOOM ON A PROJECT VIII

Afghanistan: Ensuring Nutrition through Food Security Initiatives
Isabel Navarro—FSL Operations (fsoperation@af.missions-acf.org) Manager, Afghanistan

As 70-year-old Zainab Sheraf starts to prepare for her family’s lunch, she goes to their small home garden and collects fresh vegetables of tomatoes, leeks, red radishes, pumpkin, and cauliflowers. She carefully washes them and plans to make a salad, and pumpkin and cauliflower soup to go with the wheat bread her daughter-inlaw, Mahbooba, made earlier in the morning. As the two ladies started cutting the vegetables, she cheerfully narrates how it was different from what they used to prepare for lunch last season. “We never had fresh vegetables before. The nearest bazaar is 2 hours by donkey and my son who does the marketing once a month, only purchases potatoes, onions, and one small can of tomato paste. This is only what we can afford. There are hardly any vegetables in the bazaar and most are almost rotten anyway.” A typical Afghan meal only consists of wheat bread, potatoes, tea, and occasional yogurt eaten twice daily. Livelihoods in Afghanistan are highly dependent on subsistence-level agriculture, very low off-farm income and seasonal migration. The recurring natural disasters, droughts and floods, over the last 5 years have exhausted community traditional coping mechanisms, resulting in a population more vulnerable to extreme poverty and severe food insecurity. Some 7.3 million people (31% of the total estimated population of 26 million) are food insecure with another 5.4 million people (23%) vulnerable to food insecurity. Compared with the National Risk and Vulnerability Assessment of 2005, the food security situation (NRVA 2007/08) has deteriorated in 25 of the 34 provinces. Malnutrition is extremely high in Afghanistan, with chronic malnutrition at 59.3% and underweight at 32.9%. Afghanistan has also a high prevalence of micronutrient deficiencies, especially iodine and iron, caused by insufficient diet, often the result of poverty and lack of knowledge. Zainab Sheraf’s family is one of the 5,200 household recipients in 20 villages of an early recovery program (Promotion of Women’s Education and Protection of Fragile Livelihoods in Samangan Province, Afghanistan), funded by the Swedish International Development Agency (SIDA). The program focus on the prevention of further deterioration of food and nutrition security through social transfers and livelihood protection through (1) Nutrition and Hygiene Promotion, (2) Home Gardening, and (2) Cash for Work in rehabilitating community assets. The main challenge during the initial stages of program implementation was to convince communities of the ©ACF International /// Newsletter N°16 /// April 2013 22

benefits of diet diversity when they rarely have access to vegetables and no prior experience in on how to plant them. Collaboration between ACF Food Security, WASH, and Nutrition departments began the identification of key messages integrating a holistic approach that were easy to understand and put into practice by the communities. ACF prepared 8 community-level nutrition and hygiene promotion sessions in which Mahbooba, together with other women beneficiaries in her community actively participated. To support in reinforcing the sessions in their households, the women were provided with basic hygiene kits and IEC posters. The husbands of the women including Zainab’s son, Mohammad, also participated in 8 homegardening sessions and supported with home-gardening kits containing vegetable seeds and garden tools. As the country experiences recurring droughts and dry spells, ACF encouraged the farmers to establish the home gardens close to their kitchen or water wells for easy irrigation, and efficient use of run-off and waste water. To provide a direct link between nutrition and food security, ACF conducts participative cooking demonstrations in the sessions with the women using the vegetable harvest of their husbands as primary ingredients. A festive community

Mohammad and his harvest of squash

Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

/// CONTINUED
sharing of meal ends each session. “At first, I was hesitant to get involved in home gardening. I have never done it before and I thought vegetables would never survive in our climate. But I was wrong. When we started seeing the plants grow, I was really happy. It was not as difficult as I thought it was,” recounts Mohammad. “My favorite is cauliflower and the new recipes that my wife learned through the cooking demonstrations make me proud seeing my family eating better now. We even share some of our vegetable harvest with our neighbors which we haven’t done before.” Mahbooba, while clutching her 5-month old baby said, “I used to feed my baby with bread soaked in tea but ACF taught me my own milk is good enough as my baby is too young for solid food. I learned too that I must eat nutritious food to make me healthy and I observed after eating vegetables since my husband started harvesting the vegetables for two months now, I am producing more milk than before.” Just before completing preparing for lunch, Zainab gently removed some seeds from the tomatoes and pumpkin, “we have to save the seeds for the next planting cycle, we live far from the bazaars and these seeds will continuously give us the vegetables we need.” In the next room, Mohammad proudly showed his harvest of squash, onions, carrots, and turnips all stored and ready as food stock for the coming winter. “I never imagined this abundance coming from our little home garden. I don’t worry about the winter anymore. I am thankful to Allah and the people who made all this happen. Tashakor,” Mohammad uttered, beaming with pride and a huge smile on his face. Positive Change As of December 2012, Samangan Province was classified as Phase 1¹ in Integrated Food Security Phase Classification. Food consumption and nutritional status are estimated to have considerably improved for the households who averaged below the 2,100 kcal per day in 2012. In disaster-affected areas, despite the significant effect on livelihood assets and strategies, abundant and timely humanitarian assistance contributed highly in reducing population vulnerabilities. The positive change for the 5,200 families in Samangan is proof that despite their vulnerable conditions, hoe is within reach for the Afghan people.

Zainab feeding her 3-year old grandson

¹Phase 1 means more than four in five households are able to meet essential food and non-food needs without engaging in atypical, unsustainable strategies to access food and income, including any reliance on humanitarian assistance

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RESEARCH AND TECHNICAL DEVELOPMENT
HQ RESEARCH PROJECTS

Project on Cost Effectiveness Analyses
First year update (end of first phase by April 2013 – to be continued until 2015) In 2012 ACF initiated a cost-effectiveness research project, focusing for now on two recent researches conducted on Food Security & Livelihoods and Nutrition programmes. In 2012 the research protocol was defined to analyze costeffectiveness of two recent research projects in Chad and Zimbabwe. These analyses took a societal perspective, including estimates of time and money spent by beneficiaries to participate in the interventions. Currently we are preparing a cost-effectiveness guideline document including tools to illustrate the basic methodology of cost-effectiveness analysis. In the next phase, in 2013, we will develop tools to assess cost-effectiveness of an ongoing CMAM program. Documents produced in 2012 include: Technical note on what is Cost Effectiveness + information on the current project; Technical Note on what is Value for Money; Presentation on cost effectiveness principles and methods; Two final reports on Chad and Zimbabwe Cost Effectiveness Analyses; Summary of findings on these two reports; Side event presentation on notions of cost-effectiveness to both Nutrition and Food Security staff at the Annual Workshop.
For further details, please contact: Chloe Puett—Cost Effectiveness Research Officer (cpuett@actionagainsthunger.org) Cécile Salpéteur—Nutrition Research Advisor, ACF-France (csalpeteur@actioncontrelafaim.org)

NIAP—Nutritional Impact Assessment Project (provisional name)
In our strategy to maximize the nutritional impact of our interventions, being able to better assess, understand and measure this impact is critical. In addition to the importance to grasp expected positive impacts, we also need, at the very minimum, to make sure we do not negatively affect nutrition situations in our areas of intervention (Do No Harm). Yet, because causality of undernutrition is complex, indirect and intertwined, understanding pathways through which an intervention has or not an effect on undernutrition is not an easy task, and can show to be very resource consuming. Recently developed FSL M&E Guidelines constitute an important step in this direction, with providing clear and practical guidance on methodologies and highlighting core standard indicators to be systematically monitored. As an add on to this manual, a new research project is being initiated to identify and pilot approaches and methods to be implemented by project management teams to enhance the monitoring of nutritional effects, building on available skills and resources. This multi-year project will involve external scientific and technical partners to be identified, and a pilot phase on a set of ACF nutrition-sensitive interventions.
For further details, please contact: Julien Morel —Senior Food Assistance and Policy Advisor, ACF-France (jmorel@actioncontrelafaim.org)

Project on Nutrition Causal Analysis
A Nutrition Causal Analysis (NCA) based on a new draft protocol was finalized recently in Burkina Faso in the Tapoa province (East). Results show that access to water, spacing between births and economic security of women were major determinants of undernutrition. Two new components of the methodology were a key to success: The strong qualitative component of the new methodology. To reach a consensus, a group of technical experts express through a vote their confidence in the results provided. It was the final test for the new methodology and proved to be responding to our objectives. Guidelines will now be written and published by June-July 2013.
For further details, please contact: Julien Chalimbaud—NCA Coordinator, ACF-France (nca@actioncontrelafaim.org) Theodore Kabore—Country Director, Burkina Faso (cdmadj@bf.missions-acf.org)

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FIELD RESEARCH PROJECTS

Market Gardens vs. Health Gardens
Health Gardens (HGs) are not just a rebranding of market or kitchen gardens, a traditional form of intervention for SAME/FSL. This type of project builds on ACF's expertise in Nutrition, FSL and WaSH rather than taking a sector-bysector approach. Approach and objectives of the health gardens HGs are multisectoral activities that focus on providing nutritional education and improving food diversity. They represent a long-term effort in the fight against malnutrition and improve food security of households and communities by: Creating vegetable gardens; these help feed families and generate income through sales at markets; Providing nutritional education; nutrition, health care practices, breastfeeding and sanitation. Using HG products and other local food. The concept of food security is evolving HGs are in line with the growing interest of major donors and recent international efforts to place maternal and child nutrition higher up on political agendas (e.g. the Scaling Up Nutrition and REACH initiatives). Key steps in creating health gardens Design HGs help target groups identify the causes of food insecurity and find solutions. To ensure their sustainability, HGs must rely on local capacities. Targeting HGs should target vulnerable groups in areas where the malnutrition rate is particularly high. These groups generally consist of: Households with little or no access to soil; Households that spend most of their income on food; Single women heads of households; Households with a member suffering from chronic illness; Households in disaster-prone areas; Displaced, refugee or socially marginalized households. In practice, women are usually the direct beneficiaries of HGs, because they play a leading role in household food security, health and nutrition. To effectively guard against food insecurity, HGs should also target women of childbearing age. Depending on the type of target beneficiary, HGs may be created at the community level, in Health Centers, schools and/or within collective plots. Project follow-up At minimum, each project must be accompanied by a baseline and final survey (in addition to assessments that take place over the course of the project) in order to measure its impact. Changes in behaviors and practices may also be evaluated through KAP surveys carried out before and after the intervention. Conclusion Changing nutritional status takes time. It is not easy to transition from market gardens to health gardens, because the concepts are different. HGs are a good example of how ACF can effectively combine its areas of expertise and, with the addition of a DRM component, help build the resilience of targeted households.
For further details, please contact: Alexandre Gachoud —Deputy Programme Coordinator, Dakar (agachoud@wa.acfspain.org)

Key actions of health gardens

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FIELD RESEARCH PROJECTS /// CONTINUED

Economic Impact on Anemia in Peru
Anaemia is the most widespread dietary deficiency in the world, affecting close to two billion people or one-third of the world’s population. In Peru, the disorder is an especially serious public health problem as more than 50% of preschool children, 42% of pregnant women and 40% of non-pregnant women of reproductive age are affected. The main cause of anaemia is iron deficiency, although it generally exists alongside other causes such as malaria, parasitic infections or malnutrition. Anaemia is a threat to individual health as its after-effects can last a lifetime; it can be a contributing factor to disability, or even death, and a risk factor associated with infant mortality, maternal mortality, prenatal mortality and low birth weight. It is also the cause of reduced productivity and cognitive impairment. The aim of this study is to identify, estimate and explain the economic costs for the Peruvian state and economy caused by the current prevalence of iron-deficiency anaemia. The calculation takes into account the influence of anaemia on personal development and productivity in order to measure the importance of the condition in relation to production and the cost that anaemia generates for the Peruvian state. The main methodology used in this study is based on the one developed by Jay Ross & Susan Horton (1998) as part of The Micronutrient Initiative. The results of the study show that anaemia costs the Peruvian society approximately S/. 2.777 billion (which is about four times what the state pays for premature delivery care, i.e. S/. 632 million) and that the cost incurred for treating anaemia would come to S/. 22 million. In contrast, the study finds that the cost of preventing anaemia would represent only about 2.8% of the total cost that anaemia generates for the state. The study concludes anaemia is a major economic burden for the Peruvian economy, given that the condition causes the country to lose 0.62% of GDP (as the most conservative estimate).
For further details, please contact: Elena Rivero —Senior Nutrition Advisor, ACF-Spain (erivero@achesp.org)

MAM’Out Research Project Update
The MAM’Out research project aims at assessing a context-adapted preventive approach, not based primarily on food supplementation, in order to prevent undernutrition and more specifically acute malnutrition in children under 2 year old. The objective is to evaluate a seasonal and multi-annual cash transfer program in the framework of a safety net, in terms of effectiveness and cost-effectiveness in the Tapoa province (East region of Burkina Faso, Africa). The program will be targeted to economically vulnerable households with children less than 1 year old at the time of inclusion and the cash distributed to mothers. This study will be designed as a two-arm cluster randomized intervention trial, based on randomization of rural villages of the Tapoa province. One arm will receive the intervention and one will be a control arm. The beginning of the operational activities and measurements are forecasted for May 2013, after the project’s submission and acceptance by the Burkinabe ethics committee. Cash will be transferred via mobile phones from May to September and during two years to around 1000 families. The final results are expected for the end of 2015 / first semester of 2016. This project is led by ACF – France, in collaboration with Gent University (Belgium), AgroParisTech (France), Center for Disease Control (USA) and Institut de Recherche en Sciences de la Santé (Burkina Faso).
For further details, please contact: Audrey Papucci —MAM’Out Project Research Officer, ACF-France (apapucci@actioncontrelafaim.org)

Anthropometric Indicators Review
The existence of an impressive discrepancy between the two anthropometric indicators which are currently used to identify acutely malnourished children, namely low MUAC and low WHZ, and the doubts regarding their reliability for the identification of the children who will benefit the most from the actual CMAM programs, are growing matters of concern at a time where low MUAC, by far the most practical tool available, is advocated by many as the unique anthropometric criteria to be used for CMAM. We have recently investigated these issues through the analysis of nutrition surveys and nutrition rehabilitation program datasets, and are currently planning further investigations to move forward.
For further details, please contact: Benjamin Guesdon —Nutrition Research Advisor, ACF-France (bguesdon@actioncontrelafaim.org)

Project on Nutrition and Food Security Impact of Low Input Gardens for HIV-affected Communities in Zimbabwe
Results were presented in 3 conferences and a scientific article is under preparation: ICASA - HIV in Africa - Addis Ababa, December 2011 Food & Nutrition Security (FNS) - Italy, January 2012 World Public Health Nutrition (WPHN) - Brazil, April 2012 Brochure to be disseminate for humanitarian practitioners.
For further details, please contact: Cécile Salpéteur —Nutrition Research Advisor, ACF– France (csalpeteur@actioncontrelafaim.org); Julien Morel—Senior Food Assistance and Policy Advisor, ACFFrance (jmorel@actioncontrelafaim.org)

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DEVELOPMENT OF GUIDANCE, TOOLS, CASE STUDIES AND MANUALS

ACF Case Studies: Aligning Food Security & Livelihoods with Nutrition
Three Case Studies based on ACF innovative nutritionsensitive Food Security interventions have been finalised and disseminated end of 2012. Highlighting main project aspects, achieved results and lessons learnt of interventions implemented in Myanmar, Mali and Haiti, they are available in English and French: Myanmar – SUSTAIN : A Nutrition sensitive Food Security Intervention

Cost of Diet Tool: Training and Piloting
Elena Rivero, Joaquin Cadario and Julien Morel attended in December, a short introductory training on the Cost of Diet Tool (a method of estimating the amount and combination of local foods that are needed to provide a typical family with a diet that meets their average needs in energy, protein, fat and micronutrients) recently developed by Save the Children UK. The training provided participants with an overview of the tool to demonstrate why and how it can be used to complement nutrition-sensitive assessment and surveillance. The training was very useful to gain better understanding of the tool, its objectives, rational, pre-requisites and constraints, in order for ACF to develop a strategy for testing it. The next steps for ACF are indeed to field test the methodology and tool in a couple of countries in order to assess its feasibility, possible constraints and resources required but also potential for strengthening our response analysis.
For further details, please contact: Julien Morel —Senior Food Assistance and Policy Advisor, ACF-France (jmorel@actioncontrelafaim.org)

Mali – Health Gardens, a nutrition centred approach

Haiti – Fresh Food Vouchers to strengthen diet diversification and improve resilience To be used internally as well as externally, these 8-page documents have been developed to raise awareness and share good practices related to nutrition-sensitive FSL interventions. Based on recent ACF interventions in different countries and contexts, they show how FSL interventions can contribute to better nutrition, using a nutrition lens at different steps of the project cycle.
For further details, please contact: Julien Morel —Senior FSL Advisor, ACF-France (jmorel@actioncontrelafaim.org)

ACF Food Assistance Manual Update
In the course of 2012, extensive work has been carried out to fully revise the previous ACF Food Aid Manual, with the support of a range of ACF experts, in the field and at HQs. Highlighting the strong linkages food assistance has with nutrition, but also with longer term recovery, the manual encompasses all types of food assistance interventions such as general or targeted in-kind food distributions, blanket supplementary feeding, cash and voucher transfers, and food related as well as non-food items transfers. Initially planned to be released at the end of 2012, the document has faced some delays in its finalisation, but should be available by the end of March this year.
For further details, please contact: Julien Morel —Senior Food Assistance and Policy Advisor, ACF-France (jmorel@actioncontrelafaim.org)

The Essential—Nutrition & Health
This document is intended to help better understand the issues and technical progress made in nutrition and health in order to clarify ACF’s positioning. It is intended for all stakeholders in the field and headquarters, regardless of their level of expertise in this field. The manual is composed of 19 technical fact sheets, each addressing a specific topic related to nutrition and health. It is advised to use this tool as a reference point for issues we want to further pursue. It should not be seen as a piece of literature to read from beginning to end, in one sitting. This manual is to be used during trainings and briefings.
For further details, please contact: Anne-Dominique Israel— Senior Nutrition Advisor, ACF-France (adisrael@actioncontrelafaim.org)

Ethno-Nutrition Briefing Paper Update
A briefing paper on Ethno-nutrition has been produced in English and French last October. This paper intends to define and clarify the importance of wild foods in the diet of population and their potential in the frame of nutrition prevention. It is available on the FSL Library 2013 that will be soon released.
For further details, please contact: Helene Deret —Senior FSL Advisor, ACF-France (hderet@actioncontrelafaim.org).

IPC v.2 Manuals

There are now IPC Manuals available for missions in the New York, Paris, Madrid and Nairobi offices. Please contact and request them from your counterpart in each of your respective offices in order to receive one. ©ACF International /// Newsletter N°16 /// April 2013 27

Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

WHAT HAPPENED?
Publications, surveys, reports, meetings, fora...
Mapping of Initiatives for Nutrition Sensitive Policies To get to know more what is going on in the field of nutrition-sensitive policies, an important area for our advocacy on the prevention of under-nutrition through multi-sectoral programming, ACF-France has recruited a consultant in late 2012 to support our advocacy strategy on nutrition sensitive policies and interventions. First, his work has consisted in doing an inventory of the on-going initiatives and existing guidance from international organisations, research, NGOs, etc., around nutrition sensitive policies in 5 key sectors for the prevention of undernutrition (agriculture, WaSH, social protection, education, gender). It has allowed us to identify more precisely stakeholders’ needs in terms of guidance regarding the concrete implementation of a multi-sectoral approach. Interviews of ACF key staffs and external partners (SUN, REACH, country focal points…) have been carried out to complete the analysis.
For further details, please contact: Etienne du Vachat —FSL Advocacy Officer, ACF-France (eduvachat@actioncontrelafaim.org)

PUBLICATIONS
Scientific publication Scientific publication on ACF operational research project of Prevention of Acute Malnutrition in Chad in PLoS Medicine journal : “The Effect of Adding Ready-to-Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster-Randomized Controlled Trial” – available on ACF website http:// www.actioncontrelafaim.org/fr/recherche-tchad and at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371% 2Fjournal.pmed.1001313
For further details, please contact: Cécile Salpéteur—Nutrition Research Advisor, ACF-France (csalpeteur@actioncontrelafaim.org)

ENN Field Exchange publication The impact of a cross sectoral approach to addressing konzo in DRC, by a number of ACF authors, is featured in the latest Field Exchange publication. The article summarizes the results of the impact study of a 22 month EU-funded integrated project in the Bandundu province of DRC addressing underlying causes of konzo, a neurological ailment triggered by long term dietary exposure to the cyanide in improperly processed cassava (manioc). The field article will be available online: http://fex.ennonline.net/issues.aspx. The full study report in French language can be downloaded from the ACFUSA website.
For further details, please contact: Muriel Calo —Senior FSL Advisor, ACF-USA (mcalo@actionagainsthunger.org)

FAO Synthesis AG-Nut In 2012, the FAO commissioned a review to identify commonly agreed Guiding Principles for Linking Agriculture and Nutrition, with the purpose to provide an accessible digest of recommendations on the topic, and to illuminate points of emerging consensus. The review included ACF Maximising the Nutritional Impacts of FSL interventions manual, and showed there was “a striking amount of convergence on overarching principles for how to plan, design, and support nutrition-sensitive agricultural programming”. The recommendations in the guidance notes have been synthesized into a list of 20 main messages, broadly fitting into three categories: planning a program or policy, main program activities, and a supporting set of factors based on governance, policy, and capacity. Although very much in line with the ACF Manual, the report provides interesting complementary highlights.
It can be accessed here: http://www.fao.org/fileadmin/user_upload/wa_workshop/docs/Synthesis_of_AgNutr_Guidance_FAO_IssuePaper_Draft.pdf The 20 main messages are summarized in the following 2-page brief: http://www.fao.org/fsnforum/post2015/sites/post2015/files/ resources/Brochure_AgNut_GuidingPrinciples.pdf

Institute for Development Studies Publication ACF USA has submitted an article for the IDS bulletin that shares results from the first phase of a Nutritional Causal Analysis (NCA) conducted in Thatta and Dadu districts in 2012. Based on a methodology developed by ACF International and Tufts University, ACF conducted this NCA due to critical results indicating very high levels of wasting (ie. prevalence of GAM was 17.8% while the prevalence of SAM was 3.2%) and in order to better understand the determinants of undernutrition in Sindh, to further breakdown pathways leading to these high rates of acute malnutrition, and to design appropriate and relevant nutrition-sensitive interventions and advocacy strategies.
For more information, please visit: http://www.ids.ac.uk/

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/// CONTINUED
Publications, surveys, reports, meetings, fora...
MEETINGS
SUN Initiative Representatives from ACF-IN attended different meetings around the SUN Initiative (Sept 25 -28) including: Briefing of SUN Country Focal Points by SUN Secretariat (Sandra) Save the Children & WVI launching of the Nutrition Barometer (Sandra, Nan, Serge, Maureen) 100 Years of Vitamin events hosted by DSM (Sandra) SUN High level Event (Sandra & Serge) SUN Civil Society meeting (Sandra/Maureen/Nan) During the meetings we were able to share copies of the Aid for Nutrition Report 1&2 as well as the Under the SUN report on Niger & Bangladesh. Global Conference on Agricultural Research for Development (GCARD) Bader Mahaman (Senior Agricultural Advisor) and Myriam AIT-AISSA (Senior Research Advisor) attended the Global Conference on Agricultural Research for Development (GCARD), on October 27 th to November 2nd in Punta del Este, Uruguay. This global conference gathered relevant international, regional, local stakeholders involved in Agricultural Research for Development – from the CGIAR, formerly the Consultative Group on International Agricultural Research (IFPRI, ILRI, Bioversity, etc.), to civil society organisations, NGOs and donors. ACF contributed actively in the “Household Nutrition Security” session, presenting to stakeholders, ACF’s approach, definition and some concrete actions in the Nutrition Security field (health gardens Mali, SUSTAIN in Myanmar). The contribution was appreciated. The main outputs on Nutrition Security from participants of the conference were: 1. The identification of relevant platforms/networks on Agriculture-Health-Nutrition, including the “Agriculture for Nutrition and Health”, led by IFRPI: http://www.ifpri.org/book-8125/ourwork/division/agriculture-improved-nutrition-and-health-crp4 2. The necessity/relevance to keep on promoting ACF’s “Nutrition Security” definition and approach - We identified from the ‘Household Nutrition Security” session the necessity to keep on promoting our definition of Nutrition Security, based on the conceptual framework of malnutrition (cf Black, Lancet 2008), as different stakeholders might have their own definition of Nutrition Security. In particular, the relevance of highlighting care practices and water, sanitation and hygiene needs in the Nutrition Security approach were not always put enough emphasis on. 3. The necessity to implement evidence-based research/studies in the field in order to evaluate the impact of interventions on Nutrition. ACF is currently developing a research project to enhance production of evidence on the nutritional impact of our interventions.
For further details, please contact: Bader Mahaman—Senior Agricultural Advisor, ACF-France (bmaham@actioncontrelafaim.org); Myriam Ait-Aissa—Senior Research Advisor, ACF-France (maa@actioncontrelafaim.org) More information on the conference: http://www.egfar.org/gcard-2012 More information on the CGIAR: http://www.cgiar.org/

2012 WFP-NGO annual consultation highlights On October 29th and 30th, ACF-F Executive Director participated on behalf of ACF International in the WFP-NGO annual consultation in Rome and co-led with World Vision the development of a discussion paper on NGO-WFP partnerships in Emergency preparedness and response. The paper called for Rethinking “Partnership” to enhance each other’s added value; Assuming partnership’s full scope, especially at national level ; Enhancing response analysis and strategy building ; and Improving pipeline and stocks management. The main message conveyed was the will of NGOs not to be considered solely as “implementing partners”, but to be involved at early stages of programme strategies building and project design. Following the meeting, and based on recommendations from the participants, WFP committed to an action plan with immediate steps to improve collaboration, not only at headquarter level, but also and more importantly at national and field level. The action plan calls for a “greater consultation with partners to establish and ensure a more open and robust engagement in programme design where we can work together through each step of developing WFP programmes”. ©ACF International /// Newsletter N°16 /// April 2013 29

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/// CONTINUED
Publications, surveys, reports, meetings, fora...
For further details, please contact: Julien Morel—Senior Food Assistance and Policy Advisor, ACF-France (jmorel@actioncontrelafaim.org)

ACF-USA attended the Food Security and Nutrition (FSN) Network regional knowledge sharing meeting in Washington DC (12th -15th Nov, 2012). The USAID Technical and Operational Support Program (TOPS)-funded FSN Network organized its semi-annual knowledge sharing meetings in November 2012 in Washington DC. ACF-US attended to the 3-day meeting together with many implementing partners among them: Save the Children, CARE, Mercy corps, CRS, World Vision, and more. The workshop focused on resilience, and on agriculture-nutrition linkages for improved food security and nutrition outcomes.
For presentations, handouts and other resources from FSN Network: http://www.fsnnetwork.org/document/resilience-action-improvingfood-security-and-nutrition-outcomes-fourth-fsn-network-regiona

Global Research Agenda for Nutrition Science ACF-USA and ACF-France attended the Global Research Agenda for Nutrition Science meeting in New York (17th 18th Dec, 2012). The Sackler Institute for Nutrition Science at the New York Academy of Sciences organized in 2012 a consultation with a broad range of interdisciplinary stakeholders including WHO, researchers, policy makers, and NGOs to identify critical research gaps and to define a global research agenda for nutrition science. The results of this consultation was presented during this conference and this research agenda is meant to trigger dynamic collaborations among research institutions and implementing agencies and explore how to best translate this agenda into effective action to improve human nutrition worldwide.
Meeting materials, speeches and presentations are available: http://www.nyas.org/Publications/Ebriefings/Detail.aspx?cid=38eb8a81ed18-49f4-b9d1-0a5d887e712c

WORKSHOPS & FORUMS
SMART Master Trainers’ Workshop The SMART Team at ACF-Canada undertook the first ever SMART Master Trainers' Workshop in Nairobi (January 2013) where individuals from various agencies were taught pedagogical skills on how to teach the SMART methodology in order to build institutional capacity in surveys on a more sustainable basis. A new user-friendly layout was launched for the SMART methodology website, including new videos and technical documents such as the Sampling Paper which explains comprehensively the sampling techniques and calculations used in SMART (www.smartmethodology.org). CMAM Forum The CMAM Forum was established in 2012 by a group of experts with the aim to provide a robust information-sharing mechanism that expands the knowledge base on acute malnutrition to improve health outcomes for vulnerable populations. It will build upon and link with existing initiatives. Specific objectives are: Facilitate information and resources sharing on the management of acute malnutrition/ Promote and support advocacy efforts on the management of acute malnutrition. CMAM Forum: http://www.cmamforum.org/

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

WHAT’S NEXT?
Publications, surveys, reports, meetings, fora...
Save the date ! UNICEF International Conference Against Child Undernutrition (Paris, 14-15 May 2013) The conference entitled “Bridging the nutrition security gap in Sub -Saharan Africa: a pathway to strengthen resilience and development” will bring together a wide array of par-ticipants, including Government representatives, civil society organizations, donors, agencies to share experiences and lessons learned and identify the most effective strategies. A month ahead from the G8, the conference aims to strengthen political will and address the challenge of securing long-term sustainable financing for proven nutrition interventions, including through innovative mechanisms. Training Initiative: Creating New Resources in Francophone Africa The first pilot of the “training initiative-creating new resources in francophone Africa” has been completed in January 2013. 12 students followed 9 weeks of theoretical training and 3 months practical training. A second training will start in June 2013. ACF International Learning Review 2012 The sophomore ACF International Learning Review 2012 will be published by April 2013. This will present an analysis of programme performance yielded from 30 programme evaluations in 2012, a features section drawing from evaluations and additional research and finally a selection of best practices identified through evaluations.
For the Learning Review 2011 visit the ACF-UK website.

Lancet Series In 2008, the Lancet published a series of publications on Maternal and Child Undernutrition (http://www.thelancet.com/ series/maternal-and-child-undernutrition), which strongly increased global awareness of undernutrition. Today, the Lancet plans to do a review of the progress made over the last 5 years. This will help assess the way forward, keeping the focus on low– to middle-income countries. As such, a new series on Maternal and Child undernutrition will be published by the Lancet in May 2013. It is expected that the publication of these new series will strengthen international and national pledge on undernutrition. ACF has taken part in this process. The new series will focus on the double burden of undernutrition and obesity. Goals created are evidence-based meant to focus on current and projected trends in maternal and child undernutrition and obesity; to understand the determinants of these nutritional conditions and trends; to articulate the relationships of nutrition – sensitive interventions (e.g. agricultural production, social protection, education to nutrition); to assess the current impact and potential effects of food and oil prices, international regulations and policies, climate change etc.); to prioritize possible nutritional interventions and policies to promote and support nutrition; and finally, to disseminate findings and recommendations. ACF sent grey literature and peer-reviewed papers to Marie Ruel (IFPRI), who coordinated the paper writing on nutritionsensitive programs and the evidence on their impact on undernutrition, and to Patrick Webb (Tufts University), who gathered information on nutrition in emergencies. Hopefully, these field data will help in identifying and shaping international and national priorities in the field of undernutrition in the near future. ACF is in contact with the scientists involved in writing these papers.
For further details, please contact: Myriam Ait Aissa—Senior Research Advisor, ACF-France (maa@actioncontrelafaim.org)

Contribution to the FAO SOFA 2013 report The FAO State of Food and Agriculture 2013 report, to be released later this year, will examine the linkages between food systems and human nutrition. ACF has had the opportunity to contribute to this important document by sharing some of its country experiences on the subject. Although the final version of the document is still being worked on, there are good chances that ACF’s work will be referred to. International Conference on Nutrition +21 Twenty-one years after the first International Conference on Nutrition (ICN) held in Rome 1992, the ICN+21 will be organized to review progress made, identify remaining challenges and opportunities for improving nutrition. The conference will take advantage of the increased international political attention to nutrition and ensure necessary support at all levels to develop a plan that contributes to the post-2015 UN development agenda. ACF will likely be attending.
For more information: http://www.fao.org/food/nutritional-policies-strategies/icn2/en/

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Issue N˚16 - April 2013 //// NUTRITION & FOOD SECURITY AND LIVELIHOODS ** FOR INTERNAL CIRCULATION ONLY **

WHAT CAN YOU FIND IN PREVIOUS NEWSLETTERS...?
Issue
#1

Sector
WASH

Release date
September 2008

HQ
Paris

Main articles
Caracoli en medio de la sed cuando se esta rodeado de agua - ACF Colombia Groundwater quantification in coastal area - ACF France

#2

FSL

October 2008

Madrid

Fuel efficient stoves or not? – when we are able to follow up our own recommendations - ACF Uganda Can the environment absorb our activities? The “acadjas”, a pilot fish production project on Lake Tanganyika - ACF RDC Integrated Nutrition and FS Surveillance in Malawi - ACF Malawi Projects including the concept of value chain - ACF Paraguay

#3

Nutrition

January 2009

Paris

Nutrition communautaire et sécurité alimentaire au Niger, les défis de l’intégration - ACF Niger What is Research? – ACF France Direct cash after the Post Election Violence in Kenya - ACF Kenya Direct cash project in Lira, Uganda – ACF Uganda

#4

FSL

June 2009

New York

#5

WASH

July 2009

Madrid

Sustainability factors for Water points in Liberia – ACF Liberia Light casing for rapid rehabilitation/construction open wells

#6

Nutrition

January 2010

New York

Integrated Nutrition and FSL activities in Southern Sudan – ACF Southern Sudan Projet de support nutritionnel et de sécurité alimentaire des Personnes Vivant avec le VIH - ACF RDC

#7

FSL

December 2009

Paris

Direct Cash transfer in Uganda: results & lessons learnt – ACF Uganda Partnership in program implementation: an experience of ACF in Barguna – ACF Bangladesh

#8

WASH

May 2010

New York

Hygiene promotion in emergencies: Capitalisation of ACF experiences in Nakuru and Molo IDP Camps, Kenya - ACF Kenya Groundwater research in Uganda - ACF Uganda Seed Fairs in Eastern DRC – ACF Congo Sentinel Sites in Central America –ACF Central America CFW: Food Processing Activity for Women in Palestine – ACF Palestine Réponse au séisme en Haïti : spécificités d’une réponse d’urgence en milieu urbain – ACF Haïti

#9

FSL

July 2010

Madrid

#10

Nutrition

September 2010

Madrid

Management at remote control in Gao – ACF Mali Integrated Approach –ACF Perú Bhami History – ACF India Climate change and malnutrition – ACF Int Piloting sanitation solutions for periurban UlaanBaatar – ACF Mongolia Emergency sanitation: where are we and what needs to be done? Inter-agency EMMA in Port-au-Prince – ACF Haiti Community paddy banks – ACF Myanmar Hunger Safety Nets – ACF Central America

#11 #12

WASH FSL

March 2011 April 2011

Paris New York

#13

Research

November 2011

Paris

Comparison of the efficacy of 3 nutritional products for MAM treatment - ACF Myanmar Addressing the underlying Causes of Acute Malnutrition Prevention of Acute Malnutrition among children 6-36 months – ACF Chad Addressing long term food security – ACF Indonesia Low Input Gardens – ACF Zimbabwe Tackling Banana Wilt Disease – ACF DRC Partnering in Emergency: Lessons from ACF response – ACF Pakistan Biofortification of potato crops – ACF Peru

#14

FSL

December 2011

Paris

#15

FSL

July 2012

Madrid

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