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LEARNING REVIEW 2019 ii LEARNING REVIEW 2019 1

INTRODUCTION

Learning is the transformative process mistakes we have made as it is to learn This publication would not be possible that turns information into knowledge. from our successes. without the valuable contribution of Continuous learning, reflection and our staff from across Action Against Following positive feedback last year, adaptation is critical to building Hunger, whose commitment to sharing we have structured this year’s learning knowledge and evidence. Through experiences is a clear demonstration of review around the five stages of the collectively capturing and sharing the importance they place on learning programme cycle. In order for us to knowledge we are enabled to build on and knowledge exchange. We hope to continuously improve the delivery of what we have learned, and increase inspire dialogue through sharing this our programmes, it is essential for the quality of our work. portfolio, and above all, to facilitate learnings to be gathered at every knowledge exchange and uptake. At Action Against Hunger we are stage of this cycle. committed to making learning a core part of our culture. We strive to develop ways to make learning and evidence from practice easily NEEDS ASSESSMENT accessible, enabling us and others to & ANALYSIS improve and design higher quality and S more accountable programmes. ES N D E R A P The Learning Review is an annual E R publication providing staff across P MONITORING STRATEGIC Action Against Hunger with a platform & EVALUATION PLANNING to share their learning and reflections COORDINATION

from a diverse range of projects, INFORMATION

MANAGEMENT A

D

research and experiences. V

O

C

A

C In addition to outlining best practices, Y the learning review highlights challenges encountered and how our teams have learned from these IMPLEMENTATION RESOURCE experiences. We believe that it is MOBILISATION equally as important to learn from the Left: the programme cycle

Cover image © Christophe Da Silva for Action Against Hunger 2 LEARNING REVIEW 2019 3

CONTENTS ACRONYMS

INTRODUCTION 1 BMZ Federal Ministry for Economic Cooperation MHPSS Mental health and psychosocial support and Development (Germany) ACRONYMS 3 NFHS National Family and Health Survey NEEDS ASSESSMENT AND ANALYSIS 5 BDM Becker-DeGroot-Marschak lottery NGO Non-profit organisation KEY LESSONS FROM BASELINE SURVEY AND WAY FORWARD FOR THE FIRST-1000-DAYS PROGRAMME IN INDIA 5 BFS Baby Friendly Space THE RESEARCH 4 ACTION (R4ACT) METHODOLOGY: HOW CAN RESEARCH INFORM OUR PRACTICES? 8 PDSEC Social, economic and cultural development WILLINGNESS TO PAY: IMPROVING ACCESS TO SAFE DRINKING WATER IN HAITI 11 CEPEDRENAC Coordination Centre for Natural Disaster programmes Prevention in Central America STRATEGIC PLANNING AND RESOURCE MOBILISATION 14 PDP Psychological Distress Programme BUILDING RESILIENT TOURISM IN CENTRAL AMERICA 14 CMAM Community Based Management of Acute PLW Pregnant and lactating women LOCAL ADVOCACY SOLUTIONS IN THE SAHEL 18 Malnutrition STRENGTHENING RESILIENCE THROUGH CROWDFUNDING IN SOMALIA 21 DHS Demographic and Health Survey R4ACT Research 4 Action IMPLEMENTATION AND MONITORING 24 DRM Disaster Risk management R4NUT Research 4 Nutrition INTEGRATING A PSYCHOLOGICAL DISTRESS PROGRAMME ALONGSIDE NUTRITION SERVICES - GAMBELLA, ETHIOPIA 24 BABY WASH AND PROTRACTED DISPLACEMENT: LESSONS LEARNED FROM NANGERE LOWER GOVERNMENT AREA, NIGERIA 27 DRR Disaster Risk Reduction RRT Tech Rapid Response Team PEER-REVIEW AND EVALUATION 29 FGD Focus group discussion SAT Safety Audit Tool MITIGATING AND PREVENTING GENDER-BASED VIOLENCE IN OUR FIGHT AGAINST HUNGER 29 GBV Gender-based violence SITCA Secretaría de Integración Turística IMPROVING SOCIAL INCLUSION PROGRAMMES THROUGH QUALITATIVE RESEARCH 32 Centroamericana GBV RISK MITIGATION AT NUTRITION SITES: HOW SAFETY AUDIT TOOL IS USED AS A PLATFORM TO MITIGATE GBV RISKS AT NUTRITION 34 GNC Global Nutrition Cluster SITES IN SOUTH SUDAN UNHCR United Nations High Commissioner for Refugees HS Household survey COORDINATION, INFORMATION MANAGEMENT AND PREPAREDNESS 38 UNICEF United Nations Children’s Fund CAN CARE GROUPS IMPROVE HEALTH SEEKING BEHAVIOURS? RESULTS OF AN IMPACT EVALUATION IN NORTH-EASTERN NIGERIA 38 IHC Integrated Health Centre THE EMPLOYABILITY INTEGRATION APPROACH: INTEGRATING MENTAL HEALTH AND PSYCHO-SOCIAL SUPPORT WITH EMPLOYABILITY 41 URENI Unit of Recovery and Severe Ambulatory INP+ Multi-sectoral nutrition programme Nutritional ducationE ACKNOWLEDGEMENTS 50 IYCF Infant and Young Child Feeding VHP Volunteer hygiene promoter KII Key informant interview WASH Water, Sanitation and Hygiene LGA Local Government Area WFP United Nations World Food Programme LBW Low birth weight WHO World Health Organization MEAL Monitoring, Evaluation, Accountability and Learning 4 LEARNING REVIEW 2019 Needs assessment and analysis 5

NEEDS ASSESSMENT AND ANALYSIS KEY LESSONS FROM BASELINE SURVEY AND WAY FORWARD FOR THE FIRST-1000-DAYS PROGRAMME IN INDIA

Dr Pawankumar BACKGROUND AND CONTEXT to child malnutrition, 50% (NFHS CMAM intervention strategy, it was Patil 2015-16) of pregnant women suffer necessary to understand the factors Technical Director A Lancet study by Black et al. (2013) from maternal anaemia. This, coupled contributing to the high prevalence India estimates that 40 to 50 million with poor nutrition, affects the of maternal and child malnutrition. Disability Adjusted Life Years (DALYs) foetus during pregnancy, resulting in A baseline survey was therefore Gyanika are lost to wasting in India; costing an Narayanaswamy malnutrition such as low birth weight conducted in Rajasthan, Madhya Documentation economic loss of almost US$48 billion or small for gestational age. Poor Pradesh and Maharashtra to ascertain and Research in lifetime loss of productivity. As per Infant and Young Child Feeding (IYCF) the prevailing knowledge, attitude and Consultant India’s National Family and Health practices further contribute to the high practices associated with malnutrition. India Survey (NFHS 2015-16), 21% of the levels of child wasting and stunting. To population were affected by wasting, prevent malnutrition from manifesting METHODOLOGY 38.4% had stunted growth and 35.8% in children from birth, it is important The baseline was designed for of children under the age of five were to begin interventions with pregnant pregnant women, lactating mothers underweight. and lactating women. Therefore, in with children aged six months, and addition to working with children Action Against Hunger India first lactating mothers with children aged from 6-59 months through CMAM, it began its work with rural and urban from one to two years. The sample became imperative to incorporate the slum populations in India through size for the baseline was calculated © Lys Arango for Action Against Hunger Against Action for © Lys Arango first 1000 days approach to achieve Community Based Management of using the prevalence rates of three key sustainable impact on maternal and Acute Malnutrition (CMAM). CMAM nutrition and health indicators from child health and nutrition outcomes. focusses on identification, treatment the NFHS 2015-2016: and prevention of malnutrition after In order to develop Action Against the age of six months. In addition Hunger India’s first 1000 days plus 6 LEARNING REVIEW 2019 Needs assessment and analysis 7

1. Children aged 12-23 months fully (40% or higher), lack of exclusive breastfeeding WAY FORWARD FOR THE FIRST 1,000 immunised (BCG, measles, and three doses and low uptake of ante-natal care. Dietary DAYS PROGRAMME WITH CMAM each of polio and DPT) (%) diversity in women and children was reported The findings from the baseline survey are now to be almost inexistent with a prevalence in the 2. Children under age six months exclusively paving the way for Action Against Hunger range of 1% - 9%. Poor hygiene and sanitation breastfed (%) India’s revised strategy for the first 1,000 behaviours were reported, with an average days with CMAM. It has brought to light the 3. Mothers who had at least four antenatal of 91% mothers reporting unsafe methods of

practices to be improved for better maternal Hunger Against Action for © Lys Arango care visits (%) stool disposal for their children, and less than and child nutrition and health outcomes. It half of the mothers practicing handwashing The survey questions investigated became clear that the programme should before feeding, or after cleaning their child. The demographic and socio-economic status, incorporate Kangaroo Mother Care, a WHO wasting prevalence ranged from 10% - 40% for access to hygiene and sanitation, knowledge recommended practice which involves holding India Hunger Against © Action the three states, showing a diverse range in the and practices on maternal, new-born and the new-born to the caregiver’s chest for a magnitude of child malnutrition. child nutrition and healthcare, and access to prolonged period of time. The baseline has also government schemes. The tool was pilot tested It was interesting to find that low birth weight, raised the need to find the reason behind the Community mobilier to ensure its relevance and validity. To ensure anaemia prevalence, uptake of ante-natal care, high anaemia rates and the low prevalence of arising challenges are resolved in a timely conducting the baseline exclusive breastfeeding, diet diversity and diet diversity. An in-depth understanding on with sample beneficiaries and appropriate manner, communication and WASH practices were reportedly poorer in the the knowledge levels and behaviour patterns documentation was conducted on WhatsApp. baseline in comparison to those projected by surrounding diet and nutrition existing in the government health surveys. community is required to attain sustained KEY FINDINGS AND LESSONS LEARNT impact in the long-run. activities continue to be poor. role in household level health and Despite the availability of Migration of the beneficiaries from the Therefore, innovative strategies in nutrition decision-making. Where government health and nutrition In all three states, despite diverse geographies, sampled villages posed an operational Maternal nutrition has a direct impact on the area of WASH, in collaboration possible, baseline interviews were schemes and services, access, uptake many indicators were similar. Indicators such challenge. In order to account for loss of the new-born and continues to influence the with the government, will facilitate also conducted with husbands or and service delivery remains limited. as prevalence of institutional delivery, early sample size due to migration, the current child’s diet and nutrition as the child grows improved adoption of good hygiene fathers. The preliminary findings from Collaboration with the government registration of pregnancies at health facilities estimated prevalence of migration was older. Though nutrition lays the foundation and sanitation practices that can the baseline suggested that men at each step, at the facility and the and early initiation of breastfeeding were found considered as the non-respondent rate. In for a child’s health, physical and cognitive prevent the spread of infections, and have similar levels of awareness as community level, will be required to to be performing better than others. While addition, while conducting the baselines, development and in preventing malnutrition, assist in breaking the disease cycle of women. Considering these findings, increase availability and access to Action Against Hunger India’s collaborative women were often unavailable to participate other factors such as hygiene and sanitation malnutrition. it would be important to understand health and nutrition services. work with the government during the CMAM in the survey, as they would leave to work also influence the child’s vulnerability to the knowledge, attitude and project has facilitated gradual improvements in the fields. In order to overcome this, the malnutrition. The baseline findings revealed Traditionally, nutrition and health practices of husbands and fathers The process and findings of the in some of these indicators, considerable community mobilisers would conduct the that certain practices such as safe disposal For more information programmes have women as in relation to health and nutrition. baseline have raised critical lessons work is still required to decrease malnutrition baseline survey with the women in their farm of stool, use of constructed toilets (home- contact: their main target for awareness Simultaneously, it becomes essential on programme implementation, in women and children in India. The survey fields. based or community), access to safe water, ppatil@ and behaviour change. However, to progressively include them as part systems that require improvement highlighted high levels of maternal anaemia actionagainsthunger. and handwashing practices during critical husbands and fathers along with of the programme implementation. and areas of opportunity to maximise (80% or higher), low birth weight in new-borns in mothers-in-law play an important impact. 8 LEARNING REVIEW 2019 Needs assessment and analysis 9

• Moderate evidence showed the positive At the end of the workshop, participants THE RESEARCH 4 ACTION (R4ACT) METHODOLOGY: impact of water quality at household selected the activities that their organisation level during the treatment phase of Acute would commit to implementing in their HOW CAN RESEARCH INFORM OUR PRACTICES? Malnutrition. programmes. Participants requested official • Consistent evidence showed no association ACTIVITIES AT THE HEALTH FACILITY sign-off of the report from senior management. between the presence of improved LEVEL Quarterly calls to follow up on the roll out of equally and consistently considered technical advisors jointly defined a Alan Ricardo BACKGROUND household latrines and the prevention of the roadmap will be organised over the year. Patlan throughout the process. The R4ACT list of specific ater,W Sanitation and Acute Malnutrition. • Improve water systems in health Hernandez After decades of interventions, the topic is decided collegially based on Hygiene interventions, referred as facilities Epidemiology need for improved integration of HOW WILL THESE FINDINGS ENHANCE relevance, priority and possibility to indicators, on which they needed STAGE 2. MOVING BEYOND RESEARCH: OUR PROGRAMMING? Analyst the latest available evidence into have actionable results. It involves a evidence in order to assess their PAVING THE PATH TO PRACTICAL • Systematically coordinate delivery of France humanitarian programming is now cross-sectorial needs assessment of impact on Acute Malnutrition. CHANGE household water treatment adapted to The summary of the scientific evidence recognised by all, including the Dieynaba the programmatic areas of interest and Engaging both sectors in this exercise context with Severe Acute Malnutrition complemented by the outcomes of the The R4ACT methodology uses a qualitative S N’Diaye international community. However, explores the impacts of one sector on is essential to ensure indicators management workshop, will allow all the relevant approach for stakeholder engagement. Rather Research and the quality and quantity of the current another. respond to key questions of ob th stakeholders to make decisions, design than reaching a large number of actors, a limited • Water, Sanitation and Hygiene experts Analysis Advisor evidence on health interventions in sectors and to improve integration and implement programmes based on the but diversified and qualified panel of actors train health centre staff to: a) run France humanitarian contexts is still limited. The first pilot, launched in 2017, between Water, Sanitation and best scientific evidence available, which is was invited to a one-day workshop in Paris. health centre water systems and b) Many questions are still pending to focused on the impacts of cash on Hygiene and Nutrition. fundamental to increase the efficiency and Stephanie Stern bridge the gap between research and Severe Acute Malnutrition while The panel was composed of technical advisors build caregiver capacity on correct use Action Against effectiveness of interventions. R4ACT also the 2019 pilot explored the impacts A review of the available scientific from a variety of NGOs and global clusters, of household water treatment products Hunger Knowledge programming. reviews current gaps in knowledge and will LAB Advisor of Water, Sanitation and Hygiene literature was then performed by with equal representation from Nutrition and ACTIVITIES AT THE HOUSEHOLD LEVEL advocate for research in programmatic sectors France METHODOLOGY interventions on Acute Malnutrition. a researcher in collaboration with Water, Sanitation and Hygiene sectors. The in which evidence is still scarce. This article will detail the results of the uptake advisor to make sure the purpose of the limited but diversified audience • Develop behavioural change on water Action Against Hunger the 2019 pilot and explore the various report was a practical document is to keep the process flexible and dynamic treatment in areas covered by Severe France developed the R4ACT WHAT DID WE LEARN ABOUT THE R4ACT stages of the methodology. providing a ready to use summary of while still taking into account various points of Acute Malnutrition treatment services (Research4Action) methodology in PROCESS? the existing evidence. view, which fosters constructive discussion and 2017. It provides methodological • Use of participatory methodology to STAGE 1. WHAT DOES THE facilitates transversal collaboration. The R4ACT pilots proved to be a very promising support to embed scientific evidence select the most appropriate household EVIDENCE SAY ABOUT THE KEY FiNDiNGS methodology to bridge the gap between into programming and advocacy. This IMPACT OF WATER, SANITATION Based on the findings of the review, participants water treatment method research and action. Its main strengths are method actively engages programme, • The review highlighted the lack of were requested to translate the evidence AND HYGIENE ON ACUTE • Improve information, knowledge and threefold: For more research, and uptake teams in all MALNUTRITION? COLLATING robust evidence on the majority into concrete, practical actions that teams information of indicators and the crucial need data sharing The process takes approx. 2 months stages of the research, from framing PROGRAMME-FOCUSED could implement to reinforce comprehensive 1. TIME contact: for more research on the relation for the literature review and report editing, the research question to incorporating programming on water quality. The group sstern@ EVIDENCE. between Water, Sanitation and followed by a one-day workshop, and actioncontrelafaim. scientific evidence into programmes, Hygiene interventions and Acute endorsed six key activities: regular follow-ups of the action plan roll so that the three perspectives are During stage 1, Water, Sanitation and org Hygiene, and Nutrition and Health Malnutrition. out), inclusiveness and the fact that it is action focused. 10 LEARNING REVIEW 2019 Needs assessment and analysis 11

2. INCLUSIVE The researcher’s input is starting discussions on a common work the implementation of activities. crucial in the first stage of the process to plan. WILLINGNESS TO PAY: IMPROVING ACCESS TO SAFE guarantee the robustness of the approach • Cascading the information to the field while the technical expert ensures the • Action Against Hunger launched the TISA and ensuring that the people in charge programmatic relevance of the questions research project, aligned with key R4ACT of implementing the activities commit DRINKING WATER IN HAITI explored. Inclusiveness is also achieved by findings regarding the quality of water. to implementing the action plan remains a challenge. Technical teams from the systematically choosing a cross-sectorial • Advocacy teams in West Africa drafted topic to improve integration. field should play a more active role in the Karlotine Weshe ACCESS TO SAFE DRINKING vulnerable Haitians in the short and their advocacy strategy based on R4ACT process. recommendations. Head of MEAL WATER IN HAITI medium term. 3. ACTION-FOCUSED The R4ACT process Haiti can only achieve behaviour change if efforts • The definition of indicators is important Over the past 10 years, Action • Other R4ACT participants besides Action to monitor progress. Holding participants EXPERiMENT iN PROMOTiNG are made to ensure recommendations are Against Hunger have integrated R4ACT Against Hunger has been working disseminated within the teams and if they accountable to these indicators remains a HOUSEHOLD WATER TREATMENT recommendations into Health and Nutrition challenge. to facilitate access to safe drinking are integrated in new proposals, strategies, strategy revisions, COVID-19 response water in vulnerable communities in From June 2018 to February 2019, interventions and advocacy. plans, new proposals, joint assessment The next pilot will therefore explore ways to Haiti, particularly in cholera-prone Action Against ungerH implemented a questionnaires, etc. better engage field operations from the outset. areas. Our work includes water project funded by UNICEF to promote WHAT HAS ALREADY CHANGED? We are planning to scale up the methodology point construction, water point home water treatment. The strategy • The findings of the review were presented WHAT STILL NEEDS TO BE DONE? thanks to its very simple pattern: what do rehabilitation, supply of drinking revolves around two main axes: in two international scientific conferences: • It is important to have a person responsible we know? What should we do? How can we water and promotion of home water distributing fully subsidised coupons University of North Carolina, and Research for moderating the discussion at the internal change? The adoption of R4ACT reinforces the treatment. These initiatives stem to users of unsafe water points for the 4 Nutrition (R4NUT) level as well as with other organisations that overall learning culture of our organisation, from the fact that the country’s poor acquisition of a home water rt eatment • The Global Nutrition Cluster and the Water, take part in the R4ACT workshop to ensure which has a strong positive impact on the access to drinking water is conducive solution/Aquajif, and supporting the Sanitation and Hygiene cluster are kick- that both sectors continue collaborating on quality of services delivered. to water-borne diseases and thus vendors of water treatment products. increases the risk of malnutrition. The intervention reached 8,048

According to the results of the beneficiaries with the involvement Hunger Against Action for Lucien © Jhemson Mortality, Morbidity and Service Use of 10 vendors. As a first step, Action Survey (EMMUS VI, 2016-2017), only Against Hunger gave a bottle of Aquajif 60% of the Haitian rural population has to households in order to familiarise access to improved water sources and them with this product and its use. the prevalence of diarrhea is 20.6% Then, each beneficiary received two © Stéphanie Stern for Action Against Hunger Against Action for Stern © Stéphanie for girls and 21.8% for boys under the coupons covering the entire price of age of five. Due to the impossibility a bottle of Aquajif in order to connect of supplying all areas with hydraulic households to their nearby retailers. infrastructures quickly, Action Against The coupon distributions were coupled Hunger is relying on home water with awareness sessions to treatment to improve the situation of 12 LEARNING REVIEW 2019 Needs assessment and analysis 13

encourage purchase and use of Aquajif after However, a study conducted in February 2019 These key lessons prompted us to conduct HOW TO ACHIEVE BETTER RESULTS? UNICEF, the project’s donor, organised a lessons the intervention. The results of the final survey showed that availability and access are the main a post-intervention follow-up survey three learned workshop with different partners they showed that the majority of the targeted factors in the use of these products and that months after the project. From March 2019 to are funding in the WASH sector. This study population had adopted the use the water the willingness to pay for a bottle of Aquajif May 2019, Aquajif vendors sold a total of 45 Social marketing has showed that in any intervention aiming treatment product. During this survey, 77% is actually less than 57 gourdes. This study bottles combined. The people who frequent to increase the use of home-water treatment of the households visited underwent a test used the Becker-DeGroot-Marschak (BDM) the outlets are mostly former beneficiaries. products, special attention should be given to for residual chlorine in drinking water (a sign lottery, an experimental method, to avoid Assuming that each of these 45 bottles was the restocking of the points of sale and the that the water has been treated). Results show reporting bias. BDM’s exercise consists of a free bought by a different beneficiary, only 0.56% of retention of users. These learning exercises that the beneficiaries didn’t use the correct lottery game, in which respondents have the the beneficiaries continued to buy the product. PRODUCERS Sensitisation / promotion fuelled the design of a new project. Building on dose of the product. Only 45% of the tests opportunity to buy the product at the maximum They understand the health benefits of treated lessons learned, the new project will feature: showed an appropriate residual chlorine level price they wish to pay for it. This method puts water and they use domestic water treatment WHOLESALER • A social marketing strategy that makes between 0.5-1g/L. However, traces of chlorine the consumer in a real situation of purchase. products when they are given free of charge. use of declining vouchers in order to in drinking water were found in approximately The results suggest that users are willing to pay However, they do not buy them, even when RETAILERS progressively acclimatise users to buying 70% of beneficiary households, up from 43% of between 32 and 35 gourdes for the bottle (its they are available nearby. roct home water treatment products. households at the baseline. The vast majority of selling price is 50 gourdes). USERS households report treating 2 to 3 buckets of 25 • Continuous awareness and promotion Money liters of water per day. 32% of beneficiaries said activities outside the project period. they wanted to integrate this product into their • The establishment of a framework household’s current expenses and are prepared agreement between the producer of Aquajif to spend 57 gourdes on average to get a bottle NGO Sensitisation / promotion and Action Against Hunger in order to (the price is 50 gourdes). guarantee price stability. • Stronger connections between wholesalers and retailers of water treatment products. Figure 2: Distribution chain of home water

© Christophe Da Silva for Action Against Hunger Against Action for Silva Da © Christophe treatment products. 70% Endline Baseline For more information contact: rddmeal@ht- Community Figure 1: Presence of chlorine in drinking water actioncontrelafaim. sensibilisation on org (Source: Endline) water treatment 14 LEARNING REVIEW 2019 STRATEGIC PLANNING AND RESOURCE MOBILISATION 15

the last two years, interventions have been plans from private companies to withstand the some of the project’s activities, such as the implemented around four axes: impact of disasters, which would put business minimum standards for the certification of STRATEGIC PLANNING AND continuity, jobs and development at risk. “resilient hotels” and the creation of a “pilot” • Assessment of the existing risks award to companies that are committed to One of the challenges we faced was the • Improvement of the public-private capacity Integrated Risk Management and Disaster Risk RESOURCE MOBILISATION for disaster prevention and mitigation preconceived notion that entrepreneurs and Reduction in Guatemala. the general population erew already resilient, • Improvement of Disaster Response and that building additional resilience would Public and private partnership and DRR BUILDING RESILIENT TOURISM IN CENTRAL AMERICA Preparedness be too costly. The greatest challenges have interventions from the tourism sector • Promotion of resilient and sustainable been to achieve a change in the behaviour of are an example of regional integration tourism business people concerning responsibility that has favoured i) the protection of life; Luis Rolando MULTI-THREATS AND (DRR) practices. The main tourism this approach to the tourism sector by and commitment to civil society, and for ii) the improvement of the quality and Sánchez VULNERABILITIES destinations are in areas with a low connecting the national Chambers of This project has been developed in alliance state entities to strengthen their work in competitiveness of tourism enterprises; iii) DRR & Agro- culture of disaster preparedness. Tourism with civil protection bodies with the National Chambers of Tourism Central America is the world’s second collaboration with the private sector. the collective multi-stakeholder support; iv) Climate Additionally, the tourism sector in to generate coordination for the of Guatemala (CAMTUR) and Nicaragua most vulnerable region to adverse the promotion of investment with resilient Coordinator the region has no history of inter- development of resilient tourism in (CANATUR), Universities (UNAN-UNI), The project created spaces for coordination Central America climate and geological hazards and parameters and; v) the promotion of disaster institutional coordination on DRR four pilot areas. Governing Bodies in charge of DRR, tourism between the tourism and civil protection Programme is therefore constantly exposed to risk reduction from public and private issues. entrepreneurs, Municipal Governments and sectors and trained members of civil society investment as a contribution to sustainable multiple threats. Tourism is a major The eruption of the Volcano Fuego regional governmental bodies (SITCA and on DRR and disaster risk management (DRM) economic development. Arlen Martinez driver of the economy and is highly PUBLIC-PRIVATE PARTNERSHIP in Guatemala led to a number of CEPREDENAC). It represents an example of issues. Local and national authorities also DRR sensitive and vulnerable to the AND DRR APPLIED TO THE joint initiatives between the public collaborative, holistic and multidimensional joined the trainings in the aim of contributing Sharing good practices and experiences in Coordinator expectations and confidence of visitors TOURISM SECTOR and private sectors in recovery and work that has managed to improve resilience in to safe and resilient tourist destinations in dialogue spaces before regional bodies such Nicaragua in the event of a disaster. Indeed, reconstruction processes, which Central American destinations. inter-institutional coordination. as the Central American Tourism Integration Action Against Hunger in Central beyond the most direct humanitarian highlighted the importance of Secretariat (SITCA) and Coordination Centre America and its’ partners developed We learned that the recognition and inclusion impact of disasters, their occurrence coordination in implementing resilient WORKING TOGETHER TOWARDS for Natural Disaster Prevention in Central a response plan to address this could damage the reputation of the practices. RESILIENCE of all stakeholders is key to establishing America (CEPEDRENAC) has contributed problem. Climate and geological tourist destinations, with negative strategic public - private alliances to save to strengthening processes of adoption of disasters affect communities that Since 2000, Action Against Hunger The initial alliance between the tourism and effects on livelihoods and the local lives, prevent and reduce losses, ensure rapid DRR initiatives for the tourism sector with a completely depend on the tourism has worked to promote DRR by civil protection sectors revealed a lack of economy. In recent years, the region recovery of the affected area, its population view to future replication, consolidation and sector for their livelihoods. Loss of this including innovative approaches from mutual knowledge between both areas of has faced Hurricane Otto, Hurricane and livelihoods. sustainability. Nate and the eruption of the Fuego source of revenue will undoubtedly the private sector. The organisation’s work in the countries, particularly when faced accumulated experience has been Volcano, which all caused human drive swathes of the population with a hypothetical emergency or disaster in PUTTiNG REGiONAL iNTEGRATiON iNTO THE FUTURE OF TOURISM RESILIENCE into poverty. Action Against Hunger key to the development of DRR tourism destinations. On one hand, there was PRACTiCE For more losses and significant material damage. has been working under a Public in Guatemala and Nicaragua to no coordination mechanism for emergency and The coordination between these sectors has information These disasters particularly affected Following these initial trainings, the governing Private Partnership model in Central strengthen the resilience of the most disaster response in these communities, and opened the door to a new stage of tourism in contact: tourist destinations with fragile body of civil protection in Guatemala replicated analetilic@ knowledge of Disaster Risk Reduction America since 2015. We expanded vulnerable tourism destinations. In on the other hand, there were no contingency the region. For instance, the regional entity for ca.afcspain.org 16 LEARNING REVIEW 2018 STRATEGIC PLANNING AND RESOURCE MOBILISATION 17

Risk and Disaster Management in Central America and the Dominican Republic has LOCAL ADVOCACY IN THE SAHEL included the issue of risks in its minimum quality standards of the sector, and scaled it up to the Central American Tourism Menna Seged CONTEXT sustainable investment in the delivery Integration System. DRR standards Abraha A of services related to food safety presented by Action Against Hunger, Advocacy Officer Action Against Hunger has been and nutrition. This approach often the National Chambers of Tourism and West Africa present in the sub-region (Mali, involves strengthening the technical, Civil Protection, were adopted and Spain Mauritania, Niger) for fifteen years1, managerial and financial capacities recommended for implementation in implementing multi-sectorial projects M - Amadou Bousso of key decision-makers at the local tourism zones. Advocacy that aim to reinforce resilience within level during workshops held in Mali, Coordinator communities for the prevention and The Guatemalan Chamber of Tourism Mauritania and Niger. Mauritania treatment of malnutrition. prioritised creating spaces for discussion IN MALI around resilience. Even after the Djaffra Traore The main challenge Action Against F D closing of the project, it continued to Advocacy Hunger faces in the region is that of Since 2017, Action Against Hunger open new spaces for DRR discussion Coordinator ensuring the continued delivery of has undertaken advocacy actions in with government entities. It presented Mali services related to food safety and partnership with the National Federation the topic at world forums alongside Lucile Hermant nutrition. To overcome it, our efforts of Community Health Associations at the Ministry of Tourism, such as the Advocacy Officer are twofold. First, we ensure that ADVOCACY CENTRED ON the national and local level in order International Tourism Fair held in Madrid Niger nutrition is systematically integrated COMMUNITIES to advocate in favour of sustainable in January 2020. At the local level, into communal development plans investment towards the continued Action Against Hunger uses a 5-step tourism destinations have adopted tools and budgets, and we support the delivery of services related to food methodology to conduct an in-depth for territorial and business planning that implementation of a multi-sectorial safety and nutrition by local authorities. analysis of the socio-economic and allow them to improve their disaster response at the decentralised In 2019, thanks to our advocacy work, health situation of local communities. preparedness. The sector’s heightened level. Second, we support the 53 communes in the Kayes region Together with town councils and vulnerability to disasters has contributed formulation and implementation of integrated nutritional security into other partners in the area, plans, their social, economic and cultural and increasingly coordinated a proactive multi-stakeholder dialogue at the policies and budgets are analysed development programmes (PDSEC). For approach to planning, training and regional level, and advocate for the example, the commune of Gadougou © Action Against Hunger Against © Action inclusion of nutrition in budgets with in order to identify underlying preparing tourism destinations. We built two maternity wards, and recruited will continue exploring public-private parliamentarians. deficits, as well as opportunities for partnerships in future projects to build on these lessons learned around maximising 1 In Mali, in the Kayes region, these interventions started with Kita Cercle (2007) before reaching Kayes Cercle (2016) and Bafoulabé stakeholder engagement and project Cercle (2018). In Mauritania, Action Against Hunger is present in Guidimakha, Nouakchott, Hodh El Charghi and Gorgol. In Niger, impact. interventions have been deployed in Tahoua, Maradi and Diffa since 2005. 18 LEARNING REVIEW 2019 19

two obstetric nurses, while the commune of municipality of Tchaké covered the costs of commune of Tabotaki and the construction of Sefeto-Nord built a structure for the care of water supply for its IHC. The health evacuation treatment rooms in the commune of Tamaské. children admitted to the nitU of Recovery and system particularly benefited from this increase Severe Ambulatory Nutritional Education (URENI) in financing, reaching up to CFA 1,900,000 per Faced with the reluctance of some local elected within the community health centre. municipality (€2,900). officials to seek alternative sources of funding, an inter-municipal meeting was organised, during This unprecedented success was made The main challenge was that the majority of local which the communes presented the challenges possible thanks to the strong mobilisation elected officials did not master the methodology they faced in terms of recovering funds, of all stakeholders in the process, such as for developing and reviewing PIAs. Action monitoring, and carrying out activities, as well municipalities, local media, community nda Against Hunger therefore organised trainings in as the solutions they had put in place to remedy district health centres, and administrative and planning and budgeting that were provided by them. Some communes were thus able to serve technical authorities, including mayors. the decentralised directorates of the Ministry of as models to others. Planning. This peer-to-peer capacity building has LOCAL ADVOCACY COMPLEMENTS proven to be sustainable as local actors who have THE DIFFICULTIES OF DECENTRALISATION

NATiONAL EFFORTS concrete experience of cooperation between AND THE CHANGING POLITICAL Hunger Against Action for Bagaya © Apsatou different levels of governance will then replicate LANDSCAPE In Niger, at the national level, Action Against it on other occasions. Hunger worked with the Ministry of Public Health In Mauritania, despite several notable advances, to elaborate a roadmap for the resumption of strong partnerships with the network of women INNOVATIVE SOURCES OF FINANCING parliamentarians and mayors’ associations; National Protocol for Integrated Management TO MOBILISE RESOURCES of Malnutrition (PCIMA) activities by the state. commitments made by mayors following inter- This document provides for the implementation To compensate for the limited resources of communal workshops, significant challenges of coordinated recovery plans between the communes in Niger, a campaign of mobilisation remain. authorities and humanitarian actors. Within this of good will was launched with town councils. context, advocacy actions carried out at the Representatives of diasporas, the private sector, Decentralisation in Mauritania was instituted in communal level led to an increase in the number as well as influential personalities were identified 1986 through the creation of municipalities that of activities related to nutrition and health to participate in mobilisation workshops. During were given certain competences, which had been included in the Annual Investment Plans (PIA). these workshops, the mayors presented the the abilities of the state until then. However, the Advocacy actions also led to an increase in the health situation in their respective communes, impact of these reforms on communal structures is still limited. Indeed, the municipalities have for communal development have often been municipalities changed mayors during the last share of domestic financing dedicated to these as well as current nutrition and health activities allowed to relapse, partly because of difficulties elections in 2018. Indeed, out of 18 communes activities. in need of funding. The various representatives not made any progress in terms of recovering revenue and mobilising external funding. Very being able to edit and revise the plan, with the where Action Against Hunger intervenes, 12 new made commitments to help and collection exception of those that have benefited from the mayors were elected. With each new elected For example, the municipality of Mayahi committees were set up. Since then, several few municipalities submit requests for funding, For more information support of a partner. official, we have been forced to restart the five contact: contributed to connecting its Integrated Health infrastructure works have been carried out, rather, it is the partner that takes the place of step cycle and organise new trainings, thereby mabraha@ Centre (IHC) to the water reservoir, while the the municipality and offers funding. The plans In addition to financial constraints, several including the renovation of the IHC in the slowing the rate of progress in the area. accioncontraelhambre. org 20 LEARNING REVIEW 2019 STRATEGIC PLANNING AND RESOURCE MOBILISATION 21

shallow well, Action Against Hunger will top 1. Setting up the platform and sensitising, 3. An expert panel reviewing and deciding STRENGTHENING RESILIENCE THROUGH up with $28,427.50. The rehabilitated water mobilising and training community members whether the project proposal that has been catchments and shallow wells by the SWS-DRP on how to propose projects. submitted meets the criteria to qualify for project are currently supporting the communities funding through the online platform. 2. Communities (endorsed by their local CROWDFUNDING IN SOMALIA amid the looming drought and water crisis in authorities) and initiatives (endorsed by 4. Selected projects receiving a start-up Hudur, while complimenting WASH projects an organisation) submitting projects to workshop.Communities should have access targeting IDPs with water trucking. an online crowdfunding platform like to one on one support on how they can Fardosa Hussein BACKGROUND AND CONTEXT activities. For too long, decisions on Shaqadoon were responsible for Based on the experience of the Action Against Bulshokaab. create awareness about their project with Communication what gets to be funded have been taken sensitising communities to get a better the support from their endorsed The standard humanitarian funding Hunger team in Somalia, there are four steps Manager by everyone except the communities understanding of how crowdfunding organisation. Somalia approach is primarily donor driven: most affected by those decisions. In works to promote community ownership to ensuring that a crowdfunding initiative is a top down approach with little Hudur, in the south west of Somalia, over social initiatives. They have successful: Dr Arero Halkano engagement with beneficiaries and local HoD Food Security Action Against Hunger in collaboration transformed the community mindset Government actors. The beneficiary with Shaqadoon, a local NGO, started an to contribute towards a common goal and Livelihood contributions to programming in Somalia online campaign to raise funds for through crowdfunding by mobilising and particular need examining as they are communities living in Hudur through training community representatives who not well integrated into the standard their online platform called Bulshokaab. have then presented successful crowd project design approach. A different This platform is for development funding projects in Gedo region. approach to funding and project design initiatives across the Somali region. is crowdfunding. This aims to integrate Bulshokaab is an initiative of the Somali The community was mobilised to form local resources such as beneficiary Resilience Program (SomReP), a 13 member committee (consisting of communities, local authorities, private a consortium of seven international intellectuals, religious groups, elders, investors and diaspora populations agencies (Oxfam, ADRA, Action Against youth groups and the local authority) to through an online fundraising Hunger, Danish Refugee Council, CARE be in charge of every project who then platform. Not only can this generate International, COOPI and World Vision opened accounts in both Dahabshil and extra resources for humanitarian and International) aimed at building resilience Salaam bank. The project was posted on development funding, it can also enhance across Somalia. their online platform and people from accountability, transparency and effective across Somalia and the diaspora started programming. Through a collaborative USiNG THE APPROACH iN contributing money towards the three process, government and local actors SOMALiA shallows wells and one borehole for the can also be involved in the procurement/ community in Hudur distirict. finance process. Action Against Hunger in collaboration with Shaqadoon established a Currently, Sheikh Aweis borehole The concept of crowdfunding has been crowdfunding platform for projects with crowdfunding is at $10,330 and $3117 Somalia Hunger Against © Action introduced in Somalia in recent years a social impact. Seeking to secure for the three shallow wells in Shidle, One of the shallows that the with many Somalis showing interest funding from the administration, Kheyr Cabdille and Waney village in community and Action Against in contributing to community owned individual citizens, non-profit Hudur. With the amount raised for each Hunger have crowdfunded for in organisations and private companies. Waney village Hudur district South West Somalia. 22 LEARNING REVIEW 2019 IMPLEMENTATION AND MONITORING 23

KEY FINDINGS AND LESSONS LEARNT such as complaints, suggestions, enquiries and to all local financial institutions who provided appreciations are shared through either SMS or the FINTECH mobile money services in Somalia Through the formation of committees for the through the Interactive Voice Response (IVR) making it simple for those with access to mobile IMPLEMENTATION AND MONITORING crowdfunding project, a sense of community system. The IVR has been a unique initiative, since banking to contribute through the platform. ownership was developed as members of the it allowed beneficiaries to share their feedback community organised and made decisions at directly by sending a recorded message through Lastly, community projects are not a familiar each stage of the project. This also allowed for an easy to remember short-code (310), which is concept in most rural areas in Somalia. Some INTEGRATING A PSYCHOLOGICAL DISTRESS transparency and accountability as committee then captured into a platform where Shaqodoon of the challenges that arise from crowdfunding members regularly updated the community on the maps the nature of the feedback into categories. for this project include reluctance from the PROGRAMME ALONGSIDE NUTRITION SERVICES – amount of funds raised on the platform. This type of technology friendly feedback communities to contribute to projects, with many citing that there should be projects other hant Various stakeholders were brought together mechanism has really boosted the confidence GAMBELLA, ETHIOPIA level in communities. construction and rehabilitation of water points in through the crowdfunding initiative. The the community. community, local authority and ministries at state On the other-hand, some of the challenges Andy Solomon- BACKGROUND AND NEED anxiety, psychosomatic1symptoms2,2 containing a Baby Friendly Space (BFS). and national level were involved in the process we have encountered is the limited financial Action Against Hunger will assess the impact Osborne HoD/ adjustment disorder, negative behaviour, A BFS is a holistic, safe space providing Experience of working in mental health of raising awareness and mobilising people to systems that hinder the diaspora community from of this approach during Action Against Hunger Technical suicidal ideation and neglect of both Infant and Young Child Feeding, Care shows us that often those most in contribute through the crowdfunding platform. contributing to the platform. We are currently SomRep EU southwest drought recovery end line Advisor MHPSS family and self. Most affected are Practices and Psychosocial Support need are least likely to access services. Shaqodoon have in the past succeeded in raising using Shaqodoon’s Crowdfund platform, who evaluation. heT findings of the endline evaluation Ethiopia vulnerable groups including mothers to pregnant and lactating women Reaching out into the community and $300,000 from local diaspora communities for are a local organisation that is not internationally will be disseminated through social media (Twitter, and young children, which impacts basic and infants as part of an integrated talking about psychosocial issues, one of their crowdfunding initiatives in Jubaland. registered therefore limiting contributions from Facebook), high level events organised by the infant and child care practices. Community Management of Acute promoting anti-stigma messages, Somali diaspora who have credit card facilities. government/private investors and sector work Malnutrition (CMAM) programme. Community members have also had an building knowledge among family, Following the formation of South Sudan However, they do have Taaj service, a money groups meeting (food security clusters, resilience opportunity to give their feedback through a community leaders and teachers allows and the subsequent civil war, hundreds The BFS teams reported transfer company. Taaj is limited to the diaspora working group forums) to create awareness on HIGH LEVELS Beneficiary Feedback System that allows for greater chances to identify and engage of thousands of South Sudanese fled community who have credit card facilities and the approach’s viability and promote confidence OF POOR MENTAL HEALTH AND the organisation to give first-hand response with those in need of psychological the region into neighbouring countries, are not familiar with remittance companies such in the contributors to support future funding for PSYCHOSOCIAL PROBLEMS on any matters arising from the crowdfunding such initiatives. assistance – especially among the most including Ethiopia. In response to a AMONG THEIR PREGNANT AND project as well as other projects. Feedback as Dahabshiil. The current platform is connected hidden and vulnerable in the community. renewed round of fighting and violence LACTATING BENEFICIARIES, and which led to a new influx of refugees, noted that many were not engaging Reports on the mental health of South a new camp was established to host with services regularly. Stigmatisation Sudanese refugees in camps in the 82,000 individuals. As part of Action of poor mental health also seemed to region (UNHCR, 2016) showed high Against Hunger’s response, five be contributing to isolation and a lack levels of moderate to severe poor nutrition centres were constructed, each of engagement. As there was no mental mental health including Post-Traumatic health provision in the camp, a special Stress Disorder, major depression, acute 2 Psychosomatic Symptoms – such as psychosocial support sub-activity named pain or shortness of breath, or more the ‘Psychological Distress Programme’ For more information contact: general symptoms, such as fatigue or (PDP) was developed as a pilot under the [email protected] weakness BFS range of activities in the next round 24 LEARNING REVIEW 2019 Implementation 25

of funding, that involved establishing a small team protection and health agencies, and advocate secure long-term funding for their mental health CHALLENGES of psychologists to link into the community. The with NGOs and UN agencies at cluster and programme in the same camp targeting adults service was designed as a mobile (peripatetic) coordination level. through the health sector. The main challenge lies in longer- activity, with the team being able to move around term financing. For most donors, This pilot helped us understand how we can reach the camp. The team were able to provide activities KEY FINDINGS & LEARNINGS Mental Health and Psychological in different locations such as ‘under the tree’ in and better assist those who are most vulnerable. Support activities usually sit outside the camp community, in schools, health sites, The PILOT WAS ABLE TO EVIDENCE A We found that mothers and caregivers were quick of nutrition interventions and are other NGO buildings as well as in Action Against HIGH PREVALENCE OF POOR MENTAL to engage with the range of services offered, more typically considered part of a Hunger sites including the Baby Friendly Space. HEALTH AMONG BENEFICIARIES. illustrating that with sensitive programming (that health or protection interventions. Psychologists reported from one-to-one sessions included building a lexicon of words that describe Securing funding for these type of mental health issues in their language) and with WHAT WAS OFFERED of high levels of multiple issues including: programmes can therefore be more depression (67%), acute anxiety & fear (44%), strong linkages via nutrition services, trust could difficult, although positioning this The primary objective of the service was to psychosomatic symptoms (41%), self-harming quickly be established. In beneficiary feedback as an integrated programme with reach out and engage with those in need of & suicide ideation (19%), drugs/alcohol (self interviews, 98% said they found services helpful nutrition was successful. psychological support that were being missed or or partner) (15%), and psychotic symptoms and 85% said they would recommend this to Another challenge is to ensure that were hidden – particularly om thers and caregivers (14%). Other key findings showed that 45% of others mothers and caregivers they knew. there is a suitable referral pathway who were part of the nutrition programme. This children referred (between 5-10 years old) were A particularly important learning concerning for more severe cases. Support from also included family members. The service also for symptoms related to epilepsy. 86% of the complementarity of nutrition and mental a regional hospital with a psychiatric wanted to contribute to improving the acceptance referrals for children (16 years old and under) health services, is the effectiveness of the BFS unit is helpful, and collaboration of mental health and understand more about how were for developmental, intellectual and/or as a linkage between nutrition, IYCF, child with universities in the region with mental health is seen within the Nuer refugee physical impairment issues. The results showed care practices and psychosocial support. As mental health departments can be population. a number of hidden issues. One worth noting is most mothers used the BFS, they had already beneficial for mental health advocacy. that 8% of adolescent and adult females coming The programme was implemented by three experienced a more psychologically orientated Both regional hospitals and local to counselling sessions sought help for problems teams, comprising of three qualified psychologists service that incorporated their emotional well- universities can play a vital role in relating to gender based violence including and three local speaking psychosocial workers, being and this contributed to establishing of providing clinical resources such as rape. This led to the establishment of a close working in pairs. The teams were clinically trust and improved acceptance of working with staff and students. collaboration with GBV and Child Protection supported by one Senior Psychologist and a psychologists. This also worked effectively for providers for referrals and case management. Mental health and psychosocial support (MHPSS) GBV and protection beneficiaries who preferred Technical Advisor in the programme. These teams These findings clearly indicate the huge need to discuss issues initially with the psychologists would provide group and individual therapeutic for mental health support within the refugee who then linked them to protection agencies. It is

sessions, organise awareness campaigns in the population, and have provided evidence for the therefore vital for future programming to create For more information Ethiopia Hunger Against © Action community, train teachers and community leaders humanitarian community, supporting further links between the various services, taking a more contact: on psychological first aid and mental health initiatives in this sector. For example, a specialist holistic approach that considers all aspects of [email protected] awareness, make and support referrals with mental health NGO used these findings to health and well-being. acf.org 26 LEARNING REVIEW 2019 IMPLEMENTATION AND MONITORING 27

materials for constructing a ‘tippy tap’); broaden analysis. in the intervention community (16.7%) BABY WASH AND PROTRACTED DISPLACEMENT: complementary feeding items (lidded cups than in the non-intervention community and bowls, child cutlery and play mats); KEY FINDINGS (23.0%), and a binary logistic model showed and training on child WASH and nutrition. that children in households with improved LESSONS LEARNED FROM NANGERE LOCAL When compared with the non-intervention 5,562 PLWs were targeted across a period sanitation were three times less at risk of community, rates of handwashing of 18 months, and interventions were diarrhoea than those in households with GOVERNMENT AREA, NIGERIA were significantly higher (17.2%) in the administered as part of a wider multi- unimproved sanitation. intervention community, with 90.4% of sectoral nutrition programme (INP+), which PLWs in Nangere demonstrating consistent was implemented in partnership with EVALUATION and adequate use of soap upon endline UNICEF, the WFP and the local government. Kanaganathan BACKGROUND military interventions have depleted and washing, 85.6% lacked access to observation. While 90.9% of Baby WASH The Baby WASH package was implemented participants reported daily use of the in Nangere LGA with the aim of improving Rangaiya security barriers and exposed pockets safe latrines, and 14.1% used soap ASSESSMENT OVERVIEW WASH Head of Despite economic growth in recent of famine, allowing humanitarian and water for handwashing. Among complimentary feeding items and child play household sanitation and reducing the Department decades, Nigeria continues to carry organisations to access the displaced. the participants surveyed, ash was A mixed methods study comprising 800 mats, acceptance of the ‘tippy tap’ remained prevalence of stunting and malnutrition Nigeria one of the most severe malnutrition not known as an alternative to soap, household surveys (HSs), 11 key informant low, with 96.05% of PLWs expressing a among children within their first 1000 burdens in the world. According to THE BABY WASH APPROACH and knowledge of water treatment interviews (KIIs) and 9 focus group preference for traditional kettles. days of life. While an overall improvement the Nigeria Demographic and Health practices was minimal. The findings discussions (FGDs) was undertaken to in household sanitation and diarrhoea A growing body of evidence indicates Risk perception of child diarrhoea incidence Survey 2018, 37% of Nigerian children called for a multi-sectoral response, determine the relevance, effectiveness prevalence was observed, the sustainability that access to safe water, sanitation remained low among PLWs in both aged 6 to 59 months are stunted, 7% underlining the potential that a more and sustainability of the response. For of the approach was, upon evaluation, and hygiene (WASH) is a key communities, and, although Baby WASH are wasted and 22% are underweight. integrated approach to programming comparative purposes, data from the target questionable. determinant of growth in a child’s participants demonstrated significantly UNICEF estimates that just 18% of could have in remedying the high group was mapped against that of a non- nutritional development, with a better knowledge of 6 faecal to oral Many PLWs in the intervention community Nigerian children aged 6 to 23 months rates of stunting and global acute intervention community in Tarmua, who did number of studies signalling the need transmission routes, fewer than half were expressed that, although they wanted to receive the minimum acceptable diet, malnutrition (GAM) in the region, not receive the package. for stronger integration of het WASH able to identify routes besides drinking implement their learnings from WASH and 80% of malnourished children which, in 2017, stood at 68.8% and and nutrition sectors of rp ogramming. HSs were constructed using an Open Data dirty water or eating food contaminated by training sessions, they often lacked the under 5 lack access to treatment. 14.7%, respectively. Kit platform, and answers were recorded flies. Additionally, there was no significant resources to do so fully and effectively. In line with this evidence, a Link Regionally, stunting is most prevalent In response, Action Against Hunger using mobile devices. 9 of the 11 KIIs difference (p<0.05) in the number of PLWs Only 46% of households in the survey area Nutrition Causal Analysis (LinkNCA) in the country’s northern states, where applied the Baby WASH approach were conducted individually, and 2 were who identified child mouthing as a cause of had access to a safe water source such as a conducted by Action Against ungerH non-state violence under the Boko – an integrated package targeting conducted in 2 groups of 2 and 4 members. diarrhoea between the communities, and borehole or protected well, and those who in 2017 found inadequate access to Haram Insurgency has uprooted more children in their first 1000 days of life FGDs were undertaken in 5 intervention FGDs in both revealed that many PLWs still fell outside of this percentage felt that, on a safe WASH to be a major risk factor than 2.5 million from their homes. Of (the critical window of opportunity communities and 4 non-intervention believed that diarrhoea was a symptom of practical, day-to-day level, using sterilised, For more information for malnutrition in Nangere Local all states, Kebbi, northwestern Nigeria, for preventing malnutrition). The communities, 8 of which were identified teething. boiled water at all times during baby care contact: Government Area (LGA), Yobe State. hodwash@ng- bears the highest proportion of pilot aimed to address the LinkNCA’s as comprising the highest number of was not easily achievable. The study revealed that 99.1% of Despite these findings, the recalled actionagainsthunger. stunted children (57%), while Anambra findings by providing pregnant and participants in the INP+ programme. The households in the survey area relied prevalence of diarrhoea among children In KIIs, community stakeholders also org in the Southeast bears the lowest lactating women (PLWs) with basic fifth intervention community, a smaller rural on untreated groundwater for drinking under 2 was significantly lower (p<0.05) expressed concerns over the sustainability (18%). In Yobe, northeastern Nigeria, handwashing resources (soap and community in Nangere, was selected to 28 LEARNING REVIEW 2019 PEER-REVIEW AND EVALUATION 29

of the Baby WASH package in Nangere LGA, emphasising that, in exclusively targeting PLWs, interventions were unlikely to promote community uptake of safe WASH PEER-REVIEW AND EVALUATION practices, and, in turn, the development of safe WASH environments for children who had reached roaming age. They also emphasised that, because the Baby WASH package was primarily implemented by Action Against MITIGATING AND PREVENTING GENDER-BASED Hunger staff, interventions replicated those rolled out in emergency response contexts, rather than those that would VIOLENCE IN OUR FIGHT AGAINST HUNGER facilitate sustainable development. Zuhra Aman BACKGROUND how Action Against Hunger and its An end line project evaluation was RECOMMENDATIONS Action Against nutrition partners could improve their conducted to better understand the At Action Against Hunger we know The issues outlined above emphasise that, if the Baby Hunger accountability to mitigate and prevent intended and unintended outcomes, Gender Unit that gender inequality and gender- GBV in the fight against hunger. The best practices, challenges and WASH approach is to facilitate community resilience and Canada based violence (GBV) are both a cause long term uptake of safe WASH practices in protracted project focused on four main activities: recommendations for the future and consequence of hunger. Knowing that can be used to inform decision- displacement contexts, household level interventions this, the organisation has taken steps 1. TRAINING AND SENSITISING making for the ROLLOUT OF A need to be integrated with those that improve WASH at to promote gender equality with humanitarian teams on core gender METHODOLOGY TO INTEGRATE the community level. Findings from the HSs, FGDs and initiatives such as the organisation’s equality and GBV concepts; GBV RISK MITIGATION KIIs suggest that more direct stakeholder engagement in Gender Minimum Standards and to 2. STANDARDISING CORE AND GENDER EQUALITY IN interventions, coupled with a greater focus on capacity look at ways to prevent and mitigate REQUIREMENTS FOR NUTRITION ORGANISATIONS. building initiatives that allow community workers to take GBV in our work. In 2019, Action MAINSTREAMING GENDER ownership of WASH and nutrition training sessions, would Against Hunger wrapped up a two- in Action Against Hunger’s An important outcome of the greatly enhance the Baby WASH approach’s sustainability year pilot project on ‘ENHANCING offices with the rollout of Gender project was around collaboration and long term effectiveness. It is also evident from KIIs that THE ACCOUNTABILITY FOR Minimum Standards; and coordination, which has brought interventions need to target all caregivers (including fathers GENDER-BASED VIOLENCE WITH 3. ADAPTING KEY TOOLS used by together the Action Against Hunger and the elderly) to ensure that the full impact of Baby HUMANITARIAN NUTRITION country offices to consider gender headquarters to work collectively WASH training is realised. ORGANISATIONS’, funded by the equality and GBV, these tools were on mitigating the risks of GBV in its Bureau of Populations, Refugees and consisting of surveys, assessments, day to day activities, programmes, Such changes could be reinforced by (a) engaging local questionnaires, and checklists, and institutions (such as mosques, schools and community Migration (PRM), within the United and projects. This has created shifts © Action Against Hunger Ivory Coast Ivory Hunger Against © Action groups) to disseminate and reiterate child WASH and States State Department. 4. MONITORING AND in thinking and practices on the the project to ground mainly around staff as well as nutrition messages; (b) mobilising volunteer hygiene For more information The project was piloted in three EVALUATING collect information about the the managements in Action Against promoters (VHPs) to monitor household WASH practices; contact: countries – Bangladesh, Mauritania, and (c) grouping PLWs according to the age of their children. Tippy tap usage zaman@ progress of project activities as Hunger country offices. The project demonstration. actioncontrelafaim.ca and South Sudan – and looked at they were happening. approach had helped to create a very 30 LEARNING REVIEW 2019 PEER-REVIEW AND EVALUATION

important space within the organisations WHAT WE LEARNED FROM THE only beginning. Through its actions across during a learning workshop in Geneva, • CREATE AWARENESS to tackle and embrace challenges linked to EVALUATIONS the country programme, I have observed Switzerland. Participants for this event AND CONTINUOUS GBV in nutrition programmes. However, changes in staff behaviour, we are gradually were members from the GNC, ORGANISATIONAL support In the beginning of the project, gender was there should have been emphasis on the recruiting more women; colleagues are UNICEF, Mercy Corps, Tech Rapid on mainstreaming gender in our for team members. ground on the ingenuity of the people and SOMETHING ELSE respectful to one another and our working Response Team (RRT), and Action activities and programmes. They believed integrating gender required communities experiencing those challenges mothers can come to work knowing there Against Hunger Spain participated in specialised expertise and that it was not • SUPPORT PRACTICES AND first-hand. The future projects show focus is the breastfeeding room to accommodate this event. INITIATIVES on gender equality integral to nutrition activities. As the more on the power of contextualised them. With such inclusive workplace, our and GBV risk mitigation. project continued, they felt gender was evidence on the potential innovation that creativity, effectiveness and efficiency Overall, external staff appreciated the something more, meaning it might require • EMBRACE A LEARNING exists in the programmes. are improving, and everyone feels more efforts made by ctiA on Against Hunger additional structure, resources, and extra CULTURE by exploring and sharing invested in the success of the country in mitigating the risks of GBV in Another important dimension is the time to work. Team members felt that these nutrition through practical approaches. the tacit knowledge that helps programme.” create dialogue, discussion, and additional activities would deviate from relevance of the project to nutrition However, there is still a lot that needs learning. activities. The evaluation found that the the organisation’s mandate and expertise. LEARNING AND SHARING to be done in integrating gender project work and its uptake demonstrated By the end of the project, team members lenses and mitigating GBV by all actors • INVEST IN COMMUNICATION that mitigating GBV issues is clearly recognised that integrating gender For learning and sharing purposes, learning including gender-aware programme FOR LEARNING by documenting relevant and has a transformational equality and GBV means transforming workshops were organised to share the designs, systematic monitoring, sharing data including tools, capacity for the whole sector. Therefore, existing approaches. Fitting gender into results of the end line evaluation with evaluation, and learning, evidence documents, ideas, dialogues with Action Against Hunger and other nutrition work means identifying issues Action Against Hunger country teams, sharing, continuous awareness raising the activities were appreciated by the humanitarian and development Global Nutrition Cluster (GNC) members, that are harmful and excludes at-risk partner organisations, nutrition cluster at all levels on why gender matters. networks. nutritional clusters and all other relevant or vulnerable groups. Transforming our members, and relevant government entities actors who were engaged in the project in approaches does not necessarily require in Bangladesh, Mauritania, and South WHAT iS NEXT FOR ACTiON • CREATE COMMUNITIES OF different capacities. more resources, but instead thinking Sudan. AGAiNST HUNGER? PRACTICE by bringing together SOMETHING DIFFERENT by reassessing other actors, organisations, Also, a blog page was created to Action Against ungerH is committed to Among many useful outcomes of and transforming our current ways of networks, and individuals for present the evaluation process that integrating the learning from this pilot experience and knowledge sharing. the project, a thinking framework – working. This includes piloting, sharing best was an opportunity to document the project and other initiatives across SOMETHING ELSE, SOMETHING practices, involving teams at all levels, and learnings, visualise the data real-time, and the Action Against Hunger network MORE, AND SOMETHING DIFFERENT ensuring programme participants are at the communicate the emerging highlights of to mainstream gender equality and – emerged from the project evaluation. centre of our work. The framework shows how Action Against the evaluation. The blog also provided integrating measures to mitigate Hunger team members in three pilot This change is well-illustrated by an an opportunity for the respondents to and prevent GBV. At Action Against countries struggled to situate gender anecdote from a team member in South communicate and share their views and Hunger, we will: equality and GBV risk mitigation in the Sudan: “The culture and habits of the insights on the project activities. Canada Hunger Against © Action nutrition programmes until they were able country are patriarchal and difficult to In a larger scope, the learnings from the to merge it. tackle. When I arrived, the project was end line evaluation were also shared 32 LEARNING REVIEW 2019 PEER-REVIEW AND EVALUATION 33

IMPROVING SOCIAL INCLUSION PROGRAMMES THROUGH QUALITATIVE RESEARCH

Dea Tsartsidze SOCIAL INCLUSION and social inclusion of vulnerable collect other forms of data that may Monitoring PROGRAMMING IN SOUTH communities. However, given the further inform programming. This and Evaluation CAUCASUS complexity and multi-faceted nature implies, however, that several other Manager of social inclusion programming, components that relate to the success Despite recent economic growth, the South Caucasus monitoring and evaluation of such of a programme remain unobserved. South Caucasus region, and Georgia programming has proven to be Johannes Casera in particular, has consistently faced difficult. Increasingly, the complexity of Junior EU Aid a wide range of socio-economic Volunteer development programming require the challenges. These challenges, which South Caucasus MONITORING AND consideration of deeper and further are underscored by prevalent EVALUATION IN DEVELOPMENT reaching areas of impact that cannot poverty, include inadequate access PROGRAMMING be understood through quantitative to employment, entrepreneurial and research alone. Qualitative research, educational opportunities and gaps Various kinds of toolkits can be used in response to this concern, helps in soft skills. To address this, diverse to monitor and evaluate a programme, to elicit deeper insights and explore social inclusion programmes have been with Monitoring, Evaluation, participants’ behaviour, perceptions introduced across the region. Accountability and Learning (MEAL) and understandings. However, teams often relying on quantitative the mainstreaming of qualitative Action Against Hunger in the South data to inform, substantiate, and approaches to monitoring and Caucasus has been an important player conceive programme findings. Most evaluation is often overlooked and in tackling economic inequalities and commonly, these toolkits are used to remains a key challenge. disengagement of vulnerable groups. collect data on key socio-economic Central to Action Against Hunger’s indicators at regular intervals IMPLEMENTING A QUALITATIVE programming is the adaptation and before, during, and after programme RESEARCH APPROACH implementation of the Employment implementation, to determine its © Tako Robakidze for Action Against Hunger Against Action for © Tako Robakidze and Entrepreneurship Shuttle success. In 2019, Action Against Hunger in methodology, developed by Action the South Caucasus decided to take Generally, however, monitoring and For more Against Hunger Spain. Through on the challenge of going beyond this methodology, social inclusion evaluation is considered as being quantitative data to implementing a Entrepreneurship Shuttle information programming in the South Caucasus separate from programme activities, qualitative research approach in its participants exhibiting their contact: and programme implementers rarely products at the forum. dtsartsidze@ has yielded positive results, including social inclusion programming. sc.acfspain.org increased participation and economic go beyond quantitative data to 34 LEARNING REVIEW 2019 Monitoring and Evaluation 35

The qualitative research approach, participation. MEAL team also learnt that qualitative incorporating carefully-designed data can be used to support effective • INNOVATE: As with any approach to methodologies and tools, aims to ensure that programme implementation. In many cases, monitoring and evaluation, the experience participants, or programme beneficiaries, the information obtained carries with it the of the South Caucasus reiterated the validity and reliability that is necessary to associate with a development programme transformative potential of being over several months and thus the inform effective programming. This involved innovative in the implementation of a programme becomes an integral part of Hunger Against Action for © Tako Robakidze following a number of key steps, ranging from robust qualitative research approach. their lives. Naturally, participants develop clearly defining research objectives and the For instance, the MEAL team learnt that their own ideas and perceptions of how sampling methodology, to the adoption of pre-existing quantitative information on programmes could best function and what appropriate data collection and analysis tools. research participants could be uniquely could be improved. The team learnt that leveraged to supplement qualitative such insight can be instructive and carry In implementing this approach, the South research efforts; whether it is to stimulate pertinent guidance on how a programme Caucasus MEAL team identified several discussions, formulate questions, or even can be tailored and adapted to better meet Entrepreneurship Shuttle key learnings that stand to inform efforts determine a primary sampling pool. the needs of beneficiaries. participants working during a to collect and use qualitative research in breakout session of a forum. • BE INDEPENDENT: Another critical In the South Caucasus, the qualitative future programming. At the heart of these lesson was the importance of guaranteeing lessons is the value of qualitative research in the independence of the monitoring information collected through key development programming. and evaluation process and ensuring informant interviews (KIIs) and focus group social inclusion programme that aimed team in implementing a qualitative research design and implementation. that it remains distinct from programme discussions (FGDs), among other tools, to improve employment skills tracked approach in monitoring and evaluating social behavioural change to find that the When qualitative research is valid and reliable, WHAT HAVE WE LEARNT? implementation. A failure to distinguish confirmed that programme participants inclusion programmes. Read alongside a between personnel and/or protocol in were eager to share their views and programme resulted in participants how-to guide on implementing qualitative it can significantly improve programmes The South Caucasus experience elicited these parallel processes risked skewed experiences. Qualitative information reporting increased confidence in the research, the lessons shared in this review by providing a deeper understanding of use and application of skills to secure a number of useful lessons. These are findings—the programme team was less collected from a social inclusion aim to provide a basis for the development participants’ perceptions and feelings. The inclined to fully report on qualitative employment. Reliance on quantitative described below and include ways to improve programme, for instance, revealed that of a comprehensive framework around South Caucasus’ experience has demonstrated information from participants, and data alone would have only confirmed implementation of qualitative research programme participants were dissatisfied mainstreaming qualitative research approaches that MEAL approaches to qualitative research participants were less inclined to share whether or not a participant was able to can be strengthened through an openness approaches and steps that can be taken to with over-exposure to corporate volunteers secure employment. Qualitative research in future programming. their honest opinions with the programme to adapt, a willingness to innovate, and a ensure that qualitative data is used in an team. In response, a distinct MEAL team as part of the shuttle sessions. The MEAL can generate unique findings and deeper In advocating the collection and use of commitment to independence. In doing so, effective manner. was set up that was not directly involved team communicated this feedback to insight into the success of a programme in the implementation of programme programme implementers, encouraging which, in turn, can enrich learning and qualitative data, the team is confident that the experience also confirms that qualitative • ADAPT: A key takeaway is the importance communication, be it internally among the this is a widely replicable approach that research can be used to support effective of being open to adapting the approach activities. This helped to increase them to make necessary adjustments. objectivity, eliminate bias and, in turn, programme team or externally in donor elicits valuable insights from programme programme implementation and enrich both throughout the research process. For • ENRICH COMMUNICATION: The reporting. instance, when the MEAL team recognised improve the validity and reliability of participants and provides a unique participant- internal and external communication. Action research findings. MEAL team also learnt that the adoption led perspective on what already works in a Against Hunger in the South Caucasus aims to that programme participants had different of a qualitative research approach stood LOOKING AHEAD programme and what can yet be improved. continue to implement, refine and share new linguistic backgrounds and competencies, • SUPPORT IMPLEMENTATION: In to yield a wide range of unique findings adaptive steps were taken to ensure that all Accountability to participants also obliges lessons from this approach as it consistently

addition ot improving the qualitative that can enrich both internal and external This article reflects the experiences of Action Hunger Against © Action questionnaires, interviews, and discussions research process through flexibility, communication efforts. For instance, Against Hunger’s South Caucasus MEAL programme implementers to use qualitative strives to better monitor and evaluate were translated to encourage meaningful innovation, and independence, the qualitative information obtained from a findings to continuously refine programme development programmes. 36 LEARNING REVIEW 2019 PEER-REVIEW AND EVALUATION 37

2. LACK OF FEMALE STAFF ON SITE 3. THEFT AND ASSAULT AROUND THE 4. TOOL APPLICABILITY IN STABILISATION NUTRITION SITE CENTRES HOW A SAFETY AUDIT TOOL IS USED AS A PLATFORM CHALLENGES: 60-70% of nutrition sites lack female staff to facilitate referral of gender CHALLENGES: Theft and assault were CHALLENGES: A pilot of the SAT in Action TO MITIGATE GENDER-BASED VIOLENCE RISKS AT sensitive cases and collect feedback from especially common on sites located in urban Against Hunger’s stabilisation centre in women who are not comfortable reporting areas or adjacent to markets, and, findings Malualkon, Aweli East County found that a NUTRITION SITES IN SOUTH SUDAN issues to male staff. indicated that risk of GBV increased with significant proportion of survey questions were distance travelled to nutrition sites. not applicable. Dimple Save BACKGROUND THE TOOL 1. LACK OF BENEFICIARY RECOMMENDATIONS: Gender-diverse Strengthen advocacy Develop an adapted Head of Nutrition AWARENESS ON AVAILABLE staffing is critical to quality service delivery, and RECOMMENDATIONS: RECOMMENDATIONS: South Sudan In South Sudan, the cumulative The SAT was designed to identify FEEDBACK AND COMPLAINT should be made a standard on all nutrition sites. with local authorities and community leaders to tool to capture risks specific to stabilisation effect of years of conflict, violence potential GBV-related safety risks MECHANISMS increase overall coverage of nutrition services centres, including those related to child and James Justin and destroyed livelihoods has led to at and around nutrition sites. To do and decrease distance travelled. caregiver overnight stay. Nutrition a humanitarian emergency of high this, a combination of structured CHALLENGES: Generally, women 5. LACK OF DATABASE FOR PARTNERS TO Data Manager proportions. The recently revitalised and semi-structured questions considered local authorities (police, South Sudan DIRECTLY UPLOAD THEIR ASSESSMENTS peace process promises to offer new were formulated to assess risks and traditional leaders, public radio opportunities in the coming years challenges experienced by women and stations) as their primary reporting CHALLENGE: Currently, Action Against for South Sudan’s women, men and girls. These questions formed the basis channels for GBV-related safety risks. Hunger supports the nutrition cluster with children. of the following three key activities While some women indicated that the compilation of after action safety audit included in the tool: they might report an issue to site staff, data received from partners. A cluster-level Violence, abuse and exploitation a reluctance to report issues on site repository for SATs and reporting templates An observation checklist remain the greatest protection risks to 1. was noted among many beneficiaries. would maximise efficiency and strengthen data women and girls, reflecting continued 2. Focus group discussions (FGDs) RECOMMENDATIONS: Strengthen analysis. gender inequalities exacerbated by with beneficiaries the prolonged crisis. Naturally, these communication on programme RECOMMENDATIONS: Develop a risks extend to nutrition sites, and 3. Key informant interviews (KIIs) feedback and complaint mechanisms harmonised reporting mechanism (including a nutrition programme beneficiaries are with staff at nutrition sites by implementing one or more of the master database, reporting templates, guidance among the most affected. To assess following: (1) monthly staff meetings notes and supportive supervision) for after and address these risks, Action Against THE PILOT between first-line implementers action safety audits at the cluster-level. For more information and field office staff; (2) FGDs with contact: Hunger, in collaboration with UNICEF In early 2019, the tool was piloted direct beneficiaries at the site level; nutco@ssd- and Care, have developed a gender- in eight of Action Against Hunger’s (3) individual interview forms; (4) actionagainsthunger. based violence (GBV) Safety Audit Tool 35 nutrition sites. This identified the comment boxes at field office gates; org (SAT) for the nutrition facilities. following key risks faced by women and (5) hotline numbers (where and girls and recommendations to Beneficiaries interviewed applicable) to enable anonymity. address these: during safety audit . 38 LEARNING REVIEW 2019 Preparedness 39

IMPLEMENTATION OF THE SAT IN SOUTH to and from sites were widespread among current feedback and complaint mechanisms. SUDAN beneficiaries. Assault, theft and intercommunal Additionally, greater engagement of nutrition youth fights were identified as key barriers to staff to develop site-specific strategies for The SAT was implemented in South Sudan by service use, and, in Paguir, caregivers reported mitigating barriers to service use is required the national nutrition cluster in three phases: making longer journeys through bush and to improve access. Finally, a thorough review PHASE 1: INDUCTION OF NUTRITION swampland to mitigate GBV-related risks. A of fencing and security barriers is required CLUSTER PARTNERS lack of water points on journeys to and from at stabilisation centres in high risk areas to sites was also noted as a barrier in Paguir, and determine if reinforcement is needed. Partners were familiarised with the SAT during a number of beneficiaries raised concern over the national nutrition cluster meeting in August the lack of reporting channels for GBV issues ACTIONS: In response, Action Against 2019. This was followed by a sub national beyond the facilities. Hunger have already undertaken a number of nutrition cluster induction via skype. actions, including: improving gender diversity These issues were, however, raised among more on nutrition sites; enhancing fencing at sites PHASE 2: DATA COLLECTION, ANALYSIS positive comments, and, in FGDs, beneficiaries in high risk areas; sensitising staff to GBV AND REPORTING commented on the friendliness and helpfulness and gender discrimination; repairing locks To avoid overwhelming partners in the nutrition of staff at nutrition sites. In stabilisation centres, in latrines; deploying mobile teams for long cluster and maximise uptake of the safety audit caregivers felt safe among male staff, and distance journeys to and from sites; integrating methodology, the rollout of the SAT followed agreed that the presence of guards brought GBV safety training into 2020 proposals; and a two-tiered approach. While the observation them ‘peace of mind’ when accessing the strengthening feedback mechanisms through checklist was rolled out across all sites, FGDs facilities. Finally all beneficiaries were satisfied onsite suggestion boxes. with the services, and felt that staff provided with community members and programme staff WAY FORWARD were targeted at sites where implementing ample information regarding treatment, partners had capacity to facilitate and analyse products, how often to use the facilities and PHASE 3: GBV LEARNING WORKSHOP sessions. when to return. Moving forward, a follow-up GBV learning RECOMMENDATIONS: Upon evaluation, workshop will be organised with nutrition PRELIMINARY ANALYSIS AND REVIEW findings from the SAT’s pilot and rollout partners to share key lessons learned, review KEY FINDINGS: The observation checklist signal the need for greater gender diversity observation data and overall findings, analyse was rolled out across a total of 583 nutrition on nutrition sites and further staff training on key trends identified through consultations, and sites and 47 stabilisation centres. Key findings gender, GBV and referrals. It is also evident that plan how to highlight findings. Attendees will

were similar to those elicited during the pilot: stronger community advocacy on gender and include UNICEF (Regional and Country), WFP, Hunger Against Action for © Lys Arango a significant proportion of sites lacked female GBV is required to improve reporting channels and national and local partners in the nutrition staff, and protection concerns regarding travel beyond the facilities, and increase awareness on cluster. 40 LEARNING REVIEW 2019 Coordination, INFORMATION MANAGEMENT AND PREPAREDNESS 41

LESSONS LEARNED ON THE COORDINATION, INFORMATION EVALUATION PROCESS The evaluation methodology was cost efficient as it used existing routine data from the monitoring health system that are MANAGEMENT AND PREPAREDNESS robust enough to ensure representation of the population. However, as with all existing data sets used for secondary analysis, there CAN CARE GROUPS IMPROVE HEALTH SEEKING is a risk of data quality issues. Ensuring best practices in data collection and management BEHAVIOURS? RESULTS OF AN IMPACT EVALUATION would improve greatly the quality of future IN NORTH-EASTERN NIGERIA evaluations. LESSONS LEARNED ON PROJECT Ali Mohamed To address food security and nutrition delivered, focusing on key aspects of EVALUATION OF THE CARE IMPLEMENTATION Nassur challenges in Yobe and Borno states maternal and child health, including GROUP APPROACH Epidemiologist in Nigeria, Action Against Hunger optimal infant and young child feeding Based on this experience, we can see that Demographic and Health Survey and Biostatistician is using the Care Groups aim to and maternal nutrition practices, there is a great potential of behaviour change (DHS) data from the Nigerian Federal France elicit positive changes in behaviours hygiene practices, common diseases Figure 3: The Care group cascade used in using the Care Group approach, as this model Ministry of Health were reviewed related to nutrition and health. The and utilisation of healthcare services. Nigeria (illustration adapted from Care Groups: allows implementation at scale and with Armelle Sacher for evidence of outcome-level Social and approach combines cascaded training Every month, Action Against ungerH A Reference Guide for Practitioners 2016) positive effect on entire populations. Several improvements in health seeking Behavior Change and peer support groups and aims nutrition staff trained field-based good practices were identified by the project behaviours. Indicators examined were Technical Advisor to reach at least 80% of pregnant female health promoters selected team during a review workshop, such as antenatal carevisits, postnatal care USA women, mothers and caregivers of from target communities. In turn, the WHAT DID THE CARE GROUP introducing an additional layer to the original visits, healthy facility utilisation rates, children under two years in the area of promoters cascade the learning to APPROACH CHANGE? model, importance of constructive supervision, Dieynaba infant mortality rates, and low birth adjusting promoter’s workload, replacing S N’Diaye intervention. In 2018, an impact study 10-16 volunteers who then replicate The results detailed in table two are • Postnatal visits also increased following the weight rates. pregnant volunteers close to delivery period, Research and was carried out in the two states to it with a further 10-15 households summarised here: start of Care Group activities. and the importance of participatory methods Analysis Advisor assess the strength of the programme. through meetings and home visits. Changes in indicators were • The greatest improvements were observed • Data quality issues meant that the effect on such as games and storytelling that make the France This strategy enabled one nutrition modeled over time and compared infant mortality and low birth weight could THE CARE GROUP APPROACH iN staff to reach between 5,400–8,100 in antenatal care attendance and facility sessions more attractive. Stephanie Stern between baseline (2015) and post- utilisation rates. This included an increase not be assessed. No significant impact on NORTH-EAST NiGERiA households every month (Figure 1), Action Against implementation of the Care Group in the number of women attending all four changes to mean infant mortality was and in total, approximately 146,500 Hunger Knowledge In the Care Group approach, a approach (2018). antenatal visits. detected due to lack of data or its quality. households are reached each month LAB Advisor structured curriculum of lessons is France through face-to-face activities. 42 LEARNING REVIEW 2019 Coordination 43

Based on the evaluation results, we believe peer level might not be enough. The project MSF Belgium also reached out to Action that the approach can still be improved to should assess, and address barriers linked to the Against Hunger staff to build on its experience. support behaviour maintenance for antenatal physical environment and the social and gender The care group curriculum implemented by care. The antenatal care lesson should be norms,which may hinder women's access to Action Against Hunger in Uganda was adapted introduced at the start of the curriculum and health services. based on the recommendations provided by more opportunities to reinforce the behaviour our study. could be created. Attending all antenatal HOW ARE WE MOVING ON? visits is a complex behaviour, that requires Care groups can be implemented at large scale, The evaluation was presented at the 3rd planning, time, and reorganising household task. and influence positively health-seeking R4NUT Research for Nutrition Conference in Promotors should be trained on techniques behaviors of a large population. Future November 2019 and at UNICEF Workshop on to help women manage these difficulties, like implementers should embed these lessons wasting, in Senegal, in November 2019 where using reminders and goal setting. In addition, learned in similar interventions, assess implementation, cost and curriculum design behaviour change intervention at individual and their impact and share their findings to were discussed. ensure continuous learning and programme improvements. CONTROL INP+ ECHO

MEAN MEDIAN MEAN MEDIAN MEAN MEDIAN

Coverage of one antenatal visit 58% 52% 91% 73% Increase 149% - Increase Coverage of four antenatal visits 2.10% 1.40% 3.64% 2.90% Increase 4.42% 3.70% Increase Percentage of postnatal visits (within 3 days) 21% 14% 30% 27% Increase 23% 15.5% Increase Facility utilisation rate 0.27% - 0.44% - Increase 0.88% - Increase Infant mortality rate 17.01% 0 6.70% 0 No change 14.80% 8.20% Decrease* Low birth weight rate 15.83% 11.60% 10.97% 9.25%* Decrease* 15.01% 12.30%* No change © Sébastien Duijndam / Dalam for Action Against Hunger Against Action for Dalam / Duijndam © Sébastien Figure 4: Summary of indicator changes * These changes cannot be attributed to Care Group programming

A ‘Result Reliability Index’ was calculated according to data quality and applicability of the difference-in-difference model. The relative strength of these results is color-coded as low, medium, and high. Care Group programming was most strongly associated with a rapid improvement in health facility utilisation.

Low Reliability Index Medium Reliability Index High Reliability Index Each session starts with a game to break the ice and create a safe space for sharing experiences. 44 LEARNING REVIEW 2019 Resource mobilisation 45

THE EMPLOYABILITY INTEGRATION APPROACH: INTEGRATING MENTAL HEALTH AND PSYCHO-SOCIAL SUPPORT WITH EMPLOYABILITY

Eugénie Parjadis BACKGROUND direct employment. The intervention formally recognised as essential in this MEAL Advisor often includes a cash for work intervention’s final evaluation. As a UK From 2017 onwards, Action Against component, which supports the result, Action Against Hunger Iraq staff Lara Colace Hunger's food security and livelihoods rehabilitation of communal facilities have been working together to better sector in Iraq, has been transitioning FSL Technical Advisor, and infrastructure while ensuring frame the iNTEGRATiON from the delivery of large-scale food Middle East Pool short-term employment schemes. APPROACH. France assistance programming to refugees Alexandre Letzelter and internally displaced persons in In the post-conflict context of a Good practices have been put in place MHCP-GP Technical camps and out of camps, towards the massive population displacement and for impactful action. At programme Advisor, Middle East provision of sustainable livelihoods economic crisis, the targeted audience design stage, protection aspects have Pool solutions to remainees and returnees. for this approach needs to strengthen also been integrated into business France More particularly, the sector has been their resilience to socio-economic grants and apprenticeship activities, addressing unemployment of youth shocks. Motivation is central for the through internal and external referrals. and women in urban areas. placements’ success, as well addressing Business grants and apprenticeship For more information psychosocial barriers to employability. beneficiaries are now selected on the contact: In the past three years, Action basis of online registration, which Against Hunger has implemented In response to these needs and in Hoger Tahseen Arif allows better inclusion of persons with fslpm-do@iq- a range of projects focused on the order to ensure sustainability of disabilities and specific risks of actionagainsthunger. EMPLOYABILITY APPROACH. the project, a psychosocial follow- vulnerabilities. Assessments are then org Beneficiaries can benefit from up was integrated into livelihoods’ carried-out by staff who are Hunger Against © Action employability assistance ranging intervention. It consisted in providing livelihoods and psychosocial workers. from technical capacity building, beneficiaries with indispensable life, Endale Dlasso They visit families to discuss and financial assistance for micro and small social and emotional skills in addition fslpm-do@iq- address their issues, as well as detect actionagainsthunger. businesses, to apprenticeship schemes to material support. The integration sensitive cases. Apprentices’ working org co-funded by local enterprises, and of livelihoods and mental health was conditions are monitored weekly. 46 LEARNING REVIEW 2019 Resource mobilisation 47

LEARNiNG: iNTEGRATiNG LiVELiHOODS empowered in the market and local economy. NEXT STEPS: INTEGRATION OF MENTAL With regard to SELECTiON PROCESSES, AND PSYCHOSOCiAL ASSiSTANCE One said “I attended all the mental health and HEALTH AND PSYCHOSOCIAL SUPPORT the current scoring system will be revised iMPROVES SOCiO-ECONOMiC psychosocial support sessions as they provided NEEDS TO BE TAKEN FURTHER accordingly and the selection committee will iNCLUSiON me with a lot of positive energy.” be integrated to ease discussions between Through systematic learning workshops, livelihoods and protection staff. Employability The integration approach increased the Life, Social and Emotional trainings coupled Action Against Hunger Iraq identified ways to livelihoods and psychosocial resilience of its programmes are at the crossroads of several with psychosocial follow-up have proved to be further foster inter-sectorial integration in their types of vulnerabilities. They need to provide beneficiaries, as evidenced by recent learning beneficial for both livelihoods and protection employability programmes. exercises in employability projects such as a specific psychosocial services for ndividualsi components, especially for women who had that could eventually not qualify for a job final evaluation and learning workshops. not entered the labour market before. Involving Action Against Hunger will allocate more RESOURCES to the integration approach. More but are in a situation of psychological distress. Beneficiaries acquired life and communication women in the employability schemes proved The employability programs are a good entry to be a challenge. It required adaptation of human resources are needed on the protection skills through mental health and psychosocial side to ensure greater coverage and increased point for detection of psychosocial needs and support sessions, improving their well-being, trainings’ time, support for transportation internal referral. solutions and, not the least, support by inclusion in the provision of the mental health self-esteem, communication, confidence and and psychosocial support services. decision-making skills in addition to increasing psychosocial workers aimed at overcoming Joint MONiTORiNG visits need to be the sustainability and profitability of heirt cultural gender barriers and coping with OUTCOME INDICATORS which consider encouraged as well so that the situation of economic activity. They were able to make harassment in the workplace. both livelihood and psychosocial support will each beneficiary can be understood holistically. informed and adapted livelihoods choices and The short duration of interventions is also a be designed, and will consider the inclusion of iNNOVATiVE SOLUTiONS will be to integrate the market, thus increasing their challenge. The employability approach requires mental health, wellbeing and resilience aspects. considered in order to involve and maintain socio-economic inclusion in the community. more time than emergency interventions to The provision of CROSS TRAINING at the women in the job market, such as services Performance evaluations conducted five meet long term sustainability achievements inception of a new program will also support oriented to women with children and different months after activities recorded a satisfactory linked with job inclusion and retention. the collaborative approach between the two working times. 66% of apprentices still at work and 70% sectors. of grants beneficiaries still running their Overall, the integration approach enhanced the The overall future interventions will need to businesses. project’s relevance, effectiveness, efficiency, Livelihoods and protection staff will better be more linked to LOCAL PARTNERS, to sustainability, and impact, emerging as one of jointly engage on carrying-out joint INITIAL ensure a complementarity of action and long Hunger Against © Action Persons with disabilities in particular reported the best practices across the apprenticeship ASSESSMENTS of beneficiaries’ enabling and term sustainability. In this end, availability how the livelihood and psychosocial support and business components of the livelihoods limitation factors to enter the job market. A of locally managed microfinance solutions sessions enabled them to overcome their intervention. good understanding of the barriers individuals will also be assessed in order to replace the psychological difficulties due to their personal might be facing would facilitate targeting. direct provision of grants, with a consequent financial and disability ituas tion, and feel improvement of cost-efficiency. 48 LEARNING REVIEW 2019 Acknowledgements 49

ACKNOWLEDGEMENTS

The production of the Learning Review would not have been possible without the hard work and support of our Action Against Hunger staff THE FOLLOWING PEOPLE CONTRIBUTED ARTICLES TO THE 2019 LEARNING REVIEW: both in the UK and around the world. Zuhra Aman Action Against Hunger Gender Unit, Canada Ali Mohamed Nassur Epidemiologist and Biostatistician, France THE 2019 LEARNING REVIEW WAS PRODUCED BY: Menna Seged Abraha Advocacy Officer West Africa, Spain Eugénie Parjadis MEAL Advisor, UK Farzana Ahmed Kim Winkler (Graphic design & editorial support) Advocacy Coordinator, Mauritania Technical Director, India MEAL and Information Management Advisor Communications and Knowledge Management Officer Amadou Bousso Dr Pawankumar Patil Action Against Hunger UK Action Against Hunger UK Johannes Casera Junior EU Aid Volunteer, South Caucasus Kanaganathan Rangaiya WASH Head of Department, Nigeria Joel Woolfenden Lara Colace, FSL Technical Advisor, Middle East Pool, France Armelle Sacher Social and Behavior Change Technical Advisor, USA Project Officer Action Against Hunger UK Dr Arero Halkano HoD Food Security and Livelihood, Somalia Luis Rolando Sánchez DRR & Agro-Climate Coordinator, Central America Mission Lucile Hermant Advocacy Officer, Niger MANY THANKS TO THE FOLLOWING PEOPLE FOR EDITING, REVIEWING AND DEVELOPING ARTICLES FOR THIS PUBLICATION: Dimple Save Head of Nutrition, South Sudan Fardosa Hussein Communication Manager, Somalia Chloe Airey Jake Ireland Andy Solomon-Osborne HoD /Technical Advisor MHPSS, Ethiopia James Justin Nutrition Data Manager, South Sudan Research, Evaluation and Learning Intern Communications and Learning Intern Stephanie Stern Action Against Hunger Knowledge LAB Advisor, Action Against Hunger UK Action Against Hunger UK Alexandre Letzelter MHCP-GP Technical Advisor, Middle East Pool, France Cleo Chevalier-Riffard France Hugh Lort-Phillips Project Officer, MEAL and Information Management Djaffra Traore Advocacy Coordinator, Mali Senior Nutrition Assessment Advisor Arlen Martinez DRR Coordinator, Nicaragua Action Against Hunger UK Action Against Hunger UK Dea Tsartsidze Monitoring and Evaluation Manager, South Alan Ricardo Patlan Hernandez Epidemiology Analyst, France Caucasus Elena Grüning Juliet Parker Gyanika Narayanaswamy Documentation and Research Project Officer, MEAL and Information Management Director of Operations Karlotine Weshe Head of MEAL, Haiti Consultant, India Action Against Hunger UK Action Against Hunger UK Dieynaba S N’Diaye Research and Analysis Advisor, France

James Hunter MEAL Team Coordinator Action Against Hunger UK © Lys Arango for Action Against Hunger FOR FOOD. FOR CHILDREN FOR CHANGING AGAINST THAT GROW MINDS. HUNGER UP STRONG. AGAINST AND AGAINST LIVES IGNORANCE MALNUTRITION. CUT SHORT. AND FOR CLEAN FOR CROPS INDIFFERENCE. WATER. THIS YEAR, FOR FREEDOM AGAINST KILLER AND NEXT. FROM HUNGER. DISEASES. AGAINST FOR EVERYONE. DROUGHT FOR GOOD. AND DISASTER. FOR ACTION. AGAINST HUNGER.