Nutrition coordination in Zimbabwe: Achievements and Challenges
By Dianne Stevens, UNICEF Zimbabwe
Dianne Stevens is the Nutrition Manager with UNICEF in Zimbabwe. She chairs the Nutrition Technical Consultative Group responsible for nutrition coordination in Zimbabwe. Dianne has 10 years experience in working in emergencies both with NGOs and the UN and has been with UNICEF in Zimbabwe since 2004.
Over the past several years, Zimbabwe has experienced political and economic upheaval resulting in rampant inflation, drought, unemployment, food shortages and general deterioration across multiple sectors. Combined they have the potential to create a nutritional crisis.
In 2004 there was a vacuum in the coordination of nutrition activities in Zimbabwe. However, through a process of negotiation, UNICEF was given permission to establish the Nutrition Technical Consultative Group (NTCG) with a focus on consultation and sharing of best practice rather than coordination. Since August 2004 the NTCG, chaired by UNICEF, has been meeting monthly and is increasingly accepted by Government as the United Nations (UN) nutrition coordination mechanism. Over the past year there has been wide consultation in Zimbabwe on moving towards cluster coordination. The cluster approach has not yet been officially activated in Zimbabwe. However, the approach has been collectively endorsed at a Workshop on Humanitarian Reform in June 2007 and by the IASC Country Team. The next steps are for the IASC Country Team to make a formal submission to the Emergency Relief Coordinator.
This article highlights some of the challenges and successes to date of the UN-led nutrition coordination mechanism in Zimbabwe.
Coordination and Leadership
A health centre
There are differing perspectives on the humanitarian situation, particularly between Government and the international community, leading to debates about whether Zimbabwe's situation is an emergency. As a result, the UN has had to be flexible in its humanitarian programming in order to address needs. Furthermore, although Government has nominally been in charge of coordinating emergency nutrition interventions, it has not played an active role in this. The NTCG was formed initially with an information-sharing mandate but also took on a 'low profile' coordination role. Through advocacy, negotiation and diplomacy, the benefits of having a coordination mechanism are now recognised by Government (although it is technically not a member, it does now send a representative to some meetings.)
Since 2004, UNICEF in its role of chair of the NTCG has effectively acted as a broker between the Government and the non-governmental organisation (NGO) nutrition community. NGOs had not been permitted to conduct nutrition surveys or establish therapeutic feeding programmes in isolation of government. Through this role, more NGOs are becoming involved in support to both nutrition surveillance and Community Therapeutic Care (CTC).
Thresholds and Supplementary Feeding
Government has its own established protocols for the treatment of acute malnutrition that are not entirely in accordance with international protocols. For example, the Government has a threshold of responding when acute malnutrition is above 7% - the national policy on supplementary feeding dictates that all supplementary feeding is blanket wet feeding of all children under five years, in geographical areas identified with high acute malnutrition. With global thinking on emergency thresholds shifting, and with trend analysis indicating a deteriorating situation with regard to acute malnutrition, partners are willing to intervene using the national threshold of 7%. However, international agencies are generally not supportive of the delivery mechanisms in the national supplementary feeding policy. Evaluation of the large-scale, blanket wet supplementary feeding programme (SFP) in 2003 was not positive in terms of resources and opportunity cost. Zimbabwe has therefore been facing a dilemma in 2007as acute malnutrition levels are approaching 7% and in some districts are above national thresholds and may deteriorate further. The NTCG is coming together on developing a common position on supplementary feeding and working towards solutions that can be negotiated with Government.
Capacity and data
Due to the limited capacity of the Government health system, their ability to monitor the impact of emergency nutrition programmes is challenging, especially as there are more than 60 Ministry of Health and Child Welfare (MoHCW) hospital based therapeutic feeding sites across the country. It is therefore difficult to establish the actual numbers of admissions, performance of therapeutic feeding sites, types of support required, commodity needs and sites that require external support. Much of the contingency planning is therefore based on weak data.
Mothers and children at a health centre in
Hyperinflation of more than 15,000% makes the logistics of programming very difficult. The unavailability of cash and fuel is particularly problematic. Local NGOs often find it difficult to get into the field and staff salaries are eroded affecting morale and turnover. Through the coordination mechanisms, the UN is supporting NGOs through payment in USD (United States dollar) or USD equivalent, providing fuel to implementing partners and disbursing funds in ZWD (Zimbabwe dollar) based on timing of the activity rather than in large lump sums.
There is a difficult donor and funding environment in Zimbabwe involving restrictive conditions on funding. Support is provided mainly to humanitarian interventions and there is restriction on support to government interventions. This poses challenges when emergency nutrition interventions are primarily the domain of the government. It has therefore been very difficult to attract support to treat malnutrition in the context of HIV/AIDS although donor advocacy and linking malnutrition to HIV proposals has resulted in some success in attracting funding.
Zimbabwe has a strong nutrition infrastructure with tertiary training in nutrition and also provincial and district level nutritionist positions within the MoHCW. However, the 'brain drain' over the past several years has meant that many of these positions are now vacant or are filled by new graduates with limited experience. Because of this there is a diminishing capacity to implement quality nutrition programmes, including the treatment of severe malnutrition. UNICEF has been providing support to the National Nutrition Unit in the establishment of community based nutrition programming, including CTC, to alleviate the strain on the health services. Some NGOs provide nutrition support to health clinics. However, since historically the MoHCW has had good capacity, few NGOs have been involved. UNICEF through the NTCG has been working to improve government and NGO collaboration.
Addressing chronic nutritional problems
Nutrition trend analysis in Zimbabwe has shown increasing levels of chronic malnutrition and the Demographic and Health Survey (DHS) of 2005/6 found national levels of stunting of 29%. Addressing chronic malnutrition requires an integrated response including food security, care practices, health aspects of malnutrition and water and sanitation. However, Zimbabwe does not have a National Nutrition Policy in which to frame these interventions. A 2005/6 nutrition intervention mapping exercise found that the focus of NGO nutritional activities is on food security with few working on the health and care components of malnutrition. In 2007 the NTCG emphasised capacity development of its members and a number of trainings were conducted to broaden nutrition skills. Plans are in place to develop a National Nutrition Policy and the NTCG will be included in the consultation process.
Greatly expanded reliable data
Given the reluctance of the MoHCW to allow nutrition surveys, few have been conducted since 2003 to inform programming. In 2004, UNICEF started supporting the Food and Nutrition Council to establish a National Food and Nutrition Sentinel Site Surveillance System (FNSSS). The system now collects data biannually in 23 sites but is flexible and can be expanded to respond to worrying trends. This occurred following the June 2007 assessment and has resulted in the October assessment covering 60 rural districts and selected urban sites. Through the FNSSS the country now has access to timely nutrition data to inform programming. The NTCG has facilitated NGO involvement in the FNSSS in their areas of operation and NGOs are encouraged to participate in the FNSSS rather than conduct their own surveys.
The NTCG has undertaken an intervention mapping exercise for the Nutrition Sector. The 2005/6 Who-What-Where Atlas has been developed to serve as a planning tool for improved coordination in nutrition. Continued mapping is planned on an annual basis to determine the response capacity of the sector and identify key players for specific activities. In June 2007 the second Nutrition Atlas was published which is part of a broader initiative that includes intervention mapping for child protection (Orphans and Vulnerable Children (OVC)) and water and sanitation. Mapping exercises include already implemented activities as well as planned activities, in order to further strengthen coordination. Data collection tools are standardised to promote recognition and participation among partners.
Creation of the NTCG
A focus group discussion in Zimbabwe
The NTCG has acted as a forum for presenting, A focus group discussion in Zimbabwe D Stevens/UNICEF, Zimbabwe, 2005 sharing and discussing best practice in nutrition and HIV - an emerging area where new findings and guidelines regularly enter the public domain. The NTCG has opened its membership to include agencies working in HIV.
The NTCG has maintained a degree of emergency preparedness for Zimbabwe with coordination mechanisms in place for a scaled up response if needed. The Group meets monthly and is active in emergency preparedness activities including contingency planning and capacity development.
Currently, many non-specialists are working in the nutrition sector as well as members of the NTCG. Based on findings from the Nutrition Atlas and from a training needs assessment done with members of the NTCG, a training programme was conducted in 2007 with an emphasis on nutrition education for people living with HIV/AIDS (PLWHA).
There has been considerable consultation around Zimbabwe becoming a global cluster. Several workshops on UN humanitarian reform, and specifically on cluster coordination and what it means for Zimbabwe, have been conducted. Deliberations from these meetings and workshops are always fed back to the NTCG. The Group is in the process of discussing possible implications for nutrition coordination so that all members are fully aware and have participated in the process.
The 'Atlas' intervention mapping exercise, which describes who is doing what and where in the nutrition, water and sanitation and OVC sectors, has been a successful initiative to link coordination between the sectors. There is strong representation of different sectors in each of the coordination meetings along with strong informal linkages.
Zimbabwe's complex and colliding problems present enormous challenges to the nutrition sector. However, greatly improved coordination and reliable and current data have created the foundation for effective interventions. As the need in Zimbabwe grows, it is vital this coordination is maintained and donor support is broadened.
For further information, contact: Dianne Stevens, email:firstname.lastname@example.org
Taken from Field Exchange Issue 32, January 2008