November 2014 Issue 48 ISSN 1743-5080 (print)

Programming experiences and learning from the nutrition response to the Syrian crisis Contents......

1 Editorial Views Turkey 2 ENN’s perspective on the nutrition response in the Syria crisis Field Articles 67 DRC experiences of cash assistance to non-camp refugees in Turkey and Lebanon Lebanon 70 Experiences of the e-Food card programme in the Turkish Field Articles refugee camps 8 Designing an inter-agency multipurpose cash transfer programme in Lebanon Iraq 11 Postscript 12 Institutionalising acute malnutrition treatment in Lebanon Views 14 Infant and young child feeding support in Lebanon: 73 Syrians in Iraq: Refugee response within a major strengthening the national system humanitarian and political crisis 17 UNICEF experiences of the nutrition response in Lebanon 20 WFP e-voucher programme in Lebanon Regional 22 Characteristics and challenges of the health sector response in Lebanon Research 25 WFP experiences of vulnerability assessment of Syrian 75 International legal consequences of the conflict in Syria refugees in Lebanon Field Articles Views 79 The Syria Needs Assessment Project 28 Towards a 21st century humanitarian response model to the refugee crisis in the Lebanon Views Jordan 81 Nutrition response to the Syria crisis: UNICEF's perspective Field Articles Bonus articles online: www.ennonline.net/fex 30 Aid effectiveness: determining vulnerability among Syrian refugees in Jordan 33 Evolution of WFP’s food assistance programme for Syrian An Informal Settlement during Storm refugees in Jordan Alexa in December 2013 35 Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment 38 Managing infant and young child feeding in refugee camps in Jordan 41 Postscript 42 The situation of older refugees and refugees with disabilities, injuries, and chronic diseases in the Syria crisis Views 44 UN and INGO experiences of coordination in Jordan Syria Field Articles 46 WFP’s emergency programme in Syria

50 GOAL’s food and voucher assistance programme in Northern Syria 54 WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management 57 Experiences and challenges of programming in Northern Syria 60 Non-food cash voucher programme for IDPs in Northern Syria 61 Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria Views 65 Coordinating the response to the Syria crisis: the southern

Turkey cross border experience 2013 SC Lebanon, Baroudi, Ahmad ...... Editorial ...... Ahmad Baroudi, SC Lebanon, 2013 SC Lebanon, Baroudi, Ahmad

pproximately two year aer the outbreak of civil war in Syria in April 2011, the ENN decided to compile a special issue of Field Exchange on the humanitarian responseA to the crisis that unfolded. is decision was based on the fact that there was (and remain) a number of unique features of this ongoing regional emergency and it presented an important opportu- nity to capture programming experiences and learn- ing. In particular, the massive and unprecedented scale of need amongst those displaced in Syria (there are now over 9 million displaced Syrians and it is the Children inside an improvised shelter biggest refugee crisis faced by UNHCR in its 64 year in Baalbek District, Bekaa Valley history) combined with the generosity of host gov- ernments and the donor community (including many non-traditional donors) in meeting needs; the tions. Many of these organisations/institutions have WFP in the region. Cash has largely replaced general programming challenges of remote management in not been part of the formal coordination structures food distributions in the regional response apart conflict affected Syria and of serving the needs of established as a response to this emergency and this from in Syria itself. Cash has also been used to sup- non-camp populations in refugee hosting countries is one of the reasons why we found it difficult to en- port access to other critical needs, such as health (the vast majority of refugees are not in camps); the gage with and capture the programming experiences care, shelter and livelihoods, with these ‘nutrition- substantial impact of the refugee population on host of these entities. By all accounts, the humanitarian sensitive’ programmes implemented by a variety of response of the Syrian community – at home and UN and INGOs. We have also broadened our hori- populations, and the unprecedented scale of cash abroad – has been huge, zons to feature articles from agencies specialising in and voucher programmes being employed in the re- water, sanitation and hygiene (WASH), shelter, and gion. At the outset of compiling this special issue, it e outcome of these efforts is in effect a triple edi- gender based violence related programming that was not clear to the ENN what, if any, nutritional tion of Field Exchange comprising 35 field articles touch on nutrition. Two articles were ‘commis- challenges were being faced. is only began to (plus four postscripts), nine views pieces, one research sioned’ by the ENN – one explores the legal basis for emerge as we engaged with key actors and under- article, on evaluation, one news piece and three military involvement on humanitarian grounds in took a number of country visits. e ENN views ar- agency profiles. e unprecedented number of arti- Syria, a pro bono piece of work by an international ticle that accompanies this editorial is an attempt to cles generated has meant that for practical and cost barrister, Natasha Harrington, enabled by A4ID3. set out the nutrition challenges of this crisis and purposes, we have produced it in two forms: a full on- e second article is an anthropological review of emerging issues as we see them. line edition (available at www.ennonline.net/fex) and the nutrition-related social aspects of the refugee ex- this smaller print edition. For print, we have selected perience in Jordan, which involved a month of field e ENN began the process of compiling this programme-oriented articles informed by consider- special issue a year ago, conducting over 100 tele- work by two anthropologists and an ENN volunteer. ations of geographic spread, range of sectors and ere are also a number of cross-cutting features in phone interviews (at headquarters, regional and ‘richness’ of learning. e online edition will feature country level) with agencies working in the region articles, such as coordination mechanisms, informa- on the UNHCR Syria response interagency informa- (UN, INGOs, NGOs, donors and research groups) tion management and challenges of remote pro- tion sharing portal, the ‘go to’ online destination for in order to obtain agency briefings, hear program- gramme management in Syria. What all these programmers in the region2. ming experiences and scope out potential areas of articles have in common is that they provide a rich interest for field articles. At the outset, in September A number of field articles have fallen by the way- font for learning. e accompanying ENN views 2013, ENN met with staff in UNHCR, IFRC, ICRC side, largely as agencies came to view the material as piece attempts to synthesise key themes emerging and OCHA in Geneva who provided overviews of ‘too sensitive’ for publication. Although disappoint- and lessons learned with respect to nutrition pro- their respective agency responses in the region and ing, some of the authors have stated that the process gramming and response. helped identify key issues to highlight in the edition. of writing the article was useful for internal lesson roughout this process, we have been genuinely ree ENN Technical Directors then visited the re- learning even though the material cannot be dissem- struck by the incredible engagement of humanitar- gion in March/April 2014 to meet with 45 country inated more widely. ere is also material in this ian staff with us to candidly share and write their offices in Jordan, Lebanon and southern Turkey, in- special issue that has been written anonymously to stories, typically in ‘out of office’ time in evenings, terviewing more than 60 staff involved in the re- protect the interest of agencies, as well as articles weekends and whilst on leave. e authors remained sponse. Efforts to conduct a short trip to Damascus where the authors have purposively omitted or eminently patient with our nagging for final dras. proved unsuccessful given the security situation. steered clear of information which could jeopardis- All the agencies were incredibly supportive of our Field visits, facilitated by WFP, Save the Children ing future programming. country visits. We extend a huge thanks to all. Jordan, IOCC and UNHCR, were conducted to see programmes first hand. On return to the UK, the e special issue provides a truly unique We hope you find this special publication of Field ENN team continued to work closely with authors overview of programming experiences in the region, Exchange to be useful for your work and an enjoy- to develop and finalise articles and met again with as well as insights into the institutional architecture able read. We welcome feedback including letters to Geneva based agencies in July 2014, to share the and challenges involved in supporting program- the editors (contacts below). essence of our observations now reflected in the ming. If you can, we encourage you to access the Jeremy Shoham & Marie McGrath ENN views piece (see page 2). ‘bonus’ content online. e field articles cover a wide range of programming experiences in Syria, Jordan, (Field Exchange Editors) and It is important to note that we reflect the experi- Lebanon, southern Turkey (both cross-border into Carmel Dolan (Guest Editor) ences of the ‘traditional’ humanitarian community; Syria and refugee programming within Turkey) and it proved too challenging (this time) to capture ex- Iraq. A number of articles describe programmes for 1 For want of a better term, non-traditional humanitarian actors periences from the immense non-traditional1 hu- scaling up the treatment of acute malnutrition and are those operating outside the ‘traditional’ UN agencies and manitarian community that has responded to this NGOs effort and includes Arab donors, local NGOs, Syrian support for infant and young child feeding (IYCF) diaspora crisis, including several important non-traditional in Jordan and Lebanon. ere are several articles on 2 http://data.unhcr.org/syrianrefugees/regional.php donors and a large number of faith-based organisa- the food voucher programmes implemented by 3 http://a4id.org/ ...... 1 Views...... ENN’s perspective on the nutrition response in the Syria crisis By Carmel Dolan, Marie McGrath and Jeremy Shoham

Unless otherwise stated, referenced articles feature in Field Exchange 48.

hile the ENN’s role is first and fore- Syrian ‘people of concern’ (2,998, 118 registered tion of Field Exchange demonstrates that the nutri- most to capture programming expe- refugees) at an estimated annual cost to these gov- tion sector identified and focused on two main pro- riences and lesson learning (and we ernments of over $3.7 billion3. In Lebanon and gramming areas: establishing capacity for the hope we have done this success- Jordan, the government policy is to facilitate inte- treatment of acute malnutrition in children (partic- Wfully), it is perhaps inevitable that the ENN team gration of the Syrian refugee population into the ularly in Lebanon and Jordan) and support for IYCF, would make observations and therefore formulate host population or into informal tented settlements in particular, breastfeeding support. Whilst nutri- views about the response from a nutrition perspec- (ITS). In Turkey, the government’s policy has seen tion activities in Syria also have heavy emphasis on tive. Given the sheer amount of content generated 220,240 Syrians hosted in 17 camps, and 623, 385 acute malnutrition treatment and breastfeeding sup- across a breadth of programming and contexts, our Syrians settled amongst the host community4. port, there is “equal importance” given to preventive observations go beyond a typical editorial and we Within Syria, the humanitarian community is re- measures in evolving programming, such as mi- have taken the liberty to write this views piece. In it sponding to the needs of the internally displaced ei- cronutrient supplementation6. we share our perspective on what we have observed ther from the capital Damascus or through cross regarding programming experiences and the related border operations implemented largely from south- Treatment of the acute malnutrition institutional architecture and challenges involved in ern Turkey and Jordan. e combination of dis- Pre crisis, the nutrition situation is Syria was defined coordinating the response. placed and refugee populations makes the Syria as ‘poor’ with global acute malnutrition (GAM) 7 situation the largest crisis of its kind in living mem- prevalence reported at 9.3%, stunting at 23% and It is hoped that our reflections will contribute to 8 ory and the largest refugee crisis in UNHCR’s 64 under-fives anaemia at 29.2% . In late 2012, an initial collective learning and may help inform the ongoing year history. Another feature of the crisis has been nutrition survey of Syrian refugees in Lebanon and response in Syria, as well as future programming in the transition from early blanket food aid distribu- Jordan indicated a low prevalence of GAM: (4.4% in similar contexts. However, it should be stressed that tions to a highly targeted, organised and unprece- Lebanon; Jordan, 5.1% in the non-camp population this is not an evaluation or review by the ENN. dented humanitarian cash and voucher programme, and 5.8% in Za’atari camp). e continued influx of Rather, this views piece is a convergence of perspec- meeting food, health, shelter, livelihoods and non- refugees, poor living conditions in the ITSs in tives amongst the ENN team who visited the region food needs. Lebanon, low breastfeeding rates and the widespread as we reflected on what we were hearing and read- use of infant formula in the host and refugee popu- ing, and as themes and patterns began to emerge. In To date, the overall refugee response seems to lations, combined with anecdotal reports of acute order to bring coherence to our views, a guiding have successfully averted a nutritional crisis in spite malnourished children, led to increasing concerns question we have posed has been ‘how effective has of the unprecedented scale of this emergency and amongst the nutrition community about threats to the humanitarian sector been in addressing the nu- the challenging context, including the dispersed na- nutritional status9. Furthermore, whilst the recorded trition needs of those affected by the Syria crisis?’ ture of the population and difficulty of providing prevalence were ‘acceptable’ in global terms, to na- We have largely considered this on a technical and services to large non-camp as well as camp dwelling tional representatives, any cases of acute malnutri- programmatic level although perhaps inevitably is- populations. Prevalence of acute malnutrition is low tion were unacceptable in this context10. ese sues that have underpinned and shaped the re- in Jordan and Lebanon and as implied by the lack of factors prompted the decision by UNICEF and a sponse, e.g. analytical capacity, leadership and nutrition survey data from Turkey, is not considered number of non-governmental organisations (NGOs) coordination, have emerged as critical factors for an issue amongst the refugees hosted there. Due to to scale up treatment programmes in Lebanon (such consideration. access constraints, up to date, representative nutri- as described by International Orthodox Christian tion data from within Syria are not available and Charities (IOCC)11 and Relief International12) and in Overview therefore, the picture in Syria is less clear. However, Jordan (such as implemented by Medair13, Jordan e Syria crisis has resulted in an unprecedented following a number of pilots, great efforts are under- Health Aid Society (JHAS)14 and Save the Children number of refugees and displaced people in need of way to establish credible nutrition surveillance sys- Jordan15). As neither country had prior experience of food, health, shelter, protection and other basic serv- tems in key conflict affected governorates5. It is implementing treatment programmes, considerable ices. e refugee hosting Governments of Jordan, hoped that this initiative will rapidly fill the nutri- investment was made in building national capacity16 Lebanon, Turkey, Egypt and Iraq1 with the support tion data gap in. and in training initiatives17. ese experiences are of the traditional and non-traditional2 humanitarian featured in a number of interesting articles, many community, have been meeting these needs with an The nutrition sector’s response: treatment that worked to integrate scute malnutrition treat- enormously impressive programme of support. At of acute malnutrition and infant and ment in the healthcare systems in Jordan and the time of writing (September 2014), these host young child feeding (IYCF) Lebanon. A similar scale up has not been seen in the Governments continue to support 3,030,653 million Te profile of collated nutrition articles in this edi- Turkey Government led response.

1 We focus on Lebanon, Jordan and Turkey given this is where 6 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO 14 Ruba Ahmad Abu-Taleb. Experiences of emergency nutrition we have documented experiences in this edition. We recognise response to malnutrition in Syria: a focus on surveillance, case programming in Jordan. that Iraq and Egypt have also hosted significant numbers of detection and clinical management. 15 Sura Alsamman. Managing infant and young child feeding in refugees. 7 Syria Family Health Survey (SFHS), 2009 refugee camps in Jordan. 2 For want of a better term, non-traditional humanitarian actors 8 Ministry of Health, Nutrition surveillance system report, Syria, 16 James Kingori. UNICEF experiences on nutrition in the Syria are those operating outside the ‘traditional’ UN agencies and 2011. response; Najwa Rizkallah. UNICEF experiences of the nutrition NGOs effort and includes Arab donors, local NGOs, Syrian 9 Najwa Rizkallah. UNICEF experiences of the nutrition response response in Lebanon; Ruba Ahmad Abu-Taleb. Experiences of diaspora and businesses. in Lebanon. emergency nutrition programming in Jordan; Linda Shaker 3 2014 funding appeal. Currently 44% funded (correct as of 18th 10 ENN interviews in Jordan and Lebanon. Berbari, Dima Ousta and Farah Asfahani. Institutionalising September 2014). Accessed at 11 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. acute malnutrition treatment in Lebanon. http://data.unhcr.org/syrianrefugees/regional.php# Institutionalising acute malnutrition treatment in Lebanon. 17 James Kingori. UNICEF experiences on nutrition in the Syria 4 file:///C:/Users/Marie/Downloads/TurkeySyriaSitrep12.09 12 Jamila Karimova and Jo Hammoud. Relief International response; Hala Ghattas Linda Shaker Berbari & Omar Obeid. .2014.pdf nutrition and health programme in Lebanon The impact of the NiE regional training initiative: the Lebanon 5 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff. WHO 13 Gabriele Fänder and Megan Frega . Responding to nutrition experience 2010-2014; Caroline Abla. Experiences on Nutrition response to malnutrition in Syria: a focus on surveillance, case gaps in Jordan in the Syrian Refugee Crisis: Infant and Young in Emergencies Training for Syrian refugees response in Jordan. detection and clinical management. Child Feeding education and malnutrition treatment...... 2 Views ...... A subsequent cross-sectional cluster survey in tion data to inform programming28. Small-scale as- Lebanon in 2014 appeared initially to confirm the sessments, in Idleb, Ar raqqa and Aleppo gover- fears of an impending nutrition crisis, with the norates in Northern Syria, described in an article by prevalence of GAM increasing from 4.4% to 5.9% in World Vision International29, found low levels of Lebanon and to just under 9% in the Bekka Valley GAM (MAM < 2.6% and SAM <0.5%). Similarly, where a substantial proportion of refugees resided nutrition screening (mid upper arm circumference However, the anticipated case load from this preva- (MUAC) during a measles vaccination campaign) by lence estimate was not being seen in screening ac- MSF in Tal-Abyad District of Al-Raqqah gover- tivities in Lebanon or Jordan18 or found in other norate found a prevalence of 0.6% GAM30. However assessments19. Furthermore, the few cases that were Médecins sans Frontières (MSF) supported clinics detected oen had pre-existing co-morbidities20. were identifying a higher caseload than prevalence Increasing uncertainty about the reliability of the figures indicated, leading to the decision to provide Lebanon survey data, led to UNICEF requesting treatment for acute malnutrition treatment. Of those CDC21 to carry out a re-analysis of the data in 2013. subsequently admitted 45% (119 cases) were infants is revealed that there had been some data manip- under 6 months – an age group traditionally ex- Lebanon IOCC, 22 ulation regarding height measures and resulted in cluded from surveys and nutritional surveillance. communities38 and in Syria. Support to non-breast- a readjustment of GAM prevalence to just 2.2% Surveys have not been conducted in the hardest to fed infants has not been entirely absent – we feature (0.4% SAM). Doubts have also been cast about the access locations so a more serious situation may articles on successful targeted programmes of sup- validity of the earlier Lebanon 2012 survey and exist in the besieged locations. However, WHO have 23 port in Za’atari camp in Jordan (UNHCR/Save the Jordan 2012 nutrition survey , fuelled by the recent been strengthening nutrition surveillance through Children Jordan) and in Lebanon (IOCC). But they UNHCR survey in Jordan in 2014, which suggested health centres in Syria in a number of conflict-af- are small scale and for the vast majority of Syrian in- a dramatic fall in GAM to 1.2% amongst non-camp fected governorates since April 2014 so that nutri- 24 fants dependent on infant formula, whether within and 0.8% in camp refugees . tion data should become increasingly available in Syria or in host countries, access to supply is un- the coming months31. It is certainly good news that the prevalence of known and by all accounts, either inaccessible or ex- acute malnutrition is so low in this population. Infant and Young Child Feeding (IYCF) pensive in absolute terms or relative to other However, the issues around the integrity of nutrition e second main focus of the nutrition response household needs39. data raise the real prospect that the drive to scale up treatment of acute malnutrition was unnecessary in has been on IYCF. Whilst breastfeeding is culturally Undoubtedly, addressing IYCF needs have been both Jordan and Lebanon or at the very least, that accepted and commonly practised amongst Syrians challenging in this response, particularly in Syria 32 limited resources might have been used to better ef- (most mothers initiate breastfeeding) , exclusive where access is limited and remote programme fect elsewhere. It is difficult to put a figure on the breastfeeding rates are low, and breastfeeding falls management the only means to deliver40, and in host 33 level of resources devoted to scaling up treatment off considerably by 1 and 2 years of age . Infant for- communities where refugees are scattered and diffi- programmes but these are likely to have been con- mula use is a recent and increasing form of infant cult to identify and follow up.41 e region has a 34 siderable. For example, in Lebanon, 30 primary feeding that is culturally accepted . is context track record of misuse of infant formula in crisis health care (PHC) centres had been ‘activated’ to indicates a need for both breastfeeding and artificial times.42 An added complication is that standard treat acute malnutrition25, whilst further capacity is feeding support, and flags the need for particular IYCF indicators and programming options are heav- provided through mobile clinics26 and extensive attention to complementary feeding given the low ily biased towards breastfeeding populations where community screening looking for cases. continued breastfeeding rates. Our compilation of infant formula use is the exception. Low breastfeed- Furthermore, the importation of therapeutic feeding experiences suggests the nutrition sector has largely ing rates identified in 2012 and 2013 assessments products has undoubtedly been costly in both fallen short of meeting the wider IYCF needs of amongst Syrian refugees in Jordan and Lebanon cre- Lebanon and Jordan27. It is interesting to note that infants and children. ated breastfeeding targets but no actions or advo- whilst attention to GAM rates has defined a signifi- Our collation of articles reflects that the pro- cacy around meeting the immediate nutritional cant proportion of the Lebanon and Jordan nutri- 43 gramming emphasis has been particularly on breast- needs of non-breastfed infants . e Joint Rpaid tion response, this has not been the case in southern feeding support in a bid to protect and ideally Assessment of Northern Syria (JRANS) 2012, the Turkey. We could find no reference to GAM in the 44 increase breastfeeding rates. is has yielded some Syria Integrated Needs Assessment (SINA) in Dec refugee camps in Turkey, possibly because the 45 strong and necessary breastfeeding support pro- 2013 and GNC scoping mission in Syria , data from Turkish Government and Turkish Red Cross (TRC) gramming in Lebanon35 and Jordan36 and is the surveys in Lebanon and Jordan, and articles we fea- drives the shape and content of the response and the focus of attention on IYCF support within Syria . ture by GOAL, MSF, Action Contre la Faim (ACF), role of United Nation (UN) agencies and interna- IOCC, WHO, UNICEF and Medair all noted need tional NGOs is less influential. However, there have been large gaps in attention and action on support to non-breastfed infants (or in- or demand for infant formula supplies and support. In other aspects of the response (notably within fants who are breastfed but heavily dependent on in- But for a few small scale exceptions (as outlined ear- Syria) there has been a lack of representative nutri- fant formula), especially to refugees in host lier), agencies were not willing to take it on, espe-

18 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee response to malnutrition in Syria: a focus on surveillance, case 38 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jordan; Gabriele detection and clinical management. children and women nutritional needs in Jordan. Fänder and Megan Frega. Responding to nutrition gaps in 29 Emma Littledike and Claire Beck. Experiences and challenges 39 Gabriele Fänder and Megan Frega. Responding to nutrition Jordan in the Syrian Refugee Crisis: Infant and Young Child of programming in Northern Syria. gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Feeding education and malnutrition treatment. 30 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Child Feeding education and malnutrition treatment; Maartje 19 WFP VASyR assessment in 2013 MUAC based assessment found Saskia van der Kam. Emerging cases of malnutrition amongst Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van a prevalence of 1% MAM and 0.4% SAM. Susana Moreno IDPs in Tal Abyad district, Syria. der Kam. Emerging cases of malnutrition amongst IDPs in Tal Romero. WFP experiences of vulnerability assessment of Syrian 31 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO Abyad district, Syria; Hannah Reed. GOAL’s food and voucher refugees in Lebanon. response to malnutrition in Syria: a focus on surveillance, case assistance programme in Northern Syria; Ann Burton. 20 Foot Linda Shaker Berbari, Dima Ousta and Farah Asfahani. detection and clinical management. Commentary on experiences of IYCF support in the Jordan Institutionalising acute malnutrition treatment in Lebanon; 32 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, response. Najwa Rizkallah. UNICEF experiences of the nutrition response Saskia van der Kam. Emerging cases of malnutrition amongst 40 Hannah Reed. GOAL’s food and voucher assistance programme in Lebanon. IDPs in Tal Abyad district, Syria. in Northern Syria. 21 Centres for Disease Control and Prevention 33 Susana Moreno Romero. WFP experiences of vulnerability 41 Gabriele Fänder and Megan Frega. Responding to nutrition 22 Najwa Rizkallah. UNICEF experiences of the nutrition response assessment of Syrian refugees in Lebanon. gaps in Jordan in the Syrian Refugee Crisis: Infant and Young in Lebanon; personal communication. 34 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Child Feeding education and malnutrition treatment. 23 Personal communication. It is not possible to confirm these Saskia van der Kam. Emerging cases of malnutrition amongst 42 Ali Maclaine and Mary Corbett (2006). Infant Feeding in suspicions, as was possible with the Lebanon 2013 data. IDPs in Tal Abyad district, Syria. Emergencies: Experiences from Indonesia and Lebanon. Field 24 Bilukha O et al (2014). Nutritional Status of Women and Child 35 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Exchange 29, December 2006. p2. Refugees from Syria – Jordan, April-May 2014. MMWR/July Institutionalising acute malnutrition treatment in Lebanon. www.ennonline.net/fex/29/infantfeeding 25, 2014/Vol. 63/No. 29 36 Sura Alsamman. Managing infant and young child feeding in 43 Inter-agency nutrition assessment Syrian refugees in Jordan. 25 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. refugee camps in Jordan; Gabriele Fänder and Megan Frega. Host communites and Zaatari camp. Final report, January 2013. Institutionalising acute malnutrition treatment in Lebanon. Responding to nutrition gaps in Jordan in the Syrian Refugee 44 In the SINA, 23.5% of key informants reported a predominance 26 Jamila Karimova and Jo Hammoud. Relief International Crisis: Infant and Young Child Feeding education and of exclusive breastfeeding, 72.3% reported mixed feeding, and nutrition and health programme in Lebanon. malnutrition treatment. 3.4% exclusively used infant formula. The use of animal milk to 27 Sura Alsamman. Managing infant and young child feeding in 37 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO feed infants under 6 months was also reported. Key informants refugee camps in Jordan. response to malnutrition in Syria: a focus on surveillance, case called for infant formula as a key priority. 28 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO detection and clinical management. 45 Accessed via the GNC Global Coordinator...... 3 Views ......

case studies featured60,61. Breastfeeding support pro- grammes amongst refugees in Jordan have seen im- provements in knowledge but not practice62. Observations of a small anthropological study com- 63 WFP/Dina Elkassaby missioned by the ENN also question the ambition and even appropriateness of the zeal and method of breastfeeding support, given the reality of the IYCF context. A postscript by Ann Burton asks whether the humanitarian sector is really ready to support ‘informed decisions’ by mothers to not breastfeed64. ere is no question that there is a need for pro- tection and support of breastfeeding in mixed fed populations. ese contexts are particularly chal- lenging, and Lebanon, as an example, has a long his- tory of struggling with inappropriate infant formula marketing both by companies and medical person- nel, and widespread Code violations in both normal and crisis times. Experiences around IYCF in the 2006 conflict65 laid the groundwork for a Lebanese cially as they couldn’t ensure targeting or guarantee in February 201451. It was not well accepted by the national programme focused on strengthening 66 water, sanitation and hygiene (WASH) conditions community and significant follow up has been nec- Code implementation . It is important that human- (as recommended by policy guidance), or go against essary to support its use52. No provision for comple- itarian crises and the associated response don’t un- agency policy positions not to supply infant for- mentary food for children living in the host dermine national efforts to strengthen policy and mula46. e consequences of poor coverage of sup- community was made. Fortified complementary programming around breastfeeding protection and port to formula dependent infants are not well foods are not available in the Jordanian shops linked support. A mother from Syria has the same right to documented – most infants are dispersed in host to the WFP voucher scheme, while fortified foods support for breastfeeding as a mother in Sudan. But communities or within Syria. Some insight is pro- available in pharmacies are prohibitively expensive53. equally, a non-breastfed infant has the same right to vided in an article by ACF, where almost half of the e WFP VASYR assessments in Lebanon in 2012 humanitarian protection as a breastfed infant. infants aged 0-< 6 months admitted to ACFs acute and 2013 pointed to extremely low dietary diversity Many of the issues highlighted reflect a tension be- malnutrition treatment programme in Lebanon had amongst children and highlight the micronutrient tween the public health interest to support breast- received infant formula, and breastfed admissions status risk amongst both children and adults54 but feeding versus individual rights and realities. 47 were not exclusively breastfed . In the same pro- no evidence of concerted action. In Lebanon, no one e characteristics of the IYCF response indicate gramme, 70% of admitted children aged 6-23 organisation was willing to undertake blanket dis- a lack of strong critical analysis of the IYCF situa- months were using infant formula on presentation. tribution of micronutrient powders (MNPs) for chil- tion, weak stewardship of the technical response and An article by MSF from northern Syria found that 55 dren aged 6-59 months . e consequences of a lack of emergency preparedness by in country ac- more than half of the admissions to their treatment inadequate support to complementary feeding are tors pre-crisis. Anticipating ‘trouble ahead’, attempts programme were infants under six months of age; now reflected in the high prevalence of anaemia in to secure funding for a regional IYCF expert in early the lack of safe formula feeding (supplies and con- both countries; amongst Zaatari camp refugees in 2013 were unsuccessful67. ese experiences chal- ditions) was a significant contributing factor (high Jordan is now at 48.4%, a “problem of major public lenge us to rethink our conception of what IYCF in cost, erratic supply, low availability) and despite 56 health significance” according to WHO criteria . emergencies entails and the IYCF programming much advocacy, there were no programmes to sup- models in the Middle Eastern context.68 Indeed the port formula dependent infants on discharge48. is Questions are raised by a number of articles as to characteristics of the IYCF Syria response may have caseload was not picked up by surveillance or survey whether infant formula use has been overly ‘policed’ exposed a fundamental flaw in how we frame IYCF data as data on infants under 6 months were not in- in this context. ere were riots over access to infant in emergencies in policy guidance, which influences cluded. is has been described as an information formula in the early days of Zaatari camp in Jordan programming approaches. Defined as the protection blind spot and is being challenged even in largely and subsequently, tensions around subjecting moth- and support of optimal IYCF69, current guidance breastfeeding populations49. ers to physical assessments to determine whether they could breastfeed or not57. Infant formula is ex- largely caters for artificial feeding in exceptional cir- It appears that complementary feeding support cluded from the voucher programmes documented cumstances/as a last resort and is usually relative to in this emergency response also falls short. Featured in Syria58 or in Jordan, only stocked in pharmacies breastfeeding. It could be that the IYCF develop- articles describe limited access to fortified comple- and so not available through the WFP-supported ment agenda has overly influenced IYCF emergency mentary foods for children in Za’atari camp in food voucher schemes for non-camp refugees59. response, such that pragmatic compromises on Jordan; a three month ‘stop gap’ supply was provided Tensions around infant formula supply were also ob- global feeding targets in the immediate term are in 2013 by UNHCR50 with only a sustained supply served in the Turkish refugee camps during the poorly catered for in challenging humanitarian con- of SuperCereal Plus eventually established by WFP ENN’s field visit and are reflected in a number of texts; we are loath to compromise our high stan-

46 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, 51 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee 60 Luigi Achilli and Raymond Apthorpe. The social life of nutrition Saskia van der Kam. Emerging cases of malnutrition amongst children and women nutritional needs in Jordan; Sura among Syrian refugees in Jordan. IDPs in Tal Abyad district, Syria; Linda Shaker Berbari, Dima Alsamman. Managing infant and young child feeding in 61 Suzanne Mboya. Artificial feeding in emergencies: experiences Ousta and Farah Asfahani. Institutionalising acute malnutrition refugee camps in Jordan. from the ongoing Syrian crisis. treatment in Lebanon. 52 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee 62 Gabriele Fänder and Megan Frega . Responding to nutrition 47 Juliette Seguin. Challenges of IYCF and psychosocial support in children and women nutritional needs in Jorda; Gabriele Fänder gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Lebanon. and Megan Frega. Responding to nutrition gaps in Jordan in Child Feeding education and malnutrition treatment. 48 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, the Syrian Refugee Crisis: Infant and Young Child Feeding 63 Luigi Achilli and Raymond Apthorpe. The social life of nutrition Saskia van der Kam. Emerging cases of malnutrition amongst education and malnutrition treatment. among Syrian refugees in Jordan. IDPs in Tal Abyad district, Syria. 53 Ann Burton. Commentary on experiences of IYCF support in 64 Ann Burton. Commentary on experiences of IYCF support in 49 Kerac et al (2010). Prevalence of wasting among under 6-month the Jordan response. the Jordan response. -old infants in developing countries and implications of new 54 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee 65 Ali Maclaine and Mary Corbett (2006). Infant Feeding in case definitions using WHO growth standards: a secondary children and women nutritional needs in Jordan. Emergencies: Experiences from Indonesia and Lebanon. Field data analysis. Arch Dis Child. Published Online First: 2 February 55 Najwa Rizkallah. UNICEF experiences of the nutrition response Exchange 29, December 2006. p2. 2011. Open access at:http://adc.bmj.com/content/early/2011/ in Lebanon. www.ennonline.net/fex/29/infantfeeding 02/01/adc.2010.191882.full 56 Bilukha O et al (2014). Nutritional Status of Women and Child 66 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. 50 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee Refugees from Syria – Jordan, April-May 2014. MMWR/July 25, Institutionalising acute malnutrition treatment in Lebanon. children and women nutritional needs in Jordan; Sura 2014/Vol. 63/No. 29 67 Personal communication from four sources. Alsamman. Managing infant and young child feeding in refugee 57 Sura Alsamman. Managing infant and young child feeding in 68 Suzanne Mboya. Artificial feeding in emergencies: experiences camps in Jordan; Gabriele Fänder and Megan Frega. refugee camps in Jordan. from the ongoing Syrian crisis. Responding to nutrition gaps in Jordan in the Syrian Refugee 58 Hannah Reed. GOAL’s food and voucher assistance programme 69 Operational Guidance on Infant and Young Child Feeding in Crisis: Infant and Young Child Feeding education and in Northern Syria. Emergencies, v2.1 (2007). http://www.ennonline.net/ malnutrition treatment; Ruba Ahmad Abu-Taleb. Experiences of 59 Ann Burton. Commentary on experiences of IYCF support in operationalguidanceiycfv2.1 emergency nutrition programming in Jordan. the Jordan response...... 4 Views ...... dards. How to enable and see through informed Anaemia Lebanon (from 12.2% (2012) to 17.3% (2013). Child choice by a mother is not well catered for. A refram- e data on anaemia suggests that it should have at- stunting has not featured in articles from the refugee ing of the objectives of IYCF-E support in humani- tracted more of an analytical focus. Whilst anaemia hosting countries; an exception is a WFP article de- tarian terms, rather than in purely optimal feeding was prevalent in the Syrian population pre-crisis, the scribing their cross line and cross border program- terms, would allow us to accommodate, at least at a first survey of anaemia prevalence amongst refugees ming in Syria. Here, there has been the recent policy level, contexts where infant formula use is in Lebanon and Jordan only took place in 2014, i.e. introduction of Nutributter® (a nutritional supple- prevalent. is would be one important critical ac- some 3 years aer the crisis began. Prevalence of ment) with a view to preventing childhood stunting tion to emerge from this leaning. It remains that anaemia amongst camp refugees in Jordan was amongst children aged 6-23 months. Distributions whilst elements of existing IYCF policy guidance found to have deteriorated from pre-crisis levels to of the supplement started in May 2013 and fulfilled have fallen short, the global Sphere standards on 48.4% in under five’s, a problem defined by WHO as 71% of the plan for January 2014; over 17,240 chil- IYCF (2011) clearly state that “actions must enable of ‘major public health significance’72. It remains dren in Aleppo and Al-Hasakeh were assisted out of access and supply of breastmilk substitutes to infants prevalent amongst refugees in the Jordanian host 24,249 children. As with anaemia, UNHCR has well who need it”. Clearly, this standard has not – and community at 26.1%73 and in Lebanon at 21%74. e developed guidelines and a menu of options for as- continues not – to be met. increase in the prevalence of anaemia in Lebanon sessing and managing stunting in refugee popula- and continued moderate levels in Jordan in a context tions which includes consideration of food Applying an Afro-centric lens to a middle- of low and possibly declining levels of wasting points supplementation products and a range of interven- eastern context to inadequate access to high quality foods rather tions spanning health, WASH and food security de- e ENN’s view is that there has been an over em- than a lack of calories– especially amongst children pending on the stunting prevalence. But the phasis on the treatment of acute malnutrition and 6 months of age and above. We have already high- guidance appears not to have been put into practice. on IYCF and that the nutrition sector has (to borrow lighted major constraints regarding access to forti- It appears that emergency nutrition actors have a quote from a previous and infamous evaluation of fied foods for complementary feeding. e UNHCR not yet forged links with development actors to ad- the Great Lakes Emergency in 1996) to some extent, guidance on anaemia indicates that in high anaemia vocate for actions to address stunting and anaemia, ‘missed the point’. at’s not to say nutrition com- contexts, a low quantity Lipid Nutrient Supplement which is a missed opportunity to ensure a ‘contin- munity didn’t respond in good faith to what was per- (LNS) (for 6-24 month olds) or blanket micronutri- uum of care’ in the context of child malnutrition. ceived to be an emerging nutrition crisis at the ent powders (MNP) (for 6-59 months olds) can be is is symptomatic of a much wider and global dis- outset of the response, as described earlier. However considered to reduce levels of anaemia in emergency connect between the emergency and development the nutrition community appeared to adopt and contexts75. We also know from recent work amongst sectors whereby efforts to address acute malnutrition stick with a largely Afrocentric lens to the nutrition other refugee populations that high levels of are largely perceived as the domain of emergency nu- problems in the region, i.e. the sector expects to see anaemia in refugee settings may indicate high levels trition response, and stunting and anaemia as the high mortality and increased GAM in an emergency of other micronutrient deficiency diseases.76 Our ar- concern of development actors. However it remains or feels there is a need to demonstrate risk, with ticles describe how within Syria, WFP and UNICEF that on the anaemia/stunting front, UNHCR has well programmes put in place at the ready to treat. have been distributing micronutrient powders to pre- developed guidance that includes wasting and stunt- Whilst considerable IYCF emergency experiences vent micronutrient deficiencies; in Jordan, there has ing, along with wasting, as key nutrition indicators also come from Asia, they draw heavily from pre- been blanket supplementary feeding programmes with associated programming interventions. A key dominantly breastfeeding populations. It may also (BSFPs) in Za’atari and Azraq camps but not to the question is therefore, what hampered putting this be that acute malnutrition treatment and IYCF were host community; in Lebanon, MNPs distribution has guidance into practice? Clearly, there are compelling the only ‘nutrition’ areas that donors would (even- been limited to PHCs aer the child is seen by the reasons to identify and overcome barriers and foster tually) fund; “selling nutrition to the wider human- paediatrician77. On balance, this reflects limited ac- more integrated, holistic policy and programmes itarian community was challenging without a tion to monitor micronutrient deficiency disease which protect and improve nutritional status. glaring nutrition crisis (no severely emaciated chil- prevalence or to implement programmes to address Non-communicable diseases (NCDs) dren reported)”70. Added to this, flawed/suspicious anaemia (and other micronutrient deficiencies). Another significant ‘gap area’ or issue which the nutrition survey data in Lebanon and Jordan and the emergency nutrition community has not yet raised low breastfeeding rates helped paint the picture of a Stunting relates to the treatment and prevention of NCDs that refugee populdifficult without a “ation on the brink Furthermore, little attention has been paid to child have a nutritional aetiology/management aspect, e.g. of a nutritional crisis with the concomitant need to stunting in terms of discerning the trends, underly- ing causes or identifying potential interventions. diabetes, hypertension and heart disease. e demo- provide acute malnutrition treatment and promote graphic and disease profile of Syrian refugees is that breastfeeding at all costs. Mortality associated with severe stunting (<-3 SD height for age) is higher than that for moderate acute of a middle-income country, characterised by a high Gaps in nutrition response malnutrition at 5.5 times (MAM 3.3 times)78. Given proportion of chronic or non-communicable dis- We feel that the momentum to scale up of treatment that there are contexts where severe stunting preva- eases. A UNHCR survey in Lebanon in July 2014 for acute malnutrition and promote breastfeeding lence is higher than the prevalence of MAM (e.g. found 14.6% of over 18 year olds had one chronic may have distracted from undertaking a sector wide Zaatari camp Jordan (2014): moderate wasting 0.9%, condition, with the prevalence highest amongst the 79 and thorough needs assessment of all the nutrition severe stunting 2.9%; Lebanon (2013) 1.8% moder- oldest (46.6% in over 60 year olds) . e main re- problems facing infants, children, mothers and other ate wasting, 2.8% severe stunting), it would be justi- ported chronic conditions of nutrition interest were vulnerable groups (the elderly, the sick), including fiable for the humanitarian nutrition community to hypertension (25.4%), diabetes (17.6%) and ‘other’ maternal and child anaemia (and possibly other have highlighted stunting as a nutrition problem re- cardiovascular disease (19.7%). e NCD problem micronutrient deficiencies), child stunting, overweight, quiring further analysis and attention. Cautious in- amongst older people is also reported in other arti- and non-communicable diseases (NCDs) - all of trepretation of figures implies that stunting cles we feature by Caritas, HelpAge International and Handicap International80. Treatment is difficult which were prevalent in the Syrian population pre- prevalence had in some instances, seemed to halve to access for many of those with these pre-existing crisis and very likely to remain a problem or even from 23% (2009) by the early stages of the crisis and conditions (the UNHCR survey found 56.1% were increase risk as a result of the crisis. e combination then deteriorate over the response, most notably in of an Afrocentric response model and the perceived need to seek donor funding for the more typical 70 James Kingori. UNICEF experiences on nutrition in the Syria Situations. UNSCN and for example: Woodruff BA et al (2006). response. Anaemia, iron status and vitamin A deficiency among emergency nutrition problems, raises the question 71 Anon. Coordinating the response to the Syria Crisis: the adolescent refugees in Kenya and Nepal. Public Health as to whether the nutrition sector should have southern Turkey cross border experience. Nutrition. Vol 9, Issue 1, p 26-34. focussed its attention on additional areas of need 72 Bilukha O et al (2014). Nutritional Status of Women and Child 77 Najwa Rizkallah. UNICEF experiences of the nutrition response and advocated to donors to expand their nutrition Refugees from Syria – Jordan, April-May 2014. MMWR/July 25, in Lebanon. 78 lens to reflect the wider range of nutrition problems 2014/Vol. 63/No. 29 Khara, T, & Dolan, C. (2014). Technical Briefing Paper: 73 Bilukha O et al (2014). Nutritional Status of Women and Child Associations between Wasting and Stunting, policy, program- faced in the region. Donors may also have had a Refugees from Syria – Jordan, April-May 2014. MMWR/July 25, ming and research implications. Emergency Nutrition Network hand in the lack of sectoral critical analysis of this 2014/Vol. 63/No. 29 (ENN) June 2014. Report available at: http://www.ennonline. situation, for example by requiring signs of raised 74 Najwa Rizkallah. UNICEF experiences of the nutrition response net/waststuntreview2014 79 GAM rates before investing in a dedicated nutrition in Lebanon. Frank Tyler. Characteristics and challenges of the health sector 75 UNHCR Operational Guidance on the Use of Special Nutritional response in Lebanon. 71 working group in Turkey or failing to resource Products to Reduce Micronutrient Deficiencies and 80 Report summary. Insight into experiences of older Syrian strong regional IYCF leadership. To put it another Malnutrition in Refugee Populations. UNHCR, 2011. refugees in Lebanon; Lydia de Leeuw. The situation of older way, have there been significant gaps in the emergency http://www.ennonline.net/unhcrogspecialnutritionalproducts refugees and refugees with disabilities, injuries, and chronic nutrition assessments and responses? 76 Assessing micronutrient deficiencies in emergencies. Current diseases in the Syria crisis. practice and future directions. Nutrition Information in Crisis ...... 5 Views ...... unable to get access to care), is costly for service very little use of anthropometry to help define and CTs may increasingly need to replace in-kind food providers and requires long term commitment to understand vulnerability or more specifically, nutri- aid in humanitarian contexts where conditions such care. ere is a risk that following a low fat/salt diet tion vulnerability. Nutrition surveys could theoreti- as market functionality support their implementa- has not been possible given the limited cash transfer cally have been used to greater effect to help define tion. Given that the food aid system in the past has (CT) or food voucher transfer resources available to population strata in most need of nutritional support worked largely due to the mutual interests of multiple refugees and the displaced; the ENN is not aware of or indeed to endorse the targeting decisions taken, stakeholders (governments, farmers, business inter- any analysis that has taken place of the suitability or e.g. monitoring the nutrition of households excluded ests, and humanitarians) can we assume that a differ- cost of foods available in relation to NCDs. A ques- from CTs. Furthermore, nutrition indicators (in- ent set of stakeholders involved in CT programming tion for the nutrition sector is whether there should cluding anaemia and stunting) could have been use- will be able to leverage the same political support and have been closer engagement with agencies like ful to help define households for inclusion in CT therefore level of resources and how will this be as- WFP and the International Committee of the Red programmes. Finally, given the unprecedented scale sessed? Could it also be that we are seeing in the Cross (ICRC) implementing food voucher pro- and duration of the CTs being implemented in Syria region the first test of this? grammes to ensure that the diets needed to manage refugee hosting countries (particularly in Jordan, A second set of questions arises in relation to the these conditions were available, promoted and af- Lebanon and Turkey) it seems as if the opportunity institutional architecture around cash programming fordable. If so, does the sector have adequate guid- to conduct robust research into the nutritional im- in humanitarian contexts. We raise these issues as they ance material to inform such assessment and pact of these programmes has not been capitalised affect and are impeding programming. e Inter analysis? If this isn’t the role of the emergency sector, upon. is is unfortunate given the dearth of pub- Agency Standing Committee (IASC) system does not what checks and balances are there for development lished data on this in a global context where human- have a ‘Cash Cluster’ in that cash is subsumed under actors to take on these considerations? itarian CT programming is becoming more a multiple of working groups (or indeed clusters) in normalised. ere is currently an enormous gap in Added to this is the issue of overweight (18% any given emergency depending on the level of con- understanding whether and how CTs either prevent prevalence overweight in U5’s pre crisis81) which is ditionality95,96. e questions that might follow begin or address undernutrition (wasting, stunting and mi- a risk factor for NCDs. Mean weight-for-height z- with who coordinates policy and practice and who is cronutrient deficiencies) in humanitarian contexts. scores in Za’atari and outside the camp in the 2014 accountable for the overall coherence and convergence survey were above the WHO standard population Cash programming of cash programming in any given emergency. Going mean, indicating that Syrian refugee children in e scale and scope of CT programming in the Syria further, one could ask is there need for other technical Jordan on average were slightly overweight rather region has been unprecedented within a humanitar- agencies to support the type of conditional program- than suffering from wasting82. As with the artificial ian programme context. A large component of the ming that WFP undertake, does the UN system need divide which separates policies and programmes for CT programming has effectively replaced in-kind to re-configure the roles and responsibilities of the var- wasting and stunting, it is rare for overweight to be food aid or general rations86,87,88. Cash has also been ious technical agencies around CT programming and recognised and addressed in emergency pro- used to support access to shelter, health care, heating who defines these roles and responsibilities to ensure grammes even where these are prevalent and the sit- supplies89, and promotion of livelihoods90. Much has coherent programming (a related question is how are uation, as with Syria, is protracted. e (soon to be been achieved and there has been enormous and in- the UN agencies to be held accountable for CT pro- released) first Global Nutrition Report will highlight valuable lesson learning documented in this edition gramme performance). ere is also a set of questions the fact that ‘multiple burdens are the new normal’ with regard to CT programming design and imple- as to how the nutrition community fits into this archi- which raises a question for both the emergency and mentation91.Indeed this was one reason why the tecture to ensure maximum nutrition impact of CTs. development nutrition communities as to how they ENN sought to compile a special issue on the Syria In the case of the Syria crisis, we have already high- can better assess and respond to the multiple needs crisis response and to capture as much of this expe- lighted the absence of nutrition assessment and analy- of affected populations within their own program- rience as possible. ere are two stand-out issues sis informing targeting and access to ncessary foods, ming and through engagement with each other...in around CT programming which the ENN believe e.g. complementary foods for children, infant formula, other words, can our systems connect and embrace may be emerging in the Syria response: low sugar and low salt, etc. Is there a need to develop the ‘new normal’? minimum standards (SPHERE) for cash program- e first relates to availability of global resources ming in humanitarian contexts and should the nutri- Vulnerability criteria for large scale CT programming in a humanitarian tion sector be at the ‘head table’ in helping to define A critical issue for the entire humanitarian sector in context. Many agencies (including donors) are those standards? We would argue yes. the Syria response has been how to develop vulner- openly admitting that the current level of CT pro- ability criteria to assist with targeting decisions. CTs gramming is unsustainable and that substantial re- Nutrition coordination and leadership and in-kind distributions were initially implemented ductions and increased targeting will be necessary e scale of the Syria crisis response has inevitably as blanket distributions for refugee populations in over the coming months, especially in light of RRP 6 led to coordination challenges. e crisis has re- the two main hosting nations (Lebanon, Jordan) and failing to meet its budget pledging targets92,93. A ques- sulted in unprecedented numbers of internally dis- for most of the camp populations in southern Turkey. tion that arises is whether the ‘sector’ can assume the placed people in Syria and refugees being hosted in However, appreciation of a greater complexity to same level of resource availability for CTs in human- southern Turkey, Lebanon, Jordan and Northern what constitutes vulnerability and the need to con- itarian contexts as has been available for in kind food Iraq. Whilst the main responsibility and financing serve scarce resources in light of under pledging by aid in the past. To put it another way, are donor re- for the refugee response has been by the host gov- donors to various Regional Response Plans (RRP) sources for in-kind distributions completely fungible ernments, UNHCR has been at the forefront of UN has led to greater targeting of increasingly scarce re- or exchangeable with regard to cash provisions? is agencies with ultimate accountability for the wellbe- sources83. e pressure to target resources has meant question seems all the more pertinent given trends ing of refugees. A large number of national agencies development of vulnerability assessment tools such that may be emerging with regard to in-kind food aid (e.g. Turkish Red Crescent), international NGOs as the score cards used by UNHCR84 and the rounds availability and provision. ere are suggestions94 and other UN agencies supporting the governmen- of Vulnerability Assessment of Syrian refugees that a number of factors related to trade (and trade tal responses, all of whom require financing, infor- (VASyRs) implemented by WFP85; WFP’s e-voucher agreements), climate change, and programming pref- mation, coordination and technical leadership to programme in Lebanon targeted 70% of refugees fol- erences, are in the process of coming together in a assess and meet the needs of those affected. A num- lowing the 2013 VASyR. However, apart from MUAC way that may reduce the reliability of in-kind food ber of articles in this edition give valuable insight measurements in the 2012 VASyR, there has been aid provision in the future with the implication that into UN and international NGO coordination97.

81 UNICEF State of the World’s Children Report. 2014. camp refugees in Lebanon and Turkey. Syrian refugee response in Jordan. http://www.unicef.org/sowc2014/numbers/documents/ 87 Kathleen Inglis and Jennifer Vargas. Experiences of the e-Food 93 Simon Little. Towards a 21st century humanitarian response english/SOWC2014_In%20Numbers_28%20Jan.pdf card programme in the Turkish refugee camps. model to the refugee crisis in the Lebanon. 82 Bilukha O et al (2014). Nutritional Status of Women and Child 88 Ekram Mustafa El-Huni . WFP e-voucher programme in 94 Personal communication, Ed Clay. Refugees from Syria – Jordan, April-May 2014. MMWR/July 25, Lebanon. 95 Isabelle Pelly. Designing an inter-agency multipurpose cash 2014/Vol. 63/No. 29 89 Christian Lehmann and Daniel T. R. Masterson. Impact transfer programme in Lebanon. 83 Hisham Kighali, Lynette Larson and Kate Washington. Aid evaluation of a cash-transfer programme for Syrian refugees in 96 Leah Campbell. Meeting cross-sectoral needs of Syrian effectiveness: determining vulnerability among Syrian Lebanon. refugees and host communities in Lebanon. refugees in Jordan. 90 Francesca Battistin. IRC cash and livelihoods support prog- 97 Key articles include: Alex Tyler and Jack Byrne. UN and INGO 84 Hisham Kighali, Lynette Larson and Kate Washington. Aid ramme in Lebanon; Isabelle Pelly. Designing an interagency experiences of coordination in Jordan; Simon Little. Towards a effectiveness: determining vulnerability among Syrian multipurpose cash transfer programme in Lebanon. 21st century humanitarian response model to the refugee refugees in Jordan. 91 Isabelle Pelly. Designing an inter-agency multipurpose cash crisis in the Lebanon; Profile: Syria INGO Regional Forum (SIRF); 85 Susana Moreno Romero. WFP experiences of vulnerability transfer programme in Lebanon. James Kingori. UNICEF experiences on nutrition in the Syria assessment of Syrian refugees in Lebanon. 92 Volker Schimmel. UNHCR cash programming in emergencies – response; Anon. Coordinating the response to the Syria Crisis: 86 Louisa Seferis. DRC experiences of cash assistance to non- implementation and coordination experience during the the southern Turkey cross border experience...... 6 Views ......

Within Syria, agencies are responding to the for southern Turkey for 3 months (Dec 2013 to Feb sessments, analysis, and interpretation and in turn, needs of the internally displaced through operations 2014)108. is deployment met with a number of dif- the shape and content of the nutrition related con- running out of the capital Damascus in coordination ficulties and did not lead to a longer-term nutrition siderations across all related sectors? Arguably, had with the Assad Government. Aid is provided to gov- coordination appointment. there been robust leadership and ownership, the ernment and non-government (so called cross-line nutrition sector may have avoided the dominant With the benefit of overview of the different programming) held areas of Syria98. Fascinating in- emphasis on the scale up of treatment for acute country responses and multiple agency program- sights into the these operations are shared in an ar- malnutrition whilst failing to address anaemia. ere ming, the ENN has been surprised that a protracted ticle by WFP, which reflects on the rationale and could have been a more objective and context- Level 3 crisis should have had such marginalised nu- experience of working with and through specific appraisal of the IYCF situation that needed trition coordination structures and focus. is may Government in an operation which has gradually (and still needs) a more critical analysis of the situ- in part reflect the lack of a coherent sectoral negotiated and secured enough humanitarian space ation, some innovation and new types of program- overview, which could objectively clarify the nutri- to help meet the food needs of 4.2 million largely ming to address needs. In terms of objective overview, tion situation for a wider audience to inform pro- displaced Syrians. Ironically, in the face of immense it is interesting to see what the Syria Needs Assessment gramme decision-making. Instead, nutrition has ‘nutrition’ achievement, as we go to press, WFP is on Project (SNAP) has brought to the humanitarian the brink of a dramatic scale down of its Syria oper- been limited to a focus on acute malnutrition treat- sector in terms of humanitarian data sharing and ations in the face of a looming resource crisis. A sec- ment in the context of low levels of GAM and a sub- analysis109; perhaps there are some lessons to be ond article by WHO describes their nutrition set of IYCF, namely breastfeeding protection and learned for the nutrition sector? programme, closely coordinated with UNICEF and support. If we therefore accept that the nutrition WFP, to rebuild nutrition surveillance, develop capac- community has not adapted its nutrition lens to re- Accountability ity to treat acute malnutrition, support breastfeeding, flect the range of nutrition needs that typify a One final thought relates to accountability within and prevent malnutrition through micronutrient dis- Middle East emergency and has been almost entirely the nutrition sector. Given the missed opportunities tribution/Ready to Use Supplementary Food (RUSF) absent from the design and implementation of an in the nutrition response, how do we hold ourselves distribution in what remains a highly insecure and unprecedentedly large scale social protection pro- accountable and institutionalise learning to avoid challenging operartional environment. is edition grammme (cash and vouchers), a number of ques- making these mistakes again? e answer is a very also features a variety of ‘cross border’ programming tions about coordination and leadership arise, which difficult one as we still lack clarity around roles, re- largely from southern Turkey which supply aid to include: sponsibilities and leadership in the nutrition sector. the displaced in the northern non-government held At the very least, we think a sectoral evaluation fol- 99 i) Should the nutrition sector have had dedicated areas of Syria . Coordination of cross line and cross lowing a large-scale emergency programme of this working groups to enhance analysis and re border programme are characterised as complex, type would add real value to collective learning, sponse and/or should nutrition have been more highly political, fast changing and, particularly in Whilst there are many evaluations following each mainstreamed in the overall response by having the context of the cross border programme, highly new emergency, these are either agency specific representation (sub-working groups) in other sensitive, resulting in tensions amongst the interna- evaluations or on rare occasions, evaluations across 100 working groups like cash and WASH? If so, how tional agency actors . As a marker of the sensitivi- the overall multi-sectoral response. e last sectoral and by whom should this have been coordi- ties, it is noteworthy that a number of articles about evaluation for nutrition (and other sectors) following nated and who should have resourced this? cross-border programming that agencies committed a multi-agency humanitarian response was in 1996 to write for this special issue have been withdrawn ii) Should the Nutrition Cluster have remained for the Great Lakes Emergency. Subsequent attempts at various draing stages due to concerns about the active in southern Turkey’s cross-border pro- at similar system-wide, collaborative evaluations potential impact of the article on their agency’s ac- gramme and also been activated to address the (e.g. following 1998 Hurricane Mitch and the 1999 tivities. Despite all these challenges, the Syria re- nutrition needs of refugee populations in Kosovo crisis) did not bear fruit possibly due to sponse is hugely impressive in terms of the scale and Lebanon, Jordan, etc, to share the load with lack of “effort and collective spirit”110. Without level of programme innovation, the dedication of UNHCR? critically examining the overall coherence of our humanitarian staff working in this context, as well iii) Should the Nutrition Cluster have been acti- nutrition responses in emergencies, we risk repeating as the commitment and resourcing from the host vated to support the affected host community and donor governments. in refugee hosting countries? the same mistakes over and over again. Should there iv) What is the role of nutrition-related develop- not be regular nutrition sector evaluations of emer- e IASC cluster mechanism has not been for- ment actors to prepare for a crisis and to gency responses to ensure that we learn for the next mally activated in the refugee hosting countries as actively influence the international emergency time, do we have sufficient collective will to pull to- UNHCR has overall responsibility for the refugee effort in delivering a context specific and gether on this, and if so, who should lead on this? operation. Rather, sectoral working groups have timely response? been established covering food security, health, shel- is Middle East emergency has, and continues v) Where is the responsibility for a coherent and ter, protection and education with UNHCR at the to be, uniquely challenging in its scale and complex- objective nutrition sector assessment and overall coordinating helm - pretty much in the mir- ity. ere has been an extraordinary response from response overview without which there has ror image of the cluster system101,102. Within Syria, a vast array of stakeholders across many sectors, and similar working groups exist to coordinate the re- arguably been a poorly analysed and partial nutrition indicators suggest that a large-scale nutri- sponse103. Until very recently, nutrition working response? tional emergency has thankfully been largely averted. groups had not been established in any of the coun- Implicit in these questions is a question about lead- However, nutrition vulnerabilities remain poorly tries, possibly because the low levels of GAM were ership and the ability to critically analyse what is analysed and inadequately addressed and, indeed, not seen by agencies (including donors104) to justify being done in the name of nutrition. Many of the such vulnerabilities may well worsen as the availabil- the need for dedicated nutrition coordination. obvious shortfalls in the collective nutrition response ity of resources for the Syria crisis rapidly decline. Nutrition coordination in southern Turkey, Jordan to the Syria emergency speak to a lack of leadership. e nutrition community-both emergency and de- and Lebanon has, therefore, been absorbed into a Was there a clear, objective lead agency for nutrition velopment is needed as much now as in the height of small sub-group of the health working group. In in this crisis to oversee the scope and quality of as- the crisis. Let’s hope we can rise to the challenge. Turkey, despite considerable efforts by some inter- national NGOs and the Global Nutrition Cluster (GNC) to garner increased attention to nutrition, as 98 Rasmus Egendal. WFP’s emergency programme in Syria. 103 Rasmus Egendal. WFP’s emergency programme in Syria. 99 Hannah Reed. GOAL’s food and voucher assistance programme 104 a sector it occupies a very small space in the overall Anon. Coordinating the response to the Syria Crisis: the in Northern Syria; Anon. Non-food cash voucher programme southern Turkey cross border experience. 105 information exchange and coordination meetings . for IDPs in Northern Syria; Emma Littledike and Claire Beck. 105 Emma Littledike and Claire Beck. Experiences and challenges e Jordan nutrition sub-working group has been Experiences and challenges of programming in Northern Syria; of programming in Northern Syria; Personal communications. particularly active with infant formula control, ac- By Kathleen Inglis and Jennifer Vargas. Experiences of the e- 106 Sura Alsamman. Managing infant and young child feeding in cess and management, arguably not a good use of Food card programme in the Turkish refugee camps; Maartje refugee camps in Jordan; Ann Burton. Commentary on Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van 106 experiences of IYCF support in the Jordan response. coordination energies . A nutrition sub working der Kam. Emerging cases of malnutrition amongst IDPs in Tal 107 Najwa Rizkallah. UNICEF experiences of the nutrition response 107 group has recently formed in Lebanon . Abyad district, Syria. in Lebanon Coordination in the nutrition sector, in contrast to 100 Anon. Coordinating the response to the Syria Crisis: the 108 Emma Littledike and Claire Beck. Experiences and challenges the other main sectors such as food security, health, southern Turkey cross border experience. of programming in Northern Syria. 101 and WASH has not had dedicated coordination staff. Alex Tyler and Jack Byrne. UN and INGO experiences of 109 Yves Kim Créac’h and Lynn Yoshikawa. The Syria Needs coordination in Jordan. Assessment Project. e GNC, recognising the need to get nutrition on 102 Simon Little. Towards a 21st century humanitarian response 110 John Borton (2004). The Joint Evaluation of Emergency a stronger footing and following a 1 week scoping model to the refugee crisis in the Lebanon. Note these Assistance to Rwanda. HPN. Issue 26, March 2004. mission in Sept 2013, deployed a cluster coordinator coordinating mechanisms may have changed since...... 7 Field Articles...... Designing an inter-agency multipurpose cash transfer programme in Lebanon

By Isabelle Pelly

Isabelle Pelly was Save the Children’s Food Security & Livelihoods Adviser in Lebanon until September 2014, and co-chair of the Lebanon Cash Working Group. She is a specialist in food security and livelihoods, and cash transfer programming, with experience spanning programme design and management, advisory roles at field office and headquarters, programme policy, and inter- agency cash coordination.

The author is very grateful to Maureen Philippon (ECHO), Joe Collenette (Save the Children Lebanon) and Carla Lacerda (Senior inter-agency Cash Adviser in Lebanon) for their insight and support. This article is a reflection of the author’s professional experience and does not necessarily reflect the position of Save the Children more broadly.

his paper reviews the inter-agency efforts to Specifically, there was no baseline market assessment set up a multipurpose cash assistance pro- undertaken as part of the feasibility assessment for win- gramme in Lebanon, as part of the response terisation cash programming. Rather, the decision to to the Syrian refugee crisis, over the last year implement the cash transfer programme was based on Tsince the onset of winter 2013/14. It highlights lessons agency concerns related to the delivery of an in-kind or learned through large-scale cash programming in voucher response for winter, following significant oper- Lebanon to date, and the necessity of high quality tech- ational delivery challenges (including documented

Lebanon nical and operational design supported by responsive fraud) with these modalities in winter 2012/13. In coordination mechanisms. e paper discusses the chal- October 2013, the Lebanon CWG commissioned a study Bonus articles online: lenges of a transition to multipurpose unconditional of the stove market to assess market availability and ac- (from here-on ‘multi-purpose’) and inter-agency cash cess to this key winter item. is report did highlight the Field Articles programming including the cross-sectoral engagement elasticity of the stove market in Lebanon, but also • Challenges of IYCF and psychosocial and strong leadership required for an effective pro- warned of a considerable gap if the majority of targeted support in Lebanon • Relief International nutrition and health gramme that works across traditional sector-based hu- refugees chose to purchase a stove unit at the outset of programme in Lebanon manitarian coordination structures and sector- winter. e risk of additional stove demand being met • Integrating community-based nutrition mandated agencies. e paper draws out key lessons for through imports from Syria (thus to the detriment of awareness into the Syrian refugee future programmes, and potential inter-agency pre- the Syrian market) was also emphasised. However, the response in Lebanon paredness measures to overcome coordination and tech- timing of the report, which was released when the deci- • IRC cash and livelihoods support nical hurdles. sion on the choice of cash as an assistance modality had programme in Lebanon already been made, and the lack of sufficient buy-in • NRC shelter programme in Lebanon Background/lessons learned from Lebanon’s • Postscript winterisation cash programme • Save the Children’s child centred shelter 1 Since early 2014, the Syrian response in Lebanon has Targeted families that had been found eligible for assistance programming in Lebanon as part of the overall targeting exercise conducted by UNHCR • Competing for scarce WaSH resources: been a test-case for the establishment of an inter-agency and WFP and living 500m above sea level; 2) Families the new concern for Syrian refugees multipurpose cash transfer programme. e design of (registered and unregistered refugees, and Lebanese) living in • A day in the life of a lactation specialist this programme sought to build on the lessons learnt informal tented settlements (ITS) and unfinished buildings. Postscript to 'Infant and young child from the inter-agency ‘cash for winterisation’ programme feeding support in Lebanon: which reached nearly 90,000 refugee households with strengthening the national system' Lebanon Cash Working Group – Syria an average of $550 throughout the winter of 2013/14. Box 1 Regional Refugee Response Evaluation is programme relied on harmonised targeting criteria1, • Impact evaluation of a cash-transfer and agreed-upon cash transfer values, intended to meet Purpose: Key forum for discussion on CTP across sectors programme for Syrian refugees in Lebanon the costs of a stove per household, and monthly heating and for design of multi-purpose unrestricted cash Views fuel for five months. e rapid operationalisation of assistance programme • The potential role of local academia in this programme, delivered through a common ATM History: Established in early 2013 in response to protracted crises – the example of the card across the majority of agencies involved, was a demand by NGOs to coordinate on design of CTPs. American University of Beirut success. However, there were significant gaps in the Participants: Up to 50 agencies (including government, programme design, which provided a learning platform UN and NGOs); core group of 10 staff from representative Research agencies for decision-making • Insight into experiences of older Syrian for the design of a multipurpose cash programme for refugees in Lebanon 2014 onwards and are outlined in the following section. Leadership: Cash Coordinator, Senior Cash adviser (jointly hosted by UNHCR & Save the Children) and • Meeting cross-sectoral needs of Syrian Firstly, whilst the delivery of the programme was har- refugees and host communities in Lebanon rotating NGO co-lead monised, the approach was developed directly by Frequency of meetings: Monthly (previously bi-weekly). News UNHCR as lead of the non-food items (NFI) working • The impact of the NiE regional training group and lacked technical input from cash program- Weblink and resources: initiative: the Lebanon experience ming experts within the Lebanon Cash Working Group http://data.unhcr.org/syrianrefugees/working_group.ph p?Page=Country&LocationId=122&Id=66 2010-2014 (CWG) (see Box 1). www.ennonline.net/fex ...... 8 Field Article ...... within the wider inter-agency coordination struc- ture (particularly the NFI working group), unfortu- nately reduced the value of this piece of work, and the take up of its recommendations, which included

monitoring of supplies and prices; and mitigating ef- WFP/Sandy Maroun forts including in-kind contingency stock and very strong beneficiary communication regarding the up- coming cash programme. In parallel, the lack of technical input into pro- gramme design resulted in a cash transfer value cal- culated based on perceived sector-specific needs (fuel and stove cost) rather than on overall under- standing of household income gaps and needs. e downfall of this approach in the Lebanon context is reflected in the inter-agency impact evaluation of the winterisation programme led by IRC2. is analysis reveals that the majority of additional cash was spent on covering gaps in food, rent and water expenditure, whilst on average only 10% of the as- Bassam is shopping for food for his family using sistance was spent on heating fuel and clothing. the electronic blue card at a contracted shop in Baouchrieh neighborhood in Mount Lebanon. Almost half of the beneficiaries reported that their heating supplies were not sufficient to keep warm. is is not due to unavailability of the supplies in the market, but because beneficiary income (through e experience of this winterisation cash pro- process aspired to move away from the outdated labour and assistance) income is so low that they are gramme, led to a desire and willingness to (a) fur- ‘project and sector-based approach’ and promote forced to prioritise basic expenditures. ther harmonize cash programme design including increasing coordination, at minimum to avoid du- targeting, monitoring and delivery mechanisms and plication and ideally to harmonise the implementation Secondly, the design of the winterisation re- (b) transition to longer-term and scale-up of multi- modality. In Lebanon the ambition was also to go sponse suffered from significant timing challenges purpose cash assistance as a strategic shi within the one step further in order to give the recommendations due to a multiplicity of changes and competing pri- response. is therefore required the CWG, through of the CWG a binding character. is was not for- orities occurring simultaneously within the broader the broader coordination system, to draw on these malised as such, as despite best intentions, no agency response. In September 2013, a targeting process for technical and operational lessons learned and proved ready to relinquish its decision making ‘regular’ food and NFI assistance was introduced, retroactively apply best practices. ability. Rather, good will and strong harmonisation using a demographic burden score developed on the efforts have been the driver of successful coordination basis of the VASyR 20133 findings. is resulted in a e focus of early 2014 was therefore oriented outcomes as has the alignment of donors (particularly reduction from blanket targeting to circa 70% of the around: checking assumptions on the feasibility of ECHO and DfID) who have proven instrumental in registered population receiving assistance. Whilst cash assistance (particularly relating to markets and ensuring that the recommendations of the CWG targeting for winterisation cash assistance did build banking system functionalities); developing com- are followed. on this process (see footnote 1), it also introduced a mon objectives and the resulting monitoring frame- parallel system by using different targeting criteria work for multipurpose cash assistance; and im- e Lebanon experience demonstrated that indicators (such as altitude), which created signifi- proving and streamlining operational design, with building technical consensus requires strong and le- cant confusion for households, as well as agencies, the objective of establishing a one-card system for gitimate expertise, leadership and ownership of the which were ill-equipped to describe this process. the delivery of WFP food assistance and multipur- process. However, no decision is purely technical e fear that households may be excluded from as- pose cash assistance, rather than the two systems and at a certain point potential technical refine- sistance during the oen bitterly cold Lebanese win- outlined above. is ambitious workplan was set-out ments have to cease and a decision made to go with ter led to an emergency ‘verification’ exercise by the co-leads of the Lebanon CWG in February an optimal (albeit not perfect model). Technical pro- through household visits, aiming to re-include 2014 following an ECHO-led meeting in Brussels on gramme design staff need to be supported by strong wrongly excluded households, which further in- cash coordination in Lebanon. e challenges en- management, and acknowledge the balance to be creased confusion for vulnerable households. In par- countered in delivering on this workplan are de- allel, a significant change was made to the tailed in the section below. 2 See article by IRC Lebanon on the evaluation of the Lebanon operational delivery of ‘regular’ food assistance, as The programme design to date winteristation programme. WFP transitioned from a paper voucher to an e- 3 Vulnerability Assessment of Syrian Refugees: voucher more or less contiguously with the roll-out e crux of the future inter-agency programme http://data.unhcr.org/syrianrefugees/download.php?id=3853. of the UNHCR ATM card used for winter cash as- design, building on in-country lessons to date, was 4 CaLP, Comparative study of cash coordination Mechanisms, sistance. A large proportion of refugees, many of defined through a consultancy led by Avenir Analytics, June 2012, and Fit for the Future – Cash Coordination, May 2014 whom had never used electronic payment methods which set out to outline and define the optimal op- in the past, simultaneously received two cards, with erational set-up for multipurpose CTP. is model Multi-purpose inter-agency cash very different functionalities (i.e. e-vouchers re- aspired to build on the scale and coverage of WFP’s Box 2 programme design deemed at POS at local pre-identified food shops existing e-voucher programme (delivered through and winter cash assistance withdrawn at ATMs), and BLF bank) and use this delivery platform (through Key objective: To prevent the increase of negative coping mechanisms among severely vulnerable oen from two different agencies (i.e. WFP and adding a separate cash ‘wallet’ to the same card), Syrian refugees during the period of cash assistance UNHCR and their different partners). Despite sig- and WFP’s implementing partners, as the basis for nificant efforts to create separate effective training the delivery of cash assistance. is model is visualised Target population: Economically vulnerable Syrian Refugees and helplines to differentiate the cards this was sub- in Figure 1, and other key components of the pro- optimal from the beneficiary standpoint as well as gramme design which evolved through multi-agency Targeting methodology: Proxy-Means Testing from the perspective of value for money and opera- consensus are summarised in Box 2. (PMT) through a pre-identification ‘bio-index’ applied to the UNHCR ProGres database, or through tional efficiency. Challenges transitioning to multipurpose application of an economic vulnerability Notwithstanding these challenges, the CWG was inter-agency cash programming, and questionnaire eventually able to influence the technical quality of lessons learned for future responses Target numbers: 28% of Syrian refugees identified the winterisation programme through the develop- Aspiring to a common technical and as highly economically vulnerable (circa. 66,700 ment and roll-out of common baseline and moni- operational approach households as of June 2014), although funding toring tools. e ATM card platform also enabled e CWG workplan and programme design outlined shortfall is significant parallel other cash programmes (i.e. conditional above aimed to address technical and operational Monthly cash transfer value: 175 USD per month cash for livelihoods or shelter programmes) to be issues specific to Lebanon, whilst designing a robust intended to complement Monthly income to meet delivered through the same cards, through cross- operation that makes the process in Lebanon inno- the Survival MEB; intention is to increase cash loading of cards between agencies. vative and valuable for future cash operations. is transfer value during the winter months ...... 9 Field Article ......

Calculating the transfer value of the severely Figure 2: Multiplier effect of cash-based assistance Box 3 economically vulnerable households Survival Minimum Expenditure Basket (SMEB): This includes the minimum food required to meet 2100 kcal/day, the minimum NFI, rent in Informal Settlements, minimum water supply required per month. Clothes, communication and transportation are calculated based on average expenditures.

To Calculate Proposed Cash Assistance: $ value SMEB $435 Minus midpoint of Severely Vulnerable income $110 (using expenditure as a proxy) Minus average food assistance package provided $150 by WFP Transfer Value $175

struck in a refugee operation between technical needs from a holistic perspective, which typical co- stakeholders (whilst acknowledging some of WFP’s good practice, and operational reality and scale at a ordination structures are not set up for, and risks donor constraints). Against this backdrop, WFP in- time of funding stagnation. As a specific example, the perception that the roles of specific sectors or tends to conduct a pilot study comparing the food the dialogue over the value of a monthly transfer and institutions are being challenged. In Lebanon, a security outcomes of cash vs. vouchers, before mak- the number of people to be assisted was heated in particular challenge was the convergence of the de- ing any decision on a change to a pure cash modality. Lebanon between advocates of a ‘broad but shallow’ livery of sectoral assistance towards the UN-led is, despite inter-agency monitoring analysis approach contributing a minimal amount to a larger proposed models (WFP for food assistance; and demonstrating that food is prioritised at household number of households versus a ‘narrow but deep’ ap- UNHCR for NFIs), which remain relatively inflexible level relative to other basic needs. Acknowledging proach ensuring survival needs were met for fewer to changes in modality. Existing and well-documented possible resistance and the desire amongst some to households. Also, whilst statistically extremely ro- limitations to cash coordination in the global hu- retain the status quo, the donor community needs bust, the targeting methodologies developed by the manitarian coordination structure4 manifested them- to be clear and united in demanding a refined struc- CWG and its ‘Targeting Task Force’ do not enable a selves again in Lebanon. is demonstrated the tural response. ‘ranking’ of households within the 28% most vulner- need to apply best practice when coordination struc- Engagement with the Government able which makes ‘narrow’ targeting imperfect. tures are initially established, namely the distinction Multipurpose cash assistance design also requires between strategic and technical coordination, and proactive and continuous engagement with pre-ex- Recognition of multi-purpose cash assistance the need for formalised working linkages with all isting government social protection schemes, to as a cross-sectoral modality sector working groups and within the humanitarian ensure optimum harmonization on targeting and By definition, the multipurpose nature of the planned coordination architecture. assistance requires coordinated engagement across assistance value, and appropriateness relative to the traditional sector divides. Indeed, in the current In parallel, coordinated design of multi-purpose socioeconomic context -minimum wage, poverty context, the proposed assistance package (see Box cash programming inevitably results in decisions line, national safety nets, etc. In Lebanon, two par- 3) only provides a contribution towards meeting that will affect agency sense of territoriality, partic- ticular challenges were faced - firstly, the Government survival needs, thus leaving a gap between income ularly when there are questions of efficiency and of Lebanon’s (GoL) reluctance to accept the proposed and expenditure, particularly during the winter how best to achieve economies of scale to be tackled. Survival Minimum Expenditure Basket (SMEB) for month. To date, all assistance monitoring reports ere are a slew of practical and political reasons Syrian refugees, to which multipurpose cash assistance for Lebanon demonstrated that the two priority ex- why the humanitarian community may resist is intended to contribute; and the value of the SMEB penditures are food and rent, but the exact prioriti- change. e clear recommendation from the consul- relative to the package of subsidized services (including zation of expenditures is not known. While there tancy on the optimal operational set up was to limit education and healthcare) provided to poor Lebanese may be discussion at household level on what to the number of partners possibly to the extent that in through the Ministry of Social Affairs’ National spend the money on (see comments on winter as- a given area WFP partners and the “cash” partner Poverty Targeting Programme (NPTP). Specific con- sistance above), multi-purpose cash transfers must should be the same. e basic principle of fewer cerns of the GoL are the inequity between these come with the acknowledgement that households partners is agreed. What is not is which partners are forms of assistance, and institutional and political will make their own choices anyway: to place the ready to relinquish or refine their role. A striking ex- constraints in moving to a cash-based model of decision power with the people assisted may be the ample of this is the fact that WFP has maintained a social protection for the Lebanese population (al- adult age of humanitarian assistance. Such an ap- protective approach to food by using a food voucher, though WFP is partnering with the NPTP for an proach encourages a broader analysis of household which has been perceived as territorial by certain extension of the e-voucher programme to 5,000

Figure 1: Recommended optimal operational set-up for CTP Information / (Avenir Analytics report) Concerns Hot line

Monitor

Eligibility Card progress lists Data

Programming Planning Quality Control Distribution Families

RAIS Bank

RRP6 Actors Coordination & Quality (CWG) Assistance Allocation (UNHCR) Delivery (WFP) Implement (IP’s) PoC’s

...... 10 Field Article ......

Lebanese households by the end of 2014). Another agencies (including UNHCR) have begun imple- as with all significant changes in the role and per- concern alluded to by the GoL has been the broader menting their cash programmes applying key elements ception of cash assistance globally, robust M&E and economic impact of cash on Lebanese markets. of the common model. impact evaluations (such as that led by IRC6) will IRC’s recent analysis of the multiplier effect of cash- continue to be necessary to demonstrate the effec- Nonetheless, a few key stumbling blocks remain. based assistance has demonstrated that each dollar tiveness of cash assistance as a means of holistically e development of the targeting methodology was of cash assistance spent by a beneficiary household addressing household needs. An over-arching tech- far more onerous and complex than expected, and generates 2.13 dollar of GDP for the Lebanese econ- nical take-away is the need for strong decision- as of August 2014, 2 different indices are proposed omy; this figure is 1.51 in the food sector for the making on divisive and debatable issues including for targeting food assistance and cash assistance, WFP e-voucher programme.5 See Figure 2. targeting and transfer value, as these ultimately which will inevitably lead to beneficiary and agency need to be judgement calls based on best evidence, Need for an over-arching budget confusion with targeting, and will require additional not a perfect science. e effectiveness of inter-agency discussions was resources to administer. Additionally, whilst in April also hindered by the absence of a dedicated planning 2014, the Avenir Analytics consultancy urged an im- e successful design and set-up of a multi-pur- budget for cash assistance in 2014: the idea was mediate transition to a one-card system using WFP’s pose/ sector cash assistance programme across agen- foreseen in the RRP6, but even where a cash modality e-card platform (administered by BLF bank), this cies requires a radical change in the existing sectoral was specified, the potential budget for multi-purpose has still not materialised as discussions on costs and and agency-based structure that defines the majority cash assistance remained siloed under different sec- legal constraints between WFP and UNHCR have of current humanitarian responses. While the toral headings, thus contributing to a projectised not been resolved. Whilst M&E tools based on the Transformative Agenda, World Humanitarian approach incompatible with the design of multi- common framework are under development, these Summit and Level 3 triggers have signalled a signifi- purpose cash assistance. As a result, the technical remain to be rolled out across agencies, and the cen- cant shi in this direction, more efforts need to be and managerial decisions relating to targeting and tral analysis function has not yet been defined. made to ensure that accountability, targeting frame- transfer value versus scope and scale of programming, Evolving role of Cash Working Group works and holistic approaches are prioritized for re- sources and coordination above sectoral divides. lacked direction as neither donors nor UNHCR e role of the CWG has continuously evolved Until this approach becomes widespread, exemplary were able to provide clarity on anticipated budgets, alongside the technical and operational discussions leadership and vision is required at individual and resulting gaps in assistance. e principle outlined above. In response to the need for strong agency managerial level, as well as through the UN- adopted by the CWG was to advocate for an overall leadership and decision-making, a core group (in- led coordination structures, optimally through an budget based on a package of assistance to meet the cluding UN, NGO and government representatives) empowered CWG. Survival MEB for all highly vulnerable households was elected. e group has consistently drawn from (28% of the registered refugee population), as outlined the resources developed by CaLP around docu- e Lebanon multipurpose cash assistance pro- in Box 2.is amounted to over $200m for a 6 menting Cash Coordination best practices globally. gramme design has highlighted some of the broader month period; but uncertainty over agency capacity In addition, a senior cash advisor position was political constraints in applying such leadership and to meet this gap remains significant, with UNHCR created under the inter-agency coordinator in an direction, as well as the critical role donors can play reducing their initial budget for cash assistance attempt to provide strategic oversight on the use of in driving decision-making on issues as contentious from $36m at the beginning of the year to $9m in cash assistance across the response. e elected core as cash assistance. In due course, effective program- June. is links to another critical budgetary issue group is tasked with making recommendations ming may be exemplified by one agency leading on which is the plateauing of funding for the Lebanon either through consensus or by a majority vote. delivery of cash assistance across a response. Whilst response in 2014 despite the ongoing increase in Time will tell whether this proves to be a relevant this may be operationally optimal, a formal set-up the number of refugees, which further lends credence model for effective and accountable decision-making, needs to anticipate the operational and legal chal- to a common operational set-up designed to optimise and its applicability in other contexts. At present lenges (including traceability of funds and reporting effectiveness (see Figure 1). donors are not part of this core group, but this may requirements) of inter-agency cash transfer pro- need to be revisited at a later date. In Lebanon, Current state of progress (August 2014) grammes, i.e. through pre-agreed HQ-level frame- donors have consistently been pressed to align with Notwithstanding the challenges outlined above, by work agreements. Another way of conceptualising and enforce CWG recommendations. DfID and August 2014, a critical mass of common recom- such a model is to envisage a distinct role for indi- ECHO in particular have been very engaged in sup- mendations had been produced by the CWG (as vidual agencies in the overall design, implementa- porting key decisions, and then feeding to the wider summarised in Box 2), making it almost impossible tion and monitoring of a cash assistance donor group. is coordination implies a need for a programme, building on agencies’ unique strengths to fall back to stand alone projects: the targeting more strategic and transparent inclusion of donors. recommendations had been issued and initial ben- - NGO consortia are a prime example of such a set- eficiary lists produced, the transfer amount agreed Conclusions and recommendations for up, and one which may be used to optimise the de- upon, the M&E framework designed, and clear rec- future multi-agency processes livery of cash assistance in Lebanon in 2015. ommendations on the optimal operational set up Based on the ongoing challenges detailed here, fun- For more information, contact Isabelle Pelly, email: outlined. e fact that the CWG had laid out all damental lessons have emerged for applicability to [email protected] or these tasks early in its February 2014 workplan, future humanitarian contexts. Implementing a mul- i.pelly@savethechildren,org.uk ; +44781 514 6504 supported by two meetings on multi-purpose cash ti-purpose cash assistance programme inevitably assistance called by ECHO in Brussels contributed implies agencies, donors and governments relin- 6 to clarity and accountability around the deliverables. quishing control over the use of cash assistance at See article summarising the evaluation of the IRC programme in this edition of Field Exchange Donors were interested and could use clear recom- household level. is fact continues to create dis- 5 WFP Economic Impact Study: Direct and Indirect effects of the mendations to make informed decisions on the rel- comfort at agency level, and in engaging with gov- WFP value-based food voucher programme in Lebanon. evance of the proposals received, and a number of ernments, particularly in a refugee setting. Hence, August 2014

By UNHCR Lebanon and UNHCR Cash Section, Division of Programme Support and Postscript Management, Geneva

UNHCR is fully behind the move toward adapting is too important not to get right. First of all, the general, and specifically in Lebanon, are complex its assistance to the specific needs of refugees winterisation programme was not an and deserve thorough analysis. The ECHO and other persons of concerns, hence its unconditional or multipurpose grant meant to Enhanced Response Capacity grant (2014-2015) preference for multi-purpose grants where compensate for shortfalls in minimum and the careful consolidation of learning appropriate and feasible. We are greatly expenditures. It was a grant designed for the foreseen in the grant, will be used by UNHCR and appreciative of the effort the author has made to purpose of winterisation - to keep people warm. partners to this end. UNHCR remains committed describe the process and lessons learned from Two evaluations (both on implementation and on to working with partners in Lebanon to ensure winterisation assistance in Lebanon (2013-2014) impact) have been completed and will inform the the best possible platform for cash programming, and subsequent efforts to operationalise a design of the 2014-2015 winterisation assistance enabling gains in providing effective and multipurpose grant programme which started in programme. In relation to multi-purpose cash efficient humanitarian assistance. August 2014. However we also feel that the topic programming, the operational constraints in ...... 11 IOCC field officer screens a Syrian refugee child for malnutrition in the Bekaa valley

Institutionalising acute malnutrition treatment in Lebanon

By Linda Shaker Berbari, Dima Ousta and Farah Asfahani

Linda Shaker Berbari is Country Representative at International Orthodox Christian Charities (IOCC) Lebanon and nutrition focal point for IOCC. She holds a Masters in Nutrition and is pursuing a PhD on infant and ebanon is a middle income country that Activation of PHCs for the screening and young child feeding in emergencies. Linda has has had to endure a number of wars and management of acute malnutrition through more than ten years’ experience in community emergencies since 1975. roughout those capacity building and provision of on-the-job nutrition and development work. different emergencies, Lebanon has never support Lhad a nutrition crisis, even during previous periods As Lebanon already has an established network of Dima Ousta is the Health of civil war. Today, with more than 1 million Syrian PHCs providing health services to both the Lebanese and Nutrition Coordinator refugees hosted in the country, there is fear that and the Syrian refugee community, the acute mal- at IOCC. She has an M.Sc due to the underlying causes of malnutrition, acute nutrition treatment programme relies on this existing in Human Nutrition and malnutrition may be a problem that the Lebanese structure. ere are more than 800 centres in Lebanon Diploma in R.D. health system may have to deal with. e Lebanese that provide health services that are registered with Credentialing and has heath system is considered one of the strong services the MoPH. However, only around 180 are part of participated at the NIE- in the country, especially within the private sector. the Network of PHCs; these are PHCs accredited by Regional Training in 2012 in Lebanon. She However, most nutrition and health problems that the MoPH that provide a comprehensive list of serv- joined IOCC in September 2013. the system is equipped to face include problems ices. Many of these centres are privately owned or that are related to overnutrition rather than under- supported by local organisations. Whether part of Farah Asfahani is the nutrition. At the outset of this crisis, Lebanon did the Network of PHCs or not, at the outset of this Health and Nutrition Area not have any protocols for treatment of acute mal- crisis, none of the centres was equipped to, or even Coordinator for nutrition, health care providers were not familiar knew about, how to screen and manage acute mal- Beirut/Mount Lebanon with the different forms of malnutrition that may nutrition. erefore, IOCC’s programme targeted region for the acute arise during emergencies, and health services were 50 PHCs across the country with facility-based malnutrition treatment not equipped to respond to such crises. trainings. programme at IOCC. She Nutrition programme Since May 2012, this training of health care staff has a B.Sc. in Nutrition and Dietetics and has International Orthodox Christian Charities (IOCC) (doctors, nurses, social workers) has been imple- participated in the NIE-Regional Training in started its nutrition programme in 2012, focusing mented by IOCC with technical assistance from the 2012 in Lebanon. She joined IOCC in July 2013. on emergency preparedness that mainly involved American University of Beirut (AUB) and Interna- capacity building activities for health care providers. tional Medical Corps (IMC). e training material The authors extend thanks to UNICEF and From 2011 to 2013, as the number of refugees in- UNHCR for funding the trainings and staff and is a translated adaptation of the harmonised training creased and cases of acute malnutrition started to 2 for supporting the treatment of children with package (HTP) . As the training progressed, IOCC appear, there was a need to provide case management. began to conduct its own trainings using IOCC staff acute malnutrition. Thanks also to the MoPH for e ensuing acute malnutrition treatment programme supporting and facilitating the establishment who have been trained through either the Nutrition is implemented by IOCC with support from UNICEF 3 of the programme through its established in Emergencies Regional Training Initiative (NIERT) and UNHCR and in partnership with the Ministry or other nutrition in emergency trainings. To date network of primary and secondary health of Public Health (MoPH) in vulnerable localities1 centres. Finally, the authors gratefully (July 2014), the team has trained more than 250 in all six of Lebanon’s governorates. Lebanon’s six health care staff across the country. acknowledge the support of the American governorates are made of 26 cadasters; IOCC works University of Beirut, particularly Dr. Hala in more than 15 cadasters to support the nutrition Ghattas and Dr. Omar Obeid, and of Caroline programme. e IOCC programme aims to insti- 1 Map from UN Children’s Funds (2013). Equity in Humanitarian Abla at International Medical Corps, for tutionalise acute malnutrition treatment to ensure Action: Reaching the most vulnerable localities in Lebanon, October 2013, [online], Available through: www.data.unhcr.org providing technical input and guidance on the primary health centres (PHCs) have or will have development of the programme and training 2 Harmonised Training Package: http://www.unicef.org/ the capacity to treat acute malnutrition; it is both a nutritioncluster/index_67812.html material. preparedness activity and an intervention. Key ac- 3 See article by AUB regarding the training initiative. tivities are as follows. http://www.nietraining.net/ ...... 12 Field Article ......

Capacity is also built through provision of on- An important step remains to integrate the the-job support to selected PHCs whose staff have management protocol within existing national and received the facility based training outlined above. hospital protocols. To-date, IOCC has to rely on ese ‘activated’ centres, are selected for on-the-job close follow up with hospital staff in order to make support based on a number of criteria: sure treatment protocols are followed. • ey are located in the most vulnerable areas based on UNICEF’s priority list. Community screening for malnutrition • e centre is contracted4 by UNHCR/non- A major component of the IOCC programme involves 2014 Håkon Haugsbø/NCA, Lebanon, governmental organisation (NGO)/to cover the screening for malnutrition within the community. cost of treatment. IOCC deploys a group of trained screeners to • e centre has a paediatrician who is willing to different areas within Lebanon on a rotational basis be trained. to conduct community screening for acute malnu- • e centre is willing to participate in the trition amongst children under 5 years using MUAC programme. and oedema. is helps in early identification of cases who are then referred to activated PHCs for Activated PHCs provide a variety of services including confirmation of diagnosis and treatment. Screeners screening for malnutrition amongst children under have also been deployed to UNHCR registration An IOCC field officer carefully monitors the 5 malnutrition treatment of two and a half 5 years , acute malnutrition treatment, education and vaccination centres. Screening teams have mainly year old, Mataab, in the Bekaa valley on nutrition and infant and young child feeding targeted informal tented settlements (ITSs) and col- (IYCF), and provision of micronutrients for children lective shelters all over Lebanon and have conducted under five years. Other population groups are only house to house screening in particular situations Issues, challenges and lessons learned assessed or referred where acute malnutrition is (e.g. in the village of Aarsal, at the time when a high ere have been a number of challenges implementing suspected. IOCC provides on-the-job support by influx of refugees fled from Syria in November 2013; acute malnutrition treatment in Lebanon. A primary supplying IOCC staff who assist in screening for a large number of refugees have been hosted by challenge has been implementation in an urban malnutrition amongst children under five years. Aarsalis and have settled in unfinished houses since context through existing health services in a country IOCC staff also assist in case management and the beginning of the crisis in 2011). To-date, over that has never had to provide these services before follow up on case treatment. 27,000 children have been screened (in the community and with a view to long term sustainability. and at registration centres) of which 450 were iden- So far, IOCC has activated 30 centres across the tified as malnourished and referred for treatment A limiting factor has been the ability of PHC country. Within the Syria response, there are around to the activated PHCs. staff to accommodate additional services for patients 97 centres that are contracted by UNHCR or inter- visiting the PHCs. Multiple training at each centre national NGOs. Within those centres, only those Education and awareness was necessary to ensure appropriate capacity. It was activated by IOCC provide the acute malnutrition In addition to screening and treatment, PHC staff essential to provide on-the-job support through ad- treatment services. Even where a centre is contracted provide education and raise awareness on nutrition ditional staff, especially for regular growth monitoring by another INGO that subsidises the acute malnu- for children, pregnant women and lactating women. (weight and height measurements). Finding physical trition treatment service, the training and follow up Education topics include nutrition, IYCF, and hygiene. space for the additional services was also a challenge. 6 is all implemented by IOCC . Resource material has been developed with UNICEF, ere have been difficulties gaining understanding Programme materials and supplies, including UNHCR and the MoPH focusing on both acute malnutrition and IYCF. and uptake of treatment protocols amongst health lipid-based Ready to Use erapeutic Food (RUTF), care providers, notably paediatricians, who are not 7 Ready to Use Supplementary Food (RUSF) and Integration of anthropometric indicators familiar with acute malnutrition. IOCC staff some- equipment (e.g. height boards, scales, and MUAC within existing health information system times faced resistance from health care providers to tapes), are provided by UNICEF. With funding from (surveillance) implement supplementary feeding or therapeutic UNICEF, IOCC has devised forms in Arabic to use An integral and very crucial part of the nutrition feeding programmes. Paediatricians sometimes did at the PHCs for follow up on malnutrition cases. programme involves establishing a pilot surveillance not recognise and diagnose acute malnutrition as a Within each activated PHC, children under 5 system within the MoPH. With the help of the condition. primary health department at the MoPH, anthro- years are assessed using mid-upper arm circumference e urban setting has rendered the follow up of pometric measures (weight, height and MUAC) in (MUAC) and weight for height (WFH) measurements cases more difficult. Given the movement of families addition to bilateral oedema were incorporated into and for oedema. Children are admitted to the sup- within different areas and the reluctance of some plementary feeding or therapeutic feeding programme the existing health surveillance system. Indicators families to address the issue of malnutrition, IOCC depending on the diagnosis. Children are provided include weight for height and height for age and an had to deploy health and nutrition educators to with treatment at the PHC level through weekly or IYCF indicator (exclusive breastfeeding). e system follow up cases at the community level in order to bi-weekly visits and are followed by trained staff at is to be piloted and launched at the activated primary ensure regular attendance at centres. It was difficult the community level as needed. Children with com- healthcare centres around October 2014. to convince some families about the importance of plicated severe acute malnutrition (SAM) are referred Resource development seeking and finishing the treatment. For some, there to secondary care for in-patient therapeutic treatment. An important output of the project has been the de- was a perception that treatment for acute malnutrition On average, the IOCC-supported PHCs assess a velopment of resource material for screening and was not a lifesaving intervention. Due to the distances total of around 125 children under 5 years per management of malnutrition. Referral sheets and between refugee residence and the activated centres, month, out of which around six children are admitted treatment sheets for severe and moderate acute mal- families oen did not attend due to lack of transport. for acute malnutrition. It is important to note that IOCC therefore had to fund transport costs for the programme is still in development. nutrition were devised in Arabic and provided to activated PHCs. Staff were trained on the use of some cases. IOCC has also trained eight hospitals across the these forms. Another significant component of the country on in-patient treatment of malnutrition programme included the development of training 4 A ‘contracted’ centre is where UNHCR or an NGO subsidises using the WHO revised protocol for the treatment material in Arabic based on the HTP. the cost of treatment for medical consultations for Syrian of malnutrition8. All of these hospitals are contracted refugees. Instead of paying the full fee for a medical consultation, the refugee pays a minimal fee. IOCC has by UNHCR to provide services for Syrian refugees As Lebanon does not have a national protocol for the treatment of malnutrition, the team had to prioritised contracted PHCs so as to make sure that the cost of and cover the cost of treatment of malnutrition. acute malnutrition treatment is covered by UNHCR (in most Within each hospital, paediatricians and nurses on draw on protocols from other similar countries, cases) or an NGO. paediatric wards are trained in a one-day training. such as the Yemen. ese were adapted given the 5 Weight and height are measured but weight for height only is A dietician and paediatrician from IOCC then follow unique nature of, and accumulated experiences calculated. from, the Lebanon context. For example, the use of 6 Relief International provides treatment of malnutrition in up with the staff on each case upon admission. An mobile units and in specific areas of Lebanon but not in PHCs. understanding was reached with each of the hospitals Amoxicillin in Lebanon has been debated by paedi- See article in this issue of Field Exchange. in terms of the roles and responsibilities of each atricians due to high resistance to the antibiotic; 7 Products are Plumpy’nut, Plumpy’sup and NRG5. party with regards to the treatment and follow up of thus, paediatricians were advised to replace with an 8 Ashworth, A, Khanum, S, Jackson, A, and Schofield, C. (2013). Guidelines for the inpatient treatment of severely admitted cases, as well as on the use of materials alternative antibiotic. IOCC is working with the MoPH to formalise a national protocol for treatment malnourished children. World Health Organisation. Available and supplies. Again, supplies such as F75, F100 and at: http://whqlibdoc.who.int/publications/2003/9241546093 RUTF are provided by UNICEF. that will be adopted by paediatricians. .pdf? ua=1 ...... 13 Field Article ...... After receiving individual counselling, a woman is cup feeding her child with A common challenge in the programme relates to the acceptability expressed breastmilk of RUTF and RUSF. Families and children are not used to receiving food/medicine in the form of a paste. In many cases, children do not accept the taste of RUTF and staff have to resort to alternatives such as mixing other nutrient dense products (e.g. NRG-5) with milk and juices, or adding RUTF to the child’s favourite foods (topping on bananas or biscuits). e cost of attending PHCs can be prohibitive for some families, even though a number of PHCs are subsidised by UNHCR/NGOs, since families are required to cover 25% of the cost of consultation. IOCC has worked only with PHCs that are subsidised by other NGOs who have been covering 100% of the cost of acute malnutrition consultations. However, recent cuts in health care funding for the Syria crisis means that refugees are having to pay for some of the cost of treatment of malnutrition. is is hindering the success of Pressila Derjany/IOCC, Tripoli, Lebanon, 2014 care. In addition, oen the medical treatment requires further testing for underlying causes of malnutrition (e.g. laboratory tests for anaemia, immunoglobulins, intolerances, CT-scans, endoscopies 9 Infant and young child etc.) all of which are only subsidised at 85% . In many cases, children with acute malnutrition are also diagnosed with congenital or other associated diseases such as feeding support in neurological disorders (e.g. cerebral palsy), cystic fibrosis, congenital heart disease, cow’s milk allergy, celiac disease, galactosemia, which oen are the underlying cause of the acute malnutrition. In such Lebanon: strengthening cases, treatment of malnutrition has to be adapted to the case and condition. the national system Conclusions By Pressila Darjani and Linda Shaker Berbari e most important investment lies in institutionalising nutrition services within primary health, including those targeting both acute Pressila Derjany is the Infant and Young Child Coordinator at and chronic nutrition related diseases. Lebanon provides a unique IOCC. She has a B.Sc. in Nutrition and Dietetics. She joined context for implementation of an acute malnutrition treatment pro- IOCC in December 2013. gramme but building such capacity takes time. Other nutrition related problems need to be addressed as well, such as stunting, mi- cronutrient deficiencies and other chronic nutrition related diseases that are endemic to the area. e establishment of a clinic-based surveillance system through the MoPH is expected to act as an Linda Shaker Berbari is Country Representative at essential step towards the strengthening of the primary healthcare International Orthodox Christian Charities (IOCC) Lebanon structure in collecting growth monitoring data. is will act as a and nutrition focal point for IOCC. She holds a Masters in platform for capacity building to deal with acute and chronic nutri- Nutrition and is pursuing a PhD on infant and young child tion-related conditions at the primary healthcare level. feeding in emergencies. For more information, contact: Linda Shaker Berbari, email: LBer- [email protected] The authors gratefully acknowledge the support of UNICEF and UNHCR for 9 For more information, contact: Linda Shaker Berbari, email: [email protected] funding training and salaries of staff, the MoPH for supporting and facilitating the establishment of the programme and the National Programme on IYCF for hosting the activities. Also read online 'A day in the life of a lactation specialist' that describes the experiences of Zeinab Hillani, one of IOCC’s lactation specialists in Bekaa. http://www.ennonline.net/fex

Ryan Erickson/IOCC, Lebanon, 2013 Lebanon, Ryan Erickson/IOCC, The policy and social context In 2011, the International Orthodox Christian Charities (IOCC) launched the Preparing for the Next Generation Initiative that builds on the importance of the first 1000 days of an infant’s life. rough this initiative, IOCC is working to create a strong national mother and child nutrition programme that will not only prepare the nation against any emergency but also improve the wellbeing of Lebanese children for generations to come. IOCCs programming on infant and young child feeding in Lebanon is located

Field Article Field within this initiative. is article describes IOCCs role in a recently established national programme to strengthen policy guidance and support around IYCF-E in health services in Lebanon, including additional activities that were developed to respond to the Syria crisis. In Lebanon, the only government regulation on infant feeding was a 1983 law related to the ‘Marketing of Breastmilk Substitutes’. However, an updated version was issued in 2008 (Law 47/2008) that is currently considered even stricter than the International Code of Marketing of Breastmilk Substitutes (BMS) (the Code). Unfortunately, although efforts are being put in place to enforce this law, there is evidence that health workers and even government A child is fed RUSF for the treatment of representatives are not aware of it. It is also evident that much more is malnutrition (Bekaa valley) needed in order to identify potentially available guidelines so that these can ...... 14 Field Article ......

be included within a reliable policy to support, promote and protect IYCF framework. In the absence of effective amongst both the refugee and host government policies, the private sector populations affected by the Syria crisis and non-governmental organisation in Lebanon. e programme includes (NGO) sector in Lebanon play a large the following activities which endeav- role in influencing the type of service our to promote three objectives: provided. e only available study, con- 1) Promotion of optimal IYCF ducted by Save the Children aer the practices latest Lebanese war in July 2006, showed Education and awareness activities on some key findings around policy and infant and young child feeding practices: optimal IYCF are administered at the • A lack of awareness amongst NGOs, primary health centres (PHCs), in the government and health workers hospitals and at the community level. about the Operational Guidance on To-date, IOCC has targeted more than IYCF-E and the Code 10,000 mothers with awareness on • A large number of Code violations, IYCF. Educational material were de- including inappropriate distribution veloped and tailored to the Middle of infant formula Eastern context. e UNICEF Infant • Most intervening agencies – Feeding counselling cards were trans- including international NGOs and lated, tested, and adapted. Staff at United Nations (UN) agencies – did not ensure the Lebanese Association for Early Children Devel- health care centres were trained on the use of the their partners followed Ops Guidance on IYCF-E opment. A National Programme on IYCF was es- counselling cards (see Figure 1 for a sample card). • Mothers were not adequately supported to tablished at the MOPH with support from IOCC 2) Supporting mothers to ensure optimal IYCF continue breastfeeding and World Vision. IOCC works through this pro- Mothers receive IYCF counselling during and aer • Infant feeding was not a priority. gramme in order to execute activities that support delivery (see case study for one woman’s experience). IYCF, such as celebrations for the annual World ese factors had a negative impact on prevalence e service is provided at the hospital, PHC and com- of breastfeeding and proper infant nutrition1. In Breastfeeding Week, media campaigns and other munity levels. In contracted hospitals, IOCC lactation addition, eight years aer this July 2006 war, reports promotional activities. Within the National Pro- specialists are present to ensure early initiation of from INGOs currently intervening in Lebanon in gramme, a sub-committee was created in 2011, breastfeeding, as well as correct positioning for feeding, response to the high influx of Syrian refugees as a mainly supported by IOCC, focusing on IYCF-E. etc. Follow up is provided in the community as necessary. Also, through community outreach, mothers result of the Syrian crisis, show that there are still a Response on IYCF-E to the current crisis are identified and are referred by other NGOs to the large number of Code violations and that infant In 2012, with UNICEF funding, IOCC implemented lactation support service. Typically, lactation specialists feeding is not on the priority list of interventions. a programme to support upholding the Code during counsel mothers of infants under 6 months of age Hospitals are still distributing infant formula and the Syria crisis in Lebanon. Workshops were imple- who are not exclusively breastfed. Mothers are helped paediatricians continue to inappropriately prescribe mented targeting NGOs and agencies responding to re-establish milk supply and exclusively breastfeed. it to mothers. to the Syria crisis. In addition, the publication of a 5 In most cases, this intervention is successful. e prevalence of exclusive breastfeeding is cur- joint statement was facilitated and endorsed . Since rently low in Lebanon, with only 14.8% of infants 0- August 2013, IOCC with support from UNICEF Mothers who have not breastfeed at all or have 5 months of age exclusively breastfed (MICS, 2009). and UNHCR, has been implementing a programme stopped breastfeeding are counselled on relactation Rates of childhood2 and adult obesity, hypertension and high cholesterol3 in Lebanon are comparable to 1 MacLaine A (2007). Infant Feeding during Emergencies: of usage patterns and content of calls made to a postpartum those in the United States. e prominent miscon- Experiences from Lebanon. Humanitarian Exchange Magazine. support telephone hotline. BMC Public Health. Oct 15;10:611. Issue 37. Sibai, 5 Ministry of Public Health – Lebanon and Ministry of Social ceptions, lack of proper supportive environment, 2 A et al (2003). Prevalence and Covariates of Obesity in Lebanon: Affairs. 2012. Joint Statement on Infant and Young Child and the heavy marketing of artificial feeding4 all Findings from the First Epidemiological Study. Obesity Feeding in Emergencies – Syria Crisis – Lebanon. Endorsed by contribute to the low rate of breastfeeding in addition Research. 11, 1353-1361. UN agencies and NOGs. to the absence of a global and solid policy framework 3 WHO Lebanon Health Profile, 2008. www.who.int/gho. 6 Two kinds of ‘baby kits’ are distributed to women with children countries/lbn.pdf under 2 years within the IYCF programme, as encouragement in the area of infant and child feeding. 4 Nabulsi M. (2011). Why are breastfeeding rates low in Lebanon? to breastfeed: 1) infant kit containing pyjamas, towels, In order to address this, since 2011, IOCC has a qualitative study. BMC Pediatr Aug 30;11:75., Saadé N et al. shampoo, diapers, etc. for newborns and infants. 2) hygiene kit (2010). Maternity leave and experience of working mothers in which is the standard hygiene kit containing detergents and partnered with World Vision, the Ministry of Public Lebanon. East Mediterr Health J. Sep;16(9):994-1002., Osman H personal hygiene products. Health (MOPH) and other local institutions including et al. (2010). What do first-time mothers worry about? A study

Case study Supporting Syrian refugee mothers who choose to breastfeed

By Tiziana Cauli and Rana Hage, IOCC Lebanon The 27 year old mother from Aleppo says that breastfeed because they think or are told that infant breastfeeding her child has also helped her formula is healthier. This is not true.” Aamer is 3 months old. He lives in the tented Syrian financially. Her husband is missing in Syria and she “I give her vitamins and support and I am going to refugee settlement of Khaled el Homsi, near the town has no money to buy formula milk, she says. “It’s too of Saadnayel, in Lebanon’s Bekaa valley, with his give her the food she needs to add to her baby’s diet expensive and I can’t afford it. And I am convinced after his first six months,” Hillani says. mother Mufida Al Hamsi and his 18-month old my baby will benefit from breastfeeding.” brother Jassem. Mufida did not breastfeed her first “And they gave me this,” Mufida says proudly, child and was not planning to breastfeed baby Aamer, When she first met Hillani, Mufida didn’t know how pointing at the baby romper suit Aamer is wearing. to breastfeed. She had fed her first child with infant until she was approached by IOCC lactation specialist, The vitamins Hillani mentioned are part of the formula and had been advised against breastfeeding Zeinab Hillani. Briefed on the benefits of support given by IOCC to lactating mothers. her newborn baby because she had recently been breastfeeding, she decided to defy the widespread Micronutrients are given to those who are not sick with measles. She was approached by Hillani at misconception, common among refugee mothers in receiving them from other healthcare institutions. the hospital, right after giving birth and started the area, that formula milk-fed babies are healthier When babies reach 6 months of age, IOCC helps breastfeeding her baby within a few days. than breastfed ones, especially in times of mothers integrate their children’s diet by providing uncertainties and emergencies. As a result, baby “I wish I had met Zeinab beforehand,” Mufida says. them with the proper food, when necessary. Aamer is healthy and big enough for his age. Many mothers like Mufida and their babies are In addition, lactating mothers within IOCC “He is heavier than his brother was at 3 months,” Mufida victims of misconceptions. programme receive a kit with clothes and other items says. “And he is healthier. Jassem suffered from “At the paediatric ward, I speak to mothers and ask for their babies and a personal hygiene kit for gastroenteritis while he was fed with infant formula them why they are giving infant formula to their themselves as a form of encouragement6. and he was always sick. He still has digestion problems.” babies,” says Hillani. “Some of them refuse to

...... 15 Field Article ...... and helped to re-establish milk supply if they so rienced in 2006, NGOs intervening within the Syria Programming challenges choose. In most cases, the intervention is successful, Crisis were targeted by IOCC. Workshops to ensure e main challenge around IYCF resides in addressing which depends greatly on the dedication and com- compliance with the Code and Law 47/2008 were strongly established misconceptions around breast- mitment of the mother. ere are instances when conducted for NGOs and local partners including feeding and the fact that many women are used to relactation is not possible, for example, when the health care staff. In addition, a reporting mechanism mixed feeding. Many women believe that their breast- mother is not willing, or the child is old and not was put in place to report on Code violations. Within milk is not enough and therefore resort to supple- able to latch on, or the child/mother has health hospitals, the Baby Friendly Hospital Initiative menting with infant formula. Others are influenced problems. In these cases, mothers are referred for (BFHI) was supported through trainings and capacity by the doctor’s prescription of infant formula. Some artificial feeding support (see below) where they building, especially in hospitals that have been con- believe that breastmilk production is highly affected are provided with BMS supplies, and guidance and tracted to provide services for Syrian refugees. As by the stressful situation they are experiencing. As a education on proper use. About 30% of the cases mentioned above, most hospitals in Lebanon dis- result, mothers mixed feed or fully artificially feed. choose not to or cannot breastfeed. tribute infant formula for new mothers and are not supportive of breastfeeding. In many cases, mothers Another challenge relates to artificial feeding Since January 2014 till end of June 2014, 3,150 are wrongly advised to provide formula for their in- support and the fact that this assistance is considered mothers were counselled by lactation specialists in fants based on lack of knowledge. To address this, a benefit. As previously mentioned, support for ar- all the Lebanese regions, assisting mothers with IOCC worked on prioritising hospitals that are pro- tificial feeding is provided by IOCC to non-breastfed breastfeeding difficulties, such as painful nursing, viding services to Syrian refugees in order to mitigate infants within the Syria crisis according to the latching problems and low breastmilk production. practices that may jeopardise breastfeeding. Hospitals protocol and only when re-lactation is not possible. Non-breastfed infants are supplied with formula All children under 2 years are considered equally are also provided with essential equipment and tools milk, clean water and cups until of year of age. It is viable for re-lactation, but the under 6 months age to support the initiative. a major challenge for IOCC to provide and maintain group are given priority. Lactation specialists also Artificial feeding support a supply of infant formula to 1 year of age. When work with the nutritionist to counsel the mother on Mothers are first and foremost counselled on the refugees find out that a neighbouring family is sup- optimal complementary feeding practices. is importance of breastfeeding, especially in the the plied with infant formula, they oen come up with service is available in hospitals and in the community. current crisis context. If still a mother is not willing ways to benefit from this assistance, even if the ere are cases of infants over 6 months of age who to relactate, she is provided with support on artificial mother is breastfeeding with no difficulties. Here, have not been introduced to complementary foods feeding. Although not a large component of the the lactation specialist intervenes by educating and are still exclusively breastfed or exclusively programme, IOCC has also supported interventions families about benefits of breastfeeding versus risks bottle fed. is negatively impacts the child’s nutri- to manage artificial feeding amongst Syrian refugees. of artificial feeding. tional status. Instances where this is necessary include when a e surrounding environment is not always sup- IOCC, as part of the IYCF National Programme, mother is not able to breastfeeding and where an portive so oen mothers in law, neighbours, husbands, has trained more than 200 health care staff within infant’s mother is not present. Another situation is all influence the mother’s choice. IOCC works on PHCs and hospitals to provide infant feeding support where an infant has a congenital disease that con- this by inviting all members of the family to awareness and increase awareness of mothers. is has increased traindicates breastfeeding. sessions in order to positively engage them into the the pool of available qualified lactation specialist to In non-medical cases, the lactation consultant decision making process of feeding the infant. support breastfeeding. Training material, including makes the decision to prescribe a BMS (infant for- the WHO 20-hour and 40-hour lactation courses, ere is a need to formalise the protocol for arti- mula) suitable for the infant. IOCC staff work with were adapted and used in collaboration with the ficial feeding within the Lebanon context in order the family to provide education on proper use of National Programme on IYCF. Working within to minimise harm. Just like for infant feeding in infant formula including hygiene practices. Cups PHCs, IOCC is helping create mother friendly spaces general, there is a need to have clear guidance on and clean water is also provided. e mother is pro- where mothers can meet and share their experiences. artificial feeding support. In a context such as vided with infant formula on a monthly basis. e spaces are used to conduct sessions targeting Lebanon where artificial feeding rates are high, there Supplies are purchased from the market by IOCC, mothers with children under 2 years of age. is a need to have guidance on who to provide support then unbranded (the brand is hidden with a label so to, how and for how long. e problem with funding, 3) Protecting IYCF through up-holding of the only the Arabic instructions are visible) and provided for example, is a big one, since once artificial feeding Code and Law 47/2008 to the family. One main challenge that is oen en- support is started, infants need to be supported As mentioned above, Lebanon has a history of Code countered relates to sustaining the infant formula until one year of age. Many times, programmes are violations, in both ‘normal’ and emergency situations. supply. Ideally, the infant is provided with infant less than 6 months in duration, which creates a In many instances during crisis, NGOs accept do- formula until 1 year of age, however, in some cases, challenge to be able to continue support. nations of infant formula and then distribute through funding is not adequate to continue over this period. a general distribution. ese mostly happen during Staff are faced with either purchasing a supply of Although the number of artificially fed infants special events such as periods of holidays (Eid el milk with IOCC funds (when available) until the who are supported is small, the actual need is much Fitr and Christmas). In order to mitigate such infant is 1 year of age or stopping the assistance. higher. With the rates of exclusive breastfeeding practices and prevent the flooding of Lebanon with e number of infants assisted with artificial feeding being low, the number of infants who will need ar- donations and inevitable Code violations, as expe- support by IOCC does not exceed 50 children. tificial support is higher than the existing capacity to ensure safe and adequate artificial feeding or in the case when mothers are willing to breastfeed, A Syrian refugee mother successfully breastfeeds relactation. Frontline support should include pre- her child after receiving individual counselling from an IOCC lactation consultant liminary screening for infants less than 6 months of age needing support and capacity should be increased as to providing such support. Conclusions It has been (and still is) a challenge to increase visibility and awareness on IYCF and its importance during the refugee crisis. Emphasis is still put on other “life saving” interventions, although IYCF-E is considered one. Progress has been made in the last two years, but more needs to be accomplished in terms of establishing clear guidance on IYCF support in Lebanon and ensuring sustainability. In addition, more emphasis needs to be made on creating support groups for mothers within their own communities in order to be able to face envi- ronmental challenges that hinder breastfeeding. For more information, contact: Linda Shaker

Tiziana Cauli/IOCC, Bekaa valley, Lebanon, 2014 Lebanon, Bekaa valley, Cauli/IOCC, Tiziana Berbari, email: [email protected] ...... 16 Field Article UNICEF experiences of Syrian refugees in Lebanon the nutrition response in Lebanon By Najwa Rizkallah

Najwa Rizkallah was Nutrition Specialist with UNICEF Lebanon until September 2014, having led the nutrition in emergencies programme in Lebanon for Syrian refugees since October 2013. Before that she worked as a nutrition specialist in the State of Palestine (SoP) office. She has many years of nutrition experience in emergency and non-emergency settings. Previously she was head of the Nutrition Department at UNRWA, as well as consultancy positions and lecturing. She has a Doctoral degree in Epidemiology and Population Health and a Master’s Degree in Nutritional Sciences. She is currently an Emergency Nutrition Specialist, El Fasher, Darfur, North Sudan. Thanks to the International Orthodox Christian Charities (IOCC) and Relief International for sharing the data included in this article. UNICEF

ndernutrition is a silent, yet growing Communication (BCC) materials on malnutrition healthcare level consultations for all malnourished concern in Lebanon amongst children management and IYCF in emergencies (IYCF-E) in children (SAM with complications) and supports under 5 years, as Syrian refugee numbers partnership with IOCC. the salaries of IOCC lactation specialists who provide increase steadily and the economic re- one-on-one breastfeeding counselling. UNHCR also sourcesU of both refugees and host communities di- Capacity development supports the salaries of IOCC health and nutrition minish. ose who are most at risk of malnutrition As part of the scale up effort, UNICEF supported staff. All of this work is undertaken in coordination are the least likely to seek medical attention, as they the capacity building and skills development of and cooperation with the Ministry of Public Health cannot afford the cost of travel, doctor’s fees or people at international, United Nations (UN) and (MOPH) and other main partners such as Interna- medication. While the Lebanese public health system national organisation levels working on nutrition tional Orthodox Christian Churches (IOCC), Relief 1 is willing to respond, it lacks the resources and ex- in Lebanon . A Nutrition in Emergencies (NIE) International (RI) and Action Contre la Faim (ACF). pertise to do so without support from other agencies. training course was conducted in Jordan and the main partners of UNICEF Lebanon attended an UNICEF is supporting two work modalities to One of UNICEF’s foremost priorities in emer- NIE training in Jordan in June 2013. is training scale up the treatment of malnutrition. e first gencies is to prevent death and malnutrition in the helped International Orthodox Christian Charities modality, which is conducted through IOCC4, is affected population, particularly amongst vulnerable (IOCC) and Relief International (RI) to scale up community based screening and active case finding groups: infants, children, pregnant women and their work on management of acute malnutrition for acute malnutrition, then treatment at primary breastfeeding mothers. is role includes screening with the support of UNICEF. Later on, UNICEF health and secondary health centre depending on children and women, supporting treatment of acute contracted IOCC to train community mobilisers, the cases. is involves community mobilisers screen- malnutrition, and raising awareness around appro- nurses, and paediatricians on CMAM and IYCF-E. ing children aged 6-59 months for acute malnutrition priate infant and young child feeding (IYCF) practices, More than 240 doctors, nurses, paediatricians and at the community level using mid upper arm cir- as well as prevention of micronutrient deficiencies. community mobilisers from the MOPH, IMC, RI, cumference (MUAC) and bilateral oedema. Children ACF, WFP, UNHCR and AVSI were trained by identified with either severe acute malnutrition UNICEF supported programming to date IOCC and UNICEF staff. (SAM) without complications or moderate acute A nutrition assessment of the Syrian refugees in malnutrition (MAM) are referred to PHC clinics Lebanon conducted in Sept 2012 recorded a global In June 2014, an NIE training was conducted in for treatment5. Children with complicated SAM are acute malnutrition (GAM) rate of 4.4%, which is collaboration with the American University of Beirut referred to secondary care for treatment. e second categorised by WHO as an ‘acceptable’ prevalence of (AUB) and University College London (UCL). is modality is similar in terms of screening but the malnutrition. e management of acute malnutrition professional training has been established over a treatment is conducted at home in the informal 2 was a very new area for the health care system in number of years . irty-five participants attended tented settlements (ITS) and children are followed Lebanon. Prior to the Syria crisis, acute malnutrition the training from Lebanon and other countries in up on a weekly basis aer receiving either Ready to was not at all common in Lebanon and only tended the region affected by the Syrian crisis (including Use Supplementary Food (RUSF) or Ready to Use to occur where there was co-morbidity. Given the those working in Syria) as well as MOPH staff. is erapeutic Food (RUTF) as appropriate. More than low capacity and in preparedness for a rise in caseload, training helped attendees improve their skills to re- 55,000 children have been screened for malnutrition UNICEF and IOCC moved to scale up capacity of spond better to nutritional needs of those affected since January 2014. public health providers for the detection, monitoring, by emergencies. and treatment of acute malnutrition. is decision 1 See also the article by UNICEF on capacity development in the was also informed by anecdotal reports by partners Acute malnutrition treatment services region, in this edition of Field Exchange. at the health working group of emerging cases of In Lebanon, UNICEF is responsible for programmes 2 See article by AUB in this edition of Field Exchange (p67) and that treat SAM cases without complications at com- visit www.nietraining.net malnutrition among children and poor know-how 3 munity level (within primary health care centres UNICEF provides all supplies and technical knowhow and of how to manage them, and the deaths of four SAM UNHCR pays for the hospital stay and salaries of IOCC children, at one hospital in Beqaa Valley, attributed (PHCs)), programmes that treat SAM cases with dieticians. 4 to lack of experience in SAM treatment. In addition complications as in-patients (in hospital) in collab- See field article by IOCC in this edition of Field Exchange. oration with UNHCR3 and programmes that treat 5 In the field and at the initial screening at the PHC facilities, to these activities, UNICEF undertook to ensure the MUAC is used and the cut off points used are: <11.5 cm for timely and efficient distribution of programmes sup- MAM children (at PHC level). WHO is not involved SAM, 11.5-12.4 cm MAM, >12.5 cm normal. In addition to plies, including micronutrient supplements for in acute malnutrition treatment (though WHO pro- MUAC measurements, heights and weights of children are measured and weight for height z scores are used to classify children and pregnant and lactating women (PLWs), tocols are used) and WFP is focused on food security. UNHCR covers the cost of hospital stay and primary children using the following cut-offs: MAM (≥-3 and <-2) and as well as the development of Behaviour Change SAM (WHZ<-3 z scores) ...... 17 Field Article ...... A Syrian refugee and her child arrive in Lebanon IOCC supports acute malnutrition treatment at PHCs and at the inpatient level and RI supports management in mobile clinics. For IOCC program- ming, at the outpatient level (until end of July 2014) a total of 826 cases were treated (593 cases of MAM and 233 cases of SAM). At the inpatient level (until end of July 2014), 218 cases were admitted including complicated SAM, complicated MAM, children with malnutrition secondary to disease, and infants with malnutrition. For RI programming, 519 children have been admitted and 453 discharged (87.3% cure rate, 10% defaulter rate). Fourteen children are cur- rently under treatment (July 2014). For breakdown for SAM and MAM cases, see Table 1.

UNICEF also supplies anthropometric equipment McConnell/UNHCR credit: Photo and therapeutic and supplementary foods (RUTF, GAM rate for refugees was 5.9% in all Lebanon, RUSF, high protein/energy biscuits, and emergency been significant. e consultant leading on the 8.9% in Beqaa and 6.7% in Northern Lebanon. In food rations BP5) for home based treatment and or survey was trained in SMART but, it later transpired, the assessment, MUAC identified no cases of acute treatment at the PHC clinics. For hospitals, UNICEF had outdated training. e problem was compounded malnutrition. Translating these figures into numbers provides anthropometric equipment, therapeutic by difficulties accessing the raw data from the con- meant that an estimated 10,504 children in all of food and medications such as F75, F100, ReSomal sultant engaged by UNICEF before the results were Lebanon (including 5,279 children in Beqaa and and antibiotics. released. At the time, no organisation doubted the 3,410 children the North) were acutely malnourished figures, but many expressed surprise with the high Data quality issues and in need of treatment. e nutrition situation GAM rate compared to the previous year. WFP To inform ongoing nutrition programming in was reported as worst in areas where access to safe queried the GAM rates and requested data access Lebanon and with concerns that the nutritional water, hygiene and sanitation were inadequate. which was not granted at the time, except for anaemia status of refugees had deteriorated, the nutrition data which were shared with UNHCR only. is all e interagency 2013 nutrition survey results community (involving UNICEF, UNHCR, WFP, came at a time when there were reports of increased presented to the nutrition stakeholders in Jan/Feb IOCC and WHO) undertook an inter-agency nu- caseloads of acute malnutrition from organisations 2014 endorsed the rationale for scale up of acute trition assessment of Syrian refugees between October working in the field and the SAM-associated deaths malnutrition treatment. However inconsistencies and December 2013 to obtain an update of the nu- in Bekaa Valley hospital. UNHCR and WFP requested in the findings were noted by the Centres for Disease trition situation. It was led by a UNICEF consultant. the data to undertake additional analysis. However, Control and Prevention (CDC) and by UNICEF It revealed that GAM rates (based on WHZ) in the data were never shared until the consultancy was MENARO when compared with assessments con- Beqaa Valley and in Northern Lebanon had almost over and the results were announced. ducted among Syrians in neighbouring countries doubled compared to the 2012 assessment. e such as Jordan. is led to a data quality verification To learn from the experience and ensure data exercise by UNICEF Lebanon facilitated by UNICEF quality in future assessments, a 3 day workshop Table 1: Number of children under 5 years with MENARO with support from CDC. was held by UNICEF MENARO in Amman, Jordan MAM and SAM managed as outpatients in July 2014, to update the participants with techniques though the home based treatment as It was found that the original height data of mul- part of RI programming, November on data quality verification based on SMART soware tiple children was altered aer data collection in an 2013-June 2014 for data management and data analysis techniques. irregular way, creating additional cases of GAM in e workshop was facilitated by Dr. Oleg Bilukha Cases SAM cases MAM cases all children for whom the height was changed and Ms. Eva Leidman from CDC Atlanta. Sixteen Identified 58 461 without any notification of the height change in the participants attended the workshop from UN agencies methodology or anywhere else in the assessment. Discharged 42 411 (UNICEF, UNHCR, and WFP), Save the Children, Aer changing the height values to their original Medair, MOPH representing Lebanon, AUB, Iraq, Defaulters 9 43 levels and recalculating the prevalence of anthropo- Syria, Geneva, Jordan and the regional office. e Under treatment 7 7 metric indicators, the aggregate GAM for children target audience was UNICEF nutrition focal persons aged 6-59 months from Syria was 2.2%, considerably who had been involved in nutrition assessments lower than the original assessed prevalence of 5.9% and UNICEF immediate counterparts collaborating Table 2: Original and corrected acute (see Table 2). Differences were observed across the malnutrition prevalence amongst in these assessment exercises in Syria, Lebanon, Syrian refugees in Lebanon assessed locations (see Table 3). Iraq and Jordan, particularly the MOH and UNHCR. (2013 assessment) In addition, UNICEF and its partners undertook All attendees were focal persons involved in data Original analysis: Corrected analysis: a nutrition screening campaign in the Beqaa Valley management and will be expected to play a critical prevalence in 2013 prevalence in 2013 in May to June 2014 to identify cases of acute mal- role in ensuring data quality in future assessments. % n % n nutrition and to verify the results of the 2013 e primary purpose of this data quality clinic was to review the data generated to date by a series of GAM 5.9% 81/1384 2.2% 30/1352 nutrition assessment. Of 16,531 children under 5 years screened using MUAC, 828 cases were referred nutrition assessment in response to the Syria crisis, MAM 4.8% 67/1384 1.8% 24/1352 to the PHC facilities for further investigation. is subjecting it to quality checks and updating the SAM 1% 14/1384 0.4% 6/1352 included children whose MUAC was 12.5-13.5cm participants with techniques on data quality verifi- cation. Participants were exposed to the Emergency Oedema 0.4% 6/1384 0.4% 6/1384 since routine screening by Relief International (RI) identified children whose MUAC was normal but Nutrition Assessment (ENA) for SMART soware whose WHZ was not. Referral was made to ensure for data management and data analysis techniques; Table 3: Original and corrected GAM prevalence children were caught as soon as possible. Only 518 for the majority it was their first time using ENA amongst Syria refugees in specific for SMART. During the workshop, a brainstorming locations (2013 assessment) children visited the PHC facilities for further check- up and treatment, of whom 25 children were found gave rise to the recommendations for the way forward Original Corrected to have SAM (5% of referrals) and 77 cases (15% of outlined below. analysis: analysis: prevalence in prevalence in referrals) found to have MAM, based on MUAC. e case for scaled up treatment of acute 2013 2013 When data were classified based on WHZ, the preva- malnutrition Bekaa valley 8.9% 4.5% lence amongst referred cases was 1.8% (6/336) for e corrected GAM prevalence figures, the pro- SAM and 9.5% (32/336) for MAM6. Data on co- Northern Lebanon 6.7% 3.9% gramme admission figures and the 2014 screening morbidity are not available. results confirmed that there was no nutrition crisis South Lebanon 4.3% 0.3% Challenges Beirut/Mount 4.1% 0.5% Issues of data quality 6 Weight and height data was available for a reduced number Lebanon of children due to some discrepancies in measurement. e issue with data quality that has unfolded in There remain challenges in sustaining quality measurement Lebanon around the 2013 nutrition assessment has of height and weight with high staff turnover...... 18 Field Article ......

in Lebanon. On reflection this indicated a need to players in Lebanon). Recommendations for nutrition A nutrition work plan was developed in May 2014 shi attention in the nutrition programme. e programming are as follows: (signed June 2014) with the MOPH and its partners ‘true’ scale of risk of acute malnutrition has proven in an attempt to institutionalise the nutrition pro- to be lower than originally believed and therefore Recommendation 1: Infant and young Child gramme within the MOPH PHC centres and hospitals requires a different approach/programming emphasis feeding with a view to building resilience and a sustainable than that adopted until now. On the positive side, • Strengthen positive IYCF practices (breast capacity in-country. is has involved a number of nutrition programming has helped develop capacity feeding & complementary feeding, including activities: to treat cases of acute malnutrition in country, and awareness raising through community • Establishment of a coordination body (nutrition there are examples of success in individual case mobilisation) sub-working group) in May 2014 to respond to management in this regard. However, we believe • Integrate education and communication nutrition in emergencies. Prior to May 2014, strategies in health centres that through collective effort, we have managed to there was no official coordination body on reach children before developing MAM and SAM. Recommendation 2: Micronutrient nutrition; ad hoc meetings were hosted by Two outstanding challenges are the management of intervention UNICEF to coordinate activities and nutrition acute malnutrition among infants less than 6 months, • Improve dietary diversity through food security was covered as a topic in the health and nutrition especially SAM cases, and management of acute initiatives working group. e MOPH is lead agency with malnutrition among pregnant/lactating women. • Support food fortification as part of the national UNICEF as co-lead, in addition to IOCC and programmes rather that refugee/IDP specific WFP who will co-lead alternatively on a six Micronutrients programmes month basis with UNICEF. UNICEF proposed e prevalence of anaemia in the 2013 assessment • Support supplementation – Vitamin A, iron this co–lead approach to build capacity of was unaffected by data quality issues. e prevalence and folate – in PHC services partners. e group meets every month and of anaemia in children 6-59 months for all Syrian • Support delivery of micronutrient powders reports to the health and nutrition working refugees in Lebanon was 21.0%; children aged 6-23 (MNP) as anaemia is a proxy for other mi- group. months were most affected (31.5%). Regionalised cronutrient deficiencies. UNICEF provides the • Capacity building of doctors, paediatricians, data found the highest prevalence in North Lebanon micronutrient supplements and sprinkles to nurses and community mobilisers. (25.8% amongst 6-59 months, 42.9% amongst 6-23 MOPH, IOCC, RI and others who distribute at • Community based screening and active case months). e total anaemia prevalence for non- the community level aer the child has been finding for acute malnutrition pregnant women of reproductive age (15-49 years) seen by a physician and or PHCs staff • Screening children under 2 years regarding were for all Syrian refugees in Lebanon 26.1%. • Support maternal nutrition through micronu- breastfeeding practice at the PHC and commu- Women who live in Beirut and Mount Lebanon had trient supplementation nity levels. e identified mothers with subopti- the highest prevalence (29.3%). mal feeding practices are supported by lactation Recommendation 3: Treatment of acute specialists who provide one-on-one counselling. Micronutrient provision has been a challenge. malnutrition at minimal scale is component is supported by UNHCR. In Lebanon, no one organisation was willing to un- For ethical reasons, case management should be in • Outpatient management of acute malnutrition. dertake blanket distribution of micronutrient powders place, therefore: is service is integrated within the PHC (MNPs) for children aged 6-59 months except RI • Ensure the capacity, guidelines and minimal centres/facilities of the MOPH. UNICEF is through their mobile medical units. Hence the nu- supplies exist (preparedness) for treatment of supporting IOCC in activating 40 PHC all over trition sub-working group, led by the MOPH, rec- acute malnutrition Lebanon (see article by IOCC in this issue of ommended that MNPs be distributed at PHCs aer • Ensure integration of the nutrition programme Field Exchange). the child is seen by the paediatrician. Pregnant and in PHC facilities (screening and treatment of • Inpatient management of acute malnutrition. lactating women were receiving iron folic acid tablets malnutrition cases) which will allow for Five hospitals have been ‘activated’ to treat through the Medical mobile units and or the PHC sustainability and provide services in both inpatient malnourished children. centres of the MOPH. emergency and non-emergency situations • Supporting IOCC in initiating a clinic based e problems of high pre-crisis prevalence of Recommendation 4: Rigorous monitoring of nutrition surveillance system at the MOPH anaemia and stunting and the risks of increased the situation (screening/surveillance/periodic primary health centres (PHC) centres that prevalence in the crisis were discussed amongst survey) screen, track, monitor and interpret the nutri- UNICEF and the nutrition community involved in • Screening of the refugee population on arrival tional status data of children under five the response. Most recently, this has led to a move • Integrated screening in regular public health years old affected by the crisis. to develop strategies and national protocols for the work (eg EPI campaigns) For more information, contact: Najwa Rizkallah, management of malnutrition and the micronutrient • Facility based screening email: [email protected] supplementation. A dra nutrition strategy has been • Periodic assessment/surveys where there are [email protected] developed and discussed with the technical committee substantial treatment programmes/caseloads that emerged from the nutrition sub-working group. for acute malnutrition (these surveys should is strategy is based on the UNICEF-MOPH work include coverage assessment) or if requested by plan and work with partners. More meetings will country offices take place to finalise the strategy. • Establish a nutrition surveillance system in An infant in an informal collaboration with the MOPH and IOCC. is tented settlement in Saida, Lebanon The way forward is in the early stages of development and will e reviewed and corrected nutrition data from aim to monitor the growth of children and Lebanon shows that there is not a nutrition crisis inform policy-makers on where malnutrition

and the feared decline in nutrition status has not problems exist for taking further actions. 2014 Lebanon N. Rizkalla/UNICEF, materialised. Given this, emphasis on acute malnu- trition treatment can be reduced and more emphasis Recommendation 5: Integrated response placed on prevention of stunting, anaemia prevention Promote an integrated response through delivery and treatment, and improvement in IYCF practices of a minimum package of health and nutrition re- including exclusive breastfeeding. Advocacy will be sponse, including immunisation, disease treatment, necessary to position nutrition as a priority sector in awareness raising, food security, water and sanitation order to sustain the low levels of acute malnutrition. services, shelter, to prevent malnutrition with a focus on the first 1000 days (pregnancy and until Recommendations for nutrition programming the child is 2 years of age) to prevent stunting, were developed at UNICEF regional level together reduce LBW and to improve maternal nutrition with participants at the data quality workshop in Am- • Strengthen coordination and advocacy for man, for UNICEF country offices to adapt as appro- nutrition as a priority sector. e recently priate. In Lebanon, these were shared with the nutrition formed nutrition sub working group and its sub-working group led by the MOPH, which has led respective members has a key role and to modifications to existing dra nutrition strategies responsibility for effective coordination, gap (prepared with the MOPH and other partners including analysis, information flow, strategy development IOCC, RI, WFP, and ACF as the main nutrition and harmonisation, and to foster partnership...... 19 Field Article Paper vouchers ...... in Lebanon

Ekram Mustafa El-Huni is WFP’s Head of Programmes in Beirut, Lebanon. She has worked in a variety of roles with WFP at the headquarters, regional bureau and WFP e-voucher country office levels in both in regular activities and emergencies. She holds a Masters in Development Economics with an programme in emphasis on Food Security and Human Development. The author acknowledges the work of WFP staff and

Lebanon partners, and the support of WFPs generous donors. WFP Laure Chadraoui Laure WFP

Context WFP began delivering food assistance in June 2012, country, while simultaneously addressing many of the deterioration of refugees’ food security status. following an official request from theGovernment the outstanding programmatic issues relating to the e assessment showed that nearly 30% of Syrian of Lebanon in May 2012. e Lebanese High Relief vouchers. households surveyed relied on some type of assistance Commission (HRC), UN High Commissioner for as their main livelihood source; mainly food vouchers Families in need received one e-card that is au- Refugees (UNHCR), local organisations and private (24%). Furthermore, food assistance deters the adop- tomatically uploaded with US$30 worth of credit citizens, who had been assisting Syrians up to that tion of additional negative coping strategies, thereby per person each month. e e-cards can then be re- point, found their capacities challenged to meet the freeing up cash resources to be used for other im- deemed in any of 340 small and medium size shops rising demand. In northern Lebanon, WFP began mediate needs (shelter, health, water, sanitation and spread across the country. e automatic reloading by taking over half of UNHCR’s caseload of some hygiene, education, etc.). On average, a refugee of credit means beneficiaries no longer need to 15,000 refugees and started distributing food vouchers household’s expenditure was US$774 per month; attend large-scale monthly distributions1, thereby to 1,550 refugees in the Bekaa Valley. By May 2014, nearly half of this amount was spent on food. In ad- reducing their transportation costs; the number of WFP’s operations had expanded dramatically, pro- dition, the survey found that the income versus ex- distributions is reduced simply to those who have viding monthly assistance to over 744,000 Syrian penditure gap, caused by limited livelihood oppor- newly arrived. Furthermore, e-cards provide bene- refugees, mainly through the provision of food tunities, rising rent, food and services prices, induced ficiaries with greater purchasing flexibility as they vouchers, and with one-off food parcels for newly greater use of negative coping strategies as the Syrian can purchase by preference and need and make arrived refugees. e e-voucher programme, also crisis becomes more protracted, increasing the fi- multiple purchases throughout the month. In addition, known as the ‘e-card’ programme, is WFP’s primary nancial pressure on vulnerable refugees. e assess- merchants receive their payments more promptly means of providing food assistance to Syrian refugees ment also showed that more and more families were since shops, partners and WFP no longer need to in Lebanon, accounting for over 90% of the monthly taking on debt as households spent their savings manually collect and (re-)count the vouchers before caseload. is article describes WFP’s experiences and sold their remaining assets to meet their basic payment. Since December 2013, the e-card modality in the evolution of what is currently WFP’s largest requirements. has covered the entire country and has been imple- voucher programme worldwide. mented by some of the same extended network of Monitoring Programme implementation cooperating non-governmental organisations (NGO) e VASyR collects information to help understand partners that conducted the paper voucher system. WFP began transitioning from paper food vouchers the scale and nature of vulnerability, e.g. dietary di- e cooperating partner NGOs include the Danish to electronic pre-paid vouchers (e-cards) in September versity, coping strategies, which can then be used to Refugee Council, World Vision International, Pre- 2013. As the caseload of refugees in Lebanon con- re-evaluate targeting criteria. WFP also conducts a miere Urgence-Aide, Medical Internationale, Action tinued to increase exponentially, the printing, dis- range of monitoring activities for the e-voucher Contre la Faim, Save the Children, Mercy Corps tribution and reconciliation of paper vouchers programme including post-distribution monitoring and InterSoS. became a major challenge for WFP and partner (PDM) and price monitoring. PDM of a sample of refugees allows collection of a range of data including staff, absorbing considerable staff time. Abandoning WFP also provides monthly food parcels to vul- percentage of refugees awaiting registration, per- the voucher system was not an option as it had nerable newly arrived refugees awaiting registration. centage of refugees with income sources, food con- made a significant contribution to the Lebanese ese parcels, which contain mixed rations of some sumption based coping strategies (e.g. reducing economy and the approach had proved highly suited 19 different items (including rice, wheat, flour, number of meals per day), timing of voucher re- to the urban context in a middle income country. canned foods, packaged cheese, sugar, tea and coffee, demption, amounts of fresh food purchased and As a result, WFP Lebanon shied to an electronic, etc.), help to cover a family’s food needs for a period percentage of refugees exchanging the voucher for pre-paid voucher system. E-cards were adopted as of one month. Parcels are transferred directly to cash or non-food items (NFIs)2. the primary modality of assistance due to Lebanon’s WFP’s cooperating partners in the field who store inherent ability to meet an increase in consumer and distribute the parcels each month. In addition, Highlights from PDM between January and demand without affecting its current supply lines WFP had a contingency stock of approximately March 2014 included the fact that households were and price levels. is ambitious move ensured that 35,000 food parcels that could be used in case of a eating limited fruit, pulses and vegetables and that the benefits continued to be realised by the host sudden influx of refugees, such as with the Arsal in- households who have been the longest in Lebanon fluxes in November 2013 and February 2014. have better food consumption scores, apply less food consumption based coping strategies but seem Vulnerability assessment to be applying more negative livelihood coping In May and June 2013, WFP, UNHCR and UNICEF strategies in order to cope with the lack of food. e conducted the Vulnerable Assessment of Syrian

Refugees (VASyR), a multi-sectoral annual survey 1

WFP Laure Chadraoui WFP Laure How the paper vouchers operated: Upon registration with aimed at understanding the living conditions and UNHCR, each Syrian refugee was entitled to a paper voucher, vulnerability profiles of Syrian refugees in order to which was distributed by WFP’s cooperating partners at sites guide respective responses. e survey concluded throughout Lebanon. The value of the vouchers was calculated to meet the basic nutritional requirements of that approximately 30% of households could meet refugees, based on the results of long-term monitoring of their basic food and non-food needs. e remaining prices in the country. If a beneficiary registered in the same 70% of households were deemed to be either highly month as the distribution, they were entitled to a half-value or severely vulnerable. Furthermore, the VASyR voucher to hold them over until the next distribution. The found that Syrian refugees were highly reliant on vouchers had to be spent in one go at the WFP contracted shops throughout the country. food assistance as their main food source, and thus 2 In June 2013, 34% of respondents reported exchanging one WFP assistance remained a high priority to prevent or more of their vouchers for cash or non-food items (NFIs)...... 20 Field Article ...... same PDM also reported that sixty eight percent of to provide monthly assistance to some 70% of reg- households used the WFP voucher as their main istered refugees (approximately 1,125,000 individuals) source of income. Close to half of households stated through the provision of e-cards. Inclusion is based that they earned an income (casual or waged labour) on the VASyR 2013 findings and targeting will be as one of their three main source of income. Seventeen further refined based on the results of VASyR 2014. WFP Laure Chadraoui WFP Laure per cent of households reported exchanging their e- WFP closely collaborate with UNRWA (United cards for cash to cover rent, health/medicine and to Nations Relief Works Agency) to provide food as- buy other types of food. sistance to Palestinian Refugees from Syria (PRS). By March 2014, WFP Lebanon had contracted e Needs Assessment for PRS was finalised with 282 shops and $179 million was injected into the WFP’s extensive technical support to UNRWA, in- Lebanese economy from January 2013 to March cluding training enumerators, supervising the col- 2014. Furthermore, aer the transition from paper lection of data, cleaning the databases and advising voucher to e-cards, WFP and its partners were able on the format of the questionnaires. WFP has also to significantly increase their presence at the shop been supporting UNRWA development of solid Preparing a meal level in order to conduct more regular monitoring. monitoring and evaluation tools. UNRWA is taking Food price monitoring takes place in all WFP shops the lead on providing assistance to PRS and already that are involved in the voucher programme. Food provides ATM cards through which cash is withdrawn card. In the report and during follow-up management price reports estimate the value of the WFP food for food and non-food needs. A Memorandum of meetings, it was recommended that WFP’s e-card basket, the total value of a minimum food expenditure Understanding (MoU) was recently signed by UN- platform, inclusive of data management, service de- basket, differences in prices between areas of Lebanon, RWA and WFP to commence the joint food assistance livery and implementation, be used. UNHCR – as and price variability for all commodities that can be to PRS. e activity will be funded jointly and pri- well as various other actors – expressed interest in purchased with the e-voucher. Any impact of WFP’s marily implemented through UNRWA’s existing dis- joining WFP’s e-card platform to form the OneCard activities on local prices is also assessed. tribution mechanism. platform, with a caseload of 12,000 households se- lected by UNHCR being provided with multi- Targeting WFP will also collaborate with the MoSA to sup- purpose unconditional cash assistance. e concept of targeted food assistance is based on plement the targeted social assistance package to responsible programming so that assistance reaches assist vulnerable Lebanese host communities (ap- Challenges and lessons learned those who cannot feed themselves or their families. proximately 36,000) under the National Poverty Security remains a serious concern for WFP opera- It is particularly important to target assistance to Targeting Programme. Assistance to low-income tions. While there have been some delays, suspensions the most vulnerable given the very high funding Lebanese will start in August 2014, in line with and even cancellations of food and voucher distri- needs in the region. WFP along with UNHCR and Track 1 of the Roadmap of Priority Interventions butions, monitoring visits and other activities, WFP UNICEF started targeting assistance in Lebanon in for Stabilisation recently presented by the Government has successfully delivered assistance to its entire October 2013 refocusing assistance on vulnerable of Lebanon (GoL) with the support of the World caseload each month. However, the worsening families. As a result, 70% continued to be assisted Bank and the UN. e aim of this programme is to security situation and the increasing prevalence of monthly with food assistance. One-day workshops reduce inter-community tension and help build na- violence in WFP areas of operations are threatening for WFP and UNHCR field staff were held at the tional capacity, to supplement the GoL’s targeted to disrupt distribution cycles and prevent WFP from onset of the targeting to clarify and agree on the re- social assistance package. e eligibility criteria were reaching all beneficiaries. e prospect of deteriorating ferral mechanism for these urgent cases. In addition, negotiated with the World Bank and MoSA – con- security in the wake of an escalation in conflict in a verification system was put in place for those families sisting of ‘the most extreme poor’ using Proxy means Syria, or due to any escalation in sectarianism within who stopped receiving WFP food assistance but Test (PMT) criteria3, which will be further refined Lebanon, remains a genuine concern. It appears who appealed the decision. Families living above to include standard food security indicators once refugees are increasingly mobile within Lebanon, 500 metres were also automatically verified even if the project starts. either as a result of eviction, searching for better they did not appeal. shelter or jobs or joining other family members. WFP and partners will intensify monitoring and Some reports also indicate that some refugees may e verification consisted of a household visit to verification activities in the coming year to ensure have returned to Syria. ese unrecorded movements assess the socio-economic and food security that all those in need of assistance continue to of population within Lebanon can make the analysis status. A total of around 31,000 families have been receive support. Verification activities may be further of gaps and impact of assistance more challenging visited (over 97% of all planned visits) and of intensified as banking/transaction reports are better for WFP. these, 23% (over 7,000 families) have been re-in- utilised and as a revised shop strategy is implemented cluded for assistance. WFP, working closely with (see below). WFP will also intensify sensitization e rapidly increasing number of refugees and UNHCR and other partners, conducts regular out- efforts with beneficiaries to inform them of the ad- the expectation of continuing conflict in Syria will reach and verification visits throughout Lebanon to vantages of the e-cards.).WFP will continue to assist lead to growing financial requirements for the op- check that families who need the assistance are re- newcomers and refugees pending registration through eration. As e-cards are pre-paid, WFP is now required ceiving it. WFP has also been reviewing cases referred the one-off food parcel programme. Furthermore, to have the necessary cash in their accounts at the by UNHCR, believed to be vulnerable. In May 2014, WFP and partners have placed significant emphasis beginning of each cycle. on enhancing the capacities of the government in- 159 cases were referred by UNHCR and 51 of them WFP is constantly seeking out new and reliable stitutions most impacted by the refugee influx. were deemed valid. is interim exercise will be in partner shops that can adequately provide for the place until a new comprehensive targeting and rough its cooperating partners, WFP achieved needs of beneficiaries. Finding such shops in areas review system, currently being developed by WFP 94% of its operational plan for May 2014 reaching close to refugee concentrations continues to be a and UNHCR through the inter-agency Targeting over 744,000 beneficiaries through e-cards and food challenge. In order to respond to the changing Task Force, is implemented (target date not yet con- parcels. Of this figure, the majority of beneficiaries context and increased needs, WFP Lebanon is pro- firmed). (96%) were reached through the e-card modality. posing to send out an expression of interest to all rough the technical expertise of the partner bank, vendors interested in participating in the e-card Developments and plans for 2014 WFP has been analysing spending patterns of its programme and who meet the minimum criteria. Already severely economically impacted by the con- beneficiaries over time, using data collected from is strategy is in response to stakeholders request flict, Lebanon now officially hosts over one million shop interviews and household visits. Research for a transparent process which gives equal oppor- refugees. It is expected that this number will keep shows that most households use the entire value of tunities to all retailers and is clear on the requirement increasing in 2014 to over 1.6 million, most of the e-card at once to buy dry goods and staple of participating in the process. whom are anticipated to need humanitarian assistance. items, and use other sources of cash to buy additional WFP Lebanon is working on integrating moni- In addition, it is anticipated that 1.5 million affected items throughout the month as necessary. Lebanese will need assistance, as well as tens of toring data from the bank to traditional monitoring thousands of Palestinian Refugees from Syria (PRS). An independent consultancy firm reviewed the WFP began to expand its food assistance in 2014 cash transfer programming’s operational set-up in 3 Proxy means tests generate a score for applicant households with the overall objective to ensure that food security Lebanon and a report was presented with the results based on fairly easy to observe characteristics of the household such as the location and quality of its dwelling demographic and livelihood opportunities are provided to vul- including a set of suggested options on sharing a structure of the household, education and occupations of adult nerable Lebanese and PRS, in addition to vulnerable common OneCard platform, which would see several members. The indicators used in calculating this score and Syrian refugees. By the end of 2014, WFP is planning agencies providing assistance via a single electronic their weights are derived from statistical analysis ...... 21 Field Article ...... A Syrian mother from Homs, Syria bakes bread outside her shelter in activities in order to better monitor the cash and voucher pro- Turbide, Bekaa, Lebanon gramme. WFP receives transaction data from the bank at the shop’s level. is allows sub-offices to implement tighter

controls over WFP shops by looking at monthly redemption Addario/UNHCR scores, transaction densities, and transactions outside business hours. is has led WFP to also engage in discussions with the financial service providers on how to impose anti-fraud measures at their level. For example, WFP is able to monitor shop transactions almost in real time and to freeze the POS machine as soon as a threshold of US$36,000 is reached in some sensitive (insecure) areas in Lebanon. Every month, sub-offices receive data from the bank on e-cards that have Characteristics and either not been distributed or used. WFP sub-offices conduct follow-up phone calls to these beneficiaries to inquire why they have not collected their e-cards or why they have not redeemed challenges of the the full value of their entitlement. Based on these results, WFP is able to adjust its programming (information, location of the shop…) and ensure that the most vulnerable have access to health sector food assistance. Monitoring and evaluating a project with such a vast response in Lebanon caseload remains a considerable challenge. With 340 shops, eleven cooperating partners, two food parcels suppliers and a beneficiary list dispersed throughout the country, monitoring By Frank Tyler activities have proven to be a difficult task, even without the added obstacle of insecurity in many areas. Monitoring Frank Tyler was Senior Public Health Coordinator in the Inter- highlights that beneficiaries do not always know their rights agency Coordination Unit, UNHCR Lebanon from January to with regard to shop owners and there has been a few issues October 2014. He is a humanitarian and public health specialist with shop keepers keeping e-cards at the shop to force benefi- with over twenty years’ experience implementing relief ciaries to come back and redeem in their shops. On a positive programmes. Areas of expertise include public health, disaster note, monitoring results show that just as many female and management, disaster risk reduction, and training design and male are redeeming the e-card and therefore the assistance is delivery. not generating any gender imbalance at the household level. Many thanks to all Lebanon health sector stakeholders that contributed to the Lebanon As the number of Syrian refugees continues to significantly health chapters of the Multi Sector Needs Analysis (MSNA) and the regional resilience rise, tensions between host communities and refugees are and response plan, which in part are summarised and referenced throughout. growing. Local communities are feeling the strain of this major influx, impacting shelter, food and job opportunities. Furthermore, most of the international support is going to Syrian refugees when there are vulnerable Lebanese in need of assistance too; this is why WFP is now working in close col- A Multi Sector Needs Assessment (MSNA) was conducted in 2014 by a laboration with the Ministry of Social Affairs and the World team of UN agencies and NGOs and the findings shared by sectors in the Bank to provide needed food assistance to the most extremely form of chapters. e MSNA team aimed to provide an objective overview poor Lebanese to mitigate the impact of the Syrian crisis. of the available data and Sector Working Group (SWG) views. It involved Conclusions identification of information needs, secondary data collation, data e provision of the voucher modality as compared to in- categorisation, together with consultation with sector working groups. is kind has given the beneficiary increasing dignity, flexibility, article shares some of the key observations and recommendations emerging from this review which are documented in the MSNA Health Chapter1. It

and choice in purchasing food at WFP-selected shops. e Article Field shi from voucher to e-cards has reduced the distribution re- also draws on findings from a subsequent health access and utilisation quirements and reduced protection incidents linked to the survey by UNHCR in July 20142. distribution process. It has freed up partners and WFP staff to monitor the implementation of the project, to better address problems of fraud, and most importantly, ensure that the The context most vulnerable and hungry are receiving the food assistance During the past two and a half years, e Lebanese healthcare system is that they need. Lebanon has experienced an unprece- dominated by the private sector which e choice of how WFP delivers assistance, whether by dented influx of refugees from Syria is geared towards hospital-based curative cash, vouchers, or food is made aer numerous assessments numbering over 1 million and projected care (48% of total public health expen- to determine which approach the most appropriate is, given to rise to 1.5 million. As of March 2014, diture) rather than primary and preven- the context. Cash is not necessarily a simpler or cheaper way Lebanon reached its 2050 projected pop- tive health measures. e refugee crisis of providing assistance. WFP chose to provide assistance ulation figure (4.6 million) and this will has exposed the fragile nature of the through vouchers following consultation with partners (especially continue to increase over the next year. pre-existing public health system where the Government) and carrying out financial infrastructure as- e population surge has put severe 50% of the Lebanese population have sessments. However, WFP is constantly re-assessing the strain on finite resources, the already no formal health insurance, are exposed situation, and WFP do not rule out a move to cash if it were to over stretched public services and the to very high health care expenditures be more appropriate. In this regard, WFP in Lebanon and capacities of authorities at central and and lack basic means of social protection Jordan will start a cash assistance pilot which will better local levels. is strain is keenly felt in such as pensions and unemployment in- inform our programming. e pilot will involve Syrian families, the health sector. e World Bank esti- surance. A struggle over access to public who are existing beneficiaries and will be allowed to use e- mates that USD 1.5 billion (3.4% of services that has seen a 40% increase in cards to withdraw cash from an ATM or will have the option Lebanon‘s GDP) will be needed to restore use (MoSA), is a key driver of increased to either withdraw cash from an ATM or continue using a services to pre-crisis levels, of which point-of-sale (POS) terminal for a period of six months. An USD 177 million is for health services 1 MSNA Health Chapter. Available at: external evaluation company will assist WFP with the study alone. e Ministry of Social Affairs http://reliefweb.int/report/lebanon/msna- (MoSA) and Ministry of Public Health sector-chapters-health from the inception, through to implementation and follow- 2 Health access and utilisation survey among up stages. (MoPH) report an average 40% increase non-camp Syrian refugees. Lebanon, July 2014. in the use of their services with ranges http://data.unhcr.org/syrianrefugees/ For more information, contact: of between 20-60% across the country. download. php?id=7111 Ekram El-Huni, [email protected] ...... 22 Field Article ......

tensions between host communities and the refugee population. Lebanese without private medical in- Box 1 Services covered by UNHCR and partners surance rely upon the MoPH and the National Social Security Fund to reimburse a portion of their medical • Consultation fees for primary healthcare services at UNHCR designated facilities are between 3-5,000 Lebanese Pounds (USD 2 to 3.3); the remainder of the cost is covered by UNHCR and other health partners. bills. ose on low incomes must oen choose • All routine childhood vaccinations are free for children <12 years. between paying for health and for other necessities • Medications for acute illness are free for all refugees at Ministry of Public Health (MOPH) and Ministry of Social including food. According to the World Bank, the Affairs (MOSA) linked clinics. Lebanese social security systems, including health, • For chronic medications, a handling fee of LP 1000 (USD 0.67) is paid by refugees for each refill of prescriptions. are “weak, fragmented and poorly targeted”. • Family planning services including pills, condoms, insertion of IUDs are provided for free. • Dental care is subsidised through designated primary healthcare centres. Challenges in coordination • For lab and diagnostic tests, UNHCR covers up to 85% of costs for children <5 years old, seniors ≥60 years, and e political landscape in Lebanon is dynamic. e pregnant women; the remaining 15% is paid by the patient or other agencies. In certain instances involving unstable administration and the political divides in refugees with special needs, the proportion paid by UNHCR and UNHCR partners can be increased to 90%. the Lebanese government meant there was a lack of • UNHCR pays up to 75% of the total cost of hospital services only if admission is for life-saving emergency an effective, rapid and strategic response to the healthcare, obstetric and neonatal care. Refugees and/or other agencies are expected to pay the remaining 25% refugee crisis. is vacuum with regard to the re- of the cost. If expensive care (≥ USD 1500) is needed, treatment is first approved by an Exceptional Care sponsibilities and accountabilities of government ac- Committee. The committee considers the need for, and adequacy of, the suggested treatment, the cost and tors, particularly at national level, resulted in the the need for financial assistance, and feasibility of the treatment plan and prognosis. municipalities playing a greater role in responding Source: Health access and utilisation survey among non-camp Syrian refugees. Lebanon, July 2014 to and coordinating the crisis. ere is no national administrative or legal framework for the management country. Services covered by UNHCR and partners severity of health conditions such as NCDs and of refugee affairs and the response to the refugee are summarised in Box 1. In addition, some health mental health issues across target groups, lack of crisis must be coordinated across a number of Min- partners provide free access for Syrians to primary information on utilisation rates of hospitals and re- istries. e central authority is weak, and with health care services. sponse capacity in terms of quality of health serves, refugees scattered across the country, all activities availability of medications, and lack of data on how on their behalf have to be carefully negotiated with e country has more than 950 dispensaries (offer- social determinants of health (e.g. education, shelter local religious leaders and municipal representatives. ing limited services) and primary healthcare (PHC) housing) are linked to the health status. Recom- Communities across Lebanon are largely confessional centres (providing a range of services of variable mendations on health emerging from the MSNA based and the same groups fighting each other within quality). e MoPH has chosen 193 PHC centres to included: Syria are also present in Lebanon. All humanitarian establish a primary healthcare network, of which • To strengthen disease surveillance (EWARN), efforts therefore have to carefully navigate a compli- more than 70% belong to non-governmental organi- and the Health Information Monitoring cated web of oen competing political agendas so as sations (NGOs); many were established pre-crisis to Systems of UNHCR and the MoPH. to ensure the real and perceived impartiality of the fill shortfalls in the public health system. Less than • To establish a national population based health humanitarian response to ensure access and security 10% belong to the public sector (MoPH or MoSA). survey. is could be an expanded version of of staff. e predominance of the private healthcare Public secondary and tertiary healthcare institutions the UNHCR household assessment and utiliza- sector provides a unique situation compared to other in Lebanon are semi-autonomous and referral care is tion survey to provide a health and wellbeing 4. Not all adhere strictly to the MOPH flat humanitarian situations and hampers effective co- expensive profile of Syrian refugees and vulnerable host rate for hospital care. To harmonise access to secondary ordination of health services for refugee populations. communities. is is planned for January 2015. healthcare and manage costs, UNHCR has put in Under these circumstances, the UN System and place referral guidelines in Lebanon5. Communicable diseases the international community involved in the hu- e top five communicable diseases/conditions are Heath sector issues of relevance to manitarian response established a mechanism to viral hepatitis A, mumps, dysentery, measles, and support government efforts in ensuring basic access nutrition typhoid (EWARN system, October 2014).6 To date, to protection and assistance to the increasing number In terms of nutrition and health, key considerations and to the credit of the humanitarian effort, disease of Syrian refugees in Lebanon. UNHCR, in line are communicable disease (linked to a potential outbreaks have been largely prevented. However, with its mandated responsibilities, is the designated acute malnutrition risk), the prevalence and incidence measles and increased risk of epidemics such polio, UN lead agency for the response to the Syrian of nutrition-related non-communicable disease and waterborne diseases remain. Data on immuni- refugee crisis and is ultimately accountable for the (NCDs) (nutritional factors related to aetiology sation and coverage rates in Lebanon prior to the well-being of the refugees. UNHCR supports the and/or management), reproductive health (influencing crisis is of variable quality. Access to vaccination Government in addressing existing gaps, and plays neonatal nutrition status and feeding modality), and access to primary health care services (support a lead role in coordinating the response to the Syrian 3 on breastfeeding, infant and young child feeding). Dedicated coordinators lead working groups on protection, crisis with other UN agencies, NGO partners, donors education, shelter, WASH (water, sanitation and hygiene), and local stakeholders3. Also healthcare costs may impact on household ex- health, food security, core relief items and social cohesion and penditure on food. livelihoods. All sectors are co-led with other UN agencies: e UNHCR Mission in Lebanon was in operation education and WASH with UNICEF, health with WHO, social Health information and data cohesion and livelihoods with UNDP, and food security is led with approximately 70 staff at the beginning of the by WFP. OCHA, UNDP, UNRWA and IOM are also active in the Syrian crisis in May 2011, mainly catering for Iraqi Sources of health data are summarised in Box 2. country and participate in the coordination structure. Correct and Sudanese refugees. Entering its fourth year in ere are significant information gaps on health; as of September 2014. 4 the Syrian crisis, UNHCR now have more than 600 the MSNA in March 2013 noted gaps in real time/up Syrian refugees in Lebanon. Secondary and tertiary health to date data for specific geographical areas (reporting care at a glance. January -June 2014 staff throughout Lebanon supporting 1,154,580 reg- 5 See footnote 4. istered refugees and almost as many vulnerable host is done on a national level with a time-lag of a few 6 Republic of Lebanon Ministry of Public Health Notifiable populations. e UNHCR co-leads the health sector months), limited information on the prevalence and Communicable Diseases response with WHO. e health sector facilitates planning and strategy development, undertakes Box 2 Sources of health information and data on Syrian refugees in Lebanon health assessments and analysis of needs, coordinates programme implementation, provides direct moni- The three major national sources of health data and information in Lebanon are the UNHCR Health Information toring, evaluation and reporting, and provides ad- System (HIS), the Early Warning and Response Network (EWARN) and the GoL health monitoring system. vocacy and resource mobilisation for refugees and • The Early Warning and Response Network (EWARN) was established in 2007 by the MoPH, with support from host communities. the World Health Organization. This network monitors the number of persons affected by communicable disease across the country; it does not disaggregate by demographic groups as identified in the RRP. Health service provision • The MoPH operates its own system of routine health surveillance on communicable diseases, which sources UNHCR’s public health approach is based on a pri- information from hospitals and primary healthcare centres. mary healthcare strategy. e Lebanese government • UNHCR and six key partner agencies operate a refugee Health Information System (HIS) which covers a range and UNHCR in collaboration with partners provide of health conditions of Syrian refugees in selected PHC centres. Reports are on a monthly basis from areas healthcare services to Syrian refugees in Lebanon. across Lebanon. An annual report is produced. In the highly privatised/fee charging health system Data on communicable diseases is provided by all three sources. Data and information regarding the magnitude context, refugees can receive care for free or at a and prevalence of NCDs and chronic conditions among refugees are provided by the UNHCR HIS. Information on subsidised cost at designated facilities across the NCDs among other vulnerable groups is limited...... 23 Field Article ...... services have improved but vaccination coverage (53.9%), used household income (39.4%), and/or the MoPH in assessing and improving alternative for measles and polio remains lower than the herd relied on relatives or friends for payment (27.8%). modalities for deliveries with a community based immunity threshold needed (90%)7. Deteriorating focus, with a view to decreasing the utilisation of Referral for secondary and tertiary medical care is WASH conditions in informal settlements pose high cost referral care and the medicalisation of expensive. According to UNHCR analysis16, the esti- serious health risks for the spread of communicable normal deliveries for the target population. e health mated total hospital bill for January to June 2014 was diseases8. According to the UNHCR HIS annual sector also supports the MoPH to reduce unnecessary USD17.5 million. e estimated share of the cost for survey 2013 (preliminary annual health report), referrals from PHC centres to reduce costs and UNHCR was 13.1 million (75%). e estimated an- consultations for acute illness were the primary improve efficiencies. Alternative solutions, such as nualised per capita hospital cost was USD37 per reg- reason for accessing healthcare, accounting for 74% strong advocacy for task shiing to allow a broader istered refugee. Approximately 48% of referrals were of clinic visits. e same survey found that approx- range of services that can be offered at the PHC level for obstetric care, followed respiratory infections (8%), imately 38% of visits for 33 acute illnesses were by through PHC centres of excellence, the necessity of gastrointestinal conditions (7%) and trauma and other children younger than five years (19% of population). direct international procurement of medical supplies, injuries (7%). Deliveries (births) account for 92% ob- Assessments in Beirut and its suburbs have found and allowance for foreign healthcare staff to work stetric admissions (92%); the caesarean section rate that 65% of Syrian refugee patients suffer acute within Lebanon will continue to be explored within among refugees reduced from 35% to 32%17. illness, the most common being respiratory tract the MoPHs health plan. A major barrier to overcome 9 infections and skin infections . e health needs The future is accessing the data on utilisation rates, which is among elderly Syrian refugees are particularly acute e longer term goal of the health sector’s response deemed financially sensitive in Lebanon. 10 with limited access to care and medications . is to deliver cost effective initiatives that reduce c) Disease control and outbreak prevention mortality and morbidity of preventable and treatable Non-communicable diseases Strong focus is being placed on ensuring disease illnesses and priority NCDs and, to control outbreaks e demographic and disease profile of Syrian control measures and that outbreak prevention is of infectious diseases of epidemic potential. e refugees is that of a middle-income country, char- not only integrated within all outcomes of the health healthcare sector is exploring innovative healthcare acterised by a high proportion of chronic or non- sector strategy, but is also a stand-alone outcome. delivery and financing models to ensure access to communicable diseases (e.g. diabetes, cancer, car- Disease does not recognise borders or differing quality essential healthcare for the targeted population. diovascular and respiratory disease). Pre-crisis, 45% groups within the population. Infectious diseases As part of two year regional planning, a resilience of all deaths in Syria were attributed to cardiovascular in Lebanon of epidemic potential will be a threat to 11 component is bringing together a more aligned diseases (CVDs) , half of 45–65 year old women both Lebanese and refugees. Resources are devoted focus with development actors and funders. For ex- had hypertension, and 15% of older men and women to institutional strengthening of the MoPH at the ample, the MoPH is being funded by the World had ischemic heart disease. Type II diabetes was national and local levels. e MOPH health sur- 12 Bank in the Lebanon Road Map Plan. New initiatives, common (15% prevalence) . In Lebanon, in line veillance system and Disease Early Warning System such as the Instrument for Stability – Strengthening with rising population numbers, the incidence of (EWARS) continue to be supported for expansion Health Care in Lebanon18 are being established by various NCDs (cardiovascular, diabetes and hyper- and improvement. In addition, response plans and the GoL in collaboration with UN agencies and the tension) has risen; amongst older refugees, the capacities are being further developed, particularly European Union to address tensions around access prevalence of chronic diseases such as hypertension, at the local level and in areas designated as having 13 to healthcare between Syrian refugees and host com- diabetes, and cardiovascular diseases is high . higher levels of risk of outbreaks. munities in some areas. Additional priority health A UNHCR survey in July 2014 found that 14.6% sector considerations centre on: Greater effort is being provided to ensure full of households had at least one chronic condition coverage of routine vaccinations and appropriate 14 a) Primary healthcare amongst ≥18 years . e proportion varied by age, vaccination campaigns are conducted where vaccine Healthcare is prioritised at the PHC level with increasing from 4.5% among 18 to 29 year olds to preventable disease risk is particularly high. Efforts emphasis on the quality of care, with a shi in focus 46.6% for household members who were 60 years to ensure cold chain logistics and management are from parallel healthcare services to providing inten- or older. e main reported chronic conditions were maintained will be reinforced to obtain greater im- sified support through the expanding MOPH PHC hypertension (25.4%), diabetes (17.6%), other car- munisation coverage which is of benefit to the entire network. e PHC network of centres of excellence diovascular disease (19.7%), lung disease (10.3%) population. and ischaemic heart disease (6.2%). will be supported to provide more comprehensive services for expanded numbers of patients with im- Conclusions Health care access provements in quality of care, availability of resources, e complex and highly privatised healthcare system A UNHCR household health access and utilisation number and quality of staff, minimum packages of in Lebanon in itself provides a major barrier to (HAUS) telephone survey of 560 refugee households services, community healthcare at the nursing educator ensuring accessible, affordable and quality healthcare was conducted in July 201415. It found an estimated level, community-based awareness for better health services, not only to the refugees but also host com- 12.1% of refugees needed health care services in the seeking behaviour, investing in performance standards munities supporting them. If the health response month before the survey and a majority (73.2%) and longer opening hours. is will benefit both budget is not achieved, this will greatly affect which were able to seek care mostly through a govern- refugees and the host population. e approach in- groups can be covered by the response20. It would ment-affiliated PHC facility (24.9%), private facilities volves engagement with local civil society groups mean focusing entirely on ensuring access to the (21.9%), NGO-operated PHC centres (15.2%), gov- and facilities of the MoSA that work within the most vulnerable and emergency care only. e ability ernment hospitals (8.3%), traditional or religious network and with private health care providers. of the health actors to provide financial support to healer (2.3%) and mobile clinics (0.2%). However, refugees to access health care services would have to over half (56.1%) of Syrian refugees with chronic b) Hospital care be revised, exposing refugees to increased healthcare conditions were unable to get access to care. e Referral healthcare to secondary and tertiary services costs and rates of disease and illness. e health main reasons were inability to afford fees (78.9%), continues to need improved support to cope with actors will need to maintain strong advocacy positions long wait at the clinic (13.3%), and not knowing limited government finance and additional utilisation supporting the Government of Lebanon with respect where to go (11.6%). e HAUS 2013 found broad of Syrian refugees. e national referral system to advantageous legal and political solutions that will improvement in level of knowledge about available presents a number of challenges in terms of its allow for improved healthcare services and reduced healthcare services, such as vaccination, prescription approach to refugees entering into the system. Delivery financial demands on the response. procedures and costs of medications for acute and care and its complications (obstetrics) account for chronic conditions. However, overall the level of nearly 48% of referral healthcare utilisation of Syrian For more information, contact: UNHCR Lebanon, knowledge about available health services was low. refugees19. e health sector will continue to support email: [email protected]

Healthcare costs 7 See footnote 2. European Union, 7th Framework programme. According to the HAUS survey, refugees who needed 8 See footnote 1. 13 Forgotten voices. An insight into older persons among care spent an average of USD 90 in the month pre- 9 Health Information System 2013 refugees from Syria in Lebanon. Caritas Lebanon. This report ceding the survey. at is equivalent to an estimated 10 Chahada N, Sayah H, Strong J Varady C (2013), Forgotten is summarised in this edition of Field Exchange. Voices: An insight into older persons among refugees from 14 See footnote 2. expenditure of USD 12.1 million over 1 month by Syria in Lebanon, Caritas Lebanon Migrant Center. 15 See footnote 2. all refugees in the country. e main areas of expen- 11 Maziak W, Rastamb S, Mzayekc F, Warda K, Eissenbergd T, Keile 16 See footnote 4. diture were services and treatment at outpatient and U (2007) Cardiovascular health among adults in Syria: a model 17 See footnote 4. inpatient centres (52.5%), outside facilities for medicine from developing countries‘. Annals of Epidemiology. 17(9): 18 http://www.emro.who.int/lbn/lebanon-news/improving- and supplies used for treatment (29.0%), transport 713–720 health-care-services-in-lebanon-in-the-context-of-the-syrian- 12 MEDCHAMP (2011) Project Title: Mediterranean studies of crisis.html (8.2%) and self-treatment (3.5%). To cope with the Cardiovascular disease and Hyperglycaemia: analytical 19 See footnote 4. healthcare expenditure, refugees borrowed money Modelling of Population Socio-economic transitions. 20 See footnote ...... 24 Field Article ......

Background Since the outbreak of hostilities in Syria in early arm circumference (MUAC) measurement. Infant

J Dumont/WFP, Lebanon J Dumont/WFP, 2012, there has been a massive influx of refugees and young child feeding (IYCF) practices were into Lebanon. By the end of July 2014, the official assessed for 618 children under two years of age UNHCR figure for registered Syrian refugees had (6 – 23 months). risen to 1,110,863 individuals, not including thou- sands of Lebanese returnees and Palestinians VASyR 2014 refugees from Syria (PRS).1 Lebanon shares the The main objective of the 2014 VASyR was to biggest burden in terms of the influx of refugees, provide a multi-sectorial overview of the vulner- hosting 38% of Syrian refugees in the region. In ability situation of Syrian refugees in Lebanon Lebanon, one in five people is now a Syrian one year aer the original 2013 VASyR. e study refugee. (For comparison, the 2010 pre-crisis pop- analysed the main changes in the Syrian refugees’ ulation in Lebanon was estimated to be approxi- living conditions compared to 2013, taking into mately 4.2 million.) e sudden increase in the consideration the major factors affecting any assistance required, together with increasingly change and recommends steps forward. e limited resources, required the humanitarian com- target population was Syrian refugees in Lebanon munity to focus efforts on optimising the cost- registered and awaiting registration by UNHCR, effectiveness of assistance. considering those included and excluded for as- Rama, a 7-year-old Syrian refugee girl who now sistance. It took place exactly one year later lives in Mount Lebanon. Through WFP’s e-cards, To improve knowledge of the living conditions (May/June 2014), to ensure comparability. Rama can eat fresh vegetables and fruits. of Syrian refugees, and to inform decision-making and the redesign of programmes, UNHCR, For the VASyR, there is a variation in the pop- UNICEF and WFP agreed to conduct a joint ulation stratification. e sample was stratified household survey of the registered and pre-regis- geographically, using five regions and taking into tered Syrian refugee population in Lebanon. e consideration governorate administrative bound- WFP assessment was designed so that accurate, multi- aries, operational areas and numbers of Syrian sectorial vulnerability criteria could be derived refugees registered in each region. is approach for the implementation of humanitarian assistance. allowed for information to be collected at ad- experiences of A concept note for the Vulnerability Assessment ministrative and operational levels so that it may of Syrian Refugees (VASyR), complete with the be used for decision making and to maintain methodology and a multi-sectoral questionnaire, consistency with the UNHCR-led sixth Regional vulnerability was agreed upon by the United Nations (UN) Refugee Response Plan (RRP6) for Lebanon. e and Government of Lebanon (GoL) partners, and sample of 1,750 households (350 per strata) is was shared and discussed with stakeholders representative of each of these stratums and fol- assessment of through regular multi-agency and multi-sectoral lowed a two-stage cluster random sampling meetings and workshops. e first VASyR was methodology. Syrian refugees conducted in 2013 and the second one in 2014. VASyR 2013: Key findings on nutrition e article considers two aspects of the VASyR: and food security a) A description of the approach and Food security and coping strategies in Lebanon methodology, how this has evolved in Nearly 70% of the households had some degree response to the Syria crisis situation in of food insecurity, with the majority falling under Lebanon, and lessons learned from the mild food insecurity classification. Some 12% households were classified as moderately or severely By Susana Moreno Romero implementation. b) Findings r elevant to food security and food insecure. Food insecurity seemed to decrease nutrition from the 2013 and 2014 VASYR with the length of stay in Lebanon. Most households showed acceptable food consumption and dietary Susana Moreno Romero is the Food Security VASyR methods diversity however there was a risk of a micronutrient Specialist and responsible of the VAM VASyR 2013 deficiency. Nearly half of the sampled refugees (Vulnerability Analysis and Mapping) team in More than 1,400 Syrian refugee households were WFP Lebanon since 2013, from where she has interviewed in May and June 2013, following: 1) Box 1 Food security classification coordinated the 2013 and 2014 VASyR amongst a two-stage cluster random sampling proportional other assessments in country. She has worked as to population size, and 2) a stratified sample ac- The formula used provides a score that reflects a food security and nutrition analyst in Rome cording to registration date: awaiting registration, two key dimensions of food security: the actual WFP HQ, South Sudan, Bolivia, Sierra Leone, registered between zero and three months, regis- status of the households (particularly, in the short Niger and Argentina with WFP, INGOs and tered from three to six months, and registered term), for which the food consumption score governmental institutions. She holds a PhD in for more than six months. A total of 350 households (FCS) is the key indicator, and the forward looking nutritional anthropology. in each stratum were interviewed. perspective/access to long-term food security, which is measured through food expenditure The author would like to highlight that other Sector-specific criteria were discussed and share and the coping strategies. contributors to the article, providing extensive agreed upon at the sector working group level The three factors considered (FCS, food analysis support, include Catherine Said and (water, sanitation and hygiene (WASH), education, expenditure share and coping strategies) are Mazen Makarem from the VAM team in WFP food security, protection, and economic), or converted in a 4-point scale and the score is the Lebanon. through internal discussions (shelter, health, non- result of an average of points assigned to each food items (NFIs)). According to the criteria factor. Based on this, households were classified The author extends thanks to all Syrian refugees, agreed by the eight sectors, households were clas- into four food security categories: food secure, mildly food insecure, moderately food insecure stakeholders and field monitors that have sified under four categories of vulnerability: severe, and severely food insecure. participated in and made possible the 2013 and high, mild and low. e classification of households 2014 VASyR. Partners involved in 2013 and/or according to their food security situation is based The full method known as CARI (Consolidated 2014 VASyR included ACF, ACTED, Care, HI, on a composite indicator that considers food con- Approach for Reporting Indicators on Food 2 Intersos, Mercy Corps, MPLP, NRC, REACH, sumption, food expenditure share and coping Security) is available in: 2013 VASYR report . Shield, SI, UNHCR, UNICEF and World Vision. strategies (see Box 1). In addition, extensive data were collected on the health and nutritional status 1 UNHCR Lebanon Portal: http://data.unhcr.org/syrianrefugees/ of 1,690 children between six and 59 months country.php?id=122 (52% males; 48% females) including mid upper 2 http://54.225.218.247/wfp/documents/Lebanon/VASyR.pdf ...... 25 Field Article ......

years were reported as being sick during the 2 weeks prior to the survey. e most common symptoms were fever (51%), cough (45%) and diarrhoea (35%); 14% of the children who were sick had other symp- toms including allergies, infections, asthma or measles. Approximately 48% of children were reported J Dumont/WFP, Lebanon J Dumont/WFP, to be sick with more than two symptoms. Children under 2 years old were significantly more likely to be sick, mainly due to diarrhoea and fever.

Ahmad (in yellow) and his IYCF practices continued to be poor, much like friends with donated dates 2013, with the meal frequency and diet diversity distributed by WFP in Bekaa being the main limiting factors. e minimum ac- ceptable diet was met by 4% of children aged between 6 and 23 months. Half of the children in this age had applied coping strategies in the previous month; frequency and 85% of the children surveyed did range were breastfed, 63% received complementary around 90% applied coping strategies related to not meet the minimum dietary diversity require- feeding, 18% had the minimum acceptable meal their food consumption. e most common food- ments the day prior to the survey. frequency and 18% had the minimum diet diversity related coping strategies were: • Only 5% of children under the age of two of four food groups. Similar to 2013, the most con- 1. Relying on less preferred or inexpensive food consumed vitamin A rich fruits and vegetables sumed food groups for children were cereals and (89% of households) and meat or fish. e food groups most con- tubers (56%), dairy products (54%) and eggs (26%). 2. Reducing the number of meals and portions sumed by children were dairy products (54%), e risk of micronutrient deficiencies continues to sizes per day (69% of households) grains, roots and tubers (46%), followed by fruits be an issue due to the low consumption of Vitamin A 3. Reducing portion size of meals (65% of and vegetables not rich in Vitamin A (26%) and rich vegetables and fruits and meat and fish that were households) eggs (24%). is child food consumption pattern consumed by 9% and 6% of children, respectively. 4. Restricting women or adult’s food consumption so inferred a risk of micronutrient deficiencies. How VASyR 2014 will inform programming that children may eat (8% and 49% respectively) How VASyR 2013 informed programming e 2014 VASyR is being used as a basis to refine Most of the refugees surveyed relied on the assistance e 2013 VASyR was used as a basis to determine the level of vulnerability in the population and of friends, family or humanitarian organisations to the level of vulnerability in the population and in- further inform targeted assistance interventions. meet their basic needs. Adult food consumption pat- formed targeted assistance interventions. WFP along VASyR results have also been the key source of in- terns implied a risk of micronutrient deficiencies. with UNHCR started targeting assistance in Lebanon formation on refugees’ household living conditions, in during September and October 2013 refocusing for the Regional Refugee Resilience Plan 2015-16, Health and nutrition of children assistance on vulnerable families. As a result, 70% which is currently under discussion. At the same Almost half of the surveyed children under the age of registered Syrian refugees continued to be assisted time, the regional multi-sectorial vulnerability profile of five years (45%) were reported as having been monthly with food assistance from WFP, as well as provided by the VASyR allows activities and objectives sick during the two weeks prior to the survey. e baby and hygiene kit assistance from UNHCR. within sectors to be prioritised. most common symptoms were fever (63%), coughing (51%) and diarrhoea (35%), while 19% of the sick VASyR 2014: Key findings on nutrition and Evolution of the VASyR children showed other symptoms like allergies, in- food security Context of the VASyR assessments fections, asthma and measles. Children under two Food security and coping strategies Since the 2013 VASyR took place in May/June 2013, were significantly more likely to be sick, including a According to the 2014 VASyR, 13% of Syrian refugees the context in Lebanon and the situation of Syrian much higher incidence of diarrhoea. are moderately or severely food insecure, 62% are refugees in-country may well have been affected by mildly food insecure and some 25% are food secure. the following factors: e prevalence of acute malnutrition amongst ese results show a decline in food secure households • e number of Syrian registered refugees in survey children was very low; out of 1,690 children by 7% compared to 2013, mainly due to the fact Lebanon has surpassed 1 million. e Syrians between six and 59 months, 22 (1.0%) were found there is a higher percentage of households that need currently in-country could account for one to be moderately acute malnourished (MUAC 124- to cope because of lack of food or money to buy quarter of the population living in Lebanon, 115 mm) and 0.4% severely acute malnourished food. e food security situation is worse in Akkar which may clearly have further implications on (MUAC <115 mm). ere had been no increase (North Lebanon) and the Bekaa Valley, where 22% the increasing tension with the host community, since 2012 (SMART survey). and 16% of households respectively were found to the strain on the infrastructure in Lebanon and Out of the 618 children between six and 23 be moderately and severely food insecure. e situ- access to shelter, employment and essential basic months old that were included in the survey, only ation is best in Beirut and Mount Lebanon where services (health, education, water, sanitation, 6% had a minimum acceptable diet according to 6% of households were found to be moderately and electricity). WHO IYCF indicators.3 About 50% of children be- severely food insecure. • As part of responsible programming, various tween six and 23 months were breastfed the day In 2014, 28% of Syrian refugee households had types of assistance (food, hygiene and baby kits) prior to the survey. Breastfeeding practice decreased to apply crisis or emergency coping strategies, which shied from blanket to targeted assistance significantly with child age; three-quarters (75%) of is 6% more than last year. e percentage of house- during September and October 2013. Targeting infants under the age of one year were breastfed, holds spending savings as part of their coping strate- of assistance was aimed at households most in dropping to about half of children between one and gies has decreased significantly compared to 2013; need, with some 70% of the Syrian refugee one and a half years old, and decreasing to 25% in it moved from the most important assets-depletion population thus continuing to receive the above children between one and a half and two years old. coping strategy to the third most important, aer assistance. Although 30% of the registered pop- ulation was deemed as able to cover their basic Infant and young child feeding practices were borrowing money or reducing essential non-food expenditures like education or health. e majority needs without engaging in irreversible coping found to be poor among Syrian refugees in Lebanon strategies (and thus no longer qualifying for representing a risk factor for malnutrition due to (82%) of Syrian refugee households borrowed money in the last 3 months, which is 11% more than last assistance), it is also part of responsible pro- some of the following issues: gramming to monitor how the targeting of • Delayed introduction of complementary foods year. Half of the households have debts amounting to US$400 or more. irteen per cent of households assistance affects the Syrian refugee population (aer the recommended 6 months of age) was as a whole. common. Over 40% of children under the age have poor and borderline consumption in 2014, of one, and 25% of children between one and which represents a 6% increase as compared to 2013. one and a half years old had not received com- 3 WHO 2008. Indicators for assessing infant and young child plementary foods (based on 24 hour recall). Of ese results highlight a trend towards a worsening feeding practices. Part 1: Definitions and Part 2: Measurement. the children between one and a half and two of the general food security situation of Syrian http://www.who.int/nutrition/publications/ infantfeeding/ years, 10% had not received complementary 9789241599290/en/ refugees, without dramatic changes. 4 The SMART survey results were subsequently reviewed and foods. corrected. This found a lower prevalence of acute malnutrition • About three quarters of children surveyed did Health and nutrition of children than initially estimated. For more details, see article by UNICEF in not meet recommended minimum meal Nearly 70% of surveyed children under the age of 5 this issue (p32)...... 26 Field Article ......

• e time spent by Syrian refugees in Lebanon and given the availability of results from the SMART of family members that live together or in different may have positive or negative effects. Refugees nutritional surveys conducted in 2012 and 2013. living structures, eat out of the same pot, and share may have increasingly adapted to the new con e nutrition component of non-communicable the same budget that is managed by the head of the text, may have a better awareness and network disease (NCD) was not assessed as this was not se- household. e definition of households registered facilitating access to some services, and may lected at the sector working group level, although with UNHCR is more stringent and considers pro- have a better knowledge of assistance benefits. chronic diseases (self-reported) are included in the tection factors so that registration cases are considered On the other hand, time implies a higher risk of ‘specific needs’ module of the VASyR. as separate households regardless of the common exhaustion of resources (e.g. savings and/or expenditure shared. Since the household definitions assets) and difficulties to continue coping Conclusions are not the same, this implies that some ‘VASyR through loans. e VASyR provides a very valuable comprehensive households’ have more than one UNHCR registration picture on living conditions for Syrian refugees to case number. Establishing the limits of the household VASYR 2014 provided the follow-up to the 2013 better inform decision-making. e assessment is remains a challenge due to the high number of study to explore the impact of these issues. statistically sound with representative data at different combinations that are found in the field. levels (registration date, regional). At the same time, Stratification by region it is operationally feasible to undertake in an emer- e food security situation of Syrian refugees in Since the 2013 VASyR, there was evidence of regional gency context when information is needed in a Lebanon has deteriorated in the previous year. As disparities within Lebanon for different indicators, short period of time so as to re-design programmes savings and assets are being exhausted or becoming but a lack of comprehensive and representative in- according to evolving needs. It strongly contributes more limited, households engaged in more severe formation at regional level based on sound assessments to identifying main needs as well as areas where strategies to cope with the lack of food or money to or standard methodology. ere was mounting interest more detailed information would be required to buy food. ese coping strategies included reducing coming from the humanitarian community to better better address any sector-specific concerns. expenses on health or education. e average house- understand these regional differences in the refugees’ hold size is 6.6 members and generally, only one in- situation and fill this critical information gap. is e VASyR has a set of implementation challenges dividual is able to work, mainly in temporary em- geographical stratification was used in the 2014 to overcome and one broad limitation. e main ployment. is is insufficient to cover the US$762 VASyR. limitation is that the VASyR does not provide all on average that a given household reportedly spends the detailed information needed for each sector; it Stratification by registration date on a monthly basis. Also, about one fourth of house- does not replace in-depth sector-specific surveys. holds do not have any member working. Almost Stratification by registration date was included in Only the most critical indicators are selected per VASyR in 2013 but not in 2014. One of the main half of refugee households live below the poverty sector so that the overall questionnaire can be line of US$3.84 per person day. Compared to last reasons behind the stratification by registration date feasibly rolled-out. e approach was to conduct a in the 2013 VASyR was to explore whether this year, refugees depend more on external sources of wide-ranging multi-sectoral, higher-level survey cash like WFP’s food vouchers or loans, and less on variable affected household vulnerability and could that can be carried out without requiring an overly therefore help better define the need of assistance. skilled work or their own savings. Borrowing money long assessment of interviewees. Challenges and is occurring more frequently and debt amounts are e 2013 VASyR showed that refugees awaiting reg- means to address these are as follows; istration or recently registered did tend to show higher than last year. Female-headed households poorer living conditions for some indicators compared 1) Improve on information collected, through iden- and single-headed households with dependents have to those registered for a longer period of time Yet tifying key sector-specific questions that provides also increased compared to 2013, exacerbating the overall, vulnerability was not significantly different the essential information needed for decision-making difficulties to access work. Despite the fact that among these strata. Information about living condi- and help better define the thresholds that more ac- households are employing coping strategies, food tions by registration date is available from the 2013 curately identify vulnerability. is process requires consumption of most food groups as well as diet di- VASyR, and if repeated in 2014, strata would have intra and inter-sectoral discussions with each sector versity has also reduced; this year, households are changed given the disproportionate number of attempting to attain the most information possible less likely to have acceptable food consumption. refugees in each strata in 2014, most of them registered for their own purposes5. Although the questionnaire Expenditures on health, water and hygiene items over 6 months ago. us the analysis by registration should be contextualised and revised in line with have increased. is has occurred possibly in response date was carried out with the 2014 VASyR data, but lessons learnt from previous assessment exercises, to the reduction in hygiene and baby kits in-kind with no representativeness by registration group. efforts carried out at the international level to stan- assistance and also to the water scarcity situation in dardise vulnerability questions, categories and thresh- Lebanon. In 2014, there are proportionally more Nutrition indicators olds would facilitate this process significantly. Such refugee households without access to bathrooms, MUAC and oedema results in the 2013 VASyR in- work should take account of specific contexts like sufficient access to water, soap or hygiene items. dicated a 1% prevalence of moderate acute malnu- urban or semi-urban areas, refugees not residing in e security situation is also deteriorating for Syrian trition (MAM) and 0.4% severe acute malnutrition camps, and situations in middle income countries. refugees who experience an increasing harassment (SAM) (1.4% global acute malnutrition GAM)). and extortion. ese results were lower than malnutrition prevalence 2) Further enhance data quality. e number of determined by weight for height in the SMART nu- enumerators needed for an assessment of this scale As the conflict in Syria continues and there is no tritional survey of 2012 (4.4% GAM), as well as the where field data collection takes about 2 weeks, expectation of an early resolution, the number of results that were later released in the 2013 SMART ranges between 64 and 82. ese enumerators need refugees in Lebanon continues to increase. It is esti- nutritional survey4. e decision to remove MUAC to be trained in different sector-specific questions, mated to reach 1.5 million registered by the end of from the 2014 survey was based on the following as well as in the VASyR methodology. Training of 2014. It is expected that the Syrian refugees’ living reasons: trainers has been identified as the best approach conditions will continue to deteriorate and the • In this population, MUAC underestimates acute but this requires extensive efforts in standardising impact of the crisis will also worsen the situation malnutrition compared to weight for height. training modules, providing clear guidelines on the for the most vulnerable Lebanese population. is • Given the low acute malnutrition prevalence in methodology, process and questionnaire along with will be compounded by the security situation, which the population based on MUAC, the precision close supervision at different levels. ese three is tenser in the last months due to the increasing needed to track potential changes would have factors are key to minimising regional differences number of refugees but also to the recent events in required a larger sample size than needed for in interpreting questions, methodology and in stan- the northeast part of the country (Aarsal) as well as the VASyR purposes. dardising how to manage unpredictable situations. in Iraq. e combination of these ingredients con- • Due to the lack of significant changes in acute One of the main objectives of 2014 VASyR has been stitutes a risky context for Lebanon’s stability, malnutrition rates found in the 2013 SMART to improve data quality by introducing these elements especially if overall assistance is reduced by any nutritional survey compared to 2012, it was not but it is a continuous process. In addition, in VASyR given funding constraints. deemed worthy to introduce, to the 2014 2014, quality monitors from UN agencies accom- For more information, contact: Susana Moreno VASyR, the added complexity of training and panied the enumerators during the field data col- Romero, email: [email protected] implementing the MUAC exercise (including lection. ere were two monitors per region, to the standardisation test for enumerators). strengthen and support the supervision role, and it especially revolved around quality of information 5 Each sector proposed their key questions based on international Weight for height and micronutrient status data collected during the interviews. agreements and tools but also considering the nature of the were not collected in 2013 or 2014, as this would assessment and context (assessment at household level in urban have added undue complexity to the VASyR which 3) Clarity around the definition of households used. and semi urban refugee population in a middle-income country) For the VASyR, a household is considered to consist as well as the indicators used by the sectors for the regional is meant to be an emergency multi-sectoral assessment response plan...... 27 Views......

Towards a 21st century humanitarian response model to the refugee crisis

in the Lebanon By Simon Little Simon Little is DFID's former humanitarian advisor to Lebanon, a position he held from January 2013 to July 2014. He is currently seconded by DFID to the UN Resident Coordinator’s/Humanitarian Coordinator’s Office and is currently working on developing Lebanon’s 2015 humanitarian/stabilisation plan.

is article represents the views of the author and is not an official DFID position. It was written in early summer 2014, before the sixth Regional Response Plan (RRP6) mid-year review.

Background e humanitarian situation in Lebanon is changing. A model response or a challenging introduced elsewhere with a focus on the distribu- Aer two years of a resource-intensive response, response model? tion of material lifesaving assistance. In applying a delivered through multiple agencies and sectors, With greater numbers of refugees seeking sanctuary response model heavily influenced and shaped by the anticipated reduction of humanitarian funding in Lebanon from mid to late 2012, the responsibility practice in Africa, the humanitarian community is likely to change the scope and shape of the to lead and coordinate the humanitarian effort was may have failed to acknowledge the contextual dif- response. As a result, it is unlikely that what was debated between UNHCR and the UN Office for ferences of responding in middle income Lebanon, achieved in 2012 and 2013 (a comprehensive package the Coordination of Humanitarian Affairs (OCHA). with well-established basic service delivery and a of life-saving assistance delivered to an ever enlarging e former declared that a steadily increasing flow functioning private sector. Whether a model that is caseload of refugee and non-refugee beneficiaries) of refugees accorded it the lead coordinating role, predominantly focused on disbursing vast quantities will be achievable in the future. whilst OCHA highlighted aspects of the Transfor- of material assistance was best suited to the speci- mative Agenda, notably the Cluster System and re- ficities of the crisis in Lebanon – even during the In the evolution of all crises, there are key mo- inforcing the role of the Humanitarian Coordinator. peak period of refugee influx – is debatable3. ments when the humanitarian community has to Although the swelling of refugee numbers strength- make difficult decisions regarding the future main- ened UNHCR’s claim, there were some within the It is interesting to note that eight sectors were es- tenance and delivery of the response and for humanitarian community who remained perplexed tablished under UNHCR stewardship pretty much in Lebanon, the mid-2014 review of the sixth Relief as to why a cluster system, far from perfect but the mirror image of the cluster system. e aforemen- Response Plan (referred to as RRP6), represents refined over successive crises, was overlooked. Whilst tioned eight sectors are jointly coordinated by a such a time. UNHCR is certainly mandated to lead/coordinate UNHCR sector coordinator (with the exception of refugee responses, introducing a sectoral response the food security sector) and a Government of e dimensions of the crisis in Lebanon are stag- Lebanon (GoL) representative4. Six of the sectors have gering. e country hosts the highest per capita (though different from the cluster system largely in name only) caused confusion and delays amongst three or more coordinating agencies with global clus- refugee population in the world and the RRP6 is set ter lead agencies, such as UNICEF for WASH, WHO at $1.7 billion for 2014. As of mid-2014, however, humanitarian actors more familiar with a cluster approach refined in recent crises. Nonetheless, struc- for health, etc. joining a UNHCR and GoL represen- the appeal was just 17% funded ($287 million se- tative. is might be viewed as a suboptimal arrange- cured). It is unlikely that the RRP6 will secure any- tures and leadership is one thing but for those we seek to assist, what’s delivered is always more im- ment with sectors coordinated by two UN P3/4’s, where near the $881 million secured against RRP5 5 portant than who delivers it. whereas one might suffice and may contribute to in 2013, though refugee numbers are expected to costly and potentially cumbersome coordination6. continue to grow. A scaled up response was predicated on the deliv- 1 e need for continued humanitarian and/or sta- ery of blanket food assistance, hygiene, baby kits etc., The GoL/World Bank estimates that by end 2014, Lebanon complemented by more selective transfers of educa- will have sustained economic losses totalling $7.5 billion due bilisation/development assistance can be largely to the crisis in Syria. tion, health and shelter support. e mode of deliv- 2 negated through the provision of livelihoods/em- Valued at $1.21 billion the appeal budgets of the three ery drew heavily on experience and practice acquired ployment opportunities. However, there is no easy frontline UN agencies (UNHCR, UNICEF and WFP) collectively in successive crises over the past three decades, rein- constitute 71% of RRP6. As well as supporting UN activities, way to create employment in a politically fragile en- forcing the traditional response hierarchy with UN donors such as DFID have provided bilateral support to INGOs. vironment where the economy is haemorrhaging1 3 One of the principle differences between responding in agencies securing the lion’s share of donor funds, and and where the three primary employment sectors Lebanon and elsewhere are the costs associated in thereaer subcontracting the bulk of on the ground maintaining a response. (agriculture, construction and services) are already 4 delivery to a range of international non-governmen- These are: education, food security, health, non-food items heavily congested. Cash for work schemes delivered (NFI), protection, shelter, social cohesion, and water, tal organisations (INGOs)/NGOs2. As a rule of by humanitarian and non-humanitarian actors are sanitation and hygiene (WASH). The protection sector has the thumb, the more partners involved in delivering an providing value and utility to those that benefit but, following two subgroups: Child Protection in Emergencies operation, the less optimal the arrangement, in part (CPE) and Sexual and Gender Based Violence (SGBV). collectively, the employment created amounts to 5 because of the duplicate costs associated with UN The annual cost of engaging a P4 UN officer in Lebanon is tens of thousands of work days, rather than the mil- estimated at around USD 200,000+. oversight and INGO delivery (e.g. two sets of prem- 6 lions required. In the absence of a massive multilat- By way of emphasising the suboptimal response model at play, ises, vehicles, personnel, HQ costs, etc). Operating it is worth highlighting the assessment of need. A recent DFID erally funded public works scheme capable of costs can spiral further if the implementing INGO funded Multi Sector Needs Assessment reviewed 88 multi and providing long-term employment to thousands of single sector assessments conducted during 2013. The GoL, delivers through a national partner. refugees and poor Lebanese, many households will Red Cross Movement, Gulf actors and others outside the RRP6 probably conducted a further 30 or so assessments. All these continue to rely on the assistance provided by the In terms of assistance delivered the response assessments take time, cost money, duplicate effort and seek humanitarian community. model applied in Lebanon is little different to that similar information that may serve to confuse beneficiaries...... 28 Views ...... Over the past couple of years, the humanitarian What distinguishes Lebanon and how of coverage and service provision. Cuts are inevitable response in Lebanon has grown in direct propor- should we do things differently? and there is a danger than the response simply loses tionate to the needs that exist, and the resources At an operational level, there’s little to distinguish steam and gradually peters out. e narrowing of available to respond to such needs. As a result, esti- the crisis in Lebanon – and the resulting need for sectoral focus will be accompanied by fewer and mates suggest that 100 or so humanitarian/develop- humanitarian assistance – with comparable crises fewer target households receiving assistance. Equally, ment agencies are currently present (though not all in Africa or Asia. As such, it makes perfect sense the gaze of donors, responders and the media may active) in Lebanon, employing upwards of 3,000 in- that the response offers an integrated package of be turned by a future emergency with Lebanon, not dividuals, around 350 of whom are thought to be in- lifesaving assistance, delivered through experienced inconceivably, being abandoned to a painful cycle ternational staffers7. e collective cost of staffing and proven partners employing tried and tested of ever diminishing returns. this operation is conservatively estimated at $00’s of methods of delivery. e proactive approach recognises the operational millions annually with an estimated 20% of overall dilemma and looks to adjust in advance of its conse- project funding expatriated through personnel and Most forecasters agree that humanitarian funding quences. is is already taking place and the current other out of country costs. Furthermore, though for Lebanon probably plateaued in 2013. e year Cash Transfer Programme offers a useful illustration. RRP5 may have mobilised $881 million in 2013, just 2014 will likely experience a steady reduction (per- A recent review of the operational set up of cash pro- 50-60% of this is thought to have been converted haps 60% of that mobilised in 2013?) with a steeper gramming in Lebanon suggested a number of refine- into assistance and/or services that reach the bene- decline in funding anticipated for 2015. Conversely, ments that, if introduced, could provide a leaner, ficiary end user with the balance likely to have been as funding reduces the number of vulnerable people, more responsive and cost effective delivery model. absorbed by a range of in and out of country admin- both refugees and non-refugees are expected to in- crease. So it really will be a case of looking to do more istration/operating costs8. Cost saving measures might a reduction in the with considerably less! Compounding the challenge number of actors involved in transferring cash, uni- So, the response model in Lebanon has been de- of dwindling resources is the fact that Lebanon is an fying the coordination of cash transfer program- signed and structured to adhere to the prevailing extraordinarily expensive context in which to oper- ming, attenuating the structure for transferring cash, model of cross-sectoral multi-partner engagement. In ate. e cost metrics of the response in Lebanon are utilising a single ATM cash transfer mechanism, etc. this, the UN oversees a response model implemented enormous. Which other past or current response in large part by INGOs. National and international model is predicated on a household minimum ex- Operational refinements only go so far as the staff are employed at the centre, and field level, to co- penditure basket (MEB) of $607 per month with the scale of the crisis will outstrip available resources- ordinate and implement. From the outset of the crisis survival basket costed at $435 per month or $5,220 the response model can be adapted until no further the role of the private sector has been limited as has per annum10? e costs simply don’t bear compari- adaptation is possible. To make a real impact, the the willingness and/or ability of GoL structures and son and yet, peculiarly, the response model employed community needs to be bolder and more ruthless in services to engage. e response model in Lebanon in (for example) Kenya and Lebanon, and across the introducing change. As a matter of urgency we need has assumed a largely predictable form. world, is effectively the same. to review the optimality of the current structure, specifically the future requirement for 24 UN agen- e current response model has probably grown Because the cost of responding in Lebanon is so cies and 100 INGOs11. We need to consider the ap- beyond the means of donors to sustain it and whilst extraordinarily high, the international community propriateness of maintaining the current sectoral scaling up proved challenging, scaling back is prob- can ill afford suboptimal response systems or deliv- structure and the various working groups and task ably more so with personnel and logistics tied to ery mechanisms. Against the backdrop of reducing teams therein. All these structures are populated long-term contracts. Donors played a part in driving humanitarian funds, it’s imperative that the current with high cost international personnel. In addition, the response agenda as did the media and by exten- response model is adjusted to be certain that agen- we should take the opportunity to review the value sion the public. In today’s overheated and overly cies are truly delivering impact and value for money. of a decentralised, resource intensive coordination competitive humanitarian sector, it would have been In recognising the challenge and cost of continuing system. In essence we need to determine whether unusual, if not unconscionable, for any of the larger to operate in Lebanon two options are presented: the the existing response structure enables us to deliver agencies, be they UN or INGOs, not to have sought first, a reactive/inactive approach; the second, a more with less? With the crisis in Lebanon unlikely a foothold in Lebanon, though very few of either proactive approach. to end anytime soon we need new humanitarian type operated in middle income Lebanon pre-crisis. order to ensure that our future focus remains firmly Typically, in the free for all that follows the onset of e reactive/inactive approach. As indicated pre- on those we are here to serve, rather than shoring crises, those that vacillate are le behind and thus po- viously, the RRP6 has secured less than one-fih of up institutional mandates or finances. tentially bere of funding9. With the exception of in- the funding needed for the year at the time of writing. is is cause for concern, if not entirely un- stitutional outliers, such as ICRC and MSF, this is For more information, contact Simon Little, email: expected. Few expect 2014 funding levels to equal unacceptable to the extent that the contemporary hu- [email protected] manitarian market demands action from all, even those achieved in 2013. With fewer funds, the hu- those with limited contextual experience. manitarian community is less able to maintain levels 7 The number of national and international staff is not exact but estimates put those currently employed by humanitarian agencies in Lebanon as follows; the four main UN agencies (UNHCR, UNICEF, UNRWA and WFP) employ national and international staff in the following ratios: UNHCR 480:160; UNICEF 100:20; UNRWA and WFP 61:15. Bear in mind that UN agencies subcontract the bulk of implementation to INGOs.

McConnell/UNHCR McConnell/UNHCR National/international staffing levels for the lead INGOs (DRC, IRC NRC, SCI) are as follows: DRC 550:50; IRC 300:26; NRC 353:23 and SCI. The total number of international personnel engaged in the response clearly runs to hundreds of posts with thousands of national staff engaged. 8 The estimates presented are based on rudimentary calculations from individual funding proposals received over the past 18 months. 9 At the start of 2013, 22 INGOs were included in RRP4. By the end of the year, this number had increased to 51 INGOs. The number of INGOs represented in RRP6 has grown yet further. The overall INGO/NGO community is thought to number in the order of 100 agencies. Twenty-four UN agencies are present in country (source: Inter-Agency Coordinator, Lebanon). 10 In 2012 Lebanon’s GDP per capita was $9,705 or approx. 50% more than the estimated survival basket. Though the MEB was calculated to cost the minimum living expenses for refugees, the figure is comparable to the $4 per day poverty line presented in the GoL’s National Poverty Targeting Programme. 11 The Red Cross Movement has its own parallel structure with the International Committee of the Red Cross (ICRC), the Anas, a 12 year old boy, washes his face after finishing work in a charcoal International Federation of the Red Cross and Red Crescent shop in Bebnine, Akkar, Lebanon. Anas works also in a grocer’s shop. He Societies (IFRC) and 18 partner National Red Cross Societies makes $3 to £4 per day and is proud of supporting his family. orbiting around the Lebanese Red Cross...... 29 Field Articles...... Aid effectiveness and Vulnerability Assessment Framework: determining vulnerability among Syrian refugees in Jordan

By Hisham Khogali, Lynnette Larsen, Kate Washington and Yara Romariz Maasri

Hisham Khogali is an Kate Washington is the lead facilitator independent consultant for the Vulnerability Assessment with 19 years of experience Framework development with UNHCR. in a range of humanitarian Previously, she worked for 5 years with contexts. Hisham has an CARE International in Jordan and has MSc. in Human Nutrition over 13 years of regional experience from LSHTM and has worked for NGO’s, the Red across Syria, Lebanon and Jordan. She holds a Master of Cross Movement and various UN agencies. In Sciences degree in Development Studies from SOAS, Jordan, he worked for the Assessment University of London. Capacities Project (ACAPS). Yara Romariz Maasri is an Associate Lynnette Larsen is a humanitarian information Coordination Officer with UNHCR Jordan management specialist who has managed and has been supporting the Jordan Humanitarian Information Centres in Kosovo, Vulnerability Assessment Framework Iraq and Liberia and similar IM efforts in the since November 2013. She previously 2005 Pakistan earthquake, 2008 Cyclone Nargis worked in refugee resettlement for over (Burma) and 2010 Haiti earthquake responses. four years in Lebanon, Kenya and Cameroon, and was co- She co-led implementation of the OCHA’s IM editor of the Fahamu Refugee Legal Aid Newsletter for three capacity building strategy and developed an IM years. She holds a Master of Science in Forced Migration strategy within the Cluster approach. from the Refugee Studies Centre, University of Oxford.

The current VAF development team consists of Kate Washington, Harry Brown, Marco Santacroce and Carolyn Davis. The work of the VAF team has been overseen and supported by Alex Tyler and Volker Schimmel of UNHCR. WFP and UNICEF have also provided essential support throughout the development process.

Bonus articles online:

Field Articles he conflict in Syria, which began in 2011, actually have required some differentiation in the type has continued to create a worsening refugee of support they received? Second, it was highly likely • Meeting nutritional needs of Syrian situation. ere is currently a growing pop- that there would be a reduction in resources available refugee children and women in Jordan 1 ulation of 3,033,972 registered refugees in as the crisis continued and other crises around the surroundingT countries and the region.Realising the • UNHCR cash programming in world emerged; a better targeting mechanism would emergencies – implementation and challenges that this number of refugees posed combined be needed to determine eligibility for limited aid. coordination experience during the with the need to be more effective, UNHCR’s Field Syrian refugee response in Jordan Information Support Servicessection launched a project The project approach entitled ‘Design and implementation of the framework In order to test the concept of a vulnerability analysis • Experiences of emergency nutrition for humanitarian aid effectiveness.’ e main objective framework, piloting was undertaken in Jordan in both programming in Jordan of this UNHCR initiative is to improve aid effectiveness, the refugee camp context (specifically Zaatari camp) • Women’s protection and empowerment by ensuring a needs-based and principled approach and with refugees in urban areas of the country. e programming for Syrian refugees in to humanitarian response. In order to achieve this pilot focused on health and cash assistance. e project urban Jordan: challenges and lessons objective, UNHCR and its partners needed to work was planned in three phases. ese were: learned together, at country level, to agree on and put in place Phase 1: Scoping and coordination: mechanisms for: Research Identification and engagement of key stakeholders, • The social life of nutrition among a) Definition of vulnerable groups/house holds in review of existing vulnerability assessment methods, Syrian refugees in Jordan need of assistance, and agreement on minimum set up and meeting of steering group. sectoral data to inform this definition with partners Phase 2: Facilitation and design: b) Identification of vulnerable households News Support to sector leads to develop a vulnerability as- c) Development of shared tools (database and data • Experiences on Nutrition in Emergencies sessment strategy, database and data entry tool design. Training for Syrian refugees response in entry form) for the tracking of assistance provided Jordan by UNHCR and partners, agreement on data Phase 3: Lessons learned and recommendations: consolidation, and protection, data ownership, Document a lessons learned exercise UNHCR ap- Agency Profile sharing/access agreement with partners proached ACAPS2 to support the projectas a non-op- • Jordan Health Aid Society (JHAS) erational entity in the region, i.e. without any assistance e process was driven by two factors. First, an interest • Jordan Hashemite Charity Organisation programming. Furthermore, ACAPS have specific as- (JHCO) in providing the right support to vulnerable people; for example, was it enough to provide the same support 1 As of 17 November 2014, http://data.unhcr.org/ syrianrefugees/ www.ennonline.net/fex to all disabled people when their vulnerabilities may regional.php ...... 30 Field Article ...... sessment expertise and experience and had enjoyed previous successful partnerships with UNHCR. Sup- port by ACAPS included the deployment of an as- sessment expert to work in country with UNHCR and all relevant partners in a collaborative manner to define vulnerability based on emergency life- saving needs, and specifically to define eligibility criteria for refugees receiving assistance, in the 2014 Kohler/February UNHCR/J. health and cash assistance sectors (as a starting point). Phase 1: Scoping and coordination is phase took place in the second half of 2013. A Syrian refugee family tells a UNHCR staff UNHCR has an established methodology for assessing member about life in a tented settlement. vulnerability. is method, using the Specific Needs codes3, was applied in the Syrian refugee context as in other contexts where UNHCR works. is ‘group’ In order to ensure a common understanding of Generating a relative household vulnerability approach has a number of key weaknesses including: vulnerability, the following three characteristics of ‘score’ would be done through a mix of sector-based vulnerability were proposed and agreed in initial and cross-cutting quantitative and qualitative indi- • Generalisations about vulnerable groups tend meetings/workshops with partners. Namely that cators. Linking to location data for each household to exclude those that are generally not thought vulnerability is: would enable agencies to analyse the data by vul- of as vulnerable, e.g. at a workshop in Zaatari • multi-dimensional and differential (varies across nerability level, programming sector and geographic camp, the issue of men being vulnerable partic- physical space and among and with in social areas. It was proposed to start with data collection ularly to violence, but also their potential to groups) through the UNHCR registration and re-registration commit violent acts due to unemployment, was • scale dependent (with regard to time, space and process and home visit data, with an eventual ex- raised. In addition, in the context of Jordan, units of analysis such as individual, household, pansion of the collection process to, for example, adolescent girls are particularly vulnerable (e.g. region, system) selected NGOs, in order to speed up the development to becoming child brides). Yet neither unem- • dynamic (the characteristics and driving forces of a significant body of information. e project ployed men nor adolescent girls are included in of vulnerability change over time). would also focus initially on refugee households the specific needs codes of UNHCR. outside the established refugee camps because of • Generalisations about vulnerable groups also fail ese principles underpinned Phase 2: the facilitation both the larger size of the target population and to recognise that not everyone in a vulnerable and design of a vulnerability analysis system. high levels of assistance still being provided in the group is equally vulnerable (UNHCR addresses Phase 2: Vulnerability Analysis Framework: camp setting. e data would be centrally stored this through exclusion criteriain the cash developing an inter-agency approach and made available to participating agencies subject programme). Aer a two-month hiatus during the development to normal concerns for privacy and sensitivity of • A group approach is one dimensional and of the annual Refugee Response Plan (RRP 6), work data. Linking the data to UNHCR’s Refugee Assis- cannot capture the fact that a household or on the Vulnerability Analysis Framework project re- tance Information System (RAIS) would eventually individual can be in more than one disadvan- sumed in mid-November of 2013. Meetings with enable analysis of humanitarian assistance effec- taged group at a time, i.e. potentially having UNICEF and WFP led to a decision to broaden the tiveness in reducing or preventing vulnerability by greater vulnerability. scope of the project beyond the Cash Assistance establishing a household record of assistance to be • A group approach also does not explain why working group and invite the participation of a wider matched against a vulnerability profile. someone is disadvantaged; an elderly person is range of stakeholders in its development. Following not vulnerable because they are old, but perhaps Developing ‘indicators’ of vulnerability informal presentations of a proposed approach to because they are isolated or lack resources to To increase awareness of the project and initiate the groups of United Nations (UN) agencies, international maintain themselves. development of vulnerability indicators, a day-long non-governmental organisations (INGOs) and donors, • e approach also does not take account of the workshop in February 2014 brought together rep- an inter-agency steering committee, (consisting of temporal and spatial aspects of vulnerability; resentatives of sectors and sub-sectors to dra list five UN agencies, five INGOs and two donors) was people can move in and out of vulnerability, e.g. of approximately 25 indicators from which a final established to guide further development of an as- a Syrian refugee who gains employment becomes (shorter) list would be culled. Although the seriousness sessment methodology and implementation6. less vulnerable, or refugees with proximity to with which all the participants approached the work services may be less vulnerable than those roughout discussions with potential new partners, was impressive, the groups achieved varying degrees further away. the key objective of the project remained the devel- of success in fleshing out indicators. Some groups opment of a standardised approach to assessing were able to reach a more detailed articulation while Initial reviews of secondary data and meetings with household vulnerability to support equitable pro- others struggled to move beyond the discussion partners of UNHCR, both in health and cash assis- grammatic decisions. A standard list of approximately phase. Although most participants felt the task was tance, revealed that different systems were being 10-15 household indicators of vulnerability, developed a challenging one, comments from several participants used for identifying vulnerability. is was particularly by the humanitarian community through existing indicated appreciation for the consultative approach true in the case of cash assistance where a number sector and inter-sector coordination mechanisms, chosen. e exercise, in addition to providing an of partners had adopted a scorecard approach.How- would be used by UNHCR and other agencies in de- important first step in the development of indicators, ever, different scorecards were used by different termining eligibility for assistance. However, it was also helped to solidify the image of the project as an partners.e score card approach provided a more stressed that while a household vulnerability ‘score’ inter-agency initiative and one that would provide transparent approach to determining vulnerability could be used as a factor in decision-making, it useful tools and information for a broad range of and enabled a multi-dimensional approach that in- should not be the sole criterion used in decision- humanitarian actors. corporated both vulnerable groups and potential making. Furthermore, the final decision on allocating coping strategies/vulnerabilities. However, the scoring 2 any assistance would always rest with the individual ACAPS is the Assessment Capacities Project: it supports and of cards created divisions amongst partners for agency responsible for managing the particular in- strengthens humanitarian capacities to carry out coordinated whom there was no standard scoring mechanism4. assessments before, during and after crises. Through tervention. Because vulnerability is not a static concept, is difficulty in agreeing scoring may have been development and provision of innovative tools, know-how, the frequency with which a re-assessment would be training and deployment of assessment specialists, ACAPS exacerbated by organisational mandates5. It is also carried out was identified as one of the critical con- aims to contribute towards a change in the humanitarian important to recognise that different organisations siderations in operationalising the exercise. Additional system’s current practice with respect to needs assessments. had different objectives for their cash assistance 3 The UNHCR Specific Needs Codes categorise refugees into risk analysis would be carried out throughout the programmes, with some adopting a one off emergency groups such as unaccompanied minors, disabled etc. project development process to identify any potential 4 assistance approach and others (e.g. UNHCR) adopt- More specifically the weighting of scorecards was different. harmful impacts of the assessment on households, 5 Organisations weight vulnerabilities based on the objectives ing a three month (renewable) cycle approach. Cash for example, the potential impact on marginal popu- or specific persons of concern that they wish to target. assistance may be conditional or unconditional.Score- 6 lations who fail to qualify as the least vulnerable but Steering Committee Members: CARE, Danish Refugee Council, cards also rarely took into account access to services Handicap International/Help Age, Première Urgence - Aide for whom assistance may be a critical factor in pre- as a key vulnerability determinant. Médicale Internationale, Reach, WFP, WHO, UNICEF, WHO and, venting a deterioration in circumstances over time. UN Women...... 31 Field Article ......

• In March 2014, an inter-agency participatory propriate types of intervention and acknowledges assessment was conducted with Syrian refugees, the holistic and interlinked nature of vulnerability. through 70 focus groups, with responses disag- gregated by age, gender and disability. e VAF Risks and safeguards indicators were included in the discussions of Given the impact that the household vulnerability refugee priorities/key concerns, and perceptions score could potentially have on the assistance received of their own or their community’s vulnerabilities. by a household, it is important that the nature and UNHCR/J. Kohler/February 2014 Kohler/February UNHCR/J. • An assessment tool was designed using the VAF limitations of the data are clearly understood by all indicators identified in the February workshop. actors and that safeguards are included in the frame- • A World Bank team has conducted a detailed work to minimise the risk that data are misused. A Syrian refugee, with her analysis of indicators used by UNHCR for Cash Discussions with the Protection Unit in UNHCR family in Ramtha, Jordan Assistance decisions, using proGres7 and Home have also taken place throughout the process. Visit data. From a welfare perspective, this e assessment process needs to be carefully Definition of vulnerability and framework provides an objective validation of many of the considered to minimise exclusion risk, i.e. the risk outcomes VAF indicators. that households or segments of the refugee population • Standard Operating Procedures (SOPs) on how e February workshop also established a working are excluded from the process or their level of vul- the tool could be applied have been draed by definition of vulnerability for the Syrian Refugee nerability is incorrectly categorised and they are ex- the VAF team. Crisis in Urban areas of Jordan: “the risk of exposure cluded from receiving assistance. One example of a • A Communication strategy for both partners and of Syrian refugee households to harm, primarily in mitigating action which has been developed and is beneficiaries has been developed, and a relation to protection threats, inability to meet basic being piloted (see above) is an appeals process by Communications Specialist was brought on needs, limited access to basic services, food insecurity, which households can contest any changes in the board to implement the initial phase. and the ability of the population to cope with the provision of assistance based on VAF vulnerability • e VAF data collection tool was piloted and consequences of this harm”. Using this as a basis for scores. is will continue to be articulated at a rolled out in June with over 15,000 house-holds defining the scope of the Vulnerability Assessment sector level as the VAF is rolled out. having been interviewed to date. Framework (VAF) that is being developed, the VAF Additionally, there is a risk that refugees those inter-agency steering committee is overseeing the roughout July-September, building on the work without support, may eventually become vulnerable VAF development process which will have the fol- of the World Bank, econometric analysis of the VAF so that there is a need for periodic re-assessment or lowing outcomes: data was conducted and a VAF Welfare model that other means by which to identify changing household identifies the characteristics of vulnerable house- circumstances. • Data against VAF indicators are collected at the holdswas developed. is model uses predicted ex- registration stage by UNHCR and during home As stated above, the VAF process minimizes risk penditure as a proxy for welfare and provides a visits by UN agencies and NGOs, and are of exclusion for refugees through mapping of the vulnerability spread across those uploaded into a central database. 1) appeals process, or fast-tracked reassessment for households that have been interviewed. Data col- • With the data regularly updated, the data base border line cases lection is ongoing with UNHCR, through imple- will generate a ‘vulnerability profile’ for each 2) periodic update of vulnerability status menting partner International Relief and Development refugee household, based on thresholds of 3) quality assurance of data collectors and database. (IRD), interviewing approximately 5000 new house- ‘extremely vulnerable, very vulnerable’, etc. holds a month. • Partners are able to access the database and It is important to highlight that the VAF will not re- place the need for sector-specific detailed needs as- conduct queries, while ensuring that confiden- In August an inter-agency appeals mechanism sessments, but will assist in streamlining planning tiality and protection rules are respected, e.g. workshop was held and an appeal mechanism and of such assessments and/or programmatic inter- query: percentage or number of extremely interface designed. is appeals mechanism is now ventions by, for example, identifying geographical vulnerable refugee households in Irbid gover- being piloted in cooperation with the WFP. Refugees areas where a large number of cases with a sector- norate, or a district of Irbid. can appeal for re-instatement in the WFP food as- specific ‘flag’ are located. • Partners will be able to conduct sector-specific sistance programme, following cuts made to the queries, to help them better target their assis- beneficiary list based on criteria developed as a VAF validation plan and roll out tance by geographical area and household level, result of the WFP Comprehensive Food Security Finally, the VAF steering committee is now articulating prompting further technical assessments. Monitoring Exercise conducted in December a validation plan that will review and validate the • Partners who have identified beneficiaries for 2013/January 2014. In October, an appeals database different components of the Welfare/Vulnerability individual household assistance are able to check in RAIS was developed by UNHCR and launched model and the Sector Level rules before the VAF is the ‘vulnerability profile’ of that household in beta version8 to assist in the process. fully rolled out to partner organisations. e validation against the database, by uploading a list of plan will use a participatory and inter-agency/in- A user interface module in the RAIS is being de- unique identifiers (e.g. UNHCR or Ministry of ter-sector approach. Further consultations with veloped by UNHCR, to allow updating of vulnerability Interior registration number). ey may then be refugees to review vulnerability indicators and indices scoring at the household level, access to interested able to modify their decision of whom to assist, will be conducted. Additionally, multifunction teams partners to inform assistance decisions, and from based on the vulnerability profile. will conduct ‘blind’ visits to a randomised selection which vulnerability trends analysis can be extracted. • e VAF should reduce duplication of assistance. of households (across the vulnerability thresholds) Partners are encouraged to log assistance they e VAF team also facilitated an additional par- that have undergone VAF interviews and scoring to have provided to a refugee household in the ticipatory interagency inter-sectoral workshop in assess the accuracy of the models and rules. On the database. If partners are systematic in this entry, October 2014 to elaborate Sector Based Vulnerability basis of the results of these validation activities, the other partners can then see which households Assessment Rules that will complement the steering committee and a peer review committee of have already been assisted in the database, when Welfare/Vulnerability Assessment model. e work- other vulnerability specialists from the region will searching for the unique identifiers. shop built on work conducted in Lebanon to define sign off on the VAF models and the full set of VAF • rough periodic reports, the humanitarian sector level vulnerability decision trees. Each sector tools will be made available to partners. community will be able to monitor trends in was tasked with looking at the multiple data points Currently, the VAF aims to be fully operational vulnerability by geographical area, informing available from the VAF questionnaire and UNHCR and launched in January 2015. During an initial six broader strategic processes, such as the Regional home visit form in order to identify and then month period there will be a VAF oversight committee Response Plan. articulate sector specific indices of vulnerability and who will monitor the use of VAF tools and VAF develop weights for each, which allow a sector level Ultimately, VAF data will provide a comprehensive data by partners. By June 2015, Phase 3 of the calculation of vulnerability. is sector level scoring picture of vulnerability among refugees that may be process will be conducted with a full review of the is still under review but will allow for a more used for advocacy purposes and for planning and process to date, revision of the models or rules as nuanced picture of household vulnerability. For prioritising of aid interventions. necessary and the documentation of lessons learnt example, VAF partners will be able to access infor- and recommendations. Progress to date mation that tells them a household’s overall vulner- e VAF process is multifaceted and a number of ability score but also a breakdown of relative vul- For more information, contact: Kate Washington, key components have been developed, piloted and nerabilities by sector. is should allow for pro- email: [email protected] rolled out, these include: grammatic decisions to be made on the most ap- ...... 32 Field Article ......

WFP assistance Since the onset of the Syrian refugee crisis in mid- pletely to vouchers in camps aside from the daily dis- 2012, WFP has been providing food assistance to tribution of bread (due to concerns over the government Syrian refugees in Jordan in a number of ways. WFP bread subsidy), each refugee receives WFP monthly began providing food assistance through the provision vouchers valued at 20JD (US$28.20). In communities of hot meals in Zaatari refugee camp when it first refugees receive the full voucher value of 24JD opened in July 2012. WFP transitioned to take home (US$33.84) per person per month. is amount is rations of dry ingredients by October 2012; this was based on the cost of a basic food basket which provides followed by the provision of paper food vouchers that approximately 2,100 kcals per person daily. Ongoing refugees can redeem in shops from September 2013 monthly price monitoring conducted by WFP and its including the large supermarkets which opened in partners has shown that food prices in participating January 2014. In non-camp settings, assistance began shops are similar, and oen cheaper, than those in the with hot meals to a few hundred families in transit non-participating stores2. Since January 2013, WFP centres, followed by the introduction of paper vouchers has kept the voucher value constant at JOD24 in August 2012. In January 2014, the transition to e- (US$33.84) per person per month as food prices have vouchers began in communities and all UNHCR reg- remained relatively constant, even decreasing in some istered Syrian refugees should have an e-card by the areas of Jordan.3 end of August 2014. WFP’s voucher programme in WFP Jordan Jordan is implemented through three established co- In April 2014, for the first time in the history of operating partners (Islamic Relief Worldwide, Human humanitarian assistance, Azraq refugee camp opened Relief Foundation and Save the Children International), with a fully-fledged WFP supermarket along with and a fourth recent addition, ACTED, in the newly WFP food vouchers. is meant that all refugees opened Azraq camp. is article describes the different arriving in the camp could start purchasing their own Evolution of types of assistance, how and why they evolved. food immediately. Food distributions in Zaatari refugee camp e number of beneficiaries of WFP’s voucher pro- WFP’s food Following the opening of Zaatari refugee camp in July gramme increased steadily from 67,500 individuals 2012, WFP distributed hot meals from local restaurants in January 2013 to 537,000 individuals by February to camp residents twice a day, typically consisting of 2014. All registered Syrian refugees living in host assistance rice, a protein source such as chicken or meat, together communities have been able to redeem their vouchers with bread, fruit and a vegetable. is was not sustainable in 77 designated shops in 12 governorates (July 2014). for the rapid influx of refugees that followed (rising Shops are contracted by WFP’s partners and are programme from 3,685 individuals in August 2012 to 129,756 in located in areas with a significant concentration of April 2013). us, WFP transitioned to the distribution refugees. In these communities, the head of the house- of dry rations in October 2012, once kitchens with hold receives two paper vouchers every month. Each for Syrian cooking facilities were available for camp refugees to voucher is valid for two weeks and will expire if not use. e rations, consisting of rice, lentils, bulgur wheat, used during the validity period. e voucher value pasta, oil, sugar and salt, were distributed from dedicated varies according to the household size, as each individual refugees in distribution sites to all residents every two weeks. receives the equivalent of 24JD (US$33.84) monthly. Together with the daily distribution of bread, this E-voucher programme provided 2,100 kcal per person per day. UNHCR also WFP assistance to Syrian refugees living amongst the Jordan provided additional complementary food normally host population in Jordan is now carried out through consisting of canned tomatoes, tomato paste, tuna, electronic food vouchers. is programme is imple- canned beans and tea through the same distributions. By Edgar Luce mented through a partnership with MasterCard and Paper voucher assistance a local bank, Jordan Ahli Bank (JAB), under its Cor- For the past two e paper voucher modality was introduced for the porate Social Responsibility (CSR) programme. E- years, Edgar Luce has registered refugees living amongst the host community vouchers function like a pre-paid debit card, with been working for (August 2012 – 19,000 beneficiaries) and later in WFP transferring the voucher value directly to the e- WFP Jordan as a Zaatari camp (September 2013 – 104,000 beneficiaries). voucher on a monthly basis through the partner bank Programme Officer e introduction of the voucher programme helped (see Figure 1). WFP has now transferred almost all by monitoring bring a sense of normalcy to Syrian refugees allowing refugee households to electronic vouchers in the host operations, writing them to shop in regular supermarkets for their preferred communities and started to pilot this approach in reports and acting as the VAM foods. e vouchers also offered access to a greater camps as well. E-vouchers allow the beneficiaries to (Vulnerability Assessment and Mapping) diversity of foods with higher nutritional value, spend their entitlements in multiple visits to the shops focal point. He has more than five years of including fresh fruits, dairy products, meat, chicken, and are also more discreet and therefore less stigma- international experience in agricultural fish and vegetables. is programme also led to jobs tising. As the cards are recharged automatically through development and humanitarian relief for nearly 400 Jordanians in WFP’s partner shops the partner bank, beneficiaries are no longer required working with NGOs prior to the UN. where refugees used their vouchers; more than $229 to travel to monthly distributions to receive their food million has been injected into the local economy since assistance. When making a purchase in the supermarket, its launch through till July 20141. refugees must present their e-vouchers together with Thanks to Henry Sebuliba, WFP for helping coordinate inputs, reviews and In Zaatari camp, vouchers were initially redeemed 1 Economic impact study: Direct and indirect impact of the WFP approvals in the article’s development. in shops run by 16 partner community-based organi- food voucher programme in Jordan, April 2014. sations (CBOs). In January 2014, WFP established 2 For example, in April 2014, a standard food basket cost JOD21.60 two supermarkets in Zaatari camp allowing camp (US$30.24) in participating stores and JOD21.80 (US$30.52) in based refugees’ food needs to be met entirely through the non-participating outlets. Source: Economic impact study: vouchers. WFP gradually decreased the distributions Direct and indirect impact of the WFP food voucher programme in Jordan, April 2014. of dry food rations while increasing the value of the 3 Food basket is composed of rice, bulgur wheat, pasta, pulses, vouchers. Now that food assistance has shied com- sugar, vegetable oil, salt and canned meat...... 33 Field Article ...... their matching UNHCR refugee identification card and input their four digit security code – the same process used for regular credit and debit cards.

Key findings and lessons learned e paper voucher system was introduced as as- sessments showed that Jordan has a fully integrated market structure with the necessary commercial and physical infrastructure to meet increased con- sumer demand without affecting its current supply lines and price levels. Furthermore, since Syrian families are accustomed to shopping for their food, vouchers allowed them to continue their regular approach to purchasing food, helping to return a sense of normality to their lives while enabling them to select their preferred food items and meet their individual consumption and dietary needs. WFP keeps an open policy regarding what food items are selected; beneficiaries are able to purchase all food items except soda, chips and candy. e WFP food voucher programme builds linkages between refugees and host communities and helps to stimulate local economies through the promotion of local production and sales. Findings from a recent WFP Economic Impact Study4 show that WFP as- sistance will equate to 0.7% of the Jordanian GDP through the voucher programme in 2014. e (paper vouchers have to be spent in one go and only less is also spent on administrative and logistical voucher programme has already led to some US$2.5 allow two shopping visits per month). is is useful costs. us, with vouchers more total value is trans- million investment in physical infrastructure by the for refugees who have limited storage facilities es- ferred to beneficiaries. Similarly, it is impossible to participating retailers, created nearly 400 jobs in pecially during the hot summer months or limited cost the added value for refugees in making their the food retail sector and generated almost US$6 access to transportation. It also is a much more own household food decisions. With vouchers WFP million in additional tax receipts for the Jordanian discreet assistance modality, which is important was able to scale up quickly and absorb the high government. when living in host communities where tensions number of refugees crossing on a daily basis. us, are increasing over time. While vouchers in general vouchers are by far the preferred mode of assistance e gradual shi to e-cards brings several im- are more costly than the purchase of bulk com- when compared with in-kind food in Jordan. E- portant benefits to both Syrian refugees and WFP. modities, given the transfer value of vouchers has vouchers are even more efficient given WFP does ese include allowing refugees to spend their to cover retail prices and is therefore higher per not need to print hundreds of thousands of paper monthly entitlements in multiple visits to the shops person than the cost of bulk food purchases, much vouchers every month, sort and distribute them through partners, then reconcile all redeemed vouch- Figure 1: Number of WFP beneficiaries in camps and communities (Jan 2013-July 2014) ers. As part of the partner bank’s CSR programme, most services are provided to WFP free of charge, 500,000 including the printing of all cards, loading of the 450,000 monthly assistance and tracking and reporting. 400,000 WFP has a robust monitoring system that covers 350,000 all activities such as e-cards, paper vouchers, school 300,000 feeding in camps, nutrition activities. WFP monitors 250,000 all partner shops, shop owners, prices in both partner 200,000 and non-partner shops for comparison purposes, beneficiary perceptions, distribution sites and house- 150,000 hold food security information, such as food con- 100,000 sumption scores and coping strategies on a regular 50,000 basis. Because WFP assists nearly all registered 0 Syrian refugees in Jordan, the prevalence of food insecurity amongst Syrian refugees is relatively low 5

Jul-13 at 6% in communities . Furthermore, food con- Jan-13 Jan-14 Oct-13 Jun-13 Jun-14 Apr-13 Apr-14 Feb-13 Feb-14 Sep-13 Dec-13 Mar-13 Mar-14 July-14 Nov-13 Aug-13 May-13 May-14 sumption is also high, as 90% have an acceptable Community Camps food consumption score with only 8% classified borderline and 2% poor. Initial monitoring findings of the e-card modality showed many Syrian refugees in Jordan are illiterate and thus unable to read and fully understand the voucher programme. In response, WFP created communication materials with illustrated explanations of the e-card process. Monitoring has also shown that shop owners are more satisfied with the e-card modality given they are paid much faster and do not need to track thousands of paper vouchers. Lastly, beneficiaries have explained their content

4 Economic impact study: Direct and indirect impact of the WFP food voucher programme in Jordan, April 2014. 5 Findings from the Comprehensive Food Security Monitoring Exercise (CFSME) conducted in January 2014, report released July 2014. http://documents.wfp.org/stellent/groups/public/ documents/ep/wfp266893.pdf Rein Skullerud/WFP ...... 34 ...... Emergency, email: [email protected] Press Information Officer–WFPSyria Regional For more information, contact: DinaElkassaby, for themselves inatimeof even crisis. provide to ability the refugees Syrian affording to approach mid-term more a devise to governments Syria, WFP is working around with sister agencies and host operations refugee current of costs fiscal the Given month. one of horizon funding a working with when challenging extremely is refugees of influx large possible a assist to ready are stocks Maintaining the cash flow and ensuring contingency continues to pose challenges for future foodtiming of assistance.donations to meet cash flow requirements, also required to operate hotlines as well. callsper month through its hotlines. All partners are 1,500 thanreceivesmore average,WFP One-card. bankand counseling beneficiaries on how to use the the to numbers forgotten pin or e-card lost laying otheragency hotlines for non-food related issues, re- distributionsof shops,andreferring beneficiaries to feedback mechanism answering – questionsbank, all on partners locations have hotlines as an effective beneficiary to financial literacy training for beneficiaries. WFP,cooperating partners and retailers inaddition to trainingsystem as well as lines help andcentres call desks, help as such facilitiesproviding is bank the Lastly, information. account/transactions and partners with remote web access for card maintenancecoordination, while providing WFP and cooperating for project implementation, team monitoring, focal facilitation support and customer experienced an use and subaccount activity. e bank has designated beneficiaries’card on reporting timely andhensive also the role of the partner bank to provide compre- is Ithousehold. beneficiary each for cards prepaid bank accounts for all WFP retailers and for producingbank is also responsible, if necessary, for establishing eretailers.selected all in point-of-salemachines maintainingproviding, re-andsponsibleinstallingfor is and system card prepaid the of accounting andmonitoringoversight,control, the for cedures though prepaid cards. e bank has established pro- efficient mechanism for the electronic voucher andeffectivesystemsafe, a managingmaintainingup,and etary needs compared to the receipt of in-kind food. more able to cover family members with specific di- are voucherthey as programmethe general with in utial fnig icuig nuig the ensuring including funding, Sustainable n diin o h WP oln hse b the by hosted hotline WFP the to addition In JAB, WFP’s partner bank, is responsible for setting

WFP Jordan

Andrew Robinson/Medair, Jordan, 2013 By Gabriele FänderBy Gabriele Frega andMegan malnutrition treatment Feeding education and Infant and Young Child Refugee Crisis: in JordantheSyrian Responding tonutritiongaps This project is supported through generousThis issupported fundingfrom project UNICEFand WFP. Field Article Afghanistanin Somalia/Somaliland, andIndia. troduced to complementary foods eaius epcal po ifn ad on cid edn patcs aogt oh the both amongst practices, feeding child refugee and host populations. young and infant poor especially behaviours, on the national level indicate a prevalence of 46% of prevalence a indicate level national the on early initiation of breastfeeding amongst mothers low in Syria was atvery reports 32%, while breastfeedingat42.6% prevalence ...... 7 6 5 4 3 2 1 and high anaemia prevalence rate among children of toddler age. people exacerbated existing the problems of scare resources. sudden e survive. to means population influx and forneed basic items, shelter, food, or careand health for over amillion half resources without nations, neighbouring into thousands drove Syria in hundreds violence of and Conflict later, million. yearone a half grownby had it in refuge taken had who families Syrian 45,000; about ofto increased had year,refugeessame of number the ofthe Jordan. September handful By a only were there 2012, of start the At Background spectively amongst infants less than 6 months of age is significantly lower in Jordan, at 39% and 22% re- region evidenced by low exclusive breastfeeding prevalence for infants less than 6 months 6 than less infants for prevalence breastfeeding exclusive low by evidenced region http://www.unicef.org/infobycountry/syria_statistics.htm International Baby Food 2011 Network, Action http://www.unicef.org/infobycountry/syria_statistics.html http://www.unicef.org/infobycountry/syria_statistics.html =nutrition&goButton=Go WHO, Profile, Country Nutrition http://apps.who.int/nutrition/landscape/report.aspx?iso=SYR&rid=161&template WHO http://who.int/vmnis/anaemia/data/database/countries/jor_ida.pdf statistics.html UNICEF http://www.unicef.org/infobycountry/syria_statistics. html, http://www.unicef.org/infobycountry/jordan_ Prior to the Syrian crisis, infant and young child feeding (IYCF) practices were poor in the 7 . ese findings suggest inadequate pre-existing health and nutrition preventive nutrition and health pre-existing inadequate suggest findings ese . experience invarious roles Amman. Previous work Programme, basedin in theSyria Crisis Response Nutrition Advisor with Medair Regional Healthand FänderGabriele isthe 6 . Early initiation of breastfeeding and exclusive breastfeeding 5 and only 37% of children 6-9 months of age had been in- been monthshad ageof6-9 children of 37% onlyand 4 . e most recent figures report exclusive report figures recent most e . 2 According to FAO (2011) [email protected] communication focal point. liaison andexternal andisthemedia in Beirut Programme. isbased Megan Syriathe Medair Crisis Communication for Officer FregaMegan istheRegional Refugee women inthe north ofJordan north 35 3 1 , ......

gramme coverage area is the six northern governorates of Jordan (Amman, Zarqa, Mafraq, Irbid, Jerash and Ajloun). Over the course of 10 months, 4,977 PLW received IYCF education, and 31,485 caregivers were reached with IYCF and health promotion ed-

Heba Seder/Medair, Jordan, 2014 Jordan, Heba Seder/Medair, ucation through the community project. Each family is taught and counselled depending on the ages of their children, so mothers receive advice on com- plementary feeding, breastfeeding, and infant nutrition as appropriate. Families also receive information on where to go for additional services, where to get food vouchers, how to enrol in cash-assistance pro- grammes, and were to find additional health services. Education on the use of Super Cereal Plus Medair also establishes small, individual support groups, so that mothers have the opportunity to sit together and learn from one another. At this point, Breastfeeding practices need to be protected IYCF programme only two regular mother support groups are fully during emergencies; it is well known that infants In 2012, Medair began the IYCF project through a functioning in Zarqa Governorate. Other groups who are not breastfed are at a manifold higher risk partnership with the Jordan Health Aid Society meet sporadically in all programme areas. e of morbidity and mortality than breastfed children8. (JHAS), a national NGO10. e purpose of the project interest to meet and participate in mother groups is Breastfeeding is emotionally and psychologically is to protect children under five years and pregnant very high; sometimes up to 50 women try to partic- restorative to women under stress. A woman’s body and lactating women (PLW) by screening for mal- ipate in one gathering. One of the recommendations is designed to feed and nurture her child even under nutrition and educating caregivers about IYCF prac- emerging from the Medair programme will be to difficult circumstances. In emergency situations, ap- tices. e project focuses on education on exclusive scale up mother support groups in terms of enabling propriate and safe IYCF practices are less likely breastfeeding for expectant mothers, targets mothers regular meetings of the same small group, to better than under stable conditions. Bottle feeding comes with infants less than 6 months of age to encourage facilitate learning and influence behaviour change. with increased risks; poor water quality, an inability exclusive breastfeeding, and targets mothers with to sterilise the bottle/nipple, artificial ingredients in children less than 2 years to encourage the correct Mothers who are unable to breastfeed are referred breastmilk substitutes (BMS), and lack of sustain- and timely introduction of complementary food. to Medair partner clinics for professional support. ability, can all contribute to poor nutrition and A qualified midwife or an obstetrician/gynaecologist health in infants dependent on BMS. Working in collaboration with JHAS in northern specialist checks mothers to establish reasons for Jordan, Medair began education and promotion not breastfeeding. Mothers who are willing to re- Early IYCF assessment groups in JHAS clinics and in mobile clinics in the lactate receive relevant breastfeeding support. Un- Medair arrived in Jordan at the start of the Syrian surrounding areas. Each of the six fixed clinics and fortunately, for those mothers who cannot or do crisis in 2012, to respond to the growing public one mobile clinic are staffed with a nutrition officer not want to breastfeed, there is no support for BMS health and shelter needs. From the start, IYCF and who is responsible for IYCF promotion and breast- supply facilitated by any health facility outside nutrition were identified as a large public health feeding counselling and oversees the management Zaatari camp. Security issues surrounding BMS tar- need that was not being covered by other agencies. of acute malnutrition in the related health clinic. geted distribution in the camp (see below) have dis- Medair chose to focus efforts on IYCF to prevent a During 10 months of project implementation, 4,690 suaded community service providers from getting rise in malnutrition as the crisis deepened. At the PLW received IYCF education and 919 mothers en- involved in BMS distributions. Infant formula is beginning of the IYCF project, Medair explored gaged in breastfeeding counselling sessions. Medair expensive; a 250g tin costs 5 JOD (7USD) and lasts IYCF practices among Syrian refugee mothers also delivered training on IYCF, malnutrition screen- 4-5 days. As a result, many mothers use cheaper through individual interviews and focus group dis- ing and malnutrition treatment to health staff, doctors, milk powder instead. cussions in November 2012 to probe community technicians and nurses from six JHAS clinics outside perceptions and practices. An assessment in No- Zaatari camp, one JHAS clinic inside Zaatari camp Programme coverage and impact vember 2012 set a baseline for IYCF indicators to and one mobile clinic. e partner clinics are located Since the inception of the programme, communities monitor the project. in Amman (2), Zarqa, Mafraq, Ramtha and Irbid. in general, including males and fathers, have been e mobile clinic covers the South of Jordan (Karak, receptive and open to education and learning. Many e November 2012 assessment found that Jor- Madaba, Tafila, Ma’an, Aqaba). families have requested additional information about danians and Syrians had similar misconceptions IYCF from volunteers and are eager to learn more. surrounding breastfeeding. Few mothers or caretakers Community networking Medair’s project covers 60% of the refugee population understood the benefits or importance of exclusive In 2013, Medair incorporated a community net- in the northern governorates, where, as shown earlier, breastfeeding for infants for the first six months. working component into the programme that em- over 30,000 mothers and caregivers have received Refugees oen reported they exclusively breastfed ployed volunteers to educate the refugee community promotion and counselling on IYCF (average contacts but on probing, were found to give other fluids to on IYCF practices and to screen for malnutrition. to May 201411). their infants. Another common misconception was Many of the Jordanian volunteers educating the that bottle feeding was preferable, and that stress refugee communities were equally unaware of the A follow up Medair survey was carried out in on a woman’s body prevents her from breastfeeding. importance of exclusive breastfeeding, and appreciated March 2014 to examine project impact. e sampling Older generations with poor education on the the training for their own families. Training took frames involved: benefits of breastfeeding oen counsel younger place in the JHAS training centre in Amman or in • 31,485 caregivers who were visited by the women to give BMS, and younger women almost the Medair office in Mafraq (North Jordan). Com- Medair IYCF volunteers between November exclusively follow this advice. Misconceptions amongst munity volunteers initially received three days of 2013 and April 2014 and had received breast caregivers and mothers during the discussions in- training on IYCF, nutrition including acute malnu- feeding education. cluded poor advice, telling women to “give water trition, BCC (Behaviour Change Communication) • 128 caregivers with infants less than 6 months and herbs,” or that “breastmilk alone is insufficient and general health and hygiene topics, specifically were included in a 24 hour dietary recall to for infants,” and “traditional approaches are pre- preventable communicable diseases. Every month, assess breastfeeding status. ferred.” community volunteers gather in their relevant service area and receive refresher training on these topics. Additional assessments found that medical staff 8 Bahi R, et al. Bull of WHO 2005;83 (6):418-426 9 in local clinics and hospitals oen gave wrong or e community component involves 35 Medair Colostrum is the breastmilk produced during pregnancy and immediately after birth. It is low in fat, and high in conflicting advice about breastfeeding to caretakers, volunteers who conduct house-to-house visits with carbohydrates, protein, and antibodies. It is low in volume contributing to poorer nutrition and breastfeeding stand-up education presentations to teach and train and provides concentrated, highly digestible nutrition to the practices. Many hospitals and clinics oen did not entire families. Community volunteers include Syrian newborn. 10 See profile of JHAS in this edition of Field Exchange emphasise the importance and nutritional benefits and Jordanian men and women, who work to a 11 9 Mothers with breast feeding difficulties, with sick children and of colostrum aer delivery. Some doctors advised weekly target of 50-58 household visits. All volunteers with malnourished children have received several follow up women that breastmilk alone was not sufficient, de- receive a weekly incentive and transportation costs visits during the programme period. This also includes pending on the women’s diet or personal nutrition. upon submitting a weekly work report. e pro- mothers who are malnourished...... 36 Field Article ......

e survey showed an increase in breastfeeding organisations and well-meaning donors from Gulf knowledge but not an improvement in breastfeeding countries distributed huge amounts of BMS to practice. Knowledge amongst mothers of at least refugees in camps and host communities. BMS two benefits of breastfeeding had increased from products were not distributed according to assessed 49.5% (November 2013) to 71% in the community needs, for example to mothers who were unable to and 91.2% in the health facility setting (March breastfeed. BMS were usually included as a general 2014). However, exclusive breastfeeding practice item in food baskets distributed to refugee families. among the mothers who knew about breastfeeding ose distributions were in general ‘once-off’ dis- 2013 Jordan, Megan Freya/Medair, recommendations showed no change (24.2% com- tributions with no provision for sustained supply to munity survey and 25% health facility based, March infants established on these products. 2014) and in fact, was worse than the pre-crisis na- In order to regulate these BMS distributions, the tional prevalence in Syria (42.6%12). ese findings Nutrition Working Group in Jordan developed Stan- show that while a large percentage of families in dard Operating Procedures on Distribution and Jordan have been successfully educated on the Procurement of Infant Formula and Infant Feeding benefits of breastfeeding, more time and other meas- Equipment14. ose guidelines were promoted within ures to address social and cultural barriers are the wider NGO community and to donors. From needed actually to effect nutrition behaviour changes. that point onwards, donations were streamlined Among the 91 mothers of infants less than 6 through UNHCR and all BMS donations stored in Male focus group months who were not exclusively breastfeeding, a warehouse in Northern Jordan. Managing donations more than half (64.8%, n=59) fed their baby with created a large amount of work for the Nutrition infant formula, followed by other liquids including Working Group who had to decide what to do with sions, and referral information should be held water (20%), traditional soup and liquid (16.5%), the donations, which far exceeded the need for regularly. and raw milk (15.4%). Data from one health facility BMS. At one point, the Nutrition Working Group Doctors and health staff must be targeted as they showed similar results, finding that 44.4% of caregivers had to decide what to do with thousands of boxes of are the primary source of information for refugees. who were not exclusively breastfeeding fed their different BMS types and milk powder in storage. Doctors must encourage breastfeeding among patients baby infant formula. For Zaatari camp, to meet the needs of non- and hospitals must have delivery staff who promote Treatment of moderate acute malnutrition breastfed infants, clear protocols were developed good feeding practices. Mothers must also be in- (MAM) for the supply of BMS. Mothers are individually as- formed through antenatal care visits about the im- To treat MAM in children below 5 years of age and sessed by a qualified midwife from an appointed portance of exclusive breastfeeding and the benefits PLW, as implementing partner for WFP, Medair has clinic (run by the national NGO, Jordan Health Aid of breastmilk versus infant formula. e Jordanian been distributing Super Cereal Plus in a targeted Society (JHAS)15. Where BMS supply is indicated, Ministry of Health is a critical partner to champion supplementary feeding programme (TSFP)13. Mothers the mother obtains a written prescription for BMS, key IYCF messages within the country. Messaging were initially reluctant to eat this food or give it to which is supplied at designated distribution points. through radio, television and newspapers about their malnourished child, thinking it might cause Outside the camp, managing BMS has proven to be health and hygiene practices must permeate both them harm. However, Medair began cooking demon- more complicated. Refugees are widespread across the Jordanian population and the refugee community. strations during distributions at local clinics to show all six northern governorates and it is more difficult Hygiene materials should be distributed along with the women how to prepare the food, even eating to find specialised clinics across those Governorates messaging to enable long-term behaviour change. some with them. e demonstrations have helped who not only have the expertise to qualify mothers UNICEF has requested that Medair begin to remove the stigma of this ‘refugee food’. As soon as for BMS distribution, but also to facilitate supply. champion their baby friendly hospitals initiative the Super Cereal Plus was cooked during demon- Experience related to riots and attacks on distribution (BFHI), which will seek to train health workers on 16 strations, children would start eating it, finishing points in the camp related to BMS have prevented the importance of immediate breastfeeding aer the whole test portion in no time at all. e same clinics outside the camp agreeing to store BMS delivery. None of the clinics which Medair supports applied for reluctant PLW, once they tried the cooked products and be part of a BMS distribution. has BFHI status, however, this is planned in the food they all agreed it was quite possible to eat it. next stage of programming. However, everyone unanimously agreed it needed Expectations of aid sugar to improve the taste. During cooking demon- One of the challenges Medair faces in programming With regard to the needs of non-breastfed infants, strations, beneficiaries themselves who had recovered is the need to distribute physical aid along with ed- the provision of targeted supplies of BMS in the through eating the product, advocated for its use ucation. Refugees oen expect physical aid - cash, community setting is a particular challenge and re- and gave tips on how to improve its taste. hygiene items, kitchen equipment, etc. - and struggle mains an outstanding gap. to see the importance of education without accom- Acute malnutrition screening panying in-kind assistance. Community volunteers During every training session, whether with com- Since 2012, screening for acute malnutrition has are received with suspicion if they come to “only munities, volunteers or medical staff, Medair have been undertaken by Medair and community workers, talk”. Initially, families don’t see the importance of found that participants are excited to learn about targeting PLW and children under five years. e education and promotion related to IYCF. To respond how important IYCF practices are and want to learn number of children with acute malnutrition identified to this demand, volunteers have begun to distribute more. Technical support material in Arabic tailored through screening is very low, much lower than the spoons, cups, and breastfeeding shawls to women to the context of the Middle East would greatly help expected rate according to the nutrition survey find- with children under 6 months of age, as well as training delivery. ings in 2012. Out of 46,383 children screened in hygiene kits to mothers with children under 2 years. For long-term change to happen, the approach clinics and communities during the 11 months Beneficiaries put the need for cash above all other must continue to be community led and focused on project period, only 69 severe acute malnutrition needs, sometimes failing to recognise the importance the needs of poor, vulnerable families. Physical aid (SAM) cases and 124 MAM cases were identified. of other initiatives. Donors, stakeholders, and medical should accompany health messaging and education. Out of 10,088 PLW screened during the 11 months staff also typically see IYCF support approach as a Prevention programmes over curative interventions project period, 457 were identified as acutely mal- ‘so’ approach without much impact. should lead the response. nourished. e timeline for aid delivery is a challenge. In For more information, contact Gabriele Fänder, Challenges emergencies, short intervention timelines and quick email: [email protected], tel (Jordan): BMS donations and supplies impact programmes are preferred. As reflected earlier, +962 (0)796 294628 e culture of bottle feeding in Syria and Jordan behaviour change requires a longer term approach. was perpetuated through the untargeted distribution 12 UNICEF, of breastmilk substitutes (BMS) in the early days of Discussion and recommendations http://www.unicef.org/infobycountry/syria_statistics.html the response and the concept that poor diet among To tackle social and cultural barriers and increase 13 See article by WFP for more details on the TSFP. lactating women negatively impacted on their ability effectiveness of IYCF promotion in Jordan, additional 14 Available from: http://data.unhcr.org/syrianrefugees/regional mother support groups and learning groups need to .php to breastfeed. Especially during the first phase of 15 be incorporated into the education process. Com- See article by JHAS and profile of the agency in this edition of the influx of refugees into Jordan (end of 2012 and Field Exchange. through the first half of 2013), many non-govern- munity led and sponsored support groups with 16 See the article by Save the Children Jordan that elaborates mental organisations (NGOs), community-based cooking demonstrations, continual learning discus- on these BMS problems in Zaatari camp...... 37 Managing infant and young child feeding

in refugee camps in Jordan By Sura Alsamman

Sura Alsamman is nutrition supervisor at Save the Children Jordan (SCJ) is a registered Jordanian NGO established in 1974, Save the Children Jordan, responsible for the with Her Royal Highness, Princess Basma Bint Talal as the Chairperson of the Board. overall all coordination of the IYCF technical SCJ is part of and the only Arab member of the 30 Save the Children organisation functions and activities in camps and south members operating in 120 countries worldwide. In Jordan, SCJ develops much of Jordan. Previously she worked in various needed national programmes that focus on creating sustainable results where maternal and child nutrition programmes. every child attains the right to survival, protection, development and participation.

ince the beginning of the emergency In late 2012, a Nutrition sub-working group (Nu- for individual counselling sessions and follow up, in Syria, over 500,000 Syrians have trition SWG) was established as a sub-group of the five educators responsible for group education crossed the borders into Jordan Health Working Group, initially chaired by UNHCR sessions and 10 supporting Syrian community mo- and are either hosted by the Jor- and co-chaired by Save the Children Jordan (SCJ) bilisers. Sdanian community or residing in refugee from November 2013. Initial advocacy and response A simple rapid assessment was conducted in the camps. e first refugee camp in Jordan initiatives involved the development and sharing of first few days of operation in Zaatari camp, to was Zaatari, administered by the Govern- two key guiding documents through the Nutrition explore the prevailing infant feeding practices and ment of Jordan-appointed Syrian Refugee SWG, namely: challenges faced by PLWs and caregivers. is Field Article Field Camp Directorate (SRCD), with the support • Guidance Note on Appropriate Infant and Young exercise allowed SCJ to better design the counselling of UNHCR. More than 350,000 Syrians Child Feeding Practices in the Current Refugee and education sessions in the programme; it was have been registered in Zaatari camp since Emergency in Jordan (26th of November 2012)4. not intended to provide a full dataset or statistical its opening in July 2012. A large number • Standardised Operating Procedures (SOPs) on analysis. e assessment highlighted many mis- of refugees have subsequently le Zaatari Donations, Distribution and Procurement of conceptions among mothers including mothers be- camp to urban and rural areas in Jordan. Infant Formula and Infant Feeding Equipment lieving they don’t have enough breastmilk/mothers in the Current Refugee Emergency in Jordan At the beginning of the emergency, a convinced that breastmilk is drying up due to (26th of November 2012)5. number of assessments were conducted to stress/mothers believing that breastmilk is not determine the health and nutrition needs Save the Children Jordan programme enough for infants in the first few days of life. e of the refugees, including e Inter-Agency Breastfeeding in an emergency is known to be the rapid assessment indicated the need to emphasise Nutrition Assessment conducted in No- safest way to protect infants and young children the importance of exclusive breastfeeding and the vember 20121. is recommended strength- from an increased risk of infection and from becoming correct timing of starting complementary feeding. ening the awareness, promotion, and pro- malnourished. Breastfeeding support was a key rec- e assessment also identified cases of breastfeeding tection of optimal infant and young child ommendation of Inter-Agency Nutrition Assessment difficulties, like engorgement and mastitis, which feeding (IYCF) practices through preventive (as above). Given this, SCJ launched the Infant and counsellors started following up with immediately. and nutrition promoting services. Young Child Feeding in Emergencies (IYCF-E) pro- As the camp population rapidly increased, and gramme in Zaatari camp in December 2012, aer Prior to the crisis, IYCF practices were in partnership with UNICEF, two new IYCF caravans completing a technical training supported by Save already poor in Syria. According to the were established to cover all 12 districts in the camp. the Children US. e programme was funded by MICS2 survey of 2006, the prevalence of Eight new staff members joined the team to support OCHA, Save the Children US, UKAid and the Ger- early initiation of breastfeeding was 46%, in following up with mothers. e IYCF caravans man Cooperation-Save Germany. It aimed to reach and the prevalence of exclusive breast- are located in districts 3, 4 and 8, next to the three 90% of pregnant and lactating women (PLWs) and feeding in infants under 6 months of age main schools in the camp. Based on the camp pop- children under 5 years in the camp. At the time was only 43%. IYCF indicators were not ulation distribution, those caravans are reachable (November 2012), the camp population was estimated favourable in Jordan either; the 2012 DHS3 to most mothers. Each caravan currently has an ed- to be 45,0006. showed that in the past few years, exclusive ucator and a Syrian caravan assistant on a daily breastfeeding rates have dropped from e programme’s main goal was to promote, basis, along with the counsellor and community 27% to 23%. In Zaatari camp in Jordan, protect, and support appropriate IYCF practices, mobiliser assigned for each district. On average, there was a high demand for infant formula including early initiation of breastfeeding within 1 early in the crisis response. Whilst only a hour of birth, exclusive breastfeeding for infants 1 Inter-agency nutrition assessment Syrian refugees in Jordan small percentage of women requesting under 6 months, and appropriate and timely intro- host communities and Za-atari camp. Final report. January 2013 supplies were physiologically unable to duction of complementary food along with breast- 2 Multiple Indicator Cluster Survey (MICS), Syrian Arab Republic, breastfeed, common use of infant formula feeding aer 6 months. 2006 http://www.childinfo.org/files/MICS3_Syria_FinalReport pre-crisis among the Syrian refugees, cou- _2006_Eng.pdf Mother-baby friendly spaces 3 Demographic and Health Surveys (DHS) for Jordan, 2012. pled with untargeted and unsolicited dis- http://dhsprogram.com/what-we-do/survey/survey-display- tribution of infant formula in the early e IYCF programme started with the establishment 403.cfm humanitarian response and high levels of of the first of three caravans serving as a mother- 4 Available at http://data.unhcr.org/syrianrefugees/regional.php stress and anxiety among women, fuelled baby friendly space (safe haven). e caravan engaged 5 Available at http://data.unhcr.org/syrianrefugees/regional.php 6 this demand. a team of five trained IYCF counsellors responsible Current estimates of Zaatari camp population are around 90,000 people (June 2014) ...... 38 Field Article ......

120-150 mothers visit the three IYCF caravans on a ponents of the programme. It was agreed that each of colostrum and early initiation of breastfeeding, daily basis. Some mothers attend daily, others weekly Jordanian staff (counsellor/educator) would closely duration of exclusive breastfeeding, timely intro- as they wish. On average, there are 150 new visits to work with a Syrian mobiliser who was chosen based duction of complementary feeding, and indications the caravans per week. on their background (nurses, college graduates) and for prescription of infant formula (medical indications how well they knew the camp community. e mo- and where infants are not breastfed, see below). To e caravan is promoted as a safe space for bilisers main responsibilities are to identify mothers address these issues, an orientation session was con- breastfeeding, where privacy and support is provided who need breastfeeding support and help in spreading ducted for all health providers on IYCF; key messages for all pregnant women and mothers with children the IYCF messages. If they encounter mothers using were also circulated through the health coordination under 5 years. Education sessions are held in the infant formula, they direct them to the IYCF caravans, meeting. Due to the high staff turnover in such sit- caravan on a daily basis from 9:00am till 3:00pm or refer to a counsellor to investigate relactation, or uations, continuous follow up remains a necessity covering topics such as nutrition for PLW, the im- at a minimum, ensure that are preparing infant for- to ensure a unified message. portance of breastfeeding, complementary feeding, mula as hygienically as possible. It is clear that and feeding during illness. Initially, infants who e difficulties in managing infant formula having Syrian mothers as part of the team and com- were using infant formula attended the paediatrician, Monitoring infant formula prescription and dis- municating the same messages makes it much easier but now are directed to the IYCF caravan also. A pensing has been a major challenge from the begin- to communicate with the refugees and discuss their nutrient dense snack (high energy biscuit) and a ning of the crisis response in Jordan. Characteristics beliefs and misconceptions around infant feeding bottle of water are provided to mothers as incentives of optimal IYCF practices and the provisions of the practices. Difficulty following up with mothers was to visit the caravan and to highlight the importance International Code of Marketing of Breastmilk sub- one of the major challenges we faced at the beginning; of nutrition and fluids for breastfeeding mothers. stitutes (BMS) were relatively unknown. Controlling families were constantly changing their locations in Breastfeeding shawls for privacy (provided by UN- BMS (typically infant formula) supply was a new the camp (moving to a higher area, closer to the HCR as a gi in kind) were also distributed to concept among national health staff and caregivers, market, next to new arriving relatives). With no lactating mothers. A bottle/cup amnesty activity especially given that infant formula use was the contact information other than the address given in also operates in the caravan, where mothers are en- norm for the Syrian community pre-crisis. Hence the initial visit, it was very difficult to reach the couraged to exchange any feeding bottle they have most of the caregivers argued it should be part of mother again. However, with the help of the com- for a measured cup which is considered safer, more the ration or distributed for every family with munity mobilisers team and their connections with hygienic and easier to clean. children under 2 years of age. Field hospitals received street leaders, the team were able to reach many of donations of infant formula, bottles and teats and In order to respond to mothers concerns, IYCF these cases. A case study regarding one community were distributing them for all mothers. educators follow up with the various health issues mobiliser’s experiences is included in Box 1. arising in the camp. For example, food safety and Infant formula prices are relatively high. Many Coordination with partners and health facilities hygiene was emphasised when diarrhoea cases in- mothers who received it opted to sell it in the camp in the camp has also played a key role in disseminating creased and the importance of early initiation of streets or sent it outside to be sold in the community IYCF messages. rough agreements and Memoranda breastfeeding was emphasised when cases of jaundice (it was clearly seen for sale in the camp market).To of Understanding (MOUs) with different partners, were identified in newborns. In addition, the IYCF reduce distribution channels and ensure targeted educators participate actively in the sensitisation IYCF educators have the opportunity to reach mothers and conduct sessions in clinics and distribution, UNHCR followed up on this issue. A and mobilisation for the different immunisation series of meetings were held with different health campaigns. women/youth centres. Recognising that contact with mothers immediately aer birth increases the pos- providers to ensure that there was a system in place Over 18 months of operation (Dec 2012 to May sibility of exclusive breastfeeding and early initiation, to manage the process of supply provision of infant 2014), the programme has reached 15,600 mothers IYCF counsellors provide counselling sessions on a formula. It was agreed that only one health facility through the caravan and tent counselling sessions daily basis in the two health facilities providing de- would be responsible for dispensing infant formula in Zaatari camp. Non-breastfed infants are supported livery services in the camp. and a protocol was established regarding individual through individual counselling sessions. A high assessment of need and supply method (see Box 2). Acknowledging the impact of the messages com- proportion of the mothers attend with children It was very important for SCJ to make sure that municated by health providers, and noticing some under 2 years of age. IYCF caravans were not involved with any kind of cases of misinformation from health staff in the BMS prescription or dispensing. Within a few days Community mobilisers field clinics, it was crucial to ensure that unified of starting the new process, however, it was clear that From the early stages of implementation, community IYCF messages were delivered by all doctors, midwives the refugees were not happy with it. Angry men mobilisation was identified as one of the main com- and nurses. Key information includes the importance would gather at the health facility and demand infant formula. In addition, they restrained their wives from taking the physical examinations. Many infant formula Box 1 Community mobiliser – success story packs were taken by force and the midwife received several threats of attack. Sara is one of the community mobilisers working with the IYCF team in Zaatari camp. Sara decided to join the team after her successful experience in breastfeeding her youngest child and seeing how this affected his Sensitisation was critical for calming the situation. health compared to his four older sisters. Mothers and caregivers were referred to the IYCF Travelling with her four daughters, Sara arrived at the camp in the heat and dust of July 2012. As the days caravan for education sessions on the importance passed, Sara gradually settled in, amongst relatives and neighbours. She learned to cope in a difficult of controlling this prescription process and the environment, with insufficient food supplies and inadequate accommodation conditions. Sara first visited us dangers of artificial feeding in emergencies. IYCF one cold December morning in 2012, as a result of an outreach campaign we conducted in the camp. She was educators were present on a daily basis in the health pregnant with her fifth child. When she first came, she expressed her concern regarding sanitation in the camp clinic explaining the importance of breastfeeding and access to clean water. She did not possess sufficient knowledge about the benefits of breastfeeding her and superiority of breastmilk. But it was also clear child. This applied to both her and the community as a whole. that further security precautions needed to be in With her delivery date approaching, the IYCF counsellors’ visits to Sara increased. She was taught the different place. It was decided to have the prescription and positions for breastfeeding, the signs of proper breast attachment, the importance of colostrum (the first milk dispensing in two different locations - the examination produced by a mother on giving birth), as it is rich in immunologically active cells, antibodies, Vitamin A and and prescription undertaken in the health clinic other protective proteins, and much more. After Sara’s discharge from the hospital on giving birth, IYCF and the distribution at another more secure location. counsellors from SCJ continued to visit her on a weekly basis to monitor the progress of the baby’s health and Once both locations were identified (this took some weight, provide emotional support for her, and answer any questions or address concerns she may have. time), it was agreed that an IYCF staff member “For the first six months, I exclusively breastfed Tamer, as I had been advised; he is the only child I exclusively would be present in each facility to support and breastfed and I can clearly see the difference in comparison to his four older sisters. He is more resistant to monitor the process. A database was developed to diseases and infections, and is more alert and active. In addition, I myself experience great joy when I keep track of mothers receiving infant formula breastfeed him, I tend to transition into a state of serenity, tranquillity and bliss. A state that in a camp (names, ages, ration card number) to avoid dupli- environment is unattainable.” cation, to allow regular follow up to ensure hygienic Even as Tamer grew, Sara continued to visit the IYCF caravan as often as possible. She would relate her story to other pregnant and lactating mothers and her enthusiasm was infectious. Sara has become our ambassador in 7 Acceptable medical reasons for use of breast-milk substitutes. Zaatari Camp. She is such a strong advocate of breastfeeding and so we are happy to have her among our WHO/NMH/NHD/09.01. WHO/FCH/CAH/09.01. team of Syrian camp mobilisers. http://www.who.int/maternal_child_adolescent/documents/ WHO_FCH_CAH_09.01/en/ ...... 39 Field Article ......

with the locally procured fortified food porridge Box 2 Individual level assessment for infant formula prescription and followed up by IYCF counsellors. e local for- tified had a very good nutritional profile, and mothers Infant formula is prescribed based on any of the medical indications for infant formula use as recommended by were constantly instructed on preparation methods WHO7 or when physical examination of the mother finds there is no breastmilk supply. and number of meals to offer per day. All mothers requesting infant formula are required to undergo a physical examination by a midwife to determine Eventually in January 2014, Super Cereal Plus if there is breastmilk supply. This includes mothers who have never breastfed. If the midwife determines that there is no breastmilk supply, the mother is prescribed infant formula. If the mother is found to be able to was officially approved by the Jordan Food and Drug breastfeed based on physical examination and is found to have good milk supply, then she is not supplied with Administration (JFDA) and in partnership with infant formula. In practice, in most cases where mothers are already using infant formula, there is not a ‘good’ WFP, SCJ launched the Supplementary Feeding Pro- supply of breastmilk, and these mothers are generally prescribed formula. gramme (SFP) in Zaatari camp. A blanket distribution for children 6-23 months is currently taking place If the mother is interested in relactation, the counsellor follows up with her regularly and gradually decrease the quantity of infant formula provided. If the mother does not have breastmilk supply and is not interested in on a monthly basis, and a targeted distribution with relactation, then she keeps visiting the midwife on a monthly basis to receive the infant formula prescription. regular follow up is conducted for MAM cases twice a month. e Super Cereal Plus is not well accepted Infant formula is provided for infants until 12 months only. by the children compared to the local fortified Weighing infants on a monthly basis would be a useful additional indicator to inform and monitor infant formula porridge that was initially provided. prescription. Unfortunately growth monitoring is not yet in place, but its implementation is under discussion. Outside Zaatri camp As of July 2013, the SCJ IYCF programme was also and correct preparation of the infant formula and formula in Zaatari camp (camp population 79,708), providing services to the Emarati Jordanian camp to explore the possibility of re-lactation. Even with 28 mothers in Asraq camp (approx. 13,000 population) (EJC) and to the host community. EJC is a relatively the strict prescription criteria, infant formula tins and 7 mothers in Emarati Jordanian camp (EJC) small camp compared to Zaatari with a population were being sold in the camp market. us it was (about 4000 population). of only 3,600 refugees. e process of monitoring agreed with staff based in the dispensing site to infant formula was also difficult at the beginning, open each tin once the mother received it. is Complementary feeding as the clinic was providing infant formula on a mechanism worked well, as no one was then willing During the early days in Za’atri camp, the food weekly basis to all families with infants under 1 to buy an already opened tin of infant formula. ration was provided by WFP along with a comple- year of age. It took a while to convince the manage- mentary ration by UNHCR. People complained ment and the health providers of the need to control Infant formula donations and their untargeted about lack of diversity, but the main concern from a this, and the adverse effect it could have on infant’s distribution remain a challenge. Although the SOPs nutritional point of view was meeting the needs of health. e IYCF midwife is now responsible for (see earlier) have been circulated, shared and discussed children aged 6-23 months. Mothers were constantly prescribing the infant formula and only seven with all partners, individual donations of infant for- complaining that the ration didn’t include anything mothers are now receiving supplies on medical mula still find their way to the camp. It is worth adequate for this age group, and not everyone in grounds. Given the small camp population, SCJ is noting that many mothers are refusing the donations the camp had the ability to buy fruit and vegetables. able to follow up with all infants under 1 year in the or returning any quantities they receive as they are camp. Overall, 30-40 mothers receive IYCF coun- e need for a fortified food suitable for children exclusively breastfeeding. Street leaders from the selling on a daily basis in the IYCF caravan. By 6-23 months was agreed and WFP sought procure- community approached the clinic a few months ago working closely with the clinic, SCJ ensure that ment of international supply of Super Cereal Plus. with quantities of donated formula; they wanted to each infant below 6 months is being followed up by Due to complications in procurement that delayed leave it with the midwife as she would know who the IYCF counsellor in the camp. actually needs to receive it, which shows that the supplies by seven months (see below), UNHCR, community is now aware of the risks of such distri- UNICEF and SCJ stop-gapped with an intended Discussion butions. An average of 10 new mothers is prescribed short term (4 month) blanket distribution of a local Aer 16 months of implementing IYCF in the camps formula on a weekly basis. With the opening of a fortified porridge, targeting children 6-23 months and host community, we have successfully reached new refugee camp (Azraq camp) in Jordan in April (March – June 2013). Four packs of 250g each were 29,000 PLW (new visits or first counselling contacts) 2014, many lessons have been applied from the ex- provided for each child on monthly basis. Special and 40,000 children under 5 years (total contacts). periences in Zaatari camp. A system for infant cases, such as cerebral palsy children, were also in- More than 47,000 beneficiaries (mothers, fathers, formula provision has been in place from the be- cluded in the distribution. e distribution itself and grandmothers) have attended the IYCF sessions ginning. Upon prescription, mothers are given was a challenge as many security concerns were conducted in different partner’s locations. specific dates to go and receive the infant formula, raised regarding families with older children who would not receive the product. Careful sensitisation It is becoming clear that building capacity and the dispensing takes place twice a week, and a list is cooperation with health providers on communicating communicated each time from the prescription to was undertaken to inform the community and explain to them the importance and rationale of the a unified IYCF message plays a crucial role in con- the dispensing site to avoid any confusion. As of vincing mothers of the importance of breastfeeding September 2014, 226 mothers are prescribed infant product for this specific age group. e local com- plementary food was well received by families but and early breastfeeding initiation. Higher rates of was expensive. It was not available to purchase in exclusive breastfeeding are noticed among mothers An individual teaching session the camp markets. ree cycles were completed but who are regularly followed up by IYCF counsellors, the fourth did not happen due to inadequate funds. and anecdotally, many are noticing the lower incidence of diarrhoea and respiratory infections compared Referral and management of acute to other non-breastfed infants. malnutrition cases A mid upper arm circumference (MUAC) screening In terms of meeting the needs of infants dependent conducted by the SCJ team during the complementary on infant formula, greater control on the imple- food distribution period found a global acute mal- mentation of the International Code of Marketing nutrition rate (GAM) rate of 2.6%. Since malnutrition of BMS by the Ministry of Health would have been was not a major concern in Jordan pre-crisis, there very helpful. Uncontrolled distribution of infant were no clear national protocols or referral pathways. formula early in the crisis was a great cause of e Nutrition SWG developed a national protocol, tension with the community; if the community had which was later adopted by the Ministry of Health, been informed of the procedures and guidelines and draed a letter requesting permission to import from the beginning, we could have avoided many RUTF (Plumpy’nut) and fortified blended food problems. is is what is currently being done in (Super Cereal Plus). In reality, product approvals Azraq camp and there have been no problems. Now, and releasing of the products from customs took in Zaatri camp, the needs of formula fed infants are more than six months. us the identified cases being met - supplies are always available, there is a had to be managed using other interventions. Severe clear referral pathway and system in place for mothers acute malnutrition (SAM) cases were referred to who need formula and there is follow up of infants. the MSF hospital inside the camp and moderate For more information, contact: Sura Alsamman, acute malnutrition (MAM) cases were provided email: [email protected] Save the Children Jordan, 2013 Jordan, the Children Save ...... 40 Postscript ......

Postscript Commentary on experiences of IYCF support in the Jordan response

By Ann Burton, Senior Public Health Officer UNHCR Jordan

The articles by Medair and Save the Children that advocacy and training needs to also target associated with actual formula distribution. The highlight the challenges in protecting and other sectoral actors in addition to those working different approaches in the camp and non-camp promoting sound infant and young child feeding in health and nutrition. Non-traditional actors, settings in Jordan have resulted in formula (IYCF) practices in a humanitarian emergency. especially the military and emerging feeding being considerably more common in out- Much of the guidance on IYCF has been humanitarian actors, also need to be made aware. of-camp infant refugees compared to those living developed for resource poor settings. Infants in As these actors expand their geographical scope in the camp (16.1 % of those 23 months and these settings who are not breastfed have a much into other crisis-affected parts of the world - many under had received formula in the preceding 24 higher risk of dying. This risk is exacerbated by of which have considerably higher malnutrition hours versus 9.8% respectively). 2 Though the the upheaval generated by emergency settings. rates and poorer hygiene and sanitation more restricted access in the camp to BMS and There have been few articles published on situations – the effects of indiscriminate use of the IYCF programming are no doubt significant experiences of IYCF in emergencies in low to BMS on infant morbidity and mortality would be factors, more research is needed on the middle income countries, such as Jordan. Acute much more severe. determinants of infant feeding choices in malnutrition prevalence amongst Syrian refugees displaced populations. Are displaced women Another key challenge in the Syrian situation and in Jordan is low and not considered a public choosing to breastfeed because of economic detailed by these two articles is how to support health problem, and mortality rates are low and necessity as well as convenience and if so how can non-breastfed infants and their mothers to ensure stable; regardless there is always an important these factors be used to promote breastfeeding in optimal growth and wellbeing but without need to promote sound IYCF practices for optimal similar situations? undermining key messages in support of infant and young child health outcomes. breastfeeding. Much of the focus of IYCF Lastly, more consideration needs to be given to Alsamman and Fander et al highlight the poor programming has been support to breastfeeding the question of informed choice in infant feeding IYCF practices both in Syria and in the refugee mothers or relactation. Alsamman has outlined practices and to what extent humanitarian actors hosting country, Jordan, prior to the refugee the support in camp settings in Jordan to non- should withhold support for formula feeding in influx. Though it is critical to try and protect breastfed infants. In non-camp settings, this has women who have made a truly informed choice. breastfeeding throughout all stages of the been very difficult to put in place. Most refugees Are humanitarian actors prepared to support this refugee programming, this has been made much access Ministry of Health services and apart from approach in settings where the choice to formula harder by the poor practices pre-conflict, the low ad hoc support to some women, non- feed - though not optimal - does not carry the level of knowledge amongst many humanitarian governmental organisation (NGO) service same health consequences as in other settings? actors, including medical and nursing staff, and providers are not in a position to meet the Even though the Operational Guidance on IYCF-E the misconceptions around breastfeeding. There demand for infant formula which would entail promotes the minimisation of the risks of artificial were many non-traditional actors involved in the assessment of women for their ability to feeding, this is not always given the attention it response most of whom had not been exposed to breastfeed, prescription and dispensing when needs in IYCF programming. Furthermore, the the Code or the Operational Guidance on IYCF in indicated and support to non–breastfed infants. tendency is to focus on mothers who cannot Emergencies (IYCF-E). Though health and Their reluctance to get involved has also been breastfeed and not those who choose to not nutrition programme managers from influenced by security concerns based on the breastfeed. The economic considerations of an international organisations were well-versed in experiences in Zaatri Camp outlined by informed choice approach are also considerable. the current recommendations about the use of Alsamman. In Jordan, infant formula is only Infant formula is an expensive commodity and it is breastmilk substitutes (BMS), doctors and available through pharmacies and is therefore not unlikely that limited humanitarian funds could be midwives providing services were not generally available through the WFP-supported food used to support provision of formula in a situation very supportive of breastfeeding or easily voucher schemes, which has also limited formula where a woman has chosen to formula feed. succumbed to pressure from mothers and family use in out-of-camp settings. Recognising that Indiscriminate distribution of BMS and unsolicited members to provide infant formula. Practices there are mothers who will not be able to donations should still be managed as per the surrounding delivery were also not conducive to breastfeed and who will have difficulties affording Operational Guidance on IYCF-E but should a harm early initiation, with the infant often separated formula, the Nutrition Working Group is exploring minimisation approach be considered in some from the mother and started on other liquids. This the option of referring mothers who are unable to settings? The Syrian refugee situation, with most highlights the need to not only target breastfeed (after assessment by a midwife trained refugees fleeing to low - middle income countries, humanitarian service providers with training in in IYCF) for cash assistance so that they can has raised these questions and is challenging key beneficial IYCF practices but also, in the purchase formula themselves. This would be actors to review thinking on this issue. medium to longer term, to strengthen the IYCF combined with the additional support and follow component of medical and nursing school up needed for non-breastfed infants but will For more information, contact: Ann Burton, curricula and revitalise the Baby Friendly Hospital reduce the likelihood of the potential problems email:[email protected] Initiative. Unsolicited donations of BMS continue at the time One of the IYCF caravans in Zaatari camp of writing. Fortunately, the Standard Operating Procedures on Distribution and Procurement of Infant Formula and Infant Feeding Equipment1 put in place in November 2012 by the Nutrition Sub-working Group (and updated in May 2014) meant that many donations came to the attention of the nutrition actors and measures could be taken to minimise the risks associated with such donations. However, as pointed out by Flanders et al, this was very time consuming at a time when there were many other pressing priorities. Furthermore, if the NWG had been consulted prior to the donation, a request would have been made for other food or non-food items, such as age appropriate complementary food in place of infant formula. There were many donations and distributions of BMS outside of the health system demonstrating Save the Children Jordan, 2013 Jordan, the Children Save ...... 41 Field Article ......

Assisting the most vulnerable in the Syria crisis e conflict in Syria was triggered by protests in tional: via a hotline, through fixed point (Handicap mid-March 2011. Now, three years later, it has International centre established within community evolved into a complex and protracted humanitarian facilities), through referral from outside (including crisis, spilling into neighbouring countries and community focal persons), and on-the-spot identi- the wider Middle East region. Nearly three million fication by outreach teams. people have fled Syria and an estimated 9.3 million For assessing the vulnerability, Handicap Inter- people are in need of humanitarian assistance national looks at the interaction between personal across the region. Most refugees live outside of factors (such as age, gender or disability) and envi- camps in different urban and rural settings. e ronmental factors (such as access to services or the scale of the Syria crisis is stretching the capacity of availability of an assistive device when required). humanitarian actors to ensure and maintain standard Handicap International assesses basic needs (food, quality assistance that address specific vulnerabilities shelter, water, sanitation and hygiene (WASH), and needs. A global partnership between HelpAge health, household essential items, education) as well International and Handicap International led to a as specific needs (physical and functional rehabili- decision to address this recurrent issue by initiating tation, psychosocial support). Once the person is a Syrian crisis-focused inclusion programme. e assessed, the Handicap International referral focal programme is aimed at facilitating the implemen- point decides on possible internal and/or external tation of a principled, inclusive and accessible hu- referrals. As much as possible, Handicap International manitarian response for the most vulnerable, es- tries to refer to the services that already exist, to pecially older refugees and refugees with disabilities. avoid duplication. However, whenever the service e inclusion team consist of three experts: is not available or is of insufficient quality, Handicap one Inclusion Advisor in both Jordan and Lebanon International can provide complementary direct and a Programme Manager at regional level. eir services (see below) which vary depending on the inclusion mainstreaming work focuses on: context and the identified gaps. Referrals not only The situation • Capacity building of humanitarian actors to provide information but also establish a connection design and implement programmes and between the individual or household and the external activities that are inclusive towards older actor receiving the referral. of older refugees and refugees with disabilities. Handicap International can directly provide iden- • Providing technical support to humanitarian tified beneficiaries with physical and functional re- actors on age and disability inclusion. refugees and habilitation and psychosocial support services, as • Advocacy and awareness raising on inclusion well as with emergency livelihood support such as issues with the coordination structures cash assistance. e cash assistance is unconditional, (working groups, task forces, coordination refugees with to support the most vulnerable households to meet meetings) and towards donors and authorities. their basic needs, including food and shelter. In the • Leading coordination on age and disability Bekaa region of Lebanon, Handicap International disabilities, related issues through the Disability & Older also provides newcomers – refugees who have been Age Working Group in Lebanon, and the Age in the country less than 30 days – with essential & Disability Task Force in Zaatari camp household items. is in kind support for newcomers injuries, and (Jordan). is harmonised throughout Lebanon. e package is e main aim of inclusion mainstreaming work is comprised of a hygiene kit, a kitchen kit, a baby kit chronic to enhance inclusiveness of the overall response (if needed), mattresses and blankets. e World towards the most vulnerable groups, i.e. the persons Food Programme (WFP) complements all Handicap diseases in the excluded from services or response and more International’s Household Essential Items kits in specifically, older refugees and refugees affected Bekaa with a food parcel. by an injury, disability or chronic condition – as Hidden victims of the Syria crisis Syria crisis these groups of individuals are most likely to be excluded or invisible. Rather than creating parallel Extensive operational experience of Handicap In- ternational and HelpAge International has shown By Lydia de Leeuw targeted activities and services, the programme seeks the integration of age and disability consid- that people with disabilities and older people are oen overlooked in crises. Due to a variety of Lydia de Leeuw is the erations into the programming of all responding actors. obstacles they oen face particular difficulty in ac- Regional Inclusion cessing humanitarian assistance, especially when Programme Manager for Vulnerability assessment approach the available services or facilities are not adapted both HelpAge At the operational level, Handicap International and not accessible or suitable for them. At the same International and has a distinct approach toward targeting the most time, due to their age, serious medical condition Handicap International in vulnerable among the refugee population in Jordan and/or disability, these groups are oen dispropor- the Syria crisis. She has and Lebanon. Using its trademark Disability and tionally affected by crisis and displacement. Main- extensive experience in the Middle East Vulnerability Focal Point mechanism (DVFP), the stream health responses in humanitarian crises working on refugee protection, rights based organisation effectively reaches out to refugees at largely fail to address the needs of those with man- advocacy, research, and project management, community level and seeks to address the gaps ageable chronic health conditions. People living and holds a BSc and MSc in Criminology. which lead to a lack of access to, or exclusion with non-communicable diseases may face limited from, services, which could further lead to increased access to care and interruption of their treatment. Thanks to Becky Achan, Technical Advisor on vulnerability. First, mapping of the context – in- e subsequent interruptions in their treatment can Inclusion with Handicap International and cluding available services – is done. Based on that result in severe complications, including stroke (due HelpAge International in Jordan, who helped mapping, vulnerability profiles are determined for to hypertension) and gangrene foot or blindness conceptualise and develop the article outline. the different contexts. Both the vulnerability of (due to complications of diabetes), which inevitably the household and individuals are taken into leads to increasing levels of morbidity, disability, account. Subsequently, there are four entry points and mortality. During displacement, people – in for new cases to be assessed by Handicap Interna- particular older people – who have specific nutritional ...... 42 Field Article ...... needs may face challenges in accessing Humanitarian implications of the the food they need. is can lead to both existing needs qualitative and quantitative malnutrition. e prevalence of chronic diseases among Refugees living with a disability can face Syrian refugees in Jordan and Lebanon protection risks and increased vulnerability (15.6%) tells us how widespread the needs due to lack of physically accessible emer- in this regard are. In Jordan and Lebanon, gency services, breakdown in their support the three most common reasons for system, or the loss of assistive device(s). refugees seeking healthcare result from chronic conditions, specifically diabetes, As in many other crises, the Syria crisis cardiovascular conditions and lung disease. response was hampered by a lack of dis- Despite this priority need, many refugees aggregated data on older refugees, and face insurmountable challenges in covering ©L. de Leeuw /Handicap International – HelpAge International, Irbid, Jordan, 2014 refugees living with a disabilities, injury, the cost of accessing health services. In or chronic disease. erefore, in late 2013, Hameeda Salamat (65) sits in the family's apartment in Irbid. “I have Lebanon, some refugees stated that they diabetes and high blood pressure,” explains Hameeda. “I didn’t receive any HelpAge International and Handicap In- were unable to afford the cost of transport medication here in Jordan so we have been buying medicine with our ternational undertook a study in Jordan to health centres, let alone the required own money. But the new medicines I received were different and made and Lebanon aimed at creating robust ev- 25% contribution to their hospital bills. me sick.” Saadiyeh recalls: “She was very sick for a week. Then the hospital idence and data on the numbers and basic Several chronic conditions also imply day- made sure she got back to using her old medication, which she had been and specific needs of older refugees and to-day expenses, such as the cost of needles, using for seven years already. After that she became better.” Despite being refugees living with an injury, impairment blood glucose test strips or syringes. registered with UNCHR, the family was not aware that they are entitled to or chronic condition1. e study also com- get the medication for free, using the proof of their UNHCR registration. pared the needs of these oen marginalised Besides the financial barrier, there is The Handicap International mobile team provided the family with groups to the needs of the wider refugee also a gap in the quality of the management information regarding their access to free medication. population in these countries. of chronic diseases in Jordan and Lebanon. A health assessment carried out by Hel- For the data collection, 3,202 refugees pAge International found there was almost were surveyed in seven governorates in no health education for patients, there Jordan and Lebanon. All members of was limited capacity among health staff households were enumerated, interviewed to assess patients with chronic diseases and screened. Older people were identified properly, limited services available to sup- as those aged 60 years and above. e port early screening for chronic diseases survey found that 22% were affected by such as diabetes and hypertension, and an impairment, of which 6% were affected no proper monitoring with laboratory by a severe impairment. One in five sur- tests or follow up. Finally, there is a gap veyed refugees was living with more than in terms of prevention; much more can one impairment. Older people were dis- be done to raise awareness around healthy proportionately affected by impairments, living and diet. HelpAge International ©L. de Leeuw /Handicap International – HelpAge International, Tripoli, Lebanon, 2014 with a staggering 70% of those aged above and Handicap International are working 60 years presenting with at least one im- with local partners to improve prevention, Ahmad KhairBirjawi (67) takes a rest after doing rehabilitation exercises pairment. Older people were also almost as well as identification and referral of with a Handicap International physiotherapist (Abu Samra, Tripoli, twice as likely as children to present with those with non-communicable disease, Lebanon). Ahmed suffers from diabetes and cardiovascular disease. intellectual impairments. In the study it and to support the national health systems Complications of his diabetes led to the amputation of his lower right leg was found that of the surveyed refugees, to improve levels of care. in 2006. Because of the fighting in his hometown, he and his family were 15.6% were affected by chronic disease. forced to flee to Lebanon. Even though the sun is shining outside, their An age analysis showed there are three With regard to the humanitarian im- place is cold and humid. Ahmed doesn’t go outside much. As the family main profiles affected: people aged up to plications of injuries among Syrian lives on the second floor, it is extremely difficult to carry Ahmed down the 30 years, of whom 10% are affected by refugees, it is clear that the need for care stairs, so he normally doesn’t get to leave the building. A small plateau chronic diseases; those aged 30-50 years, and assistance reaches far beyond the outside the front door of the apartment is the only outside space that is of whom 30% are affected; and those aged emergency response. Many injured accessible for Ahmed.“We are looking for another place to live, refugees are struggling to find long-term 50 years or over, of whom half are affected. somewhere where there is an equal bottom floor so that he can go physical rehabilitation care, as well as is profile of different age groups and outside,” says his wife, Ilham. prevalence of chronic conditions can be post-operative care. ere is a lack of instrumental to inform the design and complete post-operative care. Handicap delivery of health services in the Syria International’s intervention, providing physical rehabilitation services, is not response. enough without other actors helping. e e Syrian conflict has been noted for limited availability of physical rehabilitation its highly disabling impact on the Syrian support is a worrying issue. Where physical population due to the levels of conflict rehabilitation care can mitigate the de- related injuries. is was confirmed by velopment of potentially permanent dis- this study in which 5.7% of surveyed ability, the lack thereof can lead to the refugees have a significant injury, i.e. one worsening of existing injury-related health that has an impact on body function and conditions. Handicap International’s in- hence a potentially disabling effect. e terventions have revealed high numbers overwhelming majority – 4 out of 5 injuries of injuries leading to amputation, as well ©L. de Leeuw /Handicap International – HelpAge International, Tripoli, Lebanon, 2014 – was directly caused by the conflict. is as spinal cord injuries caused by shelling means that in Jordan, 1 in 15 Syrian and gunshots, which result in serious and Salem Kasha (35) with his wife and children live in a small apartment in El refugees have been injured as a result of sometimes permanent impairments. Be- Mina, Tripoli, Lebanon. Salem was injured in a bombing close to his family the war. In Lebanon this is 1 in 30 refugees. yond immediate health care, these complex home in Aleppo. He is now receiving rehabilitative care for his injuries, Consistent with the nature of the conflict, injuries require long term physical reha- provided by Handicap International. Still faced with pain and limited bombing, shrapnel wounds and gunshots bilitation, psychological support, and for mobility, Salem is unable to work. The lack of an income is an increasing account for a large proportion of injuries those with permanent impairments, some- problem for his family. “I have problems moving my right hand. Now I (58%). Additionally, of those reporting times lifelong care. cannot work because of my hand, and I don’t know what to do anymore. I injury, 25% resulted from accidents such feel desperate. We have registered ourselves as refugees, but do not 1 as falls and burns – accidents that become Hidden victims of the Syrian crisis: disabled, receive any support.” Without an income, the family’s financial reserves injured and older refugees. Jointly published by more common by living in homes dam- HelpAge International and Handicap have finished, and paying the rent has become impossible. “I am asking aged by the conflict or fleeing attack. International. 2014 the landlord to wait for the next payment,” says Salem...... 43 Field Article ...... Views...... Recommendations Humanitarian actors and national systems struggle to cope with the high numbers of injuries, chronic conditions and impairments, and the continuous influx of new refugees. e mid and long term implications of injuries among Syrian refugees require that national and interna- tional health care providers work together in a collaborative effort to address the current needs of this population, but also prepare for the longer term financial and human re- source requirements needed to prepare health systems, families and communities to ensure adequate support. In particular, all stakeholders need to prioritise long-term physical rehabilitation care and post-surgical care adequately, according to the prevalence and types of injuries inflicted. Furthermore, it is critical that long term health planning in Jordan and Lebanon takes account of the need for pre- vention, monitoring and regular treatment for non-com- municable diseases to avoid heightened levels of both im- pairment requiring further care, and ultimately to reduce levels of morbidity and mortality. is could be done UN and INGO experiences of through awareness raising around healthy living and diet, health education for patients, capacity building among health staff to properly assess patients with chronic diseases, coordination in Jordan increased early screening or monitoring of chronic diseases such as diabetes and hypertension, with laboratory tests WFP/Jonathan Dumont or follow up. By Alex Tyler and Jack Byrne Current and past experiences indicate that overall, a ‘twin-track’ approach to addressing basic and specific needs Alex Tyler is Inter-Sector Coordinator for UNHCR Jordan of refugees affected by injury, impairment or chronic disease, provides the best safeguard for equal access to services for Jack Byrne is Country Director for IRC and Chair of the INGO Forum for Jordan all. In a twin track approach, actors ensure that – on the one hand – they integrate refugees with specific needs into their mainstream programming to the largest extent possible and – on the other hand – where necessary, activities are s of July 2014, there are now over sectors are linked through an Inter-Sector designed to target people with specific needs separately. 600,000 Syrian refugees in Jordan; Working Group (ISWG) – a meeting of sector For example, a refugee in a wheelchair should be able to with up to 80,000 in camps, and chairs with the aim to encourage synergies access latrines in a camp like everyone else (accessible 520,000 in urban and rural areas. between sectors – which in turn reports up to WASH design – mainstream approach) but might also Ae Government of Jordan, civil society and the heads of UN and NGOs who meet together require physical rehabilitation support for his legs amputation the international community have all stepped in the Inter-Agency Task Force (IATF). Nu- (targeted activity by a specialised agency). Both targeted up to meet the enormous needs, both of trition, together with Reproductive Health and mainstream activities are essential to ensure the full refugees and of the Jordanian communities1 and Mental Health and Psychosocial Support integration of refugees with specific needs in the overall affected by the crisis. e Jordan Refugee Re- Services (MHPSS), are sub-sectors of Health. humanitarian response. In the Syria response there have sponse is the broad frame for these. been many good examples of both targeted and mainstream Complementary yet independent from responses. However, with the current needs, a continuation Under the leadership of the Government these structures, the International NGO and expansion of both is required. of Jordan and coordinated by UNHCR, the (INGO) Forum sets common policies and Jordan Refugee Response is a collaborative pursues advocacy initiatives, based on con- For more information, contact: effort between the donor community, United sensus among the NGO community. ere Regional: Lydia de Leeuw, Nations (UN) agencies, international and na- are currently 53 INGOs signed up to the email:[email protected], tel: +962 789226128 tional non-governmental organisations INGO Forum. Jordan: Becky Achan, email: [email protected], (NGOs), community-based organisations, e scale of the refugee response and the tel: +962 788858651 refugees and Jordanian communities. Lebanon: Boram Lee, email: [email protected], myriad of partners and structures involved tel: +961 76993330 All levels of the Government of Jordan are provide a glimpse into the complexities and engaged in the response, from the Office of challenges faced in achieving effective coor- For questions regarding Handicap International’s opera- the Prime Minister, the Ministry of Foreign dination. is is a massive operation, with tional response in the region, contact: Affairs, the Ministry of Interior and the Ministry staffing numbers well into the thousands. Anne Garella, Regional Emergency Representative, of Planning and International Cooperation Each organisation has also experienced a sig- [email protected] (MOPIC), to the line ministries working with nificant expansion in staff compared to two each of the sectors, and the governorates and years ago. UNHCR alone has grown from municipalities in refugee-affected areas. In around 100 staff in 2012 to now almost 700 2014, the Ministry of Interior created the staff by mid-2014. Syrian Refugee Assistance Directorate (SRAD), Refugee Coordination pre-dates the Trans- which is the primary government entity for formative Agenda3 and is distinct from the the coordination of refugee issues in the Cluster system. More recently it has been country.

From an inter-agency perspective, the main 1 The response to vulnerable Jordanian populations is strategic framework for the response is the built into every project approved by the Government of Jordan; it is mandated that each project Jordan chapter of the Regional Response Plan responding to refugees must respond to vulnerable 2 (RRP) . In 2014, 64 partners have appealed host populations. In recognition of the need to ensure for a total of USD 1 Billion through the RRP. Jordanian communities are effectively assisted, both Delivery is organised through eight sectors— the RRP strategies in 2013 and 2014 have explicitly Cash, Education, Food Security, Health, Non- targeted host communities. In 2014, over 700,000 Jordanians are benefiting from the RRP. Food Items (NFIs), Protection, Shelter, and 2 Available at http://www.unhcr.org/syriarrp6 Saadiyah (47) is working on a dress in Irbid, Jordan Water, Sanitation and Hygiene (WASH). e 3 ©L. de Leeuw /HelpAge International, Jordan, 2014 Jordan, International, /HelpAge ©L. de Leeuw For more information, see www.humanitarianinfo.org ...... 44 Field Article ...... reaffirmed at the global level through the Refugee Irbid and Amman only went ahead aer extensive Coordination Model4. In short, in collaboration discussions with and within the INGO forum. It with the Government of Jordan and mandated by has to be said that we are not there yet, and oen the UN General Assembly, UNHCR remains the find ourselves well beyond the line of ‘the minimum coordinating organisation for the entire response. necessary’, but will go through regular ‘retrenchment’ WFP/Jonathan Dumont WFP/Jonathan e time-line for UNHCR’s engagement stretches of meetings to keep this under control. well beyond the emergency phase. It also includes Investing in Information Management as a co- longer term care and maintenance, as well as the ordination service has been important, both to fa- pursuit of durable solutions, through voluntary cilitate planning and implementation by partners, repatriation, local reintegration or resettlement to a and to shi coordination meetings from long, round- third country. the-table sessions, to being more focused on both At the same time, there are many parallels with strategy development and problem-solving. e Jor- the Cluster system. Key operational UN agencies – dan response uses a number of portals and platforms especially WFP, UNICEF, WHO and UNFPA – man- to keep partners updated. An example is Activity- age sectors in which they have specific expertise. Info6 – an online platform for planning activities While UNHCR remains overall the ‘agency of last and reporting achievements against pre-defined in- resort’, other UN agencies are committed to delivery dicators. Originally developed by UNICEF in the in their sectors, both through their own mandates Democratic Republic of the Congo (DRC), Activi- and through a series of global and national memo- tyInfo allows partners to log their own activities randa of understanding with UNHCR. International and check what everyone else is doing and where7. and national NGOs are crucial at all levels of the re- Used well it is a transparent system designed to em- sponse – from strategic leadership down to the daily power partners, enabling them to conduct simple alienating donor agencies who fund these mechanisms delivery of protection and assistance to refugees gap analysis, generating maps and charts for their and of driing farther from the real purpose of our and Jordanian communities. activities and for a geographical area or for the collective response, which is to assist those affected sector as a whole. UNHCR is aware that partners e Cluster system has also set the tone for what by the crisis. is expected from coordination; in many respects need some initial support and training to be able to contributing to the professionalisation of coordination use its full potential. With high staff turnover this It is widely acknowledged among the humanitarian as a function within aid work. e efforts of Global can be a challenge in itself. community that in Jordan, coordination and com- munication between and among INGOs and their Clusters and the Inter-Agency Standing Committee From the INGO perspective (IASC) have defined standards and guidelines, many counterparts in the UN works well relative to coor- e Jordan INGO Forum came together as an of which are applicable in refugee situations. ey dination structures in other countries in the region. informal group of the handful of organisations that have also tried and tested coordination structures It is critical that INGOs continue to advocate for had been operating in Jordan before the onset of the and appeal mechanisms – developing best practices issues that affect their ability to operate with neutrality, Syrian crisis. It has gradually played a much larger that have also been adapted by UNHCR and partners to choose well-informed representatives to speak role in overall crisis coordination as more and more across the region affected by the Syria crisis. for the collective, and to engage actively with the INGOs established themselves in Amman – with UN and the government of Jordan to protect hu- For instance, adapting best practices, the process the largest INGOs establishing both a country and manitarian space in the face of concerns over safety resulting in Jordan’s RRP has been robust. ree regional offices in the capital city. Establishment of and security, which, while unarguable, will have months of inclusive planning at the strategic and the Forum was not at the behest of donors or UN negative effects for Syrians seeking refuge in Jordan sector levels resulted in a clear strategy, peer-reviewed agencies but rather was an organic process to meet and for Syrians already here. by sector chairs, and built on over 1,200 projects or the needs of members, at first around safety, security, activities of the 64 appealing partners. advocacy and information sharing, and then to be To conclude, there are traditional rivalries between important stakeholders at the table with the UN, the some organisations – both at the UN level and Professionalising coordination clearly has many government of Jordan, and with donors. e thirteen among INGOs. Organisations do compete for funds benefits – more efficient systems, reducing duplication largest INGOs operating in Jordan programme well and for responsibilities over different sectors. While and better serving partners’ information needs. It over $100 million in humanitarian activities to aid organisations do of course recognise that pursuing also brings some risks. While UNHCR and many refugees and vulnerable Jordanians and are some of common goals collectively is the most effective way other organisations now have dedicated coordination the most operational actors in the crisis. to serve refugees’ needs, there is an ever present staff in Jordan, the danger is that coordination struc- jostling for space between the partners. Coordination Forum leadership and representation went through tures become heavy, overbearing on organisations’ cannot be blind to this, or the pursuit of the overall a number of iterations, from an informal Chair and independence and, at worst, self-serving and dislo- goals may be negatively affected. It is key that struc- Co-Chair that facilitated monthly meetings, to its cated from the realities faced by staff at field level tures are balanced, built on mutual respect, consul- present structure of a Chair and four Steering Com- and from the people we are trying to help. e pro- tative and do provide space for visibility and inde- mittee members. At the strategic levels, these five liferation of coordination structures – the ‘task force pendence of organisations. At the same time, no people represent INGOs on the Inter-Agency Task disease’ – can itself be counter-productive. Too many one organisation can go it alone, and expect to Force, the Humanitarian Country Team, the Inter- meetings are particularly onerous on the smaller deliver an impact beyond their own project. e Sector working Groups, monthly meetings with international and national NGOs, who do not have strength of the Jordan Refugee Response is that it donors, and with the government of Jordan, mainly the staffing levels necessary to attend them all. One recognises greater benefits come from collective through interaction with the MOPIC. risk is that some partners opt-out of these meetings, action of all the organisations involved, each bringing or send junior staff. is can result in actual decision Despite having a legitimate place at the table, to the table their own skills and expertise in a gen- making being further skewed towards the larger or- achieving meaningful INGO representation within uinely inclusive manner. ganisations. existing and new coordination structures remains a More information on refugee coordination in challenge. Some INGOs manage larger budgets and In Jordan, we have an o repeated mantra to Jordan can be found through the Jordan country certainly have greater operational capacity than keep coordination to the “minimum necessary to pages at http://data.unhcr.org/syrianrefugees/ many of the smaller UN agencies. Conversely, many facilitate collective action”, and that each new structure country.php?id=107 and in the dra Coordination INGOs are short-term responders with rapid staff or process proposed needs to demonstrate a clear Briefing Kit at http://data.unhcr.org/syrian- turnover, and do not have the resources to dedicate added value. We have tried various ways to meet refugees/download.php?id=6379 this standard. First, regular anonymous surveys are to the Forum or to the multitude of coordination meetings that take place on a daily basis. A particular conducted with sector members to canvass opinion 4 UNHCR, Refugee Coordination Model, November 2013, on the performance of the sectors in general, and challenge for INGOs and the UN alike are new co- available at http://www.unhcr.org/53679e2c9.pdf also to elicit feedback from sector members on how ordination mechanisms underway from various 5 See the latest survey results at http://data.unhcr.org/ coordination structures can be improved or stream- stakeholders, which tend to hinder implementation syrianrefugees/download.php?id=6158 6 lined5. Secondly, the INGO forum has a seat on the of what has already been agreed to and blur the For Jordan, Activityinfo is accessed through the URL lines around who is doing what. Additional layers www.syrianrefugeeresponse.org Inter-Sector Working Group, and is consulted on 7 See Claire Barnhoorn (2014). Spreading around the globe: design of these structures. e recent roll out of co- of coordination need strong justification and buy- ActivityInfo. Field Exchange 47, April 2014. p51. ordination fora in three governorates of Mafraq, in from all involved; otherwise there is the risk of www.ennonline.net/fex/47/spreading ...... 45 Field Articles......

SARC volunteers at a distribution centre in rural Damascus WFP’s emergency programme in Syria Syria Dina Elkassaby/WFP, Syria, 2013 Syria, Dina Elkassaby/WFP, By Rasmus Egendal and Adeyinka Badejo

Rasmus Egendal has more Adeyinka Badejo joined WFP in than 20 years of experience 2001 and is currently Deputy in international Country Director for WFP in development and Syria. Previously, she served as humanitarian aid a WFP Programme Officer in assistance. Currently he is Afghanistan, Zimbabwe, Sudan serving as Deputy Regional and in Rome and undertook Emergency Coordinator for WFP’s Emergency field work in Pakistan, Palestine, Tanzania, Egypt, Response in Syria and neighbouring countries. Cambodia, Nepal and Afghanistan.

The authors gratefully acknowledge the contributions of Sarah Gordon-Gibson, Regional Programme Manager, WFP Syria and neighboring countries; Lourdes Ibarra, Head of Programme, WFP Syria; Yasmine Lababidi, Nutrition Programme Assistant; and Nicoletta Grita, Reports Officer.

Overview WFP has had a continued presence in Syria for almost partners support the delivery and distribution of WFP 50 years, providing more than US$500 million worth food assistance. ese include SARC, 25 local NGOs, of food assistance into the country through development and one international NGO (the Aga Khan Foundation) and emergency operations. Prior to the current working in Hama governorate. rough their long es- conflict, WFP, together with its partner organisation tablished presences and extensive local networks, the Syrian Arab Red Crescent (SARC), responded to WFP’s partner organisations, local authorities and emergency food needs following consecutive droughts, community leaders mobilised to help ensure and or- assisted in the implementation of school feeding pro- ganise the safe delivery of assistance. Each partner grammes and provided assistance to Iraqi refugees has been selected to ensure their compatibility with seeking sanctuary in Syria. In October 2011, WFP WFP’s mandate and with the principles of the UN launched an emergency operation to provide relief Global Compact1 and the WFP Code of Conduct. food assistance to affected families, in what was then Considerable efforts to strengthen local capacity have a localised conflict. Initially targeting 50,000 benefi- been made throughout 2013 including supplying crucial ciaries, the operation was rapidly scaled up as the equipment and providing training on warehouse man- conflict spread over the following months. Over time, agement, safe distribution practices, and programme WFP modified the composition of the food basket, in monitoring. While allocation to partners varies on the response to changes in the availability and accessibility basis of needs, capacity and access, on average approxi- of individual commodities. A blanket supplementary mately 55% of total food rations are allocated to SARC, feeding programme (BSFP) for young children was while the remaining 45% are distributed by the NGO developed following concerns over declining nutritional partners. SARC implements distributions through its indicators. Ready-to-eat food rations were provided Bonus content online branches and sub-branches, or through local charities for newly displaced families without access to alternative in locations where it has no presence. • Stop-gapping nutrition sources of food or cooking facilities. coordination for the Syria e number of WFP staff in country has gradually In 2013, WFP gradually scaled up its response, response increased to over 200; the majority of these are national reaching close to 3.4 million beneficiaries across all Postscript to 'Experiences and staff. WFP and local partners are currently implementing 14 Syrian governorates. WFP expanded its network challenges of World Vision's three main schemes – general food distribution, BSFPs of local non-governmental organisations (NGOs) be- programming in Northern Syria' for young children and ready-to-eat rations. e latter yond SARC to enhance its capacity and reach to meet www.ennonline.net/fex rapidly growing needs. As of June 2014, a total of 27 1 https://www.unglobalcompact.org ...... 46 Field Article ...... are distributed to newly displaced families with (see Box 1). e assistance prioritises displaced limited access to food or cooking facilities during households who have lost their main source of the initial days of their displacement. In late 2014, income, as well as poor communities hosting a large two additional components were added: a school number of displaced families. Each household feeding programme to encourage regular attendance receives a food basket sufficient to feed a family of WFP/Dalia Khamissy in school and distribution of food vouchers to five for one month. e monthly family food basket promote dietary diversity for pregnant and breast- consists of a variety of commodities such as rice, feeding mothers. bulgur wheat, pasta, pulses, vegetable oil, sugar and salt. In 2014, the food basket was revised from 1680 e number of WFP staff in country has gradually kcals to provide up to 1,920 kcal per person per day. increased to over 200; the majority of these are is increase was effected as WFP’s programme national staff. WFP and local partners are currently monitoring findings suggested that families were implementing three main schemes – general food increasingly less able to access additional food from Syrian refugees distribution, BSFPs for young children and ready- alternative sources, mostly relying on the GFD. e to-eat rations. e latter are distributed to newly go shopping with quantity and composition of the basket has been e-vouchers displaced families with limited access to food or subject to changes depending on commodity avail- cooking facilities during the initial days of their ability and pipeline status. Figure 1 presents the displacement. In late 2014, two additional components target and reached populations up to July 2014. In to the targeted 227,170 civilians. e first airlis were added: a school feeding programme to encourage August 2014, food distributions reached over 4.1 were conducted in December 2013 when 6,025 food regular attendance in school and distribution of million people, or 98% of the month’s target. rations for 30,000 people were airlied from Erbil food vouchers to promote dietary diversity for preg- to cover just 13% of the monthly requirements. nant and breastfeeding mothers. Challenges rough the second round of airlis, conducted Distributions are conducted on a monthly basis in between February and March 2014, WFP was able Needs assessment in November 2013 order to balance meeting the immediate food needs to deliver just over 16,000 rations out of a planned A WFP/FAO Joint Rapid Food Needs Assessment of beneficiaries with logistical challenges associated 32,500 to support 80,000 people in the governorate. was conducted in November 2013 in Syria, in col- with such wide-scale activity across insecure areas. ese were suspended in mid-March aer Turkish laboration with the Ministry of Agriculture and In 2013, widespread insecurity restricted access to authorities granted the long awaited greenlight for Agrarian Reform and the Ministry of Social Affairs. many areas of the country, preventing the distribution the passage of 10,000 food rations into Al-Hasakeh It indicated that some 9.9 million people were esti- of assistance at the planned scale. Particularly in through Nusaybeen on the Syria-Turkey border. mated to be vulnerable to food insecurity and unable the north, escalating infighting among multiple However from April 2014, the governorate was once to purchase sufficient food to meet basic needs. Of armed groups closed access routes and deadlocked again cut-off from access. As a result, in July 2014, a these, some 6.3 million were estimated to be partic- assistance to Al-Hasakeh for most of the year, to third round of airlis was implemented from Dam- ularly exposed to the effects of conflict and displace- rural Aleppo from August 2013 and eastern Aleppo ascus. A total of 10,000 family food rations for ment and in critical need of sustained food assistance. city from September 2013. By November, the entire 50,000 people and 3,000 ready-to-eat rations to sup- A severe reduction in agricultural production, com- north-east was cut off as routes to Ar-Raqqa and port the immediate needs of newly displaced families bined with constraints in marketing available produce, Deir-ez-Zor were also blocked by continuous clashes. were delivered. During January 2014, 17,500 people as well as weakened import capacity to meet domestic Haphazard access narrowed the scope of monitoring were assisted with 3,500 ready-to-eat rations in demands, have increasingly limited food availability activities which could not be conducted in Ar- Homs and Rural Damascus. over time. Compounding the devastating effects of Raqqa, Deir-ez-Zor and Quneitra for the entire the conflict, exceptionally low levels of rainfall during year. Furthermore, shiing patterns of active conflict Each monthly cycle is typically completed over the 2013/2014 winter season conditions impacted prevented WFP teams from visiting the same sites the course of 45 days, due to access constraints and food production in 2014 and further exacerbated each month, obliging them to rotate distributions extended dispatch cycles. WFP has continuously Syria’s humanitarian crisis. Furthermore, inflation, among locations as security conditions permitted. had to make adjustments to the ration due to funding high commodity prices and growing rates of unem- Access constraints continued into 2014 as the crisis and supply chain issues. is has resulted in reductions ployment significantly reduced household purchasing became more protracted. WFP planned and ‘reached’ in ration size. ere have been many constraints to power. Foods and fuels have been severely hit by general food distribution beneficiaries are shown in providing a full ration including delays in procure- price inflation particularly in northern governorates. Figure 1 (Jan – July 2014). ment, inspection and quality issues that delay approval On the other hand, prices have actually dropped in in country and insufficient pledges from donors. To Food assistance to millions of civilians trapped some southern governorate areas. As available re- date (September 2014), cash flow problems have in besieged locations, including an estimated 800,000 sources have been depleted over time and resilience been mitigated by the use of WFP’s internal advance in Rural Damascus, remained sporadic despite un- weakened, households have increasingly resorted to funding mechanism, which have allowed borrowing relenting appeals for unhindered access. Al-Hasakeh negative coping strategies including a reduction in against future contributions. However inadequate is one of the hardest governorates to reach with hu- both the quantity and quality of food consumed, a funding commitments have become a severe con- manitarian assistance. e continued closure of decrease in dietary variety, withdrawing children straint (see later). from school and selling assets. border crossings, active fighting in neighbouring governorates and radical armed groups blocking In April 2013, WFP added wheat flour to the General food distribution (GFD) passage of trucks severely disrupted overland food food basket in response to widespread wheat flour Targeting deliveries since July 2013. As needs in the governorate and bread shortages. Targeting 70% of WFP’s planned WFP’s GFD targets the most vulnerable households continued to grow and food security of affected beneficiaries, the flour is provided to households across all 14 governorates. WFP establish the target populations deteriorated, on three instances WFP living in areas where the effects of the conflict have for each governorate on the basis of available needs was compelled to resort to costly but necessary decreased availability and reduced milling and bakery assessment as well as consultation with partners emergency airlis as the only means to deliver food capacities, to the extent that target beneficiaries are

Figure 1: WFP planned and reached general food distribution beneficiaries Box 1 WFP’s targeting approach 4.50 WFP establishes the ration type in consultation with partners, according to 4.25 4.25 4.25 4.25 4.25 4.25 4.25 4.00 nutrition consider- ations, local preferences and procurement capacity. The 3.50 3.6 3.7 4.1 3.7 3.6 ration is then approved by the relevant government authorities. Targeting 3.3 3.4 criteria are also established in consultation with partners, based on the 3.00 following vulner- ability criteria: 2.50 2.00 • Persons and households that have been displaced and have little or no 1.50 income for food 1.00 • People located in or near areas subject to armed activities with little or no income for food 0.50 • Persons and households hosting a displaced family with little or no income 0.00 for food January February March April May June July • Poor people in urban and rural areas affected by the multiple effects of the current events and who have little or no income for food. Planned Reached ...... 47 Field Article ......

governorates. Implemented in partnership with the and facilitate a return to normalcy, in 2014, WFP Ministry of Health and UNICEF, one scheme provides introduced a school feeding programme targeting monthly rations of Plumpy’Doz® (a nutritional sup- some 350,000 children in four critically affected plement for children) to children aged 6-59 months governorates, including Rural Damascus, Homs,

WFP/Dina Elkassaby living in internally displaced persons (IDP) collective Tartous and Aleppo. e first phase of the project shelters. Since September 2013, three NGOs in part- was launched in July 2014, targeting schools in nership with WFP extended the feeding programme critical districts in Rural Damascus and Tartous. beyond official IDP collective shelters to reach vul- During the first phase, up to 100,000 elementary nerable children residing in host communities in school children aged 6-12 years received daily rations Tartous, Homs and Hama. Under the second BSFP of fortified date bars, conditional on attendance. variant, the supplementary product Nutributter® for e programme, which was initially implemented the prevention of micronutrient deficiencies is being in summer schools, has been transferred to regular distributed to children aged 6-23 months living in schools when classes resumed in September. collective shelters and among host communities in the northern governorates of Syria. Inter-UN coordination Kindergarten student receives WFP has had a Memorandum of Understanding nutritional support Fuel distribution (MoU) with UNICEF in Syria, since January 2013, In response to anticipated harsh winter conditions whereby both agencies have committed, through during 2013/14, WFP provided emergency fuel sup- joint programming, to scale up nutrition interventions reliant upon WFP wheat flour distributions to meet port to vulnerable families with limited access living to address malnutrition, as well as to tackle mi- their bread needs. For the beneficiaries that receive in collective IDP shelters, in partnership with UN- cronutrient deficiencies and promote the population’s fortified wheat flour, the food basket provides ap- HCR. A total of 58 collective shelters in Homs, nutrition status. Accordingly, WFP currently focuses proximately 80% of daily caloric requirements. e Hama and Damascus were supplied with 100,000 on the prevention of acute malnutrition (using food basket satisfies approximately 52% of minimum litres of fuel to cover heating requirements for four Plumpy’Doz), while UNICEF focuses on its treatment daily caloric needs for those residing in areas not months while 10,000 heat-retention Wonder-bags® (using Plumpy’Sup and Plumpy’nut). In addition, targeted by wheat flour distributions, In areas where were distributed to families unable to cook WFP both agencies collectively focus on the prevention home baking is common, wheat flour is distributed food rations. A total of 2,500 Wonder-Bags® (out of of micronutrient deficiencies (using Nutributter and directly to beneficiaries, while in other locations, 4,100 dispatched), were distributed to families in micronutrient powder). A key challenge for both wheat flour is supplied to functioning bakeries rural Damascus, Damascus and Idleb while over organisations has been the lack of current nutrition through SARC and other partners. Governorates 24,000 litres of fuel were supplied to the 58 targeted data to guide programming, due to access constraints that do not receive wheat flour include Damascus, collective shelters. to certain areas. WFP’s programme for PLW com- Tartous and Lattakia due to availability of bakeries. plements the support already provided by UNICEF, Governorates that receive 100% of wheat flour Voucher scheme targeting pregnant and WHO and the United Nations Population Fund include Rural Damascus, Hama, Idleb,Ar-Raqqa, lactating (PLW) women (UNFPA), in the form of micronutrient supplemen- Al-Hassakeh, Deir ez-Zor and Dar’a. All remaining e October 2013 Humanitarian Needs Overview tation and reproductive health services. rough recipient governorates receive 70% of wheat flour. (HNO) estimated that 300,000 PLWs across the the Nutrition Sector Working Group, led by UNICEF, ose that do not receive flour do not get any addi- country were at risk of micronutrient deficiencies nutrition assessments are conducted to update the tional items. and required nutrition support, as well as improved nutrition situation as well as define nutrition strategies. awareness of appropriate feeding practices. In Monitoring addition, WFP’s monitoring findings illustrated that Logistics WFP have common monitoring tools and platforms access to and consumption of fresh produce (such Logistical needs inside Syria are continuously in the region, as well as dedicated monitoring staff, as fruits, vegetables and animal protein) by families, changing due to the fluidity of the security and although monitoring has been weak in Syria (only including PLW, was very limited, increasing their access situation on the ground, and require a high 15% coverage for 2013) due to insecurity and access vulnerability. Hence, WFP introduced a targeted degree of flexibility in planning. In this context, a constraints. However, by January 2014, WFP was voucher-based nutrition programme to complement complex chain of delivery underpins the implemen- able to augment its monitoring capacity by engaging the GFD ration and improve dietary diversity for tation of these programmes. third-party monitors who are able to access locations pregnant and lactating women. Lauched in July WFP imports food into Syria through the primary WFP staff cannot. is has led to an improvement 2014, the pilot is targeting initially 3,000 women in supply corridors of Beirut and Tartous, while the of the monitoring coverage to 41% of distribution Homs and Lattakia cities. Beneficiaries receive vouch- use of Lattakia port was also increased during 2013. locations. WFP monitors all accessible distributions ers to the value of US$23 to purchase fresh products, In addition, a fourth corridor through Jordan has by examining the process of beneficiary verification including vegetables, fruit, meat and dairy products, been activated in July 2014 following the adoption and the performance of cooperating partners. Ben- which are not part of the general food ration. It is of UN Security Council Resolution (UNSCR) 21652. eficiary satisfaction with the distribution procedures planned to target up to 15,000 women as this pro- WFP retains the capability to rapidly adjust its use is also monitored. Both female and male beneficiaries gramme is fully rolled out. of available corridors in response to changes in the are consulted in the process. Shop monitoring ex- operating environment. Accordingly, the expansion School feeding amines the redemption of vouchers, type of com- of additional corridors through Turkey is also under An estimated 2.3 million children in Syria are no modities purchased, prices charged as well as bene- use, thanks to UNSCR 2165. ficiary and shopkeeper satisfaction with the overall longer regularly attending school or have dropped process. Beneficiary monitoring examines household out completely. As part of the UNICEF-led ‘Lost 2 outcome indicators including food consumption Generation’ strategy to improve access to learning http://unscr.com/en/resolutions/2165 scores, dietary diversity and the various coping mechanisms used. Monitoring data allowed comparison of beneficiary and non-beneficiary households and findings indi- cated poorer dietary diversity of the latter – especially with regard to access to fruits, vegetables, meat and dairy products. Prevention of acute malnutrition In March 2013, a BSFP was initiated to provide nu- trition support to young children, prioritising 240,000 children aged 6-59 months. In 2014, over 189,000 children at risk of malnutrition were provided with nutrition support, including those in hard-to reach areas in Hama and Rural Damascus for the first time in months. Two programme variations (using different products) have been employed in different WFP working with the Syrian Arab Red Crescent (SARC) Packaging ...... Food Before Distribution 48 Field Article ......

Upon arrival in Syria, food commodities are as- sembled in five storage and packaging facilities strategically located in Safita, Lattakia, Homs and Rural Damascus. To avoid assembling the food basket on-site under challenging security conditions, food is packaged prior to dispatch, thus mitigating the risks of losses and ensuring that each family re- ceives the adequate food items. Each packaging facility produces up to 10,000 food rations every day, which are then dispatched by over 1,000 trucks each month to governorates allocated to each centre according to respective strategic advantages. Facilities A Syrian boy collects his family’s in Safita, Lattakia and Homs offering a good staging monthly ration of rice, flour, pasta, point to cover the requirements of central and north- beans, vegetable oil, sugar and yeast. ern governorates, while facilities in Damascus serve Team SARC/Idlib Media the southern governorates. is allocation maximises a logistics coordination forum in Damascus, Beirut the efficiency of food dispatches while reducing has been a slow process requiring persistence. Al- and Amman. Over 30 organisations (UN agencies, travel times, thus mitigating exposure of cargo to though at first and for many months it was only NGOs, INGOs, and donor agencies) regularly attend security threats. possible to work through SARC, WFP were gradually meetings where participants discuss logistics bot- allowed to engage with more local NGOs and were Once packaged, the family food rations are dis- tlenecks and develop common solutions for improved not shut down as a result. WFP did not control the patched to secondary storage points inside Syria humanitarian response. In addition, the Cluster modus operandi but found that they could expand and delivered to WFP partners on the basis of produces regular logistics information products in- humanitarian space in a way that was acceptable monthly allocation plans. In some cases, WFP pur- cluding situation reports, maps, assessments, meeting and met needs of millions of people, including other chases pre-packed rations which are transported by minutes, snapshots and flash updates on the Syria organisations working on behalf of the conflict suppliers directly at the handover Logistics Cluster webpage, and shares them via a affected population. WFP has worked through nu- Cluster mailing list. As of June 2014, a total of 17 merous local partners since they have better access points to partners inside Syria, without being organisations were benefiting from the Logistics processed through WFP facilities. Wheat flour to most of the governorates. is has been a very Cluster services for their operations inside Syria. As positive development and has effectively changed milling is undertaken outside of the country, in additional organisations are allowed to work in Mersin and Beirut. Subsequently, bagged wheat the landscape of civil society in Syria by investing Syria, the number of service requests has been in- in building up capacity of national agencies. flour is shipped respectively to Syrian ports or creasing. Accordingly the Cluster has been rapidly trucked to Damascus. For transport inside Syria, scaling up its operations, and continues to be ready While working in Syria, WFP have had to tread WFP utilises existing commercial transport settings, to expand further if required. carefully with regard to the cross-border programme encouraging local capacities where possible. Previously from southern Turkey as this expanded with an in- working with one single transport partner, WFP In 2014, WFP logistics in close coordination creasing number of agencies basing themselves in contracted five additional transport companies in with procurement and shipping units, updated the Gaziantep and Antakya in southern Turkey. With September 2013 to increase its delivery capacity Concept of Operations for the Syria Operation’s mounting criticism of the UN’s lack of engagement and respond to the growing need for humanitarian Supply Chain and put in place measures to mitigate in the cross-border programme, WFP began engaging assistance within the country. Each transporter is pipeline breaks and ensure timely arrival of com- with INGOs involved in cross-border work in early allocated specific areas on the basis of a previously modities in Syria. Arrangements with suppliers now 2013 and sent a number of staff to liaise with the established presence in certain parts of the country. ensure a readily available stock of food commodities NGOS and ACU in order to focus on information is maximizes WFP’s ability to deliver to all for immediate purchase upon receipt of funds by management and nurture mutual understanding. locations. For specific areas where surface access WFP. Additionally, procurement will be conducted is was followed by the deployment of a Global can be sporadic and the humanitarian situation par- solely within the Mediterranean, significantly ac- Food Security Cluster lead to work with NGOs ticularly dire, contingencies for airli of life-saving celerating lead times for the arrival of food in the doing cross-border work and to improve collaboration. supplies are arranged. country. is was a slow consensus and trust building exercise Food distributions take place at final distribution Risks to staff safety continue to represent the leading to the establishment of systems for sharing points (FDPs) agreed upon with partners. Due to greatest threat to sustaining WFP operations in the information about programming from southern the instability of security conditions on the ground, country. Should the security environment deteriorate Turkey and Damascus. the number of FDPs and their locations vary from further, WFP may be forced to reduce its footprint In May 2014, additional measures to improve month to month, as partners may no longer be able inside the country by deploying both national and operational coordination and joint planning were to perform distributions in previously accessible lo- international staff to work from alternative locations. taken. is involved constructing a joint forward cations, or beneficiaries may be unable to reach Remote management plans have been developed, looking plan that indicated where there were oper- planned distribution sites. including the increasing use of WFP’s Lebanon and ational overlaps and engaging in discussions with Jordan offices if necessary. Activation of the Logistics Cluster Following the recommendation of the UN Regional Ongoing challenges and lessons learnt Syrian refugees go shopping Emergency Coordinator for the Syria Emergency, WFP’s ability to deliver and distribute adequate with e-vouchers the Logistics Cluster was activated in January 2013 food is affected by access restrictions and shrinking to support overall logistics coordination and provide humanitarian space. However, WFP continues to services to humanitarian actors responding to the work with the UN Country Team and partners to emergency in Syria. e Logistics Cluster, led by maintain a presence on the ground, implement ac- WFP, fills logistics gaps in emergencies on behalf of tivities and continuously advocate for unhindered the humanitarian community, whilst also providing humanitarian access. a platform for coordination and sharing of key WFP, and hopefully the Syrian population, have logistics information among partners. As such, it benefited from a clear WFP operational strategy at provides free-to-user services to its humanitarian the outset. Recognising the political nature of the partners, including dedicated warehousing space crisis and that high levels of insecurity were going for inter-agency cargo, as well as transport services to prevent WFP from operating as normal, the de- throughout Syria. In addition, the Cluster ensures cision was taken early on to adopt a pragmatic and support for inter-agency convoys to deliver assistance opportunistic approach. WFP began its Syria emer- to the most vulnerable communities in otherwise gency operation in 2011 and was the first organisation inaccessible parts of the country. e Logistics to launch an emergency operation without the full Cluster offers also humanitarian flights to Qamishli, approval of the Syrian government, gradually building on a cost-sharing basis. on its programming base to expand the humanitarian Furthermore, the Logistics Cluster has established space through engagement and negotiation. is WFP/Sandy Maroun ...... 49 Field Article ...... partners about how to decide on ‘who does what, where’. Another meeting was held in July 2014 where an action plan was agreed for cross-border GOAL’s food programming from Turkey, Jordan and programming from Damascus, looking at the whole of Syria. A and voucher key challenge for all stakeholders is how to determine numbers in need. Adoption of UNSCR 2165 on 14th July has had assistance

a positive impact in enabling WFP use the most NorthernDavy 2013 Adams/GOAL, Syria, direct route to reach cut-off communities. All WFP programme in programming, including cross-border and cross- line, is now managed from Damascus. ere are no Crowds gather as an aid delivery WFP cross-border operations managed from Turkey Northern Syria arrives at a GOAL office in Idlib or Jordan. is position has been taken in order Governorate, Northern Syria not to undermine the mandate under UNSCR 2165. is has made programming harder in one sense By Hannah Reed as there are complex discussions and negotiations with the Syrian Government but WFP is gradually Hannah Reed is the former Assistant Country Director for Programmes in overcoming challenges related to fragmented and GOAL’s Syria Programme. She has over 10 years of experience in the uncoordinated responses. While information about humanitarian and development sector, working in Bolivia and the Fairtrade INGO programming is treated confidentially, any Foundation, before joining GOAL in 2011. Since joining GOAL, Hannah has WFP cross-border programming from Turkey is worked in the field and support offices in GOAL’s Sudan, Haiti and Syria planned from Damascus and the government is in- programmes. formed accordingly through the office of the Hu- manitarian Coordinator. An unexpected consequence With thanks to Hatty Barthorp, GOAL’s Global Nutrition Advisor, and Alison Gardner, Nutrition of the UNSCR 2165 has been an increased readiness Consultant, for their technical support. of the Government of Syria to facilitate cross-line convoys, a welcome development for WFP. is may partly reflect the battle for hearts and minds as the threat of ISIS appears to have increased.

Against the backdrop of these positive humani- Context tarian and political ‘sea-changes’ is a looming GOAL’s response to the Syria crisis began by various assessments and studies completed resource crisis affecting WFP, who will effectively in November 2012. To date, it has provided over the past six months. ese include a be running out of money for this and other pro- vital food and non-food aid to over 300,000 Food Basket Assessment (August 2013), Emer- grammes in the region in late 2014, resulting in beneficiaries through both direct distributions gency Market Mapping and Analysis (EMMA) dramatic scaling back of programming . is could and voucher programming in Idlib and studies on markets for wheat flour and veg- not be happening at a worse time as winter ap- Hama Governorates, Northern Syria, in ad- etables (January 2014) and dry yeast, rice and proaches. e irony is that in August 2014, WFP dition to increasing access to water for over lentil (May 2014), a Food Security Baseline managed to reach almost 4.1 million Syrians in

Field Article Field 200,000 people in northern Idlib. (December 2013) and Multi-sector Needs As- Syria, the highest number since the emergency re- sessment (January 2014). Design and imple- sponse began in 2011. In October, WFP hopes to GOAL Syria currently receives funds mentation also continue to be informed by still reach 4.25 million Syrians in country but will from four donors (OFDA, FFP, UKAID and ongoing Post Distribution Monitoring (PDM) provide a food basket with a 40% reduction of the ECHO1). Under OFDA, GOAL implements of all programme activities. planned caloric requirement. WFP will do everything voucher-based and in-kind Non-Food Items it can to advocate and strengthen resource mobili- (NFIs) and winterisation support. FFP fund- Programming context, including sation efforts in order to avoid a reduction of WFP ing provides Family Food Rations (FFR) challenges due to access and security assistance. and support to bakeries with wheat flour e protracted conflict has resulted in urgent, alongside a voucher-based system for the humanitarian needs across Syria. e United For more information, contact: Rasmus Egendal, most vulnerable households to access bread. Nations (UN) estimates that the conflict has email: [email protected] +962 7989 47301 A UKAID grant focuses on improved access displaced at least 6.5 million people within or Adeyinka Badejo, email: to safe water, hygiene and sanitation and Syria, with a further 2.5 million refugees in [email protected] improved food security through a mixed- neighbouring countries2. A combination of resource transfer model combining dry food direct and indirect factors has led to in excess distributions with Fresh Food Vouchers of 9.3 million people classified as in need of (FFV). Finally, Irish Aid and ECHO support humanitarian assistance. With reference to unrestricted vouchers and cash for work to aid required per sector, the Syria Integrated increase access to food and NFIs in areas Needs Assessment (SINA) found the highest WFP/Laure Chadraoui WFP/Laure with safe access to functional markets. number of people in need across the sub-dis- tricts surveyed were in need of food assistance, At the time of writing (May 2014), GOAL’s with an estimated 5.5 million people food food assistance programme is reaching up- insecure in assessed areas of northern Syria, wards of 240,000 direct beneficiaries each including 4.9 million in moderate need and month. Monthly unrestricted (food and 590,600 in acute or severe need3. NFI) vouchers are targeting 5,790 people, expanding to a total 13,200 direct benefici- Resulting in displacement, reduced access aries each month from June 2014, while to livelihoods and market disruption, in ad- voucher-based assistance to meet winteri- dition to the direct loss of life and damage to sation needs reached over 72,000 people infrastructure, the protracted conflict continues during winter 2013/14. Funding has also to impact negatively on the ability of affected been secured to expand voucher-based as- populations to meet basic food and other sistance to increase access to inputs required needs without assistance. Increased reliance In areas like Homs and Dier Ezzor, WFP in partnership for the protection and recovery of livelihoods on coping strategies reduces household re- with the Syrian Arab Red and to include food production. Crescent (SARC) conducts 1 US Office for Disaster Assistance; US Food for Peace; door-to-door food GOAL’s Food Security programme im- UK Aid Department for International Development distributions. plementation and design has been informed (UK), European Commission Humanitarian Office ...... 50 Field Article ......

siliency and results in increased immediate and sustained hu- Figure 1: Sources of food accessed by respondents manitarian need. 100% In tandem, the operational and security context continues to present challenges to the impartial and safe delivery of humani- 80% tarian aid. An increasingly fractured opposition force and changes in power dynamics requires continual operational ad- 60% justments to ensure aid can pass freely through check-points held by different and continually changing factions. Highly fluid 40% changes within the opposition movement are accompanied by an increasing trend of Government military action in opposi- 20% tion-held areas of northern Syria, resulting in continued population displacement and a highly insecure operational environment 0% for aid agencies. Deterioration in security in areas of Syria close Rice Bread Pulses Fresh Eggs Olives Vegetables Oil Tea Sugar to the border with Turkey, have also resulted in periodic and dairy oen prolonged border closures (notably in January 2014) which products Own production Food Aid in turn prevent and/or delay cross-border delivery of aid to con- Gift from relative/neighbour flict-affected populations in Syria. Purchased from local shop/market

Assessments which informed the food kit design high for vitamin A (91%) and Vitamin C ration (457 kcal per person per day (pppd) via e designs of GOAL’s Family Food Ration (FFR) and comple- (92%) and low for protein (49%), fat (41%), bread vouchers) under complementary GOAL 4 mentary fresh food vouchers for distribution from Autumn iron (24%) and iodine (15%). programming; in this instance, the FFR con- 2013 up to early Summer 2014, were informed by GOAL’s Food tained reduced quantities of pasta, rice and 5 Basket Assessment (and supporting assessment of fresh food Design of different food kits and bulgur wheat. For both FFR types, full and availability on local markets) completed in August 2013. e resulting operational difficulties half kits were also provided, designed to ensure survey objectives were to obtain information on diet quantity, In response to these findings, GOAL designed the RDA pppd was met and allocated according diet diversity, feed frequency, food availability, nutritional defi- two types of food ration. e FFR included to household size. ciencies and access to produce an evidence base and recom- tahini, raisins, fava beans and chick peas for mendations for the contents of GOAL’s FFR, and to reassess the distribution in areas without functioning mar- In practice, disruption to border crossings profile of GOAL beneficiaries, including household size and kets, and therefore not receiving vouchers to resulted in frequent delivery of only one type composition of the household. access fresh food. In areas with safe access to of food ration. is disrupted distribution as functioning markets, a dual-transfer food as- it was necessary to wait for delivery of con- Key survey findings were: sistance package was distributed that included tingents of all food ration specifications to • Percentage of households with at least one household (HH) both a dry food ration and vouchers to access cross the border. Otherwise, distributing food member with specialised nutritional requirements: children food (see Figure 3 for nutrient composition kits to all registered households in any given aged 5 years and younger (66%6), elderly (15%), Pregnant including % RDA). village at different times had the potential to and Lactating Women (PLW) (30%), and members with create security issues. chronic illness or disability (27%). All food assistance was designed to meet a • Average monthly income per HH is SYP 7,279 ($29) while target of 2,400 kcals p/d adjusted from the Modified food assistance modality average monthly expenditure on food per HH was reported Sphere standard (2,100 kcal p/p/d) by an ad- Given the unreliability of border crossings, as SYP 9,265 ($37). ditional 300 kcals p/d in order to meet increased the design of food kits has been greatly sim- • Ratio of HH member contributing to income to dependent calorific requirements during the winter period. plified for the next round of food security HH members = 1:4 For areas targeted by direct distribution of programming with one type of half kit only. dry food rations only, GOAL designed two Households will receive between one and three Figure 1 shows that the primary source of all food groups was types of food kit – a full FFR and a reduced half kits each month depending on household purchase from local markets. e average monthly food expen- FFR. e latter was provided where targeted size. A repeat of the Food Basket Assessment diture reported exceeds average monthly income, suggesting a beneficiaries were also receiving a daily bread is planned for early June 2014 to inform the high risk of food insecurity in the absence of assistance to access food, and a need to rebuild livelihoods to increase income levels. Figure 2: Current intake of common food items To assess current dietary diversity, respondents were also asked how oen they consumed food items from a specified list Canned Meat of foods common in Syria (see Figure 2). Ramadan was 3 weeks Fresh Chicken before the household survey7. e results (Figure 2) reveal very low levels of dietary diversity with the population heavily reliant Fresh Fish on bread and vegetables. e main additional foods consumed Fresh meat (eaten more than once a week) were other cereals, such as rice, bulgur and pasta, as well as lentils. Results of the assessment in Beans terms of the % Recommended Daily Allowance (RDA) for kilo- Pasta calories and micro- and macro-nutrients showed that households Fruits were able to meet an average of 900 kilocalories per person per day without assistance. e % RDA met without assistance was Lentils Flour 2 UNOCHA Syrian Humanitarian Bulletin Issue 44, 27 February – 12 March 2014 Bulgar 3 Syria Integrated Needs Assessment, December 2013 4 Fresh Food vouchers were distributed with dry food rations over this period, potatoes and only in areas where local markets will sustain a voucher-based approach 5 A household survey was conducted in August 2013, using convenience Milk sampling of 607 randomly selected households in GOAL’s operational areas. Eggs The sample covered 82% beneficiaries (of non-food aid) and 18% non- beneficiaries and a mix of rural and urban areas. Data were then triangulated Fresh milk Products through in-depth interviews in the same districts. The ‘NutVal’ tool was used for analysis of nutrient composition, while secondary data from FSLWG and Rice OCHA, WFP documents were also referenced. In terms of limitations, some areas were inaccessible to the data collection team due to security constraints Vegetables while challenges were also experienced with regards to respondents’ ability Bread to recall daily food intake. 6 Of which the average households sampled had 0.46 household members aged Oil two years and younger, and 0.90 household members aged between three and five years. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 Possible answers were: never since Ramadan, more than once per week, and Never since Ramadhan More than one time per week Everyday everyday...... 51 Field Article ......

Figure 3: GOAL mixed modality Food Assistance package: % RDA met by dry food ration and fresh food vouchers Food items Energy Protein Fat Calcium Iron Iodine Vit. A Thiamine Riboflavin Niacin Vit. C Current consumption (kcals) 900 26 19 220 6 25 557 1 0 13 30 Dry rations (kcals) 1212 38 31 94 11 251 26 1 0 15 4 Fresh foods (kcals) 184 11 7 139 1 20 591 0 0 5 20 Total 2296 75 57 454 19 295 1173 1 1 32 55 Required ration (adjusted for winterisation) (kcals) 2400 53 46 430 26 161 613 1 2 16 32 % of requirements supplied by current consumption 37% 49% 41% 51% 24% 15% 91% 60% 24% 80% 94% % of requirements supplied by dry rations 51% 71% 69% 22% 44% 155% 4% 74% 20% 95% 13% % of requirements supplied by fresh foods 8% 21% 15% 32% 5% 12% 96% 19% 15% 29% 62% % of total requirements met 96% 141% 124% 105% 73% 183% 191% 152% 59% 204% 169% final specifications of the FFR. is will focus specifi- ported) which generated an average of USD $415.5 distributions alone, reducing reliance on border cally on the % RDA currently met by targeted groups / SYP 62,018 over the same period. crossings and the transportation of food rations without assistance, and will ensure the RDA per when relying only on direct distributions. is ap- Correspondingly, the average monthly expenditure person per day is met in terms of calorific and proach also recognises beneficiary preference for on food alone across the sample was USD $81/SYP nutrient requirements. It is expected that the % vouchers. A dual resource transfer approach also 12,105 significantly higher than the average income meeting the RDA without assistance will have provides maximum operational flexibility, with the generated by irregular jobs, which represents the declined since August 2013, due to: option to increase or decrease the ration of assistance most common source of income referenced. House- • Continued trend of price increases in food items provided via vouchers and via direct distributions holds also reported that most of their income was • Reduced purchasing power as conflict affected in response to changes in market systems or in the not generated by jobs or livelihoods but by the use households deplete remaining savings, and security context. of coping strategies; 22% of the income source was • Disruption to livelihood activities pre-conflict through the sale of personal assets, whereas a further is approach has been informed by GOAL’s un- and the corresponding decrease in income 22% was credit – strategies which are not sustainable9. derstanding of market systems developed through generation capacity for much of the population. Sixty eight per cent of households surveyed also re- EMMAs on critical markets for dry and fresh food, GOAL’s assessments in 2014 demonstrate a trend of ported outstanding debt, with 72% of these reporting and by experience to date with fresh food vouchers decreasing food security within populations without that credit obtained had been used to purchase and in addition to ongoing unrestricted and NFI access to regular food assistance. Table 1 shows food. Other coping strategies identified to meet voucher programming. Food assistance will be de- average Household Food Consumption Scores (FCS) food needs include relying on less preferred or less livered through monthly food voucher distributions for populations surveyed in GOAL’s operational expensive food (62%), taking on credit (29%), in areas which will sustain a market-based approach, areas during October 2013, December 2013 and limiting portion sizes (25%), borrowing food (19%), and through dry food rations in areas without safe January 2014. and taking children from education to work (17%) access to functioning markets. or sending children or other family members to live Table 1 demonstrates progressive deterioration e use of vouchers – when market systems with relatives (15%)10. in household food security across targeted areas, permit – also seeks to ‘do no harm’ both to local with a striking increase in the number of female Recent surveys, reinforced by Emergency Market markets and to livelihoods, by avoiding the potentially headed households ranked with a ‘poor’ FCS (82%) Mapping & Analysis (EMMA) studies on critical negative impact of large volumes of imported food in January 2014 when compared to male headed markets for tomatoes, potatoes, rice and lentils, re- goods being distributed in areas where markets con- households surveyed at the same time and in the inforced the trend that food remains available in tinue to function11. same areas (40%). A sharp decline can also be seen areas with functioning markets (see Figure 4). How- GOAL welcomes the formation of a Cash Based in January 2014 figures when compared to the % of ever, food remains inaccessible to many households Response Technical Working Group (Cash TWG) female headed households ranked with poor FCS in these areas due to reduced livelihood options for actors implementing the cross-border response in October (2%) and December 2013 (14%). and the widening gap between household expenditure in northern Syria. GOAL is participating actively and income. Food security is undermined by the type of on the working group and has recently presented income source, with the majority of households Change of GOAL direction to include GOAL’s voucher process (outlined below) in response surveyed currently relying on irregular jobs (44%), voucher programming to requests from other members. e Cash TWG the sale of personal assets (29%), assistance received Given that access as opposed to availability represents has been formed to support lesson learning and ex- from relatives (17%) and previous savings (7%)8. the critical barrier to households meeting basic food change of best practice with reference to cash and is represents a worrying trend as there are only a needs without assistance, GOAL will expand the voucher based programming in northern Syria and finite number of assets that may be sold or savings current FFV modality to include vouchers for both to improve coordination. With a market-based ap- that may be utilised. On average, irregular jobs only dry and fresh food in the next phase of food security proach to assistance, it is critical that actors coordinate generated USD $65 / 9,724 Syrian Pounds (SYP) in programming. is recognises increased flexibility to ensure a ‘Do No Harm’ approach is applied to the month prior to the survey, compared to the sale afforded by a market-based approach in areas with local markets. is will mitigate against the risk of of personal assets (the highest source of income re- functional markets and when compared to direct ‘flooding’/crashing local markets should there be a significant and uncoordinated increase in voucher- Table 1: Trends in Household Food Consumption Score (FCS) based programming by other actors, reliant on the Average Male headed households Female headed households same markets, within the same timeframes. Oct-13 Dec-13 Jan-14 Oct-13 Dec-13 Jan-14 Oct-13 Dec-13 Jan-14 Details of the voucher programme design % households scored 43% 22% 15% 40% 23% 15% 58% 43% 18% Food vouchers will build on GOAL’s established ‘acceptable’ voucher modality, taking the form of printed, cash- % households scored 50% 47% 42% 56% 48% 45% 40% 43% 0% based vouchers distributed on a monthly basis and ‘borderline’ exchangeable for food items only at selected and % households scored ‘poor’ 7% 31% 43% 4% 28% 40% 2% 14% 82% registered traders. Following an assessment by GOAL field staff of Figure 4: Principal source of food* for households surveyed in northern Idlib, January 2014 trader’s stock and capacity to restock and to gauge 88% First willingness to engage with the conditions of GOAL’s

55% Second 8 Needs Assessment in northern Idlib, January 2014, GOAL. 35% 9 26% 31% Third See footnote 8 19% 15% 10 See footnote 8 12% 11% 3% 2% 1% 1% 2% 11 The EMMA on rice and lentil critical markets completed in Bought in market Food aid Gift No source of food Private production Other (Specify) May 2014 by GOAL suggested that large-scale influxes of these food types via aid agency distributions may be impacting local markets systems for these commodities *Respondents could give up to three sources of food ranked in order of importance as principalle source of food...... 52 Field Article ...... voucher scheme, traders sign a contract with GOAL Decision making around exclusion of infant formula and milk powder from the to participate in the voucher scheme. is includes Box: 1 voucher scheme and food distribution a commitment on the part of the trader only to Both breastfeeding and use of breastmilk to-use and powdered products) is happening in the redeem agreed items for GOAL vouchers exchanged substitutes (BMS) – typically infant formula – is northern governorates (source: GNC scoping by beneficiaries, namely dry and fresh foods for common in the population. In the January 2014 mission, Sept 2013); one INGO is collaborating with food security interventions (see Box 1 for decision Needs Assessment, in nine sub-districts (Armanaz, a number of these to minimise risks. making regarding vouchers related to infant feeding)12. Badama, Darkosh, Harim, Janudiyeh, Kafr Punitive measures are in place and communicated Takharim, Maaret Tamsrin, Qourqeen, and Salqin) On balance, it was decided that GOALs vouchers to traders regarding infractions to the stated terms of Idlib Governorate, 25% of respondents reported and dry rations should not include a BMS as we do of the contract. is includes temporary moving to infants 0-5m were being fed milk (regular, tinned, not have the capacity or relevant partnerships permanent exclusion from the voucher scheme if powdered or fresh animal milk), a further 17% of established to ensure appropriate targeting and substantial evidence exists that vouchers have been infants 0-5m were being fed infant formula and also provide the requisite level of support/guidance to mothers. The hygiene-sanitation conditions are exchanged for items outside the scope agreed by 41% reported other foods/liquids. Three-quarters poor and access to safe water is a problem. GOAL with traders and stipulated on the vouchers, (75%) of respondents also reported breast feeding Households still have a certain level of income in addition to other breaches of the contract signed. their infant. Various difficulties with breastfeeding were reported, such as too stressed to breastfeed from various sources, whereby GOAL FSL project is Food vouchers are eligible for one month and re- (13%) and inadequate maternal food intake (29%). trying to protect assets and the ‘income generation deemed for food by beneficiaries in a range of pot’, by providing access to as replete a diet as registered shops. Lists of shops participating and the Access to breastfeeding support and to BMS possible. We excluded BMS to reduce the risk of prices charged for key food goods are distributed to supplies for mothers is very limited in our target families choosing BMS or other powdered milks population. An international non-governmental beneficiaries with vouchers. Participating shops are over breastfeeding. Those who are dependent on organisation (INGO) is running an IYCF programme also required to display the agreed price list in their BMS still have the potential to buy from local in just five of the 134 villages that GOAL currently markets, as a greater proportion of their personal outlets to reduce the risk of voucher beneficiaries operates in, though this may be expanding which income would be available to spend on ‘essential being punitively charged for goods purchased with may bring more opportunities to collaborate. items’, given the food/ vouchers provided by GOAL. vouchers. Prices for food goods exchanged with Infant formula is expensive; the price of infant In January 2014, the predominant expenditure for vouchers are set in line with average market prices formula has risen significantly through the crisis. all households remained food, followed by health, for these goods, and are not intended to be ‘cheaper’ Untargeted distribution of infant formula (ready- water then fuel. than the same good purchased in the same markets by non-beneficiaries and using cash. GOAL vouchers continue to incorporate a series of security features13, On balance, it was decided that GOALs vouchers needs of women and children) whilst simultaneously while a rigorous system of checks ensure only the se- and dry rations should not include a BMS as we do strengthening local markets, as evidenced by positive lected families receive and redeem the vouchers; that not have the capacity or relevant partnerships es- feedback from market actors. A recent survey of the vouchers are used for NFIs only; that the traders tablished to ensure appropriate targeting and also shopkeepers participating in GOAL’s voucher scheme cannot increase prices arbitrarily and that any com- provide the requisite level of support/guidance to found that 100% reported that they would like to plaints are quickly relayed to GOAL for investigation14. mothers. e hygiene-sanitation conditions are poor sign future agreements with GOAL. In addition, a and access to safe water is a problem. Households recent rapid assessment found that 88% of key in- Shopkeepers redeem vouchers with GOAL staff still have a certain level of income from various formants surveyed who were aware of GOAL’s on a weekly basis and are reimbursed for the value of sources, whereby GOAL FSL project is trying to voucher system believe it has a positive impact on food items exchanged for vouchers. ere are currently protect assets and the income generation pot’, by the market, while 71% of shopkeepers interviewed over 200 outlets registered with GOAL’s voucher providing access to as replete a diet as possible. We who were familiar with the system stated that they scheme offering a wider range of food and NFIs. excluded BMS to reduce the risk of families choosing would be very interested in participating. An average GOAL is currently providing fresh food assistance to BMS or other powdered milks over breastfeeding. of 93% of beneficiaries stated that the frequency of upwards of 10,000 households each month via a ose who are dependent on BMS still have the po- vouchers was appropriate to their needs, while 81.5% voucher-based modality. Initial assessments and de- tential to buy from local markets, as a greater pro- of beneficiaries responded that they were satisfied mand from traders not currently registered demonstrate portion of their personal income would be available with the range of shops available to them.15 that scope exists to expand further the food voucher to spend on ‘essential items’, given the food/vouchers scheme under the proposed modification. GOAL will therefore continue to increase access provided by GOAL. In January 2014, the predominant to food and other basic needs through a voucher- Both breastfeeding and use of breastmilk substi- expenditure for all households remained food, fol- based modality, as the preferred option in areas with tutes (BMS) – typically infant formula – is common lowed by health, water then fuel. safe access to functional markets. is will be in the population. In the January 2014 Needs As- Lessons learnt on voucher programming supported by continued direct distributions of food sessment, in nine sub-districts (Armanaz, Badama, so far and vision for future. assistance when security or market capacity does Darkosh, Harim, Janudiyeh, Kafr Takharim, Maaret not permit a market-based approach. rough con- Tamsrin, Qourqeen, and Salqin) of Idlib Governorate, To date, GOAL’s experience with voucher-based tinued emphasis on robust monitoring of the impact 25% of respondents reported infants 0-5m were programming demonstrates that this is an appropriate of assistance on food security, and on market impact being fed milk (regular, tinned, powdered or fresh and effective modality to increase access to basic of modalities employed, GOAL will scale up the use animal milk), a further 17% of infants 0-5m were needs for populations in northern Syria with safe of vouchers in preference to direct distributions. being fed infant formula and 41% reported other access to functional markets. PDM demonstrates that targeted distribution of vouchers affords greater foods/liquids. ree-quarters (75%) of respondents For more information, contact: Vicki Aken, flexibility to beneficiaries than direct distributions also reported breastfeeding their infant. Various Country Director, GOAL Syria, email: difficulties with breastfeeding were reported, such (which is of particular relevance to address the [email protected] as too stressed to breastfeed (13%) and inadequate maternal food intake (29%). 12 Note that shopkeepers include a strict ban on the exchange of into the design, which are very difficult to forge and there is vouchers for alcohol, cigarettes, infant formula and powdered also a complex pattern on the surface and exact measurements Access to breastfeeding support and to BMS sup- milk. GOAL programme and M&E staff will continue closely to of the font. Replication of vouchers is therefore extremely plies for mothers is very limited in our target popu- monitor shopping periods to ensure contractual requirements difficult. 14 lation. An international non-governmental organi- are met, and including that NFIs are not exchanged for food This system includes: price setting with participating shop- vouchers. The ban on exchange of vouchers for infant formula keepers prior to each round of distributions with price lists then sation (INGO) is running an IYCF programme in and powdered milk is in line with GOAL’s policy of safeguarding displayed in participating outlets; the use of ‘shopkeeper books’ just five of the 134 villages that GOAL currently op- children and the international Operational Guidelines for to register beneficiary names, ID numbers and voucher numbers erates in, though this may be expanding which may Infant Feeding in Emergencies (2007) which state that “infant against the items these are exchanged against; careful bring more opportunities to collaborate. Infant formula should only be targeted to infants requiring it, as selection of shopkeepers against established accessibility and formula is expensive; the price of infant formula has determined from assessment by a qualified health or nutrition stock level criteria followed by signatures of contracts agreeing worker trained in breastfeeding and infant feeding issues” See to abide by the terms and conditions of GOAL’s voucher risen significantly through the crisis. Untargeted dis- Box 1 for more considerations around infant formula/powdered scheme; and clearly defined shopping and voucher redemption tribution of infant formula (ready-to-use and powdered milk exclusion from the voucher scheme. periods to guarantee close monitoring by both programmes products) is happening in the northern governorates 13 There are two serial numbers, one is random and one is staff and GOAL’s M&E team to ensure guidelines are adhered to (source: GNC scoping mission, Sept 2013); one computer generated and therefore unpredictable. Each and to reduce the risk of unauthorised duplication or use of voucher has a hologram which is GOAL-specific, patented and GOAL vouchers. INGO is collaborating with a number of these to only produced in one factory in Turkey. There is a different 15 PDM Irish Aid Vouchers Rounds 1 and 2 minimise risks. colour for each batch of vouchers. Watermarks are incorporated ...... 53 Field ArticleSyrian refugee and her child ......

Mother and child in Syria WFP

hree years into a brutal crisis, the pro- Crescent (SARC). ese stakeholders have scaled tracted conflict in Syria has had an im- up their response by adopting a holistic strategic mensely negative impact on essential approach that covers i) preventative micronutrient living conditions of the Syrian popula- supplementation; ii) screening for and referral of Ttion. Access to basic services and commodities malnutrition cases; and iii) outpatient and inpatient WHO response such as food, livelihoods, safe drinking water, treatment of acute malnutrition. WHO’s response sanitation, education, shelter and health care has has focused on strengthening screening of children to malnutrition been compromised. is in turn has increased under five years for malnutrition and hospitalised the populations’ vulnerability to poverty, violence, care of complicated cases of severe acute malnu- food and nutrition insecurity, and disease. e trition (SAM). in Syria: volatile nature of the crisis has created unpredictable and unstable living conditions for the population. Scaling up WHO nutrition activities e ongoing conflict has caused forced displace- Revitalising the Nutrition Surveillance ment, socioeconomic limitations, insecurity and System a focus on a lack of access to basic services. Coupled with Prior to the conflict, in 2009, a national nutrition recurrent droughts, the conflict has significantly surveillance system was established to report on affected food security and livelihoods and thus, acute and chronic malnutrition of children under surveillance, has adversely impacted nutritional status, especially 5 years visiting health facilities for their routine in children under 5 years; an already vulnerable immunisation. e system extended to providing population. More specifically, chronic poor dietary parents with information and a service to monitor case detection diversity, inadequate/improper infant, young child child growth. However, with the conflict driven and maternal feeding practices, as well as geo- damage to the health system and the consequential graphical and gender inequalities have heightened shortage in nutrition personnel, the national nu- and clinical the risk of malnutrition in children under five trition surveillance system has suffered from a years. reduction in the quality of nutrition service pro- vision and deterioration in reporting and moni- management According to the Syrian Family Health Survey toring. With an expected increased number of (2009), conducted prior to the crisis, the nutritional acute malnutrition cases, and a scarcity of nutrition By Hala Khudari, Mahmoud Bozo situation of children under five years of age was services, there was a concern that malnutrition and Elizabeth Hoff poor, with an estimated 23% of them being cases were going undetected. stunted, 9.3% wasted and 10.3% underweight. In order to understand the impact on overall Hala Khudari, WHO Technical Exclusive breastfeeding rates stood at 42.6% while Officer at WHO Syria, joined WHO the proportion of newborns introduced to breast- nutrition related morbidity and mortality, detection in 2011 and is a BSc (Nutrition feeding within the first hour was 42.2%1. Mi- and reporting on cases would need to be improved. and Dietetics) and MSc in cronutrient deficiencies were also recorded in In order to enhance the detection of malnourished Nutrition graduate from the pre-crisis Syria in 2011, presenting a risk for sub- children and fill the information gap, WHO is American University of Beirut. optimal growth among children; for example, collaborating with the MOH and other partners For the last 3 years she has anaemia prevalence among 0-59 month old chil- to improve and strengthen the Nutrition Surveil- helped develop the WHO nutrition response dren was 29.2%2, while there was an 8.7% Vitamin lance System. Between April and July 2014, twelve programme in Syria. A deficiency rate3 and 12.9% iodine deficiency health centres from 12 governorates were selected 4 to pilot a modified surveillance system. is mod- Mahoud Bozo is a nutrition prevalence . Neonatal mortality rates, infant mor- ification encompassed revised reporting and mon- expert/ paediatrician and a WHO tality rates and under-five mortality rates stood 5 itoring tools and providing trained human resources. consultant since Nov 2013. He at 12.9/1000, 17.9/1000 and 1.4/1000 respectively . e pilot governorates were selected using two has widespread experience in Coordinating response research in paediatric criteria: (i) conflict-impacted areas (Daraa, Homs, gastroenterology and nutrition e confluence of factors and lack of solid data Aleppo, Rural Damascus, Idlib, Quneitera and and was former general on the nutritional status alerted the humanitarian Deir-ez-zor) and (ii) densely populated areas with coordinator of paediatrics in MOH Syria (2005-2012). community to the possibility that cases of mal- high numbers of Internally Displaced Persons nutrition in Syria were going undetected. is (IDPs) (Damascus, Tartous, Latakia, Hama and Elizabeth Hoff was appointed prompted international organisations and national Sweida). Coverage rates of nutrition surveillance, WHO representative in Syria in counterparts to address the prevention, detection capacity of human resources, availability of physical April 2014 (acting representative and treatment of emerging malnutrition cases. space, and equipment needs were also assessed July 2012 – April 2014). She has With the establishment of the Nutrition Sector and evaluated within the pilot timeframe. Aside more than two decades Working Group headed by UNICEF and the Min- from the pilot centres, nutrition surveillance was experience in Africa, the Middle istry of Health (MOH) in the second quarter of also started up again in the highly conflict-affected East, Asia and Eastern Europe 2013, which emerged as a result of expanded nu- governorate of Ar-Raqqa, through the coordinated and previously was coordinator for resource mobilisation and external relations under the trition activities and increased nutrition partners efforts of WHO field staff. in the field, the response to malnutrition has Emergency Risk Management and Humanitarian Numerous constraints were reported by the Response department in WHO HQ, Geneva. gradually been strengthened. is has been realised through the involvement of key UN agencies in- pilot nutrition surveillance centres. e lack of We wish to express our sincere appreciation for the cluding the World Health Organisation (WHO), human resources, space, equipment and telecom- support and input from WHO’s information UNICEF and the World Food Programme (WFP) management team and field staff for their feedback, and key national authorities and implementing 1 WHO/MOH, Syrian Family Health Survey, Syria, 2009. commitment and responsiveness to build up the partners including the MOH, Ministry of Higher 2 Ministry of Health, Nutrition surveillance system report, information provided. Special thanks go to Dr. Ayoub Education (MOHE), as well as international and Syria, 2011. 3 Al-Jawaldeh, Nutrition Regional Advisor, for his national non-governmental organisations (NGOs) Ministry of Health, Vitamin A deficiency Study, MOH, 1998 invaluable technical support and guidance, in addition 4 Ministry of Health, Study on Iodine deficiency prevalence such as International Medical Corps, Action to the publication office at the Eastern Mediterranean in Syria, MOH, 2006. Against Hunger (ACF) and the Syrian Arab Red 5 See footnote 1 Regional Office...... 54 Field Article ......

munication-reporting utilities were cited as challenges when the security situation is dire. is varies the in line with WHO’s SAM Management Protocol, by a number of Governorates. ese obstacles were total number of centres reporting from month to updated in 2009 and 2013. So as to not create parallel especially evident in the case of Deir-ez-Zor, with a another with a typical difference of 1-2 centres. systems within hospitals, these centres have been significantly under-staffed health centre, where the integrated within paediatric departments at the single health provider present was only able to take Referral of detected cases and hospital care of main public hospitals. Support to these SCs has mid-upper arm circumference (MUAC) measure- complicated cases of severe acute malnutrition been extended in three main areas, (i) building the ments of 300 U5 children per month. (SAM) capacity of the health workforce, critical for effective e implementation of the pilot phase of the modified SAM management and treatment (ii) filling gaps in One aim of the pilot was to test the effectiveness Nutrition Surveillance System led to an increase in medicines, medical supplies and equipment for of the capacity building trainings conducted on an- the detection of cases of malnutrition requiring treatment of complicated SAM, e.g. anthropometric thropometric measurement techniques including treatment and confirmed morbidity and mortality equipment, antibiotics, minerals, vitamins and F100, weight, height and MUAC and the reporting system. due to nutrition related disease. Data collection and F75 formulas and (iii) providing technical support is included assessment of the tools and flow of analysis on SAM is still ongoing; the full report will for treatment protocols and reporting. To date, over data and adequacy of referrals and standardised be out by early 2015. is increase highlighted the 350 health professionals from MOH, MOHE and management following community based manage- importance of establishing a solid referral system private hospitals in Damascus, Rural Damascus, ment of acute malnutrition (CMAM) and WHO for specialised treatment to reduce associated mortality Homs (including Homs city and Tadmor), Hama, 2013 protocols. e findings of the pilot have demon- and morbidity. Aleppo, Idlib, Lattakia, Deir-ez-zor, and Quneitera strated what changes need to be effected for the have been trained on the WHO SAM Management next phase of the nutrition surveillance strengthening Since January 2014, WHO has supported the es- Protocol adopting best practice techniques and food which aims to expand to 10 health centres within tablishment of Stabilisation Centres (SC) for the safety measures6. Additionally, systemised reporting each governorate including enhancing capacity, pro- management of SAM in hospitals across the country vision of supplies and equipment and reporting templates and tools. e expansion began in mid- July when a team of health workers from 20 centres Map 1 Syrian Arab Republic: Revitalised Nutrition Surveillance Centres in Damascus and Rural Damascus were trained. By mid-October, 105 surveillance centres were following the improved surveillance system (see Map 1). By the end of 2014, it is anticipated that more than 115 health centres will be integrated into national surveillance system. In 2015, a number of NGOs will be integrated into the programme in order to reach more children in affected and hard- to reach areas. e regular and accurate flow of in- formation through monthly paper-based published reports shared with WHO and centrally with the MOH by main nutrition offices at the directorates of health in the governorates. Reports include cases of malnutrition in children under five years across the country that will be analysed and utilized to monitor prevalence and trends, and more importantly early detection of cases and referral for treatment. A step towards success: active surveillance in Aleppo Governorate e surveillance system in the northern Governorate Health District of Aleppo has set a high standard and many ways Nutrition Surveillance been exemplary. As one of the main population Centres centres in Syria, Aleppo city was once considered the industrial heart of the country. It is surrounded 12-Oct-1014@WHO Syria 2014, All rights reserved by large rural areas that have been severely affected by violent conflict for over 2 years. Huge population displacement, food shortages and economic losses Map 2 Syrian Arab Republic: Stabilisation Centres are some of the many hardships Aleppo Governorate inhabitants have faced, making families and especially their children more susceptible to malnutrition. With a very active surveillance team, screening for malnutrition was optimised not only through screen- ing cases entering facilities but also via mobile teams visiting shelters for the internally displaced in the city and conducting referrals for cases in need of treatment. Since the start of 2014, the surveillance in Aleppo has consistently reported on cases from four health centres in four health districts in the governorate of Aleppo (the numbers available so far are limited to specific locations in the governorate, are not statis- tically representative and therefore not included here). In the month of August, 12 facilities have been activated in urban and rural areas of Aleppo. ese facilities are expected to screen an approximate 4000 children per month. In locations experiencing intermittent violence like north Aleppo, due to the security situation, some health centres stop reporting

6 World Health Organisation, Training course on the management of severe malnutrition, WHO/NHD/02.4, 2009 ...... 55 Field Article ......

supporting populations in need including the dis- the re-activation of nutrition surveillance in 10 placed to provide breast-milk substitutes like infant health centres in Latakia, Tartous, Idleb, Hama, formula. ese requests were not supported as they Dara’a and Homs. Efforts will also be made to

WHO, Syria, 2014 Syria, WHO, counteract WHO/UNICEF global guidance to pro- improve data entry, collection and reporting through mote exclusive breastfeeding; instead, WHO focused strengthened operational capacity and procedures on promoting optimal IYCF practices. Requests for at the nutrition surveillance centres. infant formula over 2014 significantly decreased. 2) Distribution of supplies to SCs to improve and A capacity building and programme-strengthening enhance treatment of admitted SAM cases. In order project was identified as an essential element to to expand geographical coverage, WHO is drawing promote breastfeeding at the health facility and on NGO and private sector capacities across the community level with the aim of raising awareness country. NGOs operating hospitals will be trained among lactating mothers in both displacement and supported with in-kind donations to also be shelters and host communities. Since early 2014, able to treat detected complicated SAM cases. WHO has conducted five trainings for more than 3) Mainstreamed IYCF activities through extensive 190 doctors and health workers from Aleppo, Dam- trainings for health workers in the health centres ascus, Rural Damascus, Quneitera, Sweida, Homs, providing nutrition surveillance, allowing them to Derezzor, Hama, Latakia, Hassakeh, Tartous and deliver key messages to mothers on the importance Daraa in cooperation with the MOH-primary health of breastfeeding and complementary feeding. Fur- Baby girl admitted to WHO supported care department. Trainings covered the importance SC who was sucessfully treated and thermore, two courses of training of trainers will be of breastmilk, its constituents, techniques on initiation discharged 12 days later implemented to decentralise IYCF trainings across of breastfeeding and its benefits for both child and the country, contributing to raising the awareness mothers. through a developed hospital reporting template, of mothers visiting health centres or hospitals, or has been initiated in collaboration with MOH. Breastfeeding promotion has been streamlined residing in displacement shelters or the host com- across all WHO nutrition activities. It has been in- munity. As of August 2014, SCs in hospitals were estab- cluded in all training courses conducted on nutrition 4) Strengthened coordination with the Nutrition lished in nine governorates with MOH and local surveillance allowing surveillance health workers Working Group partners will be crucial in enhancing NGOs. Centres within the public hospitals are avail- to conduct breastfeeding consultations for concerned a coordinated referral process from surveillance able in Damascus (2), Aleppo (1), Hama (1), Lattakia visiting mothers. Data collection on breastfeeding centres, outpatient and inpatient treatment centres. (1), Qutaifeh in Rural Damascus (1), Homs (1-Tad- rates will also be included through the nutrition Nutrition sector partners including MOH and SARC mor), Quneitera (1), Sweida (1), Deir-ez-Zor and surveillance system in the upcoming months, pro- predominantly supported by UNICEF have worked Idlib (1) (see Map 2). Eight of these centres have re- viding information for analysis of trends and further to establish Outpatient erapeutic Programmes ceived SAM cases in Damascus, Aleppo, Lattakia, investigations on causal factors of the changes to (OTPs) in health centres to include the follow up Idlib, Deir-ez-Zor, Sweida and Hama. In cities where breastfeeding rates. As yet, no assessment has been and management of both SAM and MAM (moderate public health facilities have been significantly damaged conducted to investigate any links between breast- acute malnutrition) cases. Additionally, preventative such as Homs, Deir-ez-Zor (Boukamal), Dara’a and feeding status and acute malnutrition. Ar-Raqqa, cases are referred to private or NGO nutrition services and blanket supplementation has hospitals. Preventative micronutrient supplementation been supported by WFP. ese efforts have been Equally important to strengthening treatment capacity, strongly coordinated and continue to be through Reports from Damascus, Homs, Dara’a, Aleppo, preventative measures against micronutrient defi- regular Nutrition sector meetings and bilateral meet- Latakia, Hama and Deir-ez-Zor have been received ciencies have also been scaled up by nutrition ings with UN sister agencies to bridge programmes on complicated cases of SAM requiring urgent working group partners through blanket distribution and fill in gaps working towards a holistic CMAM medical attention. In the case of Hama, over a of ready-to-use supplementary foods (RUSF). WHO approach. period of three months (April-July), 42 cases of has also contributed to this initiative through the WHO in coordination with nutrition sector part- complicated SAM were admitted in comparison to distribution of micronutrients for children and ners has scaled up its nutrition response to help al- six cases admitted between January and March mothers during immunisation campaigns and in leviate nutrition insecurity from a health perspective, before the establishment of the SC. Further expansion health facilities. In 2014, up to 900,000 children aiming to provide quality nutrition services at health of SCs to all governorates is planned with the aim and 7500 adults were provided with micronutrient facilities to prevent, detect and treat cases of mal- to situate at least one centre per governorate to supplementation. manage the caseload of SAM cases requiring hospi- nutrition and related mortality and morbidity. Efforts talised care. Future centres will be located in hospitals The way forward continue to obtain a clearer picture of the prevalence in Deir-ez-Zor (Deir-ez-Zor city), Dara’a, Tartous, During the second half of 2014, WHO will be further of malnutrition across the country. Halting the in- Sweida, Qamishli, and Hassakeh. enhancing its nutrition activities across four main crease of malnutrition prevalence during the pro- areas: tracted Syrian crisis is crucial for children’s health, Mainstreaming Infant and Young children 1) Further strengthening of the nutrition surveillance well-being and physical and cognitive development. feeding promotion system will be achieved through conducting decen- For more information, contact: Hala Khudari, Infant and young child feeding (IYCF) and breast- tralised trainings on nutrition surveillance to expand feeding promotion has been prioritized and main- WHO Technical Officer - [email protected] streamed within most nutrition support activities. In Syria before the crisis, the rate of six-month ex- clusive breastfeeding had been consistently low (ap- proximately 43%). Without the proper support of health staff and community based initiatives, lactating mothers have been struggling during the crisis with initiating breastfeeding. In many cases, due to dis- placement and overcrowded living conditions com- pounded by conflict-related distress, mothers lose confidence in the quantity and quality of their breast- milk, stopping breastfeeding all together and resorting to other practices. During an observational mission in early 2013, doctors and midwives reported an in- creasing number of women who wished to breastfeed their infants, mainly because they could not afford infant formula. Due to the short stay in health facilities following delivery, help with initiation of breastfeeding had been insufficient. Also during Nutrition programme 2013, WHO received numerous requests from NGOs in downtown Amann WFP-dina el-kassaby ...... 56 Field Article Experiences and challenges of programming in

Northern Syria Measuring height during the WVI supported anthropometric assessment Anon, Northern Syria By Emma Littledike and Claire Beck

Emma Littledike has been the Claire Beck is the Global In addition to this article, a personal Health and Nutrition Manager for Emergency Health, Nutrition account of the Emma Littledike's World Vision International on the and WASH Team Leader for experiences in stop-gapping nutrition Northern Syria response since World Vision International. coordination of the Syria response is September 2013. She was the included in Field Exchange 48 online, Nutrition Sub-Working Group www.ennonline/net/fex Lead February to May 2014.

orld Vision International (WVI) set Aleppo governorate, Northern Syria to determine and the need to keep services running. Lack of iden- up offices in southern Turkey in the need for and nature of health and nutrition in- tification documents was also an issue. May 2013 and began work in Jarab- terventions. e assessment team was made up of ulus and Manbij, Aleppo governorate members of WVI’s Global Rapid Response Team. Building IYCF and SAM treatment capacity Win response to the escalating violence in Syria and e target population for the assessment comprised Supports to IYCF and SAM treatment capacity were reports of large scale internal displacement. is internally displaced persons (IDPs) living both in also provided. A planned IYCF training for all health article describes their experiences in supporting one camp and amongst the host community (four and water, sanitation and hygiene (WASH) staff was nutrition and related primary healthcare program- additional camps were later established to meet the postponed due to insecurity in the field. Instead, ming to internally displaced persons (IDPs) between needs of the increased number of IDPs arriving). two doctors crossed the border for accelerated two May 2013 and April 2014. e priority needs voiced by the IDP and host com- day training. ey were equipped with training munity during the rapid assessment in Jarabulus, materials and technical guidelines in Arabic language, Current IDP situation (May 2014) Aleppo governorate were access to health services and equipment to replicate it back in Syria during e total number of IDPs in Jarabulus is currently food, shelter and improved water, sanitation and hy- the aernoons when the clinic was closed. In estimated at 22,875 and the total catchment population giene (WASH) facilities for the camp residents and practice, they could only deliver part of the training is approximately 68,000. e total number of IDPs in town inhabitants. Access to breast milk substitutes due to clinical demands. Guidance on the treatment Manbij is estimated at 115,518 with an estimated was also reported as a major issue. of severe acute malnutrition (SAM) was also provided catchment population of over 1 million. In Jarabulus, through technical resources and discussion. is the camps are managed by an independent Syrian Programme response proved sufficient for the paediatrician to begin individual with strong relationships in the community. Primary health service support treating acutely malnourished children who came Informal camps have been established in collective WVIs immediate priority was to establish support to the clinic, rather than referring them for treatment community spaces such as schools and unfinished to primary health care services. Health services were at the hospital, which was 45 minutes travel by road buildings. ere are a greater number of informal limited, consisting of a number of private doctors and not always secure. F75 and F100 were made camps in Manbij than Jarabulus. Organised and es- and a Qatari Red Crescent Field Hospital. e Syrian using locally available ingredients as commercial tablished camps in Manbij are managed by other IN- Arab Red Crescent clinic had not functioned for a product was not available (see later for issues around GOs. e majority of IDPs at the camps are from while. IDPs could not afford to visit the private supplies). Until then, the few children that presented Homs, Hama and within Aleppo governorates. doctors and the camp management was unable to at the clinic with SAM had complications and were cover the cost of medicines for the residents. In con- referred to the hospital for medical treatment where Early needs assessment junction with the local leadership, including the no nutrition support was provided. At the time of initial assessment by WVI, only back- health committee, a small primary health care centre e initial rapid assessment was observational; ground nutrition data from Syria was available. Pre- (PHC) was established in June 2013 next to the main it was not possible to collect data on feeding practices. crisis, Syria had a high global acute malnutrition camp in the area. A paediatrician, midwife and two Informed by background (national) data, all health (GAM) prevalence of 9.3%, stunting (23%) and un- nurses were hired to provide services, while a com- staff were sensitized to the importance of exclusive derweight (10.3%). Micronutrient deficiencies in munity mobiliser was hired to conduct health and breastfeeding. However the demand for BMS was children 0-59 months were also prevalent: 29.2% nutrition assessments, to provide psychosocial support high from the IDP and vulnerable host community. anaemia, 8.7% Vitamin A deficiency and 12.9% to women and to counsel on optimal IYCF in all the 1 ere was no BMS programme at the time although iodine deficiency Pre-crisis infant and young child collective centres. An English and Arabic speaking infant formula was available to purchase locally (see feeding (IYCF) practices were poor. National figures coordinator linked expatriate and Syrian staff. All later under ‘challenges’). As a result of consultation show a low initiation of breastfeeding within the staff were qualified within the Syrian health system with the governing group, WVI adapted the organ- first hour of birth (42.2%) and low exclusive breast- and selected with support from the local council isation’s Women, Adolescent and Young Child Space feeding amongst infants < 6 months (42.6%) (national and the health committee, who approved all appointees. 2 (WAYCS) model and instead of having separate survey, 2009) . e percentage of children under 2 Initially, expatriate staff visited the projects biweekly dedicated spaces for women and children, an alter- years who are not breast-fed is estimated at 10%. for ongoing training and support, but once the border 3 native more culturally appropriate approach was (2009) . According to national data from 2006, the was closed to expatriates in July 2013, all support, timely complementary feeding rate for children 6-9 supervision and training was done either remotely months was 36.5% and the proportion of children 6- through phone or skype access, or at the nearest 1 11 months who received the recommended minimum Revised Syria Humanitarian Assistance Response Plan (SHARP), border crossing on a bi-monthly basis. Few Syrian Syrian Arab Republic, January- December 2013 4 number of complementary foods per day was 20.8% . staff could cross the border to meet with management 2 Syrian Family Health Survey, 2009 3 staff as this was time consuming and had to be well Figure estimated from area graphs in Trends in Infant Feeding In May 2013, an observational rapid area assess- Patterns, January 2009 ment was conducted by WVI in Jarabulus District, planned due to the busy work schedules in the field 4 Multiple Indicator Cluster Survey, Syrian Arab Republic, 2006 ...... 57 Field Article ......

decided upon which was to set up WAYCS within cases are being managed by a select few INGOs at Severe acutely malnourished child on admission at PHC in clinic facilities. Staff began to hold small meetings their supported inpatient and outpatient facilities Aleppo governorate for women in one of the clinic rooms to support across the country. WVI is the only external (INGO) them in breastfeeding and complementary feeding. health provider in our operational areas in Northern It meant, however, that it was harder to include Syria. Anon, NorthernAnon, Syria husbands and wider family in these sessions. To Due to cultural norms and medical hierarchy, it help overcome this, staff made tent-to-tent visits is also proving difficult for humanitarian agencies and collection centre visits to all pregnant and lac- to support in-patient facilities to improve the treat- tating women to provide support and education. ment of SAM with training and support. Designated Further nutrition assessments in-patient referral facilities need to be identified in When WVI programmes began in June 2013, there each governorate and there is a requirement for were no current nutrition data available. By August training events inside Syria to be delivered by a 2013, two rapid mid upper arm circumference highly qualified consultant. Many health personnel (MUAC) assessments had been conducted by two that are both employed by the regime, working in- Box 1 Treatment of a case of SAM INGOs among children in Idleb and Ar raqqa gov- dependently or for an INGO are unable to cross the ernorates in northern Syria. Both found low preva- border into Turkey without a passport. Travel to An infant presented to the clinic with acute lence rates of SAM (<0.4%) and moderate acute Aleppo to acquire a passport carries substantial watery diarrhoea having already received malnutrition (MAM) (<2.4%). Both assessments safety risk. e need was therefore identified for a treatment with antibiotics and oral rehydration had limitations. e larger rapid assessment in Ar strong distance learning training package comprised salts (ORS) from a private physician. The child had raqqa5 was conducted alongside a measles vacci- of narrated videos in Arabic that could be stored on a history of chronic diarrhoea and had been nation campaign making it difficult to ensure USBs and disseminated in-country. Whilst this is formula fed since birth (never breastfed). The child quality data collection and the majority of children inferior to practical ‘on the job’ training at in-patient had a WHZ <-3 and MUAC 11cm at 9.5 months of measured were <12 months. e rapid assessment facilities, it is perhaps the only way to improve treat- age. The infant showed signs of marasmus and in Idleb on 4,230 children did not provide enough ment, particularly in areas with poor access such as dehydration. He had a fast pulse and dry hair. His information on the sampling methodology and Deir ez zor and Homs. weight on presentation was 5.5kg (a weight household selection to determine how representative recorded at the private clinic was 6kg). it was. Of note, we have seen a higher caseload of mal- nutrition cases in the past two months. ere have The staff began treatment by stopping the course Given these limitations and the report of 30 been around 30 cases of malnutrition (24 moderately of antibiotics, given the lack of evidence for the cases of severe and moderate acute malnutrition malnourished and six severely malnourished) iden- infection diagnosed. For the first two days, to clinics between June and December 2013, WVI tified at the clinics. ReSoMAL solution was provided (5ml/kg =30ml undertook an anthropometric survey amongst IDPs every half an hour). This was prepared as 5% in Jarabulus district, Aleppo governorate on 20th erapeutic food supplies Dextrose, 1.8g of sodium chloride and 1.5g of – 24th December 2013. Both weight-for-height z Establishing a supply of therapeutic and supple- potassium chloride in one litre of water. F100 was score (WHZ) and MUAC were assessed. Given the mentary feeding products has been problematic. also given and it was prepared as: 80g powdered operational constraints, training on anthropometric Our agency could find no local equivalents of RUTF full fat milk, 45g olive oil, 50g cane sugar, 1g assessment was compromised and relied on guidance in Turkey and acquiring therapeutic feeding products potassium chloride, 0.5g magnesium citrate, 2mg documents, video links and a survey leader (pae- from reputable suppliers has been difficult. e cus- copper acetate and 20mg of zinc acetate diatrician) with research experience in nutrition toms cost to import products is excessive. For dissolved in 1 litre of boiling water and set to cool. and anthropometric assessment. e assessment example, an RUTF order worth $650 carried a The F100 was given to the child in 60ml doses was carried out during a difficult time (snow and customs clearance cost of $5000 on top of a $1500 every 2 hours. Vitamin A was also given for 2 days. conflict) and the methodology had to be adapted shipment cost. Increasing the order quantity did The clinic staff reported that they cannot prepare to survey accessible areas. e prevalence of acute not improve the cost efficiency. Our agency managed F75 as there is no skimmed milk. malnutrition was again found to be low: 2.6% to find a supplier who helped to secure customs global acute malnutrition (GAM), 0.5% SAM and clearance free of charge as a one-off gesture of On the fourth day they gave the child Bactrim 8.1% underweight (low weight for age). Prevalence support. However supplies had to be shipped straight syrup and on the 8th day, gave iron. The child of stunting was 22% (7.7% severe). A photograph into Syria (since the agency was not registered in recovered and then maintained his pre-hydration of each child’s measurement was taken and examined Turkey and so goods could not be stored in-country). weight (6kg) during this stabilisation period. for accuracy; the main limitation was an inaccurate us it was not possible to share the supplies with During the following 10 days, the quantity of F100 adjustment for clothing weight (see images). other Turkey-based INGOs and Syrian NGOs as was increased and under supervision, he In September 2013, a joint scoping mission was planned. Border closures further prevented staff proceeded to gain weight at a rate of 15g/kg/day carried out by the Global Nutrition Cluster (GNC) sending supplies back to Turkey to share with other (90g/day). For another 20 days, the child was Rapid Response Team (RRT) consultant in Northern agencies. Importing and storing products in Turkey managed at home with increased F100; his father Syria to assess the nutrition situation. requires agencies to be registered as organisations was capable of preparing F100. The child’s weight undertaking medical activities. A number of agencies increased to 8kg and MUAC increased to 12.5cm. Scaling up services: small scale needs, are not yet registered, despite their efforts, due to He was discharged on lactose free milk until one large scale challenges the length of time required to submit and get year of age and then transferred to full fat milk Case management of SAM feedback from applications. (reconstituted NIDO). The child now drinks full Whilst the prevalence of SAM was low, there was a cream milk, one boiled egg, and fruit daily. He need for small-scale treatment capacity. Existing Access to health care: the role of the private returns to the clinic for regular weigh in. capacity was weak given lack of training and low sector exposure of staff to WHO treatment protocols. In Manbij city, Aleppo governorate, there are 289 Source: INGO worker e majority of in-patient facilities did not follow doctors working privately providing high quality care. IDPs are not able to pay the commercial prices Severe acutely WHO protocols and used intravenous fluid as one malnourished of the main treatment methods for children with for treatment at private clinics. Many primary and child aer 3 SAM and complications. Exceptions were specialised secondary clinic health care staff provide free con- weeks treatment children’s hospitals in Aleppo and Damascus that sultations or a negotiated lower payment rate but are part of the Syrian Ministry of Health (MoH) given financial and time constraints, they are only and which follow WHO treatment protocols. In able to see a small number of patients per day. WVI Syria, there was no commercially produced F100 has recently embarked on a 1 year pilot of a small- or F75 available so locally prepared F75/F100 was scale health care voucher system using the private used instead. An example of case management of a sector to provide quality services to IDPs who had SAM case is given in Box 1. little or no household income (April 2014 – 31st March 2015). In general, community based management of acute malnutrition is being explored but there is no 5 Anon, NorthernAnon, Syria community health worker network in existence so The actual number of children measured is not confirmed...... 58 Field Article ......

e pilot targets children under 5 years in select rently (May 2014) there is almost none available. consultants. Trainings are oen conducted in a large areas of Manbij. ey will receive a voucher entitling WVI has not procured infant formula as the pro- community space and videoed for the benefit of new them to one consultation at any private clinic and gramming focus was on breastfeeding support and staff who may join in the future. medicine from a pharmacy over the 12 month procurement and transport of medicines and supplies project period. At WVIs primary healthcare facilities from Turkey has been a huge challenge. Effective contingency planning was another im- in Jarabulus and Manbij, children under 5 years portant lesson learned, given conflict and escalations have the highest proportion of respiratory tract in- Innovations in fighting have led to hibernation (temporary sus- fections, gastrointestinal diseases and acute malnu- Remote training delivery pensions of activities) and border closures. ese trition. ey are also the most vulnerable group to ere have been many challenges in delivering train- factors have complicated both movement of staff acquire diseases with outbreak potential such as ing, such as lack of Arabic speaking trainers available into and out of Syria and distribution of medical acute jaundice syndrome, acute watery diarrhoea, in Turkey, border closures preventing travel, and and therapeutic food supplies. e temporary ces- polio and measles. limitations on the number of participants at venues. sation of clinic activities had a huge impact on the A training of trainers relies upon staff prioritising population as there are no other health providers. e caregiver presents the voucher to an accredited delivering training in-country which may not be We learned that detailed contingency planning is primary or secondary healthcare provider that they feasible depending on the area, workload and available essential. Supplies need to be pre-positioned and select, along with the eligible child’s IDP registration resources. is led WVI to develop a distance stored appropriately and staff need to have completed card. Aer the consultation, the provider then learning package in the style of Khan Academy security training and be thoroughly briefed on submits a claim to the agency to obtain reimbursement videos6. Also, WVI has worked with a regional security standard operating procedures. for the services provided with all required paperwork, GNC/UNICEF IYCF consultant to produce a har- Given the difficulties with procurement for un- including detailed patient records. If the healthcare monised translated IYCF training package using registered agencies and transportation of supplies provider issues a prescription, the caregiver can training materials from many NGO nutrition actors amidst border closure, early hire of a medical pro- obtain medicine from an accredited pharmacist by working in the region. A series of videos on all nu- curement specialist is essential to support supply presenting it along with the voucher and the eligible trition topics, particularly IYCF-E and nutrition in chain establishment and management. e hiring child’s IDP registration card. emergencies, will be produced on USBs for distri- of pharmacists within Syria to dispense medicines bution to all NGOs and passed onto Syrian health Healthcare providers will receive an induction to patients and manage and plan stock from an staff. Pre- and post-training tests are also being de- on the voucher system detailing the beneficiary age early stage was also essential. Our INGO has procured veloped and added to the USBs so that agencies can group eligible to receive treatment, records required drugs from Turkey and within Syria. Sourcing drugs check and verify that the staff have watched the for verification and how they can claim. Additionally, from within Syria can be a challenge for staff since videos and understood the content. Given the high a number of vouchers will be issued from the agency’s not all pharmacies have the amount in stock that is turnover of medical staff in many areas, this also en- PHCs in Manbij to patients in need of quality sec- required, forcing them to visit many times and buy sures that training new staff is not an additional ondary healthcare treatment from specialist doctors. piecemeal. Research also needs to be conducted burden. evaluating the quality of medicines and supplies A demand-side financing scheme such as this is available for purchase inside Syria. WVI has developed expected to reduce financial barriers to access and Discussion Remote management led to the development of an assessment tool to gain more information about therefore should improve utilisation of health facilities production, regulation and gauge the opinion of by IDPs. Since the voucher scheme allows the robust data collection mechanisms which were set up in the early stages of the programme in September. Syrian pharmacists and health staff about the quality caregiver to choose the providers, this should en- of medicines. Procurement and distribution of es- courage quality health care services through increased A Health Information Management System (HMIS) was developed to monitor consultations for all mor- sential primary health care medicines across the competition in the market. Targeting children under border has posed significant challenges. Supplies 5 years should also reduce the possibility of voucher bidities including malnutrition. e HMIS auto- matically calculates incidence, prevalence and case have had to be sent out with biscuit shipments and selling and misuse. By design, revenue earned by a once across the border, transporting them within health facility from IDPs is directly proportional to fatality rates per geographic area. Data can be cross checked with patient records. Data entry is simple areas affected by conflict to the project sites has the number seen. erefore, this scheme should en- been extremely difficult. hance the quality and quantity of targeted private for field staff and data collation is automatic. ere healthcare services. WVI will monitor quality of is a need for a standardised database system which A thorough understanding of the situation in consultations randomly to ensure clinics signed up can be used by all INGOs and Syrian NGOs and pa- terms of health staff and facilities existing in the to the scheme are providing adequate services. tient ID cards. Given the difficulties with ensuring a areas and resources available is very important. Es- consistent supply of medicines, establishing a strong tablishing an ambulance was a real challenge given BMS supplies and support pharmacy system is also integral to provide inventory there were no equipped suitable vehicles for use. A As reflected in the early needs assessment, the reports and determine needs ahead of time. e large van, which had been badly damaged and aban- demand for BMS was high from the community; a HMIS and pharmacy system combined enabled us doned in the conflict, was donated by local authorities reflection of its common use. Uncontrolled and un- to produce an annual forecast of pharmaceutical and refurbishing and fixing the vehicle was a major targeted distributions of BMS remain common, products required per clinic on a monthly basis, effort. Procurement of specialist ambulance equipment however determining the extent to which this is taking seasonal fluctuations in morbidities into con- from Turkey was also extremely time consuming happening is extremely difficult, especially given sideration. In addition to data management systems, and problematic. Both of these factors led to a time the response is managed remotely. Some actions beneficiary feedback mechanisms were also important delay in the establishment of ambulance services have been taken at coordination level to try and to ensure quality of service provision. Putting these which was not anticipated at the beginning of the minimise risks (see postscript). standardized systems into place in each project early programme. Gaining knowledge of the health care was essential to gain an indepth understanding and system generated the idea for voucher provision in- e need for support with safe artificial feeding provide a greater level of support. stead of the establishment of more clinics which was identified as particularly important in areas re- may not be sustainable. It was deemed more effective ceiving large supplies of BMS. Information, Education Remote management calls for strong and consistent for a larger number of doctors to remain in their and Communication (IEC) materials (posters and communication via telephone daily at designated private clinics and benefit from supplementary pay flyers) were provided to all agencies on how to times, and regular trainings (in Turkey, online and to treat IDPs than for a smaller number to give up prepare formula safely. ere was one observational in Syria). Given access to programmes was not their work for a position at a WVI clinic which may report of infant formula being distributed into cups feasible, the building of health worker managerial not be able to run sustainably. An indepth assessment from a large tank / container and handed out so in skills became as integral as health technical guidance, of the capacity of all private clinics and pharmacists addition to the IEC, the working group also identified is currently being conducted. the need for safe feeding kits to be distributed. particularly for Health Coordinators in each location. Provision of training about humanitarian standards For more information, contact: Emma Littledike, Infant formula availability in the markets in Syria and regulations was also critical given all health staff email: [email protected] has been very sporadic and prices are higher than had no prior experience of working on a humanitarian before the conflict. It is not affordable for IDPs and A personal account of the experiences of Emma programme. Creativity was critical to ensure staff vulnerable host communities. Prices range from $7- Littledike in stop-gapping nutrition coordination received quality training given the difficulties with 10 for 1kg in Jarabulus and Manbij when it is of the Syria response is included in Field Exchange available. A small amount is available in pharmacies border closure and lack of passports. Training delivery 48 online, page 126. but it is not enough to meet the needs of the com- was through a variety of methods including Webex, munities. It is also available in some markets. Cur- training of trainers, videos and contracting Syrian 6 https://www.khanacademy.org/ ...... 59 Field Article ......

A displaced family in Maskaneh, near Homs in western Syria Non-food cash voucher programme for IDPs in Northern Syria By an international NGO WFP/Dina Elkassaby Written April 2014

he war in Syria is now in its third year the INGO office to keep the price as agreed or con- vendors increased the amount and the diversity of and having displaced over four million stant. An exception was if vendors wished to sell at the items they brought to the second market day. Syrians internally – with over 2 million a lower rate (while maintaining quality) to attract Feedback fleeing their country to Jordan, Lebanon, buyers, they were free to do so. Beneficiaries had A rapid post distribution survey was conducted TIraq and Turkey – there is no end in sight. In also the right to negotiate on price in order to buy which found that all 420 households had spent Northern Syria, over 200,000 Syrians are living in more items. Either way, better deals could be made 100% of their vouchers. e top three purchased internally displaced population (IDP) camps, namely for the same quality of product. e agreements commodities were hygiene materials, plastic mats, Atmeh, Qah, Karameh, Aqqrabat, Bab-Al-Hawa and also included clauses on the respect of humanitarian and clothing (see Figure 1). Beneficiaries indicated Al-Salham, while 35,000 people are living in non- principles and using an agreed upon stable exchange that they were highly satisfied with the programme camp settings in villages.1 rate of Syrian Pound (SP) to United States Dollar (USD). Field monitoring and support was undertaken and commented that it was the first time in two Provision of assistance to such a large number of by the field staff. years that they were able to do their own shopping. displaced people in camps with inadequate infra- ey were pleased to regain their ability to make structure is a challenge to humanitarian organisations. Vendors were identified from nearby Syrian cities their own decisions about what to purchase for Most of the emergency response involves in-kind and their capacity to meet the identified needs was their families. However they commented that the distributions of food and non-food items. ese in- assessed. Twelve vendors were selected to participate price of goods had risen sharply over the past years terventions have been effective in saving lives and in the market day to create enough competition to due to loss of SP value. Some of the beneficiaries preventing a further deterioration in the humanitarian lower the prices, however only seven were able to observed that prices were three times higher compared situation. However, the approach has several draw- participate. e five vendors who did not participate to what they used to pay in their hometowns a backs, including the fact that it is a huge logistical pulled out at the last minute; no reasons were given couple of years ago. Overall, the pilot programme burden and time consuming activity -from pro- but may have been due to security issues or lack of was appreciated by the beneficiaries because it gave curement to stocking and transporting commodities sufficient stock. them the opportunity to choose goods depending to distribution. is is made all the more difficult in on their needs, the goods were from Syria, the sup- Implementation conflict affected areas. Also, it disempowers the pliers were Syrian, and the response time between A total of 420 IDP households benefited from the affected population as it does not provide them the need assessment and the market days was very pilot programme in the camp. Each household was with the ability to decide what commodities they short. ere was no security problem and no com- provided with 12 vouchers, worth 12,000 SP (69 want or prefer. With the aim of mitigating these plaints were registered from the beneficiaries or the USD). e vouchers had denominations of 3,000, problems, a pilot voucher programme was designed vendors. To date (May 2014), the programme has 1,500, 600 and 300 SP, to provide more flexibility in and implemented by an international non-govern- not been repeated but the team is preparing to scale shopping for smaller or bigger items. mental organisation (INGO) in one of the IDP up the voucher system to other camps. camps. Two market days were selected and agreed on Conclusions with the beneficiaries and vendors. e vendors Overview of voucher programme e voucher programme was a speedy response to trucked their goods to the camps on the agreed is involved voucher distribution and the arrange- the camp IDPs and the best way to address their dates and the camp leaders were responsible for se- ment of two market days at which to spend the basic needs. Satisfaction among the beneficiaries curing a space for the market place and for crowd vouchers. e programme was implemented over was very high mainly due to a high level of partici- control. e INGO staff monitored all activities one month. e programme was informed by a pation (involving the beneficiaries) during the needs during both market days and provided guidance needs assessment and market assessment (1 week) assessment, the market assessment and consultations when needed. At the end of the first market day, the by the INGO, followed by vendors’ selection and at various levels. Also, use of local suppliers (Syrian) vendors packed their remaining items and carried beneficiary registration before implementation. who are known by the community and part of the them back to their home towns. With a better un- same culture helped to supply materials that fit to derstanding of what the IDPs wanted to buy, the e needs assessment involved four focus group the context and cultural values of the IDP’s. e discussions (FGD) to understand the IDPs’ need voucher system has proven to be applicable in an for non-food items. e FGDs were conducted with Figure 1: NFI voucher spending in Syrian IDP camp setting. It was implemented quickly in an IDP camp men, women, young boys and young girls. ey in- emergency context to address basic needs of the dicated that the top three priorities were hygiene IDP’s, and carried lower risks due to the requirement items, clothing, and kitchen items. e preference for less logistic activities and low visibility of the was for Syrian made items that met their social and approach. cultural values, such as scarves, long skirts, specific shampoos and detergents. Based on the identified Above all, the voucher approach empowers ben- needs, market prices were collected for the major eficiaries and respects their dignity as it gives them items and maximum prices were agreed with the the right to choose how they meet their needs, vendors that would apply for the two market days. which is fundamental principle of the humanitarian is was undertaken to protect the value of the charter. vouchers that was based on the findings of the market assessment. Findings from the market and price assessments were shared with both vendors Plastic mats Clothing 1 Turkey and Syrian refugees: the limits of hospitality. and beneficiaries. e arrangement was governed http://www.brookings.edu/research/reports/2013/11/14- by a signed memorandum of understanding with Hygiene materials Kitchen items syria-turkey-refugees-ferris-kirisci-federici ...... 60 Field Article ......

Pre-war food and nutrition situation Al-Raqqah governorate is in the North of Syria and MSF, either directly or through a partnership with Brigitte Breuillac/MSF, Syria, 2013 Syria, Breuillac/MSF, Brigitte has Al-Raqqah city as its capital. e governorate is the national hospital in both medical and non- divided into the three districts of Tal-Abyad, Al- medical positons. When MSF OCA first began work- Small market in a town Tawrah and Al-Raqqah. Tal-Abyad district was es- ing in Northern Syria, the expatriate staff were able located in Idlib area, Syria timated to have around 200,000 inhabitants, of to live and work alongside the national staff. In Jan- which around 40,000 were internally displaced pop- uary, 2014, with significant changes in the leadership ulations (IDPs) (March 2013). ere are no official of the area, a major security incident and closure of collective centres or camps in Tal Abyad district. the border crossing from Turkey into Syria, MSF e IDPs live with host families or in empty buildings withdrew expatriate staff from Syria and switched Emerging or makeshi accommodation with limited protection to a remote management style of working. National from weather conditions. Staff were then supported by expatriate staff in Turkey via phone, email and skype. With regards to Pre-war, before March 2011, the main economic cases of the nutrition programme, this meant that with each activity in Al-Raqqah governorate was agriculture, admission, the Syrian medical doctor would call with the Euphrates as an important source of water the expat medical doctor responsible and discuss malnutrition for irrigation2,3. In combination with imports from the patient’s condition and treatment plan. ese neighbouring countries, food availability generally patients were followed up by the expat daily, via met the needs of the growing population. With amongst IDPs phone calls with the on duty physician. Trainings fixed price policies from the government, staple for national staff doctors and nurses were conducted food was accessible for all. e agricultural sector via emailed power point and skype, and proved to was hit hard by the water crisis that peaked in 2008, in Tal Abyad be successful even with this unusual method of which increased unemployment and reduced local management. In May 2014, MSF closed the pro- food production. e event coincided with external gramme completely (see discussion for more details). district, Syria economic factors and neo-liberalisation policies driving up prices of food, fertilisers and energy. Nutrition situation 2013 By Maartje Hoetjes, Wendy Rhymer, Lea ese developments caused many Al-Raqqah farmers In March 2013, an exploratory mission by MSF Matasci-Phelippeau, Saskia van der Kam to move from their lands to the southern cities, in found no cases of acute malnutrition. Two months the hope of finding a job4,5,6. later, in May 2013, a mid-upper arm circumference (MUAC) screening was included as part of a measles Maartje Hoetjes is a Undernutrition was a problem in pre-war Syria, vaccination campaign (including children from 9 Medical member of the reflected in 9.7% of children under five years un- months old to five years). is was undertaken to MSF emergency team, derweight for their age, 2.3% wasted7 and 29% stunt- update information on the nutritional status of the currently working in ed8. Underweight and wasting were reported to be IDP community given their situation (displacement, South Sudan. She more prevalent in Al-Raqqah governorate, with the lack of income), a recent measles outbreak and an- worked as Medical 6-11 months age group mostly affected9. In Al- ecdotal reports that that mothers had difficulties Coordinator in Syria Raqqah governorate, there were no specific protocols finding appropriate food (infant formula) for their from February to November 2013. or programmes in place for the treatment of moderate children. Wendy Rhymer started and severe acute malnutrition. Since the outbreak working with MSF-OCA of the conflict, agricultural production has been e MUAC screening found a 0.6% prevalence in 2007 as a nurse/ further hampered by insecurity limiting access to of global acute malnutrition (GAM). irty eight 10 midwife and was MSF fields and markets, as well as the high price of fuel . cases (0.1%) of severe acute malnutrition (SAM) medical coordinator for Moreover, the region experienced damage to its ir- were identified amongst 34,997 children screened 11 Northern Syria from rigation canals (10%) . Shortages of food, due to (see Table 1). e vast majority of the identified December 2013 to May limited production as well as import problems, have cases were children younger than 1 year of age. e 2014. Wendy was interviewed by the ENN in been regularly reported and the prices of bread and highest numbers and percentages of malnourished 12 early May 2014. other food have significantly increased . were found in the Central area, with the majority in Tal Abyad town. In the city, the malnourished cases Lea Matasci-Phelippeau MSF operations in Northern Syria Médecins Sans Frontières Operational Centre Am- is psychologist and 1 sterdam (MSF OCA) has been working in Northern Hoetjes, M. The impact of armed conflict on health in worked in Syria as mental Al-Raqqah governate, Syria. KIT/Royal Tropical Institute: health officer. She is Syria, Al-RAqqah governorate, Tal-Abyad district, August 2014 currently working as since February, 2013. Medical programmes include 2 Masri A (2006) Country Pasture/Forage Resource Profiles. Mental Health Officer in inpatient paediatrics, as well as general outpatient Rome. services for adults and children. Services also include 3 Goodbody S, del Re F, Sanogo I, Segura BP (2013) FAO/WFP South Kivu, Democratic crop and food security assessment mission to the Syrian republic of the Congo, for MSF OCA. antenatal care, postnatal care, sexual and gender Arab Republic. Damascus. based violence care, family planning, as well as 4 Nasser, R; Mehchy, Z; Ismail AK (2013) Socioeconomic roots Saskia van der Kam is routine immunisation. e mental health programme and impact of the Syrian crisis. Damascus. the nutrition expert of includes individual and group counselling sessions, 5 International Crisis Group (2011) Popular protest in North MSF in Amsterdam. psycho-educational sessions and outpatient psychiatric Africa and the Middle East (IV): the Syrian people’s slow motion revolution. Brussels/Damascus. care. e nutrition programme includes inpatient 6 Rifat H, Ismail KA, Nawar AH (2010) Syrian Arab Republic therapeutic feeding and ambulatory therapeutic Third National MDGs Progress Report. Damascus. feeding care. Expanded Programme of Immunisation 7 Wasted defined as acute malnourished with weight-for- (EPI) support has been provided to outlying villages. height <-2 z score. This includes moderate (MAM) and severe acute malnutrition (SAM)). Donations of emergency medicines and medical The authors gratefully acknowledge the work 8 Stunting defined as Height-for-Age <-2 z score supplies to other facilities in the surrounding area 9 of Medecins Sans Frontieres Operational UNICEF (2008) Syrian Arab Republic Multi Indicator Cluster are also provided. Survey: 2006. Geneva, Switzerland Centre in Amsterdam (MSF OCA), the team 10 The wheat production of 2013 showed a decline of 40% MSF OCA in Syria and Vanessa Cramond, Until May 2014, the expatriate team included compared to the trend of the previous 10 years and the Emergency Manager (Medical) at the two Medical Doctors, two Nurses, a Mental Health livestock sector in Syria has significantly reduced. Source: Emergency Support Desk at MSF-OCA. Officer, a WASH (Water, Sanitation and Hygiene) See footnote 2. 11 See footnote 2. officer, a Project Coordinator and a Logistician. To 12 Sections of this publication are part of Maartje Hoetjes M (2014) The impact of armed conflict on health in this date, 78 Syrian national staff were working with Al-Raqqah governate , Syria Hoetjes’ dissertation for a Masters in International Health1...... 61 Field Article ......

Table 1: MUAC screening during vaccination were clustered. Percentages of children with a Mothers spontaneously expressed fears for their chil- campaign, May, 2013, Tal Abyad district, Syria MUAC <125mm ranged from 0-10% per area in dren, in particular lack of fresh milk, since this item MUAC <115 mm 115- 125- >135 mm Total the city. e most common explanation for mal- is never included in food donations. Infant formula <125 mm <135mm nourished children with no underlying medical milk is generally available but the prices are very Number 38 180 1,161 33,618 34,997 issues was that caregivers had no money to purchase high; mothers simply cannot afford it. e only item % 0.1% 0.5% 3.3% 96.1% 100% infant formula. Seven medical cases were children that was received on a regular basis by IDPs living in with “a hole in the heart” (a congenital heart some of the schools was free bread, donated by Table 2: MUAC screening in mobile clinics, 3rd defect). MUAC screening by mobile clinics was different armed groups. IDPs living in one of the August - 21st September, 2013 also used as a way of monitoring the trend in the schools reported receiving free rice regularly. population. is showed no increase in malnutrition MUAC <115 mm 115- 125- >135 mm Total Meal frequency <125 mm <135mm (see Table 2). MUAC screening from July to Sep- tember 2013 of children attending the inpatient Before the war, Syrians used to have three meals per Number 3 2 29 637 671 day (breakfast, lunch and dinner). e survey in- % 0.4% 0.3% 4.3% 94.9% 100% clinic did not show an alarming number of mal- nourished (Table 3). vestigated the number of meals IDPs are currently eating each day. As Figure 3 shows, 52% of the Table 3: MUAC screening in inpatient clinics, 1st Despite the low number of malnourished cases women interviewed (n=20/38) reported that their July -15th September, 2013 identified in the vaccination campaign, an increasing families are having the usual number of meals, 16% MUAC <115 mm 115- 125- >135 mm Total number of malnourished cases were attending in are having only two meals (n=6/38) and one third <125 mm <135mm the mobile clinics in between April and May 2013. of the families are eating more than three meals Number 16 8 22 383 429 is triggered the opening of an Ambulatory er- (n=12/38) per day. In response to the question “do % 3.7% 1.9% 5.1% 89.3% 100.0% apeutic Feeding programme (ATFP) at the end of you oen feel hungry?” almost 75% (n=29/39) of May 2013, followed by an Intensive erapeutic those interviewed replied “yes”. Unfortunately, meal Table 4: Average price increase between Feeding Centre (ITFC, inpatient facility) at the quantity could not be ascertained. However, since pre-war and August 2013 beginning of July 2013. Since the start of the pro- three-quarters of respondents reported oen feeling Food Average price increase % gramme, the number of admissions has increased hungry, it can be inferred that those who are still Bread + 233 % slightly week by week. In order to have a better having three meals (or more) are actually eating Oil + 294 % picture of the factors affecting the nutritional status smaller quantities of food. Flour + 424 % amongst the Tal-Abyad population, MSF undertook Diet diversification Milk + 424 % a small qualitative survey among the most vulnerable Rice + 639 % populations in the Tal-Abyad region of Syria in In Syria, all the family usually eats together, unless August 2013. there are guests or in the case of a special event, Figure 1: Family size when women and children eat separately. e diet Qualitative survey pre-crisis was varied and mainly composed of grains 8 e surveyed population was IDPs living in schools (bread, rice, bulgur, etc.), vegetables (soup, salads, in the Tal Abyad region13. A total of 39 persons etc.), beans (chick peas in hummus and falafel, lentil 7 were interviewed, all women, about their living soup, etc.), dairy products (yoghurt, milk, cheese) 6 circumstances and food security. e data were meat and eggs. e survey revealed that people’s 5 collected using a questionnaire administered by current daily diet is generally composed of grains 4 MSF staff working with the mobile clinics. e (bread, spaghetti, rarely rice) and vegetables (73% data covered a period between mid-August and 3 of adults, 63% of children). Only two people reported mid-September 2013. eating dairy products (milk, yoghurt). Meat and Number of families 2 eggs are scarce and not consumed but beans and Family composition 1 lentils are part of the diet. For some IDPs, the Figures 1 shows the family size amongst those 0 variety of food is even more limited; seven people surveyed. e average family size was 5.9 with 1 2 3 4 5 6 7 8 9 10 11 12 reported that adults are only eating grains, with five Family size (adults & children) 79% (n=30) having 3-7 family members. e ma- people saying that the same is true for their children. jority of the families (84% (n=32)) had one or In some cases, adults are favouring their children two children aged 5 years or under (see Figure 2). Figure 2: Number of children younger than (n=6/33), by giving them the available vegetables 5 years per family Twenty two families (58%) had one or more chil- and/or milk. In a small number of cases (4/33) the dren younger than 12 months (one family had opposite is true, and parents report eating more 18 two children under this age). vegetables than their children. 16 Availability and access to food 14 Infant nutrition and breastfeeding practices 12 All but one interviewed woman (n=38/39) reported 10 that a wide range of food was still accessible at “ And mothers should breastfeed their 8 local markets. However, for some of the women children two complete years for those who 6 (n=9), access to markets was not easy since they want the breastfeeding to be complete”

Number of families 4 live 10-15 km away. Public transportation is ex- (Qu’ran, 2nd verse, Al Bqarah, 233:37) pensive (100 Syrian Pounds); most walk long dis- 2 Breastfeeding is a practice accepted and even 0 tances to reach the market, sometimes arriving 1 2 3 4 too late to find the items they need as the market promoted by the holy Qu’ran. In fact, in “Islamic Number of children < 5yrs old starts early in the morning. Culturally, men are instruction, mothers are entitled a monthly payment 14 supposed to do the shopping. Only women with from their husbands to breastfeed their children ”. ‘special circumstances’ (widows, divorced) are ‘al- Breastfeeding was also used sometimes as a social Figure 3: Meal frequency lowed’ to go out shopping. Married women should regulator; if a mother breastfed another baby in ad- not leave the house regularly. ose interviewed dition to her own baby, they would become “brothers 25 reported the major problem affecting people’s nu- of milk”. Marriage would therefore be forbidden be- tween the two children in later life in a culture 20 trition is that prices continue to rise and there is a lack of money due to unemployment (see Table where intra-familial marriages are still common. 15 4). is has a direct influence both on the quantity Also, according to custom, the parents of a woman and quality of food that can be purchased. who has been breastfed can ask for a larger dowry 10 than if she was not breastfed. Almost 100% of the respondents reported

Number of families However, according to national staff, using formula 5 having received at least one donation of food and non-food items (NFI) from different actors (Turkish 14 Al-Akour NA, Khassawneh MY, Khader YS, Ababneh AA, 0 Red Crescent (TRC), Qatari Red Crescent (QRC), Haddad AM (2010) Factors affecting intention to breastfeed 1 2 3 4 5 6 Saudi Arabia, local court, private donations). Most among Syrian and Jordanian mothers: a comparative cross- Number of meals per day of them, however, stressed that donations occur sectional study. Int Breastfeed J 5: 6. doi:10.1186/ sporadically and they need regular donations. 1746-4358-5-6...... 62 Field Article ......

Figure 4: Breastfeeding practice, Syria 2006 (UNICEF) Figure 5: Meal frequency

100

90 Weaned (not breastfed) 20 80 Breastfed and complementary foods 70 Breastfed and other milk/formula 15 60 Breastfed and non-milk liquids 10 50 Breastfed and plain water only

Percent 40 Exclusively breastfed 5

30 Number of people 20 0 10 City water City water Trucking City water & City water & Well & trucking well trucking 0 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Water supply Age group in months Source: MICS milk became the new “fashion” in pre-war Syria. findings of the June/July 2013 assessment, MSF cates that the malnutrition was a larger problem in ere are several possible ‘cultural’ reasons for this: launched a water and sanitation intervention in the Tal Abyad district than could have been expected people started to think that formula milk was better most affected schools and started up mobile clinics based on surveillance data, which does not include than mother’s milk, some (urban) women started targeting the collective centres. this age-group. According to the ITFC medical staff, to have concerns about preserving the beauty of the majority of the children included in the pro- their breast and men who refused formula milk for Nutrition programme gramme were infants < 12 months. e team iden- their wives felt they might be perceived as mean. Doctors and nurses in Syria have not been trained tified a number of contributing factors to malnutrition All these factors have meant that duration of breast- on how to diagnose and treat malnutrition and pro- in these infants: a low rate of exclusive breastfeeding, feeding has been decreasing and that some mothers tocols and guidelines were not in place to support significant use of infant formula in recent years, es- have not breastfed at all. Furthermore, Syrian the medical practitioners, as malnutrition was not calating prices and decreased availability of infant mothers also believe that babies benefit from water, common. is gap in medical care was one of the formula and inappropriate feeding (e.g. use of animal water and sugar, a local type of “sheep clear butter”, reasons for MSF to intervene given the cases of milk) when infant formula unavailable. or tea in addition to breastmilk. Exclusive breast- malnutrition identified in the MUAC screening. feeding was and is still far from being a generalised MSF began by integrating Ambulatory erapeutic MSF market surveys showed a tremendous in- practice. ese findings are supported by a UNICEF Feeding Centre (ATFC) services into outpatient crease in prices of infant formula, from a pre- survey which showed that less than half of infants clinic activities at the beginning of June 2013. MSF conflict price per can of 300SYP to 1500SYP in were exclusively breastfed at birth in 2006; in Al- also supported an ITFC in the paediatric ward in September 2013 and 1700SYP in February, 2014; Tal Abyad hospital from July 2013. Out of an Raqqah, the exclusive breastfeeding rates was esti- more than a 500% increase. mated even lower, only 26.5%15. estimated under 5 population of 30,000 in Tal Abyad, the team expected 10-15 admissions per month for Programming challenges In the past decade, many efforts were made by complicated SAM (0.5%). At the outset, there was some resistance from the the Ministry of Health (MoH), in collaboration doctors and nurses to follow the MSF nutrition pro- Between July 2013 and April 2014, malnutrition with UNICEF, to provide breastfeeding education tocols. As these staff members had limited or no ex- was the principal reason for 5.3% of all admissions and promote exclusive breastfeeding for the first 6 perience with malnutrition, there was a belief that in the in-patient paediatric ward. In the same period, months. According to data collected by UNICEF, the patient was sick due to other reasons, and SAM was the main cause of mortality (21%) in the from 2007 to 2011, 43% of women exclusively therefore only needed interventions such as intra- ward, followed by respiratory tract infection (RTI) breastfeed during the first 6 months, and 25% con- venous fluids and antibiotics. But with training, we and accidental intoxication (drinking petrol, cleaning tinued partial breastfeeding until their baby was 2 were able to change this to a certain extent. years old. According to the data collected in the solutions) (both 10.5%). All deaths due to malnutrition MSF survey, 68% (n=26/38) of the women inter- occurred amongst infants under 6 months. is does All issues related to breastfeeding and re-lactation viewed reported that they were currently breast- show an important trend compared with the mortality were a challenge, in particular: feeding. Among them, 20 had babies aged < 12 profile before the conflict, when malnutrition did • Given the culture of using infant formula, knowl- months and four of them reported exclusively not appear in the under-five’s mortality profile. edge of breastfeeding among staff and patients was very low. Some mothers had not breastfed at all or breastfeeding. When asked if infant formula was All patients under 5 years, presenting to either had stopped two or three months ago, although available, only three mothers replied affirmatively. the paediatric inpatient facility or the outpatient fa- For the majority of women, infant formula had be- cility, are screened for malnutrition. Children whose come too expensive. MUAC is below< 135 mm are assessed using weight- Health and sanitation for-height z score (WHZ). All children are also as- Lack of access to good quality water was the second sessed for oedema. Any child with WHZ <-3 or most common complaint amongst respondents aer oedema is admitted. Patients are admitted to the in- lack of access to food. e surveyed IDPs got their patient ward (which is within the paediatric inpatient water supply from three different sources: city water facility in the national hospital) and a caregiver is (tap), water trucking, and wells (See Figure 5). Out present from admission to discharge. Usually this NorthernAnon, 2014 Syria, of the 39 people interviewed, 49% (n=19) complained caregiver is the mother, although sometimes an al- about water quality, mainly saying that it is “bad”, ternative female family member is designated to “dirty” or “salty”. Only one respondent complained stay. MSF ITFC nutritional guidelines are followed, that there was “not enough” water. Despite this, which include the use of F-100, F-75 and Ready to only 3/39 stated that they were boiling water. Lack use erapeutic Food (Plumpy’nut) as needed. In of fuel was a main reason for this. e third most the ATFC, patients are seen and assessed by the nu- common complaint (7 people mentioned it) was trition nurse in the outpatient department on a poor hygiene due to overcrowding. Hygiene supplies weekly or bimonthly basis, depending on the con- were included in donations but again, this happened dition of the patient. too sporadically. To date, the majority (75%) of cases have been ese findings support observations during the direct admissions to the inpatient feeding programme. assessments in the IDP collective centres in June/July Between July and December 2013, 70 children were 2013 where the MSF team concluded that the IDP’s admitted to the ITFC of which 36% (n=25) were living there suffer from skin diseases, such as scabies, younger than 6 months. From January to April lice and ringworm. Furthermore, 80% of the IDPs 2014, 49 patients were admitted to the ITFC of interviewed reported suffering from diarrhoea, due which 59% were younger than 6 months. is indi- to bad hygiene and water quality. Following the 15 See footnote 8. MUAC measurement in an infant ...... 63 Field Article ......

breastfeeding in these circumstances and organised breastfeeding promotion and individual support as much as possible given the challenging circum- stances. Despite concerns about the general food security, this did not manifest itself in the nutritional state of older children or the general population. However, it was quite visible in very young age groups, who need high quality foods, including a source of milk or other foods of animal origin. As food security and dietary diversity is low and there are no signs of improvement, MSF considered

Brigitte Breuillac/MSF, Syria, 2013 Syria, Breuillac/MSF, Brigitte blanket selective feeding for all children, as well as improving hospital food and lobbying for more food aid and humanitarian support. However two major constraints hampered implementation of these ac- tivities. Tal-Abyad is situated in a rebel controlled area in the north of Syria. is meant denial of regular cross-line support through UN coordinated Ambulance in front of an advanced medical post food aid or nutritional support as this needed gov- supported by MSF in Idlib area, Syria ernment permission. Importation of foods by MSF was not straightforward either. Furthermore, a sig- nificant security event involving MSF staff meant their children were still under the age of 6 months. e supply of therapeutic foods and items was that expatriate staff were physically withdrawn from In this age group, the options for therapeutic feeding problematic. It was difficult for agencies to access Syria in February 2014; this meant that new pro- include breastmilk, therapeutic milk and infant for- international supplies of these foods and agencies gramme elements, like the roll out of breastfeeding mula. Relactation is a difficult process, even with were unable to procure comparable nutritional sup- promotion and support, could not be properly im- experienced health professionals providing advice plies locally. ere was a rupture in the supply of plemented. and support, and mothers who are committed to F100 milk in January, 2014 so that MSF was required the process. As exclusive breastfeeding was not a Conclusions and recommendations to purchase infant formula locally as an interim e Syrian context is relatively new for MSF, therefore common practice amongst most women and the measure to use in therapeutic feeding programmes. staff, there was limited drive to persist with relactation. we would like to share some lessons learned. In the Finally, the defaulter rate of the therapeutic immediate term, to address the needs and challenges • When these children reached their target weights feeding programme was high (30% to 50% of the we have identified, we consider that: and were ready for discharge, the problem presented exits) both for the inpatient and outpatient pro- that many of the mothers had not yet achieved ex- ere is an urgent need for unrestricted access grammes. Some of the reasons for default are not to people in need throughout Syria and unhindered clusive breastfeeding and therefore would need to unusual for a feeding programme; these included resort to giving infant formula. In ATFP where chil- cross border activities. the fact that some of the patients were IDPs, and • Nutrition assessment and surveillance systems dren are followed up aer having been treated in their families were moving to another location and the inpatient ward, MSF only provides breastfeeding should include infants younger than 6 months, that sometimes the caregiver was unable to stay and be alert to potential changes in the under advice and support, and does not give a supply of with the patient in the hospital, due to other re- infant formula following the general international one year age group. sponsibilities at home. However, what was reported • ere is an urgent need to supply infant policy. is le many families in the difficult position most commonly with regards to patient default was of again trying to acquire infant formula, as no formula to babies whose mothers have not been that the parents did not understand or value the breastfeeding and therefore have a limited or other local or international non-governmental or- care being provided to their children. Due to a lack ganisation in the area was providing this to patients. lack of milk supply, and who are unable to of understanding of malnutrition, there was distrust e motivation to come to the ATFC for follow up afford or find infant formula for their babies. that therapeutic milk would be sufficient to support was low as nothing other than advice was provided. • Medical professionals should be trained on these patients. Also, once patients under 6 months breastfeeding to help educate pregnant women • Occasionally infant formula was supplied through were transferred from the ITFC to the ATFC and and to provide skilled support to establish the ATFC, but the team saw this as an exception. If no longer were being given therapeutic milk or breastfeeding and overcome difficulties. ere mothers thought that they could receive formula infant formula, mothers questioned the need to is a need to explore the use of medications to milk, it would have undermined all the hard work come weekly for weight and physical assessment. assist women in increasing their milk supply. that was done in the ITFC to motivate mothers to Discussion Strengthened individual support should be stimulate and restart breastfeeding. Moreover, the complemented by a breastfeeding community Despite difficulties in active case finding and screen- fear was that MSF would be overrun by mothers re- awareness campaign focusing on the need to ing, the number of acutely malnourished was higher questing infant formula. breastfeed exclusively for the first 6 months of than expected. e initial assessment and the sur- age, targeting not only mothers but their families • e time that expats were on-the ground was not veillance did not indicate the importance of malnu- and the community. sufficient to train staff fully on breastfeeding pro- trition in the Syrian IDP and host community. is • Management of acute malnutrition (likely motion, and remote support to breastfeeding was a can be partly explained by the large proportion of requiring training), vaccination and targeting challenge as locally there was virtually no experienced infants younger than 6 months amongst admissions, the top three illnesses should be integrated into person on the ground. Predominantly male staff as these generally are excluded from screening and normal paediatric health care structures. were unable to give breastfeeding support, as only community assessment. • Blanket selective feeding programmes providing female staff are able to discuss and assist patients Reasons for acute malnutrition in infants appear high quality foods to young children and PLW with breastfeeding. Most of the female staff had to be a low rate of breastfeeding, lack of clean water, and better quality general food distributions never breastfed before. Also midwives had minimal lack of resources to buy infant formula milk and could prevent further deterioration of the experience teaching patients about breastfeeding. physical exhaustion of the mother. Treatment of nutritional status. • Although many breastfeeding videos were avail- malnourished infants works in the short term, but e MSF programme in Tal Abyad has been closed able, as well as pamphlets/books, due to cultural aer discharge from the inpatient ward, a dilemma since May 2014; leaving very few agencies addressing considerations, these materials were deemed too arises. MSF did not supply infant formula for use at malnutrition in Northern Syria. ere is an urgent sensitive to use with patients in the programme al- home, but the families would face the same difficulties need for others to secure access and step up their though some were useful to train the national staff. with feeding their babies as an alternative referral or nutrition support activities in Northern Syria. A training plan was developed with the help of an support system was lacking. MSF actively lobbied experienced Save the Children staff but the security other agencies for such support but none was forth- For more information, contact: Maartje Hoetjes, situation prevented implementation. coming. Overall MSF recognised the importance of email: [email protected] ...... 64 Views......

Turkey, Yayladagi (Hatay region), February 2013

Coordinating the response to the Syria crisis: the southern Turkey cross border experience WFP/Jane Howard

is views piece was developed by the ENN based on eight key informant interviews with donors, UN agencies and INGOs carried out during an ENN visit to southern Turkey in early April 2014, subsequent follow-up by email and meetings with OCHA Geneva and the Global Nutrition Cluster in June 2014. All contributors have seen various dras but requested to be anonymous. Note that this views piece reflects the experiences up to April 2014 (with some updates related to UN Resolutions). Other developments in the coordination mechanisms may have taken place since this time.

Background e onset of the conflict in Syria, which resulted in carried out in January 2013 was an NGO Forum led e UN therefore effectively adopted an ‘indirect the establishment of government and opposition initiative. e formation of the Assistance Coordi- support’ modus operandi for southern Turkey. controlled areas (the latter are predominantly in nation Unit (ACU)3 in November 2012 brought an- OCHA in coordination with global cluster lead UN northern Syria), has meant that to date (April 2014), other prominent player in cross-border programming agencies, INGOs and donors, set up working groups the humanitarian response has largely been admin- and it was hoped that this structure would take on for each sector. Most of these working groups were istered through two separate and uncoordinated operational coordination. However, a number of co-chaired between INGOs and UN agencies or programming approaches1. Firstly, humanitarian internal challenges prevented ACU from taking on cluster representatives (without cluster activation) agencies based in the Syrian capital Damascus, work this role. In addition, OCHA arrived in southern and the majority of them had dedicated coordinators, through the consent of the Syrian Government and Turkey in February 2013 with a mandate to promote funded by donors, to chair and steer the group’s with the Syrian Arab Red Crescent (SARC). Secondly, coordination of information management and needs work. e working groups replaced the NGO Forum agencies administering services into northern Syria assessments of the cross border programme. is and provided a far more effective space for technical do so largely through programming planned and engagement led gradually to the establishment of coordination within sectors – especially around in- coordinated from southern Turkey. is is referred IASC4- like coordination mechanisms. e efficacy formation sharing and certain elements of operational to as the cross border programme2 and was initiated of this mechanism was challenged by the lack of coordination. e membership of the working groups in the early months of the crisis by a number of di- cluster activation in Syria at that time, the constraints was extended to cover a wider range of partners, in- aspora Syrian based agencies and international non- faced by UN agencies for their direct involvement in cluding Turkish and Syrian NGOs which fed into a governmental organisations (INGOs) with support a response that was clearly opposed by the Syrian broader coordination architecture, including an in- from a small number of humanitarian donors. e Government, as well as a lack of buy-in by INGOs to ter-sector working group, as well as a strategic, de- coordination experience from the cross-border pro- coordination by a UN agency (OCHA) that was not cision-making body with key representatives of the gramme has highlighted a number of lessons learnt itself operational in the cross-border programme. humanitarian community to provide overall lead- and challenges for the humanitarian sector. Coor- Despite these challenges, there was an increased call ership for the response. dination and planning for nutrition programming, for more coordination, in particular between pro- However, major challenges remain due to the in particular, appears to have been a casualty of gramming from Syria and programming across the absence of an official mandate for stronger UN op- some of these challenges. is is the main focus of southern borders of Turkey into northern Syria. erational involvement6. As a result, UN agencies this views piece. To date (April 2014), UN agencies present in provide support and guidance on humanitarian Coordination in the absence of a cluster southern Turkey have largely (with some exceptions mechanism and to varying degrees) had to operate an information 1 See later for updates in this regard with respect to UN Resolution Within Syria, the Damascus based UN agencies ‘firewall’ system between their cross border coordi- 2165. nation work and their operations based in Damascus. 2 At the time of writing, programming across other borders, such as opted for sectoral coordination with UN cluster from Iraq and Jordan, existed but at much smaller scale and are lead agencies working with a government co-lead. ere were two main reasons for this. e first was not covered in this views piece. For nutrition, UNICEF as the cluster lead agency the risk of the Syrian Government finding out about 3 Created in November under the initial leadership of Suhair has been ‘double hatting’ providing technical input, UN cross-border activities from southern Turkey, al-Atassi, a vice president of the National Coalition for Syrian which could jeopardise their work in Government Revolutionary and Opposition Forces as well as a crucial coordination role. In the opposition 4 Inter Agency Standing Committee controlled areas of Syria however, there has not controlled areas of Syria, i.e. the Syrian Government 5 Some INGOs have also adopted a similar approach, i.e. basing been any official UN coordination presence. In may place restrictions on UN agencies working both themselves in Damascus and not implementing cross-border southern Turkey, the national and INGOs involved sides of the divide or even stop their activities alto- programming. 6 This situation has changed since the adoption of Resolution 2165, in the cross border programme established a coor- gether. e second was the potential risk to pro- later in this article and footnote 9. dination mechanism known as the NGO Forum, gramming activities and staff involved in the cross- 7 Subsequent and further actions by WFP to coordinate and align which shared information as best it could between border programme if information was shared with cross border and cross line operations following Resolution 2165 Damascus based programming staff and government are shared in an article in this 48th edition of Field Exchange. Of operational agencies(largely INGOs). A joint rapid particular note, all WFP operations in Syria, whether cross border 5 assessment mission into northern Syria (JRAM) counterparts . or cross line, are now planned from Damascus...... 65 Views ......

risk and needs and this has constrained the level of attention to the sector. Between September 12th and 20th 2013, the WFP/Jane Howard GNC undertook a scoping mission to “assess the nutrition context and potential nutrition informa- tion-sharing mechanisms within the humanitarian response for northern Syria”. It was undertaken by a two person team – one member of the GNC Rapid Response Team (RRT) and a nutritionist seconded from an INGO. It was prompted by a lack of infor- Hanna’s and her mother, Hayat, 65, waited 15 mation and data about ‘nutrition in emergencies’ days on the border before crossing into Turkey. Yayladagi (Hatay region), February 2013 programming in northern Syria and by concerns regarding lack of understanding regarding infant and young child feeding (IYCF) in this context. It standards, training and planning of humanitarian share information amongst all stakeholders, as well identified that coordination on nutrition needed to programmes in support of NGO operations. WFP, as opening up more border crossing points from be enhanced, with particular emphasis on IYCF. in particular, has managed to use its regional hub in southern Turkey. However development in this regard Suggestions were made regarding potential coordi- the capital of Jordan, Amman, as a forum for infor- needed the subsequent Resolution 21659 – considered nation structures and systems. Subsequently, from mation sharing, thus overcoming to some extent a “breakthrough in efforts to get aid to Syrians in mid December 2013 to mid- Feb 2014, a GNC RRT the firewalling constraint7. According to many stake- need10” – with the first UN convoy which crossed member (hosted by an INGO) was deployed “to holders interviewed during the course of the ENN into Syria from Turkey through the Bab al-Salam provide coordination, technical and information visit, this has resulted in better ‘gap’ analysis by WFP, border crossing on 24th July 2014. Food, shelter ma- management support” on nutrition to the cross- its implementing partners and the food security terials, household items and water and sanitation border Turkey based operation. Whilst inroads in sector in general. e lack of operational involvement supplies for approximately 26,000 people in Aleppo raising the profile and engagement on nutrition be- of the UN in southern Turkey for the cross border and Idleb Governorates were transported. e Syrian tween agencies was reported,11 the profile of nutrition programme has meant that implementing agencies authorities were notified and more convoys anticipated. remained hugely constrained and was essentially do not have access to financing mechanisms such as Nonetheless, at the time of interviewing (April 2014) short lived given the short term nature of the de- the Emergency Response Fund (ERF) or stocks of there was still considerable mistrust between INGOs ployment. e mission placed considerable emphasis non-food items (NFI) and medicines. Furthermore, working in southern Turkey and the UN agencies. on IYCF (particularly breastfeeding support) as a the absence of the cluster mechanism has also meant Although INGOs and donors understood why the priority issue for response and the need for a nutrition that there is no agency identified in the role as UN agencies have operated in the way they have, survey to establish whether acute malnutrition was provider of last resort – a key feature of the IASC there is constructive criticism about how they could a problem. Many stakeholders disagreed with these cluster mechanism and important to ensure account- have combined the maintenance of their ‘safe’ position recommendations and also felt that the three month ability to both beneficiaries and to donors. in Damascus whilst working more effectively with period should have resulted in more robust nutrition agencies in southern Turkey. is has been referred ere are ongoing tensions for many agencies data and analysis to inform programming. to as the ‘anonymisation of the response’ and links working on cross-border programming who believe to a widespread view that the UN agencies could e absence of nutrition data in northern Syria that OCHA and the UN agencies could have operated have reached out more to INGOs, found better ways has been a constant anxiety for implementing agencies more effectively. One view is that OCHA interpreted to share information (perhaps using the WFP regional that are aware of high levels of food insecurity and its role as one of reporting information rather than hub model) and also connected more fully with lack of access to health care and clean water for coordinating the meaningful assessment and analysis Syrian NGOs working cross border. Syrian agencies many internally displaced people and in the besieged of information and the mapping of key gaps to are increasingly becoming involved in the working areas. A nutrition sub-group has recently been set ensure more equitable access to food and non-food groups but this greater engagement has been a slow up as part of the health working group for the cross- assistance. An opposite view from within the UN process. ere is also a strong view amongst the border programme and is working to provide the family is that the refusal of many INGOs to share donors and INGOs interviewed that as the UN is analysis and programming recommendations needed information with the UN has made it impossible to non-operational, their legitimacy for coordination for the nutrition sector. However, there are very few do meaningful assessments and analysis. Whilst is intrinsically diminished and that the UN should agencies involved directly in nutrition programming NGOs have been advocating for better coordination, have been clearer from the start about what they and added to this, the absence of a UN agency pres- there have been sensitivities and dynamics with could, or could not do. INGOs and donors have ence in the nutrition sub group has reduced the OCHA that have continued to constrain strengthened therefore been lobbying to have an INGO co-chair level of authority typically needed to influence donor coordination. To some degree, personality clashes on the inter-sectoral working group in order to financing allocations and their response. have been a part of this problem yet other sectors, strengthen operational coordination. However, OCHA notably education, food security and child protection A question is raised as to how, in a ‘level 3’ emer- have been unable to grant this request as this arrange- have done well, highlighting that sectoral coordination gency, which is in its fourth year, there is not a ment would not be in line with IASC guidelines. with concomitant donor support can lead to enhanced standalone nutrition sector working group in south- coordination even in the most challenging situations. Nutrition sector coordination and ern Turkey with a lead agency providing credible is, however, has not been the experience thus far leadership assessment and analysis of the overall nutrition sit- with the nutrition sector. Many actors working in southern Turkey are of the uation. ere is also a related question as to why the view that there has been an absence of leadership GNC was not enabled to sustain a presence in south- e firewalling of information between the cross- around nutrition programming and coordination. ern Turkey in order to provide coordination for nu- border programme in southern Turkey and the Syria is has meant that there has been a lack of thorough trition analysis and operational planning for the programme has meant that southern Turkey based sectoral analysis of the main nutrition problems cross border programme. INGOs have had little information about program- faced within Syria and amongst the refugees. Added ming being coordinated and implemented from the to this has been the limitation of the global benchmark Damascus side, while agencies in Damascus do not 8 for defining a nutrition emergency, which requires See footnote 7 know what is being planned and implemented 9 high or increasing levels of GAM for funding to be Resolution 2165, unanimously adopted by Council members cross border8. As a result, there have been examples on 14 July, authorised the United Nations and our partners to activated. In essence, donors wanted to see a higher of duplication of aid where the so called cross-line use routes across four additional border crossings with GAM before agreeing to a dedicated nutrition Turkey, Jordan and Iraq. The resolution also authorised the programme into northern Syria has been implemented working group and programme of funding. Whilst establishment of a monitoring mechanism to confirm the in areas where NGOs operating from southern there are examples of low GAM and nutrition cluster humanitarian nature of supplies brought through those Turkey have already worked. In addition, there are crossings points. Available at: activation in emergencies such as Haiti and the also concerns that areas exist where both the cross- http://unscr.com/en/resolutions/2165 Philippines, the donor focus in the Syrian crisis has 10 line and cross border programme have not reached Under-secretary-general for humanitarian affairs/emergency been largely confined to other sectors such as WASH relief coordinator Valerie Amos, executive director of the WFP areas in need. (water, sanitation and hygiene) and child protection. Ertharin Cousin and Executive Director of UNICEF Anthony e passing of UN Resolution 2139 in February Lake, Statement on Security Council Resolution 2165 on ere is no doubt that the Syrian crisis has lacked a humanitarian access in Syria. 2014 raised expectations about greater freedom to well-articulated and coherent analysis of nutrition 11 GNC End of Mission Report (Feb, 2014) ...... 66 Field Articles ...... Danish Refugee Council

The Danish Refugee Council distributes food, hygiene kits, baby kits, blankets and cooking sets to refugees from Syria DRC experiences of cash assistance to non-camp refugees in Turkey and Lebanon Turkey

By Louisa Seferis Louisa is the MENA Regional The author would like to thank the DRC teams for their Livelihoods & Cash Advisor continued work with Syrians across the region, in particular for the Danish Refugee the DRC Turkey and DRC Lebanon teams for their dedication Council (DRC). She has to beneficiary-focused, evidence-based programming. worked for three years with Thank you also to DFID for its innovative approach to the DRC for the Syrian crisis funding DRC in Turkey, and to ECHO and UNHCR for their on livelihoods, cash and regional partnerships with DRC on the Syrian crisis. emergency programming in Syria, Lebanon, Turkey and Iraq. Prior to 2011, she worked for four The abstract was submitted for the ENN Technical Meeting years in Africa on conflict and displacement on nutrition at Oxford (7-9 October 2014), and DRC through protection, livelihood, and reconciliation presented the concept during the marketplace initiatives with international NGOs. She holds a presentations. The box on benefits and risks of cash transfer master’s degree in humanitarian assistance and programming was also published in a DRC Evaluation and conflict resolution from Tufts University. Learning Brief.

ash programming has been used on an un- Programming context precedented scale in the Syrian crisis, largely Since the beginning of the Syrian crisis in 2011, Syria’s due to the urbanised nature of the Syrian neighbouring countries have dealt with the refugee refugee caseload in affected countries and influx in various ways – building numerous and well- Cthe well-developed markets and banking systems. is equipped camps in Turkey, providing blanket assistance article outlines the main contexts in which urban Syrian to all registered refugees in Lebanon, and establishing refugees find themselves and their specific vulnerabilities, massive camps and processing centres at the Syrian especially with regards to access to labour markets, border in Jordan. Regardless of the initial approach, by credit and assistance. Unusually, we have found a need 2012, Syria’s neighbours all hosted a significant number to understand and respond to the psychosocial needs of non-camp refugees, many of whom settled in urban of men, given how the crisis has undermined their areas in the hopes of accessing income opportunities. provider role in the family. Until now, the humanitarian In 2014, Syrians outside of camps constitute the majority response has failed to address this issue adequately. of Syrian refugees in the Middle East.1 e article will also review, from the Danish Refugee Bonus content online Council (DRC)’s perspective, how humanitarian pro- DRC has been present in the Middle East, and in gramming for non-camp refugees in Lebanon and particular in Syria and Lebanon, since 2007. While pro- Views Turkey has evolved in order more holistically to meet grammes in Syria focused on mainly Iraqi and Somali refugees’ changing needs in the face of protracted dis- refugees in urban areas, in Lebanon, DRC started a • A day in the life of a WFP field small programme to support Palestinian youth vis-à- monitor working in the Syrian placement, incorporating more traditional humanitarian responses with innovative and large-scale cash pro- vis livelihoods and self-reliance. e onset of the Syrian refugee camps in south-eastern crisis shied DRC Lebanon’s focus to provide emergency Turkey gramming. Finally, the article will explore DRC’s expe- riences and share observations around conditional www.ennonline.net/fex versus unconditional cash. 1 http://data.unhcr.org/syrianrefugees/regional.php ...... 67 Field Article ...... assistance to Syrian refugees, later expanding the and 45,200 in Kilis3. ere are probably more non- living for much less. e cost of living in Syria intervention to a holistic approach involving pro- camp refugees in these provinces who have not reg- remains significantly lower than in Lebanon. Despite tection, community services and livelihood initiatives. istered with AFAD (Disaster and Emergency Man- inflation within Syria due to the conflict, many basic DRC began its operations in Turkey in early 2013, agement Presidency of Turkey) and are therefore goods (food/non-food) are still subsidised by the modelling its response aer successful interventions not reported by UNHCR. e majority of non- Syrian government or produced locally – albeit in a in Lebanon and elsewhere that concentrated on camp Syrian refugees in Turkey live in urban or much more limited capacity than before the conflict. non-camp refugee populations. Given the scale of peri-urban areas, renting and sharing accommodation Moreover, the devaluation of the Syrian pound needs and the urban displacement context, DRC with an average of 1-4 other families and surviving offsets the increased prices in the black market, considered cash transfers a relevant and cost-efficient through temporary employment (mainly which is still cheaper than Lebanese markets. way to provide assistance. In late 2013, DRC Lebanon daily/monthly labour) and minimal assistance. Since embarked on a large-scale unconditional cash as- May 2014, DRC Turkey has assessed 2,100 Syrian Lebanon v Turkey context sistance programme to support families during the families in Hatay province, southern Turkey. eir In both Lebanon and Turkey, Syrians face challenges winter,2 and in 2014, DRC Turkey initiated cash as- main concerns, challenges, income and rental costs to generate stable income, which in turn affects sistance through a DFID two-year grant aimed at are shared in Box 1. their ability to meet basic needs as assistance wanes. providing assistance to vulnerable families and tran- Oversaturated labour markets, particularly for un- e majority of households assessed (75%) share sitioning to livelihoods support in 2015 (project skilled workers, either mean that there are fewer job all expenses between the households and individuals on-going). opportunities or the jobs available put Syrian refugees sharing a dwelling, which includes food and heating. in competition with the host community labour The situation in Turkey In Turkey, refugees outside of camps face inte- force. Syrians, generally willing to work for less pay Turkey is the host country with the largest network gration challenges such as language barriers4 and than the host community, oen crowd out local of camps for Syrian refugees (civilians and combat- very few social ties, resulting in higher tensions labour. is is particularly true for sectors such as ants). While the number of refugees within camps with local communities and difficulty finding em- construction, agricultural work, daily or temporary in Turkey peaked by the end of March 2014 at just ployment. Syrians in Turkey have very few oppor- work and the service industry. For example, restaurants over 224,000 people, according to UNHCR, the tunities to access credit with shops, and landlords in some parts of southern Turkey oen now employ number of non-camp refugees has steadily increased generally demand rent/utility payments every month young Syrian boys, starting from around 10 years to over 564,000 by mid June 2014 – a 61.1% increase without exception or flexibility. Syrian men who do old, to clear tables, wash dishes and translate for since the end of 2013. e majority of non-camp manage to find temporary jobs (daily, weekly, or Arabic-speaking customers. refugees live in southern Turkey in provinces along sometimes monthly) oen complain that they are the border, with the largest concentrations in While many programme elements are similar not paid at the end of the work, and they cannot Gaziantep, Sanliurfa, Hatay and Kilis provinces. between Turkey and Lebanon because non-camp pursue any legal recourse because they have no ere are over 166,262 non-camp refugees in refugees in both countries face similar challenges right to work in Turkey.5 ey say the Turkish em- Gaziantep, 108,349 in Sanliurfa, 134,275 in Hatay, (lack of employment, high cost of living, especially ployer will just find another Syrian to replace him, rent/food, etc.), there are also marked differences. and generally not pay him either. Refugees say that In Lebanon, there are no camps so all refugees are working more in Syria means improving your quality essentially ‘non-camp.’ e ties that existed between Box 1 of life; “in Turkey, working more means just trying Syria and Lebanon prior to the conflict have eased to survive.” refugees’ integration – notably the language and ex- Assessment results of 2,100 Syrian change of goods and services (approximately 500,000 families in Hatay province, southern Syrian Kurds are the notable exception, as they Turkey can integrate into Kurdish areas of southern Turkey Syrians worked in Lebanon prior to the conflict, (e.g. Urfa Province) and enjoy better access to social many of them seasonally). Syrians in Lebanon also Refugees’ main concerns and challenges networks and community support. is is also con- have access to credit in local shops to buy foods and (households could report more than one goods, or with landlords to delay rent payment concern): sistent with findings from DRC’s livelihood pro- • 86% reported a lack of job or self-employment gramming in the Kurdish regions of Iraq, where when families have no income. However, the existing opportunities Syrian Kurds who receive business grants have a ties and similarities between Syria and Lebanon • 66% reported they had an insufficient food high success rate due to their social networks and have also given rise to tensions based on communities’ supply therefore access to credit, resources, connections affiliations, many of which are exacerbated by hu- • 60% faced discrimination by the host manitarian assistance to Syrians only. Syrians were community and a customer base. perceived to receive huge amounts of assistance, • 77% reported difficult access to humanitarian assistance The situation in Lebanon while the Lebanese received nothing, and Syrians Lebanon hosts the largest number of Syrian refugees were “stealing” jobs from local communities because Income per month: in the region, both in terms of absolute numbers they were willing to work for much less. In Turkey, • 16% of households assessed earn 800 TL or more (approx. 400 USD) (over 1,138,000 refugees) and as the greatest pro- the social ties between refugees and local communities • 34% earn between 500 and 800 TL (approx. 250- portion of its population (over one-fih of the total are minimal (Kurds being the exception), which 400 USD) population currently in Lebanon is now Syrian).6 means Syrians faced integration issues from the be- • 22% between 300 and 500 TL (150-250 USD) Given the initial small number of refugees and sig- ginning. ey also have limited to no access to • 9% earn between 100 and 300 TL (50-150 USD) nificant humanitarian presence, agencies provided credit, so they rely more on assistance, income and • 1% earn between 1 and 100 TL (up to 50 USD) assistance to all registered refugees (with some or- selling assets to make ends meet per month – land- • 18% reported zero income ganisations focusing on the smaller number of un- lords and shop owners rarely give refugees a ‘grace 70% of households reporting a monthly income registered refugees). Between 2012 and 2013, the period’ to pay bills. said the main source of income was labour. refugee population grew exponentially and the hu- 10% indicated that their main source of income was manitarian community struggled to maintain the selling assets and/or using savings. same level of assistance. At the same time, the gov- 2 For more information, please see http://www.cashlearning. ernment did not change its ‘no camp’ policy, which org/resources/library/417-unconditional-cash-assistance- Rent: meant refugees sought shelter through any means via-e-transfer-implementation-lessonslearned?keywords= • 43% pay rent between 100-300 TL (50-250 USD) danish+refugee+council&country=all§or=all&modality • 41.5% between 300-500 TL (150-250 USD) possible – renting with other families, inhabiting =all&language=all&payment_method=all& document_type= • 11% pay rent of 500 TL or more (250 USD) unfinished buildings, living in informal tented set- all&searched=1&x=58&y=15. • 1.5% pay up to 100 TL (50 USD), and 3% do not tlements, etc. Hosting “fatigue” and reduction in 3 UNHCR SitRep, 7 July 2014 pay rent (hosted by other families) humanitarian assistance compounded refugees’ diffi- 4 In Hatay Province, 66% of Syrian families assessed by DRC reported that the language barrier was a main problem they Number of people per dwelling: cult situations; since the end of 2013, the humanitarian faced in Turkey. • 45% of households live in dwellings with 6-10 community has drastically reduced its assistance, 5 In order to apply for a work permit, Syrians must have people from providing cash and in-kind assistance to 70% residency papers – these are difficult to obtain in general, and • 34% of households live with 1-5 people of registered refugees to now planning cash assistance the most vulnerable families do not have valid passports • 21% live with over 10 people in a dwelling to 5-10% of refugees. (required for the residency application). In 2014, Turkish authorities may loosen restrictions on applying for work The majority of households assessed (75%) share Finally, the cost of living in Lebanon is also ex- permits through bylaws (exemptions for certain sectors/ all expenses between the households and occupations or geographic areas). individuals sharing a dwelling, which includes food tremely high and meeting basic needs is difficult, 6 Source: UNHCR, 2014. http://data.unhcr.org/syrianrefugees/ and heating. especially for Syrians used to the same standard of country.php?id=122 ...... 68 Field Article ......

The psychological effects of the Syrian majority of Syrian refugees cite their main needs as Table 1: Coping strategies to meet food needs crisis food and shelter. us far, agencies in Turkey have adopted by Syrian refugees, Hatay e majority of humanitarian protection and social not had a precise understanding of the minimum province, Turkey (2,100 households) responses concentrate on services to women and expenditure basket (MEB) of a Syrian family. Indeed, Coping mechanism (Families could list % of children, who are perceived as the most marginalised transfer values appear extremely low compared to more than one) total groups. However, in this crisis, men also need prices of food. e Turkish non-governmental or- Consumed less preferred or less expensive 84% support. e psychological impact of the crisis on ganisation (NGO) Support to Life estimates that a foods Syrian men across the region is quite specific, as family of six people needs about 470 TL (approx. Reduced the number of meals per day 73% 235 USD) per month to eat a balanced diet, including many feel that they cannot assume their traditional Reduced spending on non-food items 72% role as breadwinners and providers to the family. fresh food. Most agencies are providing around 25% “Just give me a job, let me work. e rest, I can take of this in food assistance via e-cards that must be Limited portion size 49% care of myself.” DRC staff observed many physical redeemed in specific shops, whose prices are generally Spent savings on food 30% disputes and instances of domestic violence, not fair but oen above bazaar or street vendor prices, Restricted adult consumption (so children 16% just with project beneficiaries, but also in everyday particularly for fresh food. could eat) life. With the prioritisation of services provision to DRC therefore has shied much of its in-kind Purchased food on credit or borrowed 16% women and children, there is little space for men to direct assistance for refugees to cash modalities and money to buy food socialise outside of the house in settings where they in particular, unconditional cash. DRC considered Had school aged children working 13% feel comfortable sharing their stories. In DRC’s com- unconditional cash the best option given the vul- Asked for food (including begging) 12% munity centres in Turkey, which serve mainly non- nerability of families eligible for monthly assistance camp Syrian refugees, there was a marked difference Skipped entire days without eating 4% (as compared to all households assessed), and their when activities and facilities were designed taking Not applicable 5% necessity for flexibility and choice to meet needs into account both men and women’s interests (including monthly. e monthly cash assistance will not be mixed-gender activities). In particular, DRC introduced Moreover, evidence from other contexts demon- able to cover 100% of a family’s monthly needs, so story-telling activities for adult men, as staff found strates that consumption patterns change over time11 maximising purchasing power is essential. Moreover, this group to be the ones struggling the most to deal and also with regards to the type of shocks, i.e. establishing and maintaining conditional or restricted with trauma and displacement. Men expressed gratitude families required to move may prioritise shelter in having the space to come together outside of the cash assistance programmes is extremely labour- over food, while household level shocks, as when pressure of everyday life to find a job or act in a intensive and counter-productive in such flexible someone falls ill, may require expenditure on health certain way. and developed urban markets – artificially restricting care. erefore, while refugees will nearly always markets (by selecting and only working with certain spend a large portion of cash assistance on food, Use of cash assistance by urban refugees vendors) can encourage discrimination against further research is needed to understand to what Syrian refugees outside of camps live in urban envi- voucher holders, including potentially influencing extent they are sacrificing dietary diversity, quality ronments and engage with markets every day. Coun- price inflation. Instead, DRC prefers to emphasise or quantity of food consumption to meet other tries such as Lebanon and Turkey, particularly in the beneficiary selection process, in order to identify equally pressing and basic needs. the urban areas, enjoy relatively free and generally and assist the most vulnerable families, and to focus informal markets – businesses can start (and close) on the monitoring process to track how the money Discussion easily, and there are few regulations on small and is spent and its impact on households’ situations. Most of DRC’s direct assistance to refugees has fol- ad-hoc enterprises such as grocers, coffee shops, lowed the general trend of humanitarian aid in the barbers, etc. Moreover, refugees need cash to meet Impact of coping on food diversity, region – starting as in-kind support (food parcels basic needs, which across the region they identify quantity and quality and non-food items) and gradually moving towards as mainly food, shelter, and health (education, In any displacement situation where refugees do cash-based responses, such as food vouchers or con- hygiene items, etc. are generally less prioritised). In not have access to reliable income or sufficient as- ditional cash for rent. e acceptance of unconditional these areas, cash programming makes sense. However, sistance, families will restrict the quantity, quality cash, both by host governments and the international many humanitarian agencies prefer either to give and diversity of food consumption. Syrian refugees humanitarian community, only came about in full items in kind or provide conditional assistance (e.g. are no exception. However, prior to the crisis, even force by mid-2013. is shi to cash is part of DRC’s cash for training) or restricted through vouchers poor Syrian families enjoyed varied and plentiful overall strategy to respond as holistically as possible (paper or electronic), such as food vouchers. Many diets, due to the low cost of living in Syria – largely to Syrian refugees’ needs outside of camps, with a agencies are concerned that refugees will not spend because of the vast array of locally produced goods dual protection and livelihoods approach. e need the cash as organisations intend. is is because and subsidised staple foods (flour, milk, even fuel to create safe spaces, such as community centres, there is still a perception that in-kind or restricted and cooking gas). is means that any change in where refugees and host communities can access cash will better meet needs, because “we don’t know food consumption will be experienced more dra- information and services and socialise is essential. what they will buy with cash.” is is despite extensive matically and is a stark reminder of their displacement. At the same time, vulnerable individuals and families research worldwide on displaced populations and DRC assessments show that Syrian refugees almost want support to meet self-defined needs, to decrease the use of cash in humanitarian assistance, demon- immediately sacrificed food quality to meet basic dependence on humanitarian assistance, and plan strating that the vast majority of recipients do spend needs. In addition to this, families assessed in Hatay for the future. e first step is to assist directly responsibly.7 Research shows that the amount of Province in Turkey adopted a number of coping those most in need, which DRC believes is oen cash or voucher transfers, proportional to a family’s strategies, in order to meet food needs (see Table 1). done most efficiently through cash, as well as move towards more sustainable support such as skills de- estimated minimum expenditures, determines how Anecdotal evidence and monitoring data suggest velopment, job placement and facilitating business much food the family can purchase, which is “obvi- that Syrian refugees in the Middle East are restricting development, when feasible. It is much more difficult ously critical to the effectiveness of the transfer in dietary diversity due to high prices, even when to influence or support sustainable livelihood solutions improving consumption (amount of food able to be receiving electronic vouchers for food.10 ey are purchased, dietary diversity, negative coping mech- mainly purchasing and consuming cereals/grains, anisms, etc.)8.” Anticipated expenditure is an aspect pulses, oil, and limited quantities of cheese, while 7 Sarah Bailey 2013 of household consumption that is not considered in they forgo meat and other dairy products such as 8 Sarah Bailey, 2013 most assessments or evaluations – it is already quite 9 milk. It is unclear if this will have a lasting negative In Lebanon, qualitative (focus group discussions) and difficult for refugee households to estimate their quantitative (household surveys by phone) in 2014 indicate impact on health and nutrition, since refugees do actual expenditures. e main response we hear that refugees’ main needs are food, shelter and healthcare. In manage occasionally to buy small quantities of fresh about planning expenditures is that there is no plan- Turkey, focus group discussions revealed the main needs as foods and protein; it is also unclear how humanitarian food and shelter; refugees have very little access to credit/ ning – when an emergency comes up (usually med- assistance could address dietary diversity concerns, debt sources, and therefore have limited time to accumulate ical), refugees will borrow money or drastically enough money to buy food and meet rent/utility obligations. given the fact that delivering fresh food in-kind is reduce other expenditures (delay rent payment, eat 10 Source: Household monitoring visits with non-camp not feasible. One suggestion is to increase the cash only basics or rely on family/friends for food, etc.). refugees in Turkey and Lebanon, 2014. transfer value provided to each family, but given evi- 11 See Longley et al, 2012. As summarised by Bailey (2013): “The Refugees across the region have reported house- dence from other contexts and the huge needs, many use of the transfer changes according to changing needs, hold priorities and the fact that they cannot meet households have gone so long without assistance that seasonality, livelihoods and the objective of the programme. In this case, the first transfer had the highest proportion spent 9 all of their basic necessities. Although needs vary given additional cash, they might prioritise other ex- on food, and transfers towards the end of the intervention in each refugee context and for different groups, the penditures such as rent, health, education, etc. were more geared toward supporting recovery.” ...... 69 Field Article ...... for refugees in urban contexts where labour market or supply trends have a greater effect on people’s ability to earn a reliable income; moreover, many vulnerable refugee households may not be able or willing to generate income. Cash is therefore a key tool in providing direct assistance to vulnerable families to meet self-identified needs and provide temporary income to alleviate economic vulnerability. e question remains how to transition from cash to more sustainable support in urban environments. Cash allows families to meet self-identified priorities, as well as giving choice and dignity. ere are both benefits and risks to this pro- WFP/Jane Howard, Hatay Region, Turkey, 2013 Turkey, Region, Hatay WFP/Jane Howard, gramming approach (see Box 2). Conditional cash, which seems to offer a more straightforward transition from traditional sector-based humanitarian responses, has drawbacks in terms of stigma, discrimination by vendors, and pricing issues (taxation and artificial control of market dynamics). At the same time, unconditional cash raises concerns about Experiences of the e-Food agencies’ loss of control / diversion of assistance, compromising nutrition, and creating dependency. ere has been a lack of technical card programme in the nutrition rigour in informing cash programming design and evaluation and implications of this on urban refugees in the Syria crisis response. is will require renewed focus in future responses. Turkish refugee camps For more information, contact Louisa Seferis, email: [email protected] or [email protected] By Kathleen Inglis and Jennifer Vargas

Kathleen Inglis currently works with the WFP as the Programme Communications Officer. She has worked in Box 2 humanitarian aid in various capacities from Considering cash: benefits and risks communications to logistics and information Benefits management in protracted emergencies including Dignity: Cash recipients do not queue visibly to receive assistance, Sudan, Ethiopia, Afghanistan, Pakistan and DRC. the content of which is determined by external actors in the “best interest” of beneficiaries. Jennifer Vargas currently works with the WFP in Turkey as Empowerment: In any conflict or displacement context, vulnerable the Information Management/ Reports Officer. She has families have to prioritise certain needs over others, regardless of the studied the region and refugee crises extensively and this levels of assistance they receive. With cash, families can choose marks her first foray into the humanitarian community. directly which needs to prioritise; even with conditional cash (e.g. food vouchers), recipients can select what is most important to them. Cash can also improve certain members’ decision making within the household in a positive manner. Cost efficiency: Cash reduces operational costs and provides more “cash in hand” to beneficiaries (although it is important to note that this is not always the case). Because recipients meet self-identified needs, there is generally a lower rate of aid diversion or sale. Multiplier effects: Cash transfer programming can directly benefit local markets more than providing in-kind assistance, and can revitalise/strengthen local economies as well as benefit host commu- nities. Overview Improved monitoring and evaluation: e Government of Turkey has generally maintained an open-border Strong cash programming emphasizes monitoring and evaluation as policy with Syria since the first Syrian refugees began crossing the border the core activity to determine how cash is spent and its impact on in April 2011. ree years later, Turkey hosts more than 900,000 Syrian households, markets and communities. Cash programmes can there- ‘guests’ - 220,000 live in 22 camps and approximately 700,000 in urban fore provide more comprehensive feedback on people’s needs, centres. ese estimates are considered conservative as registration vulnerabilities and coping strategies, in addition to the humanitarian continues and by the end of 2014, the Government expects the total impact on local contexts and communities. number of Syrians refugees will reach 1.5 million. Prominent news sources,

Risks Article Field such as the New York Times, Reuters-Huffington Post, have expressed Markets: If improperly assessed beforehand, some cash modalities concerns about the livelihood of Syrians residing outside of camps; food can negatively affect markets by causing inflation or supply shortages. security, shelter and education were among the most basic unmet necessities People (households, individuals): Cash can exacerbate existing mentioned. us far, provision of food assistance to off camp populations household tensions or negatively impact dynamics between house- is limited to small scale interventions within non-governmental organisations’ hold members (e.g. the head of household chooses not to spend (NGOs) area of operations. In the coming months, WFP plans to offer money on food for the children). In extreme cases, cash given to a technical assistance to the Government to conduct a needs assessment woman could increase her exposure to domestic violence, for exam- and develop an appropriate modality for the sustainable provision of food ple. In addition, cash programmes without end points/exit strategies assistance to most vulnerable populations outside of camps. and complementary assistance (counselling, training, etc.) run the risk of creating dependency rather than meet needs; although this is also e international community has oen lauded the Turkish Government the case for in-kind assistance programmes, it is especially concerning for its generous response to the crisis. e Government of Turkey estimates for cash because the assistance is another form of income and families that its provision of aid has surpassed US$3.5 billion, while the international can become reliant on it (like remittances or other external support). community has thus far provided some US$150 million in assistance for Community dynamics: Depending on how beneficiaries are selected Syrian refugees in Turkey. e camps, moreover, have received considerable and existing community dynamics, cash can worsen relations between recognition for the quality of shelter and service provision for the refugees. recipient and non-recipient groups (although the same can be argued e Prime Ministry’s Disaster and Emergency Management Presidency for in-kind assistance). This is especially pertinent between refugee and (AFAD) is responsible for the management of all camps across ten gover- host communities, particularly in countries where governments may norates. e World Food Programme (WFP), in partnership with the not have the means to provide social safety nets/cash assistance to its Turkish Red Crescent (TRC, known as KIZILAY), has worked extensively economically vulnerable citizens. with AFAD to provide food assistance to all civilian camp populations...... 70 Field Article ......

Electronic food card programme: how it approach recommended by WFP’s voucher feasibility capable partner with a field presence in all of works study. is proposal was well received by the gov- the camps. (KIZILAY is the largest humanitarian e WFP/KIZILAY Electronic Food (e-Food) Card ernment and was included in the United Nations organisation in Turkey and is part of the Programme was officially launched in October 2012 Regional Response Plan. In consultation with AFAD, International Red Cross and Red Crescent to provide food assistance to 12,000 beneficiaries in the Deputy Directorate General for International Movement. e organisation was founded under Kilis camp. e programme was envisioned as an Political Organisations within the Ministry of Foreign the Ottoman Empire on 11 June, 1868). efficient and innovative way of supporting families Affairs and KIZILAY, it was agreed to implement a • Donors recognised the added value of the tri- in camps to purchase diverse and nutritious food gradual strategy to transition from in-kind food as- partite partnership between WFP, KIZILAY items of their own choosing with an e-card. e sistance to a market-based approach with the and AFAD, which enabled significant contribu- total amount of assistance for the household is elec- provision of vouchers. tions to be channelled through a UN agency to ease the burden of the Syrian crisis response on tronically loaded onto the e-Food Card in two Finding the best solution based on the Turkish Government and people. separate instalments per month. At the end of the context month, the balance remaining on the card, if any, is Within the context of Turkey, that of a middle- e comparative advantage of the WFP/KIZILAY cleared and returned to the WFP/KIZILAY e-Food income, emerging market economy with strong na- programme rests in the level of expertise both WFP Card Programme account. An updated list of family tional capacity and pre-existing emergency-response offers in e-voucher programming and KIZILAY members still residing in the camp is provided by mechanisms, the role of international organisations offers in emergency response, in Turkey and abroad. AFAD on a monthly basis and the amount uploaded shied from solely providing humanitarian assistance WFP’s vast experience with cash and voucher pro- to the card for the month is adjusted accordingly. (monetary or otherwise) to providing innovative grammes (C&V) and food security ensures that To use the card, the persons undertaking the shopping programming that works in conjunction with existing standard operating procedures were established at must present their camp ID card at participating national resources and capabilities. e launch of the onset of the Syrian response in Turkey, which markets and the container or tent number/family the WFP/KIZILAY e-Food Card Programme in facilitated programme transparency, beneficiary par- number must match that printed on the e-Food Turkey was the first instance of an electronic voucher ticipation and donor confidence. KIZILAY had a Card. e e-Food Card only works in the terminals system being used at the outset of an emergency re- wealth of experience in emergency and development of shops selected by WFP, KIZILAY and the Gov- sponse. Simply put, it was the right tool, at the right work at home and abroad. ernment; this allows for oversight and monitoring, time, in the right place and was only possible because ensuring that sufficient quantities of various nutritious For instance, KIZILAY had developed its electronic of existing infrastructure and context: and fresh food products are available for purchase card in mid-2012 for a pilot programme to assist • Interactions between international organisations, by households at competitive market prices. e social vulnerable groups in Turkey, which made it non-governmental organisations (NGOs), and entitlement can be redeemed in camp shops or the tool of choice. It was further adapted and used the Government of Turkey were more synergistic shops located in nearby urban centres. All shops in the e-food Card Programme, thereby greatly re- than would normally take place in less developed are under contract with KIZILAY and monitored to ducing lead time required for establishing agreements nations; the government supported and facili- ensure compliance with programme regulations and with financial institutions and designing and testing tated the programme and transition process. highest standards of quality. the practical functioning of a market based welfare • AFAD-established and managed camps and system. Moving from in-kind food assistance to a provided beneficiaries with cooking facilities, market-based approach electricity and commercial food markets located Merits of the market based approach Prior to the introduction of the WFP/KIZILAY e- within the camps. e programme has proven highly successful in Food Card Programme, the government authorities • e agriculture and the commercial food-sector terms of beneficiary satisfaction, effective use of were the sole entities responsible for providing food in Turkey is strong: the country is among the limited resources and investment in the local economy. assistance and the modality varied from camp to world’s leading producers of agricultural products Over 90 percent of interviewed beneficiaries prefer camp. In the last week of July 2012 (when WFP and and Turkey has been self-sufficient in food the e-Food Card to hot meal provision. With regard AFAD conducted the initial voucher feasibility as- production since the 1980s. to efficiency, the programme allows for over 70 sessment), half of the registered population (43,679) • e electronic banking system in-country is percent savings when compared to the provision of received daily cooked meals and the other half established and robust. hot meals, also eliminating food waste that inevitably received parcels of dry food every two weeks and • e use of vouchers both as a national welfare occurs at distributions. e programme directly im- fresh food on a weekly basis. e composition of and safety-net mechanisms for vulnerable pacts local communities as beneficiaries use the en- meals and food parcels was highly diversified and Turkish populations, and by commercial entities tirety of their food entitlement at shops that are oen exceeded the internationally agreed standards providing meals for employees, existed in owned, managed and supplied by local retailers. on daily dietary intake of 2,100 kilocalories, which Turkey prior to the Syrian crisis. AFAD was responsible for the establishment of com- is sufficient to meet the nutritional needs of disaster • KIZILAY’s 150 years of experience in emergency mercial markets located inside camps. However, in affected populations. As an example, the daily caloric response offered WFP a reputable and highly the Hatay region where camps are located close to content of cooked meals in one of the camps in Hatay ranged between 3,000 and 5,000 kilocalories per person per day and the content of dry and fresh food parcels ranged between 26 to 45 items. Likewise, the cost of assistance greatly differed across the camps, with the monthly cost for cooked meals ranging from US$147 to US$170 per person. ese figures reflect the generous and first-rate response by the Government and local authorities, while at the same time raise questions regarding the sus- tainability of the services provided. At the time, it was expected that Syrians would return to their re- spective homes within a reasonable period of time. More than three years aer the onset of the crisis that shows no signs of abating, demands, duration and scale of programming have increased, as well as the need for innovative and effective responses. By April 2012, as the crisis continued to worsen and unanticipated numbers of Syrians kept crossing over the border, the Government of Turkey agreed to a ‘burden-sharing’ proposal with the international community. In August 2012, at the behest of the Turkish Government, WFP met with AFAD to discuss the possibility of providing complementary food assistance using voucher-based transfers, an ...... 71 Field Article ......

First home-cooked meal since arriving in Turkey: Nazari household On the first day of launching the e-Food Card food for my family with my own hands. The children can Programme in Nizip II camp in April, 2013, WFP staff taste the things we used to eat in our homeland thanks spoke with the Nazari household to learn what the to the e-Food Card Programme.” Families enjoy the

family’s first fresh cooked meal would be since fleeing social norms of shopping and cooking for themselves WFP/Jane Howard Photo: their home in Syria several months before. The father and the camp managers have reported less food waste was preparing a Syrian dish, “Sinyat Khidhar”, made compared to the days of hot meal provision, as well as from fresh eggplant, tomatoes and onions with a mix less stress for camp staff and the beneficiary families. of spices to serve to his mother, his wife (who had The e-Food Card has also encouraged gardening and recently given birth in the camp) and their three establishment of bread-baking facilities where A family bakery bakes Arabic flat bread to cater to the taste of Syrian refugees, young children. He told WFP staff, “I enjoy making the infrastructure and resources permit. they also deliver to the camps. urban centres, WFP and KIZILAY identified, assessed in camps for a relatively long period: 51 percent at lower prices to beneficiaries. Beneficiaries generally and contracted existing commercial food markets arrived over a year ago, another 42 percent arrived attain high levels of dietary diversity; they can located outside of camps to participate in the pro- 7 to 12 months ago, and recent arrivals (less than 6 purchase basic items for the nutritious diet established gramme. e e-Food Card Programme served as a months) only represent 7 percent of the total in- in the food basket. e high cost of infant formula, model for WFP’s rollout of electronic vouchers in camp population. e average size of a household is however, has been a continuing challenge, com- Jordan and Lebanon and for the AFAD card which six members. Beneficiary heads of households in pounded by the fact that a large majority of mothers is operational in all camps in Turkey. Turkey are, in 90 percent of cases, married and ten do not breastfeed past six months. percent are single or widowed. irty-five percent Step by step expansion of households are headed by females while only Sustainability of operation – funding and By July 2013, the programme had rapidly expanded seven percent of households are headed by the shortfalls to cover 115,000 beneficiaries living in camps in ten elderly. Most of the interviewed families have children Looking forward, the mid-year review of the Regional provinces. At this stage, owing to WFP funding under five years of age and interviews revealed that Response Plan 6 (July- December 2014) stipulates constraints, expansion plans were arrested and the for every working-age person who has the physical that around 250,000-300,000 people will need food programme capped to serving only fourteen of the possibility of generating income, there are two de- assistance in the next six months and WFP will 22 existing camps. Each beneficiary received 80 pendents, which demonstrates a high level of socio- require US$58 million. Currently, WFP Turkey Turkish liras per month (approximately US$40) economic vulnerability. reaches 225,000 people per month and requires loaded onto their family’s e-Food Card that could US$8 million to do so; the operation faces a pipeline be used in participating markets. AFAD continued Despite the constant monitoring activities of break approximately every six weeks. WFP is funded to deliver food assistance in the eight remaining WFP and KIZILAY, and in almost all camps by entirely by voluntary contributions and remains camps not covered by WFP and KIZILAY, either market monitoring committees, high prices in con- vigilant and engaged with donors in order to secure through provision of hot meals or in late 2013, tracted shops continue to pose challenges. WFP the funds. through the newly launched AFAD E-Card pro- and KIZILAY monitors continue to advocate with gramme – based on the WFP/KIZILAY programme all stakeholders for fair market prices in all partici- Emmanuel Safari – staff profile model – that was also being utilised in some camps. pating markets. Rampant drought has been one WFP is the largest humanitarian agency in the world contributing factor to price increases. Turkey has and as such, draws personnel and expertise from all In response to the primary challenge of inadequate been dealing with a drought that began at the end corners of the globe. e first Cash &Voucher pro- funding which constrained programme expansion of 2013 and is causing major difficulties for agricul- gramme officer sent to Gaziantep in south-eastern throughout 2013, the Government of Turkey proposed tural producers. e drought, in conjunction with Turkey is a tall man from Rwanda named Emmanuel to WFP a cost-sharing arrangement for the provision high temperatures, has severely decreased the yield Safari. Emmanuel has extensive experience with the of the food ration for Syrians in all camps. Here, the of various nuts, fruits, vegetables and grains. e implementation of C&V programming in many WFP/KIZILAY contribution to food assistance would wheat harvest has decreased by at least 21 percent countries including in Rwanda, Haiti, Egypt, Tunisia, reduce from 80 to 60 Turkish liras (US$30) and from 2013 and Turkey will be required to import Lebanon and Mali. Inquisitive residents of Gaziantep AFAD would supplement this with an amount of 20 wheat to meet demand. Economists predict that the constantly stopped this unusual and friendly visitor Turkish liras (US$10) per beneficiary per month drought will continue to raise the prices of food to exchange a few words with him and, when bold, onto the AFAD e-Card for food purchases and 5TL and keep affecting consumers throughout 2014. e to request a photo with him! Safari’s first impressions for non-food items also complemented by in-kind drought has decreased water reserves and affected of the government assistance to its Syrian guests donations. By June, 2014, this tripartite arrangement energy production, thus increasing the price of elec- were about how much was being done and the in- has been implemented in all 21 camps where the tricity throughout the country as well. Other com- credible hospitality and generosity of the Turkish Government requested WFP assistance, accounting pounding factors include fluctuations in the value people. for food security to over 217,000 beneficiaries in of the Turkish lira, decreased food supply as well as For more information, contact: Kathleen 45,000 households, who shop at a total of 58 shops. the creation of monopolies in camps with very few e monthly transfer to beneficiaries is US$6.6 Inglis, email: [email protected] and participating shops. As a response to the monopoly Jennifer Vargas, email: [email protected] million which is directly spent in markets and, issue in particular, WFP and KIZILAY with the en- therefore, directly invested into the local economy. couragement of AFAD are now actively looking to To read about the day in the life of a WFP field Monitoring and evaluation activities contract more shops outside the camps to foster monitor, Afaf Shasha, working in the Syrian WFP has a robust monitoring and evaluation (M&E) greater market competition and to encourage the refugee camps in south-eastern Turkey, visit Field and reporting programme in place; field monitoring provision of high quality commodities and services Exchange 48 online, p148. staff (FMS) work in coordination with KIZILAY field staff to ensure markets have a wide variety of Emmanuel Safari – staff profile quality products for sale at market-value prices in hygienic and secure locations. Monitoring tools in- WFP is the largest humanitarian agency in the world clude: a post distribution monitoring questionnaire and as such, draws personnel and expertise from all (PDM) to be applied at the household level, an corners of the globe. The first Cash &Voucher (C&V) WFP/Kathleen Inglis onsite monitoring checklist (OSM) to be filled by programme officer sent to Gaziantep in south-eastern Turkey is a tall man from Rwanda named Emmanuel monitors when visiting participating shops, and a Safari. Emmanuel has extensive experience with the beneficiary contact monitoring questionnaire (BCM) implementation of C&V programming in many applied to beneficiaries coming out of these shops. countries including in Rwanda, Haiti, Egypt, Tunisia, Additionally, Price Market Monitoring (PMM) is Lebanon and Mali. Inquisitive residents of Gaziantep conducted on a monthly basis in the contracted constantly stopped this unusual and friendly visitor to shops where e-Food Card Programme beneficiaries exchange a few words with him and, when bold, to redeem their e-vouchers, as well as in non-partici- request a photo with him! Safari’s first impressions of pating city shops. the government assistance to its Syrian guests were about how much was being done and the incredible WFP and TRC looking to contract more shops outside the camps to foster greater WFP monitoring findings indicate that the ma- hospitality and generosity of the Turkish people. market competition jority of programme beneficiaries have been living ...... 72 Views...... WFP/Abeer Etefa WFP/Abeer Iraq Syrians in Iraq: Refugee response within a major humanitarian and

political crisis By Lynn Yoshikawa

Lynn Yoshikawa is an analyst with the Syria Needs Analysis Project (SNAP) based in Amman, Jordan. She has worked in the humanitarian sector for over 10 years in Afghanistan, Southeast Asia, the Middle East and in headquarters, primarily focused on policy research.

About the Syria Needs Analysis Project (SNAP): ments of humanitarian needs in complex emergen- ACAPS and MapAction established SNAP in January cies and crisis through the provision of 2013, a project aimed at supporting the humanitar- context-specific inform-ation and analysis. MapAction ian response in Syria and neighbouring countries by (www.mapaction.org) is an interna- tional NGO providing an indepen- dent analysis of the humani- whose mission is to assist responders to humanitarian tarian situation of those affected by the Syrian crisis. emergencies by providing mapped information and ACAPS (Assessment Capacities Project, other information management services that enable www.acaps.org) is dedicated to improving assess- rapid situational assessment and decision making. is article was completed in early October 2014.

ith about 215,000 Syrian refugees1 or 2013, a lack of information and shared assessments on less than 7% of the total registered num- the unfolding situation was evident (for more on SNAP’s ber of Syrian refugees in the region, work, (see page 156). Despite the relatively low number Iraq hosts the smallest number of Syrian of NGOs operating in the area, the humanitarian situation Wrefugees. Iraq has generally welcomed these refugees in appeared largely under control, with the authorities of ethnic solidarity to the semi-autonomous Kurdistan the KR-I taking the lead and investing an estimated Region of Iraq (KR-I), where the vast majority of Syrians USD 120 million2 in the construction of camps and the reside. Partly as a result of this as well as due to the provision of water and other services. While Syrian unique complexities of operating in the KR-I, the inter- refugees, who were largely of Kurdish origin, were national response to the Iraq refugee influx has been initially welcomed by the local population in 2012, the somewhat neglected compared to other neighbouring KR-I authorities became increasingly concerned with countries in the region. However, the June offensive by the impact on its security and booming economy, and the Islamic State (formerly known as the Islamic State closed the border in May 2013.3 In central Iraq, where of Iraq and the Levant, ISIL) and various Iraqi groups the situation was more volatile, the border crossings have put the war-torn country back into the spotlight had been closed in 2012, but about 9,000 Syrians,4 and re-ignited sectarian violence, as well as fears across primarily from Deir-ez-Zor governorate, had fled to the region. As the latest wave of conflict and displacement Iraq and were hosted in a camp and urban areas around in Iraq takes its toll, – threatening to break Iraq apart and further fuel the conflict in Syria – the humanitarian 1 UNHCR Refugee Response Portal, accessed 8 October 2014. response will be further challenged by deepening inse- 2 Amnesty International, 3 January 2014. curity, uneasy acceptance of aid agencies by parties to http://livewire.amnesty.org/2014/01/03/life-getting-harder-for- syrian-refugees-in-iraqi-kurdistan/ the conflict and complex geopolitical interests. 3 UNHCR, 16 December 2013. http://www.unhcr.org/syriarrp6/docs/ Since the Syria Needs Analysis Project (SNAP) began syria-rrp6-iraq-response-plan.pdf#B 4 UNHCR Refugee Response Portal, accessed 13 July 2014. remotely analysing the Syrian refugee situation in Iraq, http://data.unhcr.org/syrianrefugees/settlement.php?id=178 as well as other host countries in the region, in January &country=103®ion=85 ...... 73 Field Article ......

bid to persuade them to move to camps. In addition and thousands more to disputed territories which to providing legal status to rent homes, residency are now largely under Kurdish control. e IDP permits also allow the holder to work legally, hence, influx to the KR-I has overwhelmed the limited and they are sought aer by refugees, both in and outside generally weak public services available, diverted of camps. Since mid-2014, UNHCR succeeded in attention from the Syrian refugee response, and all three KR-I governorate to agree to a common heightened tensions. ese factors have contributed

Marco Frattini/WFP, Iraq, 2013 Iraq, Frattini/WFP, Marco policy on residence permits and fast tracking permits to at least 10,000 refugees returning to Syria in for Syrian registered with UNHCR, although some recent months, despite increasing insecurity and minor administrative issues persist. limited access to aid in areas of return. is latest displacement comes on top of the Syrian refugee Despite its oil wealth and semi-autonomous influx; over half a million displaced from Anbar status, the KR-I remains dependent on Baghdad to governorate this year, about one million IDPs and access revenues from oil resources. is arrangement returning refugees and about 100,000 stateless people. is further complicated by various political disputes While there are common drivers of conflict fuelling regarding the sharing of oil wealth and territories the border town of Al-Qa’im. Due to its remote lo- one another in both Syria and Iraq, Iraq’s humani- claimed by both Baghdad and the KR-I. Despite cation and insecurity, only a handful of agencies tarian crisis presents a formidable challenge in its these long-standing disputes, Iraq’s political leadership worked in the area and since the Islamic State’ own right and should not be conceived of as simply has also been politically dependent on the Kurds in takeover in June, access has been virtually impossible. an ‘appendage’ to the current Syrian crisis. order to form a coalition government. In late 2013, As the conflict escalated in 2013, particularly in KR-I made a deal to export some of its oil out To date, the international humanitarian com- Aleppo and Damascus where a number of Kurdish through Turkey, a move Baghdad claimed was illegal, munity has gained limited acceptance by the Islamic communities reside as well as between Kurdish and as revenues did not go through the central govern- State, both in Syria and in Iraq, and when access opposition armed groups in eastern Syria in mid- ment. As a result, Baghdad cut off budget payments has been established, aid agencies are subject to 2013, IDPs began to congregate on the Iraq-Syria to the KR-I in March, leading to delayed salary pay- strict conditions. Western donors are concerned border. As humanitarian conditions deteriorated, ments of many civil servants.6 e KR-I’s budget that aid could be diverted to groups labelled as ter- the KR-I authorities opened the border in late August, crisis also affected the government’s ability to maintain rorists and counterterrorism-related restrictions leading to an influx of 60,000 Syrians in one month. the camps, which it had established and maintained, may further impede humanitarian access to those e KR-I and aid agencies were overwhelmed by the with teachers and health workers reporting significant in need. e legacy of remote management of hu- influx but managed to stabilise the population and delays in the payment of salaries. New camp facilities, manitarian operations in Iraq (which began in the establish new camps. In the subsequent weeks and such as schools, had been built but were unable to 1990s) persists and will continue to hamper an ex- months, the border crossings were again closed and start classes due to lack of KR-I financing to hire panded presence of humanitarian organisations, as dozens of new international aid agencies also arrived teachers.7 well as their ability to monitor needs and account in the KR-I to help with the response. While new e KR-I authorities have expressed their wish for aid. While Saudi Arabia contributed USD 500 funding was made available for the refugee influx, 11 for Syrian refugees to reside in one of the eight es- million to UN agencies for the Iraq crisis, thereby aid levels levelled off in early 2014 even though the addressing ongoing concerns about lack of funding refugee population had swelled nearly threefold in tablished camps. As a result, the needs of urban refugees have been neglected and little comprehensive from western donors, attention and funding will the past year. Although some NGOs considered inevitably decline, and the Iraqi government must longer-term programming for refugees,5 there was information on their status was known until a recent needs assessment was undertaken by REACH. Ac- take responsibility for the protection and well-being little traction among local authorities for this type of of its people. In the past efforts to ensure that these programming, leading to a number of aid agencies cording to UNHCR registration figures, just over 40% of Syrian refugees are residing in camps in KR- responsibilities are transferred to, and undertaken deciding to scale down either due to the lack of by, Iraqi authorities failed as witnessed in the post- funds or other implementation challenges. I. In the largest Syrian refugee camp, Domiz, food aid was being distributed for over 75,000 people in Saddam Hussein era. SNAP missions to Iraq found the operational March, however, verification efforts have revealed SNAP’s aim has been to build a common situational environment in the KR-I to be much more complex that more than 20,000 beneficiaries were actually awareness of the humanitarian situation in Iraq to than hitherto understood. While the environment residing outside the camp and have now been taken inform decision makers. However, the unfolding in the KR-I is relatively ‘unrestricted’ and secure, off of beneficiary lists.8 To date, UN agencies have crises in Iraq have made this task infinitely more compared to non-Kurdish areas of Iraq and other primarily targeting refugees resding in camps with complex. e response and coordination architecture host countries, the context poses additional challenges little official UN assistance going to urban refugees. has become fragmented between those responding not experienced in other countries. First and foremost, In late 2013, local authorities in Erbil instructed aid to the IDP crisis through the cluster system and while all neighbouring countries have influenced agencies not to provide non-food items, cash or those operating in through UNHCR’s refugee response and been influenced by the Syrian conflict, Iraq’s shelter assistance to Syrian refugees outside of the coordination mechanisms. Donors also mirror the internal divisions and regional allies bring an addi- camps, even during the winter.9 Similarly, Dohuk au- fragmentation with different funding mechanisms tional layer of geopolitical interests resulting from thorities did not currently permit NGOs to provide for refugees and those affected by Iraq’s internal the deepening split between Sunni and Shia popu- cash assistance or gender-based violence programming crisis. With over one million Iraqis displaced this lations since the 2003 US-led invasion, the increasing for non-camp refugees. While there has been some year alone, it will be increasingly difficult to maintain autonomy of the KR-I from the central Iraq govern- room for manoeuvre for aid agencies to negotiate and work through these bureaucratic and institutional ment, and Turkey and Iran’s interests with the KR-I with local authorities, the restrictions have largely divisions and prioritise funding according to the in relation to their respective Kurdish populations. discouraged UN agencies from significant expansion assessed humanitarian needs. e process of main- In relation to Syria, the situation is further complicated of aid activities into urban areas. streaming the response and coordination remains by the fact that Kurdish areas in eastern Syria are unclear, but SNAP established a presence in Erbil in administered by a Kurdish political party, which e fall of Mosul to the Islamic State and armed Sunni groups in June, followed by offensives on a August to support decision makers with independent has a historically intense rivalry with the dominant analysis of this highly complex crisis in order to political party currently in power in the KR-I. number of towns in northern Iraq and along the Syrian border has led to a massive humanitarian inform the difficult decisions which lie ahead. Secondly, while the KR-I appears to be one crisis and dramatic consequences for the whole For more information, contact: cohesive entity and is oen treated as such by the region. e conflict led to the displacement of over [email protected], aid community, the reality is that its governance 1.25 million people between June and October, ac- tel (Jordan): +962 798 693 473 and administration structures are highly de-centralised cording to IOM,10 with some Iraqis even fleeing and each governorate has its own set of policies re- across the border to Syria and thousands more to 5 garding Syrian refugees. For example, Dohuk gov- NGO interviews, Erbil, 5-9 May 2014 Turkey and Jordan. Minorities, particularly, Yazidis 6 Wall Street Journal, 23 May 2014. http://online.wsj.com/ ernorate, which hosts the lion’s share of Syrian and Christians, have been severely persecuted and 7 UNHCR, 6 May 2014. http://reliefweb.int/sites/reliefweb.int/ refugees within Iraq, has been issuing residency subjected to summary executions, siege tactics, and files/resources/UNHCR-Iraq_Syrian_Update_1-15_Apr_14 _2 permits to both camp-based and urban refugees, gender-based violence. Millions more have been .pdf UNHCR, 13 April 2014. while Erbil and Sulaymaniyah governorates have affected by violence and shortages of food, water http://data.unhcr.org/syrianrefugees/download.php?id=5256 8 World Food Programme, 24 March 2014. http://reliefweb.int generally adopted a more restrictive position towards and fuel. Most IDPs originated and fled within the 9 NGO interviews, 5-9 May 2014. Syrians, and had largely stopped providing residency northern governorates of Ninewa and Salah Al- 10 Displacement Tracking Matrix, IOM, 3 October 2014. permits to urban refugees since in early 2013 in a Din, but over 700,000 reportedly entered the KR-I 11 New York Times, 1 July 2014...... 74 Research......

WFP beneficiary International legal in Damascus consequences of the conflict in Syria

WFP/Abeer Etefa By Natasha Harrington Natasha Harrington is a barrister (a member of the English Bar). She is currently working in Eversheds law firms’ public international law and international arbitration group in Paris. Natasha’s practice includes advising and representing governments, international organisations and private clients on a wide range of public international law matters. She has a particular interest in international humanitarian law and international human rights law. In this regard, she regularly undertakes pro bono work and has previously worked for Amnesty International. Natasha has also undertaken training in international humanitarian law with the International Committee of the Red Cross.

The ENN is a partner of the charity A4ID1 through which we secured the pro bono services of Natasha to develop an article about the legal framework around military intervention on humanitarian grounds. We extend sincere thanks to A4ID (particularly John Bibby, Head of Communications and Policy) for brokering this arrangement, to Eversheds law firm for supporting this endeavour, and to Natasha, who went way beyond her initial remit to accommodate our questions and an ever-complicating context. Article completed 20 June 2014. Regional A. Introduction e term “humanitarian catastrophe” has particularly by the parties to the conflict (Section B) profound meaning in relation to the situation in Syria. b) the responsibility of the international community Aer three years of civil war, over 150,000 people are to react to the crisis in Syria, and in particular, the estimated to have been killed and more than 2.5 million “Responsibility to Protect” (Section C), and Syrians (over 10% of the population) have fled to neigh- c) the scope, under international law, for intervention bouring countries. In addition, at least 9.3 million Syrians in Syria by third States without UN Security Council inside Syria are in need of humanitarian assistance, over authorization (Section D). 2 6.5 million of whom are internally displaced. B. Breaches of International Law e existence of a “humanitarian catastrophe” is a during the Conflict in Syria trigger point for action under certain doctrines of in- Documenting all of the violations of international law ternational law. For example, the Responsibility to carried out during the Syrian conflict would be an im- Protect (or R2P) doctrine recognises an obligation on mense task, one that perhaps only the International the international community to prevent and react to Criminal Court (ICC) or a specialist tribunal could at- humanitarian catastrophes. Certain international lawyers tempt (see below). erefore, this section highlights and States, including the UK, also argue that under in- just some of the most grievous violations of the rules of ternational law it is permissible to take exceptional international law carried out by the parties to the conflict measures, including military intervention in a State, in in Syria. order to avert a humanitarian catastrophe (hereaer Applicable Legal Rules referred to as “humanitarian military intervention”).3 e rules of international humanitarian law apply to is article examines the legal consequences of the the conflict in Syria because it is a non-international Bonus articles online: humanitarian crisis in Syria. It addresses: armed conflict: an intense conflict between a government a) the serious breaches of international humanitarian and a number of well-organised rebel groups. In addition Views law and international human rights law committed to international humanitarian law, international human • Artificial feeding in emergencies: experiences from the ongoing Syrian 1 Advocates for International Development (A4ID) is a charity that 3 See Response to Questions from the House of Commons Foreign crisis helps the legal sector to meet its global corporate social responsi- Affairs Committee, Humanitarian Intervention and the Responsibility bility to bring about world development. It provides a pro bono to Protect, 14 January 2014. Available at: http://justsecurity.org/wp- Agency Profile broker and legal education services to connect legal expertise with content/uploads/2014/01/Letter-from-UK-Foreign Commonwealth development agencies worldwide in need of legal expertise. -Office-to-the-House-of-Commons-Foreign-Affairs-Committee-on- • Syria INGO Regional Forum (SIRF) 2 Report of the Secretary-General on the Implementation of Security Humanitarian-Intervention-and-the-Responsibility-to-Protect.pdf Council Resolution 2139 (2014), 22 May 2014, UN Doc. S/2014/365, (last accessed on 23 May 2014). www.ennonline.net/fex para. 17...... 75 Research ......

published an open letter in e Lancet in which they cited “systematic assaults on medical professionals, facilities and patients...making it

WFP/Abeer Etefa WFP/Abeer nearly impossible for civilians to receive essential medical services”. 13 Some health facilities have been repeatedly attacked, and over 460 health- care workers have reportedly been killed in Syria.14 UN staff and medical professionals have also been abducted or detained by the Syrian authorities and rebel groups.15 (7) Access to Humanitarian Relief: rapid and unimpeded access to humanitarian relief for all civilians in need, without distinction, must be ensured by the parties to the conflict. Both the Syrian government and rebel forces fre- quently interrupt access to humanitarian relief, par- Souad and her three-year-old son, who is disabled, fled their 16 homes in Deir Ezzor to Al-Hassake city where they are living ticularly basic medical equipment. For example, a in an abadnoned building without any heat or electricity. report by the UN Secretary-General states that: “Medical supplies including life-saving medicines rights law continues to apply in Syria.4 For example, violence, in government detention facilities.7 and vaccines, and equipment for the wounded and Syria is a party to the International Convention on Recently, certain rebel groups such as the the sick are commodities privileged through the Geneva Civil and Political Rights (the ICCPR) and the Con- Islamic State of Iraq and al-Sham8 (ISIS) are Conventions. Denying these is arbitrary and unjustified, vention Against Torture. reported to have increased their use of torture and a clear violation of international humanitarian against civilians.9 law. Yet, medicines are routinely denied to those who Violations of International Law by the Parties need them, including tens of thousands of women, to the Conflict in Syria (3) Prohibition against the use of starvation of the children and elderly. e Security Council must take (1) Protection of civilians and distinction: the parties civilian population as a method of warfare: the action to deal with these flagrant violations of the to the conflict must not attack civilians, and use of starvation against the civilian population basic principles of international law.”17 must always distinguish between civilians and is absolutely prohibited. is means that, for combatants and civilian objects and military example, during a siege civilians must be able Security Council Resolution 2139, adopted on targets. e parties to the conflict must not to leave, and food and humanitarian supplies 22 February 2014, demanded unhindered humani- undertake “indiscriminate attacks”, which by must be allowed access to, the besieged area. tarian access in Syria “across conflict lines and across their nature strike civilians and military objec- e Commission of Inquiry has noted reports borders”. Its preamble states that the arbitrary denial tives without distinction. of starvation in areas besieged by the Syrian of humanitarian access may constitute a violation authorities, such as Yarmouk.10 Human rights of international humanitarian law. However, the is rule has been repeatedly violated by both groups have accused the Syrian government of Syrian government refuses to authorise cross-border sides to the conflict. In particular, the use by using starvation as a weapon of war.11 deliveries of aid through border crossing points that government forces of barrel bombs in civilian it does not control18, including crossing points iden- areas violates the rule of distinction. In May (4) Prohibition against the use of chemical and tified as “vital” to reach over one million people in 2014, the UN Secretary-General reported that: biological weapons: the use of chemical and areas that are otherwise impossible to reach.19 “Indiscriminate aerial strikes and shelling by biological weapons in armed conflict is also Government forces resulted in deaths, injuries strictly forbidden under international law. In an open letter to the UN Secretary-General, a and large-scale displacement of civilians, while However, a chemical weapons attack on 21 group of legal experts argued that if consent for armed opposition groups also continued indis- August 2013 reportedly killed hundreds of relief operations is arbitrarily withheld by the Syrian criminate shelling and the use of car bombs in people. A recent UN report on the situation in authorities, then such operations may be carried 5 populated civilian areas.” Syria also contained information about the use out lawfully without consent.20 However, the UN of toxic gas.12 (2) Torture and inhuman treatment: the use of has not accepted this advice. It has maintained that torture is absolutely prohibited, and cannot be (5) Protection of humanitarian relief personnel the consent of the Syrian government is necessary justified by a state of emergency or war.6 and medical personnel and facilities: the for humanitarian operations, unless the UN Security parties to the conflict must protect and respect Council specifically authorises such operations under An Independent International Commission of humanitarian relief and medical personnel. Chapter VII of the UN Charter.21 Inquiry for Syria (the Commission of Inquiry), Medical facilities must be protected and must set up by the UN Human Rights Council, has not be attacked. In a recent report, the UN Secretary-General found evidence of the widespread use of tor- called on the Syrian government to allow cross- ture, as well as incidents of starvation and sexual (6) In September 2013, a group of doctors border aid deliveries and said that by withholding

4 The International Court of Justice considered the relationship government and rebel forces. aid convoys, resulting in scarcity of the most basic medical between international humanitarian law and international 11 http://www.amnesty.org/en/news/syria-yarmouk-under-siege- necessities such as syringes, bandages and gloves. Oral Update, human rights law in Legal Consequences of the Construction horror-story-war-crimes-starvation-and-death-2014-03-10 (last 16 June 2014, p. 7, para. 46 and p. 8, para. 51. of a Wall in the Occupied Palestinian Territory, Advisory accessed on 19 June 2014). 17 Report of the Secretary-General on the Implementation of Opinion, I.C.J. Reports 2004, p. 136, at p. 178, para. 106. The UN 12 Report of the Secretary-General on the Implementation of Security Council Resolution 2139 (2014), 23 April 2014, para. 52. Security Council called on both the Syrian authorities and Security Council Resolution 2139 (2014), 22 May 2014, UN Doc. 18 Report of the Secretary-General on the Implementation of armed groups to cease all violations of human rights in Security S/2014/365, para. 12. Security Council Resolution 2139 (2014), 23 April 2014, para. 35. 19 Council Resolution 2139, para. 2. 13 Open Letter: Let us Treat Patients in Syria, The Lancet, 16 Report of the Secretary-General on the Implementation of 5 Report of the Secretary-General on the Implementation of September 2013; http://www.thelancet.com/journals/lancet/ Security Council Resolution 2139 (2014), 22 May 2014, UN Doc. S/2014/365, para. 31. If the fighting continues, there is a risk Security Council Resolution 2139 (2014), 22 May 2014, UN Doc. article/PIIS0140-6736(13)61938-8/fulltext (last accessed on that border-crossings with Turkey could be permanently S/2014/365, para. 3. 26 May 2014). closed, compromising the delivery of aid to approximately 9.5 6 Common Article 3 to the Geneva Conventions 1949; Articles 14 Physicians for Human Rights calculates that Syrian government million people. Syria Needs Analysis Project, Potential cross- 7 and 14(2) (non-derogation) of the ICCPR; and Article 2(2) of forces are responsible for 90% of 150 reported attacks on border assistance from Turkey to Syria, April 2014. Available at: the Convention Against Torture 1984. hospitals. http://physiciansforhumanrights.org/press/press- http://reliefweb.int/sites/reliefweb.int/files/resources/potential 7 Independent International Commission of Inquiry on the Syrian releases/new-map-shows-government-forces-deliberately- _cross_border_assistance_from_turkey_to_ syria _0.pdf (last Arabic Republic, Oral Update, 18 March 2014, pp. 3-4. attacking-syrias-medical-system.html (last accessed on 26 May accessed on 23 May 2014). 8 Also known as the Islamic State of Iraq and Syria or the Islamic 2014). 20 Open letter to the UN Secretary General, Emergency Relief State of Iraq and the Levant. 15 Report of the Secretary-General on the Implementation of Coordinator, the heads of UNICEF, WFP, UNRWA, WHO, and 9 Independent International Commission of Inquiry on the Syrian Security Council Resolution 2139 (2014), 23 April 2014, para. 42. UNHCR, and UN Member States, 28 April 2014. Available at: Arabic Republic, Oral Update, 16 June 2014, pp. 6-7. http://www.msf.org/article/five-msf-staff-held-syria-released http://www.ibanet.org/Article/Detail.aspx?ArticleUid=73b714 10 Independent International Commission of Inquiry on the Syrian (last accessed on 19 June 2014). fb-cb63-4ae7-bbaf-76947ab8cac6 (last accessed on 23 May 2014). Arabic Republic, Oral Update, 16 June 2014, pp. 8-9; also 16 The International Independent Commission of Inquiry on Syria 21 Under Chapter VII, measures to enforce decisions of the UN referring to attacks on food distribution points by both cites removal of essential medical and surgical supplies from Security Council may be adopted...... 76 ...... A young girl and her mother in Idlib Governorate its consent, the Syrian government “is failing in its responsibility to look aer its own people”22, invoking the language of Responsibility to Protect. Recently, it has been reported that UN diplomats are discussing a Security Council resolution that would authorise cross-border aid and threaten sanctions if the Syrian government fails to comply.23 In the meantime, how- ever, aid organisations that engage in unauthorised UNICEF/NYHQ2013-0698/Diffidenti cross-border activities risk expulsion or even attack by the Syrian government.24 Summary The scale of the violations of international law com- mitted in Syria is such that the Commission of Inquiry describes evidence “indicating a massive number of war crimes and crimes against humanity suffered by the victims of this conflict”.25 War crimes are grave breaches of international humanitarian law, and crimes against humanity are acts such as murder, torture and sexual violence committed as part of a widespread and systematic attack against a Four dra resolutions have been vetoed by Russia while the General Assembly has passed resolutions civilian population. and China, none of which sought express authori- condemning the violence in Syria34, and criticising ese offences could be tried by the ICC. However, sation for military intervention. e second dra the Security Council’s inaction35, it has not recom- because Syria is not a member of the Court’s statute, resolution to be vetoed actually stated that “nothing mended military intervention or sanctions. is is the ICC has no jurisdiction unless the situation in in this resolution authorizes measures under Article likely to be partly due to the complexity of the Syria is referred to it by the UN Security Council. A 42 of the Charter [i.e. military intervention].”29 conflict (discussed below), and the difficulty of se- dra Security Council resolution referring the situ- curing support for intervention from a majority of It is no coincidence that the first and only time UN members. ation in Syria to the ICC was vetoed by Russia and that R2P has been invoked to justify collective 26 China on 22 May 2014. military action through the Security Council against us, the UN has been unable to enforce its own erefore, there is a risk that war crimes and a State was in relation to Libya.30 Russia and China demands for an end to the violence in Syria and a crimes against humanity will continue to be com- consider that regime change in Libya went beyond political resolution to the conflict. We therefore now mitted with impunity in Syria. In light of the gravity the authorisation to protect civilians that was given examine the legal scope for intervention by third of the situation, we turn to examine the responsibility in Security Council Resolution 1973 (2011)31, and States without UN Security Council authorisation. are said to be extremely wary that R2P will be of the international community to respond to the D. The Legal Scope for Third State abused to effect regime change in the future.32 crisis in Syria. Military Intervention in Syria C. Responsibility of the International Resolution 60/1, in which the General Assembly e Debate Over the Legality of Community to Respond to the endorsed R2P, only refers to collective action through “Humanitarian Military Intervention” Situation in Syria the Security Council, which is the UN organ with e situation in Syria rekindled the debate over the e R2P doctrine was developed by an International primary responsibility for international peace and legality of “humanitarian military intervention”. at Commission on Intervention and State Sovereignty security. However, the ICISS report contemplated debate was particularly intense following NATO’s (ICISS) following the failure of the international that, if the Security Council fails to act, the General intervention in Kosovo in 1999, which NATO un- community to prevent humanitarian catastrophes in Assembly might authorise military intervention or dertook without seeking prior UN Security Council Rwanda in 1994 and Srebrenica in 1995. R2P operates regional organisations might intervene with the ap- authorisation. proval of the Security Council. at two levels. First, the State itself is primarily re- e three main positions taken by States and sponsible for protecting its own people. Second, if e General Assembly has no express powers commentators in relation to NATO’s intervention the State is unwilling or unable to protect its people, under the UN Charter to authorise the use of force, in Kosovo have been reiterated in relation to Syria. then the international community is responsible for in contrast to the Security Council’s powers under ey are summarised below: doing so. Article 42. However, in 1950 the General Assembly (1) One group built a forceful argument that is was affirmed by the UN General Assembly adopted Resolution 377(V), referred to as “Uniting “humanitarian military intervention” is unlawful in 2005 in Resolution 60/1, which stated that that for Peace”. Under Resolution 377(V), if the Security because it is contrary to the prohibition against “each individual State has the responsibility to protect Council fails to exercise its primary responsibility the use of force under Article 2(4) of the UN its populations from genocide, war crimes, ethnic for the maintenance of international peace and se- Charter.36 ere are only two express exceptions cleansing and crimes against humanity”.27 UN member curity due to lack of unanimity amongst permanent to the prohibition against the use of force: the States also declared that “we are prepared to take col- members, the General Assembly “shall consider the inherent right of individual or collective self- lective action, in a timely and decisive manner through matter immediately” and may recommend collective defence (Article 51, UN Charter); and acts the Security Council should peaceful means be inade- measures, including the use of armed force where authorized by the Security Council under quate and national authorities are manifestly failing necessary to maintain or restore international peace Chapter VII of the UN Charter. 33 to protect their populations from genocide, war crimes, and security. It is oen argued that Article 2(4) of the UN ethnic cleansing and crimes against humanity.” 28 “Uniting for Peace” and R2P might provide a Charter was deliberately draed to create an However, even dra UN Security Council reso- basis for the General Assembly to make non-binding absolute rule. is protects State sovereignty, lutions condemning the violence in Syria and calling recommendations for the use of force in Syria, pro- and in particular, protects less powerful States for non-military sanctions have been vetoed to date. viding greater legitimacy for intervention. However, from intervention by more powerful States.

22 Report of the Secretary-General on the Implementation of Outcomes, para. 138. UN Doc. A/RES/60/1. Legal Science 97 (2013). Security Council Resolution 2139 (2014), 22 May 2014, UN 28 Ibid., para. 139. 33 Uniting for Peace has only been used as the basis for the UN Doc. S/2014/365, para. 51 29 Draft Resolution proposed by 19 States, dated 4 February 2012, General Assembly to recommend military intervention on one 23 http://www.nytimes.com/2014/05/24/world/middleeast/un- UN Doc. S/2012/77. occasion, in 1951 in relation to Korea (Resolution 498(V)). chief-urges-aid-deliveries-to-syria-without-its-consent.html?_r=0 30 See Resolution 1973 (2011), UN Doc. S/RES/1973 (2011). 34 Resolution 66/253 A (21 February 2012), UN Doc.A/RES/66/253. 35 (last accessed on 20 June 2014).24 Ibid. 31 Resolution 1973 authorised UN Member States “to take all Resolution 66/253 B (7 August 2012) UN Doc. A/RES/66/253 25 Independent International Commission of Inquiry on the Syrian necessary measures...to protect civilians and civilian populated B, preamble. 36 Arabic Republic, Oral Update, 16 June 2014, p. 2, para. 4. areas under threat of attack in the Libyan Arab Jamahiriya... Article 2(4) of the UN Charter provides that “All Members shall re- frain in their international relations from the threat or use of force 26 Provisional record of the meeting of the UN Security Council on while excluding a foreign occupation force of any form on any against the territorial integrity or political independence of any 22 May 2014, UN Doc. S/PV.7180.7 UN General Assembly part of Libyan territory”. UN Doc. S/RES/1973 (2011), 17 March state, or in any other manner inconsistent with the Purposes of Resolution 60/1, 2005 World Summit Outcomes, para. 138. UN 2011, para. 4. the United Nations.” See for example, Brownlie & Apperley, Kosovo 32 Doc. A/RES/60/1. For a summary of these concerns, see Z. Wnqi, Responsibility to Crisis Inquiry: Memorandum on the International Law Aspects, 27 UN General Assembly Resolution 60/1, 2005 World Summit Protect: A Challenge to Chinese Traditional Diplomacy, 1 China (2000) 49 Int’l & Comp. L.Q. 878...... 77 Research ......

whatever their political affiliations or objectives, cannot be regarded as unlawful intervention, or as in any other way contrary to international law.”44

WFP/Abeer Etefa WFP/Abeer E. Conclusion Despite the grievous violations of international law that threaten the lives of many civilians in Syria, there is no consensus of will or legal thinking around “hu- manitarian military intervention”. Meanwhile, both the Syrian government and the international community appear to be failing in their responsibility to protect the Syrian people, as the conflict leaves many people cut-off from essential humanitarian assistance. Lack of unity over “humanitarian military inter- vention” may appear to show the dominance of State sovereignty over human rights. e reality, as reflected in the R2P doctrine, is that the two normally A boy rides his bicycle through the largely go hand-in-hand because the State should protect abandoned streets of Al-Hassake city. and promote the human rights of its people. In ex- ceptional circumstances, there may come a point when “humanitarian military intervention” may be Permitting exceptions to the prohibition cumstances” in which it may be invoked must be justified, particularly where the use of force can prevent a humanitarian disaster in which the State against the use of force may lead to abuse; such sufficiently clear and narrow to limit the risk of itself is complicit. However, to reach that point there as regime change thinly veiled as “human- abuse. must be a real prospect of improving and stabilising itarian” intervention. e criteria justifying intervention that are oen the humanitarian situation through the use of force. (2) A second group argued that military interven- proposed usually include the following: Sadly, if that point ever existed in the Syrian crisis, tion in a State to prevent or avert a humanit- it may have long been surpassed. (a) an impending or actual humanitarian disaster, arian catastrophe is permissible under interna- involving large-scale loss of life or ethnic For more information, contact: Natasha Harrington, tional law. is position was taken by the UK cleansing, which is generally recognised by the email: [email protected] or government, which argued that “force can also international community; [email protected] be justified on the grounds of overwhelming (b) last resort – there must be no practicable humanitarian necessity without a UNSCR”.37 Author’s note: alternatives to avert or end the humanitarian Since this article was written, ISIS declared a Advocates of this position oen argue that the disaster; and caliphate45 on 29 June 2014 and changed its name protection of fundamental human rights is also (c) necessary and proportionate use of force – the to “Islamic State”. e United States launched air vital to the purposes of the UN, as reflected in force used must be limited in time and scope strikes against ISIS in Iraq on 8 August 2014, and the preamble to the UN Charter. ey also cite to that which is necessary and proportionate to on 22 September 2014, the United States and its potential precedents for “humanitarian military the humanitarian need. allies also launched air strikes against ISIS in Syria. intervention” such as Uganda, Liberia and now Kosovo.38 A further criterion, which is acutely highlighted in e government of Iraq requested assistance to the Syrian crisis, is the need for military intervention fight ISIS. erefore, the use of force in Iraq can be (3) A third group argued that although “humani- to be an effective means to provide humanitarian justified on the basis that it was carried out with the tarian military intervention” was not permitted relief. In Syria, it would be very difficult to ensure that consent, and at the request, of the Iraqi government. under international law as it existed in 1999, military intervention would improve the humanitarian the law could or should develop a doctrine of situation in both the short and the longer term. However, the legality of the air strikes in Syria is “humanitarian military intervention”. For the subject of legal debate. Significantly, the United example, Professor Vaughan Lowe argued that More limited forms of intervention than the States did not justify intervention on the basis of it is: “desirable that a right of humanitarian direct use of force in Syria may also pose problems humanitarian assistance, despite the atrocities com- intervention...be allowed or encouraged to develop from the perspective of international law. For example, mitted by Islamic State in Syria. Instead, the United in customary international law. No-one, no the arming and funding of rebel forces may constitute States relies mainly on the collective self-defence of State, should be driven by the abstract and the threat or use of force or an intervention into Iraq because ISIS carries out attacks in Iraq from artificial concepts of State sovereignty to watch Syrian internal affairs.43 Permanent aid corridors, safe havens in Syria. e United States argues that it innocent people being massacred, refraining from as proposed by the French and Turkish governments, does not need consent from the Syrian government intervention because they believe them selves to would be likely to necessitate military enforcement, to carry out air strikes in Syria because that govern- have no legal right to intervene.”39 involving the threat or use of force. ment is “unable or unwilling” to combat ISIS in its territory. e UN Secretary-General also appeared Despite the ongoing debate concerning “human- In August 2013, the USA and the UK threatened to to lend some support to this argument. Reacting to itarian military intervention” in international law, use force against Syria. However, the threat of force the air strikes in Syria, Ban Ki-moon observed that one thing is clear: humanitarian assistance itself is was limited to “deterring and disrupting the further they were carried out in areas no longer under the 40 lawful under international law. In the words of the use of chemical weapons by the Syrian regime” (UK effective control of the Syrian government and that International Court of Justice: government position). ere now seems to be little they were targeted against extremist groups, which support for military intervention in Syria similar to “ere can be no doubt that the provision of strictly he said undeniably “pose an immediate threat to in- that carried out in Kosovo or Libya. humanitarian aid to persons or forces in another country, ternational peace and security”. is reluctance to engage militarily in Syria is partly due to the increasing complexity of the conflict, 37 Statement of the UK’s Permanent Representative to the United government legal position, 29 August 2013, para. 4. which would make it extremely difficult to ensure Nations to the Security Council on 24 March 1999, cited in Res- 41 Independent International Commission of Inquiry on the that military intervention would make the humani- ponse to Questions from the House of Commons Foreign Affairs Syrian Arabic Republic, Oral Update, 16 June 2014, p. 6, para. 40. 42 tarian situation better and not worse. Unfortunately, Committee, Humanitarian Intervention and the Responsibility The Assessment Capacities Project, Regional Analysis Syria to Protect, 14 January 2014. Available at: http://justsecurity.org/ – Brief, 3 June 2014, p. 2. as the Syrian conflict continues the humanitarian wp-content/uploads/2014/01/Letter-from-UK-Foreign- 43 Article 2(7) of the UN Charter prohibits intervention in matters situation for many worsens as both sides flout calls Commonwealth-Office-to-the-House-of-Commons-Foreign- “essentially within the domestic jurisdiction of any state”. See to end violations of international law, and extremist Affairs-Committee-on-Humanitarian-Intervention-and-the- Military and Paramilitary Activities in and against Nicaragua groups such as ISIS increasingly use torture41 and Responsibility-to-Protect.pdf (last accessed on 23 May 2014). (Nicaragua v. United States of America). Merits, Judgment. I.C.J. 38 disrupt the distribution of aid.42 See, for example, Greenwood, Humanitarian Intervention: Reports 1986, p. 14, at p. 118, para. 228 and p. 124, para. 242. The Case of Kosovo, 2002 Finnish Yearbook of International 44 See Military and Paramilitary Activities in and against Criteria for Intervention Law, p. 141. Nicaragua (Nicaragua v. United States of America). Merits, 39 Lowe, International Legal Issues Arising in the Kosovo Crisis, Judgment. I.C.J. Reports 1986, p. 14, at p. 124, para. 242. If “humanitarian military intervention” can ever be (2000) 49 Int’l & Comp. L.Q. 934, at p. 941. 45 A form of Islamic political-religious leadership which centres justified, the criteria defining the “exceptional cir- 40 Guidance Note, Chemical weapon use by Syrian regime: UK around the caliph ("successor”) to Muhammad...... 78 Field Articles...... Gabriele Fänder/Medair, Jordan, 2014 Jordan, Gabriele Fänder/Medair, The Syria Needs Assessment Project

By Yves Kim Créac’h and Lynn Yoshikawa

Yves Kim Créac’h is currently the Project Lead for the Lynn Yoshikawa is an analyst with the Syria SNAP Project. He is a seasoned humanitarian worker, Needs Analysis Project (SNAP) based in with 15 years of experience in the humanitarian field Amman, Jordan. She has worked in the at senior level, with focus on strategy formulation, humanitarian sector for over 10 years in management of large scale humanitarian operations Afghanistan, Southeast Asia, the Middle East in complex emergencies and policy influencing. He’s and in headquarters, primarily focused on one of the founders of the ACAPS project. policy research.

A special acknowledgement goes to Nic Parham, former SNAP Project Lead, whom with his team has established the SNAP Project and developed a totally new approach to information within the humanitarian system.

year aer the start of the Syrian crisis, there were significant and persistent inconsistencies mands from humanitarian stakeholders, thematic ACAPS1 was approached by a range of in reports on the actual number of affected Syrians reports of governorate profiles3, cross border access donors to consider a small project to both inside and outside the country, the movement analysis4, etc. were produced as well. Within a month bring together all existing information and flows of populations, general humanitarian of starting the project, SNAP took advantage of an concerningA the humanitarian situation of those needs and the longer-term impact on infrastructure opportunity to support a joint multi-sectoral needs affected by the crisis. Many organisations (humani- and livelihoods in-country. is problem was further assessment in northern Syria (J-RANS). By providing tarian, governmental, media etc.) were reporting exacerbated by the sensitivities associated with in- the bulk of the technical capacity (analytical skills, on elements of the crisis, usually specific to a formation management while ensuring continued geographical information system (GIS) and assess- particular problem in a particular age-group or in a access to the affected population. It was for this ment expertise), SNAP facilitated the process for particular country, such as shelter for refugees in reason that SNAP (the Syria Needs Analysis Project) the humanitarian community to gain the first com- Lebanon or food for Palestinians in Syria. With was born in December 2012. prehensive overview of needs in northern Syria. As UNHCR country offices responsible for the coordi- a result, SNAP expanded its objectives to include SNAP was initially conceived as a two to three nation of the response in refugee-hosting countries, the provision of support to coordinated assessment person project with some remote support from the (the exception being Turkey where government took initiatives and staffing increased accordingly, with ACAPS and MapAction2 headquarters, aimed at responsibility for coordination), and OCHA respon- additional needs assessments facilitated in Dar’a improving the humanitarian response by creating a sible for coordination in Syria, obtaining a holistic and Quneitra governorates in southern Syria. shared situational awareness. Using ACAPS’ skills picture of the situation was challenging. It was also and experience in the analysis of secondary data, Concurrent to this support to primary data col- impossible to determine what was known and what SNAP would seek to build trust with sufficient stake- lection in northern Syria, SNAP worked to develop the gaps in information were, due to the sensitivities holders in the region so as to gain access to as much relationships with humanitarian actors throughout of reporting on the humanitarian situation, partic- the region. Linking quickly with UNHCR and some information as possible then, bearing in mind the ularly by agencies working from Damascus, as well key non-governmental organisations (NGOs) in various levels of confidentiality by which information as those working cross-border without registration. Lebanon and Jordan proved essential in understanding is shared, create products to inform the strategic Most actors engaged in the Syria conflict response the refugee context. It quickly became clear that decisions to be made by the humanitarian community. agreed that there was an incoherent picture of the few organisations made public their most useful As such, SNAP created the RAS (Regional Analysis humanitarian situation in Syria and neighbouring and interesting data due to operational sensitivities, of Syria), which was initially monthly and would countries, and how dynamics in Syria affected host particularly with host governments and at times, cover both humanitarian issues in Syria and neigh- with donors. us SNAP strove to build personal countries and vice versa. Humanitarian stakeholders bouring countries. In addition, due to increased de- relationships with key stakeholders across the hu- had an insufficient shared situation awareness, and manitarian community which necessitated a further expansion, deploying additional analysts in Jordan Table 1: Outline of SNAP’s information sharing protocol

Category Level of anonymisation for public disclosure 1 ACAPs (The Assessment Capacity Project) is a consortium of NGOs created at the end of 2009 to strengthen assessment Unprotected Open - can be quoted and attributed to the organisation and analysis methodologies as well as providing surge capacity for the IASC in time of crisis Protected Can be quoted and attributed to ‘an international NGO’ or ‘a national NGO’ etc. 2 http://www.mapaction.org/ Restricted Can be quoted and attributed to ‘a trusted source’ 3 For example, see latest Idlebl governorate profile at http://www.acaps.org/en/pages/syria-snap-project Confidential Cannot be quoted directly but can be used for analysis and the analytical deduction 4 For example, see: http://www.acaps.org/reports/downloader/ published without any attribution cross_border_movement_of_goods/67/syria ...... 79 Field Article ...... and Turkey and expanding the core team in Lebanon. ulation estimates and displacement are highly dy- this risk – although it does necessitate the involvement Over the first six months of the project, the SNAP namic. In the second iteration of the J-RANS in of specialists in the analysis process. Not being op- team grew from three to nine, with further expansion April 2013, SNAP included nutrition in the multi- erational in Syria also means that SNAP can publish to 20 staff planned in 2014. sectoral assessment, however, it was found that enu- information with which the Government or oppo- Key to accessing data and information in the merators lacked adequate training to properly dis- sition might disagree, although the need to ensure Syrian context has been confidentiality; many or- tinguish between food security and nutrition needs. that our publications do not compromise the safety ganisations are sensitive about details of their oper- Hence, the results blurred the lines between the two and security of staff in Syria or jeopardise humani- ations – particularly in Syria, due to the complex sectors, and in subsequent assessments, nutrition tarian operations remains paramount. was not included as a standalone sector. nature of the crisis and the need to work in areas A second strength is that SNAP has no mandate under control of the various parties to the conflict. Underpinning SNAP’s work is the view that in- for coordination or information management in a SNAP quickly developed a simple information formation is never perfect and thus we strive to give specific context and can produce independent analysis sharing protocol to facilitate the sharing of information analysis deemed ‘good enough’ to enable decisions of the whole humanitarian situation based almost and clarify the level at which it could be made entirely on information provided by others. Many 5 to be based on the best possible evidence. To this public (see Table 1 ). organisations see this as useful, as it gives them evi- end, SNAP seeks to highlight information gaps and dence from a trusted source to support interventions SNAP also aims to source and hyperlink all in- the most recent information while giving a sense of and appeals for donor funding. UNHCR in Lebanon formation in the reports to enable readers to further the reliability of the information. investigate and judge the reliability of the source. and Jordan also see SNAP’s products as contributing However, where organisations are reluctant to be Various challenges have arisen: the sheer number to their effort to coordinate the response. Coordi- associated by name with information sharing, two of actors in the crisis; the significant part played by nation with OCHA is more of a challenge due to levels of general sourcing are used: a) ‘an INGO’ or actors who do not link to the international human- the constraints faced by Damascus-based organisa- a UN agency’ etc. or b) ‘a trusted source’. Where itarian architecture (such as diaspora, armed groups, tions on publicly sharing information and analysis, partners share information on the understanding community-based and faith-based organisations, since most information coming out of Damascus- that it is not shared publicly, SNAP uses it to trian- etc.); the political sensitivity of headline numbers; based operation have to be approved by the Gov- gulate data from other sources and to inform general the operational sensitivity of information in Syria ernment of Syria. analysis. ‘Off the record’ conversations with experts (especially regarding access and border crossings); A growing part of SNAP’s focus is direct support in a particular field are useful as they may either lack of access to and information on certain areas to humanitarian needs assessments, especially within confirm or question information from other sources, within Syria; lack of information on certain groups Syria but also in Jordan and Lebanon. SNAP only highlight issues of which we are unaware, assist us and sectors; the dynamic nature of the crisis and supports initiatives that are coordinated with multiple in reprioritising issues, as well as contribute to our thus humanitarian decision-makers’ information actors such as the J-RANS6 and SINA7 exercises in overall understanding of the situation. Support to needs. Syria and the MSNA8 in Lebanon. As SNAP’s added assessment initiatives across the region also contributes SNAP thus adopts a graduated approach to in- value is in secondary data collation and analysis, we to SNAP’s overall aim, by increasing the quality of formation collection that starts with a daily trawl of are working increasingly closely with other specialist timely data available. the internet. Each piece of information is captured primary data collection organisations such as REACH. Further to that, in both Turkey and Jordan, SNAP e absence of systematically collected, reliable in a spreadsheet which categorises it according to has provided a number of assessment training to the information from Syria also presents a challenge in geographic location, affected group, sector, date, humanitarian communities and intends to further deciding the level of information that is ‘good type of information (conflict; needs; response etc.), expand this service that would include in the future, enough’. When information is scarce, a particular source, etc. e data can then be filtered by sector in-depth trainings in specific topics, such as analysis piece of information can seem especially valuable, and location, say health in Ar-Raqqa governorate, or devising sampling methodologies. but if it is highly specific (such as information on a to view all the recent/new information on health in particular village) and no comparable information that governorate. Combined with unpublished in- Monitoring the use of SNAP’s analysis and the is available, it is misleading to include it in a report formation gathered directly from other sources, this catalytic effect the project has had on assessment co- as it gives the impression that the information is the gives a basis for identifying key issues (or gaps in ordination and information sharing is one of the most important piece of information. For example, knowledge) of the situation. Weekly team analysis more challenging parts of the project. An independent credible and reliable information might be available sessions help the team identify issues for further in- evaluation undertaken nine months into the project that village X has suffered repeated aerial bombard- vestigation/data collection. Prior to the draing of found that SNAP “offered significant value to the hu- ment and that food is scarce and insufficient for the a report, SNAP invites specialists in particular fields, manitarian community in strengthening the targeting population. Without information on the situation and some general humanitarian analysts, to help of assistance and in making an important contribution in other villages in the area, reporting this information analyse the issues that have been identified as par- to a shared situation awareness” and that its relevance may give the impression that village X is the only ticularly important, and that will be highlighted in “stemmed from its ability to fill critical gaps in the part of the district witnessing direct attacks and in the report. information and analysis of the humanitarian com- need, or that it is the most in need. munity”. While anecdotal evidence suggests many One of SNAP’s strengths is that it is independent donors and NGOs, both international and national, Collecting information on nutrition in the Syrian – in that, not being an operational response organi- use and value SNAP products, their value to the hu- context has been particularly challenging due to the sation, SNAP has no cause to promote the needs in manitarian community within Syria, especially the need for specialised training of enumerators and one sector, location, or of one group over another. Humanitarian Country Team, remains unclear. achieving proper sampling in a context where pop- at all SNAP’s analysts are generalists also reduces Over the first 15 months of SNAP, it has become clear that there is a huge appetite for independent A Syrian refugee family living analysis and a consolidated report on the overall hu- in Jdita town in Bekaa valley after fleeing the war in Aleppo. manitarian situation, although views differ as to the level of detail required. SNAP has also proved that it is possible to gain the trust of a variety of organisations, UN, NGO, faith-based etc., and gain access to otherwise confidential information. However, to do this takes both time and staff and it is a constant challenge to ensure that the value of SNAP’s products is worth the cost of the project. For more information, contact: Yves Kim Créac’h, email: SNAPLead:acaps.org

5 The more detailed SNAP information sharing classification system is available at http://www.acaps.org/en/pages/syria- snap-project 6 J-RANS: Joint Rapid Assessment of Northern Syria 7 SINA: Syria Integrated Needs Assessment 8 MSNA: Multi-Sector Need Assessment WFP/Sandy Maroun ...... 80 Views......

Nutrition response to the Syria crisis: UNICEF's perspective A man and a boy in Atma, an encampment for displaced persons, near the border with Turkey

UNICEF/NYHQ2013-0691/Diffidenti By James Kingori, Dr Hayder Nasser, Muhiadin Abdullahi and Dr Khaldoun Al-Asaad

James Kingori is the UNICEF Regional Nutrition Dr. Haydar Nasser is the Chief of Health and Dr Khaldoun Al-Asaad is Nutrition Officer with Specialist for UNICEF’s Middle East and Nutrition at UNICEF Syria. UNICEF Syria. Northern Africa (MENA) Regional Office since Muhiadin Abdullahi is Nutrition Specialist with April 2011, based in Jordan. UNICEF Syria.

NB: e opinions expressed in this article are those of the authors and not of the organisations mentioned.

Background Syria is in the fourth year of escalating crisis1 and child feeding (IYCF) practices, poor water sanitation Evolution of the Syria crisis nutrition the impact on the population cannot be overestimated. and hygiene WASH) conditions predisposing to dis- response e humanitarian situation in Syria has deteriorated eases, destruction of health facilities and loss of Positioning of nutrition in the humanitarian significantly since late 2012/early 2013 with an esti- health professional leading to insufficient health response mated 6.5 million people displaced as of October care, among others. ese prevailing factors necessitate e need to establish the nutrition situation of the 2013 (2014 Syria Humanitarian Assistance Response increased attention to nutrition, to prevent any de- affected Syrian population was identified back in Plan – SHARP, Dec 2013) and 2.3 million refugees terioration and nutrition-related deaths. late 2011 following reports of below normal rains by the end of 2013 (Regional Response Plan for in the northern governorate of Syria. However, with ere has been no documented nutrition crisis Syrian Refugees, Dec 2013). On-going conflict, pop- the escalation of the conflict and subsequent limited to date in Syria and the neighbouring countries of ulation displacement, breakdown in social and public access, this initiative could not proceed and was su- Turkey, Iraq, Jordan and Lebanon that are receiving services, intermittent reports of droughts since 2011 perseded by other humanitarian priorities, such as Syrian refugees. However, the ongoing conflict in and disruption of peoples’ livelihoods, have the po- tracking population movement and facilitating pop- Syria and the resultant population displacement ne- tential to have an effect on the health, food security ulation safety, ensuring adequate daily food and cessitates response to address prevailing sub-optimal and eventually on nutritional status of the affected water, etc. With the intensification of the crisis in nutrition issues while developing preparedness plans population. e refugees are hosted in Lebanon, Syria and the neighbouring countries receiving to be able to deliver any critical nutrition responses Jordan, Iraq, Turkey and Egypt. refugees, sectors like water, sanitation and hygiene that may be needed in the future. is involves en- (WASH), health, protection, education and food se- e overall nutrition situation before the crisis hancing capacity for close monitoring of the nutrition curity were identified as priorities back in 2012, was poor with an estimated 23% stunting prevalence, situation for women and children, identifying and with nutrition not featuring prominently. 9.3% wasting and 10.3% underweight2. Exclusive treating cases of acute malnutrition that arise and breastfeeding rates stood at 42.6% while the pro- strengthening preventive interventions like infant Advocacy for nutrition as a first line of intervention portion of newborns introduced to breastfeeding and young child feeding (IYCF) support and mi- and raising its profile nationally was nevertheless within the first hour of birth was 42.2% (SFHS, cronutrient supplementation. It is important to note pursued by UNICEF and other stakeholders. However, 2009). Micronutrient deficiencies have also been that all these countries are categorised as middle ‘selling’ nutrition to the wider humanitarian com- recorded in Syria in the past, presenting risk for income countries (World Bank, 20133). Generally munity was challenging as there was no glaring ‘nu- sub-optimal growth among children, e.g. pre-crisis speaking, nutrition is oen not a priority sector in trition crisis’ (i.e. no severely emaciated children anaemia prevalence among 0-59 month old children some middle income countries and they happen to reported) like in most global emergencies. e only was 29.2% (MOH, nutrition surveillance system have limited emergency nutrition preparedness and official government report on nutrition within Syria4 report 2011), 8.7% Vitamin A deficiency rate (MOH, response capacity; e.g. no government endorsed na- reported a ‘poor’ situation, according to WHO nu- 1998) and 12.9% iodine deficiency prevalence (MOH, tional nutrition guidelines/protocols for both pre- trition situation classification criteria. e 2009 2006). vention and treatment for malnutrition or fully SFHS was viewed by most stakeholders as old data fledged nutrition department with trained nutrition to depict the current situation and therefore not ad- e ongoing crisis in Syria has disrupted peoples’ technical staffs; few, if any, technical nutrition non- daily life, affected their livelihoods, caused displace- governmental organisations (NGOs); limited gov- 1 ment and threatened people’s wellbeing. As this The crisis is associated with violence, attacks on social and ernment budget for nutrition, etc. economic infrastructure and disruption of services. The crisis persists, a considerable proportion of the pop- unilateral economic and financial sanctions have further ulation continues to depend on food aid (channelled is article describes the evolution and status of exacerbated the humanitarian situation (SHARP, Dec 2013, through direct distribution or via cash and voucher the Syria crisis nutrition response and nutrition re- page 14). systems) for survival. Compromises that would have sponse advocacy effort from UNICEF’s perspective 2 Syrian Family Health Survey (SFHS), 2009. 3 http://data.worldbank.org/news/new-country-classifications: impact on nutrition are, however, likely in terms of and provides an overview of UNICEF supported Syria and Egypt are lower Middle Income Countries while dietary diversity and frequency, separation of children regional and national capacity strengthening initiatives Jordan, Iraq and Lebanon are upper Middle Income Countries from caretakers thus affecting infant and young around nutrition in emergencies. 4 Syrian Family Health Survey (SFHS), 2009 ...... 81 Views ...... equate for response planning. Furthermore, the tation on promotion and protection of appropriate proved coverage of appropriate micronutrient absence of any significant caseload of acutely mal- IYCF practices in emergencies. is was used for intervention and promotion of nutrition sensi- nourished children reported during the routine some of the specific targeted advocacy within the tive responses alongside positive behaviour screening in health facilities and the delay in imple- region by some GNC members led by UNICEF, change activities menting the proposed nutrition survey in Syria (a through presentations in meetings, wide sharing of b) Supporting the identification and treatment of nutrition assessment was eventually started in March the comprehensive presentation, and maintaining acutely malnourished cases using internationally 2014) meant that it was difficult to convince many regular contacts. IYCF support and close monitoring approved guidelines and treatment products in the humanitarian community, including some of the nutrition situation through facility based c) Strengthening the nutrition surveillance system donors, of the need to prioritise a nutrition response screening and rapid assessment became the primary through supporting facility based and commu- within Syria. e identified need for preventative nutrition response across the five countries signifi- nity based screening for malnutrition, as well as nutrition interventions (support to IYCF and mi- cantly affected by the Syria crisis. conducting comprehensive nutrition assessments cronutrient interventions, basic capacity strengthening d) Strengthened coordination of the nutrition Overall, these various advocacy efforts have led and associated coordination), in spite of their relevance, response through promotion of the nutrition to some successes in positioning nutrition as one of didn’t trigger much interest at the early stages of nu- sector priority responses (surveillance, IYCF, the sectors to be prioritised in the ongoing human- trition response. micronutrient supplementation and treatment itarian response. of identified malnourished child), and Despite these challenges, nutrition advocacy has Successes from the nutrition advocacy effort e) Supporting integration of nutrition with other continued unabated through building evidence, Nutrition reflected in the Syria Arab Republic’s Hu- sectoral responses. making presentations in various fora, and bilateral manitarian Assistance Response Plan (SHARP): For discussions and sensitisation of strategic partners Nutrition assessment to update nutrition situation: the first time, an independent sector response plan since late 2012. e basic messages communicated Two rounds of nutrition assessments for the refugees for nutrition was introduced in the SHARP (version through this active nutrition advocacy has been 5) document developed in April 2013. is sectoral in Jordan and Lebanon have been accomplished, that though there is no documented evidence of a plan articulates the priority for nutrition sector and i.e. Lebanon Sept 2012 and Nov/Dec 2013 and nutrition crisis as yet, malnutrition and related pre- associated funding needs to allow delivery of a response Jordan Oct/Nov 2012 and April 2014 while a series ventable death can occur should there be a lapse in in the challenging operating environment within Syria of governorate level assessments among IDP children other basic services of water sanitation and hygiene, and in the countries hosting the refugees. e (Syria) in collective shelters are in their final stages in Syria health, food security and other relevant interventions. Regional Response Plans (RRP) draed by the countries (April – Aug 2014). ese new data will complement Hence preventive nutrition activities and capacity hosting Syrian refugees (Iraq, Jordan, Lebanon, Egypt the facility based screening data on weight and strengthening are regarded as paramount to avert and Turkey) do not have an independent nutrition height for children, programme reports and other nutritional deterioration. e need to know what response plan; instead nutrition is integrated in the qualitative information in the consolidation of the infants and young children are eating and the im- health and food security response plans. evidence on the nutrition situation for the Syrians portance of preventing acute malnutrition and stunt- within and outside Syria. ing through an integrated response were some of Nutrition sector established in Syria with Ministry Capacity strengthening initiatives: A series of the strategic messages used in advocating for more of Health (MOH) and UNICEF co-leadership since trainings have been conducted targeting technical resources to be directed towards nutrition in the April 2013: e advocacy for nutrition led to its public health specialists from Syria, Lebanon, Jordan, current emergency. recognition as a critical life-saving sector, in order to facilitate close monitoring of nutrition situation and Iraq, Turkey and Egypt. ese include a number of In the pre-crisis period in Syria, some aspects of evidence building, sector priority setting and sector Nutrition in Emergencies trainings with emphasis IYCF and micronutrient issues (iron deficiency, in specific strategy development, capacity strengthening, on IYCF in emergencies, specific IYCF training and particular) were given some attention through the partnership fostering, nutrition response coverage briefing sessions during coordination, rapid assess- advocacy for food fortification and iron supplements and gaps analysis, etc. Nutrition response coordination ment and community and facility based screening, delivered to mothers through antenatal care services. is currently ongoing and opportunities for integration and full five day sector/cluster coordination training Advocacy for dietary diversity has been maintained with other sectors is being explored and exploited in (see details below). Various United Nations (UN) during the emergency response, with deliberate tar- an effort to protect and promote better nutrition. A agencies and NGOs have also deployed technical geting of children and mothers. Lipid-based Nutrient number of capacity building initiatives (training ses- nutrition staff in the past year to facilitate imple- Supplements (LNS) (Plumpy’doz) and micronutrient sions, sharing of guidelines and technical discussions) mentation of various nutrition related programmes. powders (MNP) have been distributed in Syria and have been organised; a nutrition assessment has been An IYCF in emergencies specialist was deployed by Lebanon while Super Cereal Plus targeting children planned (see below); partnerships have been fostered UNICEF (in collaboration with Save the Children aged 6-23 months and beyond has also been dis- (e.g. UNICEF, WHO and WFP with and the Syrian Jordan) for six months (mid Feb – mid Aug 2014) tributed in Syria and Jordan. UNICEF has been Arab Red Crescent (SARC) and other national NGOs; to support the consolidation of information and procuring some of these products in coordination and a response matrix (4W) has been draed to en- bridging of technical gaps particularly with respect with WFP. Much of the response, coordination and hance coverage and gaps analysis. to IYCF (again, see details below). strategic discussion are held under the auspices of Syria nutrition sector strategy draed and approved UNICEF. Conclusions by the Ministry of Health (MOH) Syria in October In conclusion, although advocacy for nutrition has Further, due to the recognised need for improved 2013: is articulates broad priority response strategies led to a stronger positioning of nutrition within the IYCF related programming in the emergency context, for consideration by the various nutrition stakeholders. overall regional response, much is yet to be accom- the Global Nutrition Cluster (GNC) in collaboration ese include: plished. e established humanitarian coordination with nutrition stakeholders in the Syria, Lebanon, a) Prevention of undernutrition through accelerated structure with nutrition being one of the prioritised Iraq and Jordan compiled a comprehensive presen- promotion of appropriate IYCF, ensuring im- sectors in Syria, building of an evidence base to inform the response, monitoring, as well as response capacity, will need continued investment and support to ensure adequate provision for the treatment of identified malnourished children and to prevent deterioration of the situation. Regional and country capacity strengthening development on nutrition Nutrition related capacity strengthening efforts un- dertaken by the UNICEF Middle East and Northern Africa Regional Office (MENARO), as well as country offices and other nutrition stakeholders, are described below. is capacity strengthening effort has been necessitated by the technical gap existing on nutrition in emergencies in the Syria crisis affected countries, the need to adequately prepare for any possibility for nutrition situation deterioration and the need to NIE training enhance the quality of the ongoing nutrition response...... 82 Views ......

Table 1: MENA RO/NIE training participants, June 2013 conduct a situation analysis of the IYCF-E imple- expertise and experience. ere has been ongoing mentation activities, identify IYCF capacity gaps communication with technical staff involved in pro- Country UN NGO MOH/ Total and provide guidance on IYCF programme imple- gramme implementation (through phone, webinars, Government mentation and progress monitoring. Implementing skype calls) and technical discussion during the co- Jordan 4 6 0 10 partners in Lebanon, Jordan, Iraq, Turkey and Syria ordination meetings. e outlined capacity strength- Iraq 2 0 2 4 have been supported by the IYCF-E specialist in ac- ening effort has been complemented by strategic pre- Syria 5 3 3 11 cessing the appropriate IYCF-E training materials, positioning of essential supplies such as micronutrients, translation of IYCF-E operational guidance for pro- therapeutic and supplementary food supplies, an- Lebanon 3 5 2 10 grammes and in the IYCF-E response monitoring. thropometric equipment and development of infor- Egypt 1 1 0 2 Lebanon IYCF programmes are also benefiting from mation education and communication (IEC) materials Turkey 2 0 2 4 the technical leadership of the National Breastfeeding necessary for the community level training and aware- Committee and the technical expertise of the Inter- ness raising/ social mobilisation. Total 17 15 9 41 participants national Orthodox Christian Charities (IOCC), fa- cilitated through the IOCC partnership with UNICEF Conclusions and in close collaboration with the Ministry of Additional capacity strengthening effort is needed Public Health, Lebanon. In Turkey, special IYCF through on the job training and regular guidance Table 2: Cluster Training Participants and supportive supervision for improved quality of sessions were conducted in the Syrian refugee camps Countries WASH Nutrition intervention. is is an ongoing process that continues targeting women’s groups. ese sessions were con- to be underscored in the various coordination forums Yemen 4 4 ducted in collaboration with the women’s committees in an effort to enhance nutrition programme quality Sudan 2 2 that were organised by UNHCR. e sessions were and quality. Jordan 3 1 conducted in an open forum where women could learn about the importance of exclusive breastfeeding, Syria 8 4 Final reflections by UNICEF timely and adequate complementary feeding and ere is oen an assumed association between a hu- Lebanon 2 1 feeding of non-breastfed infants. In Syria, IYCF-E manitarian crisis and a high global acute malnutrition Palestine 1 0 has been integrated into the CMAM programmes rates with a resultant ‘automatic’ dispatch of Ready Total 20 12 established in various governorates while independent to Use erapeutic Food (RUTF) and Ready to Use IYCF interventions are under development in part- Supplementary Food (RUSF) thus translating into a nership with national partners that are undertaking misinformed response. ere may also be an as- Nutrition in Emergencies (NIE) training (2012 health promotion activities in the county. sumption that a nutrition crisis in a middle income and 2014 country can be responded to by medical staff within To address the existing capacity gap for identifying Assessment and screening the existing health care services, who could at times and treating acutely malnourished children, two re- Aspects of basic nutrition screening have been be without adequate exposure to emergency nutrition gional/multi-country training were organised by covered in the NIE training but additional training response. is necessitates consideration of the UNICEF in Jordan (June 2013) and Lebanon (June on rapid screening using Middle Upper Arm Cir- nutrition response capacity and the health system 2014), followed by additional cascaded training at cumference (MUAC) and height and weight meas- that existed before the crisis in the overall response country level. ese NIE trainings were based on urements, as well as data interpretation, has been planning and actual implementation. On IYCF, the the Global Nutrition Cluster (GNC) endorsed Har- conducted in Jordan, Iraq, Lebanon and Syria. As- need to monitor and prevent distribution of feeding 5 monised Training Package (HTP) with an emphasis sessment teams involved in the recent nutrition as- bottles, facilitation of bottle substitution with cups on IYCF in emergencies (IYCF-E) and screening sessment in Syria have been exposed to the SMART and delivery of related education, may need to be for acute malnutrition at the community level. methodology and the associated task of taking ac- better captured in the existing guidelines. Integration UNICEF MENARO organised the training in June curate anthropometric measurements. A SMART of IYCF-E and CMAM is oen viewed as a new ap- 2013 in Jordan reaching 41 MOH, UN and NGO Survey Manager training for the MENA region was proach that requires a whole set of refresher training public health professionals from Syria, Turkey, successfully conducted between 23rd and 29th – yet it should be viewed as a best practice of dealing Lebanon, Jordan, Iraq and Egypt (See Table 1). August 2014, benefiting 26 public health professionals with situation that need both programme elements. from emergency prone countries in MENA, partic- Countries such as those in the Syria sub-region, need UNHCR conducted NIE training using the same ularly Syria and neighbouring countries. package in December 2012 for their staff and partners to be encouraged to have some contingency measures, in Jordan. In May 2014, UNICEF Turkey conducted Cluster/sector coordination such as capacity, essential nutrition supply in the pipeline, or at least knowledge of the channels through NIE training for NGOs, UN agencies and the Turkish e MENA regional cluster/sector coordination which to obtain these resources and support. Red Crescent, benefiting 25 participants. In June training was conducted between 6th – 10th October 2014, UNICEF Lebanon in partnership with the 2013 targeting the emergency prone countries in e Syria crisis experience has demonstrated that American University of Beirut (AUB) in collaboration the MENA countries, benefiting 12 nutrition/public an occurrence of a humanitarian event does not with the Institute of Child Health of the University health professionals and 20 water and sanitation always translate into an immediate nutrition crisis College of London (UCL) organised a similar NIE technical staff. A deliberate effort was made to but this should not mean that nutrition is automat- conduct this joint nutrition/WASH training to foster training, largely targeting nutrition stakeholders ically relegated to a non-priority sector in the inter-sectoral coordination, which is necessary in from Lebanon and Syria, benefiting 35 participants response planning by agencies and donors. Capacity the prevention of malnutrition. All those trained from UN agencies, NGOs and MOH. strengthening and support to preventive services can be deployed in any of the countries within the are critical. Efforts on regular generation of data, UNICEF, in collaboration with MOH Syria, has region on short notice to support response coordi- even in normal times, are essential to inform ap- facilitated a series of Community based Management nation. e training covered such topics as human- propriate response while existing global guidelines of Acute Malnutrition (CMAM) training activities itarian reform, division of roles and responsibility play an important role in providing guidance to in- for MOH and NGO staff6 from various governorates among different stakeholders in an emergency form the response. Ingenuity will be required to largely focusing on the identification of acutely context, humanitarian programme cycle, collaborative malnourished children, their referral and treatment, leadership, information management, resource mo- ensure that global guidelines are adapted to the as well as the integration of IYCF-E services into bilisation, inter-cluster coordination, systems and needs of contexts such as those in the MENA region. CMAM. is effort aims to ensure reasonable capacity processes necessary for stronger coordination, trans- For more information, contact: James Kingori: exists to trigger an emergency nutrition response in formative agenda, and technical standards/ references [email protected] every governorate, if the need arises or as access in emergency response and partnership. Additional improves. e NIE training materials used in the sector-specific topics were also covered when the 5 Available at: http://www.ennonline.net/resources/htpversion2 June 2013 Jordan training have been translated into two groups (WASH vs Nutrition) were separated to 6 UNICEF, WHO and WHO boosted capacity of over 2000 staff Arabic for use at national and sub-national levels. focus on updating the participants’ technical knowl- from MOH and NGOs in Syria between Jan –October 2014 in edge on nutrition and WASH issues. the fields of CMAM, Infant and Young Child Feeding (IYCF), Infant and Young Child Feeding in health facility screening and rapid assessments emergencies (IYCF-E) General support and supplies 7 The IYCF-E issues addressed included aspects of maternal As described above, IYCF-E has been integrated Relevant guidelines have been provided to various nutrition, early initiation of breastfeeding, exclusive breast- into the NIE training7. In addition, UNICEF, in stakeholders for reference. In addition, distant and feeding, complementary feeding and dealing with non- breastfed children. The emphasis slightly varied depending partnership with Save the Children Jordan (SCJ), on-site support has been provided through field visits on the length of training as it was not fully standardized in the has engaged the services of an IYCF-E specialist to and surge support by persons with specific technical beginning...... 83 People in aid Anon, NorthernAnon, Syria Caroline Abla/IMC, Jordan, 2013 Jordan, Abla/IMC, Caroline

Participants in the NIE training in Jordan in 2012 Clinic staff outside one of the primary health centres in Jarabulus AUB Lebanon. June 2014 Lebanon. AUB

NIE Regional training, Lebanon

84 Invite to submit material to Field Exchange

Many people underestimate the value of their The editorial team at Field Exchange can support Send this and your contact details to: individual field experiences and how sharing you in write-up and help shape your article for Marie McGrath, Sub-editor/Field Exchange, them can benefit others working in the field. At publication. email: [email protected] ENN, we are keen to broaden the scope of Mail to: ENN, 32 Leopold Street, Oxford, OX4 1TW, UK. To get started, just drop us a line. Ideally, send us individuals and agencies that contribute material Tel: +44 (0)1 865 324996 Fax: +44 (0)1 865 597669 (in less than 500 words) your ideas for an article for publication and to continue to reflect current for Field Exchange, and any supporting material, Visit www.ennonline.net to update your mailing details, field activities and experiences in emergency e.g. an agency report. Tell us why you think your to make sure you get your copy of Field Exchange. nutrition. field article would be of particular interest to If you are not the named recipient of this Field Exchange Many of the articles you see in Field Exchange Field Exchange readers. If you know of others copy, keep it or pass it on to someone who you think begin as a few lines in an email or an idea shared who you think should contribute, pass this on – will use it. We’d appreciate if you could let us know of with us. Sometimes they exist as an internal especially to government staff and local NGOs the failed delivery by email: [email protected] report that hasn’t been shared outside an agency. who are underrepresented in our coverage. or by phone/post at the address above.

The Emergency Nutrition Network (ENN) grew out of a series of interagency meetings focusing on food and nutritional aspects of emergencies. The meetings were hosted by UNHCR and attended by a number of UN agencies, NGOs, donors and academics. The Network is the result of a shared commitment to improve knowledge, stimulate learning and provide vital support and encouragement to food and nutrition workers involved in Editorial team Office Support Design emergencies. The ENN officially began operations in November 1996 and has widespread support Jeremy Shoham Thom Banks Orna O’Reilly/ from UN agencies, NGOs, and donor governments. The ENN enables nutrition networking and Marie McGrath Charlotte Roberts Big Cheese Design.com learning to build the evidence base for nutrition programming. Our focus is communities in crisis and Deirdre Handy Clara Ramsay Website where undernutrition is a chronic problem. Our work is guided by what practitioners need to work Carmel Dolan Peter Tevret effectively. Phil Wilks • We capture and exchange experiences of practitioners through our publications and online forum Nathalie Willmott • We undertake research and reviews where evidence is weak Contributors for this issue: Thanks for the • We broker technical discussion where agreement is lacking pictures to: • We support global level leadership and stewardship in nutrition Adeyinka Badejo Kathleen Inglis Afaf Shasha Khaldoun Al-Asaad Ahmad Audi/SC Field Exchange is one of the ENN's core projects. It is produced in print and online three times a year. It Alex Tyler Lea Matasci-Phelippeau Andrew Robinson/Medair is devoted primarily to publishing field level articles and current research and evaluation findings Alison Gardner Leah Campbell Brigitte Breuillac/MSF relevant to the emergency food and nutrition sector. Amelia Reese Masterson Linda Shaker Berbari Caritas The main target audience of the publication are food and nutrition workers involved in emergencies Ann Burton Louisa Seferis Caroline Abla/IMC and those researching this area. The reporting and exchange of field level experiences is central to Anonymous contributors Luigi Achilli Dalia Khamissy/WFP ENN activities. The ENN’s updated strategy (following mid-term review in 2013) is available at Bassem Saadallaoui Lydia de Leeuw Davy Adams/GOAL www.ennonline.net Caroline Abla Lynette Larsen Dina Elkassaby/WFP Caroline Wilkinson Lynn Yoshikawa Dina_El-Kassaby/WFP The Team Christian Lehmann Lynn Yoshikawa Enda Moclair / DRC Jeremy Shoham is Field Exchange Editor Christina Bethke Maartje Hoetjes Frederik Copper/WFP and Marie McGrath is Field Exchange Christopher Weiser Mahmoud Bozo Gabriele Fänder/Medair sub-editor. Jeremy Shoham, Marie Claire Beck Marian Schilperoord Håkon Haugsbø/NCA McGrath, Carmel Dolan and Emily Mates are Technical Directors. Daniel Masterson Marwan I. Al-Hennawy Hanah Kalbouneh/SC Diane Holland Megan Frega Heba Seder/Medair Thom Banks is the ENN’s Chloe Angood is a nutritionist Dima Ousta Melanie Megevand IMC Project Operations Manager working part-time with ENN on a Edgar Luce Misty Buswell J Dumont/WFP based in Oxford. number of projects and supporting Ekram Mustafa El-Huni Muhiadin Abdullahi Jane Howard/WFP Human Resources. Elizabeth Hoff Najwa Rizkallah JHAS Emma Littledike Natasha Harrington L. de Leeuw /Handicap Welcome to Peter Tevret who Clara Ramsay is the ENN’s Finance Farah Asfahani Norwegian Refugee International – HelpAge has joined ENN as Senior Assistant, based in Oxford. Farah El-Zubi Council Jordan Team. International. Finance Manger, based in Fouad M Foua Norwegian Refugee Laure Chadraoui/WFP Oxford. Francesca Battistin Council Lebanon Team. Marco Frattini/WFP Frank Tyler Omar Obeid Margaret Aguirre/IMC Charlotte Roberts is the ENN’s Orna O’ Reilly designs and Gabriele Fänder Pressila Darjani Megan Freya/Medair Operations and Mailing produces all of ENN’s Hala Ghattas Rasmus Egendal Meredith Hutchison/IRC Assistant, based at the ENN's publications. Hala Ghattas Raymond Apthorpe N. Rizkalla/UNICEF office in Oxford. Hala Khudari Rob Drouen NRC Hannah Reed Ruba Ahmad Abu-Taleb NRC Jordan Phil Wilks Hatty Barthorp Saskia van der Kam Peter Biro/IRC (www.fruitysolutions.com) Haydar Nasser Simon Little Pressila Derjany/IOCC manages ENN’s website. Henry Sebuliba Sura Alsamman Relief International Hicham Hassan Susana Moreno Romero Ryan Erickson/IOCC Hisham Khogali Suzanne Mboya Sakah Malkawi/WFP Isabelle Pelly Tara Shoham Sam Tarling Field Exchange supported by: Isabelle Saadeh Feghal Thomas Whitworth Sandy Maroun/WFP Jack Byrne UNHCR Divison of Save the Children James Kingori Programme Management Suzanne Mboya Jamila Karimova & Support, Geneva. Tiziana Cauli/IOCC Jennifer Vargas UNHCR Lebanon Team Volker Schimmel/UNHCR Jo Hammoud Valerie Captier WFP photo library Josephine Ippe Volker Schimmel WHO Julie Davidson Wendy Rhymer Yolanda Romero/ACH Juliette Seguin Yara Romariz Maasri Kate Washington Yves Kim Créac'h A big thanks also to the hundreds of indivduals, too numerous to mention, who 'behind the scenes' contributed to the content of this special edition through conversations with ENN, reviews of colleagues' draft articles and field trip support. Thanks to their agencies for giving their staff licence to write. Cover The main mosque in Harem Town, Idlib Governorate, Northern Syria; Davy Adams/GOAL, Northern Syria, 2013. The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no: 1115156) and a company limited by guarantee and not having a share capital in the UK (company registration no: 4889844). The opinions reflected in Field Exchange articles are those of the authors and Registered address: 32, Leopold Street, Oxford, OX4 1TW, UK. ENN Directors/Trustees: Marie McGrath, Jeremy do not necessarily reflect those of their agency (where applicable). Shoham, Bruce Laurence, Nigel Milway, Victoria Lack, Arabella Duffield...... 85 Emergency Nutrition Network (ENN) 32, Leopold Street, Oxford, OX4 1TW, UK Tel: +44 (0)1 865 324996 Fax: +44 (0)1 865 597669 Email: [email protected] www.ennonline.net