Learning Review 2016 1 FOREWORD
LEARNING REVIEW
2016
Action Against Hunger Learning Review 2016 1 FOREWORD
Looking back at 2016, I doubt any of us could organisations responding to their needs. grounded in the reality of their work with have predicted the events that unfolded, and communities before and after disaster strikes. will shape our future for years to come. There One of the strengths of the CHS is that it is This year their evaluations highlight cross is nothing new about change, however, the context specific, and therefore provides all cutting themes such as gender, working pace of change seems to have accelerated. organisations with the same common reference with local actors, resilience, cash-based This means that as the needs of people and framework against which to assess (and interventions and understanding what this communities vulnerable to crises continues to report on) their work. Whether you are a large means for current and future programming. increase, the vision of a world free from hunger international non-governmental organisation It is not surprising that these themes are can seem further away than ever. or local one, have a single mandate or multiple, very much in keeping with the ‘Agenda for the same nine CHS commitments apply to Humanity’, and align well with the World However, there were also positive you. Importantly, these are framed around the Humanitarian Summit commitments made as developments in 2016; the ‘Agenda for affected population, incorporating the diversity part of the ‘Grand Bargain’. Putting the results Humanity’, born out of the first ever World of women, men, boys and girls. of their evaluations together with their research Humanitarian Summit, reassures me that we findings ensures that Action Against Hunger Action Against Hunger has led the global fight have not forgotten our humanity. In spite of delivers quality programming that constantly against hunger for nearly 40 years, saving those who are sceptical of the outcomes of adapts to the needs of affected people and the lives of vulnerable children and adults, the Summit, I am confident that this shared communities. I particularly appreciate that and working with their communities before commitment to demonstrate our effectiveness the key learning from programmes has the and after disaster strikes. They constantly to communities has the potential to make a potential for replication. This is invaluable from search for ways to improve the organisation’s positive difference. To do this, we need to an organisation with a proven track record for effectiveness by investing in learning, and change how we work, and put affected people high quality programming, and an inspiration to sharing the benefits of this learning with the at the centre of what we do, thus ensuring that us all. they can influence the decisions that affect sector. Both play a critical role in helping all their lives. We also need to ensure that any of us to ensure that we are not only doing It is an honour and a privilege to introduce and all responses should be as local as possible, things right, but that we are also doing the this year’s Learning Review – it is grounded and as international as necessary. right things. At the CHS Alliance, we value in reality and future focused. It certainly continuous learning as an intrinsic part of demonstrates, particularly in this fast changing The Core Humanitarian Standard (CHS) improving quality and accountability in the world, that evidence is key to informing how all provides a common reference framework that sector, and I am proud to count Action Against actors (local and global) work outlines what organisations (local/national/ Hunger as a member. with and for those affected by international) need to do to deliver high quality, crisis. and accountable, assistance and protection. In the 2016 Learning Review, Action Against In addition to this and of equal importance, Hunger shares what they have learned from JUDITH GREENWOOD it specifies what people and communities their evaluations, research and programming. EXECUTIVE DIRECTOR affected by crisis should expect from This combination is vital, as their learning is CHS ALLIANCE
2 © Julien Goldstein for Action Against Hunger Against Action for Goldstein © Julien
CONTENTS
INTRODUCTION 4 SECTION ONE: WHAT OUR EVALUATIONS ARE TELLING US 6 1.1 RESILIENCE 1.2 CASH-BASED INTERVENTIONS 1.3 WORKING WITH LOCAL PARTNERS 1.4 GENDER SECTION TWO: WHAT OUR RESEARCH IS TELLING US 23 2.1 TRANSFORMING THE TREATMENT OF MALNUTRITION 2.2 INTERVENTIONS ON WATER AND HYGIENE TO IMPROVE AMBULATORY TREATMENT OF ACUTE MALNUTRITION: WHAT ARE THE BENEFITS? 2.3 WHAT WORKS TO PREVENT ACUTE MALNUTRITION USING CASH TRANSFERS 2.4 A PORTFOLIO LOOK ACROSS COST-EFFECTIVENESS ANALYSIS SECTION THREE: WHAT OUR PROGRAMMES ARE TELLING US 38 3.1 IMPROVING INFECTION PREVENTION AND CONTROL IN SIERRA LEONE 3.2 MAPPING AND GEOGRAPHIC INFORMATION SYSTEMS: INCREASING THE EFFECTIVENESS OF ACTION AGAINST HUNGER’S NUTRITION PROGRAMMES 3.3 LIFE GEORGIA STANDS FOR LIVES 3.4 STRATEGIC FORESIGHT: THE CORNERSTONE OF HUMANITARIAN PROGRAMMING CREDITS AND THANK YOU 50
Action Against Hunger Learning Review 2016 3 INTRODUCTION BY HANNAH WICHTERICH, SENIOR PROJECT OFFICER, ACTION AGAINST HUNGER
In 2016, Action Against Hunger launched its However, after five years of insightful Learning outlining the overview of the studies, some Right: A mother new five-year International Strategic Plan. The Reviews, we considered our new strategic key findings, and lessons learned around what and her child wait document outlines our ambition to be at the direction and brand identity, and decided that could have gone better. for humanitarian forefront of bringing positive and lasting it is time to try something different… so we assistance in Borno, sat down and looked at new ways to use the SECTION 3: WHAT OUR Nigeria change to the lives of those affected by hunger. Every day, over 7,000 members of rich pool of evidence we have collected over PROGRAMMES ARE TELLING US the years and considered other channels of staff worldwide contribute to the realisation Finally, we will investigate what our knowledge. To make sure it is appropriate of this ambition. From Afghanistan to programmes are telling us. We approached and as useful as possible to Action Against Zimbabwe, and everywhere in between, we country teams and asked them to share some Hunger staff (and other readers interested), we are lucky to have highly experienced and key lessons learned. It is hoped that these collected valuable feedback on what people committed staff, united in their action to fight have the potential to be applied across our would like to hear about and thus, decided to against hunger. programmes, regardless of context. This last take a focussed look at the following: For the last five years, our team here in the chapter also discusses Action Against Hunger’s United Kingdom has had the privilege of SECTION 1: WHAT OUR Inter-Agency Regional Analyst Network global analysing and reflecting on the work you all do EVALUATIONS ARE TELLING US project, by reflecting on the importance in the annual Learning Review. We know that of strategic foresight as a cornerstone of we would not be able to write this publication In this year’s edition, first, we will examine humanitarian programming. what our evaluations are telling us. We have without the knowledge and expertise you all CONSTANTLY LEARNING contribute, so thank you for continuing to work identified key themes from recent evaluations, and explored how these themes affect our with us to share these experiences both inside One of Action Against Hunger’s values is performance. Specifically, we focus on four and outside the organisation. “constantly learning” and this remains at the areas: gender, working with local partners, core of the Learning Review, so we hope that resilience, and cash-based interventions. this new structure provides you with a rich “WE WOULD NOT BE SECTION 2: WHAT OUR RESEARCH resource from which to draw on the experience ABLE TO WRITE THIS IS TELLING US of others. It is essential to continue to share these lessons, and be open to learn from one PUBLICATION WITHOUT Next, we will consider what our research is another. So please, enjoy reading the Review, THE KNOWLEDGE AND telling us. Here we present some emerging and we look forward to continue working with EXPERTISE YOU ALL findings from our current research projects, you. giving a summary of what gaps the research CONTRIBUTE” addresses and why it is important, as well as
4 ACRONYMS
CEA Cost-Effectiveness to Build Analysis Confidence Among CHS Core Humanitarian Ethnicities Standard MAM Moderate Acute DFID Department for Malnutrition International Development M&E Monitoring and Evaluation DRM Disaster Risk Management MUAC Mid-Upper Arm Circumference FUSAM Follow Up of Severely ODK Open Data Kit Malnourished The Consortium Children REFANI for Research on GAM Global Acute Food Assistance Malnutrition for Nutritional Impact GPS Global Positioning System SAM Severe Acute Malnutrition HQ Headquarter SWOT A Strengths, iCCM Integrated Weaknesses, Community Case Opportunities and Management Threats Analysis IPC Infection UNDP- United Prevention and COBERM Nations Control Development Programme Inter-Agency IARAN Confidence Regional Analyst Building Early Network © Guy Calaf for Action Against Hunger Against Action for Calaf © Guy Response LGA Local Government Mechanism Area USD United States LINC Leveraging Dollar Employment Georgia WASH Water, Sanitation Initiatives and and Hygiene Networking Action Against Hunger Learning Review 2016 5 OUR EVALUATIONS
Renforcement de la résilience des populations pauvres et très pauvres et amélioration de la sécurité Food Security / Resilience alimentaire dans les régions du pays les plus touchées par la crise de 2012 (PRORESI-GNAGNA ) Ensemble pour l’eau et l’assainissement durable en République Centrafricaine Water, Sanitation & Hygiene
Projet intégré de réponse à l’insécurité nutritionnelle et à l’accès aux soins de Multi-sector santé au Tchad en 2015 Développement socioéconomique des populations vulnérables dans le Bahr-El-Gazel, Tchad Water, Sanitation & Hygiene / Food Security
Mitigating the Impact of the Ebola Virus Disease on the Most Vulnerable Households through Food Security / Nutrition an Integrated Food and Nutrition Security Intervention in the District of Moyamba, Sierra Leone
International Global Gender Programming, Phases 1-3 Gender
Programme Pool d’Urgence Nutrition Congo (PUNC II) Nutrition
Sustain programme. Sustainable approaches for Improved Nutrition Food Security & Livelihoods / Nutrition Safe drinking water, sanitation and hygiene support for flood affected community in Water, Sanitation & Hygiene Pakistan
Somalia Resilience Programme (SomReP) Resilience
Reducing vulnerability through disaster risk management in Khyber Pakhtunkhwa Disaster Risk Management province, Phase II
Combating gender-based violence and enhancing economic empowerment of women Food Security & Livelihoods in Northern Uganda through cash transfers
Building disaster resilient communities in Masvingo and Manicaland provinces, Multi-sector Zimbabwe
Food Security and Livelihoods - from recovery to resilience Food Security & Livelihoods
6 SECTION ONE WHAT OUR EVALUATIONS ARE TELLING US
Our annual Learning Review provides us with the space to present and reflect on findings from our evaluations. There are many other sources of evidence that can be considered, but we feel that our rich pool of evaluations gives us a great opportunity to learn and improve our humanitarian action.
This year we decided to examine cross- In this chapter, we first examine the evaluation improvement. cutting themes that are central to the way of the Global Gender Programme and what we work and the kind of organisation we other evaluations have noted with regards As a note of caution, please be aware that want to be. We analysed past evaluations to gender. We then explore our working feedback on what has worked well and what with a special emphasis on gender, working relationships with local partners to understand required improvement is largely subjective, with local partners, resilience and cash-based what has worked well and what was not based on the evaluator’s point of view. We interventions, and then reflected on what successful in order to improve our ways refer to the countries in which projects and these findings tell us about our performance. of working with partners in the future. To programme evaluations have taken place, but What should we continue to do and what enhance our understanding we discussed of course this is not a representation of all of should we do better? partnerships with Lucia Oliveira, who has been Action Against Hunger’s interventions and with Action Against Hunger for 12 years and it is not meant to single out any of our staff. We selected a sample of 14 evaluations worked as a country director in 6 different Many areas have developed and advanced 1 spanning from 2014 to 2016 . The evaluations countries, currently holding this post in Egypt. in subsequent years and we recognise that a reflect a combination of projects and project designed two or three years earlier programmes that touched upon the themes We then discuss resilience. As there are a may be very different to a project designed outlined above. For each theme we also multitude of activities that can be termed and implemented today. reviewed available Action Against Hunger ‘resilience’, this analysis covers a broad range policies and position papers, and consulted of projects and programmes, from disaster Some things might seem obvious to you, technical advisors for advice and feedback. In risk management activities to water source and some things might be unexpected. general, the analyses follow a similar pattern, interventions and income-generating activities. Nevertheless, we hope that this chapter unpacking the project cycle with regards to gives you a good sense of what our needs assessment and design, implementation, Lastly, we discuss cash-based interventions, evaluations are telling us, and some practical monitoring and evaluation, sustainability and highlighting areas where Action Against recommendations to take away on how we can recommendations. Hunger has demonstrated good practice in this improve our interventions. area, and reflecting on where there is room for
1 All managed by the Evaluation, Learning and Accountability team at Action Against Hunger, except the Somalia evaluation
Action Against Hunger Learning Review 2016 7 © Samuel Hauenstein Swan for Action Against Hunger Against Action for Swan Hauenstein © Samuel
1.1 RESILIENCE
For Action Against Hunger, resilience refers how resilience programmes are portrayed mitigation, community capacity building, to “the capacities of people, communities to donors who look for visible short-term evacuation preparedness, rescue preparedness and the systems on which they depend effects, while resilience programming is on a and relief preparedness. to resist, absorb, cope and adapt when longer timeframe. exposed to a hazard or set of hazards – while Identifying areas of improvement is key to preserving, restoring or enhancing their NEEDS ASSESSMENT AND DESIGN promoting learning within programmes. food and nutrition security.”2 Central to the With regards to needs assessment and The design of a programme is often dependent design, one area of improvement found in organisation’s resilience strategy are the on the needs assessment undertaken in programming principles that include, among six of the evaluations is for projects to gain the target area. The needs of a population a better understanding of the local context others, the integration of cyclical disaster should be the driving factor of how the risk management into all programming, during the design stage. The evaluation in programme is designed. Within the scope Chad found that multiple activities had to be and the participation and ownership by all of Action Against Hunger’s programming stakeholders of evaluation and research to adapted on the ground, because the planned related to resilience, what worked well during activities were found to not be relevant to the improve future activities. In 2016, Action the needs assessment/design phase of the Against Hunger carried out 111 projects communities targeted. For example, training programmes was the integration of activities for an intensive farming technique to fatten related to disaster risk management in 28 to build resilience. The combination of countries. A look at evaluations undertaken lean animals was planned. However, it was multiple short and long term activities, which found that this was not pertinent an area with by Action Against Hunger, directly or create a more holistic approach to resilience, indirectly related to resilience, provided limited pasture and food, and therefore the has been praised by evaluators in multiple activity was abandoned. While we promote evidence that we have made great strides contexts. In Pakistan, where the disaster to ensure programming is in line with our community-based disaster risk management, risk management approach was used, the in order to improve our design, there is a need resilience strategy. Nonetheless, there evaluation commended Action Against Hunger are still adjustments to be made, not only to promote resilience analysis as part of the for having a comprehensive approach covering needs assessment package. with programming itself, but also with six categories on the continuum: prevention,
2 Action Against Hunger, Enhancing Climate Resilience and Food & Nutrition Security: Action Against Hunger’s approach to face climate change, hunger and undernutrition in at-risk communities, 2012
8 1.1 RESILIENCE
“CONTINUOUS LEARNING IS WHAT ENSURES PROGRAMMES One of the most significant findings was one clan dominated local staff rosters which can TARGET BENEFICIARIES that some programmes had staff who knew result in programmes being shaped to target APPROPRIATELY” the needs, but were unable to design a one specific group, rather than all. programme that addressed them due to their This can lead to issues such as the treasurer own knowledge limitations. In Myanmar, the IMPLEMENTATION taking the money home for safekeeping which evaluation highlighted that the lack of staff The outcomes of the programmes are only leads to added security risks. Additionally, the knowledge relating to income-generating as good as the design, needs assessment language of disaster risk reduction protocols activities in the form of marketing specialisation and time allocated to activities. Four of the was not adapted to trainees in some of the was problematic. Additionally, programme evaluations indicate that good outcomes were programmes. In programmes when it was, such evaluations from four countries found that an achieved through the capacity building of as in Burkina Faso where simplified language excessive number of activities were planned in target populations. In Zimbabwe, the training of was used to teach beneficiaries about dietary time frames which were too short. They also disaster risk management committees created diversity, it was deemed to be a successful found issues relating to programme coverage a certain level of readiness, consciousness and approach to training. being too low. However, while programme awareness of disaster risks, in addition to the coverage could have been higher in some ways to reduce them or mitigate their impact. The remainder of the findings relating to programmes (e.g. the Sahel and Pakistan) staff Participants were seen carrying out related training and capacity building included issues capacity and funding shortages prevented this. activities post-training, and the committees with the content and insufficient time dedicated to resilience trainings. As noted in the Myanmar Beneficiary selection is an integral part of were deemed to have given a voice to the rural evaluation, the time dedicated for trainings programme design, and comes from a good population in technical issues. The evaluation is not always predictable. Delays in the understanding of the needs assessment. in Somalia provided Action Against Hunger implementation, due to the relocation of the The evaluations of resilience programmes with key lessons on the implementation of project after unrest in Northern Rakhine State, provided strong evidence that Action Against resilience programmes in the context of a fragile meant that trainings provided to farmers were Hunger involved the community in beneficiary state. The approach in Somalia of addressing delayed until the end of the project. selection. Evaluations in Pakistan, Burkina Faso both long-term and short-term needs in such and Chad found that the targeted communities contexts, as well as of including early action MONITORING AND EVALUATION played a role in the selection of beneficiaries. and transformative approaches (reinforcing While this is a positive step, there is still room local governance), has improved the ability of With regards to monitoring and evaluation, for improvement, particularly to increase the communities to better deal with shocks. some areas for improvement were found organisation’s awareness of the role social relating to indicators and data collection. Some Results from evaluations have however shown connectedness plays in beneficiary selection. evaluations identified the need to improve that certain aspects of programming may not In Somalia, the need to better understand the logframe indicators, a challenge for most aid have worked so well and need to be refined for relationships between clans and sub-clans and agencies, as resilience indicators are highly future interventions. Evaluations of programmes beneficiary households was highlighted in the contextual. In the Democratic Republic of the in the Central African Republic and Burkina evaluation. This is to ensure clan relationships Congo, where Action Against Hunger supported Faso have shown that income generating do not negatively influence beneficiary an early warning system for the nutritional activities are not always accompanied by selection. In several locations, it was clear that system, it was noted in the evaluation that training on how to manage money.
Action Against Hunger Learning Review 2016 9 1.1 RESILIENCE
expanding the indicators to include some cases have been due to high staff turnover. Action Against Hunger losing well trained staff of diarrhoea and fever from the health centres and institutional and local knowledge. could have provided additional indicators of the SUSTAINABILITY nutrition situation on While multiple areas have been identified With programmes so dependent on external as in need of improvement, it is also evident the ground. In Somalia, a number of indicators funding, it is important that programme design that some of those areas struggle due to were still seen as ‘emergency indicators’, causing ensures long term sustainability in case Action reasons beyond their control such as budgets. a challenge in monitoring resilience. To address Against Hunger cannot continue its support. Nonetheless, it is important for us to strive to this challenge, additional indicators were added Multiple successes were identified in four use the lessons learned and adjust programming to better understand how resilient communities evaluations in relation to sustainability. In accordingly. Continuous learning is what ensures are to shocks and to measure the results of Zimbabwe and the Sahel, the resilience projects programmes target beneficiaries appropriately, resilience programming. Additionally, some were considered sustainable due to the fact that and remain sustainable beyond Action Against data was missing from monitoring systems. The trainings had taken place, leading to knowledge Hunger’s presence. evaluator in Chad found that crop monitoring and skills remaining in-country following our was undertaken to see how successful harvests departure. In Somalia, Action Against Hunger RECOMMENDATIONS were. However only beneficiary crops were ensured that supply lines were left for trained • Ensure an understanding of local cultural, assessed and there was no “control” group community members. Not only were community socio-economic and environmental context. available for comparison. A control group animal health workers trained, but Action Against Hunger also supported veterinary would have been useful to understand if our • Better include the beneficiary communities in suppliers in providing medicines after the end of intervention had an effect or not. the conception and planning of projects. the project to ensure that animal care continued. In terms of data collection, two pertinent areas • Train volunteers in community-based While some evaluations commended for improvement were identified. The first was disaster risk management, for the process to certain programmes for their sustainability, the need for improved monitoring of trainee be replicated in villages where Action Against it is important to continue to strive for all knowledge. In Zimbabwe, participants were Hunger is not directly implementing. asked about official concepts and terminology programmes to implement plans to ensure that related to disaster risk management, rather than beneficiaries continue the activities beyond • Need realistic monitoring and evaluation practical disaster risk management techniques. the departure of Action Against Hunger. The activities to measure sustainability of behaviour This therefore limited the programme’s evaluation in Myanmar found that the home change. understanding of their capacity. Secondly, the gardens project had not created a system for • Measuring the effect of different activities on need was identified to improve the scheduling seed storage which meant that they remained local levels of malnutrition should be a standard of data gathering. In Sierra Leone, the Sahel reliant on a partner to provide seeds at the practice. and Burkina Faso, evaluations discovered start of each planting season. Additionally, one of the issues leading to a programme’s that collection of end line data was done over • Properly assess the environmental poor sustainability was funding gaps between different time periods to baseline data leading to sustainability of programme activities. a biased interpretation of the programme. It has projects. If funding continuity is not ensured, the been noted that this lack of consistency could beneficiaries suffer. Similarly, due to these gaps, staff tend to move on to other jobs, resulting in
10 ©Damien Guerchois for Action Against Hunger Against Action for Guerchois ©Damien
1.2 CASH-BASED INTERVENTIONS
Action Against Hunger continues to cash-based interventions. These are Chad insecurity. The Sahel evaluation highlighted integrate cash-based interventions into its (2015), the Sahel4 (2014), Sierra Leone (2016), that cash disbursements during the lean season humanitarian assistance, as an alternative Somalia (2015) and Uganda (2014). In this cross- were appreciated, and used for buying food and complementary tool to in-kind delivery cutting analysis, we measure ourselves against and paying off debts. In Somalia, the approach modality. This is aligned with the third the Grand Bargain commitment on cash-based is a common humanitarian intervention. commitment of the Grand Bargain that interventions, by highlighting areas where Consequently, the evaluator found staff to be aspires to “increase the use and coordination Action Against Hunger has demonstrated good experienced with conditional cash transfers and of cash-based programming”.3 Many of the practice, and reflecting on where we can do that beneficiaries are familiar with the tool. As a communities assisted by Action Against more. result, implementation was rapid. Hunger live in cash economies where people earn money and buy much of what they need NEEDS ASSESSMENT AND DESIGN That being said, context is important - and on the market. During an emergency, these as the Grand Bargain states, “cash cannot The 2015 Learning Review concluded that cash meet all needs”. Action Against Hunger has markets often remain operational, or recover transfers are an effective option for supporting relatively quickly, which means accessing goods demonstrated its ability to identify when cash- communities during humanitarian crises and based interventions are not appropriate. The on the local market can be a way of meeting are becoming more standardised in Action people’s needs. Through the provision of cash, evaluator commended staff in Chad (2016) Against Hunger’s response mechanisms. Similar for not using cash-based interventions in the programme beneficiaries are able to access trends have been identified in our cross-cutting essential goods and services of their choice. development of income-generating activities. analysis, where all five programmes featuring Start-up kits specific to each activity were Last year’s Learning Review found cash-based cash-based interventions were praised by the used instead, so that the inputs were not spent interventions to be an effective, efficient and evaluators for their relevance. The evaluation on immediate household needs. In a different flexible approach in supporting vulnerable from Uganda indicated that cash transfers were example, results from the Uganda evaluation populations. This year, we aim to delve deeper, perceived as giving beneficiaries the freedom indicated that the cash-based intervention and take a look at the recurring themes from of choice, therefore maintaining dignity and needed to be more holistic to the context, five programme evaluations which implement a sense of normality during periods of food since some beneficiaries who engaged in
3 http://www.agendaforhumanity.org/initiatives/3861 4 Burkina Faso, Chad, Mali, Mauritania and Niger
Action Against Hunger Learning Review 2016 11 1.2 CASH-BASED INTERVENTIONS
cultivation spent the cash on clearing land and IMPLEMENTATION generating activities, training on how to spend hiring tractors to cultivate it. In the future, the money did not always accompany the Action Against Hunger could make strategic Regarding the selection of beneficiaries, the transfer. partnerships with local tractor-hire (or other) evaluations presented different results. In the businesses to prevent this from happening. Sierra Leone programme, the evaluation found In the evaluations carried out in Sierra Leone that the target community was involved in and Uganda, evaluators commended the Despite the relevance of using cash-based the beneficiary selection process, which was programmes’ integration of cash transfers with interventions, results from the five evaluations highlighted as good practice since it avoids other interventions. Some examples included have found opportunities for improvement. tension within communities. The Uganda Village Savings and Loan Associations, nutrition Few evaluations go into detail regarding any programme used a participatory methodology sensitisations, and food security and livelihoods involvement of community members at the to identify beneficiaries, in order to ensure trainings. Integrations like these increased needs assessment stage, and whether that active participation in all of the relevant project synergies and sustainable approaches resulted in an appropriate programme design. trainings. This method allowed the programme linked to development. All of this helps us to With that said, the evaluations from the Sahel to only target the most vulnerable and “build an evidence base to assess the… benefits and Sierra Leone did mention that needs displaced by the conflict in South Sudan, which [and] impact… of cash relative to in-kind assessments were incorporated into the cash- ensured that resources were spent efficiently assistance, service delivery interventions and based interventions component of programme and effectively. vouchers”1, which is one of the key components design. However, the engagement and inclusion of the Grand Bargain commitment. of beneficiaries was insufficient. The evaluator In the Sahel programme the beneficiary stated that the Sahel programme did not selection process required improvement. In Although integrating cash transfers with Village satisfactorily include beneficiaries in the needs many communities, the village chief/leader Savings and Loan Associations were viewed by assessment and design, while the programme was the main contact. This should have the evaluators as a sustainable approach, some in Sierra Leone included beneficiaries in the been avoided, as it has historically led to shortcomings were identified. In the Uganda needs assessment, but not in the design. In the distorted results. It would have been better programme, where the Village Savings and Loan Sahel programme, the evaluator highlighted for communities to either democratically elect Associations were established, the evaluator the need to make the needs assessment the committee members, or for Action Against recognised a need for additional support and design stages more participatory for Hunger to include those that most people in the regarding comprehensive training on financial beneficiaries. None of the evaluations mention community trust. literacy, record keeping, financial management whether an in-depth market assessment took and business entrepreneur skills. In the Sierra Findings from the Uganda evaluation showed place throughout the projects, although it was Leone evaluation, it was found that the project that beneficiaries received adequate training on assumed that it was carried out in the Sahel, timeline was considered too short with too cash spending. This was found to enhance the Uganda and Chad evaluations, without further many activities to ensure the sustainability transfer’s impact, as beneficiaries were trained details being provided. of the Village Savings and Loan Associations. on ways to make the best use of their money. It takes time to set them up and provide However, in the Sahel programme where the training, and for committees to be comfortable cash transfer was connected to income- to operate without support. This was not considered possible given the timeframe.
12 MONITORING AND EVALUATION rather than for programmatic improvements. to delivery modality, including cash-based As the team spent two months checking the interventions: The Grand Bargain highlights the need to vulnerability status of households, it would “ensure that coordination, delivery and have been appropriate to collate and analyse • Ensure a clear methodology for targeting monitoring and evaluation mechanisms this data to see who the beneficiaries were. cash-based interventions beneficiaries prior are put in place for cash transfers”.1 Action Doing so would also have allowed us to to implementation. Ensure that beneficiaries Against Hunger’s fulfilment of this was mixed. contribute to the fourth component of the are included in both the needs assessment The programme in Chad was considered Grand Bargain commitment on cash, which and programme design. Also make sure to to have employed good accountability asks actors to look into the impact and risks include in-depth market assessments, as mechanisms for the food security and of cash programming on protection. it is an important step to contribute to the livelihoods component overall, which included programme design phase. a cash transfer component. Action Against As discussed, as an organisation we • Consider providing varying quantities of Hunger’s relationship with the complaints should help build an evidence base for the cash to beneficiaries depending on their committees allowed constant dialogue. A effectiveness of cash programming compared vulnerability status. Action Against Hunger community/beneficiary complaints mechanism with other types of programme (i.e. in-kind could make strategic partnerships with local was also implemented in the Sierra Leone or voucher-based). As there was also no tractor-hire businesses to avoid beneficiaries programme for the duration of the project. database to monitor implementation at an having to spend the cash transferred to them However, although beneficiaries appreciated individual or household level, only at a village on this. the initiative, it needs strengthening, since level in Sierra Leone, it was not possible to compare project results between different follow-up on the complaints was incomplete. • Contemplate letting communities either categories of beneficiaries e.g. male- or democratically elect cash transfer committee In addition, evaluation of other programmes female-headed households, or between other members, or for Action Against Hunger illustrates the need to improve our monitoring types of program. Finally, baseline data was to include those that most people in the and evaluation mechanisms. For example, collected in August, in the middle of the lean community trust. monitoring and evaluation of the project in season. Although post-distribution monitoring Sierra Leone was considered insufficient. Data was done in October, data for the Food • Link cash-for-work with Village Savings and was mainly collected for reporting purposes, Consumption Score and Coping Strategy Loan Associations for sustainability. rather than for programmatic improvements. Index was not collected until January. The As the team spent two months checking the questions and data therefore relied on • Establish a complaints mechanism. A vulnerability status of households, it would beneficiaries to recall events retrospectively, database with all complaints, required have been appropriate to collate and analyse which likely resulted in biased information. information and whether a response has been this data to see who the beneficiaries were. provided to communities must be kept up-to- Doing so would also have allowed us to RECOMMENDATIONS date to track progress. All complaints boxes contribute to the fourth component of the should be checked at least on a quarterly Based on the findings presented above, a Grand Bargain commitment on cash, which basis by the monitoring and evaluation number of recommendations are hereby asks actors to look into the impact and risks officer. presented regarding interventions related of cash programming on protection. purposes,
Action Against Hunger Learning Review 2016 13 © Francois Lenoir for Action Against Hunger Against Action for Lenoir © Francois
1.3 WORKING WITH LOCAL PARTNERS
In 2016, the World Humanitarian Summit national non-government organisations. which is also emphasised by Lucia, who shared presented the Grand Bargain, an ambitious some good and bad examples of this. document that outlines ten commitments In our 2016-2020 International Strategic Plan, designed to help organisations better prepare two of our 2020 targets are to ensure that “at “In Syria, our partnership with an for - and respond to - humanitarian crises. least 80 per cent of country strategies include intergovernmental organisation belonging Importantly, the document emphasises a local partnership strategy” and “at least 20 to the Arab League increased Action Against partnership, stating that “above all, the Grand per cent of programmes funds are channelled Hunger’s operational partnership maturity. Bargain is about the need to work together through local partners”. It is promising to The application of our own Partnership efficiently, transparently and harmoniously see that we are already partnering with Toolkit during the scoping, identification and with new and existing partners, including the local government and non-government due diligence phase proved highly beneficial. private sector, individuals and non-traditional organisations in 84 per cent of the countries It allowed us to obtain key data about the sources of funding”.5 that we work in. potential partner, exchange organisational Lucia Oliveira, Country Director for Egypt, approaches with them, and design the project The Grand Bargain’s second commitment itself. The tools include: reflects the growing recognition of local and who has been with Action Against Hunger national response to humanitarian crises, for 12 years, and worked in six countries with • a selection criteria tool that contains general, and the need to engage with and reinforce a over 20 partners, shared various insights with financial and legal questionnaires; country’s existing capacity. It is worth nothing us. She gave us examples of both good and that this spirit of partnership is already bad practice in partnerships, and key lessons • a strategy framework tool that assists in reflected here at Action Against Hunger, learned. The recommendations brought defining a collaboration strategy; where we work with over 600 partners in forward from our evaluations mirror these • a strengths, weaknesses, opportunities, and 50 countries. Our partner profile echoes this insights. threats (SWOT) analysis; and enthusiasm for working with local actors; NEEDS ASSESSMENT AND DESIGN 13 per cent of our current partnerships are • a risk analysis” with national government, 31 per cent with This analysis of our evaluations highlighted local government, and 13 per cent with local/ the need for targeted ‘scoping’ of partners, “…In Lebanon, a project was designed without 5 Available at: http://www.agendaforhumanity.org/initiatives/3861
14 1.3 WORKING WITH LOCAL PARTNERS
applying the partnership tools mentioned above. better with government structures. project. The same was found in Burkina Faso, This meant that the partner was not identified where the failure to involve local municipalities and selected properly during the scoping phase. We need to ensure we work with partners from in needs assessment and design was highlighted Although the partner accepted joining the the assessment and design phase of a project. by the evaluator as a missed opportunity. project, it quickly became clear that their way of This can help increase trust and respect, create Involving the authorities early on would have working was divergent to our own. This dictated a shared purpose and ensure that programmes allowed them to identifymunicipalities in needs an abruptend to the partnership. The project incorporate the skills and expertise of all assessment and design was highlighted by the suffered delays as a result, and demanded double partners. evaluator as a missed opportunity. Involving the the effort from staff to put it back on track for authorities early on would have allowed them both our beneficiaries and donors... The scoping “... Action Against Hunger and partners (present to identify and understand their own needs. phase of the partnership cycle must be obligatory and future) should strengthen the glue that holds Instead, we relied on community members to when engaging in any kind of partnership.” Lucia partnerships together, by aligning values and carry out some of the more challenging activities Oliveira defining core competencies from the start… The rather than a local partner. In this case, we building phase of the relationship is the one that were not inclusive enough and missed out on This experience is not unique. There are a demands more effort, and the use of workshops mutual learning. In the Somalia programme, number of contexts where, though we have and other tools to increase our togetherness. This government representatives interviewed during formed beneficial partnerships with one allows all staff to understand their role within the evaluation specifically requested that the organisation, we have failed to identify local Action Against Hunger. It also helps partner consortium coordinated with the government partners who could have added more to organisations to freely share their perspective on during the design phase. the programme’s results and sustainability. how projects should be done, and increases their One example of this was the Gender Based willingness to see the big picture.” Lucia Oliveira IMPLEMENTATION Violence and Economic Empowerment project in Uganda. The 2014 evaluation of this project Happily, evaluations noted that we achieved this “ [In Syria] staff sat in the partner’s office and highlighted the strength of our relationship in Sierra Leone and Chad, where government maintained daily contact. This enabled both with two local non-governmental organisations, authorities were involved from the outset, and organisations to build a relationship based on trust but suggested that closer partnership with in Uganda where the expertise of local non- and accountability. It also allowed Action Against the community could have increased buy-in. governmental organisation was used throughout Hunger to influence the processes and technical Further to this, in the Democratic Republic of the design and decision making phases. tools used during the project implementation… the Congo, the evaluation highlighted the need In Myanmar, the evaluation found that our Positive change only occurs when we fully to partner more with local government and partnership with a private organisation was integrate, speak the language and work with our non-governmental partners. In addition, the instrumental in ensuring the sustainability partners. Only in this way will Action Against evaluation of projects in the Sahel, Pakistan and of the project. However, it also showed that Hunger connect with partners intellectually and Burkina Faso all stressed that projects could there was poor coordination and expectation emotionally, thus overcoming deep-rooted beliefs, have been improved with greater involvement Lucia setting during the design phase. This led to a sensitivities and management cultures.” of communities and local organisations. The Oliveira misunderstanding over the partner’s capacity, evaluations for both Sahel and Sierra Leone also and significantly delayed implementation of the underlined a missed opportunity to coordinate The need to integrate fully with local partners is
Action Against Hunger Learning Review 2016 15 1.3 WORKING WITH LOCAL PARTNERS
key to ensuring successful operations. In Burkina Faso programme training was Right: A boy waters the Pakistan programme, engaging fully limited to one team within government, crops, Myanmar with the community was seen as a way of and due to high staff turnover this gaining local knowledge, as well as being knowledge was lost at the end of the cost effective. In the Sahel programme, programme. One solution to this might working in isolation from communities be to train ‘master trainers’ as opposed was found to be impossible. In particular, to individuals, who are committed to the the security environment meant that project from the design phase and ensure using local contacts who understand organisational memory and consistency. the local language and culture was vital. To be a leader in working with and MONITORING AND strengthening local partners, we have to EVALUATION make sure that the transfer of knowledge As an organisation that has committed is partner driven, and not imposed. to working with partners at a local level, This also affects partners’ staff and to strengthening their response, we turnover, which further hindered have to be able to measure ourselves project implementation, particularly in against our commitments and hold government. When partnership priorities ourselves accountable. It is difficult to are imposed from the top down, there measure how effectively we have ‘built is little or no buy-in from departments capacity’, and how well that capacity is and individuals. This results in low retained and utilised. Creating strong commitment and reduced involvement. local capacity to respond to crisis is The evaluations showed that this has about more than knowledge transfer, happened in the following partnerships, and depends on partners’ ability to apply where local organisations received this knowledge in their work. As we training from Action Against Hunger. measure ourselves against the targets In the Chad programme, we failed to in the International Strategic Plan, and account for the rotation of staff at the start to set out our country strategies for end of coordination posts, and the sheer partnership, it is vital that we find ways volume of activities they were required to measure whether or not we are really to lead. In the Myanmar programme creating capacity, or merely working too, the high staff turnover led to low alongside local actors. The present engagement and a lack of understanding evaluations suggest that in many cases, of a common goal between the three we are doing the latter. consortium members, which ultimately limited programme effectiveness. In the
16 SUSTAINABILITY Chad programme, the government was unable action. Action Against Hunger has some excellent to support the project long-term, the evaluation resources for making the leap from knowing to One way to promote sustainability is by ensuring from Pakistan showed that linking committees doing, such as the Partnership Guidelines and there is a thorough exit strategy. Without this to government structures was highlighted as Toolkit. This article proposes that we use these programme scope can shift and change, making a positive factor for sustainability. As such, a tools and the learning from shared experiences, programs less effective, or meaning that they thorough exit strategy, which considers some of and build partnerships that enrich not only our cease altogether. these risks, should be developed as part of the programmes, but of the partners who will serve building stage of the partnership cycle. It is worth those affected by crisis long after we withdraw. “ In Georgia, a very successful project, based remembering that every context is different. on the transfer of knowledge to partners and the RECOMMENDATIONS training of coaches (the ‘employment shuttle’ In addition, exit strategies should account for • Use the partnership toolkit to identify method), faced a very different challenge at the the continued supply of additional resources. For appropriate partners across sectors, map their end of the partnership. Though the employment example, in the Chad programme, partner staff capacities and interest, and carry out due shuttle methodology is still being used by the were taught to repair water pumps and provided diligence checks. At this stage, it is important trained partners, its delivery is not always in-line with a toolbox at the end of their training. The to include partners from all levels from national with Action Against Hunger’s technical approach. evaluation highlighted that this motivated them, government to the community. Although our staff still provide some coordination and allowed continued use of their skills long after the project had ended. Spare parts for the to the partners and coaches, it is felt that a tool • Involve partners from early on in the building/ water pumps were also provided in an attempt for quality control is absent... we propose to have design phase to ensure common goals and to make activities sustainable. However, the protocols put in place to regulate how partners use understanding. Action Against Hunger’s tools after we withdraw.” evaluation emphasized that working with the Lucia Oliveira government was non-sustainable, as they lacked • Define a monitoring and evaluation framework the finances to continue activities if Action from the beginning, which includes an evaluation Evaluations from Central African Republic, Chad, Against Hunger left. In the Central African of how we are positively and permanently Pakistan and Zimbabwe also highlight the need Republic programme, where repair-men were influencing our partners. to have an exit strategy in order to ensure the unable to easily access parts, the evidence effective continuation of a programme after we showed that sustainability was limited. In this • During the design phase, ensure that all withdraw. During the evaluation of a project case, establishing a spare parts supply chain project plans adequately address the exit in Zimbabwe, it became clear that the formed before withdrawing from the project would strategy and sustainability. Make sure plans are committees were dependent on Action Against allow repair-men to consistently access parts. in place to secure the supply chain before we Hunger for resources, particularly financial, and Alternatively, increased funding could be withdraw. that this was not transparent enough early on allocated to the follow-up phase of a project. in the project. Similarly, the evidence from the • Consider partner organisations’ environment Chad evaluation showed that working with the While none of these lessons may come as a when considering how and when to train government proved unsustainable, as they did shock, they serve as a reminder that knowing partners. Make sure that high staff turnover will not have the financial resources required to how to promote good partnerships, and saying not adversely affect the project. continue activities on their own. Whilst in the that we will, does not always translate into
Action Against Hunger Learning Review 2016 17 © Agnes Varraine-Leca for Action Against Hunger Against Action for Varraine-Leca © Agnes
1.4 GENDER
In the last few years we have increasingly it was managed. This in itself is a point for organisational strategy. The evaluation found recognised the need to improve gender improvement. Still, the analysis gives an that an appropriate needs assessment and mainstreaming across the organisation. We indication of if and how gender is considered in participatory process had resulted in a well- have since committed to increasing the impact projects and their evaluation. designed programme. However, it found the of our programmes for women, girls, boys and design of phases two and three, set to roll out men by analysing and addressing gender issues THE GLOBAL GENDER and institutionalise the Gender Policy and in the planning, implementation, monitoring PROGRAMME Toolkit, to be too ambitious compared with the available resources (human and financial). and evaluation of our policies, programmes and The Global Gender Programme is a four-year research. Since 2013, we have been working initiative set to develop relevant policies and The evaluation found the programme to have towards an organisational shift that would an enabling environment for the organisation help us to achieve sustainable gender-sensitive a positive effect on the design of projects at to move towards improved gender-sensitive field level. However, this is in contrast with the programming. We now need to take stock of programming. Since 2013 we have been how we are doing against these commitments. findings from the sample of project evaluations working to develop, roll out and institutionalise included in this review. This is either because In this chapter we discuss findings from the Gender Policy and Toolkit across our the Gender Programme started later than these programme and project evaluations conducted network. Recently, an external evaluation was evaluations, or possibly because the effects of during 2014 – 2016, looking specifically at conducted to assess the first three years of the Gender Programme have not yet trickled gender mainstreaming across the project implementation, in preparation for the last down consistently. Staff capacity on gender, the cycle. We also look at the findings from phase and the development of longer term establishment of policies and the evaluation of Action Against Hunger’s Global Gender Programme - an initiative to institutionalise gender into our organisational A recurring issue identified in a number of evaluations was the difficulty of recruiting a processes, systems and strategies. The analysis gender diverse staff, due to insufficient numbers of women appropriately qualified in certain suggests that there are still substantial gaps contexts. In a project in Chad, local midwives were asked to accompany health centre staff across the project cycle in relation to gender in specific activities in the community in an attempt to correct this gender imbalance. mainstreaming. Furthermore, not all of our evaluations commented on gender and how
18 “UNDERSTANDING GENDER RELATIONS IN A SOCIETY MEANS IMPROVING OUR ASSESSMENTS, OFFERING MORE ADAPTED ASSISTANCE AND INCREASING THE IMPACT OF OUR INTERVENTIONS IN THE FIGHT AGAINST HUNGER.”
Clara Ituero, Global Gender Advisor, Action Against Hunger Canada
promotion of gender equitable culture were consistency between some of the findings identified as areas of improvement, although of the Gender Programme and our project SPECIFICALLY TARGETING WOMEN on staff capacity, the evaluator suggested evaluations, sustainability is certainly an CAN ALSO HAVE NEGATIVE that more needs to be done. This is in line aspect we should continue to measure EFFECTS with our project evaluations, which showed in the next few years. For example, a The evaluation of the project in Burkina that in some contexts, staff knowledge on comprehensive gender audit, recommended Faso noted that project activities gender is limited. One evaluator suggested in the Gender Programme evaluation, will targeting women specifically could that gender appraisals should also be help us to assess the extent of gender potentially add to their workload, conducted with our partners. This highlights mainstreaming in all work areas, and over which would be counter-productive. the need to ensure that all staff involved in time. Beneficiaries raised concerns about our programmes are committed to gender the women-run health gardens, which mainstreaming, and know how to do it. NEEDS ASSESSMENT AND could become a burden considering This can be achieved by setting specific DESIGN their existing workload. Although recruitment requirements and compulsory Among the 13 evaluations reviewed, there the evaluator found that the work training. was evidence of both men and women being happened at a less busy period, it was While all staff interviewed for the Gender included in needs assessments exercises, highlighted as an issue that needs to be Programme evaluation knew of the Gender with programmes subsequently designed considered in the future. Policy, the Gender Toolkit was hardly to focus activities on the needs of women. known about or used. Similarly, there was However, 7 out of 13 evaluators reported no mention of the Gender Toolkit in the 13 that a robust gender analysis had not taken participants were women, with gender evaluations that were reviewed, whereas place during the design stage, which often ending up as a central component of the the Gender Policy was mentioned, although resulted in the limited inclusion of men or project. The evaluation of a project in only once. Sustainability of the Gender women in the programme. Pakistan mentioned its particular emphasis Programme was found to be likely, but it In Sierra Leone the evaluation found that 50 on female staff interacting with women, to was suggested that more efforts are needed per cent of the needs assessment ensure their voices were heard. It was also to guarantee that. Considering the lack of noted that the programme used the Gender
Action Against Hunger Learning Review 2016 19 Policy when developing vulnerability criteria for be increased. The programme especially struggled beneficiaries. When considering project design, four to mobilise women for needs assessments and evaluations found that the project focus on women project activities in Khyber Pakhtunkhwa Province, was appropriate, but one evaluation raised concerns an area with a highly conservative culture, and that targeting women specifically could add to their where women have limited mobility. In Somalia, workload. In the only gender-based violence project the evaluator highlighted that a robust gender included in this analysis, the gender component analysis would have aided our understanding of and the design were found to be relevant, noting the influence of gender on resilience capacity. For that the integration of a cash-based intervention to example, during the evaluation women reported the programme, which involved transferring cash having weaker supportive social networks during to vulnerable women, encouraged a more holistic times of crisis, and in general. approach to the context. RECOMMENDATIONS On the other hand, most evaluators described • A robust gender analysis is required during the inadequate gender analysis at the design stage. needs assessment to lead to a better understanding The evaluation of a project in Myanmar found that of the local cultural, socio-economic and a gender analysis had not taken place and men environmental context. were not appropriately included. The evaluation of the gender-based violence project in Uganda • Ensure staff are equipped with the tools and found that male participants were insufficiently knowledge to conduct a gender analysis which included in certain activities, and similarly in Chad, considers men, women, girls and boys, and not only the evaluation highlighted that men need to be women. more involved in activities. In both cases, the • Women need to be included at all key stages of evaluators highlighted that this is a limiting factor the project - but implementers should ensure that for project sustainability and overall strength. These project activities will not increase the burden on examples remind us that we must focus on the women, even if the outcome is positive. needs of women, girls, men and boys alike, and that the appropriate inclusion of men and women in IMPLEMENTATION project activities can help to ensure that men better recognise women’s contribution and needs, and vice Women’s representation in community-based versa. management committees was often reported
© Susana Vera for Action Against Hunger Against Action for Vera © Susana when considering gender mainstreaming in In the Central African Republic, the evaluator found project implementation. 5 out of 13 evaluations that gender was not officially analysed and women found positive trends, from good representation, were not systematically included in activities. to examples of women in key positions such as Meanwhile in a project in Pakistan it was noted that Committee President. In Myanmar, women’s groups the mobilisation of women in project activities must reported gaining influence in the community, with
20 1.4 GENDER
As Action Against Hunger often respected existing committee processes, women feeling empowered and perceptions of by the community’s standards. On the other or encouraged new committees to make Left: A man washes their roles changing among other community hand, the evaluator suggested that stronger their own decisions, it was likely not his clothes in the lake, members. advocacy messages on gender-based violence appropriate for staff to become involved Malawi could have been included in training sessions, in the gender balance of committees. However, other evaluations found that moving beyond the awareness-raising However, there is potential to influence women’s participation was insufficient. agenda. It was also suggested that the the gender make-up through agenda The evaluation of a project in Chad noted approach could have included setting and highlighting the benefits of a that women were poorly represented on responses to gender-based gender-balanced committee that better water pump management committees - violence, rather than remaining represents the community, for example the only two women that were included solely preventative. The evaluation during training sessions. were there to clean the water pumps. In also found that men were hardly Pakistan, the evaluation found that women targeted in the project. In a society were disadvantaged because they were less where men are often the key include referral of victims to available services aware of emergency stocks than their male decision-makers, this meant that the (as well as prevention) and address facilitating counterparts. This highlights the need to project did not achieve optimal results. factors such as alcoholism, alongside the root ensure that within Disaster Risk Reduction Finally, the project could have influenced causes of gender-based violence. Committees, women are the ones in charge gender relations more practically, by tackling of safekeeping the items they need, such as both root causes and the facilitating factors of MONITORING AND EVALUATION sanitary stools. gender-based violence. Gender-disaggregated monitoring was poorly LEARNING FROM THE IMPLEMENTATION reported across the evaluations reviewed, RECOMMENDATIONS OF A GENDER-BASED VIOLENCE and when it was, progress varied. Only three • Action Against Hunger needs to find ways PROGRAMME, UGANDA evaluations mentioned that the programmes to influence the gender balance of community Gender-based violence programming is not were taking the most basic steps to include committees involved in projects, and invest one of Action Against Hunger’s traditional gender in monitoring and evaluation, as per greater resources into mobilising women than intervention areas, however, a number of good the Gender Policy, by disaggregating data men. practices were highlighted in the evaluation. by sex and age. However, it is likely that this For example, gender-based violence and cash • Assign greater project-related happened in additional programmes but was transfer trainings were combined, which meant responsibilities to women to enhance their not specifically reported in the evaluations. information about the programme was shared confidence and role in decision-making. The evidence regarding monitoring and more widely. The selection of beneficiaries evaluation though suggests that substantive was participatory and had a well-defined • Action Against Hunger needs to ensure gender-related monitoring was often missing. selection criteria and a wide spectrum of that all trainings are facilitated by a man and a In fact, in three other evaluations it was ‘vulnerability’. The criteria were explained to woman – something especially imperative for mentioned that gender-disaggregated data the community and members were invited gender training. was either not collected, or that it was not to suggest participants. This meant the done for all project indicators. Specifically, one programme covered the most vulnerable, even • For gender-based violence programmes: evaluator suggested that tracking beneficiary
Action Against Hunger Learning Review 2016 21 1.4 GENDER
households more closely, with disaggregation between approach should be emphasised as a mandatory area, and Right: A child male and female-headed households, would have improved across the organisation, concepts and definitions regarding receives ready-to-use understanding on outcomes. Finally, one evaluation found gender should be shared. This was highlighted in the therapeutic food from that women were less aware than men of the project’s recommendations from the Gender Programme evaluation, an Action Against complaints mechanism. It was suggested that this could and echoed throughout the analysis of our sample project Hunger supported centre in Niger be due to a literacy barrier, which affects women more evaluations. Naturally, some areas will require more time than men. In the future, the inclusion of visual instructions and investment but others can be addressed relatively outlining how to lodge a complaint should be considered. easily and should not be compromised. Notably, we must ensure that gender-disaggregated data is collected and Although the gender agenda is much more integrated in that all our evaluations address gender across the whole our thinking than before, there is still much to be done if project cycle. This would allow us to monitor the roll out we want to become a truly gender-sensitive organisation. of the gender agenda and continue to improve our actions Therefore, gender should remain a priority working area, towards our commitment to gender sensitivity. incorporated into our values and practice. The gender © Samuel Hauenstein Swan for Action Against Hunger Against Action for Swan Hauenstein © Samuel KEY GENDER TIPS NOT FAMILIAR WITH OUR GENDER POLICY AND TOOLKIT? • INFORMATION WE NEED TO COLLECT FOR A GENDER ANALYSIS IS OFTEN ALREADY AVAILABLE. VISIT: COORDINATION WITH OTHER ORGANISATIONS IS KEY! HTTP://WWW. • GENDER IS ALSO ABOUT MEN AND BOYS AND HOW THE ACFTRAININGCENTRE.ORG/ CONTEXT AFFECTS THEM DIFFERENTLY. GPAGE/
• WE CAN BE GENDER SENSITIVE WHILE FIGHTING HUNGER. AND EXPLORE OUR USEFUL RESOURCES AND TRAINING • TARGETING WOMEN BY DEFAULT IS NOT GENDER SENSITIVE MATERIALS AND CAN PERPETUATE GENDER
22 SECTION TWO WHAT OUR RESEARCH IS TELLING US
This section outlines emerging findings from our research projects and studies in 2016 (and before) with implications for our programmes. It focuses on new operational models to improve treatment of severe acute malnutrition: highlighting our work on integrating severe acute malnutrition treatment into the integrated community-based case management model with a focus on the C-Project Phase I, and the upcoming C-Project Phase II in Mali.
The next part discusses the benefits of improving ambulatory treatment of acute malnutrition of water and hygiene interventions, focusing on recent studies in the Democratic Republic of the Congo, Chad and Pakistan; and the broader water, sanitation and hygiene portfolio including the WASH’ Nutrition Practical Guidebook.
Then we explore our Research on Food Assistance for Nutritional Impact (REFANI) project in Niger, Somalia and Pakistan, as well as the broader portfolio of work exploring different cash transfer models (MAM’OUT in Burkina Faso).
Lastly, we take a portfolio look across cost- effectiveness analysis, which is a growing area of interest across Action Against Hunger and one that can demonstrate the usefulness of the approach across all of our work – including the studies above but also for food assistance and psycho-social interventions.
Action Against Hunger Learning Review 2016 23 © Guy Calaf for Action Against Hunger Against Action for Calaf © Guy
2.1 TRANSFORMING THE TREATMENT OF MALNUTRITION
BY PILAR CHARLE CUELLAR, ICCM+NUTRITION COORDINATOR, ACTION AGAINST HUNGER6
BACKGROUND 12.6 per cent. OVERVIEW OF THE STUDY In 2014, 16 Million children suffered from Integrated community case management, The main objective of this study was to severe acute malnutrition worldwide, only a strategy to extend case management of integrate the treatment of severe acute 20 per cent were treated. In countries like childhood illness beyond health facilities so malnutrition into the delivery of health Mali and Pakistan, achieving high coverage that more children have access to lifesaving interventions by community health workers of treatment is a real challenge. In 2014, treatment (mainly malaria, diarrhoea and in order to decrease the negative impact that prevalence of global acute malnutrition rate in pneumonia), has shown high treatment economic and geographic barriers have on the the Kita region of Mali was 13.3 per cent and coverage and high quality care rates for sick coverage of malnutrition treatment. The aim severe acute malnutrition was 2.4 per cent. In children under five. was to test this approach in the two contexts the same district, treatment coverage of severe of Mali and Pakistan. Protocol of the study was The integrated community case management acute malnutrition was only 24.9 per cent. The proved by the Ethics Committee. Memorandum approach has grown to include the Pakistan National Nutrition Survey of 2011 of understanding was signed between Bamako identification and referral of children with reported a global acute malnutrition rate of University, Institut National de Recherche en severe acute malnutrition by community 15.1 per cent and stunting prevalence rate of Santé Publique du Mali and Action Against health workers, but does not currently include 43 per cent. In some of areas of Pakistan, for Hunger in Mali; and with Aga Khan University treatment of severe acute malnutrition at a instance Dadu district, anthropometric survey in Pakistan. community level. revealed a global acute malnutrition rate of
6 Research led by Franck Alé, former Research Coordinator Mali; Deepak Kumar, Research Coordinator Pakistan; José Luis Alvarez, former Head of Technical Development; Pilar Charle Cuellar, iCCM+Nutrition Coordinator; and Saul Guerrero, Director of International Nutrition Initiatives
24 MALI STUDY • What is the incidence of moderate acute malnutrition In Mali, a clinical longitudinal cohort study was carried and severe acute malnutrition among children under-five out in the region of Kita between February 2015 and years of age in areas that provide standard treatment at February 2016, to collect the evidence and answer the facility and community-level by government health care following questions: providers compared with treatment delivered by trained lady health workers? • Is severe acute malnutrition treatment delivered through community health workers as effective (cure, • What is the effectiveness (i.e. the rate of recovery death and defaulters rates) as treatment delivered at and coverage) and cost-effectiveness of treatment of health facilities? severe acute malnutrition in areas that provide standard treatment at facility and community level by government • Will coverage in the communes where community health care providers compared with the treatment health workers deliver severe acute malnutrition delivered by trained lady health workers? treatment increase after 12 months? KEY FINDINGS “USING LADY • Cost-effectiveness of the community health workers’ HEALTH WORKERS care in intervention area and the standard care in MALI STUDY control area. Will treatment of severe acute malnutrition In Mali, two groups were followed up in the cohort: TO TREAT by community health workers improve cost- one control group, which received treatment for severe SEVERE ACUTE effectiveness compared to treatment at health facilities? acute malnutrition delivered at the existing health MALNUTRITION IS facilities, and one intervention group, which received • Are community health workers providing good quality treatment for severe acute malnutrition delivered at EFFECTIVE.” of care for children suffering severe malnutrition? the health facilities and through the community health workers. PAKISTAN STUDY In Pakistan, a randomised control trial was carried out During the period, 235 children were admitted in the in Dadu district to collect evidence and answer the control group, and 699 in the intervention one. following questions:
Action Against Hunger Learning Review 2016 25 2.1 TRANSFORMING THE TREATMENT OF MALNUTRITION
In relation to cure rates, the intervention group treated without significant errors. the Mali National Primary Health Policy, ratio is reported rates of 94.2 per cent compared to 1 community health worker/ 1,500 habitants. 88.6 per cent in the control group. The risk PAKISTAN STUDY ratio of 1.07 [95 per cent confidence interval In Pakistan, a total of six union councils of the • Salary of community health workers: They 1.01; 1.13] highlights that the probability Dadu district were selected at the beginning are included as staff as part of the health of being cured is higher in the intervention of the project to implement the clinical trial. pyramid, but their salaries are supported by an group (p= 0.0028). Defaulter rates were twice 829 cases were enrolled in the clinical trial international non-governmental organisations as high in the control group compared to among the six union councils, the intervention until the end of 2019. arm involved the delivery of treatment by lady the intervention group (10.8 per cent vs. 4.5 • Model of supervision: Community health per cent). The risk ratio of 0.42 [95 per cent health workers in three union councils, with three comparative union councils offering workers are generally supervised by staff in confidence interval 0.25; 0.71] reveals that the health facilities. However, during the pilot the probability of defaulting was half of that treatment in health facilities acting as a control arm. study, closer supervision was conducted by of the intervention group (p=0.0024). Within Action Against Hunger staff. the intervention group, five children (0.8 per The results showed that using lady health cent) died compared to two children (0.9 per workers to treat severe acute malnutrition in • Training of community health workers: cent) in the control group, given the low rates children without complications is effective. In Within a 15-day training programme for in both groups, the difference is not statistically the intervention group, cure rates of 76 per community health workers, just one day is significant. cent, defaulters 3.8 per cent and death rates 0.2 allocated to malnutrition. At the beginning of the intervention, the single per cent. In the control group, cure rates were IMPLICATIONS AND LOOKING coverage rates in the two cohorts were 43.9 83 per cent, defaulters 2.5 per cent and death FORWARDS per cent in the intervention group vs. 43.8 rates 0.5 per cent. With the evidence collected, what we know per cent in the control. At the end, there is an At the beginning of the study in March 2015, now: increase in coverage within the intervention coverage rates in the control group was 43 per area compared to the control group, where cent and in the intervention group was 40.6 Community health workers can provide coverage marginally declined over the period 1 per cent. Although there was a small increase in high quality treatment for severe acute (86.7 per cent vs. 41.6 per cent). This difference coverage in the intervention arm of 5.6 per cent malnutrition in the communities, and doing so between the two groups in December 2015 (40.6 per cent to 46.2 per cent) in 2016, it was does not negatively affect the effectiveness of was statistically significant. not statistically significant and also occurred treatment. In terms of quality of care, well trained in the control arm, 55 per cent, suggesting Delivering severe acute malnutrition and supervised community health workers it cannot necessarily be attributed to the 2 treatment at community level has the potential are capable of identifying and managing intervention itself. to significantly increase treatment coverage. cases of severe acute malnutrition without The operational challenges faced were: complications. The quality of the management 3 The health community is ready to actively of such cases is satisfactory with 79.5 per cent • Number of community health workers per explore the integration of severe acute (95 per cent confidence interval: 72.1-86.9) and health structure and population: according to malnutrition treatment into integrated
26 community case management. Ministry of Health in Mali has Right: A woman arrives adapted the Primary Health Care policy and include severe acute at an Action Against malnutrition treatment into the package of actions to be delivered Hunger supported by community health worker. nutrition centre, Mali PERSPECTIVES FOR ACTION AGAINST HUNGER: 1 Scaling up of the intervention: The first idea is to increase the work in Mali, and to address the challenges described in the paragraph above: model of supervision, content and quality of training, as well as number and salary of community health workers. At the same time it is important to evaluate needs and opportunities in other countries where we are working in.
2 Uptake, fusion and communication partners: Share the study and results with health authorities, donors and non-governmental organisations, so to encourage similar interventions in other communities affected by high rates of malnutrition worldwide.
3 Action Against Hunger is the leader of a nutrition sub group in the integrated community case management task force.
Our vision is “a world without hunger”, focusing our intervention on mitigating consequences of hunger, addressing the causes and changing the way hunger is viewed. To achieve this, increasing the coverage of programmes to treat severe acute malnutrition is one of our main goals.
During several years we have been monitoring coverage of our
programmes, and it is extremely rare for coverage to exceed 50 Hunger Against Action for Stevens © Ben per cent. With both these studies, we have scientific evidence to demonstrate that another way to treat malnutrition is possible and that it allows us to treat more than double the amount of children than we used to treat before.
For more information, please contact: Pilar Charle Cuellar, iCCM+Nutrition Coordinator, Action Against Hunger Spain, [email protected]
Action Against Hunger Learning Review 2016 27 Hunger Against Action for Karzai © Reza 2.2 INTERVENTIONS ON WATER AND HYGIENE TO IMPROVE AMBULATORY TREATMENT OF ACUTE MALNUTRITION: WHAT ARE THE BENEFITS? BY MATHIAS ALTMANN, OPERATIONAL RESEARCH ADVISOR & NICOLAS VILLEMINOT, SENIOR WATER, SANITATION & HYGIENE TECHNICAL ADVISOR, ACTION AGAINST HUNGER
BACKGROUND developed by the West and Central Africa kit (water container, water disinfection Regional Water, Sanitation and Hygiene consumables, soap, cup, simple hygiene present It is estimated that 58 per cent of annual Group (including Action Against Hunger, the promotion leaflet with images) deaths caused by diarrhoea are attributable to European Union department for European Civil poor water, sanitation and hygiene conditions.7 Protection and Humanitarian Aid Operations, 2 a weekly hygiene promotion sessions at Interventions aiming at improving water quality and Unicef amongst others), and it has been health centre level with mothers/caretakers of at household level, or at promoting hand largely promoted since 2012 in various regions children admitted to the programme. washing with soap, can significantly reduce of the world. In the context of ambulatory nutritional the incidence of diarrhoea. Beyond their rehabilitation of severe acute malnutrition, we effect on infectious diseases, the evidence One of the proposed activities in this strategy is hypothesised that improving water, sanitation suggests that these interventions have a small the provision of a ‘household water, sanitation and hygiene care practices at household level but measurable benefit on stunting (but not and hygiene package’ to mothers/caretakers of would decrease incidence of related infections, on wasting). To our knowledge, no water, children with severe acute malnutrition, upon such as diarrhoea, nematode and environmental sanitation and hygiene intervention has been their admission to the health centre. The aim enteric dysfunction. As such, this would assessed, either when implemented in addition is to protect children against new episodes improve weight gain, decrease length of stay to a nutrition rehabilitation programme, or of diarrhoea and other water and sanitation in the treatment programme and improve after discharge when immune recovery is still related infections. This household water recovery proportion. For the mid-term, it would incomplete. sanitation and hygiene package includes: decrease the risk of relapsing after successful The ‘WASH in Nutrition’ strategy was 1 a household water treatment and hygiene discharge. In order to test these hypotheses, Action Against Hunger engaged in operational studies in three different contexts: Democratic 7 WHO 2014: http://apps.who.int/iris/bitstream/10665/150112/1/9789241564823_eng.pdf
28 Republic of the Congo, Chad and Pakistan. the addition of a water purifier decreased proportions. The secondary outcomes include We present here a summary of these three the average treatment time by four days. time-to-recovery, weight gain, longitudinal studies. However, the results were not statistically prevalence of morbidity (diarrhoea, vomiting, significant, as the sample size was too small. cough, and fever), adherence to the household OVERVIEW OF THE THREE water, sanitation and hygiene package, as well STUDIES SECOND STUDY IN CHAD as hygiene and care practices of the mothers/ Action Against Hunger is currently FIRST STUDY IN THE DEMOCRATIC caretakers. implementing a cluster randomised REPUBLIC OF THE CONGO controlled trial in Mao and Mondo health This project is conducted in a partnership From 2012-2013, Action Against Hunger districts, Kanem region, Chad. This trial aims between Action Against Hunger France, the partnered with the Johns Hopkins at comparing two groups: Institute of Tropical Medicine in Antwerp, Bloomberg School of Public Health to assess Belgium, and the Sahel Association of applied the effects of household water treatment on • Control group: ambulatory nutritional research for sustainable development in Chad. the treatment of severe acute malnutrition in rehabilitation Bandundu Province, the Democratic Republic THIRD STUDY IN PAKISTAN of the Congo, with funding from Procter & • Intervention group: ambulatory nutritional In Sindh Province, Pakistan, Action Against Gamble. rehabilitation and an additional water, Hunger also partnered with the Johns Hopkins sanitation and hygiene package Bloomberg School of Public Health and The general objective of the study, approved Around 1,600 children aged 6 and 59 worked on a similar study focusing on the by the Nutrition Programme of the Ministry effectiveness of household water treatment in of Health examined the treatment of severe months who were admitted to 20 health centres for severe acute malnutrition were the treatment of severe acute malnutrition and acute malnutrition in children under five with its cost-effectiveness. The research evaluates no complications. It compared the efficiency included in the study. Recruitment of the participants lasted from April to November the effectiveness of three types of household of using ready-to-use therapeutic food in water treatment - ceramic candle filters, addition to Procter & Gamble ‘Purifier of 2015 and the follow-up ended in May 2016. The primary evaluation outcomes Aquatabs, and Procter & Gamble ‘Purifier of Water’ sachets, against using only ready- Water’ sachets - as additional components to to-use therapeutic food. It was found that to be measured areevaluation outcomes to be measured are recovery and relapse community management of acute malnutrition
Action Against Hunger Learning Review 2016 29 2.2 INTERVENTIONS ON WATER AND HYGIENE TO IMPROVE AMBULATORY TREATMENT OF ACUTE MALNUTRITION
interventions. The randomised control trial study and improve data quality. Additional anticipate and address operational issues and included 901 children between 6 and 59 staff (e.g. nurses) with experience in nutrition limit external influences helps projects remain months. The enrolment started in February could be recruited to support them in their focused. It remains important to account for the 2016 and the field study ended in October daily duties. Other partnerships (e.g. research, reality of operational challenges in uptake of 2016. Results will be shared in 2017, looking at women’s organisations, traditional healers) recommendations. the length of stay in treatment centres and the might be beneficial for acceptability and weight gain when adhering to water treatment. understanding of the research process. For more information, please contact: Mathias Altmann, Operational Research Advisor, KEY FINDINGS 4 Scientific partners: we recommend scientific Action Against Hunger France, maltmann@ partners to conduct a field visit during the pilot actioncontrelafaim.org; or Nicolas Villeminot, The key recommendations for policy and phase of the study in order to ensure adequate Senior Water, Sanitation & Hygiene Technical practice, based on final results, will be available adherence to study protocol and to setup an Advisor, Action Against Hunger USA, in 2017. However, the authors have put forward adapted system for data quality control. [email protected] several operational recommendations, derived from the field experience and lessons learned 5 Operational budget (to adhere to study so far: protocols): studies often piggyback on existing operations and face various issues. These “INVOLVING HEALTH 1 Data collection: we found open data include supply, shortages of ready-to-use kit software unsuitable for this type of therapeutic foods, monitoring issues that may CENTRES’ STAFF... research project within this context, because impact on exclusion of patients enrolled in the WOULD INCREASE of difficulties with the use of tablets. We survey, or poor implementation community THEIR MOTIVATION TO recommend using other software for data entry, management of acute malnutrition protocols. such as Epi Data or Epi Info. This may jeopardise the sample or the quality of CONTRIBUTE TO THE data collected, and a delay in achieving project STUDY AND IMPROVE 2 Data quality/human resource: data quality objectives. The flexibility of a study to identify, remains a major challenge, particularly for a DATA QUALITY” research project. We recommend having a data management team, including at least two data entry officers (for double data entry) and one data coordinator (to check continuously WHY NOT CHECK OUT all potential data errors). These positions are THE WASH NUTRITION PRACTICAL GUIDEBOOK? essential for a research project and should be The guidebook places special emphasis on integrating water, sanitation and hygiene, and nutrition recognised as such. programs in humanitarian emergencies. It looks at safeguarding the health of communities affected by crisis. The guide also provides a resources section, which offers examples from the field and tools 3 Partnerships: we recommend involving to assist in integration efforts at each phase of a classical project cycle. health centres’ staff (nurses and volunteers) in data collection as much as possible. This would https://www.actionagainsthunger.org.uk/publication/wash%E2%80%99nutrition-2017-guidebook increase their motivation to contribute to the
30 © Eric Simiand for Action Against Hunger Against Action for Simiand © Eric 2.3 WHAT WORKS TO PREVENT ACUTE MALNUTRITION USING CASH TRANSFERS BY ELLYN YAKOWENKO, ASSOCIATE DIRECTOR OF RESEARCH & ZVIA SHWIRTZ, REFANI RESEARCH UPTAKE OFFICER, ACTION AGAINST HUNGER
BACKGROUND sum vs. smaller monthly instalments) may the European Commission’s Civil Protection impact on undernutrition, or how cash-based and Humanitarian Aid Department, consortium In 2015, approximately seven per cent (1.9 interventions may protect a child’s nutrition partners Action Against Hunger, Concern billion USD) of all international humanitarian security against household stress, shocks, or Worldwide, ENN and University College assistance funding was used for cash-based natural disasters. London are now able to report important interventions8 and following commitments findings across each of the project’s country made at the World Humanitarian Summit,9 the OVERVIEW OF THE STUDIES AND studies. use of this modality is expected to increase KEY FINDINGS significantly in future. There are, however, The REFANI-Pakistan study11 is a longitudinal The Research on Food Assistance for many knowledge gaps that still exist on the use cluster randomised controlled trial in Dadu Nutritional Impact (REFANI) project10 has of cash-based interventions in humanitarian district, Sindh Province, which explores how conducted three study trials – in Pakistan, contexts, particularly in regards to their ability the amount of cash given and the restrictions Niger, and Somalia – aiming to fill several to achieve nutrition objectives for young around the use of cash (e.g. unrestricted vs. critical evidence gaps, and exploring the extent children, aged 6-59 months. For example, fresh foods only) impacts the effectiveness of to which cash transfers and/or vouchers can there is little known about how the timing (e.g. the cash-based intervention in reducing the risk protect the nutritional status of children in before or during the lean season), duration of undernutrition in children 6-59 months. The emergency contexts. After nearly three years of (e.g. six-months vs. one year), and amount and study compared effects across four research research, funded by both the United Kingdom’s frequency of cash transfers (e.g. large lump arms– (1) a ‘control’ group, which received Department for International Development and
8 https://www.odi.org/sites/odi.org.uk/files/resource-documents/11296.pdf 9 https://www.worldhumanitariansummit.org/sites/default/files/media/WHS%20Commitment%20to%20Action_8September2016.pdf 10 http://www.actionagainsthunger.org/refani/refani 11 http://www.actionagainsthunger.org/refani/pakistan-country-study Action Against Hunger Learning Review 2016 31 2.3 WHAT WORKS TO PREVENT ACUTE MALNUTRITION USING CASH TRANSFERS
no- cash-based intervention; (2) a ‘standard stunting in comparison to the control group over based interventions in reducing the risk of cash’ group, which received an unconditional both the short- and longer-terms. Therefore, undernutrition in children 6-59 months. The cash transfer of the same value as the national cash-based interventions may support greater study compared effects across two research safety net programme; (3) a ‘double cash’ group, nutrition resilience among young children, arms: (1) a ‘standard’ 4-month unconditional which received an unconditional cash transfer particularly in poor and very poor households. cash transfer; and, (2) an ‘earlier/extended’ of double the value of the national safety net 6-month unconditional cash transfer. Both 12 programme; and finally, (4) a food voucher of the The REFANI-Niger study is a cluster intervention arms provided the same total value same value of the ‘standard cash’, but restricted randomised controlled trial in the region of cash, however the ‘early/extended’ transfer towards the purchase of fresh fruits, vegetables, of Tahoua that explores how the timing was disbursed two months before the peak of meats, etc. and duration of cash transfers impact the the lean season. effectiveness of the cash-based interventions REFANI-Pakistan study results show that the in reducing the risk of undernutrition in children REFANI-Niger study results found no difference larger amount of cash was the most effective for 6-59 months. The study compared effects across in effect between the standard and earlier/ improving children’s weight-based growth in the two research arms: (1) a ‘standard’ 4-month extended interventions. The study team noted short-term, immediately after the last transfer unconditional cash transfer; and, (2) an ‘earlier/ that peaks in disease prevalence, such as a was received. However, these effects were not extended’ 6-month unconditional cash transfer. sharp spike seen in the number of malaria sustained over time (6-months after the last Both intervention arms provided the same total cases over the intervention period, may have transfer), indicating that the larger amount of value of cash, however the ‘early/extended’ limited the effectiveness of the cash-based cash may only be effective at addressing short- transfer was disbursed two months before the interventions in preventing undernutrition. This term wasting outcomes. Meanwhile, each of peak of the lean season. is a cluster randomised suggests that health factors may be key drivers the cash-based interventions demonstrated an controlled trial in the region of Tahoua that in undernutrition in Niger and therefore, that impact on height-based growth, with the cash explores how the timing and duration of cash health-related interventions may be required and voucher arms all showing decreases in transfers impact the effectiveness of the cash- in conjunction with cash-based interventions © Gonzalo Hohr for Action Against Hunger Against Action for Hohr © Gonzalo
32 12 http://www.actionagainsthunger.org/refani/niger-country-study to have an impact on protecting the nutrition across two research arms: (1) a ‘control’ group, status of children during their first 1,000 days. Below: Men farming, status of children 6-59 months. These results are which received no-cash-based intervention; While REFANI focused specifically on nutrition- Niger also similar to those of Action Against Hunger’s (2) a group that received an unconditional cash related outcomes, it is important to note that MAM’Out cluster randomised controlled transfer. Data collection is still on-going for the there may be other positive outcomes created by trial study13 in Burkina Faso, which found no REFANI-Somalia study, however, preliminary the cash-based interventions (e.g. in education difference in effect on undernutrition between analysis indicates that while households or in purchasing productive assets), which were those receiving a multi-annual, seasonal cash receiving the cash-based intervention showed not captured in either the primary or secondary transfer and those in the control group. Taken improvements in most food security indicators, outcomes of these studies. This is an area where together, both the REFANI-Niger and MAM’Out no significant improvements were seen in future research is required – both in identifying indicate that cash-based interventions alone may regards to child nutritional status. There was no how beneficiary spending changed in relation to be insufficient to prevent undernutrition within difference in effect between the research arms in the cash-based interventions and how cash-based the West Africa region and that a comprehensive, reducing the prevalence of undernutrition. Final interventions inputs were used to maximum multi-sectoral approach is likely required to results of the study are expected by August 2017. effect by the beneficiary. support nutrition security. IMPLICATIONS AND LOOKING For more information, please contact: Ellyn Finally, the REFANI-Somalia14 is a non- FORWARDS Yakowenko, Associate Director of Research, randomised cluster controlled trial in the Action Against Hunger USA, eyakowenko@ internally displaced person camps of the Afgoye These REFANI country studies demonstrate actionagainsthunger.org Corridor region, which explores whether cash- the complexity of the pathways which lead to based interventions can reduce the risk of a child undernutrition, as well as the variety of ways in becoming acutely undernourished, as well as which cash-based interventions may work in how these intervention may alter the risk factors humanitarian contexts to protect the nutrition for undernutrition. This study compared effects
13 http://www.actioncontrelafaim.org/fr/content/projet-mam-out Action Against Hunger Learning Review 2016 33 14 http://www.actionagainsthunger.org/refani/somalia-country-study © Julia Belusa for Action Against Hunger Against Action for Belusa © Julia
2.4 A PORTFOLIO LOOK ACROSS COST-EFFECTIVENESS ANALYSIS BY ACTION AGAINST HUNGER’S COST-EFFECTIVENESS EXPERTS15
INTRODUCTION health sector to humanitarian interventions, pros and cons relate both to the CEA method particularly for those interventions which in general, and to its application to nutrition Combining information on programme have important impacts beyond measurable and food security specifically. “KNOWING costs and outcomes, as is done in a cost- health outcomes. THE COST VS. effectiveness analysis (CEA), can tell us more PROS OF COST-EFFECTIVENESSS BENEFITS IS AN about a programme than looking at either of Since 2012, Action Against Hunger has ANALYSIS these components separately. Focusing on been engaged in developing capacity on EXCELLENT WAY EVIDENCE FOR ADVOCACY AND TO ADVOCATE FOR effectiveness alone will limit the use of data CEA across our nutrition, food security, in strategic decision-making where resources and livelihood programmes implemented DECISION-MAKING THE INTERVENTION Among the general benefits of CEA is its are constrained. Focusing on costs alone in several country offices. In this article we TO PARTNERS, usefulness in policy and advocacy efforts. may detract from programme impact. While summarise the experiences and perspectives DONORS BUT Results from these studies can be used as one cost-effectiveness analysis is prevalent in on the application of CEA reported by ALSO WITHIN THE element to be considered for priority-setting the health sector there are some challenges various staff conducting these analyses at and advocating for certain interventions and TEAM” in translating the current CEA practice in the headquarters (HQ) and in the field. These Nepal 15 Cecile Salpeteur, Chloe Puett, and Lani Trenouth; supported by Amy Mayberry and Hannah Wichterich; based on ‘REFANI CEA Update final 2 2017’ and these articles: Cost-Effectiveness Analysis for Nutrition and Food Security Pros, cons, and lessons learned within Action Against Hunger: http://www.actionagainsthunger.org/blog/cost- effectiveness-analysis-nutrition-and-food-security Protecting child health and nutrition status with ready-to-use food in addition to food assistance in urban Chad: a cost-effectiveness analysis: https://resource-allocation. biomedcentral.com/articles/10.1186/1478-7547-11-27 Cost-effectiveness of community vegetable gardens for people living with HIV in Zimbabwe: https://resource-allocation.biomedcentral.com/articles/10.1186/1478-7547-12-11 16 http://sites.path.org/mchn/2016/08/cost-effectiveness-analysis-for-nutrition-and-food-security-pros-cons-and-lessons-learned-within-action-against-hunger/#_ftn1 17 http://sites.path.org/mchn/2016/08/cost-effectiveness-analysis-for-nutrition-and-food-security-pros-cons-and-lessons-learned-within-action-against-hunger/#_ftn2
34 “The CEA can provide a very useful additional degree of analysis on the comparison of different intervention modules and their cost-effectiveness – this is a key element to ensure that not only our beneficiaries receive the best possible service, but also that we can plan to provide such services in the most efficient way thus also reaching a higher number of people in need.” Pakistan
approaches to a wide variety of stakeholders. cost data is accurate and complete. QUANTIFYING COSTS FOR EFFECTIVE Within this, evidence on costs, resource NUTRITION SCALE-UP AND INTEGRATION use, efficiency, and effectiveness can aid in A NOVEL ANGLE FOR PROGRAMME According to the Global Nutrition Report improving programmes and inform future EVALUATION AND LEARNING 2015, more evidence is needed on the cost budgeting. As Action Against Hunger builds experience of nutrition strategies.16 This is an important in conducting CEAs, we are learning ways to limitation in the current evidence base, given ACKNOWLEDGING CONTRIBUTIONS improve our methods and practices. Field staff that nutrition and medical supplies can be OF PARTNERS, COMMUNITIES, AND are often involved in compiling data needed costly, particularly therapeutic foods, milks, HOUSEHOLDS for these analyses, and implementing staff are and their related logistical requirements.17 High Action Against Hunger CEAs employ a ‘societal key actors consulted during data collection. costs can limit the coverage and sustainability perspective’ wherever possible to understand While this is an additional task for field staff, of these activities. the broader programme costs beyond they can also benefit from the experience institutional expense records. This involves through gaining a better understanding of the In this sense, one benefit of the cost data in engaging with partners and beneficiaries various cost implications of programme design CEAs of nutrition interventions is in helping to identify and include the “hidden inputs and implementation. It also helps staff to to clarify the costs of scaling up effective provided by the community and society” (HQ). understand that the cost data collected during a services and handing them over to local Provided that all stakeholders are willing to CEA is for the purposes of evaluating the costs partners, and in aiding partners in “planning share their cost information, discussing with and cost drivers of a programme and it is not and budget development of different activities different implementing partners also can allow a financial audit, or an evaluation of individual and projects around nutrition and nutrition- triangulation of information, helping ensure that staff performance. sensitive approaches, where they otherwise
8 “Often as field 9 teams we do not realise all the costs that go into making a “As soon as they learn the objective and understand the programme function – logistics, support HR, etc. When I did the exercise of costs importance of the study and their participation, almost identification with the team, it was interesting for them to realise the costs involved. everyone shows great support for the analysis. In fact, many This definitely has an impact on motivation and accountability as a team.” expressed interest in learning more about the methodology.” Nepal Action Against Hunger Learning Review 2016HQ 35 2.4 A PORTFOLIO LOOK ACROSS COST-EFFFECTIVE ANALYSIS
lack evidence to guide their decisions in a of information to evaluate programmes, Right: A woman at field where previously little money used to be and should be considered along with work in a clinic, Nepal spent” (Pakistan). other criteria such as equity and other ethical considerations. Additionally, in the MOVING BEYOND COST-EFFICIENCY IN humanitarian field there has been historical FOOD SECURITY AND LIVELIHOODS resistance to judging programmes based on Field staff perceived that compared to nutrition cost-effectiveness, in part because of priority programmes, food security and livelihood placed on general effectiveness and speed of programmes have a stronger focus on economic response in humanitarian crises over economic analysis. However, the typical indicators used considerations.18 in existing economic analyses are outputs— number of beneficiaries reached, cost per There is a risk that decision-makers may simply unit of currency distributed—rather than compare final unit costs or cost-effectiveness outcome indicators. The shift to assessing cost ratios across programmes without considering per outcome of food security and livelihood contextual aspects influencing cost- programmes, particularly nutrition-related effectiveness in different settings, at different outcomes, is a positive step to understanding scales, and responding to different kinds of these interventions’ potential. A shift crises. In addition, some decision-makers may from cost-efficiency metrics towards cost- focus on cost information only to identify the effectiveness metrics can provide a more cheapest approach, ignoring the connection nuanced understanding of the full costs and between level of investment and quality benefits of aid programming. A programme achieved, which cost-effectiveness results which is deemed more cost-efficient is not provide. necessarily the more cost-effective and therefore a focus on efficiency measures might CHALLENGE OF QUANTIFYING MULTIPLE
provide incomplete and ultimately misleading AND DIVERSE OUTCOMES IN NUTRITION Hunger Against Action for Iguzkiza Burgui ©Daniel evidence for the most appropriate intervention. AND FOOD SECURITY CEA methods can be used to estimate the cost CONS OF COST-EFFECTIVENESS per any single outcome of importance for an ANALYSIS intervention. However, selecting an optimal outcome is not always a straightforward DANGERS OF REDUCTIVE process. In the health field, where INTERPRETATION interventions often aim to prevent, reduce, or Despite their many benefits, CEAs are also eradicate a particular disease, the choice of limited in that they contribute just one piece outcome indicator for a CEA is less ambiguous.
18 http://sites.path.org/mchn/2016/08/cost-effectiveness-analysis-for-nutrition-and-food-security-pros-cons-and- lessons-learned-within-action-against-hunger/#_ftn3
36 For nutrition and food security and cash and voucher transfer interventions malnutrition case relapse averted five Below: A woman livelihood programmes, however, the implemented in Pakistan and Niger. The months after discharge, incremental cost washes household process of selecting a single outcome outputs of this study are the results from per additional point of child development utensils, Nepal variable for a CEA may be more the analysis of the cost, cost-efficiency, score achieved 11 months after discharge, complicated. For one thing, many such and cost-effectiveness of the interventions and incremental cost per additional point programmes have multiple objectives; this researched. The results of the analysis of maternal mental health score achieved presents a challenge in either choosing include: cost per beneficiary, cost per 11 months after discharge. one primary outcome, or trying to quantify unit of currency transferred, cost per diverse outcomes and benefits in a case of wasting averted and cost per case CONCLUSIONS comprehensive way. While it is possible of stunting averted. Importantly, this Action Against Hunger will continue to calculate multiple cost-effectiveness analysis includes the costs borne by the working to build the evidence base on the ratios, one per outcome indicator, there is beneficiaries themselves as well as other cost-effectiveness of nutrition and food currently no accepted composite indicator community members. Results will be securityand livelihoods interventions. for food and nutrition security objectives, published later in 2017. In doing so, we will strive to ensure a therefore the cost per total impact across balance between standardisation of multiple indicators is not easily captured. methods, the objectives of each analysis, This had led to a range of disparate “A FOOD DISTRIBUTION and appreciation of context: both the outcome indicators being used for CEAs on PROGRAMME MAY geographic setting in which the activity nutrition and food security interventions BE THE MOST COST- takes place and the potentials and which limits comparability of results, both EFFECTIVE, BUT IF IT limitations of specific interventions. In across studies and with prior research. UNDERMINES LOCAL this way we aim to build a rich inventory There is, however, potential for future MARKETS AND of evidence on cost-effectiveness consensus on the most appropriate food LIVELIHOODS IT IS NOT of nutrition and food security and and nutrition security outcome indicators THE BEST OPTION” livelihood interventions, to increase our to be used for CEAs and how these HQ understanding of programme efficiency indicators should be presented. and find ways forward to improve their FUSAM effectiveness. COST-EFFECTIVENESS ACROSS In Nepal, the Follow Up of Severely Acutely For more information, please contact: THE PORTFOLIO Malnourished Children (FUSAM) clinical Chloe Puett, Senior Research Advisor, trial is looking at the costs incurred by REFANI Action Against Hunger USA, cpuett@ adding a new psychosocial component to Currently, Action Against Hunger is actionagainsthunger.org the standard care protocol for severely leading a CEA for the Research on undernourished children and its outcomes. Food Assistance for Nutritional Impact Several possible outcomes of interest have (REFANI) project which has examined the been identified for the CEA which include: costs associated with the achievement incremental cost per case of severe acute of nutrition-related outcomes through malnutrition recovered, or per severe acute
Action Against Hunger Learning Review 2016 37 SECTION THREE WHAT OUR PROGRAMMES ARE TELLING US
In this final section of the Learning Review, we open the floor to our country offices. This year, field staff from three programmes and staff from one Below: Women farm headquarter have shared their own innovative approaches to programming, and their key lessons learned. their land, Uganda The chapter starts with an could be incorporated into article from our country our programmes. team in Sierra Leone, which adapted its ongoing The third article explores the interventions to improve LIFE Georgia programme in infection prevention and the South Caucasus region. control in response to the This programme was praised 2014 outbreak of Ebola virus for strong collaboration disease. This piece is a good with partners, and diverse example of how to identify social inclusion through the critical strategies towards introduction of new and outbreak management and original methodologies. prevention. Our fourth and final article Our second article examines discusses Action Against the use of technology, by Hunger’s Inter-Agency outlining how using mapping Regional Analyst Network and Geographic Information (IARAN). This network Systems (often referred supports us in addressing our to as GIS) allowed us to global goals of sustainability increase the effectiveness and ending all forms of of Action Against Hunger’s hunger and malnutrition by nutrition programmes 2030. Can it be done? Read in Yobe district, Nigeria. on and see some of the steps This article highlights how already being taken to bring geographic criteria are often us closer to reaching these overlooked, and how they goals.
38 © Fatima Hrich for Action Against Hunger Against Action for Hrich © Fatima
3.1 IMPROVING INFECTION PREVENTION AND CONTROL IN SIERRA LEONE BY ACTION AGAINST HUNGER SIERRA LEONE
Action Against Hunger has been operating due to the lack of awareness of and compliance Department for International Development, Above: A girl carries a in Sierra Leone since 1991, intervening in with infection prevention and control (IPC) and implemented from May 2015 to April water canister, Sierra nutrition security in Kambia, Moyamba measures within health facilities. Failure to 2016, this project targeted 128 community Leone and Western Area (rural and urban). These comply with adequate infection prevention and health centres across 12 districts. As part of the programmes aim to address the direct and control measures, in turn, led to the infection of consortium, Action Against Hunger operated as underlying causes of undernutrition, including: many health workers with Ebola while handling the lead organisation for water, sanitation and cases in isolation and treatment centres. Ebola hygiene activities in Kambia and Moyamba. The • prevention and treatment of chronic and infection rates were serious and of the 300 organisation met the needs of 12 community acute malnutrition; staff who were infected, 221 died. health centres and one hospital in each of these two districts (24 community health centres and • food insecurity and limited livelihoods COLLABORATION WITH THE EBOLA two hospitals in total), through complementary opportunities; RESPONSE CONSORTIUM intervention. • poor health; and Infection prevention and control measures In both Kambia and Moyamba, Action Against • poor access to water, sanitation and hygiene are highly dependent on the availability of Hunger was responsible for improving three facilities. sufficient quantities of safe water, adequate main domains: water supply, sanitation and sanitation facilities, and appropriate waste waste management. In regards to water supply In response to the Ebola virus outbreak in Sierra management. Action Against Hunger was improvements, water storage and hand washing Leone in May 2014, Action Against Hunger thoroughly involved in the design and facilities with running water were either adapted its ongoing interventions to match implementation of a project developed by the provided if previously absent or repaired. This the emergency context. The Ebola outbreak Ebola Response Consortium to respond to enabled access to water in key areas in medical heavily impeded the health care system, partly these needs. Funded by the United Kingdom’s
Action Against Hunger Learning Review 2016 39 facilities (e.g. labour room, laboratory, toilets) through centres in Moyamba. These were handed over to the water quality testing, treatment and monitoring. Next, community health officers and the District Health to improve sanitation, showers, latrines and toilets Management Team. The units will contribute to adapted for persons with reduced mobility, for both the improvement of detection and management of the health staff and the patients, were repaired or communicable diseases in the future. installed. Finally, to facilitate health care waste COLLABORATION WITH GOVERNMENT management, items mitigating proper waste disposal, including colour-coded bins, were provided. In Alongside this work, Action Against Hunger addition, waste zones for proper disposal of medical undertook a health project funded by the United and non-medical waste were constructed. These States’ Office of Foreign Disaster Assistance, aimed zones included an ash pit, sharps pit, placenta pit, at strengthening infection prevention and control incinerator and waste store. These facilities were measures in government health facilities. This project essential to controlling the spread of Ebola by targeted the previously mentioned 24 community facilitating improved sanitary behaviour change health centres in Kambia and Moyamba and the among health care workers. To illustrate, prior to district hospital in Moyamba. Furthermore, an the outbreak, placentas were previously returned to additional six community health centres, a hospital, 56 patients for home disposal abiding by local custom. peripheral health units in Kambia and 88 peripheral The construction of dedicated pits in the waste zones health units in Moyamba were also included. enabled proper disposal at the health facility level, Through IPC capacity building interventions for health thus avoiding further risks of transmission to the care workers, including both clinical and non-clinical households. staff, Action Against Hunger aimed to facilitate Action Against Hunger ensured country ownership behaviour change on infection prevention and through continuous cooperation with local control measures and develop a culture of promoting authorities and building community capacity. Facility improved safety procedures in the targeted facilities. Management Committees, comprised of staff Formal trainings were conducted in close cooperation members and community representatives, were with the National Infection Prevention and Control either established or revitalised in cooperation with Unit of the Ministry of Health and Sanitation, the District Water Directorate. They were trained, who selected the topics and provided the support along with relevant health staff, on operation and material. These topics included hand washing, waste © Sophie Laurence for Action Against Hunger Against Action for Laurence © Sophie maintenance of the facilities mentioned above. management, environmental decontamination, and use of personal protective equipment. In alignment with the Ebola National Recovery Plan, Action Against Hunger constructed permanent Along with the District Health Management Teams, isolation and triage units in four community health Action Against Hunger ensured supervision in each centres in Kambia and four community health community health centre and hospital through use of the Ministry of Health and Sanitation’s Quality
40 3.1 IMPROVING INFECTION PREVENTION AND CONTROL IN SIERRA LEONE
Assurance tool. The Action Against Hunger First, sustainable water, sanitation and hygiene prevention and control is not a mandatory Left: An Action infection prevention and control monitors have facilities are critical to carrying out infection training requirement. This limitation is further Against Hunger health been assessing further needs for trainings prevention and control measures, precisely exacerbated by high staff turn-over, which worker measures through regular visits, in order to build on the in scenarios similar to the Ebola outbreak. results in a loss in the capacity built through the mid-upper arm formal trainings with on-the-job mentorship Prior to the programme, water, sanitation and these on-the-job trainings. To contribute to circumference of an infant, Sierra Leone and refresher sessions. In addition, visits to hygiene infrastructure lacked sustainability. In addressing this challenge in the long term and the health facilities were an opportunity for a different project in support of the importance make projects more impactful and sustainable, Action Against Hunger’s mentors to practice of improving sustainable water, sanitation and Action Against Hunger has committed to on-the-spot correction of errors. Throughout hygiene facilities, we recently worked with prioritise “the curriculum of all medical project implementation, the mentors conducted Facility Management Committees to ensure personnel includes infection prevention and 673 (299 in Kambia and 374 in Moyamba) the consistent functioning and maintenance control protocol as a mandatory credit course” mentorship sessions for a total of 1,680 clinical of water, sanitation and hygiene infrastructure as a policy change objective within its 2017- and non-clinical members of health facility through community engagement. Committees, 2020 Advocacy Strategy for Sierra Leone. staff. comprised of health staff and community representatives, created a link between There is no doubt that in the aftermath of Infection prevention and control committees communities and local authorities by conveying the Ebola outbreak, knowledge of infection have been established at different levels of feedback, ensuring upkeep of the facility, and prevention and control has substantially health governance (e.g. district, hospital and maintaining accountability between parties. improved in Sierra Leone, especially among the community health centre) for sustainability, and They also organised fundraising within the health workforce. The country is now better also to discuss identified infection prevention community to further emphasise economic equipped to respond to a sanitary crisis that and control-related issues. Action Against sustainability of the facilities. This community- asks for strong capacities in communicable Hunger’s infection prevention and control based approach was a great success in disease management. However, Sierra Leone mentors attended these meetings and provided strengthening sustainability of water, sanitation is still facing important challenges in health advice on the issues identified. Furthermore, and hygiene facilities. facilities that impede a full compliance with facilities have also been learning from each infection prevention and control measures. other through field exchange visits organised by Second, advocating for a more comprehensive There is a growing need for renewed attention Action Against Hunger. health curriculum for medical professionals was towards health system strengthening in Sierra identified as another opportunity for increasing Leone. Action Against Hunger will continue LESSONS LEARNED sustainability of infection prevention and to engage relevant institutions at different control measures at health facilities. One area levels in order to explore sustained solutions to Action Against Hunger reflected on some of of required improvement for implementation overcome these barriers. these lessons learned at project level, so that in was trainings were limited only to staff at the future, we can improve the sustainability of Community Health Centres, thus excluding For more information, please contact: Anwar IPC interventions. With more sustainable health Maternal and Child Health Posts or Community Ali, Deputy Country Director – Programmes, systems in place, local capacities can respond Health Posts. Furthermore, even eligible health Action Against Hunger Sierra Leone, dcd@ more efficiently and effectively to arising health staff are not all trained upon completion sl.missions-acf.org events, such as the Ebola outbreak. of their medical education, as infection
Action Against Hunger Learning Review 2016 41 Hunger Against Action for Calaf © Guy 3.2 MAPPING AND GEOGRAPHIC INFORMATION SYSTEMS: INCREASING THE EFFECTIVENESS OF ACTION AGAINST HUNGER’S NUTRITION PROGRAMMES BY ACTION AGAINST HUNGER NIGERIA
Action Against Hunger’s programmes in Nigeria MAP 1: FACILITY SELECTION IN YOBE Evaluation team mapped the Global Positioning expanded significantly throughout 2016 in STATE System (GPS) points for all clinics in the local response to increasing humanitarian needs and government areas using the Kobo mobile data a nutrition crisis in the northeast of the country. THE PROBLEM collection platform and Open Data Kit (ODK). Staff were faced with the task of rapidly scaling In Yobe state, Action Against Hunger is Secondly, we took those facilities selected using up support to health facilities to maximise the implementing an United Kingdom’s Department traditional health facility assessment tools and coverage of the nutrition programmes. for International Development funded grant mapped them to show spatial comparisons which includes support to health facilities across our active local government areas and HOW DID GEOGRAPHIC INFORMATION providing outpatient therapeutic programme amongst the whole pool of candidate health SYSTEMS HELP ADDRESS THE CHALLENGE? services. To select the facilities, the programme facilities that were assessed. Traditional selection criteria for health facilities teams initially planned to use traditional rely largely on indicators of capacity for service assessment criteria analysing facility capacity to END RESULT delivery. Limited attention is typically given provide treatment for undernutrition. However, When the programme team later selected the to geographic criteria – the distance between this approach ignored how our assessment facilities to support, consideration was given supported treatment sites and the relative criteria would potentially neglect certain areas to both traditional capacity criteria as well burden of undernutrition across different within our proposed local government areas of as the geographic coverage of facilities to be catchment areas. intervention. Sure enough, we found several supported by Action Against Hunger. As shown facilities were located in close proximity to each The Nutrition and Monitoring and Evaluation in Figure 1, the facilities ultimately assisted by other, potentially compromising access and teams decided to address these spatial Action Against Hunger were well-spaced across coverage. considerations by developing maps to assist the programming area rather than clustered in with comparative needs assessment and facility certain locations. This use of mapping maximised THE SOLUTION selection. Two examples are described below. the programme’s limited resources and expanded Then teams decided to add spatial criteria to access to quality treatment for beneficiaries facility selection. First, the Monitoring and across the widest possible geographic area.
42 3.2 MAPPING AND GEOGRAPHIC INFORMATION SYSTEMS
HEALTH FACILITY ASSESSMENT - TARMUA AND NANGERE LOCAL GOVERNMENT AREA
Action Against Hunger field staff at each nutrition Figure 1: Selected screening site, and severe acute malnutrition and Facilities based on global acute malnutrition caseloads were calculated Spatial Coverage & based on the screening data. The Monitoring and Assessment Data Evaluation team generated maps of the screening locations with pie charts showing the proportion of children suffering from life-threatening hunger at each site. A large variation was observed in number and percentage of cases in each area.
END RESULT Based on the mapping activity, Action Against Hunger’s programme teams were able to more efficiently understand where rapid scale was required in the allocation of clinics where the highest number of cases of malnutrition were discovered. The map was also used to coordinate our response in Monguno with other agencies and was provided to Unicef to assist in their resource allocation for the future scale up of services in Monguno.
LESSONS LEARNED FROM MAPPING IN NIGERIA: This process demonstrated that maps could be an effective tool to decide on the positioning of resources, including contingency stocks and priority MAP 2: MASS MID-UPPER ARM CIRCUMFERENCE SCREENINGS IN programming locations. It also could be a potential MONGUNO catalyst for fostering better coordination amongst humanitarian actors in places such as Monguno THE PROBLEM moving forward by conducting systematic mapping In the newly accessible areas around Monguno in Borno State, mass mid-upper arm activities and sharing findings to decide on the best circumference screenings were conducted to detect and refer undernourished children to application of resources in such densely populated clinics. These sites provided proxy indications of the relative caseload in each catchment towns. Action Against Hunger staff were among the area. first to collect and share project GPS coordinates from Monguno, and this collated data was shared THE SOLUTION with the Maiduguri-based information working The Nutrition and Monitoring and Evaluation teams decided to use mapping to better group for other agencies to utilize, which is an initial understand the relative needs in each catchment area. GPS coordinates were collected by
Action Against Hunger Learning Review 2016 43 3.2 MAPPING AND GEOGRAPHIC INFORMATION SYSTEMS
MID-UPPER ARM CIRCUMFERENCE AND CLINIC COVERAGE: OCTOBER
programme design collection systems and decision-making. In the Figure 2: Map and management. future, it will be useful to generate maps that of proportion of While mapping provide more strategic geographic insight on undernourished efforts have been well nutrition trends and Action Against Hunger children at each received, the system programming locations. For example, the teams screening site is not yet sustainable. would like to use dynamic, interactive platforms The work has been and begin mapping facility coordinates over driven by only a surveillance data. handful of skilled and motivated staff who The use of maps in programme implementation demonstrated an will undoubtedly require a combination of interest in mapping. “supply” and “demand” driven production. Additionally, foresight Programme teams should request maps based to create these types on decision points that can benefit from a of maps and dedicated spatial data perspective (e.g. demand). Proactive funding to do more map generation, support, and sensitization comprehensive, on spatial data by Geographic Information frequent and Systems and Monitoring and Evaluation systematic spatial focal points will be important to sustain the analysis projects such interest in and capacities around Geographic Information Systems for any country office step in the country office’s contributions to as those above would provide more timely and at Action Against Hunger (e.g. supply). These the spatial and non-spatial data sharing and valuable data to contribute to evidence-based focal persons should be tasked with identifying use at the information working group level. decision making at the field level. strategic opportunities for mapping across Action Against Hunger later provided its map Geographic Information Systems capacity sectors, providing basic technical support, and of mid-upper arm circumference screenings building – both of those who create maps and sharing lessons learned across country offices to Unicef, as they sought to place mobile those using the maps for decision-making – will and the network. Improved planning and clinics in areas with the highest caseload. High help sustain the use of spatial data. Country allocation of strategic resources for Geographic resolution, up-to-date imagery from the United offices would also benefit from technical Information Systems can help our programmes Nations Institute for Training and Research’s support to expand the types of spatial analysis make better use of maps as tools to increase Operational Satellite Applications Programme and the platforms used. the efficiency, effectiveness, and impact of our was used to manually update camp boundaries. programmes. As with any data type, it is necessary to build GEOGRAPHIC INFORMATION SYSTEMS sufficient capacity, resources, and demand AND MAPPING – THE WAY FORWARD For more information, please contact: for spatial data. The country office in Nigeria In the near-term the Nigeria Monitoring and Jennifer Majer, Monitoring and Evaluation is still in the early stages of operationalising Evaluation Department will continue working Officer, Action Against Hunger USA, jmajer@ Geographic Information Systems for to integrate spatial data into its routine data actionagainsthunger.org
44 3.3 LIFE GEORGIA STANDS FOR LIVES
BY ACTION AGAINST HUNGER SOUTH CAUCASUS MISSION
The LIFE Georgia project was designed with across two regions of Georgia. Formation the aim of contributing to poverty reduction of of the consortium of five organisations was conflict affected and displaced persons, as well both ambitious and challenging. It was not as their host communities. The project was a always easy to find mutual understanding and part of the European Union Internally Displaced agreements, however, the intense discussions Persons’ support scheme to raise conflict and exchange of ideas led to an open, dynamic affected and displaced persons out of poverty and conducive environment to develop by facilitating their integration into Georgia’s interesting and innovative approaches to broader economic development process and address internally displaced persons’ livelihoods decreasing their dependence on state and needs. The combination of this diverse external assistance. expertise allowed the LIFE Georgia project to
Georgia has experienced over 20 years of At the outset of the project a strong displacement with more than 270,000 people partnership between Action Against Hunger leaving the breakaway regions19 as a result of and four local non-governmental organisations the military conflicts in the 1990s and the 2008 was formed. The core idea of our support was August war. Protracted displacement, limited to foster employability and entrepreneurship prospects for return and a fragmented vision of internally displaced persons and vulnerable for socio-economic integration has affected host individuals, as well as to advocate with, internally displaced persons’ motivation to and build the capacities of, duty bearers achieve self-reliance and increased their through their active engagement at policy dependence on state support. level. Action Against Hunger was the lead organisation, guiding and coordinating activities of the local organisations in six municipalities 19 Abkhazia and South Ossetia
Action Against Hunger Learning Review 2016 45 3.3 LIFE GEORGIA STANDS FOR LIVES
effectively synchronise traditional with new, Against Hunger appeared to be a source of continuing their education. The achievements Right: A woman cooks innovative practices that included community inspiration for beneficiaries. The employment of the innovative methodology have been at home, Georgia mobilisation, business start-up, personal shuttle is a group of motivated unemployed documented in a documentary reflecting on development, vocational education and job people who are guided, empowered and the Employment Shuttle20 adaptation process. placement throughout the 21-months of project encouraged by a coach to develop their This experience has laid a strong platform for implementation. social skills and core employability skills further replication, and Action Against Hunger that allow them to more easily access the is now continuing the approach in its new The implementation process was very dynamic, local labour market. Initially, it was met with LINC21 project that is financed under the United combining meetings, trainings and workshops, some uncertainty, but the high commitment Nations Development Programme Confidence and beyond these formal events there was of partners, and the results experienced by Building Early Response Mechanism (UNDP- limitless and open interaction with project beneficiaries in the early months, increased COBERM). The shuttle approach is a perfect beneficiaries through informal gatherings, interest and saw a huge uptake in the shuttles tool for confidence building, and in this new conversations and exchanges. The project later in the project. The shuttle methodology project the shuttle supports unemployed geography was quite extensive stretching from has provided a new approach to tackling the people from Georgian, Kist and Chechen the capital city, Tbilisi, in the east, to the most problems of unemployment by breaking from communities in the Pankisi Gorge remote area western region of the country. The difficulties the traditional approaches to career guidance, of Georgia. of covering such a wide territory was overcome and adapting the model to the local context and through the partners’ regional presence but it the participant’s needs. The two pilot rounds What also made the LIFE Georgia project was still extremely challenging to establish first resulted in the employment of 63 per cent of unique was its accessibility and inclusiveness ties with the project participants and inspire enrolled participants, while 20 per cent were of all community members – women, men, them to build their livelihoods. Nonetheless, youth, internally displaced persons, people the constant support that the partners with disabilities and other vulnerable provided appeared to be the key towards groups. The constant feedback and critique motivating and empowering the discouraged from beneficiaries meant that project and devastated population to get engaged in implementation was an organic process, different activities that LIFE Georgia offered ready and capable to respond to emerging and to take advantage of the project’s benefits. requirements and to adjust the approach The diversity of the project initiatives allowed accordingly. This adaptation process and the the participants to make an informed decision approaches employed were captured and on whether to seek a job, go into training or documented in publications so that a wider look at the possibility of self-employment by group of stakeholders could learn and benefit establishing a business. from the experiences. These publications are as follows: The introduction of the innovative methodology, Employment Shuttle, by Action • Toolkit “Employment of Persons with
20 https://www.youtube.com/watch?v=keJkkCCs2z8&t 21 Leveraging Employment Initiatives and Networking to build Confidence among ethnicities in Georgia
46 Disability”; Disability Resource Mapping and LIFE Stories – Fostering Disability Livelihood
• Handbook “Change your future – Roadmap to Employment”
• Methodological Guide for Business Grant Support Schemes
• Methodological Guide on Employment Shuttles
One of largest internally displaced persons’ settlement, in Senaki, hosted the Closing Event in September 2016, bringing together the LIFE Georgia project partner organisations, beneficiaries, public and private stakeholders to celebrate the accomplishments jointly. The event provided the participants with the opportunity to talk about the achievements, challenges and prospects.
Overall, LIFE Georgia produced a lasting impact on the livelihoods of over 1,800 internally displaced persons and vulnerable host community members. The project helped stimulate their potential, supported them in gaining new skills, allowed them to engage their entrepreneurial talents, opened-up employment opportunities, and facilitated their inclusion in the socio-economic development of the country. When the project ended, it had created a group of empowered people who could stand up for their own rights with confidence and who have hope for a better future.
The LIFE Georgia project was implemented by a consortium of organisations led by Action Against Hunger in partnership with Association Atinati, Rural Development for Future Georgia, Education for Democracy, Social Programme Foundation in six municipalities of two regions of Georgia “I’ve learned that first you have to learn fishing yourself to later teach others and from January 2015 until September 2016. ultimately, this is what matters and drives change, rather than remaining passive and waiting for things to come to you on their own.” For more information, please contact: Maia Chkhenkeli, Programme Coordinator, Action Against Hunger South Employment shuttle participant Caucasus mission [email protected]
Action Against Hunger Learning Review 2016 47 © Daniel Burgui for Action Against Hunger Against Action for Burgui © Daniel 3.4 STRATEGIC FORESIGHT: THE CORNERSTONE OF HUMANITARIAN PROGRAMMING BY LEONIE LE BORGNE, COMMUNICATIONS OFFICER, ACTION AGAINST HUNGER UK
Action Against Hunger’s programmes in Based on the analytical outputs from the LEARNINGS Figure 1: Strategic planning Nigeria How can Action against Hunger past year we have run 4 strategic planning workshops with Country Offices leverage its programmes to achieve long- workshops in 4 country offices in sub- The challenge raised by some teams, term objectives such as the Sustainable Saharan Africa (see right). In early 2017 particularly those working in volatile Development Goals? How can we become we also ran a week-long training with 20 environments, is balancing the importance a game-changer in the systems in which directors from across the organisation to of strategic planning whilst managing by we intervene? How do we end hunger and train them on how to use foresight products a myriad of competing priorities – which all forms of malnutrition by 2030 whilst and strategic planning tools in their teams. include life-saving interventions. As is ensuring that we address the causes and By working with teams at the national, often the case when organising multi-day consequences of these global problems regional and global level to integrate strategic workshops, one of the greatest challenge systemically? foresight into planning, we can ensure that raised by organisers and participants alike, Action Against Hunger takes a systematic is that strategic planning takes time, and we The Inter-Agency Regional Analyst Network approach to networked problems, and recognise that in some contexts a few days is (IARAN) project within Action Against leverages investments and programmes a lot for a team to give up. It is for this reason Hunger aims to support the organisation in towards long-term goals, all with the aim of that we have optimised the process and addressing these questions by incorporating making the organisation a game-changer in reduced it down to the shortest it can be – 3 the concept of a plural future into strategic the sector. days. planning and programming.
“I asked the IARAN for support to define our 5 year strategy at a time of great national change... Centring strategic planning on a vision of the future makes our operations flexible and adaptable. That’s the value-added of the IARAN… Running an IARAN strategic planning workshop fosters team spirit and encourages the creation of a common vision and a strategy that’s flexible, dynamic and context-specific.” Andrea Dominici, former Country Director, Ivory Coast 48 3.4 STRATEGIC FORESIGHT: THE CORNERSTONE OF HUMANITARIAN PROGRAMMING
We have also learned through various content that summarises our analysts’ research) across the sector. We are seeing that the experiences, but most recently through the and striving to include stakeholders from across strategies that are built through our process Tanzania workshop, that inviting external the organisation in the design and production of are more futures-focused, context-specific, participants to strategic planning workshops is reports. We are also working with teams at the and robust enough to lead the integration of extremely valuable. Having the input of people global level to ensure that our services are used futures-focused analysis in the sector. who have been working in the region or with for strategic planning at all levels (cascaded the government for decades has made the down throughout the organisation) and we In response to direct feedback from the strategic output at the end of the process more encourage offices to learn from each other’s Action Against Hunger leadership, in 2017 we robust, and more adapted to the context in strategic planning process with the IARAN. will work on issues that are strategic for the which Action Against Hunger operates. It also whole organisation and reorient our focus to helps to lay the groundwork for building more We plan to continue building on these learnings the global projects portfolio. While this will effective partnerships with other organisations. in the months to come, to ensure the delivery of somewhat reduce the support at country and effective and relevant analysis, with the larger regional level, with the addition of the Strategic Running such workshops has taught us that aim of making Action Against Hunger a game- Toolkit (which we developed over the last year in order to develop a robust set of strategic changer in the achievement of Sustainable and trained 20 directors on) we hope that this options, time is both indispensable and a good Development Goals by 2030. reduction will be offset by an increase in the use investment. Pre-empting change and preparing of the analysis. for hypothetical, complementary scenarios LOOKING AHEAD makes for more flexible, agile country strategies 2017 is the final year of the IARAN pilot in In the immediate future we plan to work with that are more adaptable to systemic change. Action Against Hunger, building from the test the Bangladesh and Myanmar country offices phase in Save the Children and as a result a While the feedback from Action Against Hunger as well as with the Egypt office to build sub- portion of staff time will also be dedicated to staff who requested IARAN products is that regional and national strategies. On an ongoing projects and initiatives that will round out the they used to inform a myriad of decisions, basis we collect feedback to ensure that IARAN library and respond to critical research ensuring greater uptake of reports throughout throughout the year, directors have the support questions for the project. the whole organisation is a continuing they need to integrate foresight into their challenge. To address this, we are working to programme planning and implementation. Being For more information and support from the increase uptake through the strategic planning inter-agency, we will also be working with other IARAN, please contact: Leonie Le Borgne, workshops described above, but also through humanitarian agencies to promote foresight Communications Officer, Action Against Hunger increased communications efforts (for example analysis, preparedness and scenario/strategic UK, [email protected] developing infographics, videos and interactive planning to be integrated more widely for Action Against Hunger Against Action for © Marion Legrand
Action Against Hunger Learning Review 2016 49
© Susana Vera for Action Against Hunger Against Action for Vera © Susana
CREDITS
The production of the Learning Review would • Francine Heggie Head of Challenge & Technical Development, Action Against Hunger not have been possible without the invaluable Community Events, Action Against Hunger UK UK front line work of our Action Against Hunger staff in the field and the affected populations • Hugh Lort-Philipps Global Coverage Advisor, • Mathias Altmann Operational Research who welcomed us. Action Against Hunger UK Advisor, Action Against Hunger France
The Learning Review 2016 was produced by: • Cassie Painter DFID Relations Support • Laetitia Battisti Advocacy Officer, Action Intern, Action Against Hunger UK Against Hunger Sierra Leone • Katherine Dunlop Senior Project Officer – Information Management, Action Against • Eleanor Rogers Independent Consultant • Pilar Charle Cuellar iCCM+nutrition Hunger UK Coordinator, Action Against Hunger Spain • Natalie Sessions Research Uptake Officer, • Vincent Fevrier Senior Project Officer – Action Against Hunger UK • Maia Chkhenkeli Programme Coordinator, Information Management, Action Against Action Against Hunger South Caucasus mission • Kevin Tang Evaluation, Learning and Hunger UK Accountability Intern, Action Against Hunger • Brett Collins Regional M&E Coordinator, • Tamar Gabay Senior Monitoring, Evaluation UK Action Against Hunger Nigeria and Learning Officer, Action Against Hunger We would like to thank Action Against Hunger • Saul Guerrero Director of International UK colleagues and friends from around the globe Nutrition Initiatives, Action Against Hunger • Emilie Kindvall Evaluation, Learning and for their technical inputs and expertise. We USA Accountability Intern, Action Against Hunger want to express our deepest appreciation to • Deepak Kumar Research Coordinator UK each of the following contributors to this year’s edition: Pakistan, Action Against Hunger Pakistan Senior Project Officer, • Hannah Wichterich • Leonie Le Borgne Communications Officer, Action Against Hunger UK • Franck Alé former Research Coordinator Mali, Action Against Hunger Mali Action Against Hunger UK Many thanks to the following for editing this • Jennifer Majer M&E Officer, Action Against publication: • Anwar Ali Deputy Country Director – Programmes, Action Against Hunger Sierra Hunger USA Senior Community Fundraising Leone • Jenny Clarke • Richard Maxfield Rural and Economic Officer, Action Against Hunger UK • José Luis Alvarez Moran former Head of Development Coordinator, Action Against Hunger South Caucasus mission
50 • Lela Merabishvili Project Officer, Action Analysis, Action Against Hunger France Manager, Action Against Hunger Spain Against Hunger South Caucasus mission • Pascal Debons DRM & Resilience Senior • Juliet Parker Director of Operations, Action • Lucia Oliveira Country Director, Action Technical Advisor, Action Against Hunger USA Against Hunger UK Against Hunger Egypt • Ricardo Dos Santos Lobo Cash/KACHE • Silke Pietzsch Technical Director, Action • Chloe Puett Senior Research Advisor, Action Advisor, Action Against Hunger Spain Against Hunger USA Against Hunger USA • Aurélie Férial Deputy Regional Operations • Jean-Raphaël Poitou Desk Officer for Middle • Cecile Salpeteur Nutrition Research Projects Director, Action Against Hunger France East, Action Against Hunger Spain Coordinator, Action Against Hunger France • Alicia García-Madrid Colado Manager of • Didier Vergès DRM & Disaster Resilience • Zvia Shwirtz REFANI Research Uptake European Social-Labour Inclusion Programmes, Senior Advisor, Action Against Hunger Spain Officer, Action Against Hunger USA Action Against Hunger Spain Finally, we would like to express our • Lani Trenouth Research Officer, Action • Amador Gómez Technical Director, Action heartfelt gratitude to the evaluators for their Against Hunger USA Against Hunger Spain commitment to delivering quality evaluations for Action Against Hunger and their willingness • Nicolas Villeminot Senior Water, Sanitation • Jean-Michel Grand Executive Director, to learn with us and keep improving our & Hygiene Technical Advisor, Action Against Action Against Hunger UK evaluation practice. Hunger USA • Clara Ituero Global Gender Advisor, Action For more information on the evaluation • Ellyn Yakowenko Associate Director of Against Hunger Canada features in this Learning Review and for further Research, Action Against Hunger USA information on good practices, please contact • Hajir Maalim Regional Operations Director, the Evaluation, Learning and Accountability Special thanks for the foreword to: Action Against Hunger France Unit, Action Against Hunger - UK by email: • Judith Greenwood Executive Director, CHS • Ana Martin Desk Officer Quality, Action [email protected] or telephone: Alliance Against Hunger Spain +44 (0) 208 293 6190
Moreover, we wish to thank the following for • Amy Mayberry Head of Evidence, Action Front cover photo: © Alicia Garcia for Action their advice and support: Against Hunger UK Against Hunger
• Myriam Ait Aissa Head of Research and • Iván Molina Allende Research & Innovation Designed by Alice Hale
Action Against Hunger Learning Review 2016 51 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 THIS INDIFFERENCE. WATER. YEAR, FOR FREEDOM AGAINST KILLER AND NEXT. FROM HUNGER. DISEASES. AGAINST FOR EVERYONE. DROUGHT FOR GOOD. AND DISASTER. FOR ACTION. AGAINST HUNGER.
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