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Complementary feeding in emergencies programming – Yemen case study

This is one of four case studies in this special section of FEX to highlight the importance of a strong contextual analysis to guide the appropriate design, implementation and monitoring of actions and interventions, cross sector collaboration and integration, and proof of concept of localised initiatives that have the potential to be scaled up at national level. 

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Karin Christianson is a Nutrition in Humanitarian Contexts Specialist at USAID Advancing Nutrition.

Alison Donnelly is an Independent Nutrition/IYCF Specialist.

Kavita Sethuraman is the Director for Nutrition in Humanitarian Contexts at USAID Advancing Nutrition.

Introduction

This case study reviewed the complementary feeding programming implemented in Yemen between 2017 and 2022. A wide range of complementary feeding approaches were found despite the challenges many families faced when accessing adequate complementary foods.

Programming context

Yemen continues to suffer from the worst humanitarian crisis in the world. In 2014, insurgents took control of Sana’a, Yemen’s capital. In March 2015, a coalition of Gulf states launched a campaign of economic isolation and air strikes against the insurgents’ groups. The country is now divided into areas controlled by the internationally recognised Government of Yemen, based in Aden, and the self-proclaimed government based in Sana’a, which is home to an estimated 70% of the population. In 2020, Yemen ranked  179th out of 181 countries in the Human Development Index, a summary measure of achievement in the key dimensions of human development. If fighting continues throughout 2022, it is expected that Yemen will also rank as the poorest country in the world (OCHA, 2021).

Food insecurity and malnutrition are most severe in areas of active conflict and the surrounding areas where humanitarian access is limited by the security situation. Yemen's Nutrition Sector is led by the Ministry of Health and Population which co-chairs humanitarian coordination through the Nutrition Cluster with UNICEF in the governments of both Sana’a and Aden . The Nutrition Cluster is responsible for the prioritisation of humanitarian nutrition activities (including complementary feeding), as well as strategy and funding, in the Humanitarian Response Plan which covers the response under both governments.

Due to the risk of famine in recent years, nutrition activities focus on services that are perceived to be lifesaving, such as the treatment of wasting and ensuring minimum household food security. The implementation of multi-sector actions to improve complementary feeding through the Multi-Sector Nutrition Action Plan (MSNAP) is limited under both governments.

Nutrition situation analysis: Drivers and determinants of young children’s diets

While the Humanitarian Needs Overview does not include a detailed analysis of complementary feeding, it does include findings on dietary diversity, with the 2022 report recommending multi-sector actions to support improved nutrition.

According to SMART surveys conducted in 2021, 45% of children aged 6-59 months are stunted, while 10% suffer from wasting (MPHP, 2022). Wasting rates rise to 25% in the 6-12 months period, which likely indicates very poor practices in the initial phase of complementary feeding. Only one in 10 children aged 6-23 months in Yemen receives an adequate diet in the complementary feeding period, with only 12% receiving a minimum acceptable diet. High levels of poverty, spiralling food prices, poor access to services, and the constraints on the daily lives of women, such as movement restriction and challenges accessing financial services,  all present challenges to following recommended complementary feeding practices. A lack of knowledge on age-appropriate behaviours and a lack of interaction with children during meals have also been highlighted as barriers to appropriate practice (Busquet, 2018).

Interventions and actions for improving young children’s diets

Actions to improve the diets of young children predominantly focus on the health sector. They include one-on-one counselling by government health workers, mother support groups and nutrition promotion sessions, infant and young child feeding (IYCF) information sharing, cooking demonstrations/community kitchens, and supplementation with micronutrient powders. Examples of programmes conducted outside the health sector include home gardening and the provision of seeds, tools, and animals in addition to farmer field schools that bring together a group of farmers for hands on training to improve sustainable and nutrition-sensitive production practices, the promotion of compound flour,1 blanket supplementary feeding programmes, hygiene promotion integrated with IYCF education for pregnant and lactating women, conditional cash for nutrition (recommended that cash is used to purchase nutritious food with a soft requirement to attend nutrition education or training), and in-kind food assistance.

The main channels of service delivery were the health system – supported by non-government organisations (although the government recruits staff) – and the food system. Water, sanitation, and hygiene promotion activities were often integrated with IYCF and health interventions. Social protection systems were also used to target the families who were most in need, but this was not integrated with social behaviour change communication (SBCC) activities to promote appropriate complementary feeding. Cash and in-kind food support were provided to the head of the household who, in most cases, was male. Any SBCC activities for nutrition were usually directed at female caregivers.

Monitoring, evaluation, learning, and reported outcomes

The monitoring of indicators for complementary feeding is included in the MSNAP but national information systems do not currently collect information for most of these indicators (TASC, 2021). The Nutrition Cluster database includes some process indicators and tracks the number of children receiving blanket supplementary feeding, micronutrient interventions, and IYCF counselling.

Tracking the Nutrition Sector’s outcomes is challenging as short-term humanitarian programmes typically do not have baseline and endline assessments. Instead,  they use wasting treatment programme outcomes and IYCF output-level indicators such as the number of caregivers receiving counselling or attending support groups.

Periodic SMART surveys collect IYCF indicators. Monitoring is based on achieving a minimum recommendation (such as feeding at least four food groups) and does not usually track incremental progress (such as a child receiving three food groups instead of four). Information about programme outcomes on complementary feeding is limited due to the short-term nature of most programmes.

Opportunities and recommendations that could enhance programming were identified by stakeholders, including advocating to address complementary feeding as a priority issue, improving coordination across relevant sectors to address complementary feeding more directly, addressing complementary feeding knowledge barriers, and analysing incremental behaviour change.

Conclusion

As we were guided by the UNICEF Programming Guidance and its Action Framework to document complementary feeding in emergencies interventions in Yemen, we were able to learn that, given the complexity of the situation and the multiple challenges faced by families, multi-sector action is required to improve diets.

In theory, Yemen's policy environment is conducive to ensuring multi-sector actions to improve complementary feeding through improved breastfeeding and the provision of nutritious food. Although many policies were developed during the current crisis, in practice these policies are not prioritised by donors, are rarely reflected in humanitarian strategies, and are therefore not well funded.

To change the current trajectory, greater understanding among donors and decision makers is needed regarding the importance of nutritious diets for children aged 6-23 months. The prioritisation of the humanitarian response must be balanced to improve and scale up preventive measures in addition to curative nutrition services. Integration with other sectors, such as food security and livelihoods, may also enhance opportunities to engage men in SBCC activities.

For more information, please contact Karin Christianson at karin_christianson@jsi.com       

To return to the overview of these case studies, and find the other three, please click here

References

Busquet E (2018) Barrier Analysis of Infant and Young Child Feeding and Maternal Nutrition Behaviors in Urban and Rural Yemen May 2018. (not publicly available).

IFE-CG (2020) Review of experiences and direction on Complementary Feeding in Emergencies (CFE): Putting policy into practice. https://www.ennonline.net/cfereviewreportmarch2020

MPHP (2022) The Summary Report of Nutrition and Mortality Surveys. Republic of Yemen Ministry of Public Health and Population and Central Statistical Organisation.

TASC (2021) Nutrition Information and Analysis Systems in Yemen Volume 1 Key Findings & Recommendations. Technical Assistance to Strengthen Capabilities (TASC) Project. https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/tasc-review_nis_yemen-vol1-key_findings_and_recommendations-english-2021.pdf

OCHA (2021) Yemen Humanitarian Needs Overview 2021. https://reliefweb.int/report/yemen/yemen-humanitarian-needs-overview-2021-february-2021-enar  

USAID (2022) Complementary Feeding in Emergencies Programming in Yemen: A Case Study on Improving the Diets of Young Children During the Complementary Feeding Period. To be published

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Karin Christianson (). Complementary feeding in emergencies programming – Yemen case study. Field Exchange 68 , November 2022. p48. www.ennonline.net/fex/68/cfecasestudyyemen

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