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Evaluation report

2005 Niger: Real Time Evaluation of UNICEF's Response to the 2005 Food and Nutrition Crisis



Executive summary

OBJECTIVES AND APPROACH
The evaluation of the food and nutrition crisis which occurred in Niger in 2004-2005 was a real time evaluation (RTE) hinging on three critical objectives geared at assessing the performance of UNICEF and of its partners in the face of this crisis, namely:
• Assess UNICEF’s contribution to the monitoring of the food and nutritional status of the country before the crisis (Early Warning System and coordination / consultation mechanisms);
• Assess UNICEF’s contribution to the preparedness measures for a possible crisis that must be taken by the Government, civil society (families, communities, private sector, NGOs) and by external partners (United Nations System, international NGOs, donors);
• Assess UNICEF’s contribution to rapid humanitarian action during and after the crisis, i.e. after an immediate emergency has been declared (mobilization of human and financial resources, contribution to the coordination and the dispatching of food relief, management of malnourished children, fight against epidemic diseases, strengthening of capacities at all levels).
The RTE examines UNICEF’s performance first and foremost at the country level through the Programme of Cooperation entered with the Government of the Republic of Niger (2004-2007), but also with respect to the support provided by the West and Central Africa Regional Office (WCARO) and by New York Headquarters.
As UNICEF’s inputs are closely linked to those of the Government and of civil society, it goes without saying that they must be considered in their respective contexts. The same applies to partnerships with the other United Nations Agencies (UNDP, WFP, UNFPA, WHO, etc.) and other external aid agencies.

CONCLUSIONS
The food and nutritional crisis in Niger
For a number of years, Niger has had to deal with very high rates of acute and also chronic malnutrition among children under five. These rates were at between 14% and 20% for acute malnutrition and signalled an emergency situation. Acute severe malnutrition was also high (between 2 and over 3%). Chronic malnutrition was already up to 40%, which is a sign of long-term persistent nutritional and/or health stress. These rates would be considered alarming in other regions of the world but seem to be accepted as normal in a Sahel country like Niger. Malnutrition is also an important contributing factor in the high mortality rate of children under five (265‰ in 2000, one of the highest in the world).
Against this backdrop of malnutrition levels accepted as “normal” or “structural”, i.e. considered as customary for the country, alarming signs came up in increasing numbers in 2004-2005 and converged in the agricultural areas of Zinder and Maradi, along the Nigerian border. As it were, it is in regions considered as productive, in the granaries of the country, that the nutrition crisis gradually came to full strength, even though markets were well supplied. Millet price had reached record-high levels and, for five months, food grains were unaffordable for a large portion of the population. Meanwhile, the terms of food grains / livestock exchange were deteriorating and collapsing to the point of forcing the poorest to ruin.
Until May / June 2005, the nutritional crisis in the southern part of the country was not well understood. This phenomenon was being ignored by an analytical approach emphasizing the production and availability assessments of basic food grains while neglecting aspects connected to price increase, even though this restricted access to commodities for an important layer of a very vulnerable population devoid of any resources, for whom agriculture was the only income in a chronic indebtedness situation. Socio-economic data were insufficiently taken into account in the general poverty context prevailing in Niger, and indebtedness throws households with unreliable income into a vicious circle which they can no longer leave. The problem of low access to food is exacerbated by conspicuous deficiencies in terms of access to health services and parent education pertaining to good child care practices in hygiene, nutrition and health in general.
The Niger / UNICEF Country Programme of Cooperation 2004 – 2007
The Country Programme of Cooperation 2004-2007 aims at poverty reduction by improving living conditions for children and women. The health / nutrition budget was strongly focused on health. It was also more guided by the availability of funds – notably those that were earmarked for the eradication of poliomyelitis, to which other EPI immunizations and Vitamin A distribution could be pegged for efficiency purposes. Malnutrition has not gotten the attention it deserved on account of its importance as one of the major causes of child morbidity and mortality.
Crisis preparedness and resource mobilization
Although the UNICEF-supported Cooperation Programme has not provided many responses to child malnutrition which was described as serious, the emergency plans of UNICEF Country Office in Niamey mentioned important risks regarding the degradation in food and nutritional status which threatened the country in 2004 and 2005. In Niger, UNICEF was not equipped to properly define the malnutrition problem and to understand fully what the locations and the scope of the problem were. For lack of local expertise, UNICEF was not able, from the outset, to assume a leadership role in the area of malnutrition.
In 2004 the UNICEF Country Office in Niger and the Regional Office for Western and Central Africa realized that expertise in nutrition had to be rebuilt. No later than May 2004, the Regional Advisor voiced his concerns to the Regional Office and the Country Office with respect to the lack of human resources with nutrition skills in Niger and the country’s extreme weakness. However, the creation of posts, then the hiring of staff met with obstacles of an administrative nature, which hindered the understanding of the crisis and the timely start-up of a response, including resource mobilization and planning.
UNICEF’s Country Office in Niger made a number of efforts to mobilize resources for the therapeutic management of severely malnourished children, first of all by allocating Regular Resources (RR) to this objective, then by mobilizing the resources of UNICEF’s National Committees. It also contributed to communicating to the media what proved decisive in mobilizing resources to the level required by the magnitude of the crisis. Overall, the process was too slow, especially with respect to the international community’s response to the crisis. It proved necessary to broadcast on TV shocking footage of dying children to mobilize humanitarian action. Greater lucidity with respect to the nature and the location of the malnutrition problem, action of a more energetic and faster nature by all actors could have saved a lot of children’s lives.
During the first semester of the year 2005, the various agencies of the United Nations System in Niger did not show consensus on the nature of the crisis and sufficient coordination in the action to be taken. The sharing of responsibilities between WFP which would deal with moderately malnourished children and UNICEF which would take care of severely malnourished children was not clearly defined. Moderately malnourished children were in the end placed in UNICEF’s care, but this action only started off at a late time and at a high cost.
UNICEF’s contribution to humanitarian action since August 2005
In August of 2005, humanitarian action in favour of severely and moderately malnourished children was finally triggered on a wide scale. Thanks to support from the Regional Office for Western Africa and Headquarters, the Niamey Country Office has played an effective, decisive role in the process by assuming technical leadership and a coordination role in the area of nutrition through its support to the Ministry of Public Health and in cooperation with NGOs in the field.
The initial objective was to offer services best suited to the population that had not been available so far in order to save children’s lives. Quality assurance was developed through the adoption of a protocol for the management of malnutrition, the establishment of training programmes for its use, and the design of a monitoring system. Quality assurance has been in a state of constant improvement since September 2005, at which date a strengthening of qualified human resources clearly took place at the central as well as the decentralized levels.
In October 2005, the amount of contributions received by UNICEF was US$ 19,592,219, which exceeded by more than a third the volume of the aid that was sought at the outset. UNICEF positioned itself at the level of nutritional recovery, whether therapeutic (acute severe malnutrition) or supplementary (moderate malnutrition), by supporting the management of 226,929 malnourished children spread out in 806 centres: 23 CRENIs, 256 CRENAs and 527 CRENAMs (situation as at November 24, 2005).
In CRENI (Intensive nutritional rehabilitation care centres for severe acute malnutrition with complications) and CRENAS (nutritional rehabilitation outpatient centres for non complicated severe acute malnutrition), specific curative and preventive dietetic and medical treatments are offered. 64,924 severely malnourished children were admitted: 17,069 in 23 CRENI and 47,855 in 256 CRENAS.
162,005 moderately malnourished children are being treated in 527 CRENAM (nutritional rehabilitation outpatient centres for moderate acute malnutrition). Moderate malnutrition is the greatest provider of severe malnutrition, and the fact that so many children have been managed gives a measure of the number of avoided cases of severe malnutrition.
In actual fact, the total number of children managed is 302, 577, i.e. 226,929, to which we have to add 75, 648 children managed by the coverage operations that were made necessary for efficiency and effectiveness reasons by the all too strong prevalence of malnutrition in some villages, with a view to extend the safety net to children who are at risk of malnutrition.
A first estimate of performance indicators calculated on the basis of a reduced sample shows a recovery rate of more than 92.36%, a mortality rate of 2.93% and a drop-out rate of 4.71%. These results show the good quality of the implemented programme.
UNICEF has undertaken to ensure the availability of drinking water and sanitation services in the Centres. Some CRENI have been supplied with water and sanitation kits for use by the families of severely malnourished children. However, access to drinking water is not guaranteed for all CRENI/CRENAS, and even less so for CRENAM, as those structures can be mobile, which does not allow for a good initiation to basic hygiene habits.
The nutritional management of malnourished children is currently dissociated from the action taken by the IBS (Integrated Basic Services) programme, particularly with respect to the support to community-based growth monitoring promotion teams (EVPC) and to cereal banks. Clearly, these initiatives do not sufficiently benefit from nutrition expertise, close monitoring or good coordination with health centres.

RECOMMENDATIONS
Recommendations for the Emergency Preparedness Plan of the year 2006
The risk of an important number of severely malnourished children persisting after the harvests of the 2005-2006 campaign beyond the 2005 lean period must be at the core of the next Emergency Preparedness Plan. It is recommended to formulate a nutrition-specific sectoral plan. Besides, plans will have to be periodically updated according to the latest developments.
Additional resources for the emergency will have to be mobilized to complete the use of Other Resources (OR) for 2005. It is recommended to develop a resource mobilization strategy factoring in the importance of the media (and particularly international television channels) as means of communication and advocacy to the general public of donor countries. As far as possible, this strategy should be coordinated and harmonized with the Government of the Republic of Niger and the other Agencies of the United Nations System.
The retention of nutrition technical expertise in UNICEF’s Niamey office and in the sub-offices of Maradi and Agadez should be a priority and a part of resource mobilization. The Integrated Basic Services Programme must enjoy close “nutritional” advice and monitoring independently from the emergency as far as support for EVPCs (community-based growth monitoring promotion teams) and cereal banks is concerned.
The roles and responsibilities of the various United Nations System Agencies were clarified over the course of the year 2005. Starting in March 2006, UNICEF will assume the coordination of technical support to Acute Malnutrition (non food items and food both for severe and moderate acute malnutrition, but ensuring food for severe malnutrition) while WFP will take care of the provision of food for moderate malnutrition and WHO of health. UNICEF will continue supplying food and drugs for the management of severely malnourished children under five, whereas WFP will supply food aid for the moderately malnourished children under five. This agreement in the division of duties is an important improvement with respect to the situation that prevailed in 2005.
As far as the information, monitoring and evaluation system is concerned, support must be given again to the collection, the dissemination and the development of the analysis of monitoring nutritional data by NGOs while involving more and more the services of MSP/LGCE (Ministry of Health) and DRSP (Regional Health Services ).
The dissemination of the results of the survey carried out by the Government of Niger, CDC Atlanta and UNICEF at the end of 2005 will guide the priority targeting of the areas to be covered. Qualitative and quantitative rapid surveys will be conducted to refine the targeting process and adapt the strategy to be used (for instance, free distribution to children under three or under five, establishment of CRENIs/CRENAs/CRENAMs).
It is recommended to encourage the NGOs involved in emergency operations to remain mobilized and stay in the field. The capacity of some NGO has to be built up by training and immediate support to remedy organizational, management and storage shortcomings. An addendum to the protocol for the management of malnutrition could be formalized to bring to scale on a minimal basis the benefits offered.
It is recommended to take advantage of the presence of mothers, grandmothers or sisters in CRENI to develop and integrate educational elements pertaining to care, basic hygiene, breastfeeding, weaning and oral rehydration in case of diarrhoea and other issues relevant to health. Contact opportunities with health structures are exceptional enough to be used in optimal fashion.
The coordination group of NGOs and United Nations Agencies should be taken over by the Ministry of Public Health. Currently a place dealing mostly with information collection and exchange, it could however evolve towards a more strategic reflection and act in everybody’s interest by getting involved in mid- and long-term actions targeting the underlying causes of malnutrition. This group could be an integral part of the Coordination Unit described in the National Nutrition Action Plan. It could incorporate donors and position itself as a proposal force for the Government.
Recommendations for the 2004-2007 Country Programme of Cooperation
On the occasion of the Mid-Term Review of the 2004-2007 Country Programme of Cooperation, it is appropriate to engage in advocacy so nutrition can be defined as the first public health priority, which will encompass the enhancement of the nutrition level in the organizational chart of the Ministry of Public Health. Its budget, its human resources must be up to the challenge. Within the UNICEF Country Office in Niger, it is appropriate to materialize the creation of a full-fledged nutrition section independent from the health section.
The nutrition sector needs a comprehensive preventive and curative strategy. Nutrition had but a minor presence in the poverty reduction strategy. The 2005 crisis proves that poverty is closely linked with nutrition, particularly for children under five: a vulnerable group par excellence. Such a strategy would at least encompass the following elements: a) the improvement of financial access to health care, with free access to some good-quality preventive and curative care for the most underprivileged groups; b) the strengthening of the struggle against water-borne diseases, and particularly diarrhoea; c) the promotion of health education, hygiene, food/nutrition, breastfeeding, good child-care and monitoring of child growth; d) the consideration and management of malnutrition, under-nutrition and micro-deficiencies of pregnant and breastfeeding women, given that these aspects are a part of the strategy of reduction of insufficient weight at birth and under-nutrition of infants under six months; e) the support and promotion of existing adapted weaning flour for its use on a large scale.
A strategy to overcome malnutrition involves actions in several other sectors, among which: a) water and sanitation, with improved access to safe drinking water and hygiene in the various health facilities and the schools; b) agriculture and livestock, with for instance access to micro-credit, support to food grain banks, crop diversification, and improvement of agricultural practices. As the support provided by UNICEF will not be able to develop technical expertise in all areas, it is recommended to strengthen and search for cooperation and complementarity with other partners more especially through joint programming with other United Nations Agencies (UNDP and FAO for instance).
Hence the imperative to supply technical assistance to update the National Nutrition Action Plan (PNAN) in the period from 2003 to 2015. This plan recognizes the trans-sectoral character of nutrition, but coordination structures remain under the authority of MPS/LGCE. The Prime Minister’s office would be a better strategic choice for the Interdepartmental Committee, and elements of the crisis management and prevention system could then be integrated. This coordination committee should become operational as soon as possible.
Support to the National health information system (SNIS) must be done in cooperation with WHO. Nutrition data are a part of health indicators and must as such be integrated to the SNIS. However, at the moment, the health system can only generate a few unreliable qualitative and quantitative data because of a lack of training and awareness of health workers, and insufficient coverage and use of services.
The necessity to put in place a surveillance and warning system has been clearly proven. Technical assistance in this field will have to integrate more developed nutritional and socio-economic considerations. The community-based growth monitoring approach requires good training, regular and frequent monitoring and skills upgrading to get reliable information, and one issue still has to be solved with regards to the remuneration of women in charge of this activity. The system that has been set up must lead to a management situation, which involves both the establishment of a good reference system for severely malnourished children and “local” means of management of the moderately malnourished in connection with CSIs / health facilities. Malnutrition must both take into consideration the cultural elements pertaining to food habits and practices and those that pertain to food security at household and community levels (for instance cereal banks which are currently disconnected from any nutritional consideration).
Qualitative and quantitative surveys will have to be conducted incorporating the gender aspect so the crisis of 2005 can be better understood. Reflecting on the nutritional status of women would make it easier to narrow down the causes of the high proportion of children of insufficient weight at birth as well as that of children 0 to 6 months old. KAP (knowledge, attitude and practices) surveys will guide the communication strategy for the delivery of messages pertaining to health, nutrition and hygiene.
Recommendations and lessons learned by UNICEF
The Niger experience shows us that the various development partners did not possess adapted analytic tools in sufficient quantities to suitably define the nature and the scope of the nutrition crisis, which could not be understood with the instruments used thus far to describe food security. A nutrition crisis cannot be summarized as a deficit in food grain availability. It is located in the context of generalized poverty and superimposes circumstantial over structural causes. It is necessary for UNICEF to develop its nutrition expertise so it can unveil to government or non-government partners the policies and strategies that should be developed and show them how possible crises could be prevented or managed. In so far as partners wish to entrust UNICEF with a leadership mandate in the area of nutrition, the organization should give itself as soon as possible the means to acquire a strong technical expertise in this field. On account of the limited number of qualified nutritionists in Sahelian countries, this is in the short term a considerable challenge.
Malnutrition is a major cause of child morbidity and mortality in many countries. The existence of malnutrition thresholds considered as alarming in other countries is not so in the Sudan-Sahelian zone. This phenomenon appears to be caused by the force of habit and fatality, which is deep-rooted and lasting. For that matter, the same references or nutrition thresholds as were defined by WHO must be applied to all countries and these countries should be reminded about it. Advocacy for the adoption of these thresholds must be extended to all development partners. If high rates of acute malnutrition demands urgent action in nutrition management, the fight against chronic malnutrition (size/age ratio) is more relevant to a long-term strategy geared at health and food security in the broad sense. But neither is it of an inevitable “structural” nature, nor for that matter does it pertain to fatality, no more than food crises.
In Niger, the data on the geographical distribution of malnutrition have existed for many years.. However, the 2004-2007 Country Programme did not factor in these data, which were confirmed by the 2000 survey, MICS II. The health / nutrition component seems to have been more inspired by the availability of Other Resources from global funds and international missions (EPI and HIV/AIDS) than the situation in the field. It is not unthinkable that such practices should be so widespread on other Country Programmes. It would be appropriate to revive the practice of conducting situation analyses on the status of children as a starting point to choose priorities and determine their levels, mobilize resources and define the ensuing programming and advocacy.
Development and emergency are not mutually exclusive. There is no break between development and emergency: both situations coexist and create a continuum from an unstable situation which, on the occasion of concurrent events, may turn into a crisis; this can, among other things, unveil the shortcomings of a health system which then become exponential. The situation analysis feeds at once from the existence of data, their reliability, their cross-referencing in a current moving context in which the limits between development and emergency are never clear-cut. The example of Niger informs us on the coexistence of both. Both approaches supplement each other to reach the objective of a reduction in the mortality of children under five. It is appropriate to raise donor awareness about this situation, so the necessary resources can be mobilized on time – not only when shocking footage is broadcast on television screens.
The switch from a development situation to a crisis situation involves modus operandi changes which require other skills (quick decision-making, quick action, organization, and prioritization). Such a shift requires greater flexibility in some procedures, particularly with respect to the redeployment and the hiring of qualified human resources. The Niger example demonstrates what can be done and what can be improved in this area, particularly regarding response time, through good cooperation between the Country Office, the Regional Office and Headquarters.
The Niger experience has also been loaded with lessons on the importance of communication with international media, particularly to mobilize necessary resources for immediate humanitarian action. Within UNICEF, it is important to have good coordination of activities at country, regional and HQ levels. Communication with the media is a complex process which involves numerous actors (Governments, NGOs, independent parties). The expertise required for good media management could possibly be featured in the capacity-building programme undertaken by the Agencies of the UN System.
Another dimension of communication involves the transparency of operations and the existence of good monitoring and evaluation systems. In the haste of emergency actions, this aspect does not always receive the attention it deserves. It is also important to ensure good coordination with the Government of the country concerned and to continue to supply input to development and to the reinforcement of national capacities. The Niger experience shows that good communication with the government can be maintained, even if it seems to go against national policies and strategies, as in the case of cost recovery suspension: free care, hospitalization, food and drugs in the context of acute malnutrition.



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