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Transcript of the podcast : Alert and rapid response to nutritional crises in DRC with Alain Tchamba

Author: ENN
Year: 2017
Resource type: Other

Listen to this podcast in French

AY : Dear listeners, welcome to this ENN Field Exchange podcast. My name is Ambarka Youssoufane, regional specialist for knowledge management in West Africa and at the ENN Centre. Today I am with Alain Georges Tchamba, nutrition coordinator at the NGO International Cooperation, COOPI, DRC (Democratic Republic of the Congo) since 2010. He is responsible for the development, implementation, monitoring, evaluation and capitalisation of nutrition activities within the COOPI NGO in the DRC. Hello Mr Tchamba.

AT : Hello Mr Ambarka.

AY : Thank you for responding to our invitation. I would like to invite you to discuss an article that you wrote recently in our journal Field Exchange entitled "Warnings of and rapid response to nutritional crises in the DRC". To start with, can you tell us a little more about the work of the COOPI NGO in the DRC? For example, explain to us your role as co-lead for the DRC Nutrition Cluster. Do you have links with the SUN Movement or the focal point SUN Government? How do you work with other parts of the government, that is to say the public service? Or the United Nations, for example?

AT : Thank you for your question. First of all I will try to introduce the COOPI NGO. It is a humanitarian, non-governmental, Italian organisation that is secular, apolitical and independent. This NGO was created in Milan on 15 April 1965 by father Vicenzo Babiere. COOPI is involved in several areas, such as nutrition, health, food security, water, hygiene, protection, education and advocacy. COOPI has been involved on several continents: Africa and particularly the DRC since 1970. COOPI interventions are based on emergency and development, but also on the inter-emergency transition and development. To implement the various activities, COOPI is supported by several donors such as the World Bank, the European Union, Eco d'ici, DFID, the Common Humanitarian Fund and some aid services of European embassies, and also the organisations of the UN such as WFP, FAO, UNICEF, HCR and FINAP. So, regarding the interventions of COOPI, the organisation is implementing a project through the various provinces of the DRC and COPI has held the position of co-lead of the Nutrition Cluster since 2013. At this level, COOPI is involved in the planning and design of the humanitarian action plan. We operate within the framework of the SUN movement. We currently have links relating to management of malnutrition. Nonetheless, this consultation framework still does not have sufficiently strong links with the Nutrition Cluster. Outside the centre, at the government level, we are actively involved in capacity-building activities, supervision, monitoring and capitalisation of the projects.

AY : COOPI is involved within the framework of development and emergency-development transition. How do you ensure this transition given that, as you have just mentioned, the consultation framework of the SUN movement is not very functional?

AT : The consultation framework of the SUN movement is still not very functional. All the necessary elements are already in place but in my opinion, there is a delay in terms of personnel. However, the Nutrition Cluster has set up an advocacy strategy to guide the transition from a scenario of emergency food crisis to one of development. Based on this advocacy, realised with the Common Humanitarian Fund, the Common Humanitarian Fund has adopted a multisectoral strategy over the long term, on projects with a duration of 24 months, with the Wash component, food security, health, etc. whose links are related to the multifactorial causes of malnutrition.

AY : You mentioned in your article a dramatic decrease in malnutrition in the DRC. There are nevertheless disparities between regions, it should be noted, but what is the cause of this reduction? We have seen the rate of acute malnutrition drop from 16% in 2001 to 9% in 2014. What do you think explains this reduction in malnutrition?

AT : In 2001, the prevalence of malnutrition was 16%. It was well beyond an emergency situation. Considering the improvement seen since the EDS survey in 2013-2014, with malnutrition at 8%, we have noticed that there has been an improvement in the nutritional status nationwide, despite disparities between provinces. This improvement is attributable in large part to the efforts of the entire humanitarian community, which invests both in treatment and in prevention of malnutrition with a multisectoral approach, knowing that the causes of malnutrition are multifactorial. Specifically, the government's commitment, specific interventions sensitive to malnutrition have acted on the various determinants of malnutrition with consequent improvement in the nutritional status of the population nationwide. When I speak of specific interventions on nutrition, we could talk about support for breastfeeding, promotion of complementary feeding, treatment of malnutrition, not to mention specific measures such as improving access to water, hygiene and sanitation, improving food security, primary health care. These are sensitive and specific interventions in nutrition that have enabled an improvement in nutritional status by acting on the determinants of malnutrition.

AY : You noted that you have a relationship with the director of PRONANUT, the national nutrition program. Could you give us any greater detail on this relationship with PRONANUT?

AT : So with PRONANUT, first, the relationship starts at the level of identification of the nutrition crisis. There is a system for nutritional surveillance, food security and early warnings in the SNSAP cycle that is managed by PRONANUT. It is this body, PRONANUT, at the basis of this system, which identifies the various zones in a state of alert. Therefore, the information system here is based on surveillance sites. Every 2 or 3 months a report comes out with all the zones with warnings. When these zones are identified, depending on financial availability, PRONANUT creates surveys to determine if the warning is verified or not, and as soon as the warning is verified PRONANUT organises a meeting by inviting the partners who have the capacity, or who already have funding in relation to emergency interventions, and zones where the warning was confined will see interventions implemented by these partners. Partners must design the guiding themes of different interventions validated jointly with PRONANUT. Subsequently PRONANUT will intervene in operational matters in relation to strengthening the capacity of health personnel in the health zone. PRONANUT will carry out ongoing supervisions to see how  the management of malnutrition is changing, and finally PRONANUT will carry out an evaluation at the end. Therefore, PRONANUT is involved in the identification of the warning, in the planning of the intervention, in the implementation of the intervention through capacity building, monitoring and evaluation.

AY : Thank you very much Mr Tchamba. Among other things, you have developed several types of approaches, four types of approaches, including monitoring, PUNC, OMNITRITION that you just mentioned, the warning and rapid response project. In all these approaches, which is the institution that has had the most influence in designing the programs? Was it the donors who determined the approach, or you, as an NGO or the government, who had the monopoly on design of the strategy itself?

AT : In terms of nutritional surveillance it is UNICEF, which funds emergencies, which has influenced the development of this system. And to better test the different approaches whether PUNC, OMNITRITION, is always UNICEF that has influenced the development of all this strategy by identifying the boundaries from one strategy to the next. For example, let's look at the warning system based on empirically unproven warnings that later becomes structured into the PUNC approach; the PUNC approach consisted of intervention for a period of 3 months. However, for a period of three months not enough children can be brought on board, we cannot build a good exit strategy, we cannot implement a multisectoral approach.

AY : Just to return to the PUNC approach, what is meant by PUNC, P-U-N-C?

AT : Congo Emergency Nutrition Pool.

AY : Thank you.

AT : Yes, that three months was quite short for the PUNC approach and that the administrative provision was very weak because on average you have 15 to 20 health areas per health zone, so with the PUNC approach we cover 25 health areas. So if you arrive at a health zone which has 25 health areas, it is normal that we cannot solve the problem, we will save lives but we are not going to solve the problem in three months with a single administrative provision even if to compensate for this provision a little by setting up posts that are advanced and mobile posts; despite that, the problem is not solved. So taking into account the limits of the plan, UNICEF has set up the Scaling Up Nutrition strategy. They have said: by intervening over a long period of time, can the prevalence of malnutrition be reduced significantly? And the advantage of this approach was that the project lasted about 18 to 24 months, therefore a maximum of 2 years, and the project was implemented from an appropriate and scientifically verified monitoring system. The approach enabled administrative provision of 100% of the health zone and this approach also enabled not only the members, but also members depending on the geographical WFP strategy to be taken. But the disadvantage we found in this system, given the extent of the Congolese territory is that it became difficult to intervene in other areas of warnings. Also according to analysis, and assessments by UNICEF, which has set up the rapid response approach to nutritional crises, funded by ECHO funds through UNICEF, then we returned to a period of 6 months which is a reasonable length of time in emergency situations. The approach has been implemented from the monitoring system based on the SINSAP in warnings where the nutritional crises identified were genuine nutritional crises. We were asked to cover at least 80% of the health zones belonging to the administrative coverage. In doing this, we were able to better implement a workable multisectoral approach. We directly based this approach on WASH by applying the "WASH in Nutrition" strategy to health zones. So a quick crossover from one approach to the other was made after assessments by UNICEF and its donors. So, the strategy was primarily influenced by UNICEF.

AY : So, UNICEF is the main financial contributor?

AT : Yes, UNICEF is the main contributor and receives ECHO funds.

AY : And in this regard, were you inspired by examples of other countries when developing these approaches when devising these approaches or did you build on your own experience of the DRC?

AT : Well, we take inspiration from what is done elsewhere when we develop an approach, for example what has happened in countries like Mali or the warning system which has been set up in Burundi. For example, in Niger, the system is based on surveys. So, during a specific period, for example the month of June, we conducted surveys in Niger. Following these surveys were able to look at how we could intervene in areas of high nutritional risk to ensure that where there is an emergency, urgent care is provided. And based on this approach, which has been implemented elsewhere by UNICEF, we were able to adapt it to the DRC, while also taking into account the specific features of the country.

AY : You said before that severe acute malnutrition as well as moderate acute malnutrition were treated according to funding provided by the World Food Programme (WFP). How is it that these programs intersected? Is it that there was a bit of a "perfect coincidence", or were they in fact more often than not gaps in the management of cases of moderately acute malnutrition, given that the RSCN approach more specifically targeted severe acute malnutrition?

AT : Yes, the RSCN approach is based on acute and severe malnutrition. Indeed, the criteria required for intervention are based on a mass greater than or equal to 15%, taking into account a deficiency, i.e. a mass greater than or equal to 20%. Priority is given to mass. So we intervene because these are children at a high risk of death given their body mass. However, the project showed an average of 9.5 percent in relation to Nutritional Therapy Outpatient Units where severely malnourished children were treated safely. These units were linked to various Supplementary Nutritional Units, i.e. units treating moderately malnourished children. But, nevertheless, the absence of Supplementary Nutritional Units, in some cases, prolonged the length of the child's stay in the UNTA (Nutritional Therapy Outpatient Unit). The protocol after all recommends that, in the absence of an UNTA, the child remains in the program and leaves when the total healing criteria have been fulfilled, i.e. if we take the weight-to-height indicator greater than or equal to less than 1.5 standard deviation, that means that all children who were with healthcare providers, or in health areas where there had been no intervention by the WFP, left fully treated. Getting back to the involvement of other ministries in a multisectoral approach as part of an RSCN project, since you mentioned your full collaboration with PRONANUT in identifying leprosy, and in designing, implementing, and monitoring the approach, so to what extent are other ministries with a brief relating to nutrition involved? I mean, for example, the Ministry of Agriculture, the Ministry for Social Protection, or, in short, any other ministries which are involved. As part of the RSCN approach, only one ministry is involved at present and that is the Ministry of Public Health. But this Ministry has several divisions: the Nutrition division, and the Water, Hygiene, and Sanitation division. These two divisions are fully involved in the RSCN approach.

AY : But you also run WASH initiatives, was the Ministry responsible for WASH involved?

AT : The Ministry responsible for WASH, here in the DRC, under the aegis of the Ministry of Health. So this is the Nutrition Division I was talking about which is overseen by PRONANUT and the WASH division,  called "B5 or B9" by its founders. So there is the new office 9 and the new office 5 that are in charge of WASH. So, WASH is coordinated by the Ministry of Public Health. We are working with these two divisions, i.e. Nutrition and WASH. On the other hand, if there was a food safety component, we could involve the relevant Ministry.

AY : You estimate, in fact, in the article that just appeared in Field Exchange that about 15 to 20% of the population receives treatment for acute malnutrition cases and only 3-4 health centres offer treatment in each zone, which adds up to about 20. So, has there been an assessment of the treatment coverage or is one envisaged?

AT : Well, there has been no empirical assessment of the coverage on the basis of a survey. But, yes, we have partners who do this. Under the RSCN. We have not conducted these surveys. Nevertheless, when we talk about 15 to 20% of coverage, we mean administrative coverage. As I said, if you have 20 health centres in the health zone, that means five out of 20 areas, a percentage of the coverage, so it's not empirical coverage in terms of the numbers of malnourished children that we could have or could not identify. It is not related, but nevertheless this low administrative coverage is used in the first approach.  In other words, the PUNC approach, where we covered a minimum of 20 health centres but also set them up in order move forward and act in accordance with the law. Secondly, when we saw this limitation in terms of administrative coverage for the approaches which followed, we went over to 100% administrative coverage, and for rapid response we achieved a total of at least 80% administrative coverage. In a nutshell, coverage has not been assessed empirically but there has been a significant improvement in administrative coverage.

AY : By administrative coverage, you mean coverage of health centres providing nutritional care?

AT : Yes, and actually a health centre that looks after nutritional care may cover eight or ten villages. So, this is what is termed a healthcare provider.

AY : And the continued supply of RUTF, that is ready-to-use therapeutic food, to the health services, beyond the six months' rapid intervention, seems to be one of the greatest challenges to the sustainability of managing severe acute malnutrition. Families often are forced to pay consultation fees to cover the salary costs. Have you ever tried anything in particular to solve this nutritional problem?

AT : A constant intervention with a continued supply of RUTF is a big challenge in the DRC. Insofar as RUTF, as you know, is not produced domestically. For a start there are no local factories. There was a factory but it closed later on. Nevertheless, the government of the DRC added RUTF to the list of essential medecines. And it is putting in place several purchasing centres that can easily supply the health zones.

So, in addition, as part of the partnership between the Congolese Government and UNICEF, UNICEF, via PRONANUT,  puts the authorities in touch with incoming stakeholders for health zones in nutritional crisis. But, at a grassroots level, we implemented a number of approaches repeatedly and strengthened the multisectoral prevention strategy. In particular, nutrition-related intervention. During this period, you published several reports on your experiences in the DRC and how this strategy can also reduce the number of malnourished people. To sum up, I would say that the availability of an RUTF supply for the DRC is a challenge. The government, in the first instance, registered RUTF on the essential drugs list in order to help make the purchasing centres depot operational, while most of the stakeholders were made available by UNICEF. And given the scope of the territory, we've prioritised areas with recurring malnutrition problems and new crises.

AY : The government registered RUTF on the essential drugs list; in what year was this entry made? And, has it improved even at least slightly the supply of RUTF in health centres?

AT : Yes, the government registered RUTF in 2012,  I think, if I remember correctly. That is already a good thing to know because RUTF is often not thought of as a drug: but it is a drug, so it was a big step. And that has enabled UNICEF to supply the health centres. Subsequently, the stakeholders made available by UNICEF go through PRONANUT to register and health districts are given drugs for the treatment. So there was an improvement in the sense that health officials understood that RUTF were a medicine and not a peanut paste to be consumed in some manner or other.

AY : So registering RUTF on the list of essential drugs has permitted a greater acceptance and understanding of their usefulness, I would say.

AT : Yes, that's quite right.

AY : So it's always UNICEF that sets up RUTF. But has the government taken a step by including, for example, a budget line or providing support for the purchase of RUTF?

AT : Yes, it has. Currently, in the context of SCALING UP NUTRITION there is a budget line for this activity that also takes into account the treatment of malnutrition and therefore of RUTF.

AY : In fact you had some trouble mobilising funding for certain areas even with malnutrition rates above 15%, didn't you? Can you explain why the SCALING UP NUTRITION project was less flexible than for example than PUNC? And have you tried to draw on the PUNC experience to make the project, make the Scaling Up Nutrition project more flexible?

AT : Well the Scaling Up Nutrition project as I said, intervened in areas with figures greater than 15% or else greater than or equal to 5%. So for a long period of 18 months. Therefore this project allowed for long-term interventions. However, PUNC's adaptability during this stage, within the context of  Scaling Up Nutrition, was such that it was no longer possible to go to another health centre. So because the health zone was already there, the number was determined ahead of time. So what happened was that we were unable to respond to new nutritional crises as they occurred.

AY : But it wasn't due to resource unavailability but rather much more to a programming problem?

AT : Yes, I'll come that. So when I was talking about adaptability, this was due to the fact that the resources did not allow for funding flexible enough to meet the new crises. For example we are told that for Scaling Up Nutrition we already have two million and when you put in the two million, well there was a programming problem and a problem with resources given the duration of the project.

AY : Okay. So, the implementation of a rapid response is usually of short duration. You mentioned earlier a period of six months, after which COOPI was to transfer the management to another institution, notably to the government. However, this did not happen as expected, as only about four out of twenty or twenty-one health zones were able to continue with it beyond the intervention of COOPI. What were the main challenges for this transfer? In the areas where the project was able to continue? Who had taken on the funding, for example? Who took over the funding when COOPI stopped?

AT : We try to attract the attention of various funding institutions given the fact that the health zones, even though we could, and we did support several malnourished children, these health zones always have high admissions. What followed from this observation was that there were other areas with extremely high admissions. And so it was the third or fourth time there were interventions. And given that emergency funds have decreased significantly, we now had to prioritise certain areas. That is how our criteria became the health zones with recurring malnutrition. So we thought if we take action in these areas for 24 months, then what would the situation be in terms of nutrition? That is how the Nutrition Cluster was able to advocate to ECHO, and via the Common Humanitarian Fund, to receive funding for these areas of recurring malnutrition.

AY : In fact you talked about the advocacy that you undertook in conjunction with the Nutrition Cluster; can tell us a bit more about these advocacy activities?

AT : Well for advocacy activities carried out with the Nutrition Cluster, the latter identifies various deficiencies around the country. We have tools for this, and also through SNSAP (Early Warning Monitoring System), and via this system the Nutrition Cluster can draw up reports that are submitted to the national inter-cluster. During the national inter-cluster we try to demonstrate that there is a problem. And that the problems are recurring, so we have to draw attention to that. And then at the strategic coordination level, we also intervene and show presentations to attract the attention of the various financial backers. And through this strategy of advocacy aimed at disseminating the information and showing how critical the problem of malnutrition is, and demonstrating that these actions must occur across all sectors, we have been able to get some funds to help us operate in areas with recurring malnutrition.

AY : So you have made much more use of prevalence and admissions data with the support centres, in order to conduct this advocacy?

AT : Yes. What we did was: 1) first identify the health zones with recurring malnutrition, 2) see which health zones had a very high admission at the end of RRCN intervention. And also, we took into account new alerts, which is how we had to assess the situation.

AY : So what degree of success did you have, for example, with the advocacy? Or what challenges did you meet?

AT : Challenges in the case of advocacy were to convince 1) the donors to fund the health zones where malnutrition was due to structural problems. That was the first challenge. We managed to do that because now, you have one year of high-level intervention financed by the Common Humanitarian Fund located in the western part, where the causes of malnutrition are more structural than cyclical. 2) We had to convince the donor that the duration of project would be at least up to 24 months, so between 15 and 24 months in order for it to have an impact, but also supported by a multisectorial strategy. We fall somewhat within the context of the SUN Movement. Given the empirical evidence and everything else, the donors agreed. So what we had to do was first convince the funders to intervene in the west, and two, to act in recurring malnutrition health zones, thirdly to set up the multi-sector approach, and fourthly, to operate long-term interventions.

AY : So how did the SUN stakeholders contribute to the advocacy? If they didn't participate, do you think they could have done so in some way?

AT : Until now it's the Nutrition Cluster that's done this type of advocacy to the donors, but since we're still at a somewhat hybrid stage and the SUN Movement is slowly being implemented, I think it that the SUN leaders should at least be part of the process. And especially when you see that the members of the Nutrition Cluster are part of the SUN Movement. So advocating from the Nutrition Cluster to the donors is already a a bit like advocating for the SUN Movement. So in future this should be formalised.

AY : OK. In fact the SUN stakeholders are almost identical to the Nutrition Cluster ones.

AT : Yes, almost to 80%.

AY : Okay. So now I'd like to come back briefly to the overall strategies for nutrition across the country, particularly the plan of action for nutrition in the DRC. Is there already a common results framework, as suggested by the SUN Movement?

AT : Yes. We've developed a national multisectoral strategic plan for 2015 to 2020 in response to the need for a multisectoral approach to fighting malnutrition in the DRC, and as part of the vision of the DRC as an emerging nation with a view to 2030. This strategic plan is driven by the Office of the Prime Minister and I think you know already that it sometimes manages its multisectoral strategies well, initiating relevant intervention in various sectors, and directing actions that bear results. Today, as regards the common results framework, I think that these results were achieved, I believe, in 2015 or 2016, which allowed us to see how far the SUN Movement has been implemented.

AY : Does this action plan take into account a continuation of the support for acute malnutrition beyond humanitarian intervention?

AT : Indeed, the management of acute malnutrition beyond humanitarian actions is an integral part of the national multisectorial action plan for nutrition. Different means of funding should be found in order enable continued support for malnutrition across the territory. There are for instance initiatives which I think are being taken, such as bringing private companies or politicians to commit, for example, to the fight against acute malnutrition in their micro-projects at the parliamentary level, or within companies.

AY : Alain Tchamba, thank you once again for sharing with us your experience of the alert and rapid response to nutritional crises in the DRC. I wish you the very best for your ongoing work and hope to have another chance to talk with you. I also thank our listeners for listening to this podcast, which is part of a series of podcasts initiated by ENN to support our multi-media knowledge management site. As always, we look forward to welcoming your contributions and experiences in the field of acting for nutrition. If you have any further questions don't hesitate to send us an email at nutritionexchange@ennonline.net, or visit our website at www.ennonline.net.

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