MSF Holland Afghanistan Evaluation Internal use only MSF Holland in Afghanistan Mission Evaluation: May 2000-May 2002 Fiona O’Reilly & Jeremy Shoham 1 MSF Holland Afghanistan Evaluation Internal use only Table of Contents Summary 4 1. The Evaluation 7 1.1 Purpose 7 1.2 Methodology 7 1.3 The structure of this report 7 2. Overview 8 2.1 Food security, nutrition and health 8 2.2 Severe drought 8 2.3 WFP VAM assessment 9 2.4 UN appeal for 7.5 million “hungry” Afghans 9 2.5 Low levels of acute malnutrition 10 3. MSF Holland: changes in approach over time 13 3.1 From the rural areas to the cities 13 3.2 Drought response 13 3.3 Reducing Humanitarian space 13 3.4 Monitoring effects of the Drought 14 3.5 September 11th 14 3.6 Re-entry post September 11th 14 3.7 Monitoring Repatriation 15 4. Programmes Ongoing at start of Period evaluated (May 2002) 16 4.1 Western Districts Primary Heal Care programme (PHC) 16 4.1.1 Conclusion 16 4.2 Emergency Preparedness and Response (EPR) Kandahar 19 4.2.1Early Warning System 19 4.2.2 Infectious Disease Ward (IDW) 20 4.2.3 Conclusion 21 4.3 Bala Morgab, Badghis, PHC 22 4.3.1 Conclusions 22 5. Programmes started in 2000-2001 24 5.1 Emergency Drought Response 24 5.1.1 Incorporated nutritional surveillance activities 24 Food Crisis Monitoring 25 MUAC monitoring 25 Conclusions 27 5.1.2 SFCs in selected communities 28 Conclusions 31 5.1.3 Blanket Feeding Distribution 31 Conclusion 33 5.1.4 Mass measles campaign 33 5.1.5 EDR Conclusion 34 5.2 MSF in Internally Displaced Persons (IDPs) Camps 35 5.2.1 Shaidai 35 5.2.2 Maslakh camp 35 Surveys 37 Advocacy 38 Conclusion Shaidai and Maslakh 39 2 MSF Holland Afghanistan Evaluation Internal use only 5.3 MSF's involvement in the Paediatric Ward, Herat 40 5.3.1 Regional Therapeutic Feeding Centre (RTFC) 41 5.3.2 Conclusions 43 6. Period September to November 2001 44 6.1 Evacuation 44 6.2 Regional Approach 44 6.3 Conclusions 45 7. Programmes Started 2002 46 7.1 Emergency support to PHC in Badghis Province 46 7.1.1 Conclusion 46 7.2 Repatriation of Returnees 47 7.2.1 Conclusions 47 7.3 Chaman and Spin Boldak camps 48 7.3.1 Advocacy and co-ordination 48 7.3.2 Conclusions 49 8. Advocacy 48 8.1 Conclusions 51 9. MUAC versus Weight for height 53 9.1 Conclusions 55 10. Cross cutting Conclusions and Recommendations 56 10.1 Cross cutting Conclusions 56 10.1.1 Appropriateness of response 56 10.1.2 Assessment and analysis 56 10.1.3 Programmes serving multiple purposes 57 10.1.4 Approach to implementation in an ongoing crisis 57 10.1.5 Decision Making Process 57 10.1.6 Health programmes 58 10.1.7 Nutrition programmes 58 10.1.8 Programme closure 58 10.1.9 Advocacy 59 10.2 Recommendations 60 10.2.1 MSF General 60 10.2.3 MSF Nutrition Division 61 10.2.4 MSF Health Division 61 10.2.3 MSF Context /Advocacy 62 10.2.4 MSF Afghanistan Programme 62 3 MSF Holland Afghanistan Evaluation Internal use only Summary Purpose This report is an evaluation of MSF activities in Afghanistan between May 2000 and May 2002. These activities have mainly comprised nutritional and health programmes. The evaluation set out to i) understand MSF’s role in Afghanistan and how MSF adapted nutritional and health programmes in a rapidly changing political and operational context in the cultural setting of Afghanistan ii) examine how MSF used its proximity in the region to witness violations of humanitarian principles and law and how MSF positioned itself in its advocacy work. Methods Two external consultants with backgrounds in nutrition and health undertook the evaluation. MSF Headquarters staff briefed the consultants at the start of the evaluation. Field work took place in to Kabul, Herat and Kandahar where interviews were carried out with MSF project staff , personnel from INGOs, local NGOs, UN agencies, and MoPH staff. The consultants also attended a regional workshop in Ashgabad and a medical co-ordination day in Amsterdam. Phone interviews were conducted with staff in Quetta, Pakistan while a number of MSF staff no longer involved in the programme were interviewed in London and Amsterdam. A large volume of documentation and email correspondence was reviewed. Limitations included lack of a central repository for reports and information on the programme which meant that the consultants had to sift through scores of documents to find key information. At field level much information was lost or misplaced during the evacuation. The high staff turn over meant that most MSF international staff connected to the programme over the time period in question were no longer in Afghanistan at the time of the field visit nor were many key personnel from other INGOs and UN agencies present during the period under question. Attempts have been made to counter the effects of these limitations through accessing key personnel through other means (e.g. co-days interviews, telephone interviews, email questionnaire). However the result has been that some MSF projects are reviewed more comprehensively than others reflecting the amount and quality of information available. Where indicators for effectiveness are available they have been assessed against accepted technical standards. Where such data were not available projects have been judged on the basis of ‘impressions’ as to whether objectives and intended outcomes were achieved. Findings In view of the extremely difficult working environment in Afghanistan over the period evaluated MSF’s achievements have been impressive. MSF was involved in three provinces of Afghanistan, Badghis Herat and Kandahar. Programmes included, hospital based medical activities, emergency health and nutrition services in displaced and refugee settings and transit sites and an early warning system in sentinel sites in Kandahar. Nutritional activities included food security assessment nutritional surveillance as well as blanket and selective feeding programmes. During the period in question MSF responded to disease outbreaks swiftly and effectively, implemented thoughtful and comprehensive primary health care programmes and vaccinated thousands of children against measles. Within a context of the appalling health status of women and children and poor access to basic health facilities in Afghanistan, the focus of MSF’s operational activities was affected by what the Taliban would allow, security , a developing drought induced food crisis, lack of reliable information and how MSF perceived its role (i.e. whether it should focus on needs arising out of crisis, human rights monitoring, or health needs of the most vulnerable). In the event over the time period in question focus changed from improving health care access in rural areas to focusing on health needs in cities and eventually to safe motherhood in remote areas. The constraints under which MSF operated cannot be over stated. MSF’s primary analysis of the impact of the drought was in keeping with many other agencies, i.e. that there was a developing food crisis, which required emergency food and nutrition interventions. 4 MSF Holland Afghanistan Evaluation Internal use only Although MSF’s perception was that a General Food Distribution (GFD) was the most appropriate response, staff were conflicted about whether MSF should take on an implementing role. Ultimately the decision was taken (based on many factors and previous experience) that MSF would not ‘do’ GFDs. MSF therefor focused on advocating for a GFD and later implemented Blanket Food Distributions (BFDs) as stop gap measures. MSF implemented traditional emergency feeding programmes in a number of open settings partially to collect data which would be useful in advocacy but also to prevent severe malnutrition. However, there was limited evidence of alarming malnutrition prevalence and traditional feeding programmes were found to be inappropriate to the cultural setting eventually these were either discontinued or adapted (e.g. mobile SFP). Thorough investigation of outcomes in terms of malnutrition and mortality was not rigorously undertaken by MSF largely due to the constraints and limitations imposed by the authorities as well as cultural factors and the harsh climate. However where other agencies managed to undertake thorough representative investigation mortality was found to be high and related to disease while levels of malnutrition were lower than expected in the context of a food crisis. There was a considerable need within Afghanistan for credible information on how the drought was impacting the health and nutrition of the population. As a health agency with historical capacity in nutrition MSF have capitalised more on their comparative advantage in the health sector by analysing and highlighting the health component of the crisis and by focussing their interventions more fully on the health sector, i.e. investing more resources in further strengthening and expanding health programmes (EPR and PHC) and integrating nutrition components (where necessary) into these health programmes. Also MSF was well placed in the regional paediatric ward to strengthen and support health information systems and analysis and strengthen links in referring clinics, however this was not done. Given MSFs current core competencies, this may have been a better option than focussing on a sector (food aid) where MSF were dependent upon the commitment and response capacity of other agencies. This does not negate the validity of advocacy actions to improve food aid. MSF placed too much confidence in rapid MUAC assessments which it saw as a viable alternative to weight for height surveys. Similar prevalences of Global Acute Malnutrition (GAM)were not identified in a limited number of surveys reviewed where both indicators were measured.