The application of minimum standards during crisis
A practitioner's perspective, southern Sudan 1998/9

By Stephanie Maxwell

Stephanie Maxwell worked as the medical co-ordinator for Medicines Sans Frontiers Holland (MSFH) between May '97 and March '99, and as programme manager during the crisis period in southern Sudan. Between mid 1999 to early 2000 she was working as a nutrition consultant for Unicef in the Operation Lifeline Sudan Programme (OLS) for the southern sector. Part of the Unicef assignment included a review of some of the targeted feeding programmes being implemented in southern Sudan.

The Sphere Project was launched in 1997 to develop a set of universal minimum standards in core areas of humanitarian assistance. The aim of the project is to improve the quality of assistance provided to people affected by disasters, and to enhance the accountability of the humanitarian system in disaster response. The project was however never intended to provide a comprehensive guide for assessing interventions or cover the complete range of potential humanitarian responses. This sometimes gets forgotten in the debate over the application of minimum standards during a crisis.

The Minimum Standards specify the minimum acceptable levels to be attained in sectors of humanitarian response. Each standard has a set of key indicators which signal whether the standard has been attained. They provide a way of measuring and communicating both the impact, or result of the programmes as well as the process, or methods used.

This article examines aspects of the influence, use and impact, of the nutrition 'Minimum Standards' during the response to the 1998/9 humanitarian crisis in southern Sudan. The discussion is largely based upon consideration of Standard 2 for Targeted Nutritional Support for Severe Malnutrition, and some of the key indicators used in the context of the emergency in southern Sudan in 1998/1999. The relevant standard and indicators read as follows:

The 1998 food crisis in southern Sudan
The multiple factors that brought about the humanitarian crisis, and shaped the humanitarian response are well documented.* The principal constraints that characterised the 1998 humanitarian crisis and response in southern Sudan are summarised as follows:

Standard 2
Targeted nutritional support standard 2: severe malnutrition
Mortality, morbidity and suffering associated with severe malnutrition are reduced.

Examples of Key indicators
  • Proportion of exits from a therapeutic feeding programme who have died is <10%.
  • Proportion of exits from therapeutic feeding programme recovered is >75%.
  • Proportion of exits from therapeutic feeding programme defaulted <15%.
  • There is a mean weight gain of >8g per kg per person per day.
  • Nutrition worker to patient ratio is at least 1:10.
    •

    • Humanitarian agencies were initially denied access to the affected population by the Government in Khartoum.
    • Limited infra-structure and poor communication systems.
    • Logistical constraints, especially when airstrips were wet and/or too short, making it impossible for vital cargo planes to land.
    • Working in flat, flooded and swampy conditions.
    • Lack of experienced international and national professionals.
    • The overwhelming scale of the problem.
    • Inadequate co-ordination of the humanitarian response.
    Furthermore, one of the key prerequisites for an efficient and effective emergency nutrition intervention was not fulfilled during the early stages of the crisis. An adequate general food ration was not provided for all in need.

    Standard 1
    General Nutritional Support Standard 1: Nutrient Supply.
    The nutritional needs of the population are met.


    Awareness of the Sphere Project and the Minimum Standards
    There was limited awareness among field staff of the existence of internationally established minimum standards for humanitarian assistance. Generally, it was agency head office staff rather than 'front-line' staff who were aware of the project. In some instances, Minimum Standards were invoked as a basis for assessing the performance of agency interventions. In retrospect, a number of critical observations about the role and application of the minimum standards can be made.

    When standards can not be attained
    The two following boxes describe aspects of the therapeutic feeding programmes implemented by an MSF section in 1998 and my personal experience of adapting guidelines when faced with a complex and overwhelming situation. This highlights potential conflict with Sphere project minimum standards and the key indicators used to measure attainment of those standards. The standard in question is 'standard 2' (see box on previous page) for targeted nutritional support for severe malnutrition while the relevant key indicators are "There is a mean weight gain of > 8g per kg per person per day" and "Nutritional and medical care is provided to people who are severely malnourished, according to clinically proven therapeutic care protocols".

    Adapting the guidelines - Example 1
    After appraising the situation in one site which had a limited number of locally available qualified staff, a high level of insecurity for international staff, and resolute mothers who were reluctant to sit in a centre all day - I recommended that a simplified TFC regime be put in place.

    I recommended a two tier TFC. The two tiers were for children who did or did not have an appetite based on the assumption that those without appetite required more supervision. Malnourished children with an appetite would either come in the morning or the afternoon for approximately four hours depending on the allocated shift. Children without an appetite would be encouraged to spend more than half a day at the centre. All children received a take home ration of made up milk and BP5 biscuits. If necessary, and with time and sufficient training, I assumed that it would be possible to build on the simplified model so that it would eventually have the characteristics of a conventional TFC. The rationale for such a design was:

    • to free up time for mothers thereby reducing the likelihood of other children being admitted;
    • due to the limited number of qualified national staff available such a system meant that there were less children at the centre at any given time so that the TFC could more easily adhere to another of the key SPHERE indicators "Nutrition worker to patient ratio is at least 1:10";
    • to enable national staff to run the programme if international staff were evacuated for security reasons.


    This deliberately simplified TFC regime deviated from certain aspects of standard therapeutic care protocols/guidelines e.g. a three-phase system with 12-24 hour supervision. Understandably, this received critical attention from certain experienced MSF team members. Their concerns were real and justifiable, MSF had years of experience and who was I to adapt internationally recognised MSF nutrition guidelines. "Minimum standards for therapeutic feeding were not being met."

    Eventually, the team agreed to implement the suggested design. During the course of the programme children successfully gained weight (but at a slower rate than 8gms/kg/day) and the approach was replicated in other sites later on in the crisis. It is difficult to establish scientifically the merits of this particular intervention (after several weeks the programme was closed due to insecurity and some of the relevant data were lost). However, in Panthou during the later stages of the crisis the above design was implemented and the recovery rates were 75%. I believe such an approach was appropriate and effective for the given context.

    Limitations of minimum standards in programme assessment - Example 2
    During the crisis some MSF programmes reduced the admission criteria for the TFC from <70% wt-for-ht to <60% wt-for-ht in order to be able to cope with the overwhelming numbers. It could be argued that the Minimum Standards for targeted support to reduce mortality, morbidity and suffering associated with severe malnutrition were being met as far as possible, given the difficult circumstances encountered (including an inadequate and erratic general food ration). However, some of the relevant indicators for the minimum standard such as the "proportion of exits from a therapeutic feeding programme who have died is <10%" and the "proportion of exits from therapeutic feeding programme recovered is > 75%" could no longer be reasonably applied as children < 60% wt-for-ht are likely to suffer higher mortality. If such indicators were applied without consideration of the context one would conclude (unfairly) that the programme was of poor quality and ineffective.


    A number of critical observations about the role and application of minimum standards can be drawn from these experiences:

    a) Assessing standards in a particular context.
    While the Sphere Project offers a set of standards and indicators, neither these standards nor other internationally recognised nutritional guidelines were able to prepare or offer solutions for "front line workers" for the array of constraints and challenges faced by humanitarian agency staff during the 1998 food crisis.

    b) Distinguishing between innovative and poorly managed programmes.
    During the crisis, there appeared to be inadequacies in the capacity of some commentators to distinguish between organisations which had adopted 'innovative approaches' to deal with the overwhelming situation (which in some cases meant deviating from guidelines), and organisations which were implementing poorly managed targeted feeding programmes (which also sometimes occurred). The use of the Sphere Project as a tool did little to strengthen (and may even have undermined) the capacity to make such distinctions. In some situations, optimal programme design (as advocated in guidelines) had to be modified in order to maximise the achievement of the minimum standard.

    There were certainly instances where this apparent deviation from standard protocols/guidelines was perceived as a failure to meet standards as suggested by Sphere (e.g. the key indicator suggested as a means of assessing attainment of the minimum standard is adherence to standard protocols). The overall situation was not helped by the fact that professionals did not appear to agree readily on the most appropriate strategy for nutrition interventions, given the complex and challenging circumstances.

    c) The application of Minimum Standards and their respective indicators
    Where programme design is modified in order to maximise attainment of standards the relevant key indicators for any given standard may not be appropriate or attainable, and if applied, may indicate poor programme performance.

    d) The misleading nature of the term 'Minimum Standards.'
    Some professionals argue the standards, and their respective indicators, are appropriate for accessible and relatively safe refugee settings while in complex emergencies, they may be the ideal, but not really achievable. For example, water supply standards were not achievable throughout most of southern Sudan during the '98 crisis. But the term 'Minimum Standards' suggests they should be achievable. In certain situations, when standards and their indicators are unrealistic, the Sphere Project is considerably weakened as a tool to challenge poor practice. Perhaps a more appropriate and less confusing term may be 'international references' or 'international standards'.

    e) Using the Minimum Standards as a measure for greater accountability.
    Though well intentioned, the attempts to make agencies more accountable by promoting the adoption of the Minimum Standards in southern Sudan, did not always achieve this objective. One reason appears to be that criticism was being received defensively. In addition, due to the strains experienced by the main co-ordination body (in this case, the UN) and the lack of capacity found in local authority structures, some professionals assumed an ad hoc watchdog role. As there was no agreed mandate for such a role, this had, at times, the inadvertent effect of making agencies less willing to be transparent and did little to improve accountability.

    f) The 'right' to comment
    At the onset of the crisis, MSF was among a number of agencies who publicly voiced their concern over the World Food Programme's capacity to meet the scale of needs facing the vulnerable population. However, a number of MSF workers questioned whether it was appropriate for MSF to continue to comment on the capacity of WFP to respond to the situation when MSF could also be criticised for not adhering to Minimum Standards. This was one of the reasons why MSF reduced efforts to high-light the difficulties facing WFP.

    g) The impact of the Sphere Project in shaping the response to the crisis.
    Even with greater awareness of the project, it is unlikely that the project would have greatly helped to improve the quality and efficiency of the response, for the following reasons:
    • The Sphere Project would not have offered practical solutions to the constraints being faced by practitioners
    • Many of the Sphere Project standards would have appeared unrealistic, and it is possible that the 'baby would have been thrown out with the bath water'.
    • Where programmes had adapted their interventions and therefore appeared not to attain the Minimum Standards, indicators could no longer be appropriately applied in order to determine the quality and effectiveness of the intervention.
    One factor which would have significantly helped to improve the effectiveness and quality of the overall nutrition response, would have been a wider use of internationally recognised operational nutrition guidelines (even though I have later recommended that these need to be revised to provide recommendations on 'optimal' practice in the face of overwhelming circumstances). This is particularly true for agencies that had large numbers of inexperienced professional staff, and/or agencies with limited institutional experience of selective feeding programmes. Several agencies I visited which were implementing feeding programmes, struggled with practical issues like maintaining adequate registration books. Such difficulties could have easily been solved by the greater use of recognised nutrition operational guidelines.

    Suggestions for strengthening the Sphere project
    The Sphere Project should be commended and supported for aiming to improve practice within the humanitarian arena. However, the Project has weaknesses. Below are some suggestions to help minimise these weaknesses and maximise the value of Sphere.

    a) Reconsider the term 'minimum'
    The term 'minimum' is misleading and confusing and should be replaced by the term 'international standards' or 'international references'.
    The fact that Minimum Standards in certain contexts are unrealistic needs to be addressed.
    Criteria could be established to determine under what circumstances and how, minimum standards can be adapted to specific contexts: but always with the eventual aim of achieving international Standards. An additional chapter could be devoted to this. This process should also be supported by revising existing guidelines to include recommendations for situations where standard protocols cannot be adhered to, and compromise measures might need to be introduced.
    These measures may go some way towards reducing the intimidating aspects of the standards and prevent innovative ideas being stifled for fear of falling short of the standards.

    b) Promote the use of operational guidelines
    The Sphere Project should more actively promote the use of recognised agency operational guidelines in order to compliment the Sphere Project document.

    c) Create the necessary environment to promote accountability and transparency
    It is a matter of urgency to improve existing accountability systems and to ensure the correct environment is created to encourage agencies to be accountable and transparent. The current Ombudsman project (instigated at the World Disasters Forum in 1997) seeks to encourage agencies to adhere to the main codes and standards in humanitarian work. The project, co-ordinated by the British Red Cross, is investigating the feasibility of creating an accountability mechanism for humanitarian assistance. The Ombudsman will provide a mechanism to "help bridge the accountability gap between agencies and the claimants" of humanitarian assistance by having an independent office to investigate complaints or problems.

    d) Strengthen the link between the policy maker and the practitioner
    The link between the policy maker, researcher and practitioner needs to be strengthened. Practitioners need to be better informed of latest research findings and their link to policy development while policy makers need to be better appraised of the realities on the ground. The Sphere Project has taken the initiative to raise awareness of appropriate intervention standards around the world. This is undoubtedly a positive step and should be applauded. However, the project can only have limited impact unless there is a corresponding commitment by the agencies to institutionalise the principles, policies and values of the Project while assisting practitioners to apply these in a flexible and appropriate manner.

    See also the post script to this article.

    * Coordinating a Humanitarian Response in Sudan by Murphy et al, Field Exchange Issue 6.

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