Capacity Mapping and Capacity building in Emergencies,Afghanistan – case study

Basra HassanNutrition Cluster Coordinator

Global Nutrition Cluster Annual MeetingGeneva, 9 – 11 July 2013

Nutrition Situation

• Country was looking forward – MICS 2011 as the last National Nutrition Survey (NNS) was conducted in 2004.

• Unfortunately major errors were reported found in the Anthropometric data.

Nutrition Situation small scale surveys 2011/2012, Sentinel Site Surveillance &

CMAM.Surveys

Overall mixed picture, still high levels of nutritional vulnerability. I. Particular Concern over the: (a)conflict affected Provinces: South/South-East Regions: Only one province surveyed (Paktia with GAM 17% and SAM 5.6%) and there is assumptions others to be the same.II. Drought Affected Provinces:Northern Regions - 3 provinces of the 5 provinces surveyed showed:GAM Ranging from 9% - 14% and SAM Ranging from 2% - 4.8%.North-Eastern Region - 2 provinces:MUAC – GAM 30%; SAM – 10.7% for BadakhshanGAM – 10.4%; SAM 2% for Takhar. At National level – 9% GAM and 2% SAM at any given time . This means approx. >400,000 wasted and almost 90,000 SAM.

CMAM/Sentinel Site surveillanceCMAM>539 sites in 21 provinces servicing OTP and approx. 400 sites SFP; In 2012 CMAM Admission: 60,000 SAM and 119,973 MAM U5.Sentinel Site Surveillance in seven drought affected provinces indicates persistent acute malnutrition ranging from 14% to 23% with high incidence rates of Diarrhea ranging 4% to 15%; peak from May - Dec. Persistent Stunting – one of the highest in the world: More than 1 in every 2 U5 children is stuntedCauses:Widespread poverty, conflict, lack of availability of food and poor diet, feeding and caring practices are major causes of malnutrition in the country.In general Breast Feeding is common but poor exclusive breastfeeding and complementary feeding.

2011 Capacity Mapping Results

Results of 2011/2012 Capacity Mapping in Prioritized areas

Prioritized Technical Area

2011 2012 Remarks

NiE 25% 40% More training conducted at Regional level

Trained on SMART 18% 38% More training planned at regional level

Trained on Surveillance

26% 65% To be nationalized and therefore more training planned

IFE 8.4% 18% Better results expected in 2013

ToT - CMAM 46% 76% Better results expected in 2013

Micronutrient 11% 67% Better results expected in 2013

Trained on Cluster Approach

25% 15% Most trainings in cluster approach conducted in 2011 during the cluster roll out to regions

Trained on EPRPTrained on contingency planningExperience in drafting proposals

Trained on HTP for Nutrition in EmergencyExperience in IFE programmes

Experience on use of Breastmilk SubstitutesExperience in IYCF programmes

Experience in micronutrient programmesUndertaken ToT on OTP

Undertaken ToT on In-patient componentExperience in community mobilization

Experience in SFPExperience in OTP

Experience in In-patient component of CMAMTrained on the new WHO growth standards

Experience in new WHO growth standardsExperience of linking with other interventions

Experience in Nutrition SurveillanceTrained on SMART survey methodology

Experience in conducting SMART surveysTrained on coverage survey

Experience in coverage surveyTrained on cluster approach

Trained on nutrition in emergencyActed as nutrition cluster coordinator

Experience in rapid assessmentsLessons learnt experience

Monitoring and evaluation experience

23%18%

42%16%

8%28%

66%11%

46%54%

64%85%

71%70%

48%68%

59%26%

18%25%

24%22%

25%25%

12%32%

34%70%

20%22%

47%20%

18%35%

69%67%

76%71%

82%73%

76%76%

40%42%

58%65%

38%27%

22%20%

15%40%

7%25%

71%85%

Percentage of staff trained or experienced in technical areas, 2011 and 2012 assessments results comparison

2012 2011

Capacity building to fill in the identified gaps: To improve program functionality and response

• CMAM Training of Trainers established to support the expansion of CMAM. Two more CMAM training conducted. 75 medical doctors trained.

• CMAM guidelines revised and use of MUAC expanded and introduced and reporting format and timeline agreed with implementers.

• TFU guidelines revised and WHO conducted a number of TFU trainings.

• MN: UNICEF trained health workers on MN and conducted mass distribution of micro –nutrient supplementation.

• IYCF: Cluster developed an IYCF Pyramid regarding contact points for IYCF dialogue. All PCA’s signed with UNICEF ensured to cover IYCF and WASH.

• Cluster rollout into 5 regions.• NiE: At national level Master Trainers

representing all regions in the country established. Regional Trainings now completed. Plan to roll out to disaster prone provinces.

• NiE – Materials contextualized in Afghanistan context developed and translated in local language.

• Sentinel Site Surveillance introduced to health workers to expand the amount of data available to monitor the situation. -

• SMART Nutrition Survey: MOPH approved SMART Methodology to be the method of choice when conducting nutrition surveys in an emergency situation which lead two patched 60 cluster members trained on smart methodology .

• Coordination: Cluster rolled out in 5 Regions

• IM: Cluster hired an information management officer through standby arrangement to improve capacity of nationals on reporting.

• Bulletin: Cluster started producing a peridic bulletin for information sharing with cluster members – most of the message – translated in the local language for members in the field particularly the Provincial Nutrition Officers for regular updates

Outcome/implications60 cluster members trained on SMART. Trained members playing a big in the on-going NNSRNA - finalized and validated along with SMART survey – showing good results available to cluster members to use.Number of surveys conducted by cluster members increased (16 provinces surveyed and 3 RNAs conducted). CMAM expanded from 150 sites to 539 OTP sites and 348 SFP.Sentinel site Surveillance: Other clusters (FSAC & WASH) showed interest to participate.• Sentinel Site Surveillance – received funding from CIDA –

almost $ 7 million for 2 and half years. MOPH/PND – Great efforts to improve IYCF and agreement of IYCF-E as integral part of the IYCF policy.Implications: This played a role in improving status of Nutrition in BPHS system and brought more funds. Only cluster 95% funded in the 2013 CHAP

Enabling Factors Supportive line ministry/Department, BPHS /

government stakeholders. Nutrition prioritized amongst the 7 priority

areas of BPHS Availability of Funds – ERF, CERF, bilateral. Coordination/ training capacity Good collaboration with health, WASH and

FSAC. National Nutrition Survey – in process Innovative models of service delivery coming

soon

Challenges/Constraints Capacity – Mapping : voluntary involvement – limited participation. Capacity building - trainings for technical people and those in the field. Many

times senior management and not technical persons respond to questionnaires. Limited capacity to supervise and monitor due to inadequate government

manpower and insecurity . Sustainability:

a. Limited resources - only short- term donor funding is available. Program continuity affected and retaining staff.

b. High staff turnover in the BPHS- system based on bidding system.c. Over-burden to already over –stretched and a poorly functioning health

system.Mixed messages• Moving from Emergency Nutrition Programing to Development Programming• Change of Indicators from GAM/SAM to Stunting • From Cluster Coordination to Sectoral Coordination – Transitioning started• From One Ministry to Multi-Sector Coordination for Nutrition• Main Challenge of Short term Funding vs Long Term funding

Lesson’s Learnt• Capacity Mapping/Building is a key for success of cluster coordination and must be

envisaged in the early stages of the cluster activation.

• Without a proper mapping – difficult to estimate level of capacity.• NiE – training and capacity building – improves understanding of what is required

in Nutrition during emergencies. It also improved interest and created motivation for non-nutrition implementing agencies.

• NiE – can play an advocacy role for responding emergency related to Nutrition.• NiE – trainings at the field level should not be limited to Nutrition people but

expanded to others at supportive levels.• RNA - using a validated RNA tool along SMART survey if and when possible maybe

best way to go in situation like Afghanistan with security constraints and limited capacity along with SMART survey when if required.

• GNC – to come up with a simple but accredited tool for capacity mapping and with simple analyzing method to facilitate field staff to be able to conduct the mapping

4. Sentinel site Data produced so far

Food security, Nutrition And WASHProvince: Sari_Pul Month: JanuaryDistrict: Sari Pul Year: 2013Village: Kash qari Partner: ACTD-Oxfam

Child position

Age (Months) Sex MUAC

(cm)Oedema

(Y/N)Diarrhea

(Y/N)

Levels of Malnutirtion

Protected Water

Source (Y/N)

Water Treatment

Method

Hand washing practices

Observations hh1

hh2

hh3

Level of Hunger csi

1csi2

csi3

csi4

csi5

CSI score

Youngest 9 M 14 No No Normal No Boiling After defecation Soap availability 1 0 0 1 2 0 0 0 5 Normal Cases 35%hh using protected water sources 30% #HH litt le/no hunger 0

Before food preparationMostiquito net Mild Cases 29 #HHModerate hunger 0

Before eating Jerrican (transport&storage) Moderate Cases 1 Boiling water 66% #HHSevere hunger 0

After cleaning child faecesAsh/other for handwash Severe Cases 1 Using tablets 2% %HH lit tle/no hunger#DIV/0!

Only Child 19 M 13 No No Mild No Boiling After defecation Soap availability 1 1 0 2 1 2 0 0 6 Oedema 0 Using natural 32% % HHModerate hunger#DIV/0!

Before food preparationJerrican (transport&storage) Severe Wasting 1 Biosand filtration 2% %HHSevere hunger#DIV/0!

Before eating Severe Cases 1 Mean CSI #DIV/0!

After cleaning child faeces Total AM 2 After defecation 100% TOTAL Assessed 0

Youngest 24 F 14 No No Normal Yes Natural/sedimentationAfter defecation Soap availability 1 1 0 1 2 1 0 0 6 Diarrhea 6 Before preparing food 100%

36 F 14.8 No No Normal Before food preparationJerrican (transport&storage) Total-Diarrhea (%) 9% Before eating food 100%

Before eating Total Acute Malnutrition (%)3.03After cleaning children faeces 100%

After cleaning child faeces Total Measured 66

Only Child 36 F 14 No No Normal No Boiling After defecation Soap availability 1 0 0 1 1 0 0 0 3 Soap for hand washing 92%

Before food preparationMostiquito netJerrican for transport and storing water 18%

Before eating Bathing facility 70%

Water traitment model

Hand washing practices

Observat ions

Nutrition

Food Security

WASH

Food Security Dashboard

Coping Strategy Index

Household Hunger Scale

Nutrition Dashboard

WASHDashboard