DRAFT
Short Term Consultancy in Support of Countries Affected by the Southern Africa Humanitarian Crisis
15 October-25 November, 2002
Zimbabwe
Ms Albertien van der Veen
Consultant
Emergency and Humanitarian Action
November 2002
World Health Organization
Index Page
I. Introduction 2
II. Nutrition Assessments 3
III Surveillance 5
IV Response 6
Feeding programmes 6
General Food Distribution 8
Health Considerations 10
IV Possible Role WHO 10
Annex 1 Nutrition Assessments
Annex 2 Background to the VAC
Annex 3 Supplementary Feeding Programmes
Annex 4 WFP Implementing Partners
I Introduction
1. In view of the humanitarian crisis in Southern Africa the WHO inter-country office in Harare, Zimbabwe, is being strengthened with a nutritionist in order to support affected countries in the region. Prior to longer-term recruitment of a suitable candidate the post was filled for an interim period of 6 weeks
2. Main tasks to be performed were the following:
· Compile sub-regional data from the various recent rapid assessments undertaken in the countries affected and complement, if necessary with field visits
· Provide support to countries concerned to complete the nutritional surveys, monitor the nutritional situation and its health implications and devise operational strategies for response and intervention
· In close collaboration with all actors, elaborate a map on “who is doing what and where” and organize information exchange and co-ordination meetings among partners
· In close cooperation with country teams and major partners identify and agree on a set of indicators to be monitored in the sub-region
· Provide summarized and regular information of the nutrition situation to the WHO information officer in the UN Regional Office for Southern Africa Crisis in Johannesburg
3. In the absence of an EHA focal point in Zimbabwe (and the national ERP officer[1] assigned to South Africa), several tasks were undertaken in Zimbabwe that normally would fall to the EHA focal point, such as liasing with donors –in close co-operation with the national HARP co-ordinator and IMCI regional focal point–, (assisting with the) writing of proposals and attending inter-agency meetings.
4. Contacts were established with the MOHCW at the start of the mission during which WHO offered the Nutrition Unit of the MOHCW assistance in further analysis of nutrition data. The Nutrition Unit, welcoming this offer, could not however during the envisaged period make available the responsible counterpart, crucial in providing back-ground information on the survey, the raw data and for further strengthening capacity.
5. Two field missions were undertaken to some of the worst affected districts, in terms of malnutrition and food insecurity, located in Mashonaland Central Province in order to complement data gathered at Harare level.
6. This report serves to summarise main findings regarding the food and nutrition situation, response to date and the need to strengthen linkages with health. Particular consideration is given to the need for a pro-active data gathering by WHO, in particular through surveillance, and WHO’s possible role in strengthening capacity in surveillance and assessments.
II Nutrition Assessments
7. Two countrywide nutrition assessments have been carried out in Zimbabwe this year. In addition a number of (I)NGOs carried out nutrition surveys in their areas of operation. These include SCF (UK), World Vision (WVI), CARE, MSF Spain and CAFOD. Some rapid MUAC surveys were also carried out but results are not publicly available. Main results (and previous references) are summarised in Annex 1.
8. A countrywide survey carried out by MOHCW/UNICEF in May 2002, revealed a prevalence of global acute malnutrition of 6.4% (with severe malnutrition rating 1.4%). By comparison, two countrywide surveys carried out in 1999 revealed malnutrition rates of 6.0% and 6.3% respectively. Because confidence intervals of all three surveys overlap, there is no reason to assume that the overall prevalence of global malnutrition in May 2002 differed from the prevalence in 1999.
9. The May 2002 survey does show however, that there are significant differences between provinces on the one hand and between the two major urban areas (Harare and Bulawayo) and the rural areas on the other hand. Global acute malnutrition rates in the provinces ranged from 2.8% in Masvingo Province to 10.0% in Midlands (please refer to annex I for details). Because sample size and survey design of the 1999 surveys do not allow for a break-down of the results per province, it is impossible to say whether the situation at provincial level has (significantly) changed.
10. Other data collected in the MOHCW/UNICEF survey included mortality, morbidity, household demographics and food security. These data have been only partly analysed and cross tabulation with anthropometrical data remains to be done, in the absence of sufficient human resource capacity within the Nutrition Unit. Because this information is crucial in understanding nutrition vulnerability, developing appropriate response and setting priorities, the need to assist in further analysis as soon as possible remains.
11. The second countrywide survey was carried out in August 2002, as part of the national vulnerability assessment, the Zimbabwe VAC assessment (please refer to annex 2 for background information on VAC). This survey revealed 7.3% global acute malnutrition. Due to the fact that a different sampling method was used[2], results cannot be readily compared. More seriously, in reviewing the assessment the VAC Nutrition and Health subcommittee in its recent meeting, identified the following critical issues:
· unclear child selection (in any case inconsistent)
· doubtful quality of the anthropometrical data due to use of inaccurate the equipment
· no cross-checking of data by team-leaders on a daily basis
· no discussion on data that was cleaned out and numbers;
Upon further questioning[3], the data processor explained that problems were found in coding as well as other data inconsistencies and that problematic data was omitted due to time constraints. Approximately 1,050 children had been included in the study but only 695 records were included in the analysis. Because it was unknown which areas the omitted records came from it would be impossible to determine the bias that this might have introduced.
12. In the VAC assessment report of September 2002, results from the VAC nutrition survey were reported to reflect a trend of worsening nutritional status when compared with previous surveys. Apart from doubts about results being representative and reliable due to flaws as outlined above, results should not have been compared to results from other surveys, because the sampling method differed from other nutrition assessments, notably the nutrition assessment carried out by the MOHCW/UNICEF in May 2002. In any case, even if survey methodologies had allowed testing, differences would have not been significant (overlapping confidence intervals).
13. Nutrition surveys carried out by NGOs during the last year, mostly at district level, show global acute malnutrition rates ranging from 2.9% to 7.2%. Severe malnutrition rates varied from 0.4% to2.1%. Sampling procedures and analysis was carried out in line with international recommendations. In many surveys, underlying causes of malnutrition such as recent illness, measles vaccination coverage, vitamin A status, food consumption and supplementary feeding coverage were also assessed. Where analysis was carried out, a strong correlation was found between recent illness and malnutrition, suggesting that improving health is just as important as addressing food security. Measles coverage was between 70% and 85%, which is too low to provide herd immunity and poses a risk to outbreaks.
14. Not a single assessment carried out during the last year revealed a prevalence of global acute malnutrition that would warrant public health concerns. Levels are well below the threshold for an emergency (above 15% global acute malnutrition) and in any case not significantly different from levels found in Zimbabwe in normal years. Levels of severe malnutrition in some cases are however relative high and (sometime much) higher than the accepted threshold of 2%. Attempts to analyse this finding more in-depth have apparently not been carried out, at least have not been elaborated on in any report. It would be interesting to cross-tabulate severe malnutrition and ARI and/or chronic illness (usually not (yet) included). The high level of severe malnutrition –in some cases– could indicate a low level of body reserve.
15. Very few surveys were carried out during the last six months and data of three (known) surveys carried out after April have yet to be analysed. Also, most surveys were carried out in areas of intervention –usually consisting of the provision of supplementary feeding– possibly resulting in bias. Also areas of operation often area areas where NGOs have a (long-term) presence and these areas are not necessarily the worst affected.
16. Among MOHCW, UN agencies and NGOs there is consensus that a positive constructive review of assessments hitherto carried out will provide useful lessons learned for the way forward. There is commitment to continue to carry out nutrition assessments, which will include mortality data (CDR, U5MR and causes), morbidity data, EPI and vitamin A coverage. A firm date for the next round of assessments has yet to be set. These will not take place this year, give the time to prepare and considering that quality is more important than speed. If timetables can be matched, early next year would seem a likely possibility.
17. There is sufficient in-country capacity to carry out data-collection in the field, data-entering and cleaning, but there is a need for a full time co-ordinator to supervise the survey, provide technical assistance for the data analysis and (timely) writing of the report. There is agreement that such a person should be recruited from abroad. WHO in particular has been asked by the MOHCW, UNICEF and NGOs to provide technical assistance in nutrition assessments (and surveillance).
II Surveillance
14. Community sentinel surveillance system in Zimbabwe does not exist. There is some institutional surveillance of health indicators such as the incidence of HIV/AIDS at ante-natal care facilities and malaria at health facilities with laboratory confirmation possibilities, but in general, according to the HARP health assessment, epidemiological surveillance is weak at all levels. Sentinel surveillance of supplementary feeding programmes for children under five at community level, will start shortly.
15. The main purpose will be to monitor the implementation of the child supplementary feeding programme (CSFPs) in terms of targeting, food usage and management of programme. It will also give an indication of the programme impact on beneficiaries in terms of their nutritional status through the monthly weighing of children under five years old. The latter, in the absence of measuring equipment and experience in measuring height will (at least for the present) not include measuring acute malnutrition. Data will be collected from these sites routinely on a monthly basis and compiled into monthly reports. Tools to be used for data collection have been developed within the Nutrition Taskforce, which include a Feeding Point Register, Daily Food Usage Form, Stock Cards and Monthly Returns Form.
16. Multi-sect oral District CSFP Teams will be formed (where none exists), comprising of all stakeholders from government departments, NGOs and other agencies, to coordinate the overall implementation of CSFP. These teams will be tasked with identifying sentinel sites in the districts. Monitoring tools will be distributed to all the selected sentinel sites, which will then need to be closely monitored by the district teams to ensure regular data feedback. Personnel to assist and monitor the data collection from the selected feeding sites should be identified by the district teams, and these could be the Health or other Extension Workers at ward level and Field Officers from NGOs. The District Nutritionists will be responsible for collection of the data from the sentinel sites in the district. Sentinel surveillance data will be processed and analysed at the Ministry of Health in the National Nutrition Unit, with UNICEF assistance. Monthly reports will be shared with all members of the NWG monthly meetings.
17. Proposed criteria for the selection of the sites are somewhat ambiguous in terms of sampling methodology, hovering between purposeful and random, and lack rigid guidelines regarding the number of children to include and how to select these. Some adjustments have been suggested to avoid sampling errors and promote comparison per site over time as well as between sites.
18. In response to the findings of the HARP rapid health assessment revealing that analysis and use of surveillance data at health facility level was minimal, and response to epidemics and disease outbreaks therefore delayed, WHO has initiated a disease surveillance programme. The project aims at strengthening disease surveillance so as to be able to detect and respond promptly to epidemics and the health information system so as to be able to accurately assess the disease burden and the particular populations at risk and how it is affected by this emergency situation. Foreseen activities include:
· Training in basic epidemiology and surveillance and outbreak response
· Review the case definition for HIV/AIDS and improve diagnosis and recording of HIV related illnesses
· Review of data health information tools so as to capture narrower age groups and gender
· Support and supervision
§ Programme management
19. Among VAC partners there is agreement that there is a need to continue, after the three rounds of VAC assessments, to collect essential statistics through surveillance. WHO, UNICEF and WFP in their first meeting on this subject agreed that health and nutrition surveillance –through the collection of anthropometrical data (weight, height and age) should be combined, as both are the mandate of the MOHCW. The method of choice is community sentinel surveillance. As a potential linkage to the SADC-VAC at minutes of the health and nutrition surveillance taskforce were sent to the VAC chairperson in order to facilitate streamlining of initiatives taken by food and agriculture partners in setting up food(security) surveillance. NGOs will be invited to join and information gathered through surveillance will feed into the RIASCO.
20. A proposal for health and nutrition community based sentinel surveillance has been prepared and submitted for funding. Although the main element of the surveillance system will consist of data gathering at community-based sentinel sites by community health workers and/or environmental health technicians, community data will also be linked as much as possible with institutional data, such as to be gathered in the by WHO supported disease surveillance programme. Where national surveys are done, they can also link into the surveillance system (which, by definition, would be collecting fewer indicators more frequently). The major challenge is designing ways for the information to flow from the community level to the country level to the regional level, to make sure that the databases can merge easily together. However, because the system would be firmly rooted within the existing health system, support with logistics, training and supervision should enable all stakeholders to come up with meaningful solutions.