Dfid Nigeriahumanitarian Programme

DFID NIGERIAHUMANITARIAN PROGRAMME

BASIC NUTRITION COMPONENT

ANNEX AND PROPOSAL TO SCALE-UP “INTEGRATED BASIC NUTRITION RESPONSE TO THE HUMANITARIAN CRISIS IN BORNO AND YOBE INCLUDING MULTI-SECTORAL PILOT” FOR THE PERIOD JULY 1, 2017 TO MARCH 31, 2019

Project summary
Through an integrated approach, a consortium of three partners - Action Against Hunger, United Nations Children’s Fund (UNICEF) and United Nations World Food Programme (WFP)- will address basic nutritional needs and strengthen the food security of vulnerable populations in selected Local Government Areas (LGAs) in Borno and Yobestates. The project willinclude multi-sectoral pilot including WASH, early child care and developmentas well as livelihood activities in the identified pilot LGAs. This will build on the results achieved in the implementation of the Integrated Basic Nutrition Response to thehumanitarian crisis in Borno and Yobe (INP).
In Yobe state, Action Against Hunger will scale up present implementation in addition to deepening existing INP interventions in Nangere, Tarmuwa and Gujba LGAs. In Borno state, UNICEF and WFP will sustain integrated basic nutrition interventions in three(3) LGAs - Jere, Konduga and Maiduguri Metropolitan City (MMC). In addition, UNICEF will scale up nutrition interventions in three (3) southern Borno LGAs currently supported by INP (Biu, Bayo and Kwaya Kusar)and will also expand to two (2) additional LGAs–Hawul and Askira Uba. For the multi-sectoral pilots, two intervention locations with varied intervention packages are proposed: a Nutrition, Health, Water,Sanitation and Hygiene (WASH), food security and livelihood (FSL) and Social Protection package in Nangere LGA in Yobe state and a Nutrition, Health, WASH, FSL, Social Protection, Child Protection and Education package in Shani LGA in Borno state.
Interventions proposed for implementation for the period of July 1, 2017 to March 31, 2019 include existing INP interventions aimed at addressing basic nutritional needs through maternal dietary supplementation, micronutrient supplementation, breastfeeding and complementary feeding promotion, dietary supplementation for children, treatment of severe acute malnutrition, LLIN distribution as well as cash–based transfers to pregnant and lactating women (including caregivers of children below 2 years of age). In addition, other nutrition sensitive interventions such asfood security and livelihoods, social protection, WASH, Education (Early child care and development), child protection and women empowermentare planned for implementation in the LGAs selected for the multi-sectoral pilot[1].
The implementing partners will facilitate and coordinate the project implementation with other humanitarian organizations and the relevant ministries at the federal and state levels (Borno and Yobe).
Project start / end date
July 1, 2017 – March 31, 2019
Total budget for scale up
£33.5m(thirty three million five hundred thousand UK pounds)
Total budget per partner
Action Against Hunger = £8,000,000.00; UNICEF =£14,104,701.00; WFP = £16,602,179.00
Geographic area of implementation
Borno and Yobe States
Context
1. What is your assessment of the humanitarian emergency and how it is likely to develop during the scale-up period? What has changed over the past year, since the INP began? How has your operational presence in the north east changed during this period??
Years of insurgency and counterinsurgency in the North Eastern Region of Nigeria have resulted in widespread forced displacement, violation of international humanitarian and human rights law, severe protection concerns and a growing food and nutrition crisis of global proportion.[2]Since the commencement of INP, gains have been made by the Nigerian military which has led to improved humanitarian access to previously inaccessible areas, exposing high needs and poor nutritional indicators. However, despite the improved access to main towns and many of the villages in Adamawa, Borno and Yobe, the population of internally displaced persons (IDPs) remains high - averaging 1.8 million IDPs over one year of INP implementation - and access to areas beyond military operation territory remains limited. As of March 2017, over 1.83 million people are internally displaced in the region with foodbeing the predominant unmet need of most (69 per cent) of the IDPs (IOM DTM Round XV, March 2017).
Currently, 5.2 million people in the three states (Borno, Yobe and Adamawa) most affected by the crisis are in critical food insecurity situations (crisis, emergency and famine); of these, about 50,000 are believed to be in afamine situation and if adequate and timely remedial measures are not provided,the crisis is expected to worsen (Cadre Harmonise, March 2017). Agricultural production has fallen and security measures such as a ban on the cultivation of tall crops, road closures, controls on fertilizer and fuels, and curfews continue to negatively impact food security. Many livelihoods have been disrupted by the crisis and farming has particularly been affected as farmers are unable to access and cultivate their farmlands due to security threats. To compound this, the 2017 lean season started earlier, in April–May instead of July, and is therefore expected to last longer than usual, with farmers thus unable to cultivate the land (ACAPS, April 2017).Extremely high staple food prices limit the purchasing power of vulnerable households in the North East and food prices,particularly cereals in North Eastern markets,were reported to be 70-124 per cent higher in January 2017 than the year before (FEWS NET, February 2017). This has placed the IDP population and their host communities (who are among the world’s poorest) under continued survival stress and dependence on humanitarian assistance for basic services such as food, health, WASH and others.
It is estimated that approximately 450,000 children under the age of five will suffer from severe acute malnutrition across the three states in 2017, and without treatment, one in five of them will die.1The poor nutrition and food security situation in Borno and Yobe states is rendered more precarious in light of recent disease outbreaks in the North East, with reported cases of cholera and meningitis, and the incidence of disease is likely to increase due to the living conditions in some camps and host communities (Health Sector, March 2017).
In response to the high level of need as well as the newly accessible areas, the three consortium partners have increased their operational presence in the North East especially in Borno and Yobe states. Action Against Hunger has scaled up its response and is now delivering assistance in 12 of the 17 LGAs of Yobe. This service expansion was made possible in part by the introduction of a Regional Coordination team providing technical expertise on the ground. Similarly, UNICEF has operational presence with national and international experts in the states presently supporting nutrition interventions in eight accessible LGAs in Yobe states and in 23 out of the 27 LGAs of Borno state and this has greatly helped in the scaling up humanitarian interventions in the newly accessible LGAs. WFP is providing food assistance (in-kind food and cash-based transfers) at scale in the NorthEast. Over the past months, over 1 million people have been reached each month (i.e., 1.2 million people in March 2017). Blanket supplementary feeding is also provided to children aged 6-59 months old, pregnant and lactating women (PLW) (i.e., 374,000 children and PLW reached in May 2017).In Borno State, WFP is currently operating in 15 LGAs.
Food Security, Nutrition, WASH and resilience strengthening interventions arecritical for these vulnerable populations. While INP focused mainly on provision of life-saving interventions in humanitarian operations, this INP scale up and multisectoral pilot emphasizes preventive interventions to effectively address malnutrition and serve as a bridgebetween the humanitarian phase and development.
Needs and gaps analysis
2. What isthe need (the problem) thatthe programme will address? What assessment and analysis of needs and gaps have been carried out?
The increased scale of humanitarian assistance in the North East has contributed to the improvement of nutrition outcomes in the region as evidenced by results from recent nutrition and food security surveillanceexercises, which suggestsa decline in prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM),especially in Borno state. However, the risk of deterioration remains high as a result of lost livelihoods, the high proportion of women and children IDPs and limited market activity. Food and nutrition security as well as access to essential primary health care services remain challenging especially in areas where several facilities were destroyed. The primary livelihood activity cited in Nangere LGA was farming. With the lean season starting earlier and limited access to fertilizer and insecticides, harvests now last a household only 3-4 months, restricting livelihoods and forcing many households to adopt one or more coping mechanisms.
Rapid SMART surveys conducted in the INP- supported LGAs of Yobe state revealed high GAM rates – Nangere (GAM - 14.6 per cent; SAM - 2.6 per cent; Tarmuwa (GAM - 11.8 per cent; SAM 2.2 per cent); and Gujba (GAM - 16.7 per cent; SAM 4.6 per cent). A baseline Knowledge, Attitude and Practices (KAP) survey on Infant and Young Child Feeding (IYCF) practices conducted in Yobe state in August 2016 also showed low adoption of IYCF practices. For instance, the Exclusive Breastfeeding (EBF) rate was found to be 30 per cent with only 49 per cent of the sampled children being put to breast within an hour of birth. These results indicate GAM and SAM rates above emergency thresholds necessitating the need to sustain and scale up interventions and the need to support improving IYCF and, in particular, breastfeeding practices.
Preliminary results of a Link Nutrition Causal Analysis (NCA) conducted in Nangere LGA by Action Against Hunger identified twelve risk factors of chronic and acute under-nutrition including breastfeeding practices, inadequate access to safe drinking water and inadequate sanitation practices. The Link NCA also recorded that households with an average size of about eight persons had only 60 litres of water per day instead of the necessary 120 litres/day. The study also reported that weak hygiene practices associated with the storage and management of water were observed in the households and that animal or human excreta was present in 78.3 per cent of households surveyed, indicating the need for increased WASH interventions.
In Nigeria, micronutrient deficiency among pregnant and lactating women (PLW) is considered a public health concern (NDHS 2013). The analyses reported in the 2013 Lancet Series further confirmed that anaemia is a risk factor for maternal deaths due to haemorrhage. This is a leading cause of maternal deaths (23 per cent of total deaths). In addition, there is sound evidence that calcium deficiency increases the risk of pre-eclampsia, the second leading cause of maternal deaths (19 per cent of total deaths). Therefore, addressing these two deficiencies could greatly impact the overall well-being of pregnant women and invariably, the health and well–being of an unborn child.
In greater Maiduguri (MMC, Jere and Konduga LGAs), where a high number of displaced persons are hosted, several health facilities have been rehabilitated and restored with support from UNICEF, IRC and other partners. In Southern Borno, few health facilities have been rehabilitated, and health services are being provided from temporary community structures. Though this has made it possible to provide primary health care services to vulnerable populations, health seeking behaviour remains poor. Due to transportation costs, in areas more than 5 km away from a health centre in Nangere LGA (Yobe), women seek out traditional doctors prior to seeking help at a health facility and 46 per cent of caregiver respondents indicated the primary barrier to going to a health facility when their child falls ill is money (Link NCA results); similar behaviour is expected to be observed in Borno state. It is therefore necessary to scale up nutrition services integrated to other social services that can improve the nutrition status of the population and help increase health seeking behaviour.
There are a number of humanitarian organizations supporting Nutrition, Health, WASH, FSL and other interventions in the three supported LGAs in Central Borno - Jere, Konduga and MMC, conversely, supported LGAs in Yobe state and Southern Borno have lesser number of humanitarian actors. In Yobe, only Action Against Hunger is providing support in Nangere and Tarmua LGAs but in Gujba LGA, in addition to the nutrition and WASH support provided by Action Against Hunger, immunization, nutrition outreach services, WASH and food assistance are supported by WHO, UNICEF and WFP respectively. ICRC has also constructed a new health facility in LGA though the facility is yet to be handed over to the government hence no health services are provided. In Southern Borno, of the over 60 organizations intervening in Borno state, only UNICEF and the state government are supporting nutrition interventions in the proposed LGAs of Biu, Kwaya Kusar, Bayo, Askira Uba and Hawul; In Shani LGA – only FHI360 and UNICEF provides some support on Health while IRC and UNHCR supports some protection interventions. WASH kits are also distributed to SAM children at the time of admission to promote water sanitation and hygiene (WASH) practices in some of the LGAs in central Borno. Nevertheless, this is not happening in the health facilities in Southern Borno.
According to health facility assessments conducted by Action Against Hunger in the 3 LGAs, prior to implementation of INP, the delivery of health and nutrition services at existing health centres was poor; almost none of the staff had received training on maternal and child nutrition, especially in the areas of IYCF, CMAM/SAM, & IMNCI (Health Facility Assessment in 2 LGAs, June 2016 & Rapid Health Facility Assessment in Gujba, July 2016). In the first year of the INP, improvements to service delivery have been made as OTP services are now operational at 29 supported facilities with the government providing the staffing, however, the staffing is inadequate for the caseload. These facilities are also supported by community volunteers who help create linkages with the community, nevertheless, lessons learnt from the implementation of INP shows a strong need to further strengthen the community structures in order to mobilize caregivers of children with SAM and to also support facility structures by increasing the number of trained health workers for the provision of integrated nutrition services.
In Borno and Yobe states, INP has been providing nutrition specific interventions (treatment of SAM, provision of IYCF messages to caregivers of under 2 and micronutrient supplementation to children under 2 and PLW) and a cash–based transfer component targeting vulnerable households with severely malnourished children who have been enrolled in nutrition programme. Currently, with the support of donors, children below 5 years and pregnant and lactating women (PLW) are receiving blanket supplementary feeding in some of the wards in selected LGAs in Central and Northern Borno. However,when compared to the number in need, more needs to be done. It is essential to scale up the provision of blanket supplementary food support to PLWs to help prevent malnutrition within the first 1,000 days of life.
With the overall aim of reducing severe child malnutrition through improving quality and increasing coverage of basic nutrition services and reducing household food insecurity,the interventions being proposed will include a scale up of current activities and an introduction of a multisectoral pilot in supported LGAs of Borno and Yobe states. In collaboration with the relevant government ministries and agencies, the project will be jointly implemented by a consortium of three partners – Action Against Hunger,UNICEF and WFP - and will ensure the delivery of a package of interventions, both nutrition specific and nutrition sensitive that would contribute to improved nutrition outcomes as well as facilitate access to primary health care services through promotion and education of importance of Antenatal Care (ANC), Postnatal Care(PNC), treatment of childhood illnesses and related child health services such as routine immunization and vitamin A supplementation.
Proposed interventions and capacity to deliver
3. What is the proposed form of assistance? What activities will be undertaken?
INP Scale Up activities
The partners will scale up ongoing INP–supported activities in Borno and Yobe states. Activities will be scaled up in the three (3) LGAs - Nangere, Tarmuwa and Gujba - currently supported by INP in Yobe. Borno state services will be scaled up in six (6) LGAs – Jere, Konduga, MMC, Biu, Bayo and Kwaya Kusar - currently supported by INP and also expanded to two additional LGAs – Askira Uba and Hawul.
The proposed scale-up key activities to be undertaken include but are not limited to the following:

• Capacity building in coordination for Government:Government at national and state levels will be supported in planning, coordinating, implementing, monitoring and reporting on the nutrition in humanitarian response.
• Capacity strengthening for Skilled Health Workers and Community Volunteers/Mobilizersto strengthen service delivery: Health workers and community volunteers (CVs)/mobilizers (CMs) in existing supported health facilities and those in facilities where the project will expand will be trained and mentored on requisite themes- CMAM, IYCF and hygiene practices, MNP etc.