External Evaluation Nutrition Programmes in the Maungdaw and Buthidaung Townships, Northern Rakhine State, Myanmar Funded by ECHO Juan Luis Domínguez-González, May 2012 Photo © ACF Myanmar Th is report is commissioned by Action Against Hunger | ACF International. Th e comments contained herein refl ect the opinions of the Evaluator only. External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar TABLE OF CONTENTS 1 EVALUATION SUMMARY…………………………………………………………………………p.5 2 CONTEXT ANALYSIS………………………………………………………………………………p.7 2.1 Socio-political situation 2.2 A background to the emergency 2.3 Analysis of Malnutrition in NRS 2.4 Project background 3 CONSTRAINTS………………………………………………………………………………………p.18 4 METHODOLOGY…………………………………………………………………………………….p.18 5 FINDINGS……………………………………………………………………………………………..p.21 6 CROSS CUTTING PROCESSES…………………………………………………………………p.34 7 CONCLUSIONS………………………………………………………………………………………p.40 8 TOR CRITERIA………………………………………………………………………………………p.44 9 RECOMMENDATIONS…………………………………………………………………………….p.49 10 ANNEXES i. ToR ACF Nutrition Evaluation NRS Myanmar (final) ii. Bibliography iii. Project Logical Framework iv. Best Practice v. Itinerary Minutes vi. Map of MGD, BTD & RTD townships vii. Map of NRS - Buthidaung Township viii. Northern Rakhine State Map Evaluation report ACF Myanmar / Mar-Apr 2012 2/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar List of Acronyms ACF Action contre la Faim BTG Buttidaung HOM Head of Mission CCT Community Caretaker CMAM Community-based Management of Acute Malnutrition CP Care Practices ECHO European Commission Humanitarian Office GAM Global Acute Malnutrition GOUM Government of the Union of Myanmar GOW Gain of Weight HD Health Department HO Head Office IEC Information, Education and Communication INGO International Non-Governmental Organisation KAP Knowledge, Attitudes, Practices LOS Length of Stay MAM Moderate Acute Malnutrition MCH Maternal and Child Health MGD Maungdaw MNTN Myanmar Nutrition Technical Network MSFH Médecins sans Frontières - Holland MOH Ministry of Health MOU Memorandum of Understanding MUAC Middle Upper Arm Circumference PHC Primary Health Care PM Programme Manager RHC Rural Health Centre RHSC Rural Health Sub-centre SAM Severe Acute Malnutrition SC-UK Save the Children-UK SCCT Super Community Caretaker TBA Traditional Birth Attendant TL Team Leader UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WFP World Food Programme WHO World Health Organisation W/H Weight per Height W/A Weight per Age Evaluation report ACF Myanmar / Mar-Apr 2012 3/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar FOREWORDS This report would not have been possible without the support and encouragement of- fered by ACF in Myanmar and in London. I would like to thank ACF teams both in Yangon, in London, and in Maungdaw, Buttidaung and Sittway for all the help they have eagerly given to me, and their efforts to make me feel almost at home. I have felt very much looked after in every place I have been. I would especially like to thank ACF national staff for their hard work, their enthusiasm, their openness and their unflagging kindness and support. It happens not very often that a completely alien person finds such warm and unfaltering hospitality when visiting remote places where very committed people struggle to give the best of their skills to those in dire need. It was worth the effort to visit and share with them a much-deserved break in their daily tasks and some quiet talk. Special thanks, too, to interpreter Rezaul Mustafa for his accuracy in translating, his inde- fatigable devotion to his job, his hospitality in Buttidaung, and for the good moments I had when travelling with him. Evaluation report ACF Myanmar / Mar-Apr 2012 4/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar 1 EVALUATION SUMMARY CONTEXT ANALYSIS SOCIOPOLITICAL SITUATION Since taking up office, President Thein Sein has moved quickly to begin implementing his am- bitious reform agenda. A series of important economic, political and human rights reforms were being enacted. A release of political detainees was enforced, although some ‘die-hards’ were still kept in prison. The president reached out to government critics, including Aung San Suu Kyi and the ethnic minorities. In April 1st by-elections the National League for Democracy, won by a landslide in most states, granting her and many of her party members a seat in the new parliament. Its leader Daw Aung San Suu Kyi, the democracy advocate silenced for two decades by Myanmar’s generals with house arrests and overturned elections, assumed a new role in her country’s political transition, ap- parently winning a seat in Parliament to make the remarkable shift from dissident to lawmaker. The president gives every indication of having the political will to put Myanmar on a new path. Yet, success will be neither quick nor straightforward. Experience from elsewhere shows that the chal- lenges of transforming a country emerging from decades of ethnic conflict and authoritarianism are massive, and it is important that this be recognised in the Myanmar context. A BACKGROUND TO THE EMERGENCY The Muslim Rakhine reintegration conditions remain unsolved until today; the population is still in a constant state of precariousness and vulnerability under the tight control of the army, the MI, the border police and other groups. The level of economic development is very low, structural invest- ments are insignificant and health services poor to non-existent. Policies of exclusion and discrimination imposed on the Rohingyas by successive Burmese mili- tary regimes have prevented them from developing socially and economically, and it seems that they were deliberately designed to encourage departure to Bangladesh. ANALYSIS OF MALNUTRITION IN NRS According to ACF’s tree problem and the majority of anthropometric nutrition surveys re- viewed, which most stakeholders also seem to agree to, the main factors associated to children mal- nutrition in NRS are: a) High morbidity rates b) Poor care, nutrition, and hygiene and child care practices c) Cultural, traditional and religious behavioural patterns. d) Lack of access to food at household level. PROJECT BACKGROUND i. ACF started a nutritional programme in the NRS in 2003 after a need assessment showed that the level of malnutrition in the area justified a nutritional intervention, though it was present in the Northern Rakhine State since 1993. ii. The objective of the 2003 nutritional programme of ACF in the area was to provide nutrition assis- tance to under-five years old children and women suffering from acute malnutrition. iii. ACF nutrition programme in NRS has been carried out through the activities of two Stabilisations Centres (SC) located in Maungdaw (MGD) and Buttidaung (BTD), where both children with severe acute malnutrition (SAM) who also had medical complications, and all under-6 months old children are being treated. There are six outpatient therapeutic Programme (OTP) centres where both SAM children without medical complications and moderate acute malnourished (MAM) children are treated. iv. Next to each of the two SCs, there is a Mother Participation Centre (MPC) where SAM and MAM children who show a static weight gain in both SCs and OTPs, are sent. The CP delivers psycho- logical support to both mothers and babies. v. Community Awareness is being conducted by community-chosen volunteers. Evaluation report ACF Myanmar / Mar-Apr 2012 5/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar METHODOLOGY According to DAC criteria, relevance”, “coherence”, “coverage”, “efficiency”, “effectiveness”, “accepta- bility”, “access”, “equity”, “sustainability” and “accountability” were assessed. CONCLUSIONS 1. Extraordinary good and solid job: very effective work in the field and extremely committed staff. Without any central or local institutional backstopping ACF was able to construct a full conceptual and operational structure to treat malnutrition in NRS – together with a comprehensive nutrition information system. 2. ACF also developed a huge system of community-oriented activities, aiming at meeting the acute needs perceived in care practices, health education, community awareness, mental health wellbe- ing, etc. 3. Global and Moderate Acute Malnutrition rates overtime seem to resist all efforts made to appease them, revealing a structural situation of undernourishment with an invariable size of vulnerable children recurrently getting within and without acute malnutrition episodes. 4. It is debatable that a closer relationship with the MOH would have rendered better outcomes that those obtained by ACF on its own. 5. The lack of adequate references from the clearly unsatisfactory and poorly developed MOH healthcare network gave very little other choice to ACF than developing a network of its own to tackle severe and moderate acute malnutrition. 6. The chronic malnutrition rates of women of childbearing age in the area, is not being addressed. 7. ACF still mistakes in its reports community-based with community-oriented, and that confusion may hamper its strategies.. 8. Gender seems to having not been a constant concern in ACF nutrition projects. Only recently clas- sical rules of gender disaggregation were incorporated. 9. There seems to