For an integrated and multi-sectoral approach to nutrition in emergency, rehabilitation and development programmes: some tools and food for thought
Though nutrition is mostly associated with famine situations and overt starvation, it can actually play a central role in the planning, implementation and evaluation of relief, rehabilitation and development programmes, even when malnutrition seems invisible. Nutrition consists in much more than food or nutritional supplement distributions; rather, it can be the key to integrated, multi-sectoral and people-centered interventions.
A child is sitting on the ground, his little arms and legs are thinner than sticks and dangle in the dust; his stomach is swollen and his gaze empty. He is held up by his mother, whose eyes are shadowed by anxiety and shame: she has not been able to feed her child. A starved child and a desperate mother: such is the face of humanitarian aid; acute malnutrition rates: the ultimate signal that will trigger –or not- a large scale aid operation; the therapeutic feeding centre: the centre stage of humanitarian action, where the child is saved and the mother alleviated of her pain. For the general public, nutrition has almost unwillingly become the emblem of the tragedy and miracle of humanitarian aid.
But beyond this quasi mythical role, characteristic of situations of extreme misery, would nutrition not have a more modest, though more central, contribution to make to relief, rehabilitation and development projects? Could it not be a key to population-centred programming and implementation? Severe acute malnutrition is only the tip of the iceberg: although it affects “only” 0.1 to maximum 6% of children under 5 years in crisis situations, 5 to 20% (and up to 25%) of children suffer from moderate acute malnutrition, and more than half are chronically malnourished (stunted). In addition, a majority of children, adolescents and adults suffer from micronutrient deficiencies, which increase vulnerability to disease and undermine their learning and work capacities. Nutrition is thus a basic need, at the heart of crisis-affected populations’ other multiple needs, even when it seems invisible.
Far from being the private domain of a handful of experts, nutrition is a discipline which can provide tools to each aid worker, whether she or he be a water engineer, an agronomist, a nurse, a sociologist, a logistician, a head of mission, or a desk officer. Nobody can fight malnutrition alone, but each and every one has a role to play in preventing this starved child and mother from requiring the ultimate ‘solution’: treatment for severe acute malnutrition. Or, if the latter is inevitable, all should be done to avoid them returning a few months later, and to prevent the smaller brother or sister from following the same path as the eldest. How? This article attempts to propose some food for thought…
The reasons that can lead a child or adult to require therapeutic care (whether centre or home-based) are complex and vary from one situation to another. Collapse of livelihoods; lack of drinking water and poor hygiene; diarrhoea, parasite infections, measles or AIDS epidemics; drought; loss of harvests or livestock; population displacements leading to a collapse of social networks; psychological trauma; local beliefs and practices that undermine good health and nutrition practices… These are some of the numerous causes which can determine the nutritional status of a family and its individual members. Any stakeholder aiming to treat or prevent malnutrition needs to understand the direct and underlying causes of malnutrition. Failing to do so can only undermine the effectiveness and sustainability of an intervention.
The conceptual framework of malnutrition (see graph 1), elaborated in the early 1990’s proposes a multi-sectoral analysis of malnutrition causes, which can guide assessments, project design, implementation, monitoring and evaluation. A simple tool can support such analysis: building causal frameworks of malnutrition using simple visualisation techniques (e.g. problem and solution trees) . This exercise invites participants to conduct a comprehensive analysis of population’s needs, whether they be related to agriculture, access to safe water, education, health, social relations (in particular gender issues). Doing this exercise with a multi-disciplinary team familiar with the local context (starting with the national team) will greatly enhance the quality of the analysis.
The preparation of a solution tree will present “Reduction of malnutrition” as a common objective for an integrated approach addressing the various causes of malnutrition, bringing together different technical departments within an organisation, or highlighting potential partnerships between organisations with complementary expertise. A health agency providing nutrition treatments, for example, could partner with a food security agency that will assist patients’ families in diversifying their food production, income sources and food consumption, thus preventing relapses. Not only does the use of nutrition as a common objective facilitate the identification of cross-sectoral linkages, it also carries meaning: is a healthy nutrition status not only the reflection of an individual’s physical health, but also of his/her economic, social and psychological well-being?
Nutrition solution trees can also help identify good monitoring and impact indicators, going beyond commonly used activity indicators (number of food rations distributed, quantity of distributed seeds, number of water pumps installed, etc.). This does not necessarily imply using anthropometric measurements (weight, height, MUAC), as these often require relatively expensive and labour intensive surveillance systems, and specialised teams. Furthermore, the causes of malnutrition being complex, it is difficult to attribute the impact of a single intervention to nutritional status. For example, a well-targeted agricultural programme can generate positive results in terms of food availability, access and consumption, which contribute to improved nutritional status; but if there is endemic diarrhoea due to poor water supply and sanitation, impacts on nutritional status will remain limited. In such cases, one can select indicators relevant to one’s area of intervention and related to direct or underlying causes of malnutrition (e.g. food consumption or diarrhoea rates).
 C.f. also A Guide to Nutritional Assessment, by Ivan Béghin, 1988, WHO