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Tackling high defaulting rates in refugee camp settings – lessons from Chad

Seife Kifleyohannes Temere

Seife Kifleyohannes Temere is a Nurse Nutritionist. He has been working for International Medical Corps since 2010.

In eastern Chad there are 12 Sudanese refugee camps. Since 2004, IMC has been providing nutritional support in two of these camps: Mile and Kounoungou. The nutrition situation is precarious with a high prevalence of acute malnutrition. The Global Acute Malnutrition (GAM) has surpassed the WHO ‘emergency’ thresholds in the past, though in 2013 the GAM rate declined in all camps compared to 2010 and 2011 (see graph below). Micronutrient deficiencies are also prevalent; a UNHCR/IMC survey in January 2013 documented a prevalence of anaemia in 6-59 month olds at 52.6% (Mile) and 46.8% (Kounoungou). The refugees in these camps are highly dependent on humanitarian assistance and food aid.

Programme review

Mile refugee campDuring 2010 and 2011, IMC’s nutrition support mainly focused on the treatment of SAM and MAM; however, neither IMC nor other partners were involved in prevention activities or studies to understand the underlying causes of acute malnutrition in the camps.

In 2012 UNHCR, in collaboration with IMC, conducted a causal analysis of acute malnutrition in Mile camp. The causal framework of malnutrition (ACF/UNICEF) was used in addition to select socio-anthropological and health tools to identify the underlying causes of malnutrition. A literature review was conducted, assumptions around underlying causes were identified and discussed in workshops, and information was collected from individuals, focus groups and through observation to triangulate findings. The underlying causes of undernutrition in the camps were identified as a 1) shortage of food (food aid does not cover the refugee’s household food needs for a full month and refugees were selling part of this ration to increase their purchasing power); 2) lack of access to clean drinking water; and 3) lack of knowledge on infant and young child feeding practices.

Routine programme data were reviewed to further understand the situation. Data for the month of January showed persistently high default rates in the targeted Supplementary Feeding Programme (TSFP) and outpatient therapeutic care programme (OTP) as shown in the table 1.

Table 1

Camp

% Defaulters (Jan 2012)
  TSFP OTP
Mile 24.2% (16) 16.7% (3)
Kounoungou 19.2% (10) 17.4% (4)

The defaulter rate was well above the Sphere minimum standard of < 15%. High defaulter rates translate into poor programme coverage as children leave the programme before they have recovered. Non-response may also be linked to default because mothers may decide to discontinue their child’s participation in the programme if they don’t see significant improvement in their child’s well-being.

To investigate why there was such a high defaulter rate, a defaulter study was conducted. The study documented a number of barriers to bringing children to the programme. The most important barriers identified were the need for frequent travel outside the camp to visit family members (in other camps or in Sudan), collecting firewood, and daily waged labour. Other barriers and challenges to attendance included:

Revised programme activities

Following the results from the defaulter assessment, and with the support of UNHCR, the IMC nutrition team focused on the following key activities to reduce the high defaulter and malnutrition rates.

Results

After implementing these activities, the annual default rate decreased as shown in the table 2.

Table 2

 

T-SFP Overall
defaulter rate per year
OTP overall defaulter
rate per year
Camp 2011 2012 2013 2011 2012 2013
Mile 16.3% 12.2% 6.1% 13.1% 10.7% 4.8%
Kounoungou 16.8% 9.5% 4.7% 17.3% 11.2% 7.0%

 

Conclusion

Through a comprehensive review of the programme and investigation into the causes of defaulting, UNHCR and IMC identified the key barriers to achieving better programme coverage and impact. Concrete steps to address these barriers have been taken and the default rate has improved. However, the nutrition situation remains precarious and IMC recognises that there is still much to do to prevent and treat undernutrition in the camps. In May 2012, IMC in collaboration with UNHCR began distributing Nutributter®, a lipid-based nutrient supplement, to children 6-24 months old to prevent acute malnutrition. In addition, IMC plans to continue defaulter tracing and start new activities to further improve infant and young child feeding practices and micronutrient deficiencies.

For further information, please contact Seife Kifleyohannes Temere by email stemere@internationalmedicalcorps.org

Show footnotes

1Children not eligible for the programme are congratulated and the carer is provided with a bar of soap.

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Seife Kifleyohannes Temere (2014). Tackling high defaulting rates in refugee camp settings – lessons from Chad. Nutrition Exchange 4, July 2014. p10. www.ennonline.net/nex/4/en/tackling

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