WORKING DIFFERENTLY FOR MORE EFFECTIVE CRISIS MITIGATION AND RESPONSE

G N I RK LY WOFERENT DIF WORKING DIFFERENTLY FOR MORE EFFECTIVE CRISIS MITIGATION AND RESPONSE Photo: Gideon Mendel Authors: Wendy Erasmus and Gabrielle Appleford

INTRODUCTION The humanitarian community and national governments increasingly recognize that early warning and response are more effective and less costly than late response. While this recognition exists, the relationship between warning and response remains spurious. Early warning in the 2010/2011 food crisis in the Horn of Africa did not lead to early action and resulted in loss of livelihoods and lives i. Some have referred to this a systems failure - of both humanitarian response and development programmes - and called on multi-national and non-governmental organisations, as well as national governments, to work differently ii. This article highlights Concern Worldwide (Concern) s experience of working differently in Marsabit County, part of the arid and semi-arid lands (ASALs) of northern Kenya. It describes Concern s experience of implementing a surge model for community-based management of acute malnutrition (CMAM) in the context of northern Kenya. The description is framed around the thematic issues engaging with change, working differently, no regrets and, whose resilience? These themes have been arterial to the work of the regional Food Security and Nutrition Working Group (FSNWG) over the last year. Concern like other members of the group recognise that earlier response to early warning is paramount in a region beset with chronic crises; the changing nature of risk and vulnerability in these contexts; as well as the centrality of governance and community systems for effective and sustainable risk management over the long term. ENGAGING WITH CHANGE Photo: Phil Moore Given the predictable nature of humanitarian emergencies in the Horn of Africa, approaches that enable service coverage and are demand responsive are more likely to reach the right people, at the right time and in the right quantity with the assistance they require. This is critical given the changing nature of risk and vulnerability in the Horn of Africa; this means that we do not always know who will require assistance even if we are able to better predict when this may be required. Box 1 expands upon the changing nature of risk in drought affected areas of the Horn of Africa. This change and the need One of the focal districts, Moyale, had not seen the increases in malnutrition rates that neighbouring districts had witnessed. 2

Box 1: Changing nature of risk and vulnerability There is emerging recognition of changing socio-economic and demographic conditions and rural livelihood strategies more broadly in drought affected areas. These changes have fundamentally changed the relationship between the rural poor and drought. Given the changes in risks and livelihoods, drought responses in 2011 may not have been appropriate to this changing context. If these responses were not providing the to engage with it have been recognised by the FSNWG and other humanitarian and development practitioners iii. Concern, part of the humanitarian response during the 2010/11 crisis, engaged with this change in Marsabit County. Post response analysis was under taken by Concern and the District Health Management Teams (DHMTs) to ensure that their nutritional response remained fitfor-purpose in a rapidly changing context. This analysis revealed that there was a lack right things, to the right people, in the right quantity at the right time, did it matter if they were late or not? The recently published Change in the Arid Lands documents dramatically different expectations and future plans in pastoral communities. ECHO is challenging itself and its partners to think of the implications of these changes for drought impacts and drought risks. of pre-emergency planning; limited use of available data and contextual analysis; and, limited evidence-based understanding of how and when to scale up interventions. Concern was able to engage in an honest appraisal with government counterparts on the short comings of the response for a number of reasons including: An established institutional relationship between Concern and the DHMTs as well as county offices and stakeholders Trust between the individuals engaged in the analysis (due to staff continuity on both sides) An organisational ethos in which humanitarian and development activities are integrated within a programme approach An appreciation of the context and the need for people-centred development. The relationship also benefitted from its previous success. One of the focal districts, Moyale, had not seen the increases in malnutrition rates that neighbouring districts had witnessed. This was attributed to the way in which government and non-governmental partners, Concern being the main one, had managed the risk. This experience has been previously documented iv. In recognition of an evolving context and the need for adaptive and responsive - systems capacity, the concept for the CMAM surge response model was conceptualised. WORKING DIFFERENTLY CMAM is a strategy for outpatient treatment for malnutrition (Box 2). The CMAM surge model is premised on one of the fundamental principles of CMAM, that early detection of malnutrition leads to improved treatment outcomes and fewer cases of severe acute malnutrition, as children are treated before their malnutrition becomes severe. While the model does not prevent malnutrition it does trigger early action and community mobilisation. It responds to the call for a new design framework for CMAM programming, one that employs response thresholds that trigger support based on existing health system capacity v. The model presupposes therefore that there is some existing health system capacity and local commitment (of managers and health workers) to health Box 2: Community-based management of acute malnutrition CMAM, initially referred to as Community Therapeutic Care by Valid International and Concern Worldwide in 2002, has been widely adopted for out-patient treatment of malnutrition over the last decade and a half. CMAM protocols and treatment strategies have increasingly been incorporated into routine health systems. The approach has particularly revolutionised the treatment of severe acute malnutrition through the introduction of decentralised outpatient treatment for uncomplicated cases and inpatient stabilization for more complicated ones. CMAM was adopted as international best practice by the United Nations in 2007 and is being implemented in 60 countries worldwide including Kenya. 3

systems strengthening. As such, it is highly appropriate in a country such as Kenya which has a weak but functional health system and capable but under resourced health workers and managers. Figure 1 The model components are presented in Figure 1. Technical application of the components is not described here but is available in a complementary document vi The model is currently being piloted in three districts of Marsabit County - Moyale, Chalbi and Sololo - with support from ECHO. Activities commenced in May 2012 and continue to date. The model and its application highlight four key principles of working differently. These are described below. Systems strengthening: The CMAM surge model aims to strengthen the capacity of government health systems to effectively manage increased case loads of malnutrition during predictable emergencies without undermining the health system, the provision of other services and on-going systems strengthening efforts. Overtime, through such an approach, it can be expected that health system capacity to manage spikes in cases of acute malnutrition would improve because on-going system strengthening efforts continue through emergency states; this would be reflected in revised upwards capacity thresholds and allow Box 3: View from the field I like the model because one can make a prediction of what is going to happen when...[it] is a good and useful tool to be used to manage malnutrition especially the emergency stage where NGOs usually pump a lot of funds at the last minute, the surge model has intervention of alert, and serious stage. Martha Kule, DHMT member for increased attention to other aspects of service delivery, coverage and quality. The capacity of a health system to cope with increased needs for curative care for any disease or condition is a key aspect of health system strengthening. It is also a means of promoting preparedness under a broader disaster risk reduction framework, especially in areas where populations live in a chronic state of food and nutrition insecurity. Predictability: Health facility staff and DHMT personnel identify local factors contributing to increases in caseloads of malnutrition. Through this process, health workers can better understand which factors increase incidence of acute malnutrition and which deter health seeking behaviour; from this understanding, spikes in caseload can be better predicted. Thresholds are set by health workers based on the capacity of the health facility to respond to increases in caseload. Thresholds are grouped into four levels normal, alert, serious and emergency. Concern and the DHMTs have developed a set of response actions the surge package - for each level in the surge model allowing for predictable support. The surge package has also been costed; this also provides for greater predictable financing. 4 Demand and context driven: The process of regular plotting of admission data against the threshold enables health workers to track even slight changes in their context over time. It allows for gradual intensification of support as and when this is required based on the pre-agreed package. The model therefore promotes data for decision making at facility level and system efficiencies as external resources serve gap filling requirements for discrete periods of time only. Health workers, working closely with communities (through the Community Health Strategy) are closest to the problem should one arise vii. This allows for timely and tailored response. Accessibility: The CMAM surge model is simple, thereby increasing its relevance and accessibility and likelihood of being implemented by health workers. It allows for local ownership and stewardship of a response. An appreciation of the cost of non-response is fostered as a price tag is available for each threshold level. Box 3 provides the views of one local stakeholder from Marsabit County on implementing the surge model.

NO REGRETS Conditions in Marsabit County have recovered since the 2011 drought mitigating the need for emergency surge support at scale. However, the model has been triggered 11 times by health workers at pilot facilities. In one case, the emergency threshold was exceeded. Box 4 provides details on this event. In all events, triggering has activated a series of no regrets actions. No regrets actions reinforce long term development objectives and have no negative effect even when forecasts are not realised. The notion of no regrets emerged out of commitment to find response modalities which can avoid systemic failures and equally which are more appropriate to a changed socioeconomic and demographic landscape. Applying this understanding, the CMAM model itself can be viewed as a no regrets action. Photo: Gideon Mendel Box 4: exceeding the emergency threshold in Debel health centre Debel health centre is situated in Moyale district and serves a population of approximately 7,500 including 1,400 under five children and 1,800 women of reproductive age. The facility is staffed by one nurse supported by two Community Health Workers (CHWs). In May 2013, moderate acute malnutrition cases exceeded the emergency threshold set at 30 new admissions (actual cases = 35). This triggered surge support from the DHMT and Concern. Support included the secondment of a Community Health Extension Worker (CHEW) and an additional CHW to support the nurse; the provision of weekly on-thejob training and supportive supervision by the DHMT and Concern; the reallocation of supplies and equipment from another health facility; and community mobilisation and outreach clinics to the more distant communities. Analysis of the factors contributing to the increased caseload included the following: Mass screening and referral by CHWS during community based surveillance data collection Increased diarrhoea in May 2013 No general food distribution since March 2013. In addition, the last distribution included maize not rice. Maize is often sold for other commodities as the community prefers rice. Outbreak of camel disease leading to out migration of the camels to a neighbouring district leaving the area with inadequate milk which comprises a big part of the children s diet. The nurse was on leave in April 2013 so few admissions were done for that month. Surge support was gradually reduced and ceased altogether once the caseload returned to normal. The response had the additional benefit of securing a CHEW for the facility on a permanent basis and the repair of the broken equipment (a mother and child scale) by the DHMT. 5

Photo: Phil Moore WHOSE RESILIENCE? For Concern, building resilience requires systems thinking and adaptive capacity ix. Experience from implementing the CMAM surge model reinforces the importance of both. Making health systems disaster proof should be an aim of all system strengthening initiatives and is a true reflection of an able system. This principle applies to non-health systems as well. Concern is currently working on adapting and testing the surge model concept for animal health; social protection; and water resource management systems. Box 5 makes the case for animal health. The same model components and process of model development would be applied to social protection and water resource management, always ensuring adherence to the four principles of the model: systems strengthening, predictability, demand and context driven, and accessibility. Box 5: The case for animal health The same surge model components (Figure 1) apply to animal health. An analysis of risk would need to be undertaken to assess the factors that contribute to deterioration of animal health being sure that there is a clear link between the animal health deterioration and its impact on human health and markets. Once risk factors are identified, thresholds would be set, which, when exceeded, would trigger an appropriate level of response and a standardised, pre agreed package of support. A system of monitoring the situation against the agreed thresholds would need to be developed. In Kenya, this system could be established through the community based disease surveillance approach. Work would need to be done with the County Veterinary Department to design and cost a package of support for each level aimed at averting impact on human health. And lastly, agreement on the scale down of support would need to be negotiated and factored into the model. 6

Photo: Phil Moore CHANGING THE CONVERSATION Being part of the changing conversation, facilitated through vehicles such as the FSNWG, allows agencies the opportunity to debate, collaborate and innovate so that their interventions remain relevant to the communities and governments with whom they work. Working differently requires external agencies, such as Concern, to respect the centrality of government stewards and systems; their role as duty bearer is nontransferrable, even in times of crisis. Ways of working that reinforce this mandate need to be strictly practiced. Supporting the process of recognising and claiming rights as well as holding duty bearers to account is a role that external agencies can facilitate and should be considered part of a risk management approach. Respecting systems and processes and the centrality of their stewards and operators, also means that performance metrics need to move beyond therapeutic results so that technical quick wins do not undermine, but rather strengthen, systems in the long run. In the case of Kenya, this means that health and nutrition organisations should be measured on how high impact nutrition interventions ( HINI ) viii are achieved and not just on targets reached. The means to the end matters if resilient systems and processes are to be built. In order for external agencies, such as Concern, to remain relevant resilient if you will their technical and operational arsenal needs to expand to incorporate more measures that facilitate adaptive capacity and systems strengthening. The CMAM surge model is an example of such an approach. Being part of the changing conversation, facilitated through vehicles such as the FSNWG, allows agencies the opportunity to debate, collaborate and innovate so that their interventions remain relevant to the communities and governments with whom they work. A changing context and the changing nature of risk dictate this. It is hoped that this will mean that more agencies are doing the right thing, at the right time, and reaching the right people through the right systems so that the cycle of late response to humanitarian disaster is reversed in the Horn of Africa. 7

i Disasters Evaluation Committee (January 2012), DEC Real Time Evaluation - East Africa Crisis Appeal, Synthesis Report. ii Hillier, D. (March 2012), Managing the Risk, Not the Crisis. Humanitarian Exchange Magazine, Humanitarian Practice Network; Save the Children and Oxfam, (2012), A Dangerous Delay: the cost of late response to early warnings in the 2011 drought in the Horn of Africa. iii See for example Save the Children, IFRC, & Oxfam. 2013. Change in the Arid Lands. Nairobi, December 2013; McLean, C. 2013. Changing Drought Risks in the Arid Lands. ECHO. Presentation to the FSNWG, May 2013. http://www.disasterriskreduction.net/east-central-africa/fsnwg/documents/en/. iv Erasmus, W., Mpoke, L. and Y. Yishak, (Mar 2012), Mitigating the impact of drought in Moyale District, Northern Kenya, Humanitarian Exchange Magazine, Humanitarian Practice Network, Issue 53. v Hailey, P. and D. Tewoldeberha, (2010). Suggested New Design Framework for CMAM Programming, Emergency Nutrition Network, issue 39. vi Kopplow, R., Yishak, Y., Appleford, G. and W. Erasmus, (2014). Meeting demand peaks for CMAM in government health services in Kenya, Emergency Nutrition Network (forthcoming). vii Concern is currently testing a community-based surveillance system in order to ensure that trends at health facility level are reflective of the situation in the community. viii Concern Worldwide, (September 2013). Confronting Crisis: Transforming lives through improved resilience. Concern Worldwide s learning from the Sahel and Horn of Africa. Concern Worldwide, Dublin, Ireland. ix HINI is a package of interventions proven to reduce mortality rates. It includes management of acute malnutrition, vitamin and mineral supplementation, immunisation, de-worming, promotion of appropriate child feeding and hygiene practices, and nutrition education. Acknowledgments Citation: Erasmus, W. and G. Appleford, 2013, Working differently for more effective crisis mitigation and response, Concern Worldwide, Nairobi, Kenya. This publication may be freely, used, quoted, reproduced in part or fully by anyone provided copyright to Concern Worldwide is acknowledged and the source is mentioned and no fees or charges are made. Concern would like to thank ECHO whose support enabled this document to be published. Photo Credit: Phil Moore and Gideon Mendel Report designed by: Kul Graphics Limited