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2011 Edition of the Sphere Handbook Humanitarian Charter and Minimum Standards in Humanitarian Response

Farmers association level consultation at Chuko, Southern Nations, Nationalities and Peoples (SNNPR) province, Ethiopia, August 2009

By Susan Thurstans, Paul Turnbull, Devrig Velly, and Walter Middleton

Susan Thurstans was Nutrition Adviser within the emergency response team for Save the Children UK, at the time.

Paul Turnball is Senior Programme Adviser, Programme Division, United Nations World Food Programme, Rome.

Devrig Velly was Senior Food security and Livelihoods Advisor for ACF based in New York.

Walter Middleton is the World Vision International's Partnership Leader for Food Security and Livelihoods based in Johannesburg.

The authors gratefully acknowledge Aninia Nadig and Ali Maclaine for reviewing the article.

This article describes the main provisions and updates to the minimum standards in food security and nutrition in the 2011 edition of the Sphere handbook.

The Sphere Project and its Handbook are well known for introducing considerations of quality and accountability to humanitarian action. The handbook has become one of the most widely recognised tools for improving humanitarian response. The success of the Handbook reflects the fact that Sphere is responsive to the needs of people responding to and affected by disasters and has proved to be a relevant and 'living' document. The first 2000 edition, a revision of the first pilot edition from 1998, was again revised for 2004. Since 2004, a number of technical changes have occurred and new cross-cutting issues have evolved.

For the 2011 revision, a consultative process similar to that undertaken for the 2004 edition was adopted. The consultation process has enabled involvement of those responding to disasters as well as attempting to engage those affected, and has worked closely with the cluster approach and other relevant national and regional networks.

The process was led by a group of individual who acted as focal points, each of whom invited a group of experts to form core working advisory groups comprised of non-governmental organisations (NGOs), academic institutions, United Nations (UN) agencies, donors and independent consultants. Four focal point persons led the food chapter with three working groups, one for nutrition, one for food aid and one for food security.

This article sets out to provide full transparency to the process through the documentation and justification of technical changes to the 2011 version of the Sphere Handbook chapter on Food Security and Nutrition (referred to hereafter as 'Food chapter'). It highlights some of the larger changes that have been made and the evidence and process on which these decisions have been based.

Summary of sector changes

The Humanitarian Reform process, launched in 2005, aims 'to enhance humanitarian response capacity, predictability, accountability and partnership'. The similarity with Sphere's aim is striking, and Sphere has already worked closely with the clusters most relevant to Sphere. The cluster approach, one of the pillars of the reform process, has resulted in the advent of a strong international coordination body, particularly for nutrition, while a global food security cluster has recently been established which includes food assistance. The cluster approach is responsible for the development of standardised response recommendations, development of tools to assist in humanitarian response, and the coordination of response both on the ground and at international level.

Over recent years, the scale and significance of hunger and poverty has become ever more apparent and has resulted in a renewed focus on hunger. Increasingly large-scale complex emergencies in the context of a global financial crisis, dramatic spikes in 2008 in basic food prices, and increasingly protracted crises have all called for increased recognition of poverty as a significant underlying cause of undernutrition and the importance of striving towards achieving Millennium Development Goal 1, reduction of poverty and hunger.

Setting the scene

The introduction sets the scene for some of the changes within the chapter. The Humanitarian Charter sets out a set of principles that should govern humanitarian action and asserts the right of disaster-affected populations to life with dignity, protection and assistance. This Charter has been completely rewritten for the new edition to offer clearer language and strengthened linkage to the standards. To reflect this change, more detail on the obligations of states concerning the right to food (to "respect", "protect and "fulfil" access to food) have been included. The obligations on states includes that "In the case of disasters, states should provide food to those in need or may request international assistance if their own resources do not suffice. They should also facilitate safe and unimpeded access for international assistance." Additional text is included drawing from the Committee on Food Security's 'Voluntary guidelines to support the progressive realisation of the right to adequate food in the context of national food security', which was not available for the 2004 Handbook.

The introduction also strengthens some definitions, for example, the effects of pre-existing chronic undernutrition is recognised, the definition of 'food security' has been elaborated to describe availability, access, and utilisation, the definition of 'livelihoods' has been revised, as has the definition of 'malnutrition'. This section also recognises that good food security and nutrition disaster response is achieved through better preparedness.

A revised chapter structure

Given the changes within the sector, and in response to consultation feedback, the authors have tried to ensure the chapter reflects and therefore promotes a more integrated approach to the prevention and treatment of malnutrition and sustaining of livelihoods in emergencies. Central to this is the conceptual framework for undernutrition (see Figure 1). All aspects of the chapter and indeed many other areas covered in the three other technical chapters (Water, sanitation and hygiene promotion, Shelter, settlement and non-food items, and Health action) lie within the conceptual framework. Given this, the framework was brought forward within the chapter and used as a pillar on which the chapter is based, to promote coordination and integrated means of responding to crises.

The framework as it appears in the new chapter is itself a product of the consultation process. The draft framework was formulated based on a comparison of three different versions (Lancet, World Food Progamme (WFP), Action Contre la Faim (ACF)). The authors spent time discussing the overlapping themes within the different versions and how these fit within the context and scope of Sphere. The revised Sphere Handbook gives poverty a central role as an underlying cause, adding to the previous three underlying causes (inadequate household food security, inadequate maternal and child care, insufficient services and unhealthy environment). This reinforces food and livelihoods as primary causes of malnutrition. It also highlights the relevance of the framework to mothers as well as children and details the short and long term consequences of undernutrition.

Assessment and analysis

The assessment standards in the 2011 Handbook edition have been written to try and encourage joint assessment at the initial stages of an emergency with all sectors, and consideration of integrated in-depth assessments where appropriate. Integration or overlap of food security and nutrition assessments is strongly encouraged within the chapter. Both food security and nutrition assessment standards refer to integrated rapid assessments under the Core Standards and support global efforts to improve assessment and information management for humanitarian action1. The tool contributes to a larger multi-cluster IASC-led effort to harmonise emergency assessment to lead to a broader understanding of the context and needs rather than a focus on individual organisational concerns.

Stronger references to the food security pillars have been included. This has resulted in more emphasis on local 'systems' and market analysis as key elements to assess, as well as a better focus on food consumption indicators and coping strategies. Meaningful and practicable indicators of food diversity have been developed since the 2004 edition of the Sphere Handbook and subsequently added in this revised version (indicators such as the household dietary diversity score, household food insecurity access scale or the food consumption score). The 2011 Handbook edition integrates some updates of essential tools such as the Coping Strategy Index (CSI) revised in 2008. References to the integrated food security phase classification (IPC) have also been included (see box 1).

Box 1: Integrated food security phase classification (IPC)

Integrated food security phase classification (IPC)

The IPC2 is an interagency approach being rolled out by an international partnership of agencies which includes Care, Oxfam, Save the Children, the European Commission (EC) joint research centre, FEWS NET, FAO and WFP. It provides a common classification system which defines the severity of a situation according to pre-defined phases from 'generally food secure' to 'famine/humanitarian catastrophe', based upon a wide range of indicators of the impact of a hazard event on human health and welfare (e.g. mortality rate, nutritional status).

SMART (Standardized Monitoring and Assessment of Relief and Transitions)

The SMART method is an improved survey method based on the two most vital and basic public health indicators to assess the severity of a humanitarian crisis - nutrition and mortality. The nutrition component is based on the nutritional status of children under 5 as this is closely linked to risk of mortality and can be used to draw conclusions on the whole population based on the assumption that children aged 6-59 months are the most vulnerable group in the society. Mortality is assessed as this is the most critical indicator of a population's improving or deteriorating health status and is the kind of information to which donors and relief agencies most readily respond.

Under nutrition assessment, the 2011 version emphasises the importance of assessments beyond anthropometric surveys, and refers to the causal framework as a basis of assessing both the extent of and underlying causes of undernutrition. Reference is made to surveys assessing infant and young child feeding practices, micronutrient deficiencies and links are encouraged with other sector assessments, particularly food security and livelihood, water and sanitation and health.

When covering anthropometric surveys, following recommendations during the Handbook revision process (from both consultations and the core working group), reference has been made to the SMART (Standardized Monitoring and Assessment of Relief and Transitions) method, an internationally recognised standardised method for anthropometric and mortality surveys (see box 1 for more information on SMART).

The introduction of the WHO growth standards in April 2006 represented a significant move forward in the understanding and measurement of global child malnutrition. Reference has been made throughout the food chapter to these standards as recommended in consultations and by the core working group and the nutrition cluster assessment working group. The 2011 Handbook edition also recommends the inclusion of the measurement of mid-upper arm circumference (MUAC) of children under 5 years within anthropometric surveys for reporting prevalence of acute and chronic undernutrition and in rapid screening assessments.

In relation to interpreting levels of malnutrition, the Sphere Handbook has maintained its position on not classifying the severity of undernutrition prevalence rates in a population based on thresholds. It encourages consideration of the scale of crises related to other factors, such as population numbers affected. Though useful, rates can belie the actual magnitude of a crisis if the area of assessment is densely populated and has other risk factors. Likewise thresholds do not consider sudden changes in comparison to baseline indicators, in particular when levels do not exceed 10%3. This position is supported by the IASC humanitarian response review which concluded that there is no agreed system for estimating the severity of a crisis and the impact of humanitarian response overall. Consequently there is no set of benchmarks to which the humanitarian community can be held accountable.

New infant and young child feeding standards

The provincial consultation in Awasa, Ethiopia in August 2009

Despite evidence showing that sub-optimal breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of the disease burden in children under 5 years,4 the interventions to address infant and young child feeding are often not prioritised during rapid onset emergencies. Careful attention to infant and young child feeding (IYCF) and support for good practice can save lives.

Two new standards on IYCF have been introduced following recommendations from country consultations (particularly from India), the Infant and Young Child Feeding in Emergencies Core Group (IFE Core Group), the Working Group on IYCF Indicators and others, together with experiences from recent emergencies, notably in Myanmar, Philippines and Haiti. The new IYCF standards draw upon the 2004 version of the handbook, the International Code of Marketing of Breastmilk Substitutes and subsequent relevant resolutions (the Code), the Operational Guidance on Infant and Young Child Feeding in Emergencies (2007), and the evidence base and experiences upon which these documents have been developed.

IYCF guidelines and recommendations have undergone many changes since the initial publication of a set of indicators for IYCF in 1991. The new IYCF standards consider the protective and supportive elements of policy and legislation, coordination, communication, as well as the basic and technical IYCF interventions (skilled breastfeeding assistance, complementary feeding support, management of artificial feeding) that should be considered in response. The needs of breastfed and nonbreastfed infants, the importance of maternal nutrition and health, and the challenges of the HIV context are included.

Simple, valid and reliable indicators are crucial to track progress and guide investment to improve nutrition and health during the first two years of life. Indicators that assess breastfeeding are useful to monitor trends, develop and evaluate programmes and for advocacy. A set of core and optional IYCF indicators have been developed by the Working Group on Infant and Young Child Feeding Indicators at the global consensus meeting in 20075. These indicators have been worked into the new Sphere Handbook.

Appropriate complementary feeding following 6 full months of exclusive breastfeeding plays a pivotal role in the prevention of malnutrition and contribution to child survival. The new indicators and guidance notes for complementary feeding reflect the movement within the international community to prioritise access to safe complementary foods and to enable safe complementary feeding. The Sphere guidance reflects the more recent development and piloting of lipid based nutrition supplements that may have a role in some contexts to support nutritional intake in children during the complementary feeding period. For example, they may be provided through blanket distributions to certain target groups such as children between the age of 6 months and 2, 3 or 5 years, depending on objectives, in populations acutely unable to meet the nutritional requirements for these age groups. Strong reference is also made to the new cash and voucher standards. Evidence on the benefits of two programmes in Nicaragua and Mexico showing consistent results from large-scale conditional cash transfer programmes effect on growth, as also found with food supplementation6. These programmes combined cash transfers and nutritional education and one also included a supplementary food fortified with multiple micronutrients. Data from a Save the Children programme7 in Swaziland provides striking evidence of the beneficial impacts of emergency drought response cash transfers on children's nutrition and food security status, evidenced by monitoring of dietary diversity.

Management of acute malnutrition and micronutrient deficiencies

As reflected in the title of this section, the content covers the management of acute malnutrition that includes prevention as well as treatment. The management of moderate acute malnutrition (MAM) is currently undergoing significant changes following a retrospective study in 20088 analysing outcomes of 82 targeted supplementary feeding programmes (SFP) implemented by 16 agencies in Africa, Asia and Central America. The study highlighted the lack of consensus in objectives of SFPs. Whilst some recommendations or questions from this work are not yet at a stage advanced enough to be included in Sphere, some of the outcomes of this work are clear and the revised chapter reflects this. Most significantly, the consideration of blanket supplementary feeding as an approach to addressing MAM has been included within the guidance notes.

The 2008 SFP review highlighted that in the 2004 edition of the Sphere Handbook there were no specific programme outcome indicators for 'transfer rate' (to therapeutic feeding centre (TFC) or to hospital), or for 'non responders' (other patients that are discharged without having reached target criteria). As a consequence, organisations that reported SFP performance following Sphere recommendations did not account for these patients during monitoring and evaluation. In other words, a SFP could send 50% of its patients to a TFC because they are losing weight, yet still meet Sphere standards. Therefore, in the revised 2011 edition of the Sphere Handbook, 'non-response' has been included as an indicator, although no benchmark currently exists. Recommendations to record and monitor the number of children whose condition deteriorates to severe acute malnutrition (SAM) have been included.

Recommendations have also been included in the management of MAM section to separate 'follow-up' patients (those discharged from treatment for severe acute malnutrition and admitted to SFP), who already meet the target weight for height when they are admitted, from others. This is to prevent the overestimation of the recovery rate of the SFP programme; it is not correct to consider that such 'SAM' patients were 'recovered' at the end of the SFP follow-up period An inaccuracy in the representativeness of outcome data will have negative consequences on programming.

The management of severe acute malnutrition (SAM) has also undergone significant changes, a key development has been the roll out of Community-based Management of Acute Malnutrition (CMAM) (see Box 2). Until 2003/04, treatment for SAM was largely restricted to inpatient facilities limiting coverage and impact. New evidence now shows that large numbers of children presenting with uncomplicated SAM can be treated within a community therefore eradicating the need for hospital admission in this group9. The revised Sphere Handbook recommends communitybased management of malnutrition10 as the preferred method with wide support from the Sphere consultations.

Box 2: Community-based Management of Acute Malnutrition (CMAM)

The community-based approach involves timely detection of SAM in communities and provision of a ready to use therapeutic food (RUTF) for those classified as without medical complications. For those children with medical complications, facility-based management can precede community treatment in order to treat initial complications, stabilise the child's condition and regain a child's appetite.

There is a lack of agreed outcome indicators and benchmarks related to the treatment approach for severe acute malnutrition in use. Though some recommendations exist, there is not yet international agreement on adapted cutoffs for separate programmes. Therefore separate inpatient and outpatient indicators have not been listed, but rather the indicators refer to the treatment process as a whole.

There still remains a lack of an evidence base or established practice in addressing acute malnutrition in infants 0-6 months of age. Based on evidence from the Management of Acute Malnutrition in Infants (MAMI)11 project and wide support from consultations, this is highlighted throughout the Food chapter. It alerts the humanitarian community that with the introduction of 2007 WHO standards for the classification of weight-for-height z-scores, there will be an increase in the number of infants < 6 months identified with SAM. Though indicators for performance focus largely on children aged 6-59 months, consideration of infants < 6 months is vital and programmes should adapt as necessary to meet their needs. This may have resource and skills base implications. The authors hope the introduction of the new IYCF standards will increase the recognition amongst governments and the humanitarian community of IYCF as a life-saving intervention and therefore also contribute to the prevention and early treatment of acute malnutrition in infants and young children.

The revised standard for the management of micronutrient deficiencies has adopted a more proactive position to micronutrient deficiencies. In other words, rather than describing solely the treatment of micronutrient deficiencies, there is a larger focus on prevention12. Within the appendices there is increased information on the public health implications/thresholds with regard to the number of cases with clinical signs of deficiency.

Defining malnutrition

The management of SAM has also been influenced by the rollout of the 2007 WHO Growth Standards (see Box 3). Studies indicate that the implementation of the new standards using the same cut-offs has little effect on the overall prevalence of global acute malnutrition (wasting and/or oedema) or moderate acute malnutrition but results in a significant increase in the prevalence of SAM (severe wasting and/or oedema), particularly in infants.13,14,15 The 2011 edition of the Sphere Handbook adopts the WHO standards, which has implications for admission and discharge criteria for therapeutic and supplementary feeding programmes. Weight-for-height Z-score using the WHO standards for children 6-59 months, rather than percentage of the median, is now recommended to be used as admission and discharge criteria to therapeutic and supplementary feeding programmes.

Box 3: 2007 WHO Growth Standards

Between 1997 and 2003, WHO undertook the Multicentre Growth Reference Study (MGRS). This combined a longitudinal follow-up of children from birth to 24 months of age and a cross-sectional survey of children aged 18- 71 months. Primary growth data and related information were gathered from 8,440 healthy breastfed infants and young children from diverse ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA). The study was designed to produce a representative standard by selecting healthy children living under conditions likely to favour the achievement of their full genetic growth potential. This supported the notion that given the same environmental conditions, growth potential is independent of ethnic origin and therefore, these standards can apply in any country. As of late 2008, 75 countries had officially adopted, or partially adopted, the new WHO standards.

Following wide support, the 2011 edition of the Sphere Handbook also includes mid upper arm circumference (MUAC) as admission criteria for programmes treating acute malnutrition. Due to a shortage of data to determine which discharge criteria should be applied using MUAC, it has only been included as admission criteria. Guidance for assessing undernutrition in children and adolescents has also been updated to reflect revised WHO recommendations.

Food security

General food security

The General food security minimum standard is now stronger due to its new position in the Handbook, overarching the three subsequent minimum standards: food transfers, cash and vouchers, and livelihoods.

Prioritising life-saving responses remains the 'raison d'être' of this standard. Ensuring adequate food consumption is the most common objective in acute food insecurity. The most efficient transfer (in-kind, cash and/or a combination of both) is introduced here and linked with new references to market analysis (EMMA16, MIFIRA17). Good practice standards, guidelines and evaluations all emphasise the importance of including markets in preparedness, emergency situations and response analysis. However, in practice, emergency practitioners have often overlooked the potential and actual role of markets in emergency and early recovery responses. This may be due to uncertainty on how to understand or work with traders and other market actors in an emergency setting, and unfamiliarity with the private sector.

Food transfers

The new food transfers standards reflect updates for developments in general nutrition requirements (which are now included in this section), appropriateness and acceptability, food quality and safety, supply chain management, targeting and distribution and food use. These standards link closely to the Core Standards and Protection Principles and promote active participation of beneficiaries, support to dignity and consultation and involvement of local groups including vulnerable persons (see Box 4 for an example).

Box 4: An example of food transfers standard in action

A food transfer should meet the following criteria:

  1. targeting criteria must be based on thorough analysis of vulnerability
  2. targeting mechanisms are agreed among the disaster-affected population
  3. there should be relevant alternative distribution models for people with reduced mobility
  4. recipients should not have to walk more than 10 kilometres to the distribution site, i.e. no more than a four-hour walk
  5. ration cards, banners and/or signposts specifying the food rations during distributions should be used
  6. specific measures to counter gender-based violence at distribution points, and
  7. a complaints mechanism should be established for the registration process.

Cash and voucher transfers

The new cash and voucher standard is the product of a fruitful collaboration and consistent involvement throughout the consultation and drafting periods of the cash learning partnership (CaLP). Originating in the will to gather lessons learnt from the tsunami emergency response in 2005, the CaLP is today composed of Oxfam GB, the British Red Cross, Save the Children UK, Action Contre la Faim and the Norwegian Refugee Council. In 2010, the CaLP partnered with the International Federation of the Red Cross and Red Crescent Societies (IFRC) to expand its level of activities.

While cash and vouchers can potentially be used for other sectoral interventions (WASH, Shelter and Non-Food Items, Health), CaLP advised that most of the experience in cash and voucher transfers has been for food assistance. The standards developed should therefore be included in the 'food' chapter of the Sphere Handbook.

There is growing recognition and interest in the humanitarian sector to use cash and voucher mechanisms where appropriate to improve programme effectiveness, dignity and choice for beneficiaries and to stimulate local economies and markets.

Experience of humanitarian agencies and donors in responding to the needs of people affected by large scale disasters such as the Asian tsunami (2004) and Pakistan earthquake (2005) highlighted the need for enhancing capacity on cash transfer programming, consolidating learning and coordination of cash transfer responses. This is captured in a study conducted by the Overseas Development Institute (ODI) in 2005. "Agencies could have made more use of cash in many sectors such as emergency food and non-food assistance, unconditional cash grants soon after the disaster, assistance with providing shelter (assistance with rent, help for host families, or providing cash for building and repair direct to beneficiaries), and supporting livelihoods recovery (with cash provided for asset purchase and/or to cover start-up and initial running costs). Moreover, the tsunami experience and learning from it has highlighted many ways in which cash transfers could be more effective if designed and implemented differently".

The inclusion of a minimum standard on the use of cash and vouchers in the new Sphere handbook is also a clear indication of a growing recognition of the role that cash and vouchers can play in delivering humanitarian action that is effective, efficient and most importantly, improves the choice and dignity of disaster affected populations.

Livelihoods

Livelihoods are the means by which households obtain and maintain access to the resources necessary to ensure their immediate and long-term survival. These resources include financial capital (such as cash, credit, savings), as well as physical (houses, machinery), natural (land, water), human (labour, skills), social (networks, norms) and political (influ ence, policy) capital. Households use these assets to increase their ability to withstand shocks and to manage risks that threaten their life.

Key to those who produce food is whether they have access to land that can support production and whether they have the means to continue to farm. Key to those who need income to get their food is whether they have access to employment, markets and services. For people affected by disasters, the preservation, recovery and development of the resources necessary for their food security and future livelihoods should be a priority.

Whilst food transfers remains the main way of meeting basic food needs when disasters happen, agencies have increasingly implemented a range of food security and livelihoods programmes to help meet basic needs and reduce risks. These have included interventions that reduce expenditure, such as fuel-efficient stoves and grinding mills, and vouchers or grants to increase access to a range of goods or services, such as vouchers for milling or nonfood items, cash for work for road rehabilitation or solid-waste disposal, and grants for basic needs or livelihood recovery.

The new Sphere Handbook includes updated standards on primary production, income and employment; and access to markets. In addition to food security and livelihoods assessment checklists, a seed security assessment checklist has been added.

The 2011 edition of the Sphere Handbook includes references to new material to support the primary production such as the Livestock Emergency Guideline and Standards (LEGS)18 and the Seed system Security assessment.

Revised references

The appendix of references from the food chapter in the 2004 Handbook has been updated with a 'References and further reading section' including sources and further reading on assessment, IYCF, food security interventions, general emergency nutrition manuals, vulnerable people, management of acute malnutrition, and micronutrient deficiencies.

Expected consequences of the revised food chapter for practitioners

Part of the nutrition, food aid, and food security consultation in Addis Ababa, Ethiopia in 2009

The active engagement of the three core working groups (expert advisory groups formed of actors from NGOs, UN agencies, donor agencies and academic institutions), peer advisory groups (such as cluster working groups) and the global humanitarian community working in food security and nutrition has resulted in a widely participative process. The approach taken and the successful coordination between nutrition, food aid and food security authors ensures an evidence-based chapter which addresses both the prevention and treatment levels of response to undernutrition in disaster settings. The authors hope that the revised chapter will support the planning and implementation of integrated programmes to address the prevention and treatment of undernutrition, as represented in the conceptual framework, through better preparedness, integrated assessment, and quality interventions that meet the minimum standards outlined.

The impact of the revised food chapter is expected to improve humanitarian response meeting the minimum nutrition needs of disaster- affected populations, ensuring that they maintain their dignity, through holding humanitarian actors, including donors, to account to the revised Sphere minimum standards. Taking into account wider humanitarian reform and the cluster approach, the revised Sphere Handbook will directly facilitate the Nutrition and Food Security Clusters to achieve their mandate at global and national levels, and will also contribute to work of the Logistics Cluster. It will serve as the ultimate set of shared standards of a broadened food security and nutrition partnership group, supporting strengthened system-wide preparedness and technical capacity to respond to humanitarian emergencies.

The Sphere Handbook 2011 is available at http://www.sphereproject.org

Show footnotes

1United Nations Inter-Agency Standing Committee (UN IASC), Health Cluster, Nutrition Cluster, WASH Cluster

2Source: SCUK SCUS IPC information sheet

3ACF

4Black et al, 2008, Maternal and child undernutrition 1. Maternal and child undernutrition: global and regional exposures and health consequences. www.thelancet.com, series, January 17

5Working Group on Infant and Young Child Feeding Indicators (2007). Indicators for assessing infant and young child feeding practices. Conclusions of a consensus meeting held 6-8 November 2007 in Washington D.C., USA

6Bhutta, Z. A., T. Ahmed, R. Black, S. Cousens, K. Dewey, E. Guigliani, B. Haider, B. Kirkwood, S. Morris, H. Sachdev, and M. Shekar. 2008. What Works? Interventions for maternal and child undernutrition and survival. The Lancet 371: 1-24.

7Stephen Devereux, Paul Jere, 2008. Choice, Dignity and Empowerment Cash and Food Transfers in Swaziland An evaluation of Save the Children's Emergency Drought Response, 2007/08

8Navarro-Colorado C, Mason F, and Shoham J (2008). Measuring the effectiveness of supplementary feeding programmes in emergencies, Humanitarian Practice Network paper, no. 63

9WHO, WFP, SCN and UNICEF, (2007). Community based management of severe acute malnutrition. A joint statement.

10Including mobilisation and inpatient treatment for children with complications.

11 IASC, ACF, UCL, ENN (2010). Management of acute malnutrition in infants (MAMI) project. Technical Review: Current evidence, policies, practices and programme outcomes.

12Personal communication with Andre Briend.

13Myatt M & Duffield A (2007) Assessing the impact of the introduction of the WHO growth standards on the measured prevalence of acute malnutrition and the number of children eligible for admission to emergency feeding programmes. Background paper.

14de Onis M & al (2006) Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes. Public Health Nutrition 9: 942-947

15Seal A & Kerac M (2007) Operational implications of using the 2006 World Health Organisation growth standards in nutrition programmes: secondary data analysis. British Medical Journal. Doi:10.1136

16EMMA is the Emergency Market Mapping and Analysis Toolkit. It has been designed to assist front-line humanitarian staff in sudden-onset emergencies better to understand and make use of market systems within the first few weeks of the emergency and the early days of the response.

17The Market Information and Food Insecurity Response Analysis (MIFIRA) tool is a framework to evaluate the feasibility of supplementing food aid with cash or vouchers. MIFIRA is organised around two primary questions. First, are local markets functioning well? Secondly, if markets are not functioning well enough to supply aid, is there sufficient food available nearby to meet the shortfall?

18LEGS is a set of international standards for improving the quality of livestock programmes in humanitarian disasters based on rights. It focuses on regions prone to repeated or large-scale disasters - rapid onset, slow onset, complex. It enables humanitarian actors to design and implement projects which help to protect and/or rebuild livestock assets. A LEGS application to become a companion module to Sphere is due to be finalised in 2011.

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Reference this page

Susan Thurstans, Paul Turnbull, Devrig Velly, and Walter Middleton (2011). 2011 Edition of the Sphere Handbook Humanitarian Charter and Minimum Standards in Humanitarian Response. Field Exchange 41, August 2011. p36. www.ennonline.net/fex/41/edition