Evaluation of ECHO's intervention in the Sahel (2010 -...

Written by ICF Consulting Services Limited February 2016

Evaluation of ECHO's intervention in

the Sahel (2010 - 2014)

Final Report

This report was commissioned by the European Commission.

The opinions expressed in this document represent the authors’ point of view which is not necessarily shared by the European Commission or by the authorities of the concerned countries

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Luxembourg: Publications Office of the European Union, 2016

ISBN: 978-92-79-52733-3

DOI: 10.2795/63521

© European Union, 2016

Reproduction is authorised provided the source is acknowledge

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Evaluation of ECHO's intervention in the Sahel (2010 - 2014) – Final Report

Table of Contents

List of abbreviations

Abstract

Executive summary .................................................................................................. 1

1 Introduction ................................................................................................ 9

1.1 Evaluation scope, objectives and methodology ............................................ 9

1.1.1 Scope ............................................................................................................................. 9 1.1.2 Objectives ...................................................................................................................... 9 1.1.3 Methodology................................................................................................................... 9

1.2 Validity of the evaluation results ............................................................... 10

1.3 This Report................................................................................................ 11

2 Overview of ECHO’s intervention............................................................... 12

2.1 The rationale for ECHO’s intervention in the Sahel region .......................... 12

2.2 Description of the Sahel Strategy ............................................................... 20

2.2.1 Overview of the Strategy .............................................................................................. 20 2.2.2 Scope of the Strategy .................................................................................................. 23 2.2.3 The evolution of the Sahel Strategy ............................................................................. 24

2.3 Intervention logic ...................................................................................... 26

3 Evaluation findings .................................................................................... 28

3.1 Relevance ................................................................................................. 28

3.1.1 Targeting of the intervention and identifying the most vulnerable ............................... 28 3.1.2 Needs addressed ......................................................................................................... 32 3.1.3 Consultation with national and sub-national actors ..................................................... 33

3.2 Coherence ................................................................................................. 35

3.3 EU Added Value ........................................................................................ 38

3.4 Effectiveness, impact and sustainability ..................................................... 40

3.4.1 Effectiveness of the Strategy in reducing mortality linked to malnutrition in a sustainable way ........................................................................................................... 41

3.4.2 Effectiveness of funded projects and ECHO advocacy on influencing other donors and in contributing to LRRD ................................................................................................ 50

3.4.3 Effectiveness of actions in influencing national actors ................................................ 53 3.4.4 Effectiveness of the regional and multi-annual approach ............................................ 56 3.4.5 Main factors limiting the success of the projects funded ............................................. 57

3.5 Efficiency .................................................................................................. 58

4 Conclusions and recommendations ........................................................... 61

4.1 Relevance ................................................................................................. 61

4.1.1 Relevance of the actions to the needs of the most vulnerable .................................... 61 4.1.2 Consultation with national and sub-national authorities .............................................. 62


4.2 Coherence ................................................................................................. 62

4.3 EU added value ......................................................................................... 63

4.4 Effectiveness ............................................................................................. 64

4.4.1 Effectiveness in reducing mortality sustainably ........................................................... 64 4.4.2 Effectiveness in influencing international donors and implementing LRRD ................ 66 4.4.3 Effectiveness in influencing national actors ................................................................. 67 4.4.4 Effectiveness of the regional and multi-annual approaches ........................................ 67

4.5 Efficiency .................................................................................................. 68


List of abbreviations

3N Les Nigériens nourrissent les Nigériens (Nigeriens feed Nigeriens)

ACF Action Against Hunger

AECID Agencia Española de Cooperación Internacional para el Desarrollo (Spanish Agency for International Cooperation and Development)

AFD Agence Française de Développement (French Development Agency)

AGIR Global Alliance for Resilience Initiative

ALIMA Alliance Médicale pour l'Action Internationale (Alliance for International Medical Action)

AMCP Alliance Médicale Contre le Paludisme (Medical Alliance Against Malaria)

AVSF Agronomes et Vétérinaires Sans Frontières

BCC Behaviour Change Communication

BSFP Blanket Supplementary Feeding Programme

CAP Consolidated Appeal Process

CILSS Comité permanent Inter-Etats de Lutte contre la Sécheresse dans le Sahel (Permanent Interstates Committee for the Fight against Drought in the Sahel)

CMAM Community Management of Acute Malnutrition

CNNTA National Centre for Nutrition and Food Technology

COGES School Management Committee

COOPI Cooperazione Internazionale (International Cooperation)

COSAN Health Committees of Niger

CRENAS Centre de Récupération Nutritionnelle Ambulatoire pour la Malnutrition Sévère (Emergency Feeding Centre for Severely Malnourished)

CRENI Centre de Récupération et d’Education Nutritionnelle Intensif (Intensive Nutritional Rehabilitation Centre)

CRPs Country Resilience Priorities

CSCOMs Referral Health Centres

CSSA Cadre Stratégique de Sécurité Alimentaire (Food Security Strategic Framework)

CSP Child Survival Project

DE Germany

DEVCO International Cooperation and Development

DIPECHO ECHO's disaster preparedness programme

DfID Department for International Development

ECHO Humanitarian Aid and Civil Protection

ECOWAS Economic Community of West African States

EDF European Development Fund

EU-Del European Delegation

EWS Early Warning System

FAO Food and Agriculture Organization of the United Nations


FPA Framework Partnership Agreement

FR France

GAM Global Acute Malnutrition

GDP Gross Domestic Product

GPRSP Growth and Poverty Reduction Strategy Paper (Mali)

HCs Health Centres

HCT Humanitarian Country Team

HDI Human Development Index

HEA Household Economic Approach

HH Household

HIP Humanitarian Implementation Plan

HRP Humanitarian Response Plan

IDPs Internally Displaced Persons

IMAM Integrated Management of Acute Malnutrition

IMCI Integrated Management of Childhood Illness

IOs International Organisations

IR Ireland

IRC International Red Cross

IRP Integrated Rehabilitation Program

IT Italy

ITP In-patient Treatment Programme

IYCF Infant and Young Child Feeding

JHDF Joint Humanitarian Development Framework

MDM Médecin Du Monde

MM Moderate Malnutrition

MMR Maternal Mortality Rate

MN Malnutrition

MoU Memorandum of Understanding

MSF Médecins Sans Frontières (Doctors Without Borders)

MUAC Mid-Upper Arm Circumference

NACS Nutrition Assessment, Counselling, and Support

NGO Non-Governmental Organization

NRP National Resilience Priorities

NUSAPPS Nutrition, Sécurité Alimentaire et Politiques Publiques au Sahel (Nutrition, Food Security and Public Policy in Sahel)

OCHA (UN) Office for the Coordination of Humanitarian Affairs

OFDA Office of US Foreign Disaster Assistance

PAIN Intersectoral Plan for Nutrition (Mauritania)

PAPU The Government’s Emergency Priority Action Plan (PAPU) (Mali)


PCMMA Pre-Crisis Market Mapping and Analysis

PDM Post Monitoring Distribution Surveys

PHASE Providing Humanitarian Assistance in Sahel Emergencies

PLW Pregnant and Lactating Women

PPP Purchasing Power Parity

PU-AMI Première Urgence - Aide Médicale Internationale

REACH Accelerating the Scale Up of Nutritional Actions

RPCA Réseau de Prévention des Crises Alimentaires (Food Crisis Prevention and Network)

RUTF Ready-to-Use Therapeutic Food

SAM Severe and Acute Malnutrition

SC Stabilisation Centre

SFP Supplementary Feeding Programme

SMART (surveys) Standardized Monitoring and Assessment of Relief and Transitions

SMART (objectives) Specific, Measureable, Attainable, Results-oriented, Time-bound

SMC Seasonal Malaria Chemoprevention

SOSAR Stratégie Opérationnelle de Sécurité Alimentaire Régionale (Operational Strategy for Regional Food Security)

SPHERE Humanitarian Charter and Minimum Standards in Humanitarian Response

SRAF Situation and Response Analysis Framework

SRP (UN) Strategic Response Plan

SUN Scaling-Up Nutrition

STC Save the Children

SWAC Sahel and West Africa Club

TdH Terre des Hommes

UEMOA West African Economic and Monetary Union

UK United Kingdom

UN United Nations

UNEP United Nations Environment Programme

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

WaSH Water, Sanitation and Hygiene

WFP World Food Programme

WHO World Health Organization

W/H Weight for Height


Abstract

This report presents the results of the evaluation of DG ECHO’s Sahel Strategy, from 2010 to 2014.

The aim of ECHO’s Strategy was to reduce mortality linked to malnutrition through treatment, as well as small-scale prevention activities to address the ‘root causes’ of malnutrition.

The evaluation concludes that ECHO was effective in reducing mortality, but was not successful in reducing malnutrition overall, suggesting that the results gained may not be sustainable. Malnutrition is a continuing problem in the region and there remains a lack of government ownership of the problem, as well as a lack of national capacity. International development donors are not yet managing to address chronic malnutrition and its structural causes at community level.

This evaluation recognises some of the significant achievements of the Sahel Strategy in making steps towards the linking of relief, rehabilitation and development actions (LRRD), but also finds that more needs to be done in this area. It proposes that ECHO develop a theory of change for the future implementation of the Strategy; that it works together with DG DEVCO to develop joint humanitarian development frameworks (JHDFs); and that it develops country-level integration plans as part of its future approach in the region.


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Executive summary

The Sahel belt1 is affected by a variety of crises including recurrent natural disasters (droughts and floods) and epidemics, scattered conflict and violent extremism. The humanitarian situation in the region is worsened by high levels of poverty, rapid demographic growth and increased pressure over natural resources. Malnutrition and food insecurity are particularly acute and persistent in the region, resulting in high levels of child and maternal mortality and morbidity. An estimated 571,000 children die of malnutrition and health related causes each year in the Sahel. The region has experienced three food and nutrition crises in quick succession during the last decade (2005, 2010, 2012). In response to the 2005 food and nutrition crisis in Niger – which is estimated to have affected 800,000 children - ECHO launched the “Sahel Strategy”.

The Sahel Strategy

The Sahel Strategy is a regional, multi-sectoral and multi-annual strategy implemented by the Directorate-General for Humanitarian Aid and Civil Protection (ECHO) in West Africa. Launched in 2007, the Strategy aims to reduce – in a sustainable way - the persistently high levels of mortality linked to malnutrition among children and pregnant and lactating women (PLW) in the region.

Initially covering five countries (Burkina Faso, Chad, Mali, Mauritania, Niger), the Strategy was extended to cover Senegal in 2012 and some regions of Nigeria and Cameroon in 2014.

In its first phase (2007-2011), the Sahel Strategy focussed on three strategic objectives:

■ Improving the knowledge baseline of the causes and extent of acute malnutrition;2 ■ Implementing response actions to tackle acute malnutrition in the most vulnerable population; and ■ Advocacy and awareness-raising to stimulate international donors and national actors to scale up

nutrition services and to address the root causes of chronic and acute malnutrition.

In 2012, when the third nutrition crisis in seven years hit the region, ECHO funding increased threefold to scale up the treatment of malnourished children. Following this, there was a noticeable shift in the Strategy’s focus from knowledge building towards treatment. Advocacy directed at improving the linking

of relief to rehabilitation and development (LRRD) and the establishment of a ‘contiguum’ approach to international aid in the region3, remained an important objective. From 2013 onwards, there was an increased focus on prevention and resilience-building.

Figure 1 provides an overview of the types of actions funded under the Strategy. Most funding during the evaluated period went on food assistance and nutrition actions, though health interventions (curative and preventative) and some livelihoods, Water, Sanitation and Hygiene (WaSH) and educational actions were also funded. The majority of partners received funding over multiple years both because the problems they addressed were chronic and because multi-annual funding was expected to help ECHO partners to achieve longer-term goals such as integration of their projects into national systems, behavioural change in communities and the scaling up of their projects by development donors.

1 The Sahel belt is an arid band of land stretching 1.1 million square miles from Senegal in West Africa to Chad in Central Africa, encompassing seven countries: Mauritania, Mali, Niger, Chad, Senegal, The Gambia and Burkina Faso, along with the northern regions of Nigeria and Cameroon. 2 The Strategy also encouraged partners to pilot and collect evidence of the impact of their actions to generate an evidence base that could support advocacy actions. 3 The ‘contiguum approach’ to international aid is an integrated and encompassing approach whereby relief, rehabilitation, and development are carried out side by side in order to respond effectively to all aspects of a crisis.


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Figure 1.1 Typology of actions funded under the Sahel Strategy

Evaluation objectives and scope

This evaluation provides an independent assessment of the relevance (including coherence, connectedness and EU added value), effectiveness, efficiency and sustainability of the Sahel Strategy. It covers a five year period starting from 2010 to 2014. During this period, ECHO allocated over 523 million euros to the Sahel Strategy through ten funding decisions, of which half were regional in scope and half were country-specific. Overall, 312 projects (amounting to a value of 472.42 million euros) fall within the scope of this evaluation. These projects were implemented by a range of partners in the following six countries of the Sahel region: Burkina Faso, Chad, Mali, Mauritania, Niger and Senegal4.

Data sources and methods

The evaluation was designed to respond to a specific set of evaluation issues and questions, as articulated in the Terms of Reference. It is based on evidence sourced from:

■ Desk research: covering ECHO policy and programming documents, programming documents of other donors active in the Sahel, reports and statistical data and academic and grey literature.

■ Project documentation: an in-depth review of project reporting and ECHO’s monitoring data was conducted covering a purposefully-selected sample of 80 out of 312 in-scope projects.

■ Online survey of ECHO partners: all ECHO partners funded under the Strategy were invited to participate in an online survey. Responses were received from 50 partners, representing almost half of the funded projects.

■ Fieldwork in select countries: fieldwork was carried out in Mali, Niger and Chad to verify and supplement the evaluative evidence. Fieldwork involved on-site visits to select projects and

4 Although ECHO has also funded projects responding to the ongoing conflict in the region during this period and under the Humanitarian Implementation Plans covered by the evaluation, the Sahel Strategy and therefore, this evaluation only covers projects in nutrition, food security and related sectors

Treatment

� Treatment of medically complicated cases of malnutrition (emergency admittance)

� Therapeutic feeding of severely malnourished children

� Targeted distribution of therapeutic foods to severely malnourished children

� Support for community management of malnutrition (CMAM)

� Capacity-building of national health-workers and community health relays

� Stock building of therapeutic foods and medicines

Prevention

� In-kind food assistance and cash transfers targeted at very poor households during lean seasons

� Integration of preventative actions into treatment activities (e.g. distribution of hygiene packs to mothers of malnourished children at health centres, vaccination of malnourished children, etc,)

� Pilot livelihood projects e.g. helping communities to grow their own gardens and teaching them how to diversify their diets and food production (2010 and 2011 only)

Advocacy

� Advocacy at national and sub-national level for:

o Free healthcare for children under 5,

o Nutrition and poverty indicators to be included in national Early Warning System (EWS)

o Social safety nets,

o Multi-sectoral approaches to malnutrition, and

o National management of nutrition services.

Knowledge

� SMART surveys undertaken by UNICEF to assess malnutrition and mortality levels

� Development of the ‘Household Economic Analysis’ (HEA) method for targeting poor households in need of food assistance

� Specific studies testing different methods and approaches


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communities and interviews with a range of stakeholders including national/ local authorities, partners, beneficiaries, local health workers and other development/ humanitarian actors.

■ Regional partners’ conference: members of the evaluation team attended the Regional Partners’ conference organised by ECHO in Dakar in October 2015 which provided further insights on the performance of the Strategy as well as an opportunity to carry out consultations with stakeholders.

Validity of the evaluation results

Several factors influenced the choice of methods used for the evaluation:

■ It was not feasible to conduct a review of the full portfolio of in-scope projects due to budget constraints. A purposeful sample was therefore, selected to capture the diversity of actions funded by ECHO and the diversity of contexts in which the intervention took place;

■ For practical reasons i.e. time and budget available for the evaluation and security concerns, it was not possible to randomly select sites for fieldwork. The approach to selection of sites for fieldwork was therefore, both purposeful and convenient.

■ Lack of time-series and district-level data on malnutrition indicators meant that it was not possible to determine how the malnutrition situation had evolved in the areas that received ECHO funding.

Complementary research methods were therefore, used to enhance the reliability and validity of the data collected and to provide the basis for cross-verification, corroboration and triangulation of the evaluation results. The vested interests of different stakeholder groups were taken into account to address potential bias and to ensure objectivity. Validation workshops with stakeholders and ECHO, and external peer review also contributed to substantiate the validity of the evaluation results.

A critical reflection of the design of the Sahel Strategy

The regional approach

The Sahel countries covered by the Strategy have in common high global acute malnutrition (GAM) rates, high rates of poverty, and vulnerability to food insecurity. They also have in common insufficient access to health services, a lack of well-established social safety nets and a lack of government capacity or willingness to address malnutrition through national systems. Through the Strategy, ECHO applied a common approach of treatment, advocacy, research and prevention to a common problem. By being consistent in its messaging across the region, ECHO emitted a stronger message (on the multi-sectoral approach, on LRRD, on the scale of the problem) to partners, state actors and other donors. Learning generated through the different projects was shared at annual partner meetings and integrated into ECHO’s annual funding decisions. At the same time, ECHO’s approach was flexible enough to take account of and adapt to country specificities (e.g. variation in humanitarian needs, national capacity etc.).

Going forward, it makes sense for ECHO to retain its regional approach to tackling malnutrition. Firstly, the countries continue to be affected by the same problems. Moreover, malnutrition and poverty are increasingly affected by the conflict ongoing in the region, which affects borderland areas of the region (e.g. Lake Chad) and there is thus, a cross-border dimension to the problem. It therefore, makes sense for ECHO to continue developing its response at a regional level, while also allowing the flexibility to adapt the approach and interventions to country specificities. Secondly, considering that other important international actions aimed at addressing malnutrition and resilience – such as the Global Alliance for Resilience Initiative (AGIR) and the UN’ Strategic Response Plan (SRP) for the Sahel are implemented regionally – it will be easier for ECHO to complement these actions through a regional strategy.

The regional approach could be enhanced, however, if ECHO were to encourage a more targeted exchange of good practices and learning across countries. For example, ECHO could fund ‘twin’

actions in regions of different countries experiencing similar problems (e.g. malaria prevention actions in two areas of high prevalence, strategies to prevent low hospital retention rates in two regions of high drop-out rates, actions to improve the quality of health provision in two regions with high post-discharge rates). ECHO could also fund actions to replicate activities that have proven successful in one country in another country. Such an approach would generate an evidence base that could be used to


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encourage development donors to scale up the intervention nationally and across countries. The EU’s Directorate-General for International Cooperation and Development (DEVCO) and other donors can sometimes be reticent to fund actions that have only been tested in one locality;5 by testing them in more than one country, the evidence base will be stronger.

Country coverage

In 2014, ECHO added some parts of Cameroon and Nigeria to the scope of the Strategy. This is appropriate given high GAM and food insecurity rates in Sahel regions of these countries (Nigeria has the highest GAM rates in the region in spite of having the highest GDP per capita within the region). However, there is potentially a risk that by increasing the geographical scope of the Strategy too widely, ECHO will spread its resources too thinly which might affect the quality of its interventions. ECHO could mitigate against this risk by focussing its interventions in Nigeria and Cameroon on (a) advocacy actions that use the evidence base generated in other countries to advocate for greater government responsibility for tacking malnutrition and (b) emergency response actions to sudden food and nutrition crises. Overall, across the region ECHO’s interventions should be underpinned by a clear theory of

change and focusing on outcomes and impacts rather than outputs. Furthermore, ECHO should also consider focusing on fewer but more effective projects.

The multi-annual approach

The majority of partners funded under the Strategy received funding over multiple years. In total, 81% of all projects (279 out of 312 projects) were part of multi-phased projects. The multi-annual nature of the Strategy was driven by the fact that the crisis was chronic, and national and local capacity remained under-developed, thus requiring continuous intervention. But, as part of its exit strategy, a multi-annual framework was necessary to help ECHO partners achieve longer-term goals such as the integration of their services into national systems, behavioural change in communities and the scaling up of their projects by development donors.

The evidence suggests that the funding of short-term interventions within a multi-annual strategic

framework has been effective in reconciling ECHO’s operational constraints (that it can only support short-term actions) with the longer-term nature of the problem. The Strategy allowed ECHO to support longer-term interventions (i.e. multi-phased projects) through annual funding decisions. At the same time, annual funding gave ECHO more flexibility to respond to humanitarian crises. Each year, ECHO adapted the operational objectives of the Humanitarian Implementation Plans (HIPs) to differences in the humanitarian and political context (e.g. in 2011 it was an operational objective of the Strategy to have food and nutrition security in the programming of the 11th European Development Fund (EDF), which was being drafted that year).

While a multi-annual strategy provides more stability and predictability to partners (as compared to annual funding decisions that are not governed by a multi-annual strategic framework), it does not guarantee that partners will receive funding every year. Because of this, partners tend to design their projects around one-year implementation cycles, which can be counter-productive when trying to reach longer-term goals. The short implementation period can be a constraint for some prevention (i.e. those aimed behavioural change in the community) and capacity building activities.

ECHO partners funded from 2015 under the UK Department for International Development’s (DFID’s) PHASE6 funding will be encouraged to design projects with a span of several years as funding under the PHASE programme is almost guaranteed from one year to the other. In practice, this means developing an intervention over a three year period with interim annual objectives and targeting. To encourage partners to think longer-term, ECHO should also develop a programme-level theory of

change to which partners will be able to align to facilitate coherence and the achievement of the Strategy’s objectives.

5 DEVCO, in consultation for this evaluation, made the point that: “just because a pilot project worked in one district, in one country, does not mean it is going to work if rolled out across the country”. 6 Providing Humanitarian Assistance in Sahel Emergencies


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The multi-sectoral approach

That (severe and acute) malnutrition is caused by a multiplicity of factors and should therefore be addressed through multi-sectoral and multi-faceted interventions, something that has been acknowledged and accepted in the humanitarian and development community since the 1990s.7 Multi-sectoral approaches to malnutrition can have as aim to enhance and facilitate recovery (by reducing exacerbating factors) and to prevent the immediate or more fundamental causes of malnutrition.

The aim of ECHO’s multi-sectoral approach was principally to address some of the household-level causes of malnutrition (household food insecurity, illness and disease and poor access to water and sanitation) in order to reduce malnutrition rates. Initially ECHO applied a programme-level multi-

sectoral approach funding different partners to address specific sectors within a country. However, this broad approach did not work as partners rarely overlapped at community level, meaning that within a community only one or two sectoral causes of malnutrition would be covered. From 2013, with greater emphasis being given to prevention, ECHO began to encourage its partners to implement multi-

sectoral projects covering a number of sectors at once. Few partners have so far been able to do this (Action Contre la Faim are a notable example), though the shift appears to have encouraged more partners to integrate other sectoral components into their work (e.g. Médecins Sans Frontières, a typically treatment-focussed partner, is now integrating malaria prophylaxis into its interventions in Mali).

It is too early to tell whether the multi-sectoral approach is working or not. Overall, GAM and severe and acute malnutrition (SAM) rates have not fallen in the Sahel. This is likely due to several reasons including the fact that it is only since 2013 that partners have begun to address more than two sectors at once and due to the fact that prevention actions – apart from food assistance activities – have not yet been funded at a large enough scale to have an impact on malnutrition. Food assistance activities have failed to reduce malnutrition, mainly because they operate in isolation and do not therefore address other root causes. Two areas of intervention warranting greater attention going forward are WaSH and community

sensitisation activities, which have the potential to make a significant difference at a relatively low cost. However, if ECHO is to continue to take a multi-sectoral approach in order to reduce malnutrition it must rethink and adapt its programme design to this objective (i.e. in terms of the projects selected for funding), as is proposed in the recommendations to this evaluation.

The focus on LRRD

Malnutrition and related mortality in the Sahel is a humanitarian issue, but its causes are structural and therefore also an issue for development action. Through the Sahel Strategy ECHO tried to link its relief activities to the programmes of development donors and national government by advocating for them to jointly pursue ECHO’s objectives (nutrition, resilience) and (at field level) by advocating for donors and governments to take over and scale up nutrition and nutrition-sensitive actions. The Strategy also tried to support LRRD by integrating longer-term objectives, such as resilience-building and malnutrition-prevention, into emergency response actions and by funding partners to support the integration of health services funded by international humanitarians into national systems.

The Strategy achieved the following results in LRRD:

■ It persuaded DEVCO to earmark development funding8 for nutrition and resilience actions thus going some way towards bridging the current gap between relief and development;

■ It attracted DFID funding for resilience and prevention actions to be pursued through the Strategy; ■ It led to the launch of Global Alliance for Resilience Initiative (AGIR), an initiative which brings

together humanitarian and development donors with national actors to set priorities for national and international funding to address malnutrition.

In spite of these successes, there remains work to be done to establish an effective ‘contiguum’ approach to LRRD. ECHO’s mindset remains embedded in the ‘continuum’ approach (a linear approach dominated by ‘hand-over’ thinking). A gap exists between the actions of ECHO and DEVCO most visible in relation to (the lack of) longer-term prevention actions at community level and longer-term investment in the scaling up and integration of nutrition and nutrition-sensitive services at national

7 See e.g. UNICEF (2008) The State of the World’s Children. 8 11th EDF funding, which was decided in 2012.


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level. If DEVCO were to fund such actions these would clearly link the relief actions of ECHO to DEVCO development actions.

DEVCO is now (through AGIR) tasked with leading the way in encouraging national commitment to nutrition and resilience, though ECHO’s inputs and support can still add value (given ECHO’s technical expertise and historical knowledge); indeed, it would also be beneficial for ECHO to continue to monitor national progress towards Country Resilience Priorities (CRPs) and to intervene (in coordination with DEVCO) when it considers that these are not being met.

At national level, ECHO should continue to focus on integrating nutrition services into national health systems as a priority area. In doing so, ECHO is linking short-term humanitarian interventions to national development. As with all prolonged aid interventions, the risk of aid dependency and moral hazard amongst national actors is high in the Sahel. That actions to instil ownership among local and national actors are ongoing and that ECHO is increasingly focussing on these (see the 2015 HIP) are highly positive developments.

Assessment of the Sahel Strategy against the main evaluation criteria

Relevance

In line with its mandate (to save and preserve life during emergencies and their immediate aftermath),9 ECHO prioritised the immediate needs of the target populations and consequently around 85.7% of ECHO’s funding went to actions with a primary aid type of food assistance or nutrition. Given the mandate of ECHO and the scale of infant mortality10 in the region, the overall focus on treatment over prevention was relevant. However, the evaluators consider that more projects should have integrated WaSH and behavioural change in communities since these can be addressed through relatively low-

cost actions and can have a sustainable and important impact on preventing malnutrition.

Coherence

The Sahel Strategy was a key programme for ECHO in developing its policies around resilience and food assistance. It was also a vehicle through which ECHO developed its approach to LRRD. It can be argued therefore that the Sahel Strategy influenced key policies in these areas, and it did this on the basis of its work on the ground. In this respect then the humanitarian operations were aligned with ECHO policies because – to some extent – they influenced these.

ECHO actions have been largely coherent with wider national and regional policies, though ECHO’s funding for health care has inadvertently created some disparities between nationally funded health centres and those funded by ECHO. For example, in Mali, the free health care offered at ECHO-funded health centres draws patients away from national health centres where they would have to pay for treatment, thus undermining the viability of national health centres. Similarly, in Chad (and Mali) disparities in the salaries offered by ECHO and those offered by the national governments creates tensions between health workers working for the two systems.

EU added value

ECHO is a reference donor for nutrition and resilience in the Sahel region: donors such as DFID, the World Bank, DEVCO and the Swedish International Development Agency (SIDA) utilise evidence gathered by ECHO to develop their own programmes; ECHO’s evidence base has contributed to the development of national Early Warning Systems (EWS) and Social Safety Nets (SSN) and the experience of the Sahel Strategy also created a basis for the development of AGIR.

ECHO has a reputation and position globally as a coordinator of donor actions. ECHO’s technical

expertise (both at headquarter and field level) is widely acknowledged and respected by national actors and international donors active in the region. It is because of these qualities that DFID has recently decided to channel its funding (PHASE programme) to the region through ECHO (effectively increasing

9 Regulation 1257/1996, Article 2. 10 Based on data compiled by the World Health Organisation, infant mortality in 2010 was as high as 160.1 for every 1000 live births in Chad, 124/1000 in Niger, 113.5/1000 in Burkina Faso and 136.6 in Mali. While these levels declined to 2014, they remained high (above 100/1000 in all five countries). Infant mortality rates are lower in Senegal.


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ECHO’s budget for humanitarian aid) and that SIDA purposefully seeks to complement the funding of ECHO.

ECHO’s institutional relationship with DEVCO has also brought added value to ECHO’s work in the region. ECHO leveraged both its relationship with DEVCO in the field and the knowledge and expertise it developed through the Sahel Strategy to influence DEVCO’s programming and their participation in (and later coordination of) AGIR. AGIR, initiated by ECHO, is now being coordinated by DEVCO, who has dedicated 54 million euro of its budget for the Sahel region to operationalising AGIR. Nonetheless, the evaluators consider that ECHO – and DEVCO – could much better harness their relationship to greater EU added value not least by implementing the recommendations below.

Effectiveness and sustainability

Overall the Sahel Strategy was effective in achieving its stated objective of reducing mortality linked to malnutrition in the communities of intervention. It did this principally by funding actions to increase the number of malnourished infants detected, increasing the coverage and number of health centres treating malnutrition, and by funding the supply of therapeutic foods and medicines essential for the treatment of malnutrition. Malnutrition rates in the regions supported by ECHO, however, remain high (these continue to fluctuate from year to year and the number of children identified as suffering from SAM continue to rise).

A reduction in malnutrition rates is a more challenging and longer term issue that first and foremost requires commitment and ownership from state actors, who could be supported in their efforts by the international development and humanitarian community. The lack of national ownership and capacity remains a key challenge to achieving a reduction in malnutrition rates in the Region. ECHO, on its part, is rightly focusing on advocacy and integrated actions. However, a contiguum approach to LRRD is not evident in the region.

Efficiency

It is challenging to assess whether the Sahel Strategy achieved value for money as its objectives were not ‘SMART’ly defined11 – while indicating the ‘direction of travel’, they did not indicate the ‘distance to be travelled’. Nonetheless, given the contribution of the Strategy in reducing nutrition related mortality in the region and its wider achievements (putting nutrition issues on the agendas of national actors and international donors), it can be concluded with a reasonable degree of confidence that ECHO funding was well spent.

Recommendations

1) ECHO should more precisely formulate the objectives for funding over the next 3-5 years of the Strategy and organise its funding priorities around these objectives. If ECHO wishes to ‘exit’ its nutrition programme from the region, then it should discuss and agree internally the criteria upon which such an exit could be made. A clear theory of change should be developed for specifying the trajectory the programme should take to achieve its objectives. Ideally a logframe should be produced setting out targets and timeframes for the achievement of the expected outputs and outcomes. ECHO is currently operationalising a logframe for DFID’s PHASE programme, so a precedent has been set which should help ECHO to implement this change. More widely, ECHO should introduce ‘theory of change’ and logframes as standard tools supporting the development, monitoring and evaluation of its strategies. An outcomes- or impact-based approach to objective setting would also require investment in monitoring and evaluation tools that go beyond the collection of outputs data to performance tracking after the project has ended. In this respect, ECHO should invest resources in conducting impact evaluations.

2) ECHO should be realistic about the extent to which its actions can impact on GAM rates and design the future years of the Strategy on this basis. Specifically, if ECHO wishes to reduce GAM rates, it has three options:

■ Invest more money in community prevention activities (e.g. the building of latrines, clean-water access, behavioural change, disaster-risk reduction and livelihoods actions). This could lead to a reduction in GAM rates locally, but would need to be scaled up to have a wider effect. Most of these actions also require iterative support over multiple years, which ECHO is not well-placed to provide.

11 SMART objectives are specific, measurable, attainable, relevant and time-bound.


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Ultimately these actions would stretch the mandate of ECHO and potentially overlap with development activities. They could also lead to a reduction in the funding available for treatment and advocacy. The option is therefore not favourable.

■ Invest in small-scale prevention activities with the purpose of identifying good practices in reducing GAM that can be scaled up by other donors / actors. In particular, ECHO should replicate practices that work well in one country / region in different contexts to further test their effectiveness. Such actions would not guarantee an impact on GAM, since they would be dependent on external actors for scale-up, but they would be lower cost than direct ECHO actions and – should external partners cooperate – would be more likely to impact on GAM rates in a sustainable way.

■ Make better use of existing evidence generated through the Sahel Strategy to advocate for development aid and national investment in prevention: ECHO should also consider commissioning a review of its projects that would track the cumulative results generated in order to learn lessons about the most effective practices. Such a study could be commissioned with Sahel Strategy funding and coordinated by an ECHO FPA (Framework Partnership Agreement) partner.

3) ECHO should continue to participate in the AGIR forum, as well as in other regional fora (e.g. Food Crisis Prevention and Network (RPCA) meetings) to establish a functional ‘contiguum’ approach to LRRD in the region whereby joint objectives are established for each country and the responsibilities for the various actors are established taking account of their mandates, resources and capacities, and competencies. Elements of a fully joined up approach could include:

■ The development of Joint Humanitarian Development Frameworks (JHDFs)12 JHDFs, which could be developed jointly between ECHO and DEVCO in each of the Sahel countries. These would identify the main vulnerabilities and needs in each country, the different actions to be completed to address these and the different ways in which ECHO and DEVCO (and other actors) could contribute to addressing the problems. Such an assessment could be supported (and complemented) by ECHO’s parallel action to develop its programme theory of change (see recommendation above) and could feed into ECHO actions to develop national integration plans (see below);

■ A critical review of the CRPs to ensure that they address the specific country needs and vulnerabilities identified and that they are feasible for national governments to implement. On the basis of any challenges identified, means of addressing these through ECHO and DEVCO advocacy or through ECHO or DEVCO programming could be developed.

■ To support the ongoing strategic consultation processes associated with AGIR, ECHO projects should try to frame their project-level consultations with national actors within the context of AGIR and national commitments to ending malnutrition. The focus should be on how ECHO interventions can complement and help lay the ground for national authorities to take over. This would enable ECHO partners to design projects that have an in-built exit strategy aligned to national priorities.

4) ECHO should continue to fund projects that integrate advocacy actions at local and national level. ECHO country field officers should work closely with national partners to develop plans for better alignment and integration of its interventions with national health system. The ‘integration plans’ would analyse the level of integration of each of the “critical functions” of the health system, inter alia: (i) governance, (ii) financing, (iii) planning, (iv) service delivery, (v) monitoring and evaluation, and (vi) demand generation”.13 The plan would also serve as a tool for framing discussions and negotiations with national and regional stakeholders on integration and hand over. Such integration planning should also cover aspects of the current division between NGO-supported nutrition services and national health systems highlighted as problematic in this evaluation (salaries, provision of free healthcare).

12 http://capacity4dev.ec.europa.eu/resilience_ethiopia/document/joint-humanitarian-development-framework-jhdf-context-food-security 13 See: Atun, Rifat; Ohiri, Kelechi; Adeyi, Olusoji. (2008) ’ Integration of health systems and priority health, nutrition, and population interventions : a framework for analysis and policy choices’


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1 Introduction

The Sahel belt is regularly affected by a variety of crises including droughts, floods, epidemics and conflicts over resources. The humanitarian situation in the region is worsened by high levels of poverty, rapid demographic growth and increased pressure over natural resources. Malnutrition and food insecurity are particularly acute in the region. The region has experienced three food and nutrition crises in quick succession during the last decade (2005, 2010, 2012). In response to the 2005 food and nutrition crisis in Niger, ECHO launched a multi-annual, multi-sectoral, regional strategy (“Sahel Strategy”). Since the launch of the Strategy in 2007, ECHO has provided over a billion euros of humanitarian funding to tackle malnutrition in the Region.

This evaluation provides an independent assessment of ECHO’s intervention in the Sahel Region during 2010 to 2014. The evaluation was launched by the Directorate-General Humanitarian Aid and Civil Protection (ECHO) in April 2015. The evaluation was carried out by ICF with specialist inputs from experts in the fields of nutrition and food security interventions.

This Report details the work undertaken and provides a synthesis of the evidence collected within the framework of this evaluation; it sets out the findings and conclusions emerging from this evidence; and provides a series of recommendations to inform ECHO’s future interventions in the region.

1.1 Evaluation scope, objectives and methodology

1.1.1 Scope

The Sahel Strategy funded 312 projects in six countries (Burkina Faso, Chad, Mali, Mauritania, Niger and Senegal) during the period covered by the evaluation (2010 to 2014). Although ECHO has also funded projects responding to the ongoing conflict in the region during this period and under the HIPs covered by the evaluation, the Sahel Strategy and therefore, this evaluation only covers projects in nutrition, food security and related sectors. All actions addressing conflict (assistance to refugees and IDPs etc.) do not fall within the scope of this evaluation. The two Sahel countries of Nigeria and Cameroon are also outside the scope of the evaluation since these countries were only included within the Strategy from 2014 onwards.

1.1.2 Objectives

The overall objectives of this evaluation – as per the Terms of Reference - were to provide an independent assessment of the relevance (including coherence, connectedness and EU added value), effectiveness, efficiency and sustainability of ECHO’s interventions in the Sahel region over a five year period (2010-2014).

1.1.3 Methodology

The evaluation was designed to respond to a specific set of evaluation issues and questions, as articulated in the Terms of Reference. A variety of data sources were used to build a rich and comprehensive evidence base for the evaluation, most notably:

■ Documentary and literature review: which inter alia covered (i) relevant ECHO policy documents and funding decisions (Humanitarian Implementation Plans (HIPs)); (ii) polices of other humanitarian and development actors operating in the Region; (iii) reports and statistical data (e.g. SMART indicators) produced by UN agencies and other humanitarian agencies and donors highlighting the scale, nature and causes of the malnutrition crisis in Sahel countries; (iv) academic and grey literature on effective malnutrition interventions.

■ Project portfolio analysis: an in-depth analysis of 80 out of 324 in-scope projects, purposely selected to reflect the diversity and breadth of the underlying ‘population’ of funded projects and intervention contexts. The portfolio analysis was based on project


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documentation such as single forms, fiche-ops, interim and final reports and project evaluation reports (where available).

■ Online survey of ECHO partners: all ECHO partners funded under the Sahel Strategy were invited to participate in an online survey to collect feedback and data on relevance, outputs and results of the individual actions funded by ECHO. 50 responses were received in total. Many of the partners who responded to the survey had funded multi-phased projects which implies that de facto half of all of the projects in scope of this evaluation were covered by the survey.

■ Fieldwork in select countries: fieldwork was carried out in Mali, Niger and Chad to verify and supplement the evaluative evidence collected from above sources. This entailed on-site visits to select projects and communities. On-site visits provided the possibility for the team to make first-hand, independent observations of the projects funded by ECHO and the beneficiaries reached. Additionally, a series of exploratory interviews were carried out with a range of stakeholders during the field missions to take account of their different perspectives and to avoid bias. The following stakeholder groups were consulted in each country covered by the fieldwork:

– ECHO; – EU delegation (DEVCO); – ECHO partners (ACF, Alima, Coopi, Concern, Danish Red Cross, French Red Cross,

International Red Cross, MDM, MSF-FR, Pu-Ami, Save the Children, AVSF); – UN agencies (OCHA, UNICEF, WFP, WHO); – Donors (AECID,AFD, DfID, SIDA, USAID, World Bank); – National ministries of Health, Food Security agencies, Agencies responsible for Social

Safety Nets, etc.; – Local authorities; – Health workers (including community relays, doctors and nurses); and – Beneficiaries.

■ The evaluation team also attended a regional partners’ conference organised by ECHO in Dakar in October 2015 and used this opportunity to carry out consultations with stakeholders based there.

1.2 Validity of the evaluation results

The evaluators took a multi-staged approach to the evaluation, validating their findings at the close of each data collection phase. In the first stage of the evaluation, the findings of the project documentation review, complementary desk research and the online survey were analysed to develop emerging hypotheses for each of the research questions. On this basis points of inquiry (and subsequent research tools) for the field phase were developed. At the close of the field phase, emerging findings were validated through a workshop with ECHO partners (in Niger only), at ECHO HQ and through a presentation to ECHO Field staff in Dakar. The team of humanitarian experts who conducted the fieldwork participated in internal meetings to validate findings and the draft final report was reviewed by an independent nutritionist.

Some limitations to the method (and the evaluators’ approach to mitigating these) were as follows:

■ It was not feasible to conduct a review of the full portfolio of in-scope projects due to budget constraints (ECHO’s database does not enable automatic extraction of data, so information must be extracted manually). Whilst a representative sample of projects was selected for review, in hindsight this sampling approach meant that the evaluators could not construct a complete picture of the outputs and outcomes resulting from the programme, nor the scope of actions it covered. Findings from the documentation review were therefore triangulated with the findings of programme reporting an stakeholder interviews and validated with ECHO in meetings;


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■ At the outset of the evaluation the team expected to have access to time-series and district-level data on malnutrition indicators which would allow the team to explore rates “before” and “after” ECHO’s intervention in the Sahel countries and in “assisted” versus “unassisted” districts within these countries, thus enabling them to draw conclusions about the Strategy’s impact. However, this data was only available for some countries and only at the level of region. In the absence of this data, the evaluation team relied upon evidence in project reporting, the statements and anecdotal evidence provided by ECHO and ECHO partners and observations and information collected with beneficiaries and local stakeholders in the field to draw conclusions about the impact of the Strategy on malnutrition and mortality rates.

■ The selection of project sites and the duration and scope of field visits was constrained by (i) the time and budget available for the evaluation and (ii) security considerations. This limited the number of beneficiaries and local stakeholders that could be consulted and the depth to which they could be consulted. This has affected the validity of results somewhat, though the views of more than 25 separate groups of beneficiaries and local stakeholders are still represented in the evaluation.

More generally, the Sahel Strategy was both ambitious in scope and imprecise in laying out its expected outcomes and impacts. The explicitly defined objectives indicated the ‘direction’ of travel (e.g. reduction in mortality), but provided no indication of the ‘distance to be travelled’ (e.g. x% reduction in child mortality rate by 20XX). This lack of precision in objective-setting made it challenging to assess the effectiveness (and efficiency) of ECHO’s interventions.

1.3 This Report

The remainder of the document is structured as follows:

■ Section 2 describes the humanitarian situation in the Sahel Region and ECHO’s response during the period 2010 and 2014. It also sets out the reconstructed intervention logic for ECHO’s intervention in the Region;

■ Section 3 addresses the specific evaluation questions; and

■ Section 4 sets out the conclusions and recommendations of the evaluation.

The main report is supplemented by a Technical Annex which contains the detailed evidence base for the evaluation and is structured as follows:

■ Annex 1 lists the stakeholders consulted for this evaluation

■ Annex 2 provides the indicators of level of human development in the Sahel

■ Annex 3 is an overview of projects funded under the Sahel Strategy 2010 – 2014

■ Annex 4 discusses and describes the evolution of the Sahel Strategy

■ Annex 5 provides some data on target caseloads for treating SAM in the Sahel 2010 – 2014, the number (caseload) actually treated and (for 2013 and 2014) estimates of the number of children suffering from SAM

■ Annex 6 discussed GAM and SAM rates in the Sahel and in four case study regions

■ Annex 7 lists the main national institutions and key policy in Sahel countries

■ Annex 8 defines nutritional indicators


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2 Overview of ECHO’s intervention

This section examines the rationale for ECHO’s intervention in the Sahel region. It then looks at evolution of the Sahel strategy over the period of the evaluation and provides an overview of the nature of activity funded under this strategy,

2.1 The rationale for ECHO’s intervention in the Sahel region

Figure 2.1 The Sahel region in West Africa

Source: Millennium Ecosystem Assessment report on Ecosystems and Human Well-Being Desertification Synthesis14

Origins of the Sahel Strategy

The Sahel Strategy was launched in 2007 (after a development phase of two years) as a longer term and strategic response to the 2005 food and nutrition crisis in Niger. The crisis which affected 800,000 children,15 exposed the dangerously and persistently high levels of severe and acute malnutrition in Niger and surrounding countries. In 2005, ECHO provided aid to Niger to deal with the country’s immediate humanitarian needs stemming from the crisis, yet it also wanted to understand how malnutrition levels had reached such life-threatening levels. Subsequently, ECHO began to consider ways in which it could address not only the immediate crisis related humanitarian needs in the region, but also contribute to the prevention of such crises, by understanding and tackling the root causes of malnutrition in the region.

Humanitarian needs addressed by the Strategy

Child and maternal mortality in the Sahel region is amongst the highest in the world. Almost all Sahel countries - with the exception of Senegal - feature in the bottom 20 ranking of countries with the highest infant mortality rate according to UNICEF.16 Chad, Mali and Niger report the highest mortality rates for children under five years, with respectively 143, 118 and

15 http://www.who.int/hac/donorinfo/campaigns/ner/en/ 16 UNICEF: State of The World's Children 2015 Country Statistical Information (as shared with the evaluators by UNICEF)


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100 deaths for 1,000 live births.17 Chad, Niger and Mali also have the highest maternal mortality rates (MMR)18. In Chad, for every 100,000 live births, 881 mothers die from giving births compared to a global average of 192 mothers.19 Table 2.1 shows the infant and maternal mortality rates in the six Sahel countries for the year 2014.

Table 2.1 Infant mortality and maternal mortality rates 2014

Rate Niger Mauritania Burkina Faso Senegal Chad Mali

Infant mortality (under 1) per 1000 births

58 66.1 62.2 42.3 86.7 75.9

Infant mortality (under 5) per 1000 births

100 87.5 92.4 49.7 142.9 118.3

Maternal mortality 574 629 379 323 881 601

Source: World Bank Indicators, 2014.20 Shading highlights the highest rates in the region

The causes of infant mortality are multiple and include malaria, epidemics and disease, conflict and food insecurity, but the biggest cause is malnutrition, with an estimated 571,000 children dying of malnutrition and health related causes each year in the Sahel.21 Malnutrition means a lack of proper nutrition, caused by not having enough to eat, not eating enough of the right foods, or being unable to use the food that one does eat.22 When malnutrition is chronic, it leaves individuals, in particular children, vulnerable to shocks to their health from disease (e.g. malaria, pneumonia and diarrhoea), lack of food and infection. When such shocks occur, malnutrition can quickly and easily become severe and acute. Severe and acute malnutrition (SAM) is a life-threatening condition; moderately malnourished children can progress towards these conditions if they do not receive adequate support.23

Underlying causes of malnutrition

Undernutrition, including acute and chronic malnutrition, is caused by a multiplicity of factors usually analysed at three ‘levels’: immediate causes at the individual level (e.g. disease and lack of food), underlying causes occurring at household or community level (e.g. poor access to clean water, household food insecurity and inadequate access to healthcare) and basic causes or overarching drivers which are linked to political, cultural, religious, economic, educational, demographic systems at the sub-national, national and international levels.24 The diagram below (Figure 2.2) demonstrates the different factors that have an impact on children nutrition in the Sahel.

■ First, at the individual level, are poor maternal feeding practices, poor personal and household hygiene, poor healthcare, lack of access to water and a lack of food and nutrients. These are driven by household level factors such as a lack of access to

17 Under-five mortality rate is the probability per 1,000 that a newborn baby will die before reaching age five, if subject to age-specific mortality rates of the specified year as defined by the World Bank. http://data.worldbank.org/indicator/SH.DYN.MORT 18 Maternal mortality ratio is the number of women who die from pregnancy-related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births. The data are estimated with a regression model using information on the proportion of maternal deaths among non-AIDS deaths in women ages 15-49, fertility, birth attendants, and GDP. http://data.worldbank.org/indicator/SH.STA.MMRT 19 World Bank Indicators. 2014. Maternal mortality ratio (modeled estimate, per 100,000 live births) 20 World Bank Indicators. 2014. Mortality rate, infant (per 1,000 live births). 21 OCHA (2013) Humanitarian Needs overview for the Sahel region 2015: http://reliefweb.int/report/mali/2015-humanitarian-needs-overview-sahel-region See also: UNICEF West and Central Africa overview – last updated 2010 22 For definitions, see Annex 4 23 See WHO glossary of nutrition terms: http://www.who.int/nutrition/topics/moderate_malnutrition/en/ 24 The Communication on Humanitarian Food Assistance, adapted for the ECHO Thematic Policy Document on addressing undernutrition in emergencies, September 2013


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education and inadequate family planning practices and behaviours, poverty, and (again) a lack of access to food, water and healthcare.

■ These are often driven by a lack of opportunity and infrastructure at community level: livelihoods, access to social safety nets and availability of health services.

■ These in turn are driven by factors such as regional, national and international markets, the quality and existence of national infrastructure, and – most importantly – government policies on education, gender, health, food production, markets and employment.


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Figure 2.2 Immediate, underlying and overarching drivers of severe and acute malnutrition

Source: Jaques Prade’s Joint Humanitarian Development Framework Applied to Nutrition (graphics Cyprien Fabre), taken from Jan Eijkenaar (2014) End of Mission Report - ECHO


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In the Sahel, insufficient food production coupled with lack of adequate social safety nets and health services have meant that poor populations have depended on international aid for their food, healthcare and other services. Health infrastructure for nutrition is weak (though there has been some improvement over the evaluation period – see section 3.4.1) and a significant share of the population is highly food insecure. (It was estimated that in November 2014 one out of seven people in the Sahel were food insecure and one out of 50 people were severely food insecure.)25. National authorities consulted for this evaluation have underlined the importance of international aid in addressing malnutrition, but there is a feeling amongst donors that national authorities are ‘not doing their bit’. The most affected households are those classed as ‘very poor’ living on less than 0.5 USD per day.26 Social safety nets and local and regional policies aimed at supporting livelihoods can help to reduce household poverty and vulnerability, but these are missing or inadequate in many areas of the Sahel region.

In addition to infrastructural and political drivers, economic factors also play a major role in determining food availability and household income. In the past when Nigeria – which is the main supplier of cereal to neighbouring Sahel countries – has experienced severe flooding in recent years, this has led to a reduction in the availability of cereal, affecting countries heavily dependent on cereal imports such as Niger and Chad. Rapid population growth is also imposing additional pressure on already scarce health and water resources. Sahel’s population of around 80 million people27 is rapidly growing with some sources reporting that this is doubling every 20 years at a growth rate of ca. 3 per cent annually.28

More recently, internal conflicts and the rise of fundamentalist groups have added a new layer of vulnerability to the region, since it has displaced populations across borders and within particular states. IDPs and refugees are often more vulnerable to malnutrition and other health problems and thus they increase the need for humanitarian aid. Further, violence and conflict do not only kill and displace people, but also affect food production, which has a knock-on effect on food security. For instance, in the Lac Chad region the constant threat from Boko Haram has interrupted the agricultural and fishery production in the area. This has reduced the availability of food on the markets locally and in N’Djamena and driven up prices. The negative impact of violence on Nigeria’s food production has consequences beyond Nigeria’s borders, since the country is the main supplier of cereal to neighbouring Sahel countries.29

Overall the region’s humanitarian needs are complex and multi-dimensional and the interplay of above factors varies by country, as does each country’s capacity to cope with and address these issues.

Sectoral responses to the problem employed in the region

Since the causes of mortality in the region – and of malnutrition – are multiple, the response of aid donors and actors in the region has also been varied, with some focusing on food security while others focusing on health interventions or conflict etc. Overall, the largest proportion (41%) of international humanitarian aid during the evaluated period was allocated to food assistance, followed by health interventions (18%) (see Figure 2.3).30

The highest amounts of food assistance were mobilised in 2010, 2012 and 2013 in response to the 2010 and 2012 food crises. The vast majority of this assistance (91% or 1,884 million USD) was implemented by the UN’s World Food Programme (WFP) with funding from more than 50 individual donors. The majority of WFP’s funding came from USAID (29%), followed

25 OCHA - http://reliefweb.int/sites/reliefweb.int/files/resources/2015%20Regional%20HNO%20Final%202014Dec17.pdf 26 Jan Eijkenaar (2014) End of Mission Report - ECHO. 27 Excluding Nigeria and Cameroon, as only parts of these countries belong to the Sahel region. 28 Desertification in the Sahel, Ibid 29 Indeed, interruptions to Nigerian productivity caused by flooding in 2012 was one of the drivers of the 2012 food security crisis in the region. 30 Figure 2.2 illustrates the amount of funding (in million USD) spend on different sectors relevant to addressing the malnutrition crisis in the Sahel. It is not comprehensive of all sectors of humanitarian aid to the Sahel and therefore the data is not presented as proportions.


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by self-funding by WFP (22%) and ECHO (7%). The actions focussed on the delivery of in-kind food assistance, management of cash and/or voucher food assistance and livelihood protection programmes (including cash for work schemes). WFP also manages the pipeline and distribution of therapeutic foods to malnourished and food insecure households in the region.

Health interventions overwhelmingly focussed on nutrition related aspects during the evaluated period. Actions included targeted supplementary feeding of severely malnourished children, other life-saving medical support to malnourished children and capacity-building in health centres. Non-nutrition focussed actions have included responses to the Cholera outbreak in Chad in 2010/11 and responses to (including needs assessments of) the West African Ebola crisis of 2014 and 2015, preventative healthcare including children’s vaccinations and prevention and treatment actions for HIV. The main donor of health interventions was – by far – ECHO, funding 47% of humanitarian health interventions in the region 2010 - 2014. Other sources of funding included the OCHA-managed UN Central

Emergency Response Fund (CERF) (8%), Japan (6%) and WFP (5%).The implementing organisation receiving the most funding for health interventions was UNICEF (30% of all funding), but WFP was again prominent, implementing 16% of all health-focused funding on targeted feeding. Other key implementing organisations were MSF (10%), ACF (5%), Red Cross and Red Crescent Societies (4%).

Much less was spent on livelihood interventions (covered under ‘agriculture’ and ‘early recovery’ in Figure 2.3) and Water and Sanitation projects in the region, although these are recognised as key areas of intervention for addressing some of the root causes of malnutrition (poverty and household insecurity and poor access to water and poor hygiene and sanitation respectively). Further, emergency WaSH actions have included assistance to IDPs and refugees and responses to floods and cholera outbreaks, which are less directly connected to the fight against malnutrition than preventative WaSH actions focussed on households vulnerable to malnutrition.

Figure 2.3 Global expenditure on humanitarian aid in the Sahel 2010-2014 by sector (in millions

USD) – all donors

Source: OCHA Financial Tracker System. Countries selected: Burkina Faso, Chad, Mali, Mauritania and Niger.

Senegal not covered as only was included in the scope from 2012. ‘Other sectors’ includes coordination, education

mine action, protection, shelter, safety and security of staff and unspecified sectors.

112 137229 242 206

463

248

606466

298

52

22

71

62

65

21

21

87

150

11919

16

4251

294

8

2713

42124

196

233300

348

0

200

400

600

800

1000

1200

1400

2010 2011 2012 2013 2014

Other sectors

Economic recovery and

infrastructure

Water and Sanitation

Multi-sector

Agriculture

Food

Health


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A shift in focus to resilience

At the start of the evaluated period, there was a global shift in the focus of humanitarian and development programming and policy towards ‘resilience’ as a means to mitigating the impacts of and – in some cases - preventing disasters.31 Resilience building in the Sahel is about increasing national capacity to predict and prepare for climatic and economic changes triggering food crises. It is also about helping communities to predict and prepare for shocks and making them healthier and thus better able to cope with shocks when and if they arrive.32 ECHO have been at the forefront of promoting a ‘resilience-focussed’ approach to humanitarian and development aid around the world and have been responsible for establishing two multi-stakeholder initiatives in Africa: the ‘Supporting the Horn of Africa's Resilience' (SHARE) initiative established in East Africa in 2011 and the Global Alliance for the Initiative of Resilience (AGIR) in the Sahel in 2012.

Also in 2012, the Commission published a Communication on resilience ‘The EU approach to

resilience – learning from food security crises.33 Referring heavily to the SHARE and AGIR initiatives, it proposed a strategic framework for aid operations comprising a range of measures to increase resilience, including systematic analysis of risks and vulnerabilities, joint frameworks of action between humanitarian and development actors and greater flexibility in funding for transition situations.

From 2013 onwards, the Sahel Strategy began also to incorporate resilience considerations by explicitly introducing the following objective in its funding decisions: “Preventing malnutrition by reinforcing resilience of the most vulnerable populations”.

In 2014, ECHO’s Sahel food and Nutrition Crisis Report (covering the first two months of the year) estimated a rise in food and nutrition insecurity in 2013 driven not by drought, but rather as a result of a ‘resilience deficit’ amongst the population following a period of insecurity and instability (persistent conflict in northern Mali and increasing violence in northeast Nigeria) and a result of the frequency of food insecurity shocks. The analysis highlights the role of low resilience in region as a driver of malnutrition and underlines the need for greater work in this area. Overall, there is still much work to be done on building resilience in the Sahel, and thus the AGIR is a positive development. Positive too is the funding programme on Providing Humanitarian Assistance to Sahel Emergencies (PHASE) that DfID has recently launched for reducing morbidity and mortality and ensure that GAM rates across the Sahel are below the emergency threshold of 15%. Providing £139 million between 2014 and 2017 through a multi-year approach, the programme is expected to give ECHO a greater opportunity to focus on resilience and prevention.34

The distinction between DEVCO’s and ECHO’s approaches to the problem and the growing

focus on LRRD in the region

Figure 2.2 illustrated the drivers of malnutrition at different levels. Change in the factors driving malnutrition at household and community level is to a large extent dependent on change at national level. To combat malnutrition a ‘joined up’, multi-disciplinary and multi-sectoral approach is therefore needed. The Sahel Strategy was developed in recognition of this and of the fact that, without a continuous involvement of the international development community, a sustained reduction in malnutrition and child mortality could not be achieved. Humanitarian aid is designed to provide emergency relief to the most vulnerable persons. Such actions include food assistance, health interventions and other interventions as described above. These actions tend to target the household and community drivers of malnutrition. By contrast, development donors tend to work towards the wider development of the country as a whole.

31 Resilience is the ability of an individual, a household, a community, a country or a region to withstand, to adapt, and to quickly recover from stresses and shocks. – see COM (2012)586, dated 03.10.2012 32 Different ‘pathways to resilience’ are discussed and described in Gubbels, P. (2012) ‘A new drumbeat for the Sahel’ in Humanitarian Exchange number 55, September 2012 33 COM (2012)586, dated 03.10.2012 34 Interview


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They target not only the most vulnerable, but also wider populations and often focus on infrastructure and governance – thus the regional, national and international factors driving malnutrition. Development donors such as DEVCO work directly with national governments as partners while ECHO is prevented by the humanitarian principle of ‘neutrality’ from such interactions. Instead, ECHO seeks to influence national policy and practice through its partners which include the UN agencies and iNGOs. In theory therefore, humanitarian actions (i.e. ECHO’s interventions) and development activity (DEVCO’s activities) should be highly complementary and mutually reinforcing.

The reality is however, quite different, largely because there are inherent differences in the way the two DGs operate which makes coordination of activity practically challenging: ECHO, as an emergency donor, mobilises funding rapidly and targets those most in need / most vulnerable; DEVCO works not only for the needs of the most vulnerable, but those of the country at large with national governments being key partners whose priorities influence the course of action taken. While ECHO projects are planned annually, DEVCO plans its projects on a multi-annual basis. The grant selection process within ECHO lasts less than two months, whereas the selection process for DEVCO can take one year or more (draft proposals go through three rounds of discussion and refinement by before being accepted). The two also fund different types of partners (both fund iNGOs, but DEVCO also works directly with national and sub-national implementing partners). DEVCO’s projects usually have a wider geographical coverage, are of a higher value and are funded over a period of longer than one year.

At a more fundamental level, the two DGs had different priorities during a large part of the period covered by this evaluation: ECHO focussed on nutrition, while DEVCO’s funding in the region under the 10th EDF (which ran from 2008 to 2013) focused inter alia on governance, environment, water irrigation and agriculture.

From 2012 onwards important strides were made in linking relief to rehabilitation and development. The first of these is AGIR, which brings together both humanitarian and development donors35 to technically support the heads of government of 16 of the 17 ECOWAS countries, the three West African Regional bodies36 to work towards resilience objectives, including a reduction in hunger and malnutrition in West Africa. Whilst ECHO initiated the Alliance and coordinated it for the first two years, responsibility for coordination has now passed to DEVCO and DEVCO has also earmarked funding from the 11th EDF for operationalising AGIR. DEVCO reports that it continues to rely on ECHO’s technical inputs and advice, as well as learning from the Sahel Strategy and the first two years of AGIR to lead AGIR.

A further development is the 2014 EU Action Plan on Nutrition37 which sets common objectives for DEVCO and ECHO on addressing malnutrition globally. The Action Plan envisages stronger partnerships between the two, as well as greater responsibility for DEVCO on addressing malnutrition, since it calls for the scaling up of [nutrition] actions and the mobilisation and political commitment for nutrition. At field level, the 11th EDF has presented some opportunities for DEVCO scaling up actions piloted through the Sahel Strategy, but these are relatively rare. One DEVCO officer states: “just because a pilot project worked in one district, in one country, does not mean it is going to work if rolled out across the country”. The extent to which the Sahel Strategy has contributed to LRRD and further opportunities for LRRD are discussed in section 3.4.2.

35 ECHO, DEVCO, USAID, Canada, Austria, France, Luxembourg, Spain, Switzerland, UN agencies 36 Economic Community of West African States (ECOWAS) West African Economic and Monetary Union (UEMOA) and the Permanent Inter-State Committee for the Fight Against Drought in the Sahel (CILSS) 37 Communication on Nutrition (2014) - https://ec.europa.eu/europeaid/sites/devco/files/swd-action-plan-on-nutrition-234-2014_en.pdf


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2.2 Description of the Sahel Strategy

2.2.1 Overview of the Strategy

Box 2.1 summarises the Sahel Strategy. Each of the features outlined in the Box are then described in more detail below.

Box 2.1 Summary of the key features of the Sahel Strategy

■ Objectives: a reduction in malnutrition-related mortality amongst children under five and PLW.

■ Main focus: (Mal)nutrition

■ Approach taken:

– Regional (covering Burkina Faso, Chad, Mali, Mauritania, Niger and Senegal)

– Multi-annual (funding follow-on projects over consecutive years)

– Multi-sectoral (nutrition, food, health, WaSH, livelihoods, resilience)

– Contiguum (focusing on linking relief to development activities and on the hand-over (“integration” of ECHO actions into national systems)

■ Activities: four types of activity were funded

– Relief (treatment of malnutrition and food assistance)

– Prevention of malnutrition

– Advocacy amongst international donors and national actors

– Research into the causes of malnutrition and ways to address it

The ways through which these features interacted to form the programme’s intervention logic are described in section 2.3 and illustrated in Figure 2.5 .The overall aim of the Sahel

Strategy is to reduce malnutrition-related mortality in a sustainable way among children under five through better management (treatment and prevention) of acute malnutrition in the region.38 Additionally, the Strategy aims to influence development actors (both national governments in the affected countries and international donors) to mainstream nutrition and food security and nutrition resilience into national and local long-term development policies and programmes. The objectives of the Sahel Strategy were initially set out in a ‘Global Plan’ and subsequently adapted and developed through various annual funding decisions.39

The main focus of the Strategy was on treating and – to a lesser extent – preventing malnutrition. The key features of the Strategy’s approach were as follows:

■ A regional approach: The Sahel Strategy was regional to the extent that its priorities and objectives were largely set at regional level, partners worked across different countries and similar models (e.g. for developing Early Warning Systems (EWS), treating children, distributing food assistance) were employed in each country. There was some difference in prioritisation and focus of funding (e.g. in Mauritania there was a greater focus on food assistance and livelihoods than on the treatment of malnutrition whereas, by contrast, in Mali the focus was on treatment and healthcare), but the objectives remained the same in each country. UN partners (UNICEF and WFP) worked at regional level controlling pipelines and distributing supplies (and in the case of UNICEF, surveying the population).

Approaches between countries differed in line with ECHO’s and ECHO partner’s understanding of the main causes of malnutrition in each country, practical considerations (such as the extent to which the national infrastructure would allow certain operations, e.g. joint health and nutrition interventions, to be implemented), the extent and nature of the

38 ToR 39 From 2011 onwards ECHO Financial Decisions were called Humanitarian Implementation Plans or HIPs.


21

partner network in the country (i.e. whether partners are mainly skilled in food or health sectors) and the specific needs of the country concerned. Many ECHO partners (e.g. ACF, French and Belgian Red Cross, MSF, Save the Children and Oxfam) worked across many or all of the Sahel countries (see Annex 3).

■ Multi-annual approach: The majority of partners funded under the Strategy received funding over multiple years. In total, 81% of all FPA contracts (279) signed to support the implementation of the Sahel Strategy were used for the implementation of follow-on projects. Whilst in part this was because funding was needed each year due to the chronic nature of the crisis, the aim of multi-annual funding was to enable ECHO partners to achieve longer-term goals such as integration of their projects into national systems, advocacy goals and the scaling up of their projects by development donors. ECHO partners responding to the online survey reported that their projects changed year to year either in terms of method, in the sectors they covered or in the areas they worked. Twenty-four partners reported that they included more advocacy components as time went on and 29 scaled up their project to cover more beneficiaries. 23 partners replicated projects in new communities / districts / provinces / regions, although 16 reported that they carried out their projects in the same communities. Some of the positive results of projects reported by beneficiaries in the field (changing attitudes towards family planning, increased capacity of health workers, increased attendance at health centres) has been the result of partners being established in the communities over a period of years. However, after more than eight years of addressing mortality and malnutrition, ECHO is keen to identify an exit strategy. One such exit strategy is the integration of ECHO projects into wider national health systems. This has been a focus area for ECHO since 2013.

■ A ‘multi-sectoral approach’ to addressing malnutrition: That (severe and acute) malnutrition is caused by a multiplicity of factors and should therefore be addressed through multi-sectoral and multi-faceted interventions has been acknowledged and accepted as standard in the humanitarian and development community since the 1990s.40 Comprehensive multi-sectoral approaches (addressing all or most of the root causes of malnutrition) require inputs from multiple partners – no single partner would have the resources nor likely the skills to address all issues at once. Initially during the Sahel Strategy ECHO tried to take a programmatic multi-sectoral approach funding different partners to address specific sectors within a country. However, this broad approach did not work as partners rarely overlapped at community level, meaning that within a community only one or two sectoral causes of malnutrition would be covered. From 2013, with greater emphasis being given to prevention, ECHO began to encourage its partners to implement projects covering a number of sectors at once. Few partners have so far been able to do this (ACF are a notable example), though the shift appears to have encouraged more partners to integrate other sectoral components into their work (e.g. MSF a typically treatment-focussed partner is now integrating malaria prophylaxis into its interventions in Mali).

■ Contiguum: Malnutrition and related mortality in the Sahel is a humanitarian issue, but its causes are structural and therefore an issue for development action. Through the Sahel Strategy ECHO tried to link its relief activities to the programmes of development donors and national government by advocating for them to pursue ECHO’s objectives (nutrition, resilience) jointly and (at field level) by advocating for donors and governments to take over and scale up nutrition and nutrition-sensitive actions. The Strategy also tried to support LRRD by integrating longer-term objectives, such as resilience-building and malnutrition-prevention, into emergency response actions and by funding partners to support the integration of health services funded by international humanitarians into national systems.

The types of actions funded by ECHO, summarised under four “pillars of action”, were:

■ Treatment: includes the treatment of medical complications of emergency admittance and therapeutic feeding of severely malnourished children in CRENIs (intensive nutritional

40 See e.g. UNICEF (2008) The State of the World’s Children.


22

rehabilitation centres), the targeted distribution of therapeutic foods to severely malnourished children through emergency feeding centres (CRENAs), support for community management of malnutrition (CMAM), screening of children to identify SAM cases, capacity-building for national health-workers and community health relays, supply of therapeutic foods and medicines.

■ Prevention: – Food assistance: The provision of in-kind food assistance and cash transfers was

targeted at very poor households (with children under five years old) during the lean season with a view to prevent SAM. The rationale was that GAM peaked during the lean season, so blanket feeding at this time could help prevent cases (the approach was not as effective as hoped – see section 3.4.1).

– Pilot projects focussing on livelihoods and awareness-raising: A few projects (mainly in 2010 and 2011), that helped communities to grow their own gardens and taught them how to diversify their diets and food production.

– As part of treatment projects: most ECHO partners supporting the treatment of malnutrition aimed at preventing repeat cases by integrating non-nutritional focussed activities into their work. For example, ACF and the Red Cross integrated WaSH elements by improving hygiene and sanitation in health centres, raising awareness in communities and distributing hygiene kits. MDM raised awareness on family-planning to try to change behaviours in targeted communities and MSF (amongst others) distributed malaria nets.

■ Knowledge generation / research: in addition to the SMART surveys undertaken by UNICEF and the development of the HEA targeting method, a number of specific studies were funded by ECHO to test different methods and approaches. In addition, ECHO encouraged partners to collect evidence of the impacts of their projects. These two survey methodologies are described in the box below.

■ Advocacy was a major feature of the Sahel Strategy which involved not only partners, but ECHO itself. The aim was to influence not only national governments but also international donors. The components of ECHO’s advocacy actions were as follows:

– UN agencies, particularly UNICEF and WFP, were funded to support government policy change and increase integration of nutrition services into national systems.

– ECHO-funded NGOs were encouraged to promote and support the integration of their actions into sub-national and national systems by working with local and regional authorities.

– ECHO sought to increasingly harmonise the approaches and therefore the advocacy messages of its partners to increase impact. ECHO did this through the partner meetings, through its contact with partners in the field and by – in Niger – creating ‘alliances’ of partners whose projects would follow a single logframe.

The major themes of ECHO’s advocacy were free healthcare for under 5s, prevention and resilience, social safety nets and the integration of nutrition into mainstream healthcare systems. The major increase in funding for malnutrition by ECHO in 2012 was an integral part of this strategy, as it had as aim to increase visibility of the problem amongst donors and national actors.


23

Box 2.2 Description of SMART survey and HEA methodologies

‘SMART’ (the Standardized Monitoring and Assessment of Relief and Transitions) is a global inter-agency initiative aimed at collecting information on two key public health indicators (the nutritional status of under-fives and mortality rates) in order to help humanitarian actors prioritise funding and monitoring the effectiveness of humanitarian responses. SMART surveys are conducted to collect anthropometric data (weight, height) from which analyses of SAM and stunting levels can be made, as well as to collect information on levels of mortality.

The Household Economy Approach (HEA) is a framework for assessing vulnerability and risk levels in communities in order to target interventions at the households most in need. The approach is used to investigate how people in target communities obtain food, non-food goods and services, how much they spend on these items and how they might respond to changes in their external environment, like a drought or a rise in food prices.41 This enables planners to predict communities' vulnerability to crises and shocks like drought or

sudden increases in food prices. HEA methods are participatory, as communities play a role

in classifying the most vulnerable households in the community.

2.2.2 Scope of the Strategy

Over the evaluated period (2010-2014), ECHO implemented the Strategy through five funding decisions that were regional in scope and another five that were country-specific:

■ Sahel (2010, 2011, 2012, 2013 and 2014), ■ Chad (2011, 2012, 2013 and 2014), and ■ Mali (2014).

Through these decisions, ECHO made more than 416 million euros available for actions in the Sahel region. In most years, additional emergency and ad hoc funding decisions were published in response to worsening crises (food, conflict), amounting to a further 56 million euros being made available for actions in the region. In 2010 the Strategy covered five countries42, but in 2012, with the scale-up of funding, Senegal also became part of the scope.

Figure 2.4 shows the geographic and annual distribution of ECHO funding and projects. Over 50 per cent of the funding went to Chad and Niger, which have the highest SAM and GAM rates and the lowest capacity to respond. Niger also had the most established network of partners able to absorb the funding.

41 See Save the Children’s guidance on HEA, available at: http://www.savethechildren.org.uk/resources/online-library/practitioners%E2%80%99-guide-household-economy-approach#sthash.EMXz67BN.dpuf 42 Niger, Mauritania, Burkina Faso, Chad and Mali


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Figure 2.4 Total number and value of grant agreements by country 2010-2014, million euro

Source: ECHO, Agreements for humanitarian aid awarded by ECHO (2010-2014)

2.2.3 The evolution of the Sahel Strategy

The Sahel Strategy from 2007 – 2012 focussed on three strategic objectives or pillars of action:43

■ Improving the knowledge baseline of the causes and extent of acute malnutrition to provide better quality data and information systems for (a) needs assessment and targeting; (b) preparedness and early warning systems; and (c) the design of response strategies;

■ Implement response actions to tackle acute malnutrition in the most vulnerable population; and

■ Advocacy and awareness building to increase understanding of the causes and action needed to fight malnutrition.

In 2013, the specific objectives shifted slightly to two pillars:

■ Addressing acute malnutrition (i.e. response); ■ Preventing malnutrition by reinforcing resilience of the most vulnerable populations.

The shift in objectives was a response to the recognition that, following the crisis of 2012, greater focus needed to be given to prevention and resilience. Whilst the objectives did not explicitly refer to information and advocacy, these types of actions were subsumed under the two new objectives. The dual pillar objectives have been maintained from 2013 into the 2015 HIP.

Over the evaluated period, the Strategy evolved in focus and size. As demonstrated in Table 2.2, funding peaked in 2012 when the region experienced another food crisis. ECHO’s funding for the Strategy more than tripled (from 45.2m in 2010 to 141.5m euro in 2014).

43 Discussion based on analysis of programme and project documentation, the end of mission report of Helene Berton (Technical Assistant for the Sahel Strategy 2012-2015) and interviews with former and current ECHO staff. A more detailed discussion and an outline of the different HIPs over time is provided in Annex 3.


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Table 2.2 Number and value of grant agreements signed under the HIPs and emergency funding

in 2010-2014, million euro

Country of

operation

Projects

implemented,

total

Value and

nr of

projects,

2010

Value and

nr of

projects,

2011

Value and

nr of

projects,

2012

Value and

nr of

projects,

2013

Value and

nr of

projects,

2014

Amount

awarded

total, million

euro

Burkina Faso 60 11.45 (9) 9.61 (10) 13.29 (14) 16.20 (14) 12.98 (13) 63.52

Chad 67 11.21 (8) 11.20 (10) 36.45 (24) 18.51 (13) 24.76 (12) 102.13

Mali 37 1.85 (4) 6.80 (8) 8.96 (9) N/A 13.43 (16) 31.04

Mauritania 31 2.54 (4) 2.52 (4) 3.26 (6) 8.50 (9) 6.98 (8) 23.79

Niger 98 31.25 (21) 19.66 (19) 44.08 (19) 56.61 (22) 36.13 (18) 187.72

Senegal 10 N/A N/A 1.04 (2) 2.69 (3) 5.2 (5) 8.92

Regional 9 3,96 (2) 0.21 (1) 38.99 (3) 0.63 (1) 11.5 (2) 55,29

Total 312 62.26 (44) 50.00 (51) 146.05 (77) 103.14 (62) 110.97 (74) 472.42

Source: ECHO, Agreements for humanitarian aid awarded by ECHO (2010-2014)

2007-2010 were the formative years of the Sahel Strategy. During this period, a major focus was on collecting baseline data to demonstrate the scale and nature of the problem (including its root causes). In 2010, a food crisis hit the region. Just under 30m euro was added to the existing 32m euro budget for the Strategy that year. Emphasis was placed on food security, nutrition and health. The following year the 2011 HIP encouraged partners to design projects focussing on post-crisis recovery (e.g. cash transfers, rebuilding of productive assets and livelihoods recovery) in the wake of the 2010 crisis and a ‘reasonable harvest’ in the previous season.

In 2012, a major boost to funding enabled the scaling up of nutrition and food assistance operations in the region to reach a higher number of beneficiaries. 55% of the funding in 2012 went towards food assistance activities as compared to 43% the previous year and 42% in 2010. From 2012, ECHO adapted its mode of food assistance provision also, changing from a predominant ‘in-kind’ model to 50% in cash and 50% in kind. The aim was to reduce aid dependency and negative impacts of food aid on local markets and also to pave the way for integration of food assistance measures into national social safety nets.

In 2013 and 2014, the objectives of the Strategy further evolved with focus being placed on treatment and prevention. Emphasis was placed on the integration of ECHO-funded actions into national systems and on actions to address the underlying causes of malnutrition by taking a ‘multi-sectoral’ approach to treatment and prevention (see below on ‘key features of the Strategy’). Less focus was given to improving the knowledge baseline since the actions implemented 2007-2012 had already generated a lot of information on the scale and nature of malnutrition in the region. ECHO began to encourage partners to develop integrated projects combining nutrition, health and advocacy actions targeting Ministries of Health. MSF and ALIMA drove the shift towards a health-in-nutrition approach, favouring the treatment of infants not only for malnutrition but also for other related medical issues at the same time. ECHO began (particularly in 2014) to work towards the linking of its food assistance projects (now receiving less funding post-2012) into national response plans and national social safety nets and towards the integration of the household economic analysis (HEA) approach into national early warning systems.

Looking beyond the evaluation period, in 2015, the Sahel Strategy has been subsumed within a West African financing decision which has an overall aim of building resilience in the region particularly in relation to three types of crises which affect it: food and nutrition crises, conflicts and epidemics. The first ‘pillar’ of the funding decision covers malnutrition and food insecurity and is thus a continuation of the aims and activities of the Sahel Strategy. Pillar one continues to focus prevention and response with a further separation into food security actions on the one hand and nutrition actions on the other.


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2.3 Intervention logic

The diagram in Figure 2.5 below outlines the logic underpinning the Strategy – i.e. how ECHO expected the activities of the Strategy to contribute to the expected impact. The diagram has been developed by the evaluators on the basis of programme documentation and consultation with ECHO and other relevant stakeholders. The ‘intervention logic’ comprises a series of parallel, but interlinked causal chains. The model assumes that no single series of input, activity, output and outcome can generate the expected impact; each are interdependent: a reduction in mortality is dependent on the immediate risk of death being addressed through treatment, but longer-term a sustainable reduction is dependent on prevention activities; for prevention activities to have a longer-term and region-wide impact they require support from national authorities and international donors, which requires advocacy; advocacy messages are stronger when they are supported by evidence gathered through research.

The link between activities and the expected impact is – however – relatively weak since many risks stand in the way of the causal chain. These are outlined in the model and include environmental factors (e.g. further droughts and food insecurity crises), the need for greater scaling up of prevention actions (if a sustainable drop in mortality is to be achieved) and the reliance on national government and international donor willingness to take responsibility for funding such prevention (and treatment) activities long term. The intervention logic is also dependent on donors and/or national governments having the financial capacity to take over or scale up the activities. For this reason, the causal chain linking advocacy activities to the expected impact is particularly weak; it is dependent on too many factors outside of ECHO’s control.

The causal link between capacity-building and increased capacity in the national system is quite strong, though there are still risks to the achievement of these outcomes including systemic factors such as staff dropout and turnover in the national health system and the dependence of health centres on international aid for continuity of training, the supply of medicines and fortified foods and funding for equipment. Stronger is the causal chain between treatment and the longer-term outcomes of fewer deaths. This is because there is a direct link between treatment and lives being saved (see also section 3.4.1 for a discussion of this). However, the treatment of children cannot lead to lower overall GAM and SAM rates, because treatment – without prevention – cannot prevent the relapse of treated children nor new cases from occurring (particularly when population growth is so high). For GAM and SAM rates to drop sustainably, they require attention to be given to addressing the causal factors such as household behaviour, household poverty, household hygiene and household health.

The causal chain linking ECHO’s prevention activities to the longer-term outcomes is robust, but for this to contribute to the expected impact assumes that the activities will be scaled up. This scaling up of prevention activities was not part of the Strategy’s focus or scope, but it was an activity that ECHO expected other donors and/or national actors to take on. For these reasons, the intervention logic is highly dependent on other actors for its success and therefore ambitious.


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Figure 2.5 Intervention logic for the Sahel Strategy


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3 Evaluation findings

This section presents a synthesis of the evidence collected in response to each evaluation question. It is organised around the core evaluation issues of relevance; coherence; effectiveness; efficiency and EU added value (and the specific evaluation questions contained therein).

3.1 Relevance

This section addresses the following evaluation questions:

■ To what extent has the design of the Sahel Plan and its projects taken into account the needs of the most vulnerable populations; and

■ To what extent has the Sahel Plan appropriately addressed the humanitarian needs in the region over the evaluated period?

■ To what extent have local, regional and national communities and authorities been consulted and participated in the design, implementation and follow up of ECHO-funded projects?

In order to answer the above questions, the following issues were examined

■ Targeting of the intervention – whether the areas and groups targeted by the Sahel Plan and funded projects constituted the “most vulnerable populations” (section 3.1.1);

■ Needs of the most vulnerable – whether the actions adequately addressed the most pertinent needs of the most vulnerable (section 3.1.2); and

■ Involvement of national and sub-national actors – the extent to which sub-national and national actors were consulted in project design, implementation and follow-up (section 3.1.3).

3.1.1 Targeting of the intervention and identifying the most vulnerable

The initial aim of the Sahel Strategy was to reduce mortality and morbidity caused by malnutrition. Overtime the objectives and scope of the Strategy evolved to also address - to the extent possible (and within the limits of a humanitarian intervention) - the root causes of malnutrition, including food insecurity, poor health, poor sanitation and poor access to water. The “most vulnerable” groups within the context of the Strategy were persons most at risk of (severe) malnutrition and those most at risk of dying from (severe) malnutrition. ECHO considered those most at risk to be children under the age of five and PLW and clearly assigned these as the target groups of each of the HIPs of the Strategy 2010 – 2014 (see Table A4.2 in Annex 4). Beneficiaries were then identified through a multi-stage process:

■ Large scale surveys of malnutrition and poverty were conducted to identify the regions, districts and communities most at risk of or with the highest rates of malnutrition and poverty. Other considerations e.g. level of support from other donors and level of government investment were also taken into account;

■ Within communities, malnourished children were identified through screening processes. Screening was often undertaken by local health relays and community workers, though later on in the programme, some partners adopted other methods (e.g. Alima piloted and developed a mother-led means of screening for malnutrition);

■ Treatment activities incorporating prevention aspects sometimes took into consideration indicators of the prevalence of drivers – e.g. ACF, for its nutrition and WaSH intervention in Mauritania44 targeted beneficiaries living in areas of high levels of diarrhoea and poor sanitation coverage;

■ To identify poor households at risk of malnutrition and therefore, eligible for food assistance (including cash transfers), the household economic approach (HEA) was used;

■ There were very few single-sector prevention interventions funded through the Strategy, except for the food assistance interventions. Only in 2010 and 2011 did ECHO fund cash-

44 Project reference: 2014/91048


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for-work and other livelihood activities in Chad and Niger. Beneficiaries were selected not only on the basis of their vulnerability, but also on the basis of other factors such as food production levels in the region (WFP), suitability of the land for agricultural activities (e.g. irrigation zones) (Save the Children), level of microfinance opportunities existing in the region (WFP) and distance to travel to the cash distribution centre. Such targeting does not appear to have been always in line with the Sahel Strategy – for example, a Save the Children gardening project (2010, Niger), did not directly benefit very poor households as they “did not typically have access to garden plots near the riverbed”, but suggested that they would “gain employment” from the activity. The targeting for this project was more similar to development targeting (which considers that the vulnerable will benefit from overall economic improvements). ECHO was therefore being relevant in funding fewer

of these activities later in the programme.

Identifying the most vulnerable regions: nutritional and household economy surveys

Improving understanding and identification of the most vulnerable was a key aim of the Strategy. At programme level, ECHO invested, most notably, in UNICEF’s scale-up and maintenance of ‘SMART’ surveys throughout the region – an action which increased understanding of the scale and coverage of severe and acute malnutrition and global malnutrition (as well as stunting) levels in the region.45 ECHO also funded Save the Children to conduct household economic analyses to better understand poverty levels and the dynamics of poverty in different livelihoods groups in the region and the integration of the ‘household economic approach’ (HEA)46 as a data-collection method within national early warning systems. As a result of ECHO’s advocacy for this approach, coverage of HEA baseline studies in the Sahel region increased significantly between 2013 and 2014. In 2013 there were 50 rural baseline studies while in 2014, already 68 studies were used for the analysis in HEA Sahel atlas.47 Although the entire Sahel region is not covered, five countries have a substantial coverage – Burkina Faso (the only country in the region with full coverage), Mauritania, Mali, Niger and Chad (which had the greatest addition of new studies in 2013–14). The increased availability of data has contributed to a better targeting of regions and beneficiaries as new areas in need of support have been identified and the necessary health centres established. ECHO partners provide HEA training to implementing partners in the field before implementing activities, to ensure that they have a clear understanding of HEA approach for the identification of direct beneficiaries. In very few cases ECHO expressed concerns that this training could be of higher quality48.

ECHO partners were required to make use of SMART data and household economic data to target their actions and to predict how many children they would reach. The 2012 ‘operational guidelines’ accompanying the funding decision state that SMART survey data should be interpreted in terms of livelihood zones in order to understand aspects of seasonality, the lifestyle of the people and the link between poverty and food insecurity and malnutrition in order to better tailor and target the actions. Partners implementing food assistance projects were required (in the guidelines) to use HEA to analyse, target, monitor and evaluate their food assistance projects. 49

Subsequently, funded actions were implemented in regions and districts with a high prevalence of GAM rates amongst children under 5 (according to SMART data). In most

countries, almost all regions required intervention (Table 3.1 below). Only in Chad and Mauritania were interventions concentrated in some areas. In Chad this was partly due to the fact that only the middle part of the country is considered part of the Sahel. However, it is also due to the comparatively low number of partners operating in the country.50 In Mauritania, only

45

46 47 An Atlas of Household Economy Analysis Information Across the Sahel (2014) 48 WFP-IT project in Niger, 2011 49 See the operational guidelines to the 2012 Sahel HIP. 50 Interviews with ECHO


30

the regions with annual GAM rates judged serious using WHO criteria (see Annex 8) were targeted.

Table 3.1 Regions within Sahel countries in which the Sahel Strategy is implemented51

Country Regions in which the Sahel Strategy was

implemented

Regions in which the Sahel Strategy was not

implemented

Burkina Faso

Boucle du Mouhoun, Central-West, Centre, East, North, Sahel, Centre-East, Centre-Nord, Plateau Central

Cascade, Centre-South

Chad (Sahel regions)

Bahr el Gazal, Batha, Dar Sila, Eastern Chad, Guera, Hadjer Lamis, Kanem, Lac, N'Djamena Region, Ouadda, Salamat, Wadi Fira

Chari-Baguirmi, Borkou, Ennedi-Est, Ennedi-Ouest, Logone Occidental, Logone Oriental, Mandoul, Mayo-Kebbi Est, Mayo-Kebbi Ouest, Moyen-Chari, Sila, Tandjilé, Tibesti

Mali Gao, Kayes, Kidal (one district only), Koulikoro, Mopti (two districts only), Segou, Sikasso (one district only), Timbuktu

Bamako

Mauritania Assaba, Brakna, Gorgol, Guidmaka, Hodh El Gharbi

Adrar, Dakhlet Nouadhibou, Hodh Ech Chargui, Inchiri, Nouakchott Nord, Nouakchott Oues, Nouakchott Sud, Tagant, Tiris Zemmour, Trarza

Niger Tillabery, Tahoua, Agadez, Maradi, Zinder, Diffa, Niamey

Dosso

Source: ECHO

The relevance and appropriateness of the beneficiary targeting

Considering the high levels of maternal mortality and under-five mortality caused by malnutrition in the Sahel Region (see section 2.1.2), the selection of these groups as the

target for the Strategy was relevant. The focus of treatment activities on children under five and PLW was in line with international standards on vulnerability and malnutrition. In addition, all ECHO partners now recognise that, whilst children under five are recognised as the most vulnerable to malnutrition the 1,000 day “window” from the moment of conception to the child’s age of 2 is a critical period for development when long term implications of stunting are most acute. This “1,000 day approach” has been advocated by academics, NGOs and international organisations.52 Not only do all ECHO partners now focus specifically on providing quality care to persons at risk when within this 1000 day window, but some ECHO partners (e.g., ALIMA in Niger, ACF in Chad and MSF in Mali) began using this approach at an early stage which demonstrates (some) ECHO partners’ responsiveness to new approaches and best

practice information to improve the relevance of their activities.

Actions funded by ECHO targeted not only the regions and districts with above or near critical rates of GAM, but also with the lowest government capacity to cope with them. For example, in Maradi and Zinder (combined) only around 16% of all malnutrition cases per annum could be treated through the national system.53 Five out of the eight regions in Niger,

51 Analysis for Chad and Mauritania still to be verified by ECHO. 52 World Bank: http://www.worldbank.org/en/events/2015/02/05/ecd-and-nutrition-measurement-during-the-first-1000-days ;

World Health Organisation, Essential Nutrition Actions. Improving maternal, newborn, infant and young child health and nutrition (2013);

Black R, et al Maternal and child undernutrition and overweight in low-income and middle-income countries Maternal and Child Nutrition 1 (Lancet 2013): “nutritional conditions in adolescence, at the time of conception, and during pregnancy as important for maternal health and survival, fetal growth and subsequent early childhood survival, growth and development. Fetal growth restriction and poor growth early in infancy are now recognized as important determinants of neonatal and infant mortality, stunting, and overweight and obesity in older children and adults. Preventive efforts should continue to focus on the 1,000 days, while therapeutic efforts continue to target severe wasting. 53 As reported by ALIMA / BEFEN in consultation with them during the Niger field trip.


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namely, Dosso, Maradi, Tahoua, Tillabery, and Zinder, present the highest concentration of poverty and represent 95 percent of the country’s poor population. Poor households are more exposed to shocks and the poorest regions are the most vulnerable to food insecurity.54

Some stakeholders interviewed in the context of this evaluation raised the issue that ECHO funded actions did not suitably target nomadic communities; nor were these interventions adapted to their specific needs (for example, the use of mobile services to reach out to nomadic communities). On balance, this criticism is not valid. ECHO’s targeting is vulnerability based (instead of being status based). This means that beneficiaries are targeted on the basis of their malnutrition or poverty rate and not only their livelihood or residential status. Thus, nomads have not been particularly targeted by the Strategy even though Sahel countries having a significant nomadic population.55 Project documentation highlight the operational challenges of informing nomadic groups of local services and in retaining their attendance (e.g. at treatment clinics). However, during the evaluation process, there was no substantial evidence found that any of these groups of population had been excluded from receiving humanitarian assistance. Indeed, the ‘vulnerability-focussed’ approach appears to have worked well. Evidence from evaluation of other ECHO interventions shows that a status based approach to targeting can be counter-productive. For example in the Horn of Africa, where pastoralists were targeted as beneficiaries of DRRAP, this led to non-pastoralists in need (e.g. those living of ad-hoc jobs in per-urban centres) not having access to much needed support.

Further, in Chad, the vulnerability-focussed approach has enabled ECHO to address urban

malnutrition in the capital Ndjamena. ECHO is currently the only donor funding urban

malnutrition in Chad. In view of the high number of children affected in the capital,56 this intervention is clearly relevant. The insecurity caused by Boko Haram, and the possible displacement of IDPs to N’Djamena from CAR and other fragile border areas, is likely to increase the number affected by malnutrition there in the near future, which will make this support even more pertinent and which suggests a need for greater preventative actions. Box 3.1 provides more information.

Box 3.1 ALIMA – Urban Malnutrition Treatment, N’Djamena.

Alima and its local partner, Alerte Santé, have been funded by ECHO to treat children between 0-59 months with severe malnutrition (SAM) free of charge in N’Djamena since 2013. During the first six months of 2015 their programme had supported 10,560 children of which 2,061 had been hospitalised at the therapeutic nutrition unit (UNT) in the Chad-China Friendship Hospital in N’Djamena. Alongside two local structures, ALIMA are the only international NGO currently working on this issue, and the only organisation dealing with complicated cases. Malnutrition in N’Djamena exceeds the WHO emergency threshold level by 2%, which considering the higher population density, means that a greater concentration of children are facing problems in the capital city when compared with towns and villages in the Sahel.

The UNT is running at 150% of its capacity. Newly referred children are examined on arrival for their weight to age ratio and their middle upper arm circumference (MUAC). If necessary they are admitted to the hospital where mother and child are provided with both medicines and food until they are deemed well enough to be released. During this time, mothers are also given instructions on child health care, good feeding, and good hygiene practices. Alima also run four « mobile » nutrition centres across N’Djamena.

Targeting must be transparent and the delivery of aid must be sensitive to the perceptions and opinions of beneficiary communities. When households are singled out for support, this can create competition and rivalries within the community. HEA attempts to mitigate such issues by involving the community in the analysis of the households most in need. Fieldwork for this

54 Project Appraisal Document: Safety Net Project in Niger. World Bank, 2011 55 For example, 33% of the total population in Chad is nomadic people (Source: RGPH II et Ecosit III) 56 According to 2015 Humanitarian Needs Overview in Chad, OCHA, dec 2014, 350 000 children suffer from GAM and 97 000 children aged from 6 to 59 months suffer from SAM.


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evaluation in Chad uncovered some isolated instances of tension within and between communities, mainly because non-beneficiaries did not always understand the screening method, nor why they were kept out of the programme. Despite this challenge, they acknowledged that they still often indirectly benefited from ECHO interventions, as they were also able to take their children to supported health structures which may have better hygienic conditions and trained staff. The evaluators did not identify evidence that tension between beneficiaries and non-beneficiaries was widespread. However, it is acknowledged that – due to time and budget constraints – non-beneficiaries were not consistently nor systematically consulted for this evaluation, so it is not possible to be conclusive on the matter.

While individuals (PLWs, children suffering malnutrition) are the obvious target beneficiaries of treatment activities; prevention activities are best targeted at household level. In most multi-sectoral projects (combining treatment with prevention) visited in the field, male adults (e.g. fathers/ husbands) were not being targeted at all. Sensitisation and awareness-raising towards this group could be beneficial as it is often the adult males who take the decisions about the children’s health. In particular, efforts could be put on changing their mentalities and cultural habits. Indeed, many stakeholders agreed that different objectives require different targeting approaches. Whilst breast feeding and infant and young child feeding (IYCF) messages are best targeted at women (or primary carers), hygiene messaging (and other prevention messages) should be targeted at all members of a household in order to have an overall impact on improving hygiene and sanitation in the household. In at least one project (in Chad), vaccinations were incorrectly targeted at children who were too young to receive the vaccine (see section 3.5).

3.1.2 Needs addressed

A variety of projects were funded through the Strategy with a view to addressing different needs (see the intervention logic in section 2.3). In line with its mandate (to save and preserve life during emergencies and their immediate aftermath), ECHO prioritised the immediate

needs of the target populations and consequently around 85.7% of ECHO’s funding went to actions with a primary aid type of food assistance or nutrition (see section 2.2). According to information in ECHO’s project database only 0.2% of funding in scope of this evaluation was allocated to actions with a primary aid type of preparedness (according to this data 0.4% of projects had a secondary aid type of preparedness).57

The programme was responsive to changing needs. The 2010 and 2012 HIPs invited emergency food assistance responses where these were less of a priority in other years, and the 2011 HIP encouraged partners to design projects focussing on post-crisis recovery (e.g. cash transfers, rebuilding of productive assets and livelihoods recovery) in the wake of the 2010 crisis and a ‘reasonable harvest’ in the previous season (see section 2.2).

ECHO partners however, hold a slightly different view. According to them the Sahel strategy addressed most, but not all of the needs in the region58. Twenty-five respondents (50%) thought that some, but not all had been addressed and a further three respondents thought that some important needs had not been addressed because the Strategy had focussed largely on nutrition and food and, as such, had overlooked drivers and risks, including moderate malnutrition. 20% of respondents to the survey also commented that the Strategy either did not sufficiently address the need for behaviour change at community level, did not adequately focus on prevention activities or nor did it sufficiently address the root causes of the malnutrition problems in the region. Partners were generally of the view that ECHO should in the future allocate more funding to prevention actions. It is likely that these comments were driven by the fact that partners recognise the need for a greater focus on prevention, as does ECHO. As ECHO is the main donor for many of these partners, they would like to see ECHO

57 It should be taken into account that the HOPE database is not fully accurate, and information on sectors of aid is incomplete. Only 78% of projects had indication of the primary aid type. Nonetheless, the ratios can be considered indicative of the sectors which have received greater focus and those which have received less focus. 58 Online survey of ECHO partners. Question: In your opinion, did the Sahel Strategy address the most pertinent needs linked to recurrent food and nutrition crises in the region? (n=50).


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generate further funding for such actions. Longer-term preventative action however, logically lays in the domain of national authorities and development actors, though it falls within ECHO’s mandate to address immediate and household-level drivers of malnutrition. Indeed, ECHO and ECHO’s partners’ understanding of other humanitarian sectors (health, WaSH, etc.) make them well-placed to support and implement ‘multi-sectoral’ approaches to treatment. While many partners incorporated at least one prevention activity into their treatment actions during the evaluation period (see section 3.4.1), they did not manage to address all or a sufficient number of root causes to lower GAM and SAM rates. Indeed, the evaluators observed in the field that ECHO funded projects did not focus sufficiently on some preventative aspects (household hygiene and family planning) which could have been easily integrated into treatment actions at a relatively low-cost and to a potentially significant benefit.

3.1.3 Consultation with national and sub-national actors

Consultation with nationals and locals is of high importance as it helps to identify most pressing needs of target populations and contributes to building ownership, coherence and sustainability of activities, as well as demonstrating accountability to beneficiaries. A review of ECHO project documentation as well as the project manager responses to the online survey suggest that all ECHO partners consulted one or more key stakeholders in designing and implementing their projects. Further, from 2014, some projects (Alima in Niger, Red Cross and ACF in Mauritania) demonstrated good practice in consulting with national authorities as to the possible future integration of ECHO-funded services post-project. During the field visits a strong culture of cooperation between ECHO partners and local stakeholders was evident. Beneficiaries seem to have been consulted in most projects, though some projects lacked any mechanisms for beneficiary feedback or complaints to be raised, which threatened the accountability of the project to beneficiaries.

Consultation and coordination with national authorities

The promotion of cooperation between ECHO partners and national authorities was a central element of the Sahel Strategy. One of the specific objectives was to promote the take-up and integration of nutrition interventions by national authorities into national systems. The consultation and coordination was also important to ensure that implemented actions are coherent and in line with national strategies where possible.

According to the project documentation, most projects had consulted national authorities during the design phase as well as during the implementation phase. The results of the online survey are consistent with this finding. 74% respondents had consulted national authorities at the design stage. The consultation had as purpose to obtain agreement from the authorities on the regions of interventions, agree on the targeting approach, obtain required authorisations59, define the responsibilities of each stakeholder, and implement actions in collaboration with authorities to ensure coherence, complementarity and ownership of actions, therefore contributing to sustainability.60 Consultation had different formats: regular meetings, organised workshops and work meetings, well-established information sharing with authorities during implementation process, and other. Some partners also reported having agreement protocols with national authorities (e.g. Ministries of Health, National Food Security Councils, stakeholders responsible for national Early Warning Systems) already at the design phase, describing the responsibilities of each stakeholder. According to project documentation, national and regional authorities were involved in information exchange, joint interventions and in discussions around the integration of the project into national systems at a later date.

National authorities consulted in the field confirmed that they were adequately involved

by ECHO partners during the design and implementation phases of specific projects. However, there is a concern from ECHO that partners could do more to consult with national

59 For health and nutrition, a Memorandum of Understanding (MoU) is essential if one wants to engage in operational aspects of the programmes. For some other work like advocacy and sometimes ad-hoc capacity building, formal agreements/ MoUs are less likely to exist. 60 Information based on project documentation review and fieldwork


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authorities.61 Whilst notable achievements have been made in influencing national authorities (see section 3.4.2), there is still much to be done before national governments take ownership of the problem of malnutrition. It is therefore good practice that some ECHO partners (see

above) were already engaging with national authorities to build domestic ownership.

Based on the evidence presented above, at an operational level, consultation and involvement with national actors appears to have been largely adequate. At a more strategic level, however, engagement has not yet produced desired results as demonstrated by continuing lack of ownership by national authorities of the ‘nutrition problem’. The AGIR now should provide the forum for some transfer of responsibility to national authorities as the latter make concrete commitments to address large-scale malnutrition and food insecurity. However, during the consultations for this evaluation, ECHO partners and national authorities showed low awareness of the country resilience priorities. This suggests that greater attention needs to be paid to ensure high level policy commitments are translated into specific action

Consultation and coordination with regional and local authorities

ECHO strongly encouraged consultation with regional and local authorities and it has required partners to report on this aspect in the Single Form of each project. Regional and local authorities are important actors to consult in relation to beneficiary targeting, beneficiary needs, security situation and regards to community work. This is especially important in the Sahel, where many health services are decentralised.

The desk review found several examples of projects were regional and local authorities were not involved in the design phase. As per the online survey62 86% of all respondents had involved regional authorities in the design phase and 80% in the implementation phase. Project documentation suggests that engagement with regional and local authorities took several forms:

■ Collaborating with regional authorities in food security and nutrition clusters ■ Participating in cluster coordination meetings (reported to be held 1-2 times per month), ■ Getting into partnership agreements with the health authorities ■ Organising workshops and participating in monthly steering committee meetings with

different stakeholders to identify challenges and discuss recommendations for the project.

A strong culture of cooperation was observed Niger between ECHO partners, local authorities, and community leaders in the field in. Local authorities reported that they had been consulted in the design stage of the programmes to assess the needs of local communities. They were also strongly involved in the implementation and day-to-day operation of programmes. This was found to be positive since local authorities play an important role in the delivery of national health and nutrition services in Niger.63 In Mali, partners also collaborated closely with the regional and local authorities; they were particularly involved in the implementation of projects. For example, MSF took part in the orientation committee of the regional health policies. It was also part of the weekly monitoring committee meetings during the outbreak of Ebola. During the field visit in Mali it was found that regional and local authorities were less involved in the design phase. This was reported to be a consequence of local authorities sometimes lacking interest or capacity in the design phase.

Overall, the evaluation found no concrete issues or examples of problems that would suggest that partners’ efforts were lacking in the extent to which they consulted and coordinated with regional and local authorities, or that anything could have been done differently.

61 Interview with ECHO officials 62 Sample of respondents: 50 63 Prefectures at community level monitor nutrition support at local level (including support provided through ECHO partners) and report statistics back to the national Ministry of Health. This forms the basis for establishing a database allowing follow-ups and an appropriate monitoring and evaluation of trends.


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Consultation and coordination with local community actors and end beneficiaries

Community engagement and involvement are important elements for ensuring that interventions are relevant to the needs of the target beneficiaries and appropriately designed to cater to their specific circumstances. Community engagement also helps building ownership and mitigate any potential ‘side effects’ of their intervention (especially when an intervention involves delivering support to some members of the community but not to others). ECHO encouraged such consultation in the design phase by giving operational advice on how to target communities.64 The desk review of project documentation suggests that several projects conducted consultation with target communities during the design and implementation phases.65 The results of the online survey confirm this: 86% of respondents had consulted the community during the design phase and 88% during the implementation phase of projects.

Interviews in the field with community actors and beneficiaries also suggested that communities were consulted in the design and implementation of the projects. For cash transfer projects, some partners (e.g., WFP) consulted local communities to elaborate distribution modalities, location and timing. Communities were also often involved in identifying the criteria to determine the different level of poverty for the targeting phase through HEA. Several projects reviewed also suggested that religious institutions were consulted as part of civil society (e.g., ALIMA in Niger, MDM-FR in Niger). However, in Mali the representative of local communities for some projects reported that they were not well informed about the activities set up and decisions taken by project partners. It was also found that community leaders would have liked to be better explained why some areas and districts were targeted and others not. Had these actors been involved in the design of the project and not only informed about it afterwards, they may have felt less excluded. In Chad it was also observed that partners could do more to involve beneficiaries in project design and also to provide them with beneficiary feedback and complaint mechanisms. Indeed, ECHO monitoring of projects suggests that some projects lacked any mechanisms for beneficiary feedback or complaints to be raised. This created a lack of beneficiary accountability, particularly within larger projects (i.e. the regional food assistance project) which seemed to be less focussed on beneficiary consultation.

3.2 Coherence

This section addresses the following evaluation questions:

■ To what extent have the following issues been taken into account in the Sahel Plan and design of projects: (a) the humanitarian principles of humanity, neutrality, impartiality and independence; and (b) the principles of protection and do-not-harm?

■ To what extent have humanitarian operations been aligned with relevant ECHO policies and how can they influence existing policies further?

Humanitarian principles66

The Sahel Strategy has as its main aim to save lives and alleviate the suffering of malnourished people in the Sahel. The activities implemented predominantly involved humanitarian response (supporting those in need of food and other forms of emergency aid). In this way the programme design respects the principle of humanity. ECHO does not promote the political or economic agenda of the EU in the region; none of the ECHO funded

64 See operational guidelines, HIP 2012. 65 Based on the review of a sample of 80 of the 312 projects reviewed for this evaluation. 66 The humanitarian principles are defined as follows: (a) humanity, means “the centrality of saving human lives and alleviating suffering wherever it is found”; (b) impartiality, means “the implementation of actions solely on the basis of need, without discrimination between or within affected populations”; (c) neutrality means “that humanitarian action must not favour any side in an armed conflict or other dispute where such action is carried out”; and (d) independence means ”the autonomy of humanitarian objectives from the political, economic, military or other objectives that any actor may hold with regard to areas where humanitarian action is being implemented.” See: GHD initiative (Stockholm text), available at: http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/4180.pdf


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projects operating in conflict-affected geographical areas were co-financed from actors that offer political, economic or military support to one of the opposing parties. Moreover, ECHO does not directly fund any State activity. In this way the Strategy maintains its autonomy from political objectives and thus its design adheres to the principle of autonomy. The principle of impartiality is also maintained within the design of the programme, since the most vulnerable are targeted regardless of ethnic, livelihood or any other social grouping; there are no criteria nor provisions within the design of the programme that would restrict partners from working with particular groups. The Sahel Strategy by design does not favour any side in any of the armed conflict or disputes ongoing in the region and so can be considered neutral.

ECHO’s adherence to the humanitarian principle of autonomy (sometimes referred to as the principle of independence) means that ECHO is not able to work directly with national governments as partners. This restriction created a challenge for ECHO in achieving the

Sahel Strategy objective to influence national governments created a potential risk. In practice, to avoid the risk to independence, ECHO advocated to national authorities through its partners. For instance, in Niger, ECHO funded Oxfam to second a nutrition and food security expert to the national government to help them develop and implement their national nutrition policy. The formation of the partner alliances is seen to have allowed ECHO partners to come together to increase ECHO’s influence over government policies.

Indeed, ECHO’s commitment to the principle of autonomy has meant that in Mali and Senegal ECHO actions have not necessarily been aligned with national policies and practices where the latter are seen to be inappropriate. For example, in Senegal, ECHO and the Senegalese authorities have adopted different approaches to targeting the most vulnerable people in society: ECHO encouraged its partners in Senegal (especially the Red Cross) to apply the Household Economy Approach (HEA) of identifying beneficiaries rather than using data of the National Council for food security, which was widely acknowledged by the international humanitarian community to be unreliable (see section 3.1.3).

In Mali, the health system is based on a system of cost recovery (with a few exceptions, such as free malaria care for children under five), while ECHO projects are delivering free access to all children under five. National authorities and health workers interviewed in Mali reported that the provision of free healthcare creates competition between the Referral Health Centres (CSCOMs) benefiting from NGOs’ financial support and the ones operating without any support. ECHO’s aim is to influence the Malian government to take ECHO’s example and to provide free healthcare to families most in need. Free healthcare for under 5s is a key advocacy message of the Sahel Strategy (see section 2.2). Some progress has been made towards influencing the government in Burkina Faso to provide free healthcare and the policy has been in place in Niger since 2005 (though not fully effective). To address these tensions specifically in Mali, advocacy for free health care should be a priority for ECHO in Mali. ECHO is already pursuing this policy in Northern Mali,67 and there would clearly be value in advocating for the policy also in the South. A similar tension between national and NGO-funded health centres in Chad was being driven by differences in health worker salaries. It would be worthwhile for ECHO to survey partners and to investigate during its monitoring visits whether this is a widespread and significant issue. If found to be a problem, it would be advisable for ECHO to consider how partners might advocate for higher salaries for national workers as part of an overall strategy to integrate nutrition into national health services. However, such tension cannot always be avoided by ECHO’s actions alone and in some instances, it has to be accepted as an unfortunate, unintended outcome. For example, it would not be appropriate for ECHO to ask projects to under-pay the health workers or to cease to provide free healthcare altogether in order to align its approaches and practices with unfair and/or inappropriate national systems and practices.

Protection and do-no-harm

Protection is a cross-cutting issue in humanitarian situations concerned with creating a ‘humanitarian space’ (neutral, impartial, safe) both within which humanitarian operations can

67 See the 2014 HIP for Mali: http://ec.europa.eu/echo/files/funding/decisions/2014/HIPs/mali_en.pdf


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take place and also in its support to communities. Linked to ‘protection’, the principle of ‘do-

no-harm’ states that humanitarian actors will not undermine protection, nor exacerbate already existing inequalities.68 The responses to the online survey and the review of project documentation suggest that, overall, ECHO partners understood the risks to the principles of protection and do-no-harm in the Sahel region and took measures to mitigate these risks.

In respect of protection, the Sahel Strategy was and is being implemented in a challenging environment where the humanitarian space69 – particularly in Chad – is constantly at threat. In Chad and Niger, humanitarian actors have been targeted specifically by bandits70 and also in northern Mali, where ECHO works in highly dangerous environments. In this respect, ECHO has worked hard to maintain a humanitarian space in order to address non-conflict related concerns. In the face of pressures on national authorities from the international community (EU-Del, ADF, USAID, DfID)71 to spend national budget on security, ECHO has continued to advocate for greater spending on nutrition and food. ECHO views its advocacy work as a major tool for maintaining the humanitarian space.72

In practical terms, ECHO partners responding to the online survey reported that they follow security protocols published by the UN and by national authorities, hence avoiding travel to areas where they would be at risk. Many respondents to the survey underlined that they undertake risk analysis to ensure that the staff implementing humanitarian actions is safe and that they also ensure that all local actors involved in implementing the intervention have received security training.

Further, in relation to child and beneficiary protection, at least one partner had created ‘child friendly spaces’ in the hospitals and health centres where children and women were treated, “supporting the attachment between mother and child” and provided psychological support and referral to the national protection system in case of abuse. Several partners had also established a complaint mechanism to provide the beneficiaries a way to transfer any concerns they experienced in the course of participating in the intervention (although as previously mentioned, such mechanisms were lacking in some projects). Such mechanism is found to be important in overseeing and ensuring a transparent process and therefore reducing potential security incidents.

To encourage ECHO partners to also respect the principle of do no harm, the operational guidelines to the HIPs defined these principles and stipulate that ECHO partners must adhere to them in the field. ECHO partners responding to the online survey recognise that they implemented projects in highly sensitive environments where it was important not to cause any unintentional harm to beneficiary communities or create tensions between beneficiary and non-beneficiary communities. The evaluation team in Niger also saw evidence of the principles of do-no-harm being understood by staff and adhered to in the field. Examples witnessed included staff treating beneficiaries in a dignified way at health posts and cash distribution points73 by organising the cash distributions sites visited in a well-organised manner with banners and posters clearly indicating what items and amounts would be given per beneficiary (to reduce risks of fraud)74, and from where the funding was received.

Another way in which ECHO partners could create ‘harm’ through their interventions is by creating an aid dependency. In one Ficheop, ECHO expresses concern that a partner delivering health services had not developed an effective strategy for hand over to national

68 See for more information: http://www.cdainc.com/dnh/docs/DoNoHarmHandbook.pdf 69 The physical space in which crisis-affected communities can exercise basic rights, including the right to receive humanitarian assistance (ATHA, http://www.atha.se/content/humanitarian-space) 70 2011 Chad HIP and evidence from the team’s humanitarian expert. 71 Interview with ECHO officials. Perspective to be triangulated with viewpoints of other stakeholders in the Field Phase. 72 See the notes of the ECHO Dakar RSO team meeting, Senegal, 06 – 07 June 2013. 73 Well ordered sites with shade, mats and availability of clean water for example. 74 To prevent misunderstandings related to whether gains were coming from government or others which might compromise neutrality and independence.


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actors. Given the number of ECHO partners delivering health services in the Sahel region, this concern may apply more widely, and there is some anecdotal evidence to suggest so. For example, in the field visit to Mali, some partners were of the opinion that the strong focus of the Sahel Strategy on patient management in recent years has created a more general risk

of dependency of the national and regional health systems on NGOs and external aid. In some cases, NGOs felt that the ECHO-funded services substituted the Malian Government in the field of nutrition. Suggestions for addressing this include: involving local, regional, national authorities from the beginning of the project (to increase ownership from the start); conducting more capacity-building activities; transferring competences more systematically from project partners to local staff and authorities; encouraging partners to involve more local health care staff (instead of NGO staff); as well as setting-up and implementing clear exit and disengagement strategies.

EU policies

The Sahel Strategy was a key programme for ECHO in developing its policies around resilience and food assistance (i.e. the shift from only in-kind assistance to combined modes). It was also a vehicle within which ECHO aimed to improve its approach to LRRD. It can be argued therefore that the Sahel Strategy influenced key policies in these areas, and it did this on the basis of its work on the ground. In this respect then the humanitarian operations were

aligned with ECHO policies because – to some extent – they influenced these.

ECHO and ECHO partners report that they have taken on learning from other programmes of ECHO (e.g. the Drought Risk Reduction in the Horn of Africa Plan (DRRAP)). However, there

are potentially more lessons to be taken on. For example, ECHO could take on board more learning from its DIPECHO programmes on how education can be used to change behaviour in order to build household resilience, since few ECHO partners are focusing on education and behaviour change (e.g. in relation to hygiene or family planning) as means to prevent SAM at household level. Similarly, some standards and learning (e.g. Situation and Response Analysis Framework (SRAF), Pre-Crisis Market Mapping and Analysis (PCMMA), etc.) elsewhere promoted by ECHO do not appear to have been integrated into the Strategy even though it would have been relevant to do so.

3.3 EU Added Value

This section addresses the following evaluation question:

■ What has shown to be the EU Added Value of the actions examined (i.e. the added value of EU intervention compared to leaving the initiative to other actors; ECHO’s leadership role in raising awareness and interest in the fight against malnutrition amongst policymakers and development donors)?

EU added value is the unique value that ECHO – as an EU donor – brings to the region (in comparison with other international donors and humanitarian actors). ECHO’s main value in addressing malnutrition in the region were:

■ Its understanding of the complex needs on the ground

ECHO places great importance in needs assessments. As discussed in section 2.2, ECHO has funded specific projects to improve evidence, knowledge and understanding of the scale of the problem and its drivers. ECHO partners and donors such as DfID, World Bank, DEVCO and SIDA rely on evidence gathered by ECHO to develop their own programmes. In this way, ECHO adds value to the region through its research and needs assessment and has a comparative advantage over other donors by generating such knowledge, thereby filling a gap and generating outputs that can be used beyond the Sahel Strategy. Only USAID invests comparable resources in understanding the needs on the ground, yet it also makes use of ECHO research and data (e.g. on blanket supplementary feeding and WaSH) for its programming.

Given ECHO’s technical capacities, knowledge of the region and field presence, DFID has recently decided to channel its funding (PHASE programme) through ECHO, effectively increasing ECHO’s budget for humanitarian aid. On the other hand, SIDA funding in the region


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is not driven by any national thematic or regional strategy, so it purposefully seeks to complement the funding of ECHO and fill gaps left by ECHO; on a number of occasions these complementary resources have enabled ECHO partners to scale up projects (e.g. in Burkina Faso, SIDA funded ECF to scale up its ECHO-funded project to a further three regions (bring the total of regions reached by the partner to five. SIDA representatives consulted in the context of this evaluation, expressed an interest in exploring possibilities for directing funding through ECHO for specific projects to reduce duplication of administrative effort.

■ Its neutrality

As described in section 3.2, ECHO places a lot of emphasis on maintaining the humanitarian principles, one of these being neutrality, and it is well respected for this amongst partners and donors alike. In general, the EU is often perceived as able to be a more neutral actor in fragile states as it is arguably less influenced by bilateral geo-political, economic or historical considerations, than many individual Member States are, and who at times blur the distinctions between humanitarian aid and political, military and security objectives.

■ Its leadership and coordination role

ECHO is well positioned to coordinate and collaborate with multiple actors. ECHO is able to coordinate closely with partners because of the regular contact maintained between ECHO Field and partners, through project monitoring and through the annual partner meetings it holds. Other donors consulted for this evaluation explained that they take a much less involved and collaborative approach to funding partners (e.g. they do not conduct monitoring visits, they do not involve partners in programmatic needs assessment). Partners interviewed confirmed this. Only USAID has a similar relationship with its partners.

ECHO works through its network of partners to ensure that its message is visible also to national authorities in Sahel. As a coordinator, ECHO brings great value to other stakeholders (NGOs, donors, national authorities) who might otherwise be working in parallel or at odds with each other. Coordination in general increases the efficiency and impact of humanitarian operations. All stakeholders interviewed appreciated ECHO’s coordinating role and some have commended ECHO for formalising coordination under the Sahel Strategy by forming alliances of ECHO partners to strengthen advocacy messages.

ECHO is also able, because of its political neutrality, to consult and coordinate with other donors. As a fellow Directorate General (DG), ECHO is also better placed than other donors to coordinate with DEVCO. During the evaluated period, ECHO leveraged both its relationship with DEVCO in the field and the knowledge and expertise it developed through the Sahel Strategy to influence DEVCO’s programming and their participation in (and later coordination of) AGIR. AGIR, initiated by ECHO, is now being coordinated by DEVCO and DEVCO has dedicated 54 million euro reserve of its budget for the Sahel region to operationalising AGIR.75 Nonetheless, the evaluators consider that ECHO – and DEVCO – could much better harness their relationship to greater EU added value (see Box 3.2 below).

75 Interview with Stephane Devaux


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Box 3.2 The EU added value of ECHO-DEVCO coordination: opportunity for further

collaboration

During the last decades, the understanding of what LRRD means has shifted from a ‘continuum’ model (a linear approach dominated by ‘hand-over’ thinking) to a ‘contiguum’ approach i.e. an integrated and encompassing approach whereby relief, rehabilitation, and development are carried out side by side in order to respond effectively to all aspects of a crisis.

This evolution in thinking has, however, not yet translated into practice. One obvious constraint is the internal bifurcation of humanitarian and development functions within the Commission with separate teams having distinct budgets, strategies, portfolios, remits , funding period, processes etc. This quite naturally limits coherent visioning, planning and action.

Although some progress has been made at a strategic level, a fully complementary and coherent approach at an operational level is lacking.

Elements of a fully joined up approach could include:

■ The development of Joint Humanitarian Development Frameworks (JHDFs).76 These exist already for Mali, Niger and Nigeria, though the evaluators did not see evidence of these being operationalised nor were they mentioned in interviews with DEVCO and ECHO Field in these countries. The usability of these could therefore be questioned, though they could – if operationalised – be useful tools for coordination and operationalisation of a ‘contiguum’ (i.e. joint humanitarian-development) approach to LLRD. These would identify the main vulnerabilities and needs in each country, the different actions to be completed to address these and the different ways in which ECHO and DEVCO (and other actors) could contribute to addressing the problems. Such an assessment could be supported (and complemented) by ECHO’s parallel action to develop its programme theory of change (see recommendation above) and could feed into ECHO actions to develop national integration plans (see below);

■ A critical review of the Country Resilience Priorities to ensure that they address the specific country needs and vulnerabilities identified and that they are feasible for national governments to implement. On the basis of any challenges identified, means of addressing these through ECHO and DEVCO advocacy or through ECHO or DEVCO programming could be developed.

It is possible that without ECHO’s Field Offices, ECHO would not be able to build links with other donors and humanitarian organisations active in the region, which would mean that it would not be able to address the Sahel Strategy’s objective to influence these actors and to support LRRD. ECHO Field play a role in encouraging information exchange between partners, in disseminating knowledge and in coordinating with and raising awareness amongst partners. Having an in-country base is certainly not unique to ECHO as a donor, but it appears to be one of the ways through which ECHO adds value to the work it does compared to what it could do otherwise.

3.4 Effectiveness, impact and sustainability

This section considers the extent to which the Sahel Strategy was effective in meeting its objectives of reducing mortality and malnutrition and in influencing other actors to take responsibility for addressing these. The section corresponds to six evaluation questions which cover the following issues:

■ Effectiveness in reducing mortality rates in a sustainable way (section 3.4.1); ■ Effectiveness of actions in influencing national actors (section 3.4.2);

76 http://capacity4dev.ec.europa.eu/resilience_ethiopia/document/joint-humanitarian-development-framework-jhdf-context-food-security


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■ Effectiveness of actions in improving LRRD and influencing international donors (section 3.4.3;

■ Effectiveness of the regional and the multi-annual approach (section 3.4.4); and ■ The main factors limiting success (section 3.4.5).

3.4.1 Effectiveness of the Strategy in reducing mortality linked to malnutrition in a sustainable

way

This sub-section discusses the following evaluation question:

■ To what extent has the Sahel Plan’s objective of a sustainable reduction of mortality due to malnutrition been achieved?

■ To what extent did the ‘multi-sectoral approach’ to malnutrition adopted through the Sahel Plan contribute to a reduction in mortality?

The section considers first of all whether there was a reduction in infant mortality over the evaluated period. It then considers ECHO’s contribution to reducing mortality. Finally, the sustainability of the reduction in child mortality is considered, followed by an assessment of the effectiveness of ECHO’s prevention activities (its ‘multi-sectoral approach’).

Overall, infant mortality rates have been declining steadily in the region since the beginning of ECHO’s intervention and possibly since before. Evidence suggests that ECHO’s intervention has contributed to reducing mortality rates directly and many stakeholders rate this contribution as important, though it cannot be considered the only contributing factor to the decline.

Trends in rates of infant mortality linked to malnutrition at country level

According to World Bank data,77 infant mortality (defined as the number of infants dying before reaching five years of age, per 1,000 live births in a given year) has declined over the evaluated period across all the countries in scope (see Figure 3.1). Trends have ranged from a 39.4% decrease in mortality rates in Senegal (2007-2014) to a 16.7% decrease in Chad. A study published by Lancet in 201278 suggested that child and neonatal mortality in Niger 1998–2009 declined at an even greater rate than the World Bank data suggests. Using a 2010 household survey and eight other nationally-representative surveys79 the study found that the infant mortality rate80 declined significantly from 226 deaths per 1000 livebirths (95% CI 207–246) in 1998 to 128 deaths (117–140) in 2009 at an annual rate of decline of 5.1%. The study estimated that this amounted to 59 000 lives saved in children younger than 5 years in 2009.

77 World Bank data used as time series data is available. 78 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961376-2/fulltext 79 The 1998 and 2006 DHS studies, the 2010 Niger National Institute of Statistics (INS)’s national mortality and child survival survey (ESM), and five Standardized Monitoring and Assessment of Relief and Transitions (SMART) surveys. 80 Defined as the mortality rate in children younger than 5


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Figure 3.1 Infant Mortality (per 1,000 births), GAM, SAM and GDP per capita

Source: infant mortality: World Development Indicators, the World Bank; GAM, SAM: SMART data compilation for West and Central Africa, UNICEF 2015.


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Contribution of the Sahel Plan to the reduction in child mortality rates

All stakeholders agree that ECHO has, together with UNICEF, been the main international actor supporting the treatment of malnutrition in the Sahel region. As discussed in section 2.1, ECHO was by far the main donor of health interventions 2010 – 2014, funding 47% of humanitarian health interventions in the region. The main channels through which ECHO has contributed to reducing mortality rates are described below. Overall, ECHO’s most significant contribution was to increase the coverage of health centres offering nutrition treatment and the number of children under 5 screened and treated.

1. Funding the supply of therapeutic foods and medicines essential to the treatment of

malnutrition

UNICEF is the main provider and distributor of ready to use therapeutic foods (RUTF) and essential medicines in the Sahel. UNICEF’s supply supplements the national pipelines in the Sahel81 supplying both national and NGO-ran health centres and is thus an important component of nutrition services in the region. ECHO is the main donor funding UNICEF for this activity and UNICEF reports that it is dependent on ECHO for funding for the pipeline. Indeed, data available for 2013-14 demonstrate that ECHO funded all of UNICEF’s target caseload (i.e. the number of children that UNICEF aimed to treat) for the region in 2014 and all of UNICEF’s caseload in Chad and Nigeria (11 Sates only) in 2013 (see Table A5.1 in Annex 5, cells shaded in light grey).

Through its funding to UNICEF for the provision of therapeutic foods (RUTF) and medicines (as well as its funding of NGOs providing nutrition treatment), ECHO has contributed to an increase in the number of malnourished children treated in the region. In 2013, 2014 and 2015 ECHO committed to supporting 29 – 49% of the overall total target caseload of SAM cases in the region.82 This was as much as 100% of the caseload in Gambia and Mali and 83% of the total target caseload in 2014 (see Table A5.1 in Annex 5,).83

Over the evaluated period, the number of children (caseload) treated for malnutrition overall in the Sahel has increased from 529,483 to 1,214,645. Data available only for 2013 and 2014 (see Table 3.2) shows that this was 68% of all children under 5 with SAM in 2013 and 82% of all children under 5 with SAM in 2014.

Table 3.2 Number of children under 5 admitted and treated for SAM, all Sahel countries, 2010-

2014

2010 2011 2012 2013 2014

Actual number admitted / treated



Estimated

number of

children

under 5 with

SAM


Estimated

number of

children

under 5

with SAM


Burkina Faso 47,656 50,000 77,106 120,000 57,570 144,000 105,047

Cameroon 17,000 18,000 40,300 83,233 64,313 59,258 52,269

Chad 56,436 68,000 146,685 147,000 134,816 135,533 146,132

Gambia 0 0 3,164 7,745 4,261 7,859 4,342

Mauritania 3,400 5,000 10,757 23,901 16,035 30,741 20,170

Mali 25,000 15,000 52,156 201,000 102,787 136,000 117,995

81 Burkina Faso, Chad, Mali, Mauritania, Niger and parts of Cameroon, Nigeria and Senegal. 82 Every year, based on the number of SAM cases identified, national governments (together with other relevant actors including UNICEF) identify a target caseload for SAM cases. 83 Data on overall target caseloads and actual numbers, ECHO Field. As stated above, data not yet verified.


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2010 2011 2012 2013 2014

Nigeria (11 states) 44,098 141,310 217,506 491,862 234,543 539,147 326,947

Niger 330,893 300,000 369,036 376,724 397,442 356,324 416,994

Senegal 5,000 5,000 13,628 63,323 20,951 78,888 24,749

Total 529,483 602,310 930,338 1,514,788 1,032,718 1,487,750

1,214,64

5

% of children suffering from malnutrition treated 68% 82% Source: Data on overall target caseloads and actual numbers treated at national level 2010-2015, ECHO Field. Information on ECHO targets only available for 2013-2015.84

2. Increasing the number and coverage of health centres

The larger amounts of funding that ECHO invested in the Sahel Strategy from 2012 onwards had positive effects on healthcare coverage. ECHO partners were able to screen more children for malnutrition, fund a wider geographic area of health centres and hospitals. In Chad, ECHO funding has contributed to a significant increase in the number of nutrition clinics over the evaluation period: in 2015 there were 493 clinics as compared to 142 in 2010.85

3. Increasing the number of malnourished infants detected and treated

As the Sahel Strategy developed and partners became more established in the communities they supported, their ability to detect and treat children also improved. The mapping of project documentation shows that in particular in 2013 and 2014, most ECHO partners achieved or exceeded their targets in the number of children screened for SAM, the proportion admitted of those screened and the proportion of those admitted receiving appropriate care (correct medicines, sufficient days in hospital, etc.). Prior to 2013, projects appear to have been slightly less successful in achieving targets in admission rates. Project monitoring and reporting suggests that this was due to a number of factors including unwillingness of parents to admit their children (due to a mistrust or lack of awareness of ‘western’ medicine and/or a preference for using traditional doctors), the long distances required to access the health centres or hospitals and the difficulty for nomads in accessing healthcare when moving around the region.

Reporting and monitoring indicates that ECHO partners’ effectiveness in reaching all households and children in need improved as approaches piloted earlier in the Strategy - e.g. use of health relays, free healthcare for under 5s, distribution of hygiene packs – were rolled out in standardised, refined and improved forms. For example, the health relays employed by ACF in Mali in 2014 were highly successful in tracking children diagnosed with SAM who had dropped out of the programme to ensure that they attended the health services available: 94% of all children who had left the programme were visited at their home by a health worker. ECHO has also funded projects which have developed alternative and innovative ways to detect SAM, including the mother-led testing of SAM (by teaching them how to measure the upper arm circumference) implemented by ALIMA in Mali.

Some ECHO partners have also increased the number of infants treated for SAM, because they have attracted higher numbers of users to health clinics and increased retention rates by offering improved hygiene and sanitation in health centres and free hygiene packs for patients. Many stakeholders interviewed during the course of this evaluation highlighted that as health centres began to offer free healthcare services, this attracted higher numbers of patients and ACF in Senegal has observed that the health centres in which it implements WaSH measures (clean conditions, distribution of hygiene packs) attracts and retains a higher number of

84 ECHO are in the process of verifying this data, therefore it should be treated with caution. 85 As reported by the National Centre for Nutrition and Food Technology (CNNTA)


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patients that those which do not integrate WaSH. Increased usage of health centres was seen as a key achievement of several projects.86

According to statistics collected by UNICEF and presented at the October 2015 ECHO partners meeting in Dakar, Senegal, the overall number of new admissions for SAM to health centres in the Sahel has more than doubled in the last five years (see Figure 3.2).

Figure 3.2 New admissions to health centres in the Sahel

UNICEF presentation: ‘Situation de la malnutrition aigue au Sahel Evolution et perspectives’ ECHO

partners meeting, Dakar October 2015

4. Building / strengthening national capacity

In all three countries visited, ECHO has helped build national capacity by training health workers (especially community health workers and relays), setting up systems (e.g. databases, registration systems, stick management systems) and establishing methods (e.g. for screening). Partners, local authorities and health workers all reported that ECHO projects had built capacity in the health sector,87 though local authorities and health workers also highlighted capacity-building as one of the areas still requiring a lot of investment and international support. In Chad and Mali, health workers interviewed stated that they benefitted particularly from the training provided. In Niger, health workers consulted during the fieldwork considered that ECHO had had the biggest impact in promoting effective screening methodologies and referencing systems for follow-up.

ECHO partners have also made progress towards integrating nutrition treatment services into national health systems (e.g. Terre des Hommes in Burkina Faso and Concern in Niger); however, ECHO partners and ECHO agree that this is one of the biggest gaps remaining. Integration is “the extent, pattern, and rate of adoption and eventual assimilation of priority health interventions (in this case, screening of and therapeutic feeding for malnourished children) into each of the critical functions of a health system, which include, inter alia: (i) governance, (ii) financing, (iii) planning, (iv) service delivery, (v) monitoring and evaluation, and (vi) demand generation”88.89

86 As highlighted in the survey of and in interviews with ECHO partners. 87 National authorities however, did not mention this in their interviews. This could be perhaps because ECHO supports national actors through its partners and the national authorities may not therefore be aware that ECHO has funded the intervention. 88 Demand generation refers to the promotion of the use of health services through conditional cash transfers, health insurance or through awareness-raising activities. 89 See: Atun, Rifat; Ohiri, Kelechi; Adeyi, Olusoji. 2008. Integration of health systems and priority health, nutrition, and population interventions : a framework for analysis and policy choices. HNP discussion paper series. Washington, DC: World Bank. http://documents.worldbank.org/curated/en/2008/08/9930197/integration-health-systems-priority-health-nutrition-population-interventions-framework-analysis-policy-choices

524,483 594,713

927,170

1,112,868 1,187,302

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2010 2011 2012 2013 2014


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Sustainability of the decrease in mortality rates in the Sahel

Whilst Figure 3.1 demonstrates that infant mortality rates have decreased steadily and consistently in the region over the evaluated period, it also shows that global and acute malnutrition (GAM) rates and severe and acute malnutrition (SAM) rates remained persistently high (except for Mauritania and Burkina Faso). Even in regions within the Sahel where ECHO has funded several projects, GAM or SAM rates have not dropped (see Annex 6 for case studies on GAM and SAM trends in four sub-national regions of the Sahel).

Without a decline in acute malnutrition rates, life-saving and emergency nutrition treatment will continue to be a necessity in the region. Such activity is not sustainable without funding either from humanitarian donors or from the national budget – as life-saving healthcare is not within the mandate of development donors. National governments are not yet at the stage where they would be able to take responsibility for the SAM caseload: UNICEF and international NGOs are still managing major components of national nutrition services and are not yet considered to have the resources to fully integrate the care of SAM cases within a wholly national system (see Box 3.3 and Table 3.3).

Box 3.3 Challenges in integrating of care for malnourished children into national systems

National human resource capacity: In Niger, the government is not spending sufficient money on human resources to tackle infant mortality and malnutrition. For instance, in the health district hospital in Mirriah (Zinder) there is not a single paediatrician on the government’s staff rota. In Chad, the challenge is more structural: health workers are required to move between districts. In some cases, workers trained by ECHO partners in the treatment of SAM are then moved to health districts with no nutritional unit thus reducing the effectiveness and efficiency of the training.

Financial capacity: In all three countries visited, stakeholders agreed that the government was not financially able to take over the running of nutrition-related services. In Niger, the government has had in place a policy of providing free maternal healthcare (caesarean sections, free treatment for breast and uterus cancers, free contraceptive services and antenatal care) and a range of free healthcare services for children (e.g. consultations, surgery, medicines and lab tests) for a number of years now.90 However, in practice the government does not repay the costs of this healthcare, leaving the health centres dependent on aid or being out of pocket.

Table 3.3 shows that the declining share of health in public expenditure, despite this being an area of significant need.

Table 3.3 Health expenditure, public (% of government expenditure)91

Country 2007 2008 2009 2010 2011 2012 2013

Chad 7.31 5.24 5.45 4.85 7.62 5.94 5.94

Mali 13.78 14.81 12.14 12.32 12.27 12.54 12.32

Niger 12.24 11.38 11.07 11.09 11.87 8.68 10.02

Source: Word Development Indicators, World Bank

All international donors and humanitarian actors consulted for this evaluation (ECHO, other donors and iNGOs) agree that a concerted effort is required by all stakeholders (national authorities, humanitarian actors, development actors) to address the root causes of malnutrition. Since the beginning of the Sahel Strategy, ECHO has had this as one of its aims (see section 2.2); however, it has clearly not been able to have a lasting impact on GAM and

90 Globalhealthcheck.org (2012) “Free healthcare initiative in Niger makes health gains but many challenges remain” 91 Public health expenditure consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations), and social (or compulsory) health insurance funds.


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SAM rates because understandably, most of its prevention actions have not operated at a large enough scale and because they have not addressed all of the root causes of malnutrition. Lasting changes cannot be achieved within ECHO’s current scale of operations and mandate.

Blanket-supplementary food assistance projects have operated at a large scale across the entire Sahel region, but their primary aim has been to provide immediate relief against food insecurity. They have not succeeded in reducing GAM and SAM rates, because they were only temporary measures and because they did not address other driving factors of malnutrition such as malaria, access to water, poor infant feeding practices (e.g. the introduction of (unclean) water and or foodstuffs into the child’s diet at too early a stage), poor household hygiene leading to infections and poor access to curative healthcare (see below).

Over the evaluated period, understanding of the causes of malnutrition and practices that can address it have grown significantly. The 2012 Lancet study found that, in Niger the activities which most had a direct impact on mortality rates were: the introduction of insecticide-treated bed nets (25%); access to treatment for diarrhoea, fever, malaria, or childhood pneumonia (22%); improvements in nutritional status (19%); vaccinations (11%) and vitamin A supplementation (9%).92 The macro-factors leading to a reduction in mortality rates in Niger were improvements in access to child health services93, the use of mass national

campaigns to increase the take-up and use of insecticide-treated bed nets, measles vaccination, and vitamin A supplementation, and the introduction of national nutrition

programming following the nutritional crisis of 2005 and 2006. Other research has demonstrated that a combination of social safety nets and awareness raising around ‘key family practices’ (exclusive breastfeeding before 6 months, handwashing, sleeping under malaria nets, vaccinations, etc.) can be highly effective in changing knowledge, attitudes and practices.94 The evidence on how to reduce malnutrition is there readily available, but it requires the political will and sufficient funding to operationalise this knowledge.

Effectiveness of ECHO’s multi-sectoral approach in addressing GAM and SAM rates

That (severe and acute) malnutrition is caused by a multiplicity of factors and should therefore be addressed through multi-sectoral and multi-faceted interventions has been acknowledged and accepted in the humanitarian and development community since the 1990s.95 As discussed in section 2.2, until 2013, ECHO principally took a multi-sectoral approach at programme level, addressing what were understood to be the main root causes in each country: in Niger this was food insecurity, in Mali it was (poor) health. Thus the sectoral focus in each of these countries was on food and health respectively.

The aim of food assistance projects was to avoid episodes of acute malnutrition.96 WFP implemented a range of food assistance projects including:

■ In-kind food assistance with cash-for-work activities (focussed on land rehabilitation, water harvesting and irrigation) in Niger;

■ Unconditional targeted food and voucher distributions and targeted supplementary feeding (TSF) for under five children and PLW in Senegal;

92 It identified these factors by comparing the statistics on death and health indicator variables with statistics on the coverage of specific health interventions aimed at addressing malnutrition and mortality. The extent to which interventions had an impact on mortality rates was calculated using a specific tool which assessed country-specific or region-specific baseline information on mortality rates and the causes of death in conjunction with an analysis of background variables (fertility, exposure to Plasmodium falciparum, stunting rates) and of the current coverage of more than 60 interventions and their associated effectiveness values. 93 The expansion of health centres and health services, the training of health workers and improved functionality of health services, the establishment of community health workers and the abolishment of user fees for healthcare for pregnant women and children in 2006. 94 See Niang, Ousmane, Véronique Mistycki and Soukeynatou Fall (2012) ‘The impact of safety nets on the resilience of vulnerable households in Niger l’ in Humanitarian Exchange number 55, September 2012

95 See e.g. UNICEF (2008) The State of the World’s Children. 96 The joint in-kind and cash-based food assistance approach that ECHO pushed for in the Sahel aims to increase food consumption in households and to improve diversity in their diet by distributing fortified foods and – through the cash transfers - reduce negative coping capacities, such as the sale of assets, in order to buy food.


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■ Targeted, unconditional food distribution, with a focus on severely food insecure households at regional level.

These projects incurred some implementation and performance issues. They operated largely apart from other ongoing interventions in the region – they were not combined with health, hygiene and educational interventions. Nonetheless, overall they played an important role in paving the way for and in generating lessons that were taken on board in the development of national food security systems / social safety nets (e.g. the Dispositif National in Niger). As international donors (e.g. World Bank) and national actors have begun to focus on developing social safety nets, ECHO has been reducing the proportion of funding and project budget to WFP projects annually since 2012. Given the number of other donors funding food interventions (see section 2.1), the development in social safety nets and integration of food security concerns into national policy and practice, and the fact that regular lean season food assistance has not proven to have the preventative effect expected on malnutrition rates, it is appropriate that ECHO has begun to reduce its funding in this area. ECHO should, however, assess how it can join up ongoing funding for other sectors with food assistance and social safety net programmes of other donors (including national governments).

From 2013 onwards, most ECHO partners aimed to integrate one or more sectoral activities in the provision of nutrition-related services. This is in keeping with the comprehensive Community Management Approach to Malnutrition97 supported by ECHO which links maternal, new born and child health and nutrition to water, sanitation and hygiene, food security and livelihood initiatives.98 Such activities included the distribution of hygiene packs to (families of) patients receiving therapeutic care for malnutrition, the vaccination of children receiving care for malnutrition, the distribution of malaria nets and awareness-raising on hygiene, family planning and other areas of behaviour affecting nutrition. Many of these had a visible effect. Some examples of actions which had positive outcomes are outlined in the Box below.

Box 3.4 Examples of multi-sectoral approaches to the treatment of malnutrition in Niger99

■ In Zinder (Mirriah district), community leaders and project staff have observed a reduction in mortality which they considered to be, in part, due to behavioural changes resulting from awareness-raising around vaccinations, hygiene (to prevent intestinal illnesses and diarrhoea), breast feeding and infant and young child feeding (IYCF) practices. Other contributory factors are likely to include the distribution of malaria nets (and advice to prevent malaria), early referral by trained project community relays within project outreach services, ante-natal consultations and family planning.

■ In Tahoua (Illela), beneficiaries reported that they believe their family is getting less ill as a result their being able to avoid malaria, having access to vaccinations, healthcare and medicines and because of changes in the way they manage household hygiene and plan their families.

■ In Zinder (M’wala), unconditional lean season payments have helped women to purchase food and some clothes and medicines and avoid incurring debt (which would further reduce resilience) during the lean season. The beneficiaries reported that the payments have enabled them to evade negative coping strategies such as migration to find work in Nigeria (can raise protection and health issues if it involves sex work), collection and eating wild foods and leaves (can raise protection issues in insecure border areas) and switching to fewer meals and cassava ( a nutritionally poor diet).

Projects integrating awareness-raising to stimulate behaviour change in family planning were also found to have delivered good results in Niger. In Tahoua, local authorities and the ECHO

97 CMAM is also referred to as IMAM (Integrated Management of Acute Malnutrition) or CTC (Community-based Therapeutic Care) 98 http://www.cmamforum.org/ 99 Information based on interviews with partners, health workers and beneficiaries interviewed in the field


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implementing partner reported a difference in malnutrition rates between those families who were benefitting from family planning interventions and those who were not. ECHO considers that local populations can respond negatively to the promotion of family planning, but the ECHO projects visited during the Niger mission suggested otherwise; in each community, beneficiaries were open to the interventions and welcomed the support in managing their family planning. In one of the projects visited community participation in the project had been enhanced by engaging the religious community in the programme which had increased its success. The evaluators visiting the field in Chad also considered that family planning actions would have a positive effect in Chad. In Mali, the combination of anti-malarial actions with malnutrition screening generated positive results (see Box 3.5).

Box 3.5 Implementation of a cost-effective approach: Seasonal Malaria Chemoprevention

(SMC) coupled with malnutrition screening

SMC is defined by the WHO as the intermittent administration of full treatment courses of an antimalarial medicine to children during the malaria season in areas of highly seasonal transmission. It consists in the administration of preventive medicines to children during four visits per year. As children are the most vulnerable to malnutrition during the malaria season – which partly overlaps with the lean period – MSF started to couple their SMC activities with malnutrition screening in 2013. This required only minimal investment (e.g. training of the malaria agents to detect malnutrition, and monitoring costs), but proved to be very efficient.

For the period 2013-2014, on average they reached 172,000 children per visit. This early screening led to fewer cases of hospitalisation and early referral to health centres, which increased the number of referral towards health centres but prevented a worsening of the health situation of screened children. In addition, surveys on the results of this coupling led by MSF revealed: good coverage; acceptance of the population; positive results. MSF wants to systematically include this active screening in the package of care offered by the CSCOM.

Nonetheless, the priority of the Sahel Strategy (and of funding) was on treatment of malnutrition. There was no specific dedicated proportion of the budget for prevention

activities. Many ECHO partners interviewed in the field separately highlighted this as problematic since it prevented them from adequately addressing the root causes of SAM. Indeed many ECHO partners commented that they would have liked to have had a greater budget to invest in the provision of WaSH or awareness-raising activities, and they commented that ECHO should set aside more money for prevention activities. These field findings are supported by the findings of the online survey of partners which found that partners considered that the programme did not adequately address the root causes of malnutrition in the region. Twenty per cent of respondents to the survey also commented that the Strategy either did not sufficiently address the need for behaviour change (at government, but mainly at community level), did not adequately focus on prevention activities or did not sufficiently address the root causes of the malnutrition problems in the region. Nonetheless, as discussed in section 3.1.2, the evaluators consider that the focus of ECHO’s intervention on treatment was relevant and appropriate. Further, ECHO partners did not go so far as to say that money should be taken away from treatment activities to fund this. These findings demonstrate the value in continuing to promote a multi-sectoral approach to malnutrition and also suggest that ECHO could more clearly allocate a proportion of the programme funding to these actions.

Currently ECHO’s approach towards the multi-sectoral approach is to encourage partners to integrate more than one of the root causes of malnutrition – i.e. addressing not only hygiene, but also water access and food and health. However, only some ECHO partners have the internal capacity and skills to develop such projects. Some partners have suggested that they might be able to overcome this issue by collaborating with other partners together in consortia. This would enable an NGO specialising in WaSH to pool expertise with one specialising in health or medicine. There was a general consensus among partners in Chad, that ECHO should move to a consortium approach, whereby a number of agencies join together to implement a multi-faceted programme working under one ECHO project umbrella. Partners argued that such an approach would create less paperwork, fewer reports, better coordination and complementary activities between NGOs therefore creating cost-savings for ECHO and building towards the objective of a multi-sectoral approach. Although ECHO is willing to create


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such consortia, it has not made much progress in this respect in Chad so far; however, the partnership between ACF and MDM is a good example. Together these two partners have implemented a joint action incorporating community education, WaSH, food assistance and nutrition (screening) activities. Nonetheless, it is not possible to say yet whether the consortium approach taken has enabled the partners to have a greater effect on malnutrition prevention.

Indeed, given that ECHO does not have the budget – nor the mandate – to spend on large-scale prevention activities, it is more appropriate for ECHO to encourage its partners to pilot multi-sectoral approaches with a view to these being scaled up by development donors or the national government. Approaches which the evaluators observed as lacking at the minute are those integrating WaSH into nutrition treatment - not only through community-education activities or through the distribution of hygiene packages, but also by providing access to clean water – and family planning education. Poor hygiene practices such as open defecation and lack of hand-washing were observed during all three field missions suggesting that more needs to be done to change hygiene behaviours. Other behavioural issues, such as the tendency for mothers not to eat the right nutrients during the last months of their pregnancy, and their habit of introducing solid food into the baby’s diet before they are six months old, while diluting breastmilk with water, were also observed. WaSH, awareness-raising and

possibly family planning should be sectors in which ECHO could encourage its

partners to innovate and explore approaches in the next few funding decisions.

3.4.2 Effectiveness of funded projects and ECHO advocacy on influencing other donors and in

contributing to LRRD

This sub-section covers the following evaluation questions:

■ To what extent has the Sahel Plan contributed to influencing international donors to address the needs of the most vulnerable ; and

■ To what extent was the Sahel Plan successful in linking relief to development (LRRD), including (b) establishing a contiguum of actions between humanitarian and development donors.

Through the Sahel Strategy, ECHO has had a very visible impact on influencing the focus and direction of both DEVCO and DfID’s programming in the region. It has also guided the practices of other donors (e.g. USAID, World Bank, SIDA) who have relied upon the evidence produced by ECHO to help decide where and how to fund interventions and what type of practices to support. For example, USAID’s Office of Foreign Disaster Assistance (OFDA) have made use of ECHO’s research on blanket feeding, WASH and nutrition, and the World Bank has taken up findings of ECHO linked to social safety nets. As a lead humanitarian donor in the Sahel,100 ECHO is also able to influence Member State donors, such as SIDA and AECID, who align their funding objectives to those of ECHO and consult with ECHO on their own project selection.

Influencing international donors to address the most vulnerable

ECHO has had a major influence on how and where Member State donors (DfID, SIDA, AECID) allocate funding in the region. These donors respect ECHO’s technical know-how, in-depth understanding of the humanitarian situation, monitoring and coordination capacity and have decided to make cost savings in the region by channelling funding directly through ECHO (as in the case of DfID) or by aligning with ECHO’s objectives and essentially ‘gap-filing’ ECHO actions (AECID and SIDA). Nonetheless, this has likely been relatively easy in the case of DfID and SIDA, as these donors already take a needs-based and human rights based approach to humanitarian aid delivery, which also focuses on addressing the needs of the most vulnerable. It is less easy for ECHO to influence DEVCO’s targeting, because DEVCO

100 ECHO was also the second biggest humanitarian donor in the region after the United States of America over the last eight years (see FTS). ECHO was responsible for 18.4% of the overall humanitarian aid donations to the Sahel region. (This excludes response to floods in West Africa).


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is influenced by economic concerns and a mandate to help the entire population of a country (not only the most vulnerable) and by the governments it partners with.

Nonetheless, DEVCO reports that ECHO have had a huge influence on their programming in the area of nutrition and food security over the evaluated period, including their targeting. For example, in Niger, DEVCO report that ECHO lobbying influenced them to earmark funds for the National Implementation Programme on social safety nets and malnutrition. From 2012 DEVCO and ECHO in Niger began to develop a common support plan (“plan de soutien”) for addressing malnutrition in the region.101 All stakeholders report that the Sahel Strategy greatly influenced DEVCO to prioritise funding for nutrition under the 11th ‘European Development Fund’ (EDF) which will run from 2014 to 2020102 (see Figure 3.3).

Figure 3.3 DEVCO 11th EDF budget for food security, nutrition and rural development as a

proportion of the total 11th EDF budget for these countries

The allocation of the 11th EDF funds is not confirmed at this stage since the programme is still in its first year. However, in the NIPs for Mali, Niger and Nigeria there is an explicit focus on the most vulnerable (here: those regularly in need of food assistance). Envisaged actions for NIPs include health user fee exemptions (Burkina Faso, Niger) and social transfers for food-insecure households (Burkina Faso, Chad, Mali, Niger, Nigeria).103 In Chad, DEVCO reports that some funding will be allocated to UNICEF’s work on child development and stunting as part of the ‘1000 day approach’ to addressing malnutrition.104

DEVCO reports that this change in EDF budget and programming has led to the prioritisation of household resilience. It will be for DEVCO to influence national governments to spend this money on vulnerable households. One way it will be able to do this is with reference to AGIR. AGIR is a major achievement for ECHO in influencing international donors to focus on

the most vulnerable. Initiated by ECHO, the AGIR Roadmap and pillar of focus are based upon the findings and principle of the Sahel Strategy. AGIR aims to make the Sahel more resilient by encouraging governments to introduce (a) improving social protection for the most vulnerable households and securing their livelihoods, (b) strengthening the nutrition of vulnerable households, (c) sustainably improving agricultural and food productivity and the incomes of vulnerable households and their access to food, and (d) strengthening governance in food and nutritional security (this latter aspect includes policymaking and early warning

101 Interviews with DEVCO officials based in Niger. 102 As reported in ECHO programme documentation and interviews with DEVCO and ECHO. 103 DEVCO, ECHO, EU-DEL (2015) Draft Joint Action Plan on the Use of Social Transfers to Respond to the Sahel Food Crisis, January 2015 104 Interview with DEVCO officials based in Chad.

190285

100 78

180105

433157 515

117

416

242

0

100

200

300

400

500

600

700

Burkina Faso Chad Mali Mauritania Niger Senegal

Total budget allocated (m EUR)

Budget allocated to food security, nutrition and rural development (m EUR)


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systems). The focus on vulnerable persons is therefore a key element of the AGIR Roadmap and thus a means of influencing the international donors and national governments forming AGIR to focus on vulnerable households.

There is still room for ECHO to maintain its advocacy for the most vulnerable in the region. DEVCO officials have expressed the fact that – while they are increasingly focusing on vulnerable households in their advocacy to national governments and their programming of funds, they are still mandated to support national populations as a whole. In his end of mission report, the ECHO technical assistant for AGIR expressed a concern that the national and regional actors meeting under the auspices of AGIR gave disproportionate attention to priority (c) – food production –falling back on “conservative” approaches to addressing food insecurity at the risk of ignoring those suffering from malnutrition. Whilst DEVCO disagrees, it would be important for ECHO to continue to attend AGIR meetings to monitor this and ensure that momentum for all AGIR priorities is maintained.

Linking relief to rehabilitation and development: collaboration with DEVCO and its

effectiveness

The Sahel Strategy has played a very important role in linking relief to rehabilitation and development in the Sahel. DEVCO in Niger is also considering what lesson it can learn from ECHO in addressing malnutrition by supporting CRENIs. In Chad, DEVCO considers that its work complements ECHO’s, because while DEVCO is addressing chronic malnutrition (manifested as stunting in children), ECHO addresses SAM (manifested as wasting). DEVCO sees the need for LRRD and specifically for the continuation of ECHO’s humanitarian presence in the region. One DEVCO officer states, “There is a need to link with ECHO. I have seen a number of situations where once emergency support is taken away from the population, people fall back into crisis”. Both ECHO and DEVCO – in the field and at headquarter level – can illustrate various examples of coordination and collaboration. Over the evaluated period, as discussed, (see section 2.1 and section 3.3), ECHO and DEVCO’s objectives in the region have further aligned on key topics – particularly nutrition and resilience.

DEVCO appreciates the value of the Sahel Strategy and have taken on learning from the programme in their 11th EDF and technical assistance to national governments. For example, in 2013, in Niger, ECHO piloted a cash transfer scheme which generated lessons taken on board by DEVCO in supporting the national government’s ‘3N’ initiative. A Draft Joint Action Plan on the Use of Social Transfers to Respond to the Sahel Food Crisis was drafted by ECHO, DEVCO and the EU Delegation in January 2015. Amongst other results, it aimed to ensure that the three donors speak with ‘one EU voice’ on social transfers with key donors (DfID, World Bank) and improve “cross-fertilisation” on social transfers.

In spite of these positive findings, evaluators visiting Chad, Mali and Niger consider - and ECHO partners still express a concern - that there is, and will continue to be, a gap between the actions that ECHO funds (mainly treatment) and those that DEVCO funds (mainly large scale infrastructural or economic development projects). There is a need for iterative longer-term funding of community actions, such as repeat awareness-raising activities, education, investment in WaSH and small-scale livelihoods measures, which ECHO (constrained by its ability to only fund short term projects and its need to focus on life-saving treatment) cannot address. If DEVCO were to fund such actions these would clearly link the relief actions of ECHO to the development actions of DEVCO.

DEVCO has the mechanisms to take over and scale up ECHO actions in the region. It could do this either by funding iNGOs to implement projects, but at a larger scale, or by encouraging its national governmental partners to allocate the aid they receive directly to such actions (see also section 3.3 for more suggestions for DEVCO/ECHO joint working). Around 30% of DEVCO’s funding is mobilised each year for iNGOs whether for pilot projects, or the scaling up of actions if it is deemed that iNGOs could be more efficient or effective than national partners. The main obstacle is the timeframe: DEVCO calls for proposals last at least a year and draft proposals must go through at least three rounds of discussion before approval. However, the Sahel Strategy, by virtue of its multi-annual funding, provides the opportunity for ECHO to identify potential projects for scaling up by DEVCO. ECHO can continue to fund the


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project while the partners adapt it to the requirements of DEVCO funding. That ECHO sits in on all quality support groups that review DEVCO project proposals gives ECHO the opportunity to lobby for the scale-up and take over of its successful projects. However, ECHO partners will need to clearly evidence their project’s suitability for scale-up or long-term funding. To support this, ECHO could consider funding a cross-programme review of effectiveness. Given the discussion in section 3.4.1, it would be valuable for the review to focus on identifying projects that have been effective in being integrated into the wider health system and/or or on projects that have had some effect on reducing GAM and SAM rates amongst beneficiary populations, as well as mortality rates.

DEVCO considers that the recently established EU ‘Emergency Trust Fund for West Africa’105

might provide the opportunity for DEVCO to community-focused interventions with fewer practical constraints. The Fund will provide more than 1.8 billion euro for interventions in the region. The Fund allows the EU to contract partners through simplified and quicker procurement procedures in order to reduce selection time frames. The Fund will support projects focusing on basic services for local populations, such as food and nutrition security, health, education and social protection. Nonetheless, the Fund addresses a number of objectives, including migration management, radicalisation, and employment in West Africa, thus nutrition and food projects will have to compete against a whole array of other projects for prioritisation.

3.4.3 Effectiveness of actions in influencing national actors

This sub-section covers the following evaluation questions will be merged into two to cover:

■ To what extent has the Sahel Plan (including ECHO funded interventions and advocacy) increased government ownership of and commitment to addressing humanitarian challenges in the region; and

■ To what extent did the Sahel Plan contribute to:

– Mainstreaming food security and nutrition resilience into national and local governments' long-term development policies and practices;

– Key policy changes on food security and nutrition that could be distinguished in the region; and

– Reinforced response capacities.

Advocacy was a key element of many of the projects funded. A total of 42 online survey respondents (84%)106 indicated that the project involved advocacy activities, of which the most common advocacy activities included meetings with policymakers or authorities (95%) and awareness-raising in local communities (95%), training and educational activities for local communities (83%) and lobbying (81%). Other advocacy activities included: community visits for policymakers or authorities, support for the drafting of policy and training and educational activities for policymakers or authorities. The actors these activities targeted were: local (39 responses, 98%), regional (35 responses, 97%) and national authorities (31 responses, 89%), and to a lesser extent, the local community and international donors.

Part of UNICEF’s regional grant went towards the salary of a regional advocacy officer and towards the actions of UNICEF staff at national level to increase national support for the treatment of children and to integrate nutritional indicators (SAM and GAM) into national early warning systems. UNICEF also conducted policy reviews and provided technical support for the development of national policy on nutrition.107 Key advocacy achievements cited by UNICEF108 include the establishment of annual malnutrition SMART surveys, the incorporation

105 See the Factsheet on the Emergency Trust Fund for West Africa, published as part of the outputs of the 2015 Valetta Summit on Migration 106 Respondents provided responses relative to more than one project. 50 responses were received in total. Many of these were follow-on projects meaning that around half of all of the projects in scope of this evaluation were covered.

107 Interview with ECHO regional staff. 108 In interviews conducted for this evaluation


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of nutrition indicators into early warning systems and membership to the ‘Scaling Up Nutrition’ initiative. However, ECHO considers that UNICEF could have done more on advocacy to support policy change in the Sahel, for example through the provision of ongoing technical assistance to national governments on the issue of malnutrition. It is difficult for the evaluators to judge this. Most ECHO partners, other donors and national authorities commended the work that UNICEF was doing in the region to raise the profile of the malnutrition crisis. They considered that, jointly with ECHO, UNICEF was a key leader on this. Nonetheless, it is surprising that UNICEF did not play more of a prominent role in advocating for free healthcare in the region (Terre des Hommes and Help led on this in Burkina Faso and other NGOs led on it Mali).

Extent to which the Strategy influenced government ownership

Overall, in Chad, Mali and Niger, there have also been notable changes in the government’s acceptance of malnutrition as a pathology and an issue to be addressed at national level in the last five years. This was reported not only by stakeholders interviewed in the field, but also observed by the field teams who had previous experience of the countries visited. Such a shift in attitudes is essential if future changes in policy and practice are to be possible.

Extent to which nutrition and food is mainstreamed into government policies

All Sahel countries have action plans on food security and nutrition (see Annex 7). However, all ECHO partners and donors consulted for this evaluation argued that national governments need to take greater responsibility for addressing these issues in their own country. The aim of AGIR is to change this by passing ownership for addressing resilience to the national governments in the Sahel, increasing the likelihood for sustainable change. West African national governments have responsibility for drafting and committing to their national priorities and the technical team are there to coordinate and provide technical assistance (monitoring, help drafting national priorities, training advocacy).

An analysis of the ‘Country Resilience Priorities’ (CRPs) for Mali and Niger was conducted for this evaluation by the humanitarian experts who collected data in the field. Overall, they considered that the CRPs represented a ‘step in the right direction’, but that they were overly focussed on agricultural food production in Niger and somewhat ambitious in Mali. One expert considered that they read more like ‘development priorities’ rather than resilience ones since they do not identify shocks nor mitigation measures against the shocks at national, regional, local and household level. Their analysis is summarised below.


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Box 3.6 Assessment of the appropriateness and feasibility of the CRPs in Niger and Mali

Niger

The Niger CRP focuses on social protection to secure livelihoods. Little progress appears to have been made towards this objective in Niger. The securing of livelihoods implies that households have sufficient income for food, health, water, education and other basic needs to prevent them from needing to pawn or sell assets (e.g. animals, tools, seeds) that impact negatively on their livelihoods. In Niger, the national safety net programme does not seem to be effectively functioning yet and iNGOs are still making lean season payments to the most vulnerable as social protection. Subsequently, in 2015, neither the government nor iNGOs appear to be yet capable of achieving 'social protection to secure livelihoods'.

It also focuses on agricultural food production, but does not mention livestock or enterprise even though agriculture in Niger is challenging and therefore not the most sustainable or viable livelihood. Agriculture needs tremendous support and exceptional programming to work at household level and it will be therefore challenging to address AGIR objectives in this pillar in Niger. A more resilience-focused programme would aim at “spreading risks” at household level through a diversification of livelihood types and crops for example.

Mali

The specific objectives for 2015-2020 mark a shift from emergency response objectives towards socio-economic development objectives. The proposed establishment of strong social safety nets is a positive step towards addressing poverty (a root cause of malnutrition). Multiple stakeholders – including members from the Malian administration – stressed that there has been an overall lack of attention for malnutrition and food security in Mali in the last decades. This is mostly illustrated by the fact that the nutrition department within the Malian State is a division and not a directorate (it stands below the national health directorate and hence receives less attention and financing). The CRPs do not seem to address this situation, though it should be noted that positive developments took place in recent years, i.e. the creation of the National Nutrition Council (CNN); and the Intersectoral Technical Committee on Nutrition (CTIN).

The overall feeling of national and local stakeholders (both from the NGOs, the local authorities and governmental bodies) is that the Malian state very much depends on the international donors and NGOs in their fight against malnutrition and food insecurity; hence the objectives of the CRPs seem ambitious and probably very difficult or even impossible for the government to achieve on their own. For example the government highlighted its will to strengthen the capacities of the CSCOM and CSREF but during the field visits it clearly appeared that the local authorities and health structure were fully dependent on the help from the NGOs for capacity-building.

The evaluators also analysed the Nigerian ‘3N’ policy which aims to establish self-sufficient food production in the country in order to reduce the dependence on foreign markets which drove the 2012 food crisis. They found the objective legitimate and feasible but considered that there was insufficient focus on access to food at the household level where there is “not much potential for production” without intensive and innovative long term development programmes focussed on livelihoods and livestock production.

Currently national governments are behind schedule in designing their national resilience priorities. DEVCO has suggested that this is in part because national governments are treating AGIR like a funding programme and they are waiting for additional money from donors to develop these priorities. DEVCO also suggests that the proliferation of initiatives, strategies, networks and working groups in West Africa might be having a deterrent effect on national governments from engaging with AGIR.

Key policy changes and the extent of ECHO influence on these

DEVCO, ECHO and ECHO partners consulted report that the following developments resulted – at least in part – from dedicated advocacy efforts by ECHO and partners:


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■ The incorporation of health and malnutrition as priorities in the Niger Health Development Plan 2011-2015;

■ The establishment of the ‘Nigeriens Nourissent les Nigeriens’ (3N) initiative in Niger (2012) - a governance framework for coordinating the efforts of the various stakeholders involved in malnutrition treatment and support;

■ The establishment of the national food security mechanism “dipositif national” in Niger; ■ The integration of the National Centre for Nutrition and Food Technology (CNNTA) within

Health Ministry in Chad ■ The establishment of a ”health working group” integrating nutritional issues in the national

Parliament ■ The publication of a decree by regional authorities in Ouaddaï (Chad) to forbid the sale of

Plumpy Nut on local markets (see Box 3.7 below).

Box 3.7 Local legislation to prevent the misuse of Plumpy Nut in Chad

Plumpy Nut is ready-to-use therapeutic food distributed to families of children suffering from severe and acute malnutrition in order to treat the child’s malnutrition. Plumpy Nut can be misappropriated and does not always reach the child in need: it is commonly found for sale on markets and in households in Chad and it is common for children to be obliged to give a portion to the lead male(s). To prevent the misuse of this product, ECHO partners lobbied the health regional delegate and the governorate in Abéché to forbid their sale on markets. A prefectural decree was hence published on the 15th of October 2015 to formally forbid the sale of Plumpy Nut in markets of the Ouaddaï region, as well as the sale of any other products given for free to malnourished under five children and breastfeeding mothers.

Impact on national response capacities

ECHO played an important role in developing early warning systems in the region. At the time of the 2005 Niger food crisis, there had been no early warning. This was partly because actors had failed to consider the regional element of food security in the region – i.e. the fact that populations in Sahel were dependent on food markets in Nigeria. There were also no SMART surveys or HEA survey being conducted. There was a need for more information. In response to this, ECHO started to support HEA. ECHO’s focus on HEA led to the development of more than 60 studies by 2014 (see section 3.1.1). ECHO also lobbied the Permanent Interstates Committee for Drought Control in the Sahel (CILSS) to set up national EWS.

EWS are now well established throughout the region, based around the ‘Cadre Harmonisé’ (CH) of monitoring different indicators. Most governments in the region make use of this information, though the ECHO field officer responsible for EWS interviewed for this evaluation was highly critical of the Cadre Harmonise citing problems with its management and functionality (“the analysis is not used for the allocation of funding”). Only in Burkina Faso is the tool being managed entirely by the government and (partially) in Chad and Nigeria.109 Therefore, while it is an achievement that EWS have been established in the region, and this is – in part at least – the result of ECHO’s advocacy, there is still work to be done to improve the EWS. Nonetheless, this no longer should be the focus of ECHO’s actions since other donors (mainly DEVCO) are now taking a lead in funding this with CILSS coordinating.

3.4.4 Effectiveness of the regional and multi-annual approach

This sub-section discusses the following evaluation question:

■ To what extent has the regional approach been adapted to address the different countries’ needs? To what extent has the fragmented annual funding been appropriate to support the multi-annual plan?

109 Interview with ECHO.


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The regional approach

The regional approach was appropriate to the situation in the Sahel because it allowed for a

common approach to be applied to a common problem and encouraged exchange of

practices and lessons learned between partners working in different countries. The main forum for such exchanges was the annual partner meeting in Dakar. Within countries, partners were afforded more opportunities to exchange information, e.g. through the formalised alliance of partners in Niger or through non-ECHO specific fora such as UN cluster meetings.

Although a regional approach was applied, ECHO partners were able to tailor projects to suit the specific needs of the country of implementation (i.e. the humanitarian needs, the country policy and national capacity). There is no evidence to suggest that the regional approach

was restrictive in any way nor that countries were excluded or received a

disproportionate amount of support than others. Rather, the regional approach arguably provides flexibility to ECHO to change the share of funding given to each country each year dependent on the changing needs in the region.

Multi-annual strategic framework

The evidence suggests that annual funding has been appropriate in supporting the multi-

annual plan. The respondents to the online survey reported that it has given them the opportunity to adapt their projects by supporting greater numbers of beneficiaries (29 out of 40 respondents who implemented follow-on projects), including activities covering new sectors (24 out of 40), improving approaches (38 out of 40), and generating evidence of good practices (23 out of 40). The field visit further suggests that partners were able to reinforce positive outcomes of previous years in the next years.

However, some partners reported that they would still prefer longer-term funding. For instance, in Chad, partners reported that ECHO’s administrative and funding cycle can lead to implementation delays and problems for their implementing partners. In Niger and Mali, most partners perceived the funding of short duration projects (9 to 12 months) as a major challenge to properly enacting projects with long-term and sustainability objectives.

Nonetheless, it is believed that a fragmented annual funding remains the best option as it allows more flexibility to respond to humanitarian crisis. Furthermore, by adapting the HIPs

every year to the needs and trends of the humanitarian world, it ensures the coherence

and relevance of the Strategy. In addition, ECHO funding should be a complement to the work of development donors who fund projects over multiple years.

ECHO is currently thinking of encouraging partners to plan over several years as funding under the PHASE programme is almost guaranteed from one year to the other. In practice, this would mean to develop a logframe over a three year period with interim annual objectives and targeting. ECHO could also take better advantage of multi-annual funding, but conducting a review of its projects that would track the cumulative results generated in order to learn lessons about the most effective practices. Such a study – which could be commissioned with Sahel Strategy funding, coordinated by an FPA partner – could generate an evidence base to support development donors programming (see also section 3.4.2).

3.4.5 Main factors limiting the success of the projects funded

Based on data available, it seems that most projects met or exceeded their targets for implementation (see section 3.5).110 A number of challenges to project effectiveness were, however, identified. These include:

■ Reaching beneficiaries (and screening potential beneficiaries) located in hard to reach areas or nomadic persons who move away from health districts mid-treatment;

■ High drop-out rate of patients mid-treatment for SAM in health centres, which can impede recovery;

■ Security issues creating challenges for the movement of partners, implementing partners and/or beneficiaries;

110 Though the data on results is not comprehensive – see, again, section 3.5


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■ Low technical capacity of implementing partners (health workers, national early warning systems, etc.);

■ High drop-out or turnover rate of staff (both in iNGOs and in health centres), which prevents there being any economy of scale and creates a loss of institutional knowledge.

3.5 Efficiency

This sub-section discusses the following two evaluation questions:

■ Was the size of the budget allocated by ECHO appropriate and proportionate to what the actions were set out to achieve?

■ Could the same results have been achieved with less funding?

These questions essentially ask whether the Sahel Strategy achieved value for money for the ca. 416 million euros that was invested in the region over the period 2010 – 2014. This section begins by discussing the challenges of measuring value for money with the data available to the evaluation team. It then discusses the adequacy of project budgets (based mainly on partners’ views), followed by a discussion of project efficiency.

The Sahel Intervention Logic as a tool for assessing value for money

The intervention logic for the Sahel Strategy was outlined in section 2.3. The diagram (Figure 2.5) demonstrates the high level of dependence of the logic on external factors (development donor buy-in, national governmental buy-in, and the scaling up of the ECHO’s interventions by these actors). The Sahel Strategy was not expected to achieve a sustainable reduction in child mortality with its assigned 523 million euro alone. It was dependent on other resources – specifically those of other donors and national governments. Yet the model does not make clear, or at least try to estimate, what amount of resources might be needed to achieve the goal of a sustainable reduction in child mortality – nor does it define what it means by “a sustainable reduction”. It is therefore challenging to measure the extent to which the budget was appropriate in view of the goals of the Strategy, because the goals of the Strategy were never quantified – e.g. in terms of the % reduction in mortality rates, % reduction in GAM, etc. It would be helpful for ECHO in its programming to be clearer about the objectives it can realistically achieve within a programmatic timeframe of 1, 3 and 5 years and the assumptions it depends upon for the realization of these goals (e.g. XX euro being assigned from DEVCO funding, a willingness of governments to integrate nutrition into their healthcare system, etc.). Such an intervention logic would have to set out the risks and potential obstacles to the achievement of the (quantified) goals and measures to mitigate against these risks.

Results achieved and the challenge of measuring these

The results of the Sahel Strategy were discussed in section 3.4. These included an increase in coverage of nutrition services, more children screened and treated for malnutrition, a reduction in child mortality and improvements to national and sub-national policies. However, it is extremely difficult to assess the overall results achieved, because these have not been well documented in a measurable and aggregate format by ECHO and its partners. The number of beneficiaries supported directly and indirectly is not clear. Whilst all partners are required to state expected and actual number of beneficiaries reached in their project reporting, the definition of ‘beneficiary’ is not standardised (some report on direct beneficiaries only and others on direct and indirect beneficiaries; some count intermediaries and others do not). Further, ECHO does not store the data on results (not any other data reported by ECHO partners) in a manageable format. This makes it extremely difficult to monitor progress of the programme overall. There are no common indicators upon which partners have to report meaning that ECHO currently is not able to say:

■ What caseload of malnourished children it has reached (screened, treated, cured) (though ECHO is beginning to compile data on this);

■ What the average relapse rate for malnourished children is in supported communities; ■ How many health centres have been integrated into the national system; ■ Etc.


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As a result, it is challenging to evaluate whether the budget allocated by ECHO was appropriate and proportionate to what the actions were set out to achieve. The budget was certainly significant – the almost trebling of the budget from 2011 to 2012, enabled to ECHO to increase its coverage (adding new countries and sub-national regions) and its impact on donors. There have been some positive outcomes of ECHO’s work (see section 3.4). There have also been some lessons learned – e.g. the targeting of livelihoods projects funded in 2010 and 2011 was not always appropriate, food assistance projects have not always been efficient, greater funding could have been allocated towards the integration of low-cost prevention activities (e.g. WaSH and education) into treatment activities. Overall, ECHO appears to work efficiently (see below). Inefficiencies often only become apparent with the benefit of hindsight and experience. Notwithstanding their inefficiencies, food assistance projects funded under the Strategy contributed to very positive developments in the field of social safety nets (see sections 3.4.1 and 3.4.2). Further, for ECHO to fund WaSH and educational activities, it would have required ECHO partners to have the skills to develop such projects and it is not clear that this would have been the case: partners only seem to have started to integrate WaSH in any earnest since 2014. ACF has been a main proponent, as has the Red Cross, though Concern, Alima, UNICEF and Save the Children also incorporated WaSH into the design of their projects in 2014. Médecins du Monde (MDM) is one organisation that has incorporated family planning education into its actions in Niger.

The adequacy of project budgets

The budgets allocated to individual projects were, however, considered adequate by the majority of ECHO partners. Responses to the online survey suggest that 70 per cent of the respondents considered that project budgets were sufficient in relation to what they were trying to achieve (Figure 3.4).

Figure 3.4 ECHO partners reporting on the extent to which financial resources were sufficient

Source: ICF survey of ECHO partners; n= 50, N= 50

Project implementation efficiency

ECHO partners design their projects on the basis of a logical framework, which defines the expected result indicators and corresponding targets. Progress against these targets is reported at the interim and final stages of the project. Data was analysed for 80 projects which collectively set out to achieve 651 results targets, however the data was unclear or unquantified for 19% of these indicators. Excluding such indicators, the analysis suggested that collectively, the 80 projects reviewed had either met or exceeded 65% 344 targets

representing 65% of all measurable indicators). The remaining 230 targets had not been achieved. However, for some indicators (62), we only had interim report results.

The following explanations were provided by partners in the project documentations for missing targets:

■ Poor targeting e.g. some children were too young to receive the full vaccination. Although partners interviewed in Chad explained that beneficiary targeting had improved over time

30%

70%

The financial resources

were not sufficient

The financial resources

were sufficient


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in the country as a result of the increased availability of reliable data and expanded national coverage. This was further confirmed in Mali where most of the projects achieved or went beyond their targets.

■ Working within an existing national system (e.g. within national regulations on health admissions) was relatively challenging, as it sometimes delayed activities from starting or led to changes in targeting. For example, in Chad, during the implementation of one of the projects, the government changed the project approach from targeting all PLW for supplementary feeding programme towards targeting only malnourished PLW.

■ A number of project partners also explained that they faced a certain number of drop-outs, due to problems with referrals for instance or because beneficiaries were more likely to use traditional medicines rather than health services.

Project efficiency and evidence of wastage

The analysis of project documentation did not highlight any major issues of project wastage or implementation inefficiency. Only a few projects reviewed appeared to have experienced problems with delays in the implementation of activities. In one case (a food assistance project) however, this delay resulted in the delayed delivery of food to vulnerable populations at the critical period of food shortage. In at least two cases, implementation delays were caused by a delay in ECHO’s funding reaching the partner. In a few cases, spending was lower than planned during project implementation. In one case this was due to a lack of training and support to implementation partners. However, as a result, this partner planned to develop finance team field visits to increase and improve financial controls in the future.


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4 Conclusions and recommendations

This section sets out the overall conclusions and recommendations per evaluation criteria. Under each sub-heading the evaluation questions are repeated for convenience.

4.1 Relevance

4.1.1 Relevance of the actions to the needs of the most vulnerable

Identification and targeting of the most vulnerable

The targeting of ECHO funded actions was largely appropriate and effective. The Sahel Strategy targeted infants (<5 years old) and particularly those aged under two, as well as PLW. All available evidence - such as research carried out by UN agencies, statistical evidence such as SMART indicators and stakeholder consultations - confirms that severe and acute malnutrition is most prevalent among these groups in the Sahel region.

For their geographical targeting, partners systematically drew on data resulting from ECHO-funded HEA and SMART surveys (targeting regions with high malnutrition and poverty rates). The investment in HEA and SMART surveys was therefore highly relevant. The targeting of some single-sector livelihoods projects in 2010 and 2011 was found to be out of line with the objectives of the Sahel Strategy, since the targeting was driven by considerations such beneficiaries’ absorption capacity and the suitability of the targeted region for food production instead of vulnerability indicators.

Some good practices in targeting can be found e.g. the targeting of populations based not only on their malnutrition levels but also on indicators of risky levels of the root causes of malnutrition (e.g. poor access to water, high levels of diarrhoea, etc.).

ECHO’s ‘vulnerability-focussed’ targeting in the Sahel has directed ECHO to support beneficiaries in urban as well as rural areas (in Chad) - an action which is highly relevant, as well as innovative (no other donors are addressing urban malnutrition in the region).

Addressing the needs of the most vulnerable

The most pressing humanitarian needs of the above groups (treatment of the malnutrition and its immediate causes) were addressed through the Strategy. Further, ECHO also sought to address the immediate and household level drivers of malnutrition by funding actions to reduce vulnerability and improve household resilience (access to food, access to health, hygiene, preventative actions) and by advocating for increasing support for such measures at national level and with international donors.

Quite naturally, ECHO prioritised funding of life-saving treatment of malnutrition and related mortality over prevention actions. This was appropriate given the scale and urgency of the problem, though it does mean that not all relevant needs were addressed.

While many ECHO partners during the evaluated period were incorporating at least one prevention activity into their treatment actions, some preventative aspects (household hygiene and family planning) which could be easily integrated into treatment actions at a relatively low cost and to a potentially significant benefit were not being integrated into treatment activities – a much greater emphasis was on preventing malnutrition through food assistance and health activities.

Recommendations

It would be useful for ECHO to be more transparent about its funding for prevention actions in order to manage partner expectations and to avoid mission drift. ECHO could do this by earmarking a specific proportion of the budget for prevention activities at each programming cycle. The allocation could be developed transparently and logically if based upon a clear logframe with measurable targets set for reducing malnutrition and GAM rates (see recommendation under section 4.5).


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Innovative prevention actions that have demonstrated an effect should be further funded in different regions and countries to further test their effectiveness.

4.1.2 Consultation with national and sub-national authorities

Conclusions

The evidence suggest that partners typically consult national and sub-national sub-authorities in design and implementation of interventions. Further, some projects demonstrated good practice in consulting with national authorities as to the possible future integration of ECHO-funded services post-project. During the field visits a strong culture of cooperation between ECHO partners and local stakeholders was observed, although some health projects were not well integrated into national health systems. This raises questions about the effectiveness of the consultation process. The evaluators also consider that beneficiaries were not always fully involved at all stages of a project cycle. While there were good examples of complaint and feedback mechanisms in some cases, these were completely absent in other cases.

Recommendations

To support the ongoing strategic consultation processes associated with AGIR, ECHO projects should try to frame their project-level consultations with national actors within the context of AGIR and national commitments to ending malnutrition. The focus should be on how ECHO interventions can complement and help lay the ground for national authorities to take over. This would enable ECHO partners to design projects that have an in-built exit strategy aligned to national priorities.

To further increase transparency and accountability of partners and ECHO to beneficiaries, ECHO should make it mandatory for all partners to develop feedback mechanisms for beneficiaries. Guidance on this could be developed by ECHO or one of ECHO’s partners (Save the Children has developed such mechanisms and could perhaps disseminate information on this). Such mechanisms will increase local ownership of interventions and also help partners to monitor their own interventions and improve their services. Feedback and stakeholder consultation could form a topic within the next ECHO partner meeting in autumn 2016.

4.2 Coherence

Conclusions

ECHO demonstrated high levels of commitment to key humanitarian principles (“humanity”, “neutrality”, “impartiality”, “independence”, “protection” and “do no harm”) in implementing the Sahel Strategy. The evaluation findings demonstrate that it can sometimes be challenging to reconcile the humanitarian principle of independence with the objective of ensuring coherence with national policies and practices. This is because national practices or approaches may be driven by political or economic considerations, as well as humanitarian ones which can sometimes create incoherence with ECHO’s approach. At an operational level, ECHO partners demonstrated their awareness and application of the principles of do-no-harm and protection. ECHO’s insistence on preserving the humanitarian space when operating in conflict and insecure areas is well-respected by the international community. That ECHO has – in keeping with the principle of humanity and protection – continued to advocate for international donor and national actor expenditure on nutrition and food (while other donors have advocated for greater spending on security) is also positive.

ECHO’s funding for health care has however, inadvertently created some disparities between nationally funded health centres and those funded by ECHO. For example, in Mali, the free health care offered at ECHO-funded health centres draws patients away from national health centres where they would have to pay for treatment, thus undermining the viability of national health centres. Similarly, in Chad (and Mali) disparities in the salaries offered by ECHO and those offered by the national governments creates tensions between health workers working for the two systems. Although sometimes unavoidable, greater attention could be paid to


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anticipating and if possible, mitigating the negative consequences of these issues during project design.

As with all prolonged aid interventions, the risk of aid dependency and moral hazard amongst national actors is high in the Sahel. That actions to hand over ownership for nutrition to local and national actors are ongoing and that ECHO is increasingly focussing on the integration of nutrition services into national health systems as a priority area (see the 2015 HIP) are highly positive developments.

Recommendations

ECHO country field officers should work closely with national partners to develop country-specific integration plans that have viable targets and timelines. The ‘integration plans’ would analyse the level of integration of each of the “critical functions” of the health system, inter alia: (i) governance, (ii) financing, (iii) planning, (iv) service delivery, (v) monitoring and evaluation, and (vi) demand generation”.111 For each function, a timeline and targets should be set, with each ECHO partner taking responsibility for an ‘integration goal’. The plan would also serve as a tool for framing discussions and negotiations with national and regional stakeholders on integration and hand over. Such integration planning should also cover aspects of the current division between NGO-supported nutrition services and national health systems highlighted as problematic in this evaluation (salaries, provision of free healthcare).

ECHO might consider investigating the extent to which disparities in pay between NGO-funded health workers and national health workers is a widespread and significant problem. It could investigate this during its project monitoring visits or through discussions with partners. If found to be a problem, ECHO should discuss with partners whether any mitigating action could be taken and/or whether salaries should be covered as a key part of ECHO’s advocacy on the integration of nutrition into national health systems.

4.3 EU added value

Conclusions

ECHO adds significant EU value to the region. Its comparative advantage (its ‘EU added value’) in implementing the Sahel Strategy is its comprehensive understanding of the complex needs on the ground, its neutrality which gives it greater flexibility and power to act on behalf of the most vulnerable and its capacity for coordination. That ECHO is valued by other donors for its technical know-how and capacity for coordination has led both DfID and SIDA to align their objectives with ECHO’s thus effectively increasing the resources available to ECHO to reach its objectives.

ECHO’s capacity for coordination also enabled it to establish AGIR – a very important tool for coordinating (and influencing) international donors and national governments and regional governing bodies. Nonetheless, ECHO and DEVCO’s continued lack of joined-up or coherent programming is a missed opportunity for increasing EU added value in the region (for partners and beneficiaries). Having ECHO and DEVCO work towards the same goals through complementary activities would increase opportunities for LRRD in the region.

Recommendation (operational)

ECHO should consider pursuing joined-up programming with other Member State donors in addition to DfID. For example, SIDA is open to funding ECHO projects that align with their objectives. Such a move would be subject to there being no / little administrative burden on an already ‘stretched’ ECHO in managing the funds.

ECHO and DEVCO should seek to further ‘join up’ their approach. Elements of a fully joined up approach could include:

111 Atun, Rifat; Ohiri, Kelechi; Adeyi, Olusoji. 2008


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■ The development of Joint Humanitarian Development Frameworks (JHDFs)112 JHDFs, which could be developed jointly between ECHO and DEVCO in each of the Sahel countries. These would identify the main vulnerabilities and needs in each country, the different actions to be completed to address these and the different ways in which ECHO and DEVCO (and other actors) could contribute to addressing the problems. Such an assessment could be supported (and complemented) by ECHO’s parallel action to develop its programme theory of change (see recommendation above) and could feed into ECHO actions to develop national integration plans (see below); and/or

■ A critical review of the Country Resilience Priorities to ensure that they address the specific country needs and vulnerabilities identified and that they are feasible for national governments to implement. On the basis of any challenges identified, means of addressing these through ECHO and DEVCO advocacy or through ECHO or DEVCO programming could be developed.

4.4 Effectiveness

4.4.1 Effectiveness in reducing mortality sustainably

Conclusions

Overall the Sahel Strategy was effective in achieving its stated objective of reducing mortality linked to malnutrition in the communities of intervention. It did this principally by funding actions to increase the number of malnourished infants detected, increasing the coverage and number of health centres treating malnutrition and by funding the supply of therapeutic foods and medicines essential for the treatment of malnutrition. Malnutrition rates in the regions supported by ECHO however, remain high (these continue to fluctuate year to year and the number of children identified as suffering from SAM continue to rise).

A reduction in malnutrition rates is a more challenging and longer term issue that first and foremost requires commitment and ownership from state actors, who could be supported in their efforts by the international development and humanitarian community. The lack of national ownership and capacity remains a key challenge to achieving a reduction in malnutrition rates in the Region. The area therefore most requiring focus and investment from ECHO now is the hand-over of malnutrition treatment to national health systems. ECHO’s contribution to the sustainability of nutrition treatment in the Sahel is going to be dependent on the extent to which nutrition treatment can be integrated into the national system. Integration will require both innovation (and therefore the piloting and testing of methods) to identify means of providing quality health and nutrition treatment services to patients in a way that national services can afford and are technically able to deliver.

It is too early to tell whether the multi-sectoral approach is working or not. Overall, GAM and severe and acute malnutrition (SAM) rates have not fallen in the Sahel. This is likely due to several reasons including the fact that it is only since 2013 that partners have begun to address more than two sectors at once and due to the fact that prevention actions – apart from food assistance activities – have not yet been funded at a large enough scale to have an impact on malnutrition. Food assistance activities have failed to reduce malnutrition, mainly because they operate in isolation and do not therefore address other root causes. Further, in view of progress being made towards the development of national safety nets and in view of the support being provided by development donors (e.g. World Bank) towards this goal, the evaluators consider that the reduction in ECHO funding to food assistance projects is appropriate. Two areas of intervention warranting greater attention going forward are WaSH and community sensitisation activities which have the potential to make a significant difference at a relatively low cost.

112 http://capacity4dev.ec.europa.eu/resilience_ethiopia/document/joint-humanitarian-development-framework-jhdf-context-food-security


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Recommendation

ECHO’s contribution to the sustainability of nutrition treatment in the Sahel is going to be dependent on the extent to which nutrition treatment can be integrated into the national system. Three recommendations are therefore as follows:

Firstly, ECHO should be realistic about the extent to which its actions can impact on GAM rates and design the future years of the Strategy on this basis. Specifically, if ECHO wishes to reduce GAM rates, it has three options:

■ Invest more money in community prevention activities (e.g. the building of latrines, clean-water access, behavioural change, disaster-risk reduction and livelihoods actions). This could lead to a reduction in GAM rates locally, but would need to be scaled up to have a wider effect. Most of these actions also require iterative support over multiple years, which ECHO is not well-placed to provide. Ultimately these actions would stretch the mandate of ECHO and potentially overlap with development activities. They could also lead to a reduction in the funding available for treatment and advocacy. The option is therefore not favourable.

■ Invest in small-scale prevention activities with the purpose of identifying good practices in reducing GAM that can be scaled up by other donors / actors. In particular, ECHO should replicate practices that work well in one country / region in different contexts to further test their effectiveness. Such actions would not guarantee an impact on GAM, since they would be dependent on external actors for scale-up, but they would be lower cost than direct ECHO actions and – should external partners cooperate – would be more likely to impact on GAM rates in a sustainable way.

■ Make better use of existing evidence generated through the Sahel Strategy to advocate for development aid and national investment in prevention: ECHO should also consider commissioning a review of its projects that would track the cumulative results generated in order to learn lessons about the most effective practices. Such a study could be commissioned with Sahel Strategy funding and coordinated by an FPA partner.

Second, ECHO should continue to advocate (and encourage its partners to advocate) for the mainstreaming of multi-sectoral approaches to nutrition in the region. In doing so, ECHO should seek the support of DEVCO, since the two DGs now share common objectives and goals for nutrition (through the 2014 Action Plan). Linked to this, ECHO should conduct a critical review of the results, impacts and cost-effectiveness of the various multi-sectoral projects already funded to date. Such an evidence-base will greatly support ECHO – and DEVCO’s – advocacy actions.

Finally, as described under section 4.1.1, ECHO should continue to work towards the integration of nutrition services through the drafting and implementation of national integration plans (see recommendation on coherence).

More generally, ECHO should precisely formulate the objectives for funding over the next 3-5 years of the Strategy and organise its funding priorities around these objectives. If ECHO wishes to ‘exit’ its nutrition programme from the region, then it should discuss and agree internally the criteria upon which such an exit could be made. A clear theory of change should be developed for specifying the trajectory the programme should take to achieve its objectives. Ideally a logframe should be produced setting out targets and timeframes for the achievement of the expected outputs and outcomes. ECHO is currently operationalising a logframe for DFID’s PHASE programme, so a precedent has been set which should help ECHO to implement this change. More widely, ECHO should introduce ‘theory of change’ and logframes as standard tools supporting the development, monitoring and evaluation of its strategies. An outcomes- or impact-based approach to objective setting would also require investment in monitoring and evaluation tools that go beyond the collection of outputs data to performance tracking after the project has ended. In this respect, ECHO should invest resources in conducting impact evaluations.


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4.4.2 Effectiveness in influencing international donors and implementing LRRD

Conclusions

Malnutrition and related mortality in the Sahel is a humanitarian issue, but its causes are structural and therefore an issue for development action. Through the Sahel Strategy ECHO tried to link its relief activities to the programmes of development donors and national government by advocating for them to pursue ECHO’s objectives (nutrition, resilience) jointly and (at field level) by advocating for donors and governments to take over and scale up nutrition and nutrition-sensitive actions. The Strategy also tried to support LRRD by integrating longer-term objectives, such as resilience-building and malnutrition-prevention, into emergency response actions and by funding partners to support the integration of health services funded by international humanitarians into national systems.

The Strategy achieved the following results in LRRD:

■ It persuaded DEVCO to earmark development funding113 for nutrition and resilience actions thus going some way towards bridging the current gap between relief and development;

■ It attracted UK (DFID) funding for resilience and prevention actions to be pursued through the Strategy;

■ It led to the launch of Global Alliance for Resilience Initiative (AGIR), an initiative which brings together humanitarian and development donors with national actors to set priorities for national and international funding to address malnutrition.

In spite of these successes, there remains work to be done to establish an effective ‘contiguum’ approach to LRRD whereby relief, rehabilitation, and development are carried out side by side in order to respond effectively to all aspects of a crisis. ECHO’s strategy mind-set very much remains embedded in the ‘continuum’ approach (a linear approach dominated by ‘hand-over’ thinking a linear approach dominated by ‘hand-over’ thinking). A gap exists between the actions of ECHO and DEVCO most visible in relation to (the lack of) longer-term prevention actions at community level and longer-term investment in the scaling up and integration of nutrition and nutrition-sensitive services at national level. If DEVCO were to fund such actions these would clearly link the relief actions of ECHO to DEVCO development actions.

DEVCO is now (through AGIR) tasked with leading the way in encouraging national commitment to nutrition and resilience, though ECHO’s inputs and support can still add value (given ECHO’s technical expertise and historical knowledge); indeed, it would also be beneficial for ECHO to continue to monitor national progress towards CRPs and to intervene (in coordination with DEVCO) when it considers that these are not being met.

Also to address the gap between emergency and development, ECHO might consider trying to persuade Member State bilateral donors such as France (AFD), Spain (AECID) and Sweden (SIDA) to fund actions either to replicate ECHO piloted actions, in order to further the evidence base that can be used to promote scaling up or to fund resilience actions that are currently falling somewhat through the gaps of ECHO’s (predominantly emergency) funding and DEVCO’s (predominantly infrastructural) funding. ECHO has been successful in establishing such a relationship with the UK (DfID) who are now funding ECHO to manage its PHASE programme (Providing Humanitarian Assistance to Sahel Emergencies) in the region.

Recommendation

ECHO should continue to develop evidence bases that can be used by DEVCO. ECHO should package its evidence base in the most user-friendly way and encourage DEVCO to do more field visits.

ECHO and DEVCO should work together more strategically on their advocacy to government to ensure they are communicating the same messages (using the Nutrition Action Plan as the basis for this).

113 11th EDF funding, which was decided in 2012.


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ECHO might consider proposing ‘mini-PHASE’ programmes for other Member State donors such as Spain (AECID) and Sweden (SIDA) or coordinating with these donors to develop a joint programme pooling the resources of each donor, managed by ECHO. A pooling of resources would require the joint development of a programme and may entail some administrative burden. ECHO would need to consider whether it would be more efficient (i.e. less burdensome) to develop bilateral funding agreements with Member State donors or to try and pool their resources together as one programme.

4.4.3 Effectiveness in influencing national actors

Conclusions

The Sahel Strategy had some positive effects on national and regional policies and practices during the evaluated period. However, there is still much to be done to persuade national actors to take responsibility for addressing chronic malnutrition. Country resilience priorities being set under AGIR are ambitious and do not always appear to be appropriate (at least in Niger and Mali). While DEVCO is now leading the way in encouraging national commitment to nutrition and resilience, ECHO’s inputs and support can still add value (given ECHO’s technical expertise and historical knowledge); indeed, it would also be beneficial for ECHO to continue to monitor national progress towards CRPs and to intervene (in coordination with DEVCO) when it considers that these are not being met.

Recommendation

ECHO should continue to fund projects that integrate advocacy actions at local and national level. Advocacy efforts should focus on: (a) national authorities integrating CMAM and other aspects of nutrition response currently managed by international actors (e.g. screening, pipeline supply, training) into national health systems; and (b) on the scaling up of multi-sectoral approaches to addressing malnutrition that have proven to be effective in preventing repeat and new cases of SAM at household level. In this respect, ECHO should conduct a critical review of the results, impacts and cost-effectiveness of the various multi-sectoral projects already funded to date.

ECHO should continue to participate in West African regional fora relevant to the objectives of the Strategy (e.g. in AGIR and Food Crisis Prevention and Network (RPCA) meetings).

4.4.4 Effectiveness of the regional and multi-annual approaches

Conclusions

The regional approach was appropriate to the situation in the Sahel because it allowed for a common approach to be applied to a common problem and encouraged exchange of practices and lessons learned between partners working in different countries. Although a regional approach was applied, ECHO partners were able to tailor projects to suit the specific needs of the country of implementation (i.e. the humanitarian needs, the country policy and national capacity). There is no evidence to suggest that the regional approach was restrictive in any way; rather, the regional approach arguably provides flexibility to ECHO to change the share of funding given to each country each year dependent on the changing needs in the region.

Going forward, it makes sense for ECHO to retain its regional approach to tackling malnutrition. Firstly, the countries continue to be affected by the same problems. Moreover, malnutrition and poverty are increasingly affected by the conflict ongoing in the region, which affects borderland areas of the region (e.g. Lake Chad) and there is thus, a cross-border dimension to the problem. It therefore, makes sense for ECHO to develop its response at a regional level, which allows it the flexibility to adapt its approach and interventions to country specificities. Second, other important international actions aimed at addressing malnutrition and resilience, such as the Global Alliance for Resilience Initiative (AGIR) and the UN’ Strategic Response Plan for the Sahel are implemented regionally – it will be easier for ECHO to complement these actions through a Regional Strategy.

In spite of partners reporting that they find fragmented annual funding challenging in view of some of their project objectives (changes in policy at national level, behaviour change at


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community level); the results of projects do not confirm this. Indeed, project results demonstrate that fragmented funding has still enabled many partners to receive funding over consecutive years, which has allowed them to induce changes at national, sub-national and community level (even more so under the PHASE programme). Fragmented annual funding allows more flexibility to respond to humanitarian crisis. Furthermore, by adapting the HIPs every year to the needs and trends of the humanitarian world, it ensures the coherence and relevance of the Strategy.

Recommendation

ECHO should continue to take a regional approach in implementing the Strategy, but should seek to take better advantage of this approach by encouraging further cross-country learning and exchange. For example:

■ ECHO could fund ‘twin’ actions in regions of different countries experiencing similar problems (e.g. malaria prevention actions in two areas of high prevalence, strategies to prevent low hospital retention rates in two regions of high drop-out rates, actions to improve the quality of health provision in two regions with high post-discharge rates).

■ It could also fund actions to replicate activities that have proven successful in one country in another country. Such an approach would generate an evidence base that could be used to encourage development donors to scale up the intervention nationally and across countries.

ECHO should encourage partners to design projects with a span of several years as funding under the PHASE programme is almost guaranteed from one year to the other. In practice, this means developing an intervention over a three year period with interim annual objectives and targeting. To encourage partners to think longer-term, ECHO should also develop a programme-level theory of change to which partners will be able to align to facilitate coherence and the achievement of the Strategy’s objectives (see also the recommendation under 4.4.1).

4.5 Efficiency

Conclusions

It is challenging to assess whether the Sahel Strategy achieved value for money as its objectives were not SMARTLy defined114 – while indicating the ‘direction of travel’, they did not indicate the ‘distance to be travelled’.

Nonetheless, given the contribution of the Strategy in reducing mortality, one can say with a reasonable degree of confidence that money was well spent, although it is hard to say whether the results could have been achieved with less funding. Inevitably, lessons were generated (e.g. around the efficiency of specific large-scale projects and gaps in the current programme) and these could be used to improve efficiency going forward.

On a practical level, it would be easier to measure the impact of the Strategy, had the Strategy been developed on the basis of a clear LogFrame with expected targets to be achieved. During the evaluated period it was extremely difficult to determine the overall outputs and results achieved, because these had not been well documented in a measurable and aggregate format by ECHO and its partners. Further, ECHO did not manage the data on results (nor any other data reported by ECHO partners) in a manageable format. This makes it extremely difficult to monitor progress of the programme overall.

Recommendations

ECHO should develop a clear theory of change (intervention logic) for its continuing programme (see recommendation under section 4.4.1). Such an intervention logic would have to set out the risks and potential obstacles to the achievement of the (quantified) goals and measures to mitigate against these risks. It should assign output, outcome and impact indicators. An example of an output indicator would be “100,000 children screened for SAM”,

114 i.e. not specific, measureable, attainable, results-oriented, time-bound.


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an outcome indicator would be “100,000 infant deaths prevented” and an impact indicator would be “1% reduction in child mortality”, “1% reduction in GAM”, etc. Given the fact that PHASE is contributing to the Sahel Strategy for the next two years, it would be necessary to ensure that the ECHO intervention logic and that of PHASE are aligned and coherent.

ECHO partners should then be obliged to report on a set of common cross-programme indicators (e.g. target caseload, number children screened, number SAM cases identified admitted, GAM rates in the target community, etc.).

ECHO should develop its monitoring and evaluation systems to allow for aggregation of basic indicators on beneficiary numbers and core indicators.

ECHO should invest resources in conducting impact evaluations.


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ANNEXES


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Annex 1 List of stakeholders consulted

Table A1.1 List of stakeholders consulted

Date Stakeholder type Position Location of

interview

1 27th April 2015 ECHO, HQ B2/Chad desk officer, Cameroon and

Central African Republic Brussels

2 28th April 2015 ECHO, Field Former Technical Assistant (TA) for

Sahel Strategy, Dakar RSO Brussels

3 28th April 2015 EU Delegation EU-DEL desk officer, Niger Brussels

4 28th April 2015 DEVCO, HQ C1/Food and agricultural systems desk

officer, Crisis and Resilience Brussels

5 28th April 2015 ECHO, HQ A4/Food assistance and nutrition

coordination desk officer Brussels

6 28th April 2015 ECHO, HQ B3/Sahel Brussels

7 29th April 2015 ECHO, Field Former TA for WA, Dakar RSO Brussels

8 7th May 2015 ECHO, Field Former TA for Resilience and AGIR,

Dakar RSO Brussels

9 5th May 2015 ECHO, Field Former ECHO TA for Niger Brussels

10 14th August 2015 ECHO, Field Food Assistance TA in Dakar, Senegal;

DG ECHO, European Commission Telephone interview

11

5th – 6th August 2015 EU Delegation ■ Head of cooperation ■ Programme manager, Rural

development, food security and environment unit

Bamako, Mali

12

5th August 2015 WHO ■ Counsellor responsible for the reinforcement of the health system, Interim Representative of the WHO in Mali

■ Responsible for Mothers Health ■ Responsible for Children Health ■ Coordinator Missions to the North ■ Retired Nutrition expert

Bamako, Mali

13 5th August 2015 ECHO Field Head of ECHO Delegation Bamako, Mali

14 5th August 2015 ECHO partner Nutrition Specialist, UNICEF Bamako, Mali

15 5th August 2015 National authority Deputy Commissioner, Commission for

Food Security Bamako, Mali

16 6th August 2015 ECHO partner General Coordinator, MdM-BE Bamako, Mali

17

6th August 2015 ECHO partner ■ Medical Supervisor, AVSF ■ Coordinator for Emergency and

Resilience, Head of cooperation, AVSF

■ Deputy National Coordinator

Bamako, Mali

18

6th August 2015 National authority Ministry of Solidarity and Reconstruction of the North ■ National Director for Social

Protection and the Social Economy ■ Deputy National Director for Social

Protection and the Social Economy ■ Database Manager

Bamako, Mali

19 6th August 2015 ECHO partner ■ Head of Mission, MSF-FR

■ Medical Coordinator Responsible for Institutional Support

Bamako, Mali


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interview

20 6th August 2015 National authority ■ National Coordinator SAP (EWS)

■ Deputy National Coordinator SAP Bamako, Mali

21 6th August 2015 ECHO partner ■ Head of Mission, DRC- DK

■ Head of Project, ■ Head of cooperation

Bamako, Mali

22 6th August 2015 ECHO partner General Coordinator ALIMA/AMCP Bamako, Mali

23

6th August 2015 ECHO partner ■ National coordinator nutrition, ACF-ES

■ Reporting Monitoring Quality Coordinator

Bamako, Mali

23 7th August 2015 ECHO partner ■ Technical officer WASH, ACF-ES

■ National coordinator nutrition Bamako, Mali

24

7th August 2015 ECHO partner ■ Head of Mission ■ Assistant to the head of field mission■ Assistant WASH ■ Head of project WASH-in-NUT ■ Assistant WASH-in-NUT ■ Assistant nutrition ■ Head of project WASH/Ebola

Kita, Mali

25

7th August 2015 Implementing partner (= health workers)

■ URENI team ■ Technical director (nurse) ■ Technical director (nurse) ■ Assistant Intern ■ Head doctor

Kita, Mali

26

7th August 2015 Local leaders & implementing partners (= health workers)

■ Third deputy mayor in charge of social policies

■ Mayor (rural commune) ■ Deputy for cultural affairs in Kita and

manager of the local theatre group ■ President ■ Trainer

Kita, Gadougou, Mali

27

8th August 2015 Implementing partners (= health workers) & beneficiaries

■ Meeting with representative of and patients at CSCOM of Kita West (Kofeba

■ Technical director (doctor) ■ Supporting Agent ■ Control agent ■ President ■ General Secretary ■ Financial Officer ■ 3 Community relays (2 men/1

woman) ■ 20 mothers

Kita, Mali

28

10th August 2015 Implementing partners (= health workers), local leaders & beneficiaries

Meeting with representative of and patients at CSCOM of Konseguela

■ ■ Deputy Prefect ■ Technical Director ■ Head of local community ■ President ■ Member of the executive committee ■ Member of the executive committee ■ Mayor (rural commune)

Konseguela, Mali

29 10th August 2015 Local leaders Meeting with the president of the

FELASCOM and presidents of ASACOs

Mali


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interview

30 10th August 2015 Local leader President of the "Conseil de Cercle” Koutiala, Mali

31

10th August 2015 Implementing partners (= health workers)

■ Meeting with URENI Koutiala ■ Head of Emergency service ■ Head of paediatric service ■ Chief nurse of nutrition service ■ Medical director

Koutiala, Mali

32

10th August 2015 ECHO partner ■ Head of field mission, MSF ■ Deputy head doctor ■ Regional institutional partnership

officer ■ Responsible for external activities

Koutiala, Abidjan, Mali

33 10th August 2015 ECHO partner MSF Koutiala Koutiala, Mali

34 11th August 2015 Regional leader Third Deputy Prefect, Koutiala PrefectureKoutiala, Mali

35

11th August 2015 ECHO partners ■ Head of field mission, COOPI ■ Assistant to Medical Coordinator ■ Admininstrative officer ■ Nutritionist

36 11th August 2015 Implementing

partners (= health workers)

■ Meeting with UNRENI Segou ■ Head doctor ■ District head doctor

Segou, Mali

37 12th August 2015 ALIMA/AMCP -

Meeting with project team

■ Project coordinator ■ Nutrition Focal Point Regional coordinator

38

12th August 2015 ALIMA/AMCP -Meeting CSCOM Kolebougou

■ Head doctor ■ President of CSCOM and

FELASCOM ■ Financial officer ■ Secretary General ■ Beneficiaries

Kolebougou, Mali

39 12th August 2015 ALIMA/AMCP -

Meeting URENI Koulikouro

■ Deputy Head Doctor ■ Technical Director (nurse)

Koulikouro, Mali

40 4th September 2015 ECHO Programme Manager, ECHO Niamey, Niger

41 4th September 2015 DEVCO Chief of Section: Rural Development and

Food Security, DEVCO Niamey, Niger

42 4th September 2015 National authority Technical Counsellor and AGIR Focal

Point, 3N Initiative Niamey, Niger

43 4th September 2015 ECHO partner Country Coordinator, COOPI Niamey, Niger

44

5th September 2015 ECHO partner ■ Quality and Development Manager, STC

■ Deputy Director of Program Operations, STC

■ Operations Support Advisor, STC ■ Nutrition Manager, STC

Tahoua, Niger

45 5th September 2015 Implementing partner

(= health worker) District Chief Doctor, Tahoua (with Concern)

Tahoua, Niger


(= health worker) CSI Chief Doctor Tahoua, Niger

47 8th September 2015 Beneficiary 5-7 beneficiaries Tahoua, Niger

48 8th September 2015 Local leader Village Chief Tahoua, Niger

49 8th September 2015 Local leader Religious Leader Tahoua, Niger

50 8th September 2015 ECHO partner ■ MDM Local Coordinator Tahoua, Niger


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interview

■ Nutrition Coordinator ■ Logistics Coordinator ■ Health Coordinator ■ Food Security Coordinator ■ Family Planning Coordinator

51 9th September 2015 Local leader Chief of CSI, village of Amaloul Guidis Amaloul Guidis

52

9th September 2015 Local leaders & implementing partners (= health workers)

■ 3 village chiefs ■ 1 representative from the

management committee ■ 1 religious leader (Imam) ■ 3 community relays

Amaloul Guidis

53 9th September 2015 Local leader Mayor of theTakanamatt Commune Takanamatt

54 9th September 2015 Beneficiaries Around 80 women of the Amaloul Guidis

village Amaloul Guidis

55 9th September 2015 Local leader President, Treasury, Secretary Amaloul

Guidis

56

9th September 2015 Local leaders & beneficiaries

■ Religious Leader (Imam) ■ Management committee ■ Beneficiaries ■ Members of “école des maris”,

“Maman lumière” and mid-wives

Kossama

57

9th September 2015 ECHO partner ■ Programmes Director ■ Systems Director ■ Nutrition Specialist ■ Community Outreach Specialist ■ Logistics Coordinator

Tahoua

58

9th September 2015 Beneficiaries & implementing partners (= health workers)

■ Cash beneficiaries ■ Representatives from female

organisations ■ Community Relays

Sahiya, Niger

59 9th September 2015 Local leader ■ Village Chief, Imam Sahiya, Niger

60 9th September 2015 Implementing

partners ■ Targeting committee and conflict

management committee Sahiya, Niger

61 9th September 2015 Beneficiaries & non-

beneficiaries ■ Beneficiaries and non-beneficiaries Sahiya, Niger

62 9th September 2015 Local leader ■ CSI Chief Sahiya, Niger

63

11th September 2015 ECHO partner ■ Emergency Coordinator, WFP ■ Nutrition Expert, WFP ■ Logistics Expert, WFP ■ Nutrition Expert, WFP ■ Technical Support, WFP ■ Head of Office, WFP ■ Intern, WFP

Tahoua, Niger

64

12th September 2015 Local leaders & health workers (implementing partners)

■ Dakoro Prefect, ■ Dakoro Canton Chief ■ Mayor of Dakoro ■ Prefecture General Secretary ■ District Chief Doctor

Dakoro, Niger

65 12th September 2015 Health workers ■ Guided visit by the District Chief

Doctor Dakoro, Niger

66 12th September 2015 Health workers ■ Chef CSI/ COGES/ Superviseur

CRENAS/ MEDREF/MCD Dakoro, Niger


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interview

67

12th September 2015 Health workers & implementing partners (= local NGO)

■ District Chief Doctor ■ Nurses ■ BEFEN Project Administrator ■ BEFEN Logistics Coordinator

Dakoro, Niger


(= local NGO) ■ Regional Coordinator, BEFEN Dakoro, Niger

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14th September 2015 ■ Implementing partners (= local NGO)

■ Responsible for Communications ■ Human Resources Manager ■ Epidemiologist ■ District Chief Doctor

Mirriah, Niger

70

14th September 2015 Implementing partners health workers)

■ CRENI Chief Doctor ■ CRENI Nurse ■ Doctor ■ Pediatrics Nurse ■ Epidemiologist

Mirriah, Niger

71 14th September 2015 Implementing partner■ Coordonateur Projet, Coordonateur

General Mirriah, Niger

72 14th September 2015 Local leaders ■ Mirriah Prefect

■ Mirriah Mayor Mirriah, Niger

73 14th September 2015 Local leader ■ Mirriah Canton Chief Mirriah, Niger

74 15th September 2015 Beneficiaries ■ 5 beneficiary women Nwala-Matameye

75

15th September 2015 ECHO partner ■ Project’s Food Security Coordinator, STC

■ Deputy Project Chief, STC ■ Health and Nutrition Coordinator,

STC

Nwala

76 15th September 2015 Beneficiaries ■ 10 agricultural resilience

beneficiaries Wawou

77 15th September 2015 National authority ■ Agriculture Departmental Director Matameye, Niger

78 16th September 2015 Donor ■ Food for Peace Officer, USAID Niamey, Niger

79 16th September 2015 ECHO partner ■ Associate Country Representative,

UNICEF ■ Nutrition Manager, UNICEF

Niamey, Niger

80 16th September 2015 National authority ■ Safety Nets Unit Coordinator

■ World Bank Consultant ■ Programme Support Consultant

Niamey, Niger

81 16th September 2015 National authority ■ Technical Assistant : Food Security

and Safety Nets, 3N Initiative Niamey, Niger

82 16th September 2015 ECHO partner ■ WFP Team, Niamey Niamey, Niger

83 16th September 2015 Donor ■ Social Programmes Coordinator,

AFD Niamey, Niger

84 16th September 2015 ECHO partner ■ Chief of Delegation, French Red

Cross ■ Reporting and Advocacy Coordinator

Niamey, Niger

85 5th October, 2015 Donor ■ Adaptive Social Protection lead,

World Bank Dakar, Senegal

86 5th October, 2015 National authority ■ Executive Secretary, National Food

Security Council (CNSA) Dakar, Senegal

87 5th October, 2015 Donor ■ USAID, country desk officers Dakar, Senegal

88 5th October, 2015 Donor ■ Sahel Humanitarian Coordinator,

DFID Dakar, Senegal


76


interview

89 6th October, 2015 ECHO partner ■ UNICEF Regional Offices, EU

projects coordinator Dakar, Senegal

90 7th October, 2015 ECHO partner ■ ACF Regional officers Dakar, Senegal

91 7th October 2015 ECHO Field

ECHO HQ ■ Desk Officers, Burkina Faso ■ Desk Officer, Burkina Faso

Dakar, Senegal

92 8th October 2015 ECHO partner ■ WFP, Country desk officer Dakar, Senegal

93 8th October 2015 ECHO Field ■ Desk Officer, Mauritania / Senegal Dakar, Senegal

94 14th October 2015 EU Delegation ■ Chef du Centre

■ Assistant Technique N’Djamena, Chad

95 14th October 2015 National authority ■ CNNTA N’Djamena, Chad

96 15th October 2015 ECHO partner ■ Country director, ACF N’Djamena, Chad

97 15th October 2015 ECHO partner ■ Medical coordinatpr, MSF Suisse

■ Head of mission, MSF-CH N’Djamena, Chad

98 15th October 2015 ECHO partner ■ Project development manager,

ACTED ■ Evaluation manager, ACTED

N’Djamena, Chad

99

15th October 2015 ECHO partner ■ Representante et Directrice Pays, WFP

■ Chef de Programme, WFP ■ Chargé des relations, WFP

N’Djamena, Chad

100 16th October 2015 ECHO partner ■ Chief Child Survival and

Development, UNICEF ■ Coordinator Nutrition, UNCEF

N’Djamena, Chad

101 16th October 2015 ECHO partner ■ Chef de Délégation, Red Cross-FR N’Djamena, Chad

102

17th October 2015 ECHO partner ■ Representant Pays, ALIMA ■ Coordinatrice medicale, ALIMA ■ Coordinateur Projet, ALIMA ■ Reporting Officer, ALIMA

N’Djamena, Chad

103 19th October 2015 National authority ■ Directeur Général, ONAS N’Djamena, Chad

104 19th October 2015 National authority ■ Coordinator National, SISAAP N’Djamena, Chad

105 19th October 2015 ECHO partner ■ Senior Technical Advisor, FAO N’Djamena, Chad

106 20th October 2015 National authority ■ Secretary General,

■ Regional Director General, Ministry of Public Health

N’Djamena, Chad

107 20th October 2015 ECHO partner ■ Chef de Bureau, OCHA N’Djamena, Chad

108 21st October 2015 ECHO partner ■ Chef de Bureau, COOPI N’Djamena, Chad

109 21st October 2015 EU Delegation ■ Programme Manager

■ Programme Manager

N’Djamena, Chad

110

22nd October 2015 ECHO partner ■ Director – Emergency Operations, Concern

■ Emergency Programme Manager, Concern

N’Djamena, Chad

111 22nd October 2015 ECHO partner ■ Nutrition Coordinator, IRC N’Djamena, Chad

112 22nd October 2015 Donor ■ Communications Officer, World BankN’Djamena, Chad

113

19th October 2015 ECHO partner ■ Coordinatrice Zone Ouara, PU AMI ■ Responsable de programme

nurtition PU AMI ■ Responsable Centre de santé, PU

AMI

Abeche, Chad


77


interview

114

19th October 2015 Health workers ■ Health Centre of Djatinia ■ COGES member ■ Superviseur Distribution ■ Superviseur Santé Nutrition ■ Chargé de sensibilisation des mères ■ Relais communautaire

Abeche, Chad

115 19th October 2015 Health workers ■ Community staff of Amal Al Badawi’s

Centre - Health workers Abeche, Chad

116

19th October 2015 ECHO partner ■ Chef de Bureau d’Abeché (UNICEF) ■ Responsible d’operations, UNICEF ■ Nutritioniste, UNICEF ■ Chef de bureau d’Abeché, UNIECF ■ Responsible Changement de

comportement pour l’Est

Abeche, Chad

117 19th October 2015 Regional authority ■ GOUVERNORAT OUADDAI -

Sécrétaire Général du Gouvernorat Abeche, Chad

118

20th October 2015 Local leaders & implementing partners

■ Chef de sous Délégation ■ Coordinateur Santé ■ Coordinateur Adjoint santé ■ Président du Comité regional ■ Assistant Nutrition ■ Assistant Nutrition ■ Assistant Nutrition

Ati, Chad

119 20th October 2015 Local Authorities ■ Délégué Régional Santé

■ Medecin chef de District Ati, Chad

120 20th October 2015 Health workers ■ Ati Regional Hospital

■ Responsible CNT ■ Point Focal nutrition

Ati, Chad

121 20th October 2015 Health workers ■ Meeting with the team of COGES

and COSAN in Health Centre of Ati Est - Responsable du Centre

Ati, Chad

122 20th October 2015 Implementing

partners ■ Local Theatre Company - Séretaire

Général de la Troupe théatrale Ati , Chad

123 21st October 2015 Beneficiaries ■ Mothers Club ‘Intizar’ in Koundjourou

village Koundjourou, Chad

124 21st October 2015 Implementing

partners ■ Health Centre of Koundjourou -

Responsable du centre Koundjourou, Chad

125 11th January 2015 DEVCO HQ ■ DEVCO Desk Officer, Resilience and

AGIR Telephone interview

126 11th January 2015 Donor ■ SIDA, Humanitarian Coordinator for

Sahel Telephone interview

127 11th January 2015 Donor ■ Spanish Development Agency

(AECID) Email exchange

128 11th January 2015 ECHO partner ■ UNICEF Regional officers,

Coordinator for Nutrition in the SahelTelephone interview


78

Annex 2 Indicators of level of human development in the Sahel

Table A2.1 Key human development indicators on the Sahel in 2014

Country Population GDP per capita (2011

PPP $)

HDI ranking Size (square km)115

Burkina Faso 16.93 million $1,527.86 181 273,800

Chad 12.83 million $2,003.4 184 1,259,200

The Gambia 1.85 million $1,564.97 172 10,120

Mali 15.3 million $1,606.93 176 1,220,190

Mauritania 3.89 million $2,938.15 161 1,030,700

Niger 17.83 million $883.98 187 1,266,700

Senegal 14.13 million $2,173.52 163 192,530

Cameroon 22.25 million $2,550.93 152 472,710

Nigeria 173.62 million $5,439.62 152 910,768

Source: Human Development Index116

115 CIA. N.d. The World Factbook. Available at: https://www.cia.gov/library/publications/resources/the-world-factbook/ 116 Human Development Index (HDI), Country profiles, http://hdr.undp.org/en/countries


79

Annex 3 Overview of projects funded under the Sahel Strategy 2010

– 2014

Bu

rkin

a

Faso

Ch

ad

Mali

Mau

rita

nia

Nig

er

Sen

eg

al

Reg

ion

al

Sectors of work Years of involvement in Sahel Strategy

201

0

201

1

201

2

201

3

210

4

ACF-ES X X X X

� Coordination � Food � Health and Medical � Nutrition, therapeutic or

supp.feeding � Water / Sanitation

X X X X X

ACF-FR X X X



X X X X X

ACORD-UK X

� Food � Nutrition, therapeutic or

supp.feeding

X X X

ACTED-FR

X X X � Food � Health and Medical � Nutrition, therapeutic or


X X X X

ALIMA-FR X X

� Health and Medical � Nutrition � Nutrition, therapeutic or

supp.feeding

X X

AVSF-FR X

� Food � Health and Medical � Nutrition, therapeutic or

supp.feeding

X X

CARE-FR X

� Disaster preparedness � Food X X X

CARITAS-AT X


supp.feeding

X X

CDE-FR X

X

CHRISTIAN AID-UK X


supp.feeding

X X X

CONCERN WORLDWIDE-IR

X X � Food � Health and Medical � Nutrition, therapeutic or


X X X X X

COOPI-IT X X X

� Health and Medical � Nutrition, therapeutic or

supp.feeding

X X X

CROIX-ROUGE-BE X X

� Food X X X X X


80

Bu

rkin

a

Faso

Ch

ad

Mali

Mau

rita

nia

Nig

er

Sen

eg

al

Reg

ion

al


20

10

20

11

20

12

20

13

21

04

� Nutrition, therapeutic or supp.feeding

CROIX-ROUGE-FR X X X X X


supp.feeding

X X X X X

FAO-IT X X X X

� Coordination � Food � Nutrition, therapeutic or

supp.feeding

X X X X X

FEDERATION HANDICAP-FR

X

X

FICR-CH X

X

GAC-DE X


supp.feeding

X X

GOAL-IR X

� Nutrition, therapeutic or supp.feeding X

GVC-IT X

� Food X X

HELP-DE X X


supp.feeding � Support to special

operations

X X X X X

HOPE'87-AT X

� Food X

IMC-UK X



X X X

IRC-UK X X X



X X X X X

ISLAMIC RELIEF-UK X


supp.feeding

X

LVIA-IT X


supp.feeding

X X X

MDM-BE X


supp.feeding

X X

MDM-FR X X X

� Coordination � Food � Health and Medical

X X X X X


81

Bu

rkin

a

Faso

Ch

ad

Mali

Mau

rita

nia

Nig

er

Sen

eg

al

Reg

ion

al


20

10

20

11

20

12

20

13

21

04


MEDAIR-CH X

� Nutrition, therapeutic or supp.feeding X

MEDICUS MUNDI-ES X X X


supp.feeding

X X X

MERLIN-UK X


supp.feeding

X X

MSF-BE X X


supp.feeding

X X X X X

MSF-CH X X


supp.feeding

X X X X X

MSF-ES X


supp.feeding

X X X X

MSF-FR X X X X


supp.feeding

X X X X X

MSF-NL X



X X X X X

OXFAM-ES X X X

� Food � Water / Sanitation X X X X X

OXFAM-NL X

� Food X X

OXFAM-UK X X X



X X X X X

PU-AMI-FR X



X X

SAVE THE CHILDREN-DK

X

X

SAVE THE CHILDREN-ES

X � Food � Nutrition, therapeutic or

supp.feeding

X X

SAVE THE CHILDREN-UK

X X X X � Disaster preparedness � Food � Health and Medical

X X X X X


82

Bu

rkin

a

Faso

Ch

ad

Mali

Mau

rita

nia

Nig

er

Sen

eg

al

Reg

ion

al


20

10

20

11

20

12

20

13

21

04


SI-FR X X X



X X X

SOS SAHEL-FR X

X

TERRE DES HOMMES-CH X X


supp.feeding

X X X X X

TERRE DES HOMMES-IT X X

UNICEF-US X X X X X X


supp.feeding

X X X X X

WFP-IT X X X X X X X


supp.feeding

X X X X X

WHO X


supp.feeding

X


83

Annex 4 The evolution of the Sahel Strategy117

2007-2010 were the formative years of the Sahel Strategy. A major focus was on the collection of baseline data to demonstrate the scale and nature of the problem (including root causes). Two major projects commissioned by ECHO were Save the Children’s household economic analysis surveys of the region to gather information on vulnerable households and UNICEF’s SMART surveying of Sahel countries to help understand the scale of malnutrition in the region. Other international organisations were funded to collate an evidence base to support advocacy: e.g. FAO developed a framework for evaluating the nutritional impact of food assistance activities and WHO conducted a study into the effects of free medical care on vulnerable populations. Free access to basic healthcare for under 5s and PLW and the wider use of Ready to Use Therapeutic Foods (RUTF) were promoted by ECHO both through funding and in advocating to national and international actors.

In 2010 a food crisis hit the region. Just under 30m euro was added to the existing 32m euro budget for the Strategy that year. Emphasis was placed on food security, nutrition and health. The following year the 2011 HIP encouraged partners to design projects focussing on post-crisis recovery (e.g. cash transfers, rebuilding of productive assets and livelihoods recovery) in the wake of the 2010 crisis and a ‘reasonable harvest’ in the previous season.

In 2012, the region experienced another food crisis. ECHO’s funding for the Strategy more than tripled (from 45.2m to 141.5m EUR). This enabled the scaling up of its nutrition and food assistance operations in the region to reach a higher number of beneficiaries. 55% of the funding in 2012 went towards food assistance activities as compared to 43% the previous year and 42% in 2010. The increase in funding was the result of several factors. First, ECHO, well-established in the region, was well-positioned to recognise early warning signs of the drought. Second, it had learned from the 2010 crisis that an inadequate response can leave countries vulnerable to repeat crises within a short period of time. Third, a greater response was fitting with the EU’s commitment to resilience which was increasingly becoming a priority for ECHO (see section 2.1). From 2012, ECHO adapted its mode of food assistance provision also, changing from a predominant ‘in-kind’ model to 50% in cash and 50% in kind. The aim was to reduce aid dependency and negative impacts of food aid on local markets and also to pave the way for integration of food assistance measures into national social safety nets.

Figure A4.1 Share of projects allocated per primary aid sector per year, 2010-2013

In 2013 the objectives of the Strategy changed with focus being given to two ‘pillars’: treatment and prevention. Emphasis was placed on the integration of ECHO-funded actions into national systems and on actions to address the underlying causes of malnutrition by taking a ‘multi-sectoral’ approach to

117 Discussion based on analysis of programme and project documentation, the end of mission report of Helene Berton (Technical Assistant for the Sahel Strategy 2012-2015) and interviews with former and current ECHO staff.


84

treatment and prevention. Less focus was given to improving the knowledge baseline since the actions implemented 2007-2012 had provided a lot of information on the scale and nature of malnutrition in the region. In 2013, ECHO also harmonised and formalised different aspects of its approach e.g. the use of complementary nutrition supplements (Plumpy Nut) and the provision of cash or vouchers to complement in-kind food assistance. It also began to integrate nutrition and health into single interventions and to advocate for Ministries of Health to address malnutrition issues in their countries. MSF and ALIMA drove the shift towards a health-in-nutrition approach, favouring the treatment of infants not only for malnutrition but also for other related medical issues at the same time.

In 2014, ECHO continued to focus on the integration of ECHO-supported health systems into the national system and on improvements in the quality and coverage of health care. It also continued to harmonise the approaches used by its partners. It began to work towards the linking of its food assistance projects (now receiving less funding post-2012) into national response plans and national social safety nets and towards the integration of the household economic analysis (HEA) approach into national early warning systems.

In 2015, the Sahel Strategy has been subsumed under a West African financing decision which has an overall aim of building resilience in the region particularly in relation to three types of crises which affect it: food and nutrition crises, conflicts and epidemics. The first ‘pillar’ of the funding decision covers malnutrition and food insecurity and is thus a continuation of the aims and activities of the Sahel Strategy. Pillar one continues to focus prevention and response with a further separation into food security actions on the one hand and nutrition actions on the other.

Table A4.2 outlines the Strategy’s evolution based on information from the HIPs. The Table shows that throughout the evaluated period the target beneficiaries remained the same, though the focus areas changed as the strategic objectives shifted and as the humanitarian needs shifted slightly between prevention / response / recovery. The expected outcomes of the HIPs also differ in their specificity – for example, the 2012 HIP had a very clear goal (the inclusion of food and nutrition security into the programming of the 11th EDF), whereas in other years (2010, 2013, 2014), the expected outcomes were more broad.


85

Table A4.2 Evolution of the programme

HIP Amount Target beneficiaries Focus areas Expected outcomes

Global

Plan

2010

40m ■ Children suffering from acute malnutrition

■ PLW

■ Nutrition and health: – Blanket supplementary feeding programmes – Scaling up of screening and treatment of acute malnutrition in children – Advocacy for long-term initiatives to improve feeding and caring practices – Free / subsidised health services – Mobile health services for pastoralists

■ Food security – Short-term assistance – Seed provision – Targeted food assistance during lean period – Assistance targeting pastoralists / nomads

To improve the humanitarian situation of

vulnerable people affected by the food crisis

HIP

Sahel

2011

45.2m ■ Children under five years suffering from acute malnutrition

■ PLW

■ Innovative / replicable approaches to: – Treatment of (acute) malnutrition – Prevention of (acute) malnutrition

■ Improving targeting (e.g. SMART and HEA) ■ Post-crisis recovery (e.g. cash transfers, livelihood recovery) ■ WaSH initiatives ■ Disaster-risk reduction / resilience / preparedness

Contribute to reducing GAM rates esp.

amongst the under-5

Strengthen coping mechanisms / resilience

Increase awareness amongst government

authorities / civil society / development

partners as to the need to integrate food and

nutrition security into public policies and to

allocate sufficient long-term resources to

achieve a sustainable reduction in

malnutrition.

HIP

Sahel

2012

141.5m ■ Children suffering

from SAM and MAM ■ Food insecure ■ PLW (for nutritional

response)

■ Innovative / replicable approaches to: – Treatment of (acute) malnutrition – Prevention of (acute) malnutrition

■ Improving the knowledge base (HEA especially) ■ Intensifying advocacy ■ Preventative food assistance to households at risk of food deficit ■ Emergency response (following 2012 crisis) via food aid:

– Cash and vouchers for households for 6 months – Blanket supplementary feeding for children under 2 and PLW – Purchase food stocks for General Food Distribution to fill existing gaps – Treatment of SAM – Primary health treatment, especially for malaria

■ Immediate post-crisis recovery / resilience-building

The inclusion of food and nutrition security

into the programming of development

assistance especially in the framework of the

11th EDF.


86

HIP Amount Target beneficiaries Focus areas Expected outcomes

HIP

Sahel

2013

93m ■ Children under five

suffering from malnutrition

■ PLW (implicit only118) ■ Food insecure

■ Management of acute malnutrition and associated diseases so as to reduce mortality – Identification and treatment of SAM caseloads – Integration of these activities within the health system, – Improving quality and coverage of the intervention, – Improving stock pipelines for essential food, health and nutrition products, – Improving access to the treatment of malnutrition and heath care

■ Contribution to the strengthening of resilience of the poorest populations in order to build nutrition and food security – Measures to improve the functioning of nutrition and food security information systems

(e.g. EWS and info. on targeting) – Emergency food and cash assistance – Promotion of seasonal social safety nets, – Pilot projects and advocacy activities to encourage greater commitment to

strengthening resilience and malnutrition reduction by government and a higher level of investment in resilience action by development donors.

A sustainable reduction of malnutrition-related mortality among children under five in the Sahel

HIP

Sahel

2014

57m ■ Children under five

suffering from malnutrition

■ PLW (implicit only) ■ Food insecure

■ Management of acute malnutrition and associated diseases so as to reduce mortality: – Identification and treatment of SAM caseloads – Integration of these activities within the health system – Progress towards medical treatment cycle incl. follow-up for malnutrition in children – Improving quality and coverage of the intervention (including improving key

performance indicators, improving stock pipelines for essential food, health and nutrition products, integrating WaSH into nutrition activities)

– Improving access to the treatment of malnutrition and heath care – Improving information systems for monitoring malnutrition.

■ Contribution to the strengthening of resilience of the poorest populations in order to build nutrition and food security – Treatment and prevention of main children’s illnesses – Community actions to prevent malnutrition – Support for social safety nets – Measures to improve the functioning of nutrition and food security information systems

(e.g. EWS and info. on targeting) – Pilot projects and advocacy activities to encourage greater commitment to

strengthening resilience and malnutrition reduction by government and a higher level of investment in resilience action by development donors.

– Improving synergies between health, nutrition and food assistance activities.

A sustainable reduction of malnutrition-

related mortality among children under five in

the Sahel

118 PLW are not explicitly listed as a target group, although the section of the HIP describing the most acute humanitarian needs states, “priority in humanitarian aid action therefore needs to continue to be given to improving access to the treatment of malnutrition and heath care for … pregnant and nursing women”.


87

Annex 5 ECHO data on caseloads (target and treated) and estimated number of cases 2010 – 2014

Table A5.1 ECHO data on caseloads (target and treated) and estimated number of cases 2010 - 2014

2010 2011 2012 2013 2014

Targ

et

SA

M

ca

selo

ad

(nation

al

overa

ll)

SA

M

cases

adm

itte

d

and

treate

d

Targ

et

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M

ca

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(nation

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M

cases

adm

itte

d

and

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d

Targ

et

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M

ca

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ad

(nation

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cases

adm

itte

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and

treate

d

Estim

ate

d

num

ber

of S

AM

ca

ses i

n u

nder

5s

Targ

et

SA

M

ca

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ad

(nation

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overa

ll)

SA

M

cases

adm

itte

d

and

treate

d

EC

HO

’s

targ

et

ca

selo

ad

EC

HO

and

UN

ICE

F

targ

et

ca

selo

ad

Estim

ate

d

num

ber

of S

AM

ca

ses i

n u

nder

5s

Targ

et

SA

M

ca

selo

ad

(nation

al

overa

ll)

SA

M

cases

adm

itte

d

and

treate

d

EC

HO

’s

targ

et

ca

selo

ad

EC

HO

and

UN

ICE

F

targ

et

ca

selo

ad

Burkina Faso 101,500

47,656 101,500

50,000 100,000

77,106 120,000 96,000 57,570

29,545

120,000 144,000 115,000 105,047

96,000

96,000

Cameroon

34,000 17,000

34,000 18,000

55,000 40,300

83,233 57,616 64,313 13,772

15,624

59,258 53,332 52,269 9,800 9,800

Chad 94,000 56,436 94,000

68,000 127,300

146,685

147,000 147,000 134,816 120,540

120,540 135,533 135,533 146,132

58,746

58,746

Gambia 0 0 3,130 3,164 7,745 5,421 4,261 5,320 5,421 7,859 7,859 4,342 7,855 7,855

Mauritania 19,000 3,400 19,000 5,000 12,600

10,757

23,901 23,901 16,035 4,000 6,000 30,741 30,741 20,170 6,223 6,223

Mali 80,000 25,000 80,000

15,000 175,000

52,156

201,000 125,000 102,787 18,670

89,984 136,000 107,000 117,995

107,000

107,000

Nigeria (11 states)

309,000 44,098

309,000 141,310

208,000 217,506

491,862 296,950 234,543 50,000

50,000

539,147 323,488 326,947 67,595

67,595

Niger 378,000 330,893 378,000

300,000 393,737

369,036

376,724 376,724 397,442 96,648

258,480

356,324 356,324 416,994 213,355

213,355

Senegal 5,700 5,000 5,700 5,000 20,000 13,628

63,323 42,843 20,951 5,000 42,343

78,888 50,325 24,749 6,748 6,748

Total 1,021,200

529,483

1,021,200

602,310

1,094,767

930,338

1,514,788

1,171,455

1,032,718

343,495

708,392

1,487,750

1,179,602

1,214,645

573,322

573,322

Evaluation of ECHO's intervention in the Sahel (2010 - 2014) –Final Report

88

Annex 6 GAM and SAM rates across the Sahel and in five case

study sub-national regions

A6.1 GAM and SAM rates across the Sahel

Figure 3.1 shows that the GAM rate varies over the period 2007-2014 in all the countries, with the most distinct variances in Niger and Mauritania. The countries have a prevalence of GAM judged from poor to critical for the entire period ranging from 6.2 in Mali in 2008 to a highest of 16.3 in Chad in 2010.

Looking at each country more specifically, one can see that Niger has the highest GAM rate as well as the highest variation over the years. The GAM has increased from 12.3 in 2007 to 14.8 in 2014, with a peak at 16.7 in 2010 followed by a drop to 12.3 in 2011. The prevalence of GAM is assessed as Serious to Critical for the entire period.

In Mauritania, the GAM rate is slightly higher in 2014 than in 2007 but has suffered from relatively important variations throughout the period. The GAM increased from 8.2 to 13.1 in the period 2007-2009 followed by a decline to 10.7 in 2011 and an increase to the 2009 level in the year 2013 before dropping to 9.8 in 2014.

Burkina Faso and Senegal have managed to reduce their GAM rate, from 11.3 in 2009 to 8.6 in 2014 in Burkina Faso, and from 10.1 in 2011 to 9.8 in 2014 in Senegal. There is no data available for the precedent years.

In Mali, we can observe an increase over the years, from a GAM of 6.1 in 2008, to 8.9 in 2010 and, 10.9 in 2011.

One may assume that with an increase in GDP, people would be better off which would potentially lead to a corresponding reduction in GAM; however, from the data below for all countries there seems to be no correlation between GDP changes and GAM. For instance, Niger shows a steady increase in GDP over the period, however, the GAM remains variable with increases and decreases throughout the period.

The SAM followed the same trend as the GAM over the period.

A6.2 GAM and SAM rates in case study regions of Mali, Chad and Niger

Upon looking at the regional level, more specifically we can observe a similar trend for GAM and SAM (Infant mortality data is not available at the regional level).

In Koulikoro, Mali, one can observe a decrease of Severe Acute Malnutrition over the year. Since 2011, the SAM is below the critical level of 2% established by the WHO. On the other hand, the GAM increased subsequently from 2010 to 2011 before declining to 8.7 in 2012. However, in 2014, it reached its highest level in the period 2007-2014 (see Figure A6.1).


89

Figure A6.1 GAM and SAM in the region of Koulikoro, Mali

Source: UNICEF SMART surveys

In Kanem, Chad (see Figure A6.2), although there has been a decrease in GAM in the period 2010-2014, it has remained above the critical threshold established by the WHO for the entire period. Furthermore, there has been an increase of 2.1 between 2013 and 2014. Note that no data is available for the years before 2010, therefore an analysis pre and post ECHO intervention is not feasible. The SAM rate has also decreased from 2011 onwards, from 3.5 to 1.3 and is now below the critical level.

Figure A6.2 GAM and SAM in the region of Kanem, Chad

Source: UNICEF SMART surveys

In Niger, data were available for the period post ECHO intervention and allowed us to view the difference before and after 2010. There are great variations among the three regions, namely Maradi, Tahoua and Zinder.

Tahoua has the lowest GAM rate starting at 7.9 in 2007 and increasing to its highest point of 15.8 in 2010 before decreasing to 11.2 in 2012 (see Figure A6.3). However, the following years have experienced an increase up to 14.7 in 2014. Looking at the period before and after 2010, GAM is higher in the period post ECHO intervention. The same applies to the SAM rate.


90

Figure A6.3 GAM and SAM in the region of Tahoua, Niger

Source: WHO database provided by UNICEF

Similar to Tahoua, Maradi reached its peak in 2010 with 19.7 and has higher GAM rates in the period after 2010 with the exception of 2011 (see Figure A6.4). In the past three years, the GAM rate was above the critical threshold from the WHO which did not occur before 2010. The SAM rates also experienced an increase from 2010 to 2013. However, the rate remains lower than in 2008 and 2009.

Figure A6.4 GAM and SAM in the region of Maradi, Niger


Zinder has the highest GAM rate starting at 15.4 in 2007 and remaining above the WHO critical level for most of the period with the exception of 2011 and 2013 (see Figure A6.5). Similar to the other regions, the highest rate was reported in 2010 with 17.8. However, looking at pre and post the evaluated period, it appears that the rates are lower after 2010. The SAM rate varies significantly in the evaluation period 2010-2014 with a minimum of 1.6 in 2011 and a maximum of 4.2 in 2012.


91

Figure A6.5 GAM and SAM in the region of Zinder, Niger


On the basis of the trend analysis over the period 2007-2014, it seems that although the mortality rate has declined constantly over the years in all the countries which could suggest sustainability of the intervention, the GAM and SAM rate have not followed the same trend and follow a sporadic and undeterminable trend over the years. This has been further confirmed when looking at particular regions where ECHO intervened. Therefore, one cannot determine with certainty that there is a significant improvement in the evaluation period, 2010-2014. Also, the sustainability of the activities cannot be confirmed due to the high variability of the GAM and SAM indicators.


92

Annex 7 List of relevant national institutions involved in

addressing malnutrition in Sahel countries and relevant

policy

Table A7.1 below outlines the main national institutions and key policy relevant to the topics addressed through the Sahel Strategy.

Table A7.1 National institutions and key legislation and policy for the six Sahel countries in scope

Country Main national institutions Key legislation and policy119

Burkina

Faso

■ National Nutrition Concertation Council (CNCN - Conseil national de concertation en nutrition)

■ Ministry of Health ■ Ministry of agriculture and water ■ Ministry of social action and national

solidarity

■ Response Plan in favour of vulnerable populations, 2011

■ Plan national de développement sanitaire (2011-2020)

■ Politique Nationale de Santé (2011-…) ■ Stratégie de croissance accélérée et de

développement durable (2011-2015) ■ Politique Nationale de Nutrition (2007-….) ■ Politique de nutrition assortie d'un Plan Stratégique

(2010-2015) ■ Plan National d'Action pour la Nutrition (1999-…) ■ Plan Stratégique Nutrition (2010-2015)

Chad ■ Ministry of Public Health ■ Centre National de Nutrition et de

Technologie Alimentaire (CNNTA) – National Centre of Nutrition and Food Technology

■ Ministry of Agriculture Comité de gestion des crises de sécurité alimentaire (CASAGC) – Committee for the management of food security crises

■ Ministry of Planning and International Cooperation

■ NGOs Direction (DONG)

■ Statement to the International Community, 21 December 2011

■ Plan National de Développement Sanitaire du Tchad (2009-2012)

■ Plan National D'Action Pour La Nutrition (1997-…)

Mali ■ National Nutrition Council (CNN - Conseil national de la nutrition)

■ Ministry of Health and Intersectoral technical nutrition Committee (CTIN - Comité technique intersectoriel de nutrition)

■ Ministry of Solidarity, Humanitarian Action and Development in the North120

■ Ministry of Rural Development

■ The Government’s Emergency Priority Action Plan (PAPU) (2013-2014)

■ Growth and Poverty Reduction Strategy Paper (GPRSP) (2012-2017)

■ Politique Nationale de Nutrition (2012-2021) ■ Nutrition-specific policies (national strategy on food

for babies and young children, International Code of Marketing of Breast Milk Substitutes, nutrition document on policy, standards and procedures (PNP),national protocol for managing acute malnutrition and national program for food fortification).

Mauritania ■ Ministry of Health and Social affairs ■ Ministry of Economic affairs and

development ■ Ministry of Education: Nutrition and

health education Direction (DNES – Direction de la nutrition et de l’éducation sanitaire)

■ Intersectoral Plan for Nutrition (PAIN) (2012-2015) ■ Poverty Reduction Strategy Paper (2011-2015) ■ Plan intersectoriel de REACH (2009-2015) ■ Strategie Nationale pour la Survie de l'Enfant (2009-

2013) ■ Stratégie Nationale pour l'Alimentation du

Nourrisson et du Jeune Enfant (2007-2015) ■ Politique Nationale de Développement de la

nutrition (2005-2015) ■ Plan National d'Action pour la Nutrition (1995-…)

119 WHO – Global Database on the Implementation of Nutrition Action (GINA) 120 Ministere de la Solidarite De L'action Humanitaire Et De La Reconstruction Du Nord


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Country Main national institutions Key legislation and policy119

Niger

■ Regional and District Departments of Public Health

■ Ministry of Livestock ■ Ministry of Agriculture ■ Ministry of Water and Environment ■ Ministry of population, of women and

childhood protection ■ Ministry of Planning and Community

Development

■ Poverty Reduction Strategy Paper. Economic and Social Development Plan (PDES) (2012-2015)

■ Plan National D'Action Pour La Nutrition (2003-2015)

■ The « 3N » policy – « les Nigeriens nourrissent les Nigeriens » (Nigeriens feeding Nigeriens)

Senegal ■ National Council for Food Security (SECNSA - Secretariat Executif du Conseil National de Sécurité Alimentaire)

■ Fight against malnutrition Commission (CLM - Commission de lutte contre la malnutrition)

■ Ministry of Health

■ National Strategy for Economic and Social Development (NSESD) 2013-2017

■ Decree Mandating the Fortification of Wheat with Iron and Folic Acid (2009-…)

■ Nutrition Policy Brief (Lettre de Politique de Nutrition) (2008-2012)


94

Annex 8 Definition of nutritional indicators

■ Acute Malnutrition/ Wasting: Wasting is the result of a weight falling significantly below the weight expected of a child of the same length or height. Wasting indicates current or acute malnutrition resulting from failure to gain weight or actual weight loss.

■ Global Acute Malnutrition (GAM): We talk about GAM when the z-score of the index weight-for-height is < -3 SD (Standard Deviation). It is the sum of the Moderate Acute Malnutrition (MAM) and the Severe Acute Malnutrition (SAM)

■ Severe Acute Malnutrition (SAM): The severe acute malnutrition occurs when the z-score WH is < -3SD and/or if bilateral edema is identified.

■ Stunting: it is measured by the height-for-age index and identifies past undernutrition or chronic malnutrition.

■ Underweight: It is based on weight-for-age, and is a composite measure of stunting and wasting.

SAM is often occurs after a shock e.g. a period of acute food shortage or an illness that makes them lose a lot of weight or which prevents them from absorbing nutrients. SAM is more likely to occur in children who are already malnourished and carries a high risk of mortality and permanent physical damage. However, it can be treated successfully with intensive, therapeutic feeding. Moderate Malnutrition (MM) is a chronic state, which is caused by continuous under-nutrition either of the mother when pregnant and/or of the child in early childhood.121

Table A8.1 Statistical Definition of global and severe malnutrition, in z-score

Classification Acute Malnutrition or Wasting (WHZ)

Chronic Malnutrition or Stunting (HAZ)

Underweight (WAZ)

Severe P/T <-3 SD

and/or edema T/A <-3 SD

P/A <-3 SD

Global P/T < -2 SD and/or edema T/A < -2 SD P/A < -2 SD

Table A8.2 Classification of nutritional status according to WHO (WHO 2000)

Acute Malnutrition or

Wasting (GAM)

Chronic Malnutrition or

Stunting

Underweight

Critical ≥ 15% ≥ 40% ≥ 30%

Serious 10% ≤ GAM<15% 30% ≤ CM<40% 20% ≤ U<30%

Precarious 5% ≤ GAM<10% 20% ≤ CM<30% 10 ≤ U<20%

Acceptable < 5% < 20% < 10%

Table A8.3 Criteria to appreciate the mortality rate in a population (SPHERE 2010)

CrudeMortality Rate (CDR) 0-5 Death Rate

Emergency 1 deaths / 10000 /day 2 deaths / 10000 /day

Critical 2 deaths / 10000 /day 4 deaths / 10000 /day

121 Interviews with ECHO Field.

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DOI: 10.2795/63521

Evaluation of ECHO's intervention in the Sahel (2010 -...

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