Hunegnaw Almaw ( BSc, MPH/Nutrition, Ass’t Professor)

Department of Nutrition and Dietetics

School of Public Health
College of Medicine and Health Sciences
Bahir Dar University
Email: hunsew25@gmail.com
Cell Phone: 09-12-80-22-59

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 EMERGENCY NUTRITION
INTERVENTION RESPONSES

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 Outlines

• Introduction
• Emergency nutrition intervention plan
• Intervention Mechanisms in Emergency food aid
response
• Sphere project standards for food aid, nutrition and food
security
• Nutritional content of General Food Distribution
• Livelihood interventions
• Monitoring and Evaluation of the main nutrition
interventions
4/2/2015 1/1/2024
3
 Objectives
At the end of the session, you will be able to:
 Describe the nutrition situation and recommended actions
 Plan intervention in Emergency food aid response
 Describe mechanisms to provide feeding for the community
during an emergency accordingly
 Discuss sphere project standards for food aid, nutrition and
food security
 Describe the nutritional content of General Food Distribution
 Design coping mechanisms and strategies for nutrition
intervention
 Discuss the monitoring and evaluating the adequacy of
emergency response
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 Introduction

 An effective nutrition response usually involves several

integrated interventions to maximize the impact
 There is no fixed blueprint for which interventions to employ
in nutrition emergencies, however it is useful to consider the
following:
 The severity of the situation
 The sub-groups of the population that are at greatest
nutritional risk.
 The community understanding of their situation and levels of
capacity.
 The cost and feasibility of possible responses

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Steps of nutrition response in emergency

Step 1: Coordination and information sharing

Step 2: Conduct rapid nutrition assessment
Step 3. Selecting appropriate emergency nutrition
responses
Step 4. Planning an emergency nutrition response

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 Emergency nutrition intervention plan

 Emergency nutrition intervention plan should be based on

the rapid nutritional assessment (RNA) result.
 The response intervention programs are required when the
assessment proves that population’s general nutritional
interventions being delivered at health care facilities are
unmet.
 With limited resources, emergency service planning must
be based on the best available information and priority
needs.

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Food and emergency nutrition response programs
should focus on the following aspects:
 Programs are designed to support and strengthen existing
systems (e.g. strengthening OTP and SC, TSF, GFD and PSNP
coordination mechanisms).
 Programs should be designed to reach hard to reach population
or affected communities (Eg. Organize mobile health and
nutrition team or mobile clinic).
 If the above programs are not available in place and the nature
of emergency is worsening, establish community based
therapeutic care (CTC) and food distribution.
 Programs should be designed to support stock management at
TFP, TSFP, PSNP and GFD at all levels all times

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 The program designed for food and
emergency nutrition intervention should
fulfil the following criteria:
 Programs should be designed to protect lives of people
and to promote livelihood.
 Programs are most effective when they are well
coordinated, with a good flow of information between
stakeholders (making gaps known).
 Programs must maximize positive impact and do not harm
(i.e. competition for scarce resources/increased resources,
misuse or misappropriation of supplies).
 Programs should ensure that humanitarian services are
provided equitably and impartially

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 Implementing Emergency Nutrition Interventions

In an emergency setting, emergency nutrition interventions are

programs set-up to:
 Integrated management of acute malnutrition (SAM and
MAM) as per the MoH protocol
 Provide other critical nutrition services (i.e. growth
monitoring, micronutrient supplementation, protection of
infant and young child feeding practices) and,
 Provide food to a population that does not have access to food
(both staple and nutrient-dense), while filling the nutrient gap
(not only kilocalories)
 Along with management of the underlying or aggravating
infectious diseases

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 Nutrition intervention in Emergency
11

 Feeding & supplementation programs in

emergencies

“Every man, woman and child has the inalienable

right to be free from hunger”
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 Nutrition intervention…
13
 There are two mechanisms through which food may be provided:
» General Food Distribution
» Selective Feeding Programmes.
• General Food Distribution provides a standard general ration to
the affected population with the aim to cover food and nutritional
needs
There are two forms of Selective Feeding Programmes:
Supplementary Feeding Programmes(SFPs)
» Blanket SFP
» Targeted SFP
Therapeutic Feeding Programmes
» Traditional TFC=Therapeutic feeding centers
» CTC=community based therapeutic care
 GENERAL FOOD DISTRIBUTION
 General food distribution (GFD) is when a food ration is
given out to selected households affected by an
emergency.
 The food ration will consist of a number of items (the
minimum three are cereal, pulses and oil, but items such
as salt, sugar, fresh vegetables, tinned meat or fish can be
added).
 The general ration is normally delivered as dry items

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 GENERAL FOOD DISTRIBUTION…

 GFD are frequently used to respond to a food security

crisis or when there are high levels of malnutrition and
mortality (death) in a population.
 The United Nations (UN) World Food Programme (WFP)
is the largest organisation responsible for GFD and over
the years has developed a wealth of programme
experience.
 The International Committee of the Red Cross (ICRC) is
another key organisation implementing GFD in areas
affected by conflict where WFP may not be present

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 What are the Sphere Standards for GFD?

Food aid planning standard 1: ration planning

 Rations for general food distributions are designed to bridge
the gap between the affected population’s requirements and
their own food resources
Food aid planning standard 2: appropriateness and
acceptability
 The food items provided are appropriate and acceptable to
recipients and can be used efficiently at the household level.
Food aid planning standard 3: food quality and safety
 Food distributed is of appropriate quality and is fit for
human consumption

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 What are the Sphere Standards for GFD?

Food aid management standard 1: food handling

 Food is stored, prepared and consumed in a safe and
appropriate manner at both household and community levels
Food aid management standard 2: supply chain
management
 Food aid resources (commodities and support funds) are
well managed, using transparent and responsive systems
Food aid management standard 3: distribution
 The method of food distribution is responsive, transparent,
equitable and appropriate to local conditions.

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 Intervention criteria for GFD

 GFDs are implemented when there are acute and severe

food shortages resulting in high mortality and
malnutrition rates.
 Severe food shortages may occur suddenly such as after
an earthquake or they may have a slow onset such as in
areas with protracted drought and conflict. Food security
information is used to help determine if GFD is an
appropriate intervention

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 Intervention criteria for GFD…

 Indicators of mortality and nutritional status are

sometimes used to help determine whether a GFD should
be implemented
 Mortality rates of more than 2 deaths/10,000/day for
children under five years and malnutrition rates greater
than 15 percent are considered a serious situation
 General ration distribution is recommended if Global
Acute malnutrition rate ≥15% OR 10–14% with
aggravating factors
=These indicators together with food security information
determine whether GFD is the most appropriate response

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 Objectives of GFD

 During acute food insecurity the objectives of GFD are

primarily to save lives and protect the nutritional status
of the population.
 As the food security situation improves, the aim of GFD
may be broadened to include the protection and
rehabilitation of livelihoods of the affected population

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 Key principles of GFD

The following key principles apply:

 GFD must meet minimum nutrition requirements.
 The food aid must be fit for human consumption, easily
digested and preferably familiar and acceptable to the
beneficiaries.
 The GFD system must be fair, transparent and
accountable at all levels to prevent abuse.
 Monitoring and reporting for the GFD must take place.
 The dignity and human rights of recipients must be
protected

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 Energy Requirement
 Fat and protein should provide at least 17 percent and 10-
12 percent respectively of the energy in a well-balanced
diet.
 The total amount of energy needed by different individuals
varies, depending on physical activity age, sex, body size,
and climate.
 Pulses have about twice as much protein as cereals
(approximately 22g of protein/100g of pulse compared
with 7-12 g of protein/100g for cereal) and are rich in the
B-complex vitamins and iron.
 The protein in pulses complements the protein in cereal
grains. Examples of pulses and oil seeds are beans,
groundnuts, soya beans, sesame, sunflower seeds, and
coconut.
 NUTRITIONAL CONTENT OF GFD
A well balanced ration should provide a suitable combination of
macro and micronutrients.
 Cereal grains: comprise the bulk of food aid delivered during a
GFD
 Legumes and oil seeds: are an important source of protein and
provide a range of micronutrients for those receiving the GFD
 Canned meat, fish and cheese and dried fish: are expensive and
rarely available in sufficient quantities to be used in GFD
 Vegetable oil distributed in a GFD must be fortified with
vitamin A and is therefore an excellent source of vitamin A
 Blended foods are a processed mixture of cereals and other
ingredients

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 NUTRITIONAL CONTENT OF GFD

 Emergency rations: are usually nutritionally

balanced, ready-to-eat complete foods
 Sugar: is sometimes included in the GFD and can play
an important role in the diet by improving palatability
and, particularly in the case of a child’s diet, energy
density
 Salt: improves palatability and, when iodized, serves a
crucial nutritional function. Levels between 20 to 40 mg
iodine/kg salt are recommended by the UN

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Source: ENN and SCUK (2004) Targeting Food Aid in Emergencies Special supplement
The basic food basket (General Food Ration) includes
the following:

 Culturally acceptable staple food

 A pulse or legume, which is a source of complementary
protein, such as lentils, beans, peas, or peanuts
(groundnuts);
 Red palm oil (a natural rich source of vitamin A), vitamin
A-fortified vegetable oil, such as groundnut, soya,
sunflower, or rapeseed oil;
 A fortified blended food
 Iodised salt.

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 Where possible, the food basket should also include locally available and
culturally acceptable foods, such as

 Fruits, vegetables, condiments/spices,

 Tea, and coffee, in order to add nutrients, taste, and variety to

basic foods, to increase the palatability, familiarity, and acceptability
of prepared foods and for the preparation of cultural/traditional
foods and dishes.

 Dried skim milk should not be part of the food basket and should
not be distributed to the population.

 The only safe use of dried skim milk is for therapeutic feeding
under strict supervision.

 Breast milk substitutes should be used only in very exceptional

circumstances and when provided as generic, non-brand formulas.
Micronutrient deficiency diseases in populations dependent
on GFD

 Iron

 Vitamin A

 Iodine

 Thiamine (vitamin B1

 Niacin (vitamin B3)

 Vitamin C:
 Prevention of MNDD during emergency
 Inclusion of fresh fruit and vegetables in the ration: Fresh food
items, which are micronutrient-rich, are purchased locally and
distributed as part of the general ration.
 However, transport and storage of fresh produce can be a major
challenge.
 Addition of a particular food aid commodity: A commodity that
has a relatively high micronutrient content is added or exchanged
for another commodity e.g. addition of groundnuts and other
pulses which contain relatively high amounts of niacin, to
populations who are heavily reliant on maize (which is low in
niacin).

 Provision of fortified foods: Food fortification is the process
when one or more micronutrients are added to food during
processing.
 RATION PLANNING FOR GFD
 An initial assessment will determine the following: selection criteria for
food aid recipients,
 Population entitled to receive food aid,
 Ration size and
 Length of time food aid is necessary.

 Once this has been agreed it is possible to calculate the food aid
requirements

 In emergency situations where people have no other food sources, the main
concern is to provide sufficient food to meet all energy requirements of
the recipient population.

 The initial calculation of food aid requirements should be made on the

basis of need and not the availability of resources.

narrow
 When resources are limited, it may be necessary to temporarily
the eligibility criteria while advocating for additional resources.
There are two stages for calculating food aid
requirements.
 Stage 1: establish the energy
requirements and
 Stage 2: select the quantity and type of
food commodities to be included in the
ration or „food basket‟.
 A full food ration, which assumes that the
affected population has no access to
alternative sources of food, should meet
all the nutrition and energy needs of
the recipient population.
 Energy Content of General Food Ration

 A full ration provides 2,100 kcals/person/day

(formerly the ration was 1,900 kcals and was increased in
1997 by the UN to better reflect nutritional
requirements).
 A daily food ration of 2,100 kcals assumes the
following:
 Standard population demographic distribution,
 average body size,
 a warm climate 20 °c,
 normal nutritional and health status and
 light physical activity.
 Energy Content of General Food
Ration…
 However, 2,100 kcals/person/day does not meet the
energy and nutrition needs of ‘special’ groups such as :
o pregnant and lactating women, *

o malnourished children, and

o people suffering from certain illnesses who have a

higher energy and nutrition requirement.
 These groups may need selective feeding programmes
such as therapeutic and supplementary programmes in
order to meet their nutrition and energy requirements
 The energy and nutrition content of the ration using locally
available foods can be optimized using NutVal Software
 Energy Content of General Food Ration…
 ICRC recommends a ratio of 2,400
kcals/person/day.
 This meets the average energy needs of a
population and covers the nutritional needs of
pregnant and lactating women, the effects of cold
climatic conditions, physical activity, catch-up
growth, and nutrient losses during transport,
storage and distribution.
 The strategy adopted by ICRC aims to minimize
the need for selective feeding programmes.
 Stage one: Estimation of energy requirements

Age and structure of the population:

 A population composed exclusively of women and
children will require approximately six per cent less
energy than a standard population.
 Where males constitute the total population the average
daily energy requirements would be increased by 6 per
cent

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 Estimation of energy requirements…

Nutrition and health status of the population:

 The health status of a population may affect the average
energy requirements.
 World Health Organization (WHO) guidelines
recommend a 10 per cent increase in energy to maintain
nutritional status and avoid weight loss of asymptomatic
individuals living with HIV, while those with AIDS
related illnesses require a minimum increase of between
20-30 per cent energy intake.
 HIV infected children who are experiencing weight loss
require as much as 50-100 per cent increase in energy
intake.

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 Estimation of energy requirements…

Physical activity levels:

 If the population is involved in more than light activity the
ration should be increased accordingly:
Moderate activity (e.g. walking short/medium distances)
 Adult males +360 kcals
 Adult females + 100 kcals
 Whole population (adults and children) + 140 kcals
For heavy activity such as agricultural labor, walking long
distances and carrying heavy loads:
 Adult males +850 kcals
 Adult females + 330 kcals
 Whole population (adults and children) + 350 kcals

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 Estimation of energy requirements…

 Environmental temperature: For every 5 ºC drop

below 20ºC, an additional 100 kcal/day/person should be
provided. For example:
 15ºC - + 100kcals
 10ºC - + 200kcals
 5ºC - + 300kcals
 0ºC - + 400kcals

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 Estimation of energy requirements…

 Access to alternative food sources:

 If the population has access to alternative food sources it may
be possible to reduce the average calorie requirements
 Provision of milled or unmilled cereal:
 When recipients of food aid mill cereal the volume of the
cereal is reduced by up to 20 per cent and therefore the
nutrient and energy content of the ration is also reduced.
 A whole grain ration should compensate for this loss as well as
for the additional milling costs.
 Compensation is normally in kind and between 15-20 per cent.

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Second Stage: Selection Of Food Commodities
The following should be considered when selecting the
commodities for the food basket.
 Nutritional and dietary considerations: When people are receiving partial
rations, the foods supplied in the ration must be nutritionally complementary to the foods
people obtain for themselves.
 Risk of MNDDs: The risk of MNDDs should be considered especially for populations
completely dependent on food rations.
 Acceptability and familiarity of the food items: Wherever possible, the
staple food should be acceptable and familiar to the recipients. Also, the relative amounts of
each commodity in the food basket should reflect population preferences
 Storage, quality control, and specifications:
 All foods distributed must be fit for human consumption and meet certain quality
specifications.
 Transport, storage, and handling of the food commodities must be carried out with
care and carefully monitored.
 Flour has poorer keeping qualities than whole grain and it is therefore better to
mill the grain as close in time and distance as is practical to the final distribution
point.
 Food processing and preparation: Food commodities
should be easy to prepare and quick to cook. The time it takes
to cook food is especially important in the early stages of an
acute emergency when fuel supplies may be scarce.

 Availability and substitution of food items

 Cost of the ration and its resale value

 Themost cost-effective ratio is based on a
combination of cereals, pulses and oil

 The inclusion of high-resale commodities in the

GFD allows beneficiaries to purchase other
essential food and non-food items - such as
fruits and vegetables - that are not otherwise
available in the diet
 Availability and Substitution of Food Items

 The selection and amount of food items in the food

basket are frequently determined by
availability.

 When certain food items are unavailable they can be

replaced with other items of similar
nutritional value.

 Ideally, substitution should be temporary and

recipients should be fully informed of the
change in food basket composition through the
public information systems.
Examples of food commodity substitutions
 Blended food and beans 1 to 1
 Sugar and oil 2 to 1
 Cereal and beans 2 to 1
 Cereal for oil (not oil for cereal*) 3 to 1
 *If, for example, no oil is available for inclusion in

the ration, either 100g sugar or 150g cereals could

substitute for 50g oil.
When there is insufficient food aid available to meet ration
requirements there are three options available:
 Postpone distribution until a full ration for the total
population is available.
 Distribute an equal share of available commodities to
all of the population (i.e. a reduced ration).

 Give a larger (or full) ration to the more vulnerable

groups within the target population and a smaller (or
no) ration to the less vulnerable groups within the target
population.

 Whichever option is adopted, recipients must be kept

fully informed of changes to the distribution schedule or
amounts and the reason for the change.
 Calculating food aid requirements

 Once the size and composition of the ration has been

agreed upon, food aid requirements can be calculated
 Based on the nutrient composition, the recommendation
for complete ration/full basket in Ethiopia is : 15 kg
cereal + 0.5 – 0.9 kg oil + 1.5 kg pulses per person
per month

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 Calculating food aid requirements…

 To assist planners with determining the proportions of the

food items for the ration the following can be used as a
rough guide when planning the food basket:
 Oil constitutes approximately 5-10 per cent of the weight of
the ration
 Pulses constitute approximately 15-20 per cent of the weight
of the ration
 Cereals constitute approximately 60-75 per cent of the
weight of the ration.
 If blended food is included in the ration it usually replaces a
proportion of the cereal and may contribute approximately
10-20% of the weight of the ration

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 Supplementary Feeding Program

 Supplementary feeding programmes (SFPs) have been a

standard component of emergency response for many
years.
 Its primary aim is to prevent individuals with mild and
moderate malnutrition from becoming severely
malnourished and to treat those with moderate
malnutrition during nutritional emergencies.
 SFPs provide a food supplement in addition to a
general ration

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 Supplementary Feeding Program…

The decision to start an SFP should be based on the

following considerations:
 Results of a nutrition survey
 The general food ration/food availability
 Child mortality (death) rates and prevalence (rate) of
specific diseases such as measles and whooping cough
 Available resources and logistical factors

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 Supplementary Feeding Program…

Supplementary food can be distributed in two ways:

 On-site feeding/wet ration
 through daily distribution of cooked food/meals at feeding
centres.
 The number of meals provided can vary in specific situations,
but a minimum of two or three meals should be provided per
day.
 Take-home/dry ration
 through the regular (weekly or bi-weekly) distribution of food
in dry form to be prepared at home.
 In such programmes it may be necessary to increase the
amount of food to compensate for sharing within a household.

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 Supplementary Feeding Program…

Advantages of dry ration feeding:

 Carries less risk of cross-infection
 Takes less time to establish than on-site feeding
 Is less time consuming for mothers and carers who only
have to attend every week or fortnight.
 This leads to better coverage and lower default rates
 Leads to better coverage of children under 2 years of age
 Keeps responsibility for feeding within the family
 Is particularly appropriate for dispersed populations

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 Supplementary Feeding Program…

On-site wet feeding may be justified when:

 Food supply in the household is extremely limited so it is
likely that the take- home ration will be shared with other
family members
 Firewood and cooking utensils are in short supply and it is
difficult to prepare meals in the household.
 The security situation is poor and beneficiaries are at-risk
when returning home carrying weekly supplies of food.
 There are a large number of unaccompanied/orphaned
children or young adults.

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 Principles of SFPs

 SFPs aim to prevent and rehabilitate acute malnutrition

 A take-home specialized nutritious food is provided to the
patient (children under five and pregnant and lactating
women), with follow-up visits conducted at a nearby
health facility every two weeks.
 For SFPs to achieve the intended outcomes, it is critical
that effective and appropriate linkages are made with food
security interventions to avoid the risk of sharing the
specialized nutritious food with other members of the
household.

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 When to establish a SFP

The decision of whether to implement SFPs should take into

consideration:
1/Malnutrition rates: current and previous prevalence of GAM
and SAM in children 6-59 months, reported in Z scores.
2/Contextual factors: including the causes of malnutrition, the
socio-economic situation, the food security situation, general
ration quantity and coverage etc.
3/Public health priorities: whether other priority needs are
already being met (shelter, water health care, etc.).
4/ Available human, material and financial resources and the
objectives of the project

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 Targeted Supplementary Feeding Programs …

 Targeted Supplementary Feeding

programme aims to rehabilitate children
under five years old as well as pregnant and
lactating women (PLW) identified as acutely
malnourished during screenings.
 The selection of TSF districts is done based
on pre-set criteria.

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 Targeted Supplementary Feeding Programs …

This program is set up when:

 There are large numbers of mild and moderately acute
malnourished individuals.
 A large number of children are likely to become
mildly or moderately acute malnourished due to
aggravating factors like serious food insecurity or high
levels of disease.
 A high prevalence of people with HIV and AIDS.
 A high prevalence of micronutrient deficiencies.
 There is short-term hunger among pre-schoolers

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Blanket Supplementary Feeding Programs

 The main aim of a blanket SFP is to prevent widespread

acute malnutrition and to reduce excess mortality among
those at-risk by providing a food/micronutrient
supplement for all members of the vulnerable group (e.g.
children under five, people with HIV and AIDS, elderly,
chronically ill and PLW).

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Blanket Supplementary Feeding Programs

Blanket SFPs may be set up under one or a

combination of the following circumstances:
 At the onset of an emergency when general food distribution
systems are not adequately in place.
 Problems in delivering/distributing the general ration.
 When large numbers of mild and moderately acute
malnourished individuals are likely to become severe due to
aggravating factors.
 Anticipated increase in rates of acute malnutrition
 In case of micronutrient deficiency outbreaks, to provide
micronutrient-rich food to the target population.

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Programme recommendations for Prevention of Acute
Malnutrition and Treatment
 Sphere Standards

Correction of malnutrition standard 1: moderate

malnutrition
 Moderate malnutrition is addressed
Key indicators
 From the outset, clearly defined and agreed objectives
and criteria for set-up and closure of the programme are
established
 Coverage is >50% in rural areas, >70% in urban areas
and >90% in a camp situation

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 Sphere Standards…

 More than 90% of the target population is within <1 day's

return walk (including time for treatment) of the
distribution centre for dry ration supplementary feeding
programmes and no more than 1 hour's walk for on-site
supplementary feeding programmes
 The proportion of exits from targeted supplementary
feeding programmes who have died is less than 3%,
recovered is greater than 75% and defaulted is less than
15%
 Admission of individuals is based on assessment against
internationally accepted anthropometric criteria

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 Sphere Standards…

Targeted supplementary feeding programmes are

linked to any existing health structure and
protocols are followed to identify health
problems and refer accordingly
Supplementary feeding is based on the
distribution of dry take-home rations unless there
is a clear rationale for on-site feeding.
Monitoring systems are in place.

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 Therapeutic feeding programme

 Therapeutic feeding programmes aim to rehabilitate

individuals with SAM.
 SAM is characterized by severe wasting and/or bilateral
pitting oedema.
 The management of SAM includes the package of
activities aiming to decrease mortality and morbidity
related to acute malnutrition and potentially contributing
to a reduction in its prevalence

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 Components of a therapeutic feeding
programme

Outpatient care
 Patients with appetite and no medical complication or
those completely recovered from any medical
complications can be treated at home on an out-patient
basis.
 The OTP is run from a health centre or health post.
 In the OTP, the patient visits the health facility every
week
 Treatment for outpatient care in Ethiopia is provided
through outpatient program in health centres or health
posts.

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 Components of a therapeutic feeding
programme
Inpatient care
 Complicated cases need medical attention in the first phase of
recovery.
 Treatment for inpatient care in Ethiopia is provided through
Therapeutic Feeding Units (TFU) in hospitals or health centres and
follows WHO guidance.
 Children 6-59 months admitted into inpatient therapeutic care for
stabilization of their condition will be referred to outpatient care as
soon as their medical complications are resolving, their appetite has
returned and any oedema is reduced.
 Children with SAM have delayed mental and behavioural
development. To address this, sensory stimulation should be
provided to the children throughout the period they are in inpatient
care

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 Components of a therapeutic feeding
programme

Community mobilization
 Community mobilization, a range of activities that help
implementers understand the affected communities, build
relationships with them and foster their participation in
programme activities, is crucial for effective early case-
finding through routine screening.
 Early case finding and the quality of service provision are
the two most important determinants of case fatality rates,
programme coverage and impact.
 Sensitization messages should provide essential
information about the programme’s aims and methods.

1/1/2024
Simplified and context specific approaches in the
treatment of acute malnutrition (wasting)
 In a complex emergency context where the conventional
health care system is not working, improvising the
treatment of acute malnutrition has been considered in
several setups.
 This is expected to fill the gap and ensure the continuum
of care.
 Simplified approaches include use of simplified combined
protocol, use of non-health professionals for diagnosis and
treatment of children with SAM such as Community
Health workers, community based distribution agents,
care givers and use of reduced dose of RUTF

1/1/2024
1/1/2024
Nutrition intervention…
71
Commonly used supplementary foods in Ethiopia
72

 CSB (corn soya blend-USA) :Content in 100g: 380KCal, 18g Protein and 6g
Fat
 Famix (Ethiopia) :
Content in 100g: 402KCal,14.7g Protein and 7g Fat
 Currently on trial: Supplementary Plumpy : 500-1000Kcal /day
Ration needed
 300g/beneficiary/day
 Vegetable oil 30g/beneficiary per day
Ethiopia: TSFP 25kg CSB and 3kg oil every 3 months or 8.3kg CSB and
0.45kg oil per month
General ration Ethiopia:
• The monthly daily per capita ration is compose of 15kg cereals, 0.45kg oil
and 1.5kg pulses.
• In addition there is 4.5kg CSB and 0.45kg veg.oil for 35% of
needy/vulnerable population blanket distribution.
 THERAPEUTIC FEEDING PROGRAMS (TFPs)
73

• TFPs Provide a rehabilitative diet together with

medical treatment for diseases and complications
associated with the presence of SAM
Aim of TFPs is to:
– Reduce mortality among acutely severely
malnourished individuals and to restore health
through rehabilitation
– Reduce mortality by providing intense
medical and nutritional therapy.
 When to Establish TFPs
74

TFPs must be initiated when:

• The number of severely acutely malnourished
individuals exceeds the capacity of the local health
system/facility OR
• When the prevalence of SAM is > 3% [SAM –
percentage of children (6-59 months) with WFH z-
score < -3 and/or manifesting bilateral edema]
 Different Approaches to the Management of Acute,
Severe Malnutrition
75

Therapeutic Feeding Centers (TFCs)

• Traditionally, the management of acute, severe
malnutrition in emergencies includes setting up TFCs
• Focus has been on the attainment of acceptable
minimum standards of mortality
• Recovery and clinical outcomes in TFCs managed by
experienced agencies
• 24hr care, close monitoring, supervised feeding
 Limitations of TFCs
76

 Low coverage leading to late presentation

• Overcrowding
• Heavy staff work loads
• Cross infection
• High default rates due to need for long stay
• Potential for mothers to engage in dangerous coping
strategies to cover meals
• High opportunity cost
 Community Therapeutic Care (CTC)
77

CTC seeks to address some of the limitations of TFCs

• High coverage and low cost
• CTC approach treats the majority of the acutely, severely
malnourished at home
• No cross infection
• Mother has time to other HH members and kids
• Focuses on outreach and community mobilization to promote
participation and behavioral change
• Central to the home-based care of the acutely, severely malnourished
is the provision of appropriate therapeutic foods containing the right
mix of nutrients that will aid in treatment and rehabilitation
– Ready to Use Therapeutic Foods (RUTF) have been specially
designed for this purpose.
 Limitations of CTC
78

 Good-quality CTC is only possible where adequate

support structures are already in existence
• Cost efficiency is still under analysis
• It is not feasible in communities of households which do
not receive adequate general and supplementary food
rations, as the RUTF will be shared with the rest of the
family or sale
• The results (mortality rates, rates of weight gain, length of
stay, defaulter rates, coverage, etc.) of the CTC approach are
still under evaluation and further study is underway to
refine the approach and address some of the issues related
to the results.
 Core Principles of CTC
79

 Maximum access and coverage

 Timeliness
 Appropriate medical and nutrition care
 Care for as long as needed
 Sectoral integration and Capacity building
 The Components of CTC
80

1.Stabilization Center (SC)

• For 15% of SAM cases with poor/no appetite, clinically
complicated, +++ edema and Marasmic-Kwashikor cases
2. Outpatient Therapeutic program (OTP)
– For 85% SAM with good appetite and no medical
complication
3. Supplementary Feeding Program (SFP)
– For MAM children and PLW
4.Plus the community mobilization/outreach component
 CTC Innovations
81

 Ready to use therapeutic food (RUTF)-Plumpy nut

 Re-classification of SAM based on not only
anthropometry and edema but also using appetite
test and clinical wellness
 Inclusion of MUAC as an admission criteria
 Four new components with very high coverage
 Treatment of SAM at home or as an out patient
82
Simplified
S.
No
Indicators decision tool Action required

1. Food availability at household level Improve general rations until local food
83
< 2100 kcal/person/day availability and access can be made
adequate

2. Malnutrition rate (GAM) under 10 % - Attention to malnourished individuals

with no aggravating factors through regular community services[

3. Malnutrition rate (GAM) 10 – 14 % or - Supplementary feeding targeted to

5 – 9 % plus aggravating factors individuals identified as malnourished in
vulnerable groups
- Therapeutic feeding for SAM individuals

4. Malnutrition rate (GAM) ≥ 15 % or 10 - General rations; plus

– 14 % with aggravating factors - Supplementary feeding for all members
of vulnerable groups.
- Therapeutic feeding for SAM individuals
LIVELIHOOD INTEREVENTIONS

1/1/2024
 WHAT IS LIVELIHOOD APPROACH?

A livelihood comprises the capabilities, assets

(including both material and social resources) and
activities required for a means of living.

 A livelihood is sustainable when it can cope with and

recover from stress and shocks and maintain or enhance
its capabilities and assets both now and in the future,
while not undermining the natural resource base

 The global conceptual framework for the cause of

malnutrition, livelihood support addresses the basic
cause of malnutrition.
 LIVELIHOOD…
 Understanding livelihoods is critical to understanding
nutrition in emergencies.
 It is through livelihoods that people access to basic
services, health services, food and income security.

 Food and income security ensure that nutritional needs

can be met
 Nutritional status is a key outcome of how we analyse
and respond to livelihoods.

 Such as prevention and treatment of acute malnutrition

is not sufficient to prevent further malnutrition without
parallel livelihood interventions, food security and
adequate WASH services;
 The Livelihoods Framework And
Principles
 Common livelihoods framework that is used to determine
whether and what type of livelihoods programming is
appropriate is the ‘sustainable livelihoods framework’.

 This framework captures the main elements of what

comprises and influences, people’s livelihoods.

 The term ‘sustainable’ indicates that it should not use finite

resources or places people at substantial risk of future
survival to be be really a viable livelihood.

 If livelihoods are not saved and preserved during acute

phase of life saving interventions , there is a real risk that
lives will again be put at risk in the near future;
Source: Adapted from : Bohle HG. Sustainable livelihood security. Evolution
and application. InFacing global environmental change 2009 (pp. 521-528).
Springer, Berlin, Heidelberg
 Livelihoods Analysis And Assessment
 The livelihoods framework provides a tool for analysing people’s
livelihoods and the impact of specific shocks or vulnerabilities on
livelihoods.
 Many food security and nutrition assessment approaches incorporate
some form of livelihoods analysis.
 For example, assessments are conducted in livelihood zones (where
one type of livelihood pattern predominates) so that findings can be
applied to specific livelihood groups.

 A distinctive feature of livelihoods assessments is that it uses

participatory approaches to find out about people’s problems and
priorities.

 Emergency assessment methods which take a livelihoods approach

generally have a focus on food security as an outcome of
sustainablity
 Nutrition is one of the key outcomes of livelihood
status.

 In the past, food security assessment methods

have tended to be biased towards food aid as
a response to food crisis although this is slowly
changing.

 There are few examples of assessments which

include an assessment of the macro-environment,
e.g. vulnerability context and government
policies, which are essential determinants of
people‟s livelihood security.
 Objectives Of Providing Livelihood
Support In Emergencies
 Preventing the sale of, or maintaining, essential assets such
as livestock or farm land, and seeds .
 Providing essential assets or providing households with
the means to acquire them.
 Supporting livelihood strategies, such as livestock
production, stocking and destocking, agriculture,
small businesses or enterprises.
 Diversifying livelihoods (not that easy in emergencies).
 Improving access to markets.

 Improving the capacity of local institutions and

governments to respond to crises and to improve
livelihood security.
 LIVELIHOODS INTERVENTIONS IN
EMERGENCIES
There are a large variety of livelihood
support interventions that can be
implemented in emergencies. These can be
divided into four broad groups:
 Food and food aid

 Income and employment

 Production support

 Market support
 MONITORING AND
EVALUATION OF
EMERGENCY NUTRITION
INTERVENTIONS
MONITORING AND EVALUATION
OF THE MAIN NUTRITION
INTERVENTIONS
 Monitoring of micronutrient
interventions
Monitoring indicators of micronutrient interventions include:
 95% of vulnerable children aged 6-59 months receive an adequate
dose of vitamin A with measles vaccination.

 At least 90% of households are using salt with an iodine content of

15 parts per million

 Is the general ration corn dependent? This may lead to Niacin

deficiency.

 Is food used for the general ration over processed (Polished)? This
may lead to thiamine deficiency.

 It should be noted that impact evaluations of GFD are rarely

conducted, although considerable resources are spent
 Monitoring and Evaluation of
Therapeutic care programs
Monitoring appropriateness
 i. Quantitative indicators
 The four core performance indicators of a
therapeutic feeding program are recovery rate,
death rate, default rate and non-recovery/
response rate

 ii. Qualitative information (specific to

community based programs)
 Perceptions of the program at community level - in
particular information about; coverage; access to the
program; recovery rates; service delivery; cultural
appropriateness; lessons learned for the
continuation of the program
Monitoring the effectiveness of the program
 Quantitative indicators (minimum information)
 Total admissions, exits and number of children in the program
 Number of admissions by category of patient
 Number of exits by category
 Information on exits, weight gain and lengths of stay

 Monitoring Program Coverage

 It is important to carry out surveys to
ascertain the proportion of children in need of
assistance who receive care in the program
(expressed as a percentage)
 Evaluation of Therapeutic care programs
 Design of the program: how was the need for the program
identified, choice of the target population, what alternatives were
considered, how is coordination organized and program inputs

 Efficiency: what are the outputs of the program in relation to the

inputs, what are the costs.

 Effectiveness/Impact: is the program meeting its objectives and

international standards, what are the consequences at a wider level,
e.g. social, what are the rates of recovery/defaulter/death/etc., what
are the rates of weight gain, what is the coverage of the program.

 Sustainability/Connectedness: what is the level of integration with

the Primary Health system, are the activities of the short-term
emergency intervention coherent with longer-term programs in
place, and what will happen when the program closes
 Evaluation of Therapeutic care
programs…
 Relevance/Appropriateness: does the program meet the needs and
priorities of the local population, is this the most appropriate
intervention, timeliness of the intervention, cultural appropriateness,
is it accessible to women and all social groups.

 Coherence: does the program fit with the policies of other actors,
(politically, economically, internationally),
 what coordination with other actors takes place?
 Were there other concurrent interventions -general food distribution?
supplementary feeding, health care, water and sanitation provision?
 How is the protection of beneficiaries safeguarded?

 Coverage: were any children excluded from the program, were there
gender/age/geographical/ethnic biases to program participation, was
coverage measured with a survey.
 Monitoring and evaluation of
Supplementary feeding programs
 The Sphere standard for SFP is that 75 per cent of children who exit
from an SFP should have „recovered‟.

 Coverage of targeted supplementary feeding programs should be >50

per cent in rural areas and >70 per cent in urban areas and >90 per
cent in camp situations.

SFP
Acceptable Alarming
indicators
Recovery rate
>70% <50%
Death rate < 3% > 10%
Defaulting
< 15% >30%
rate
MONITORING AND EVALUATION OF GFD
INTERVENTIONS
A good monitoring system should determine:
 Appropriate targeting: Whether the decision to target
food within a certain geographical area is appropriate.

 Verify if the most vulnerable received the food aid:

Whether the groups in greatest need were identified in the
assessment and received the food aid.

 Realistic objectives: Whether the objectives of the GFD

were achievable and realistic. Monitoring should ensure that
food effectively reaches intended beneficiaries in the agreed
quantities and measure its impact on food security and
nutrition.

 Allows review of the system itself

 GFD…

Monitoring of a GFD program involves the following areas:

 Pipeline management (how much food is needed, how
much is available and timing of the arrival of food
supplies).

 Food management (storage, warehousing, logistics,

transport etc)

 Number and identification of beneficiaries

(numbers of people in need, registration, ration criteria,
exit and entry criteria)

 Management of food distribution (wet or dry rations,

frequency, location, full basket)
 Monitoring GFD…
Information collected on the process of GFD is used to
assess:
 Coverage: need versus availability versus access by
beneficiaries

 Efficiency of the system established

 The monitoring systems in general help to establish

whether the system established is efficient in
meeting the needs of registered beneficiaries.

 This is carried out through household visits and post-

distribution monitoring, market surveys, and
monitoring of nonbeneficiaries
 Evaluating GFD
Evaluations of GFD programs assess the following in
order to understand whether the programs had a
nutritional impact:
 Impact on food security

 Impact on nutritional status

 Impact on mortality rates(over time)

 Micronutrient deficiency
 Evaluating GFD…
In addition, the evaluation would need to take into
account the following variables:
 Modality of food aid distribution (food for work,
blanket distribution) over time.

 Modality of delivery (wet feeding or dry rations)

 Size of ration and composition of ration over time.

 Context (market access, household income,

consumption and expenditure patterns)
 MONITORING AND EVALUATION OF
LIVELIHOODS INTERVENTIONS
Key questions for monitoring
process (how the transfer was
delivered)
Key questions for monitoring
impact (what change has there
been for the recipient?)
Source: IFRC (2007) Guidelines for Cash
IFRC
Did the intended recipients receive the transfer
Did the recipients/suppliers receive the correct sums of
money
 Was the payment made on time
 Were the recipients and other stakeholders satisfied with
the process and method of implementation
 What other assistance are recipients receiving
 Types of recipient
 What was the cash transfer used for
 What did people purchase
 Were the items that households wanted to buy available
in the market
 How have sources of food and income changed
 How have coping strategies changed
 How much has income and expenditure changed since
the start of the cash programme
 Have there been any changes in consumption patterns
 Who controls the money
 Would recipients have preferred another form of cash
transfer, foodTransfer Programming
aid, in-kind Geneva:
assistance, income generation
 THE END!!!

Thank you !