Looking beyond food aid to tackle malnutrition in Sudan

The reporter talking to mothers at the nutrition center in Diraige Camp in Nyala, South Darfur. Photo by: Jenny Lei Ravelo / Devex

There were no babies or children being treated for malnutrition in Diraige camp in Nyala, South Darfur, nor was there any therapeutic food or vitamin-fortified oil being distributed to mothers at the nutrition center.

The only people present, apart from a few World Vision staff members, were 20 mothers sitting  on a large woven mat with their young children beneath a shed roofed with dried leaves — the only protection from the scorching October sun.

They were waiting for a scheduled ration of premixed food, which wasn’t coming due to a shortage of supplies, including corn-soya blend, sugar and oil, Mohammed Ahmed, assistant nutrition officer for the World Vision office in Nyala, told Devex.

Instead, mothers at the center could expect key nutrition education, such as proper breast-feeding practices or how to prepare nutritious food for their children.

Yet interest in an education initiative is harder to gain when bellies of both mother and child are empty.

It’s one of many issues humanitarian actors tackling malnutrition in Sudan are working to address. The road to nutrition isn’t straightforward, and there are many interconnected factors aside from food supply that must be addressed — including linking livelihood opportunities and engaging community members in wider understanding of nutrition interventions, as well as garnering donor support for long-term projects.

Livelihood, a potential game changer

Mona, a 24-year-old mother, was among those in attendance at the nutrition center. It was her first visit, and she was hoping to receive food for her 18-month-old child, who had been vomiting and suffering from diarrhea since she stopped breast-feeding the child three months ago.

But Atif Ismail, WFP program officer for nutrition in Nyala, suspected it had more to do with the food Mona had been feeding her baby: lentil and mashed potato with peanuts. While these foods are normally safe, nuts aren’t always cleaned well by retailers before being ground at the market, he said, and advised Mona — in Sudanese — to grind the peanuts at home instead to be sure of their sanitation.

This advice is what Mona might expect to learn from the feeding lessons at the nutrition center, but she, her friend, and many of the other mothers at the center didn’t appear to be interested in the lecture. They were there for the food and were were prepared to leave if none appeared.

Mona didn’t think she needed the lesson, especially since her sister taught her how to feed her child, she told WFP staff.

But Marc-Andre Prost, WFP’s deputy head of program based in Khartoum, emphasized that how to feed a child is not something a mother knows just because she’s a mother.

“It’s something that you learn … primarily from your own mother … or your own grandmother,” he said.

The problem, however, is that some of these lessons are based on traditional practices that could potentially be harmful, which is what the organization and its implementing partners are trying to address through behavior change communication.

The yellowish milk produced by a mother who has just given birth, for example, is rich with antibodies that can help build a child's immune system, but many Sudanese believe it to be unfit for infant consumption. During the weaning period, meanwhile, mothers may limit the consumption of fish and eggs because of cultural taboos attached to them, not understanding that this could have an impact on their children's growth and development.

But changing behaviors is easier said than done, especially when the main incentive for the mothers to come to the nutrition center — food — is not always available.

So WFP Sudan is trying a different tactic: linking livelihood and income-generating activities to nutrition services. Training mothers how to make fuel-efficient stoves and briquettes under the Safe Access to Fuel-efficient Stoves, or SAFE project, is one example. They can train other women afterward and sell the briquettes. The organization is also looking to get men in the community to participate by offering a food for work scheme, where the community identifies a priority project — for example, a hafir, or an underground water reservoir — and men or women receive food in exchange for labor in constructing it.

Prost said the agency has already launched similar programs in some areas in Darfur. The food for work program, for example, is already being piloted in Kassala in eastern Sudan, with the goal of mainstreaming it in all of the agency’s nutrition interventions across the country.

The deputy head of program, however, cautions against expectations that the service will be fully integrated in all areas with nutrition interventions.

“The operating environment is not always conducive,” he said. “I mean it’s fairly obvious that when you cannot go, when you cannot spend more than half an hour on the ground because there is security issues, there’s much less you can do. So in areas that are very tense, in terms of security, our ability to link and to integrate is less.”

Mona and her 18-month-old child. They went to the center, expecting to get food. Photo by: Jenny Lei Ravelo / Devex

The added value of community engagement

Before organizations can incentivize parents to participate in their children’s nutrition journey, they need to reach them — a task that can’t be achieved without engaging the community.

Ideally, nutrition centers should be a one-stop shop for all nutrition interventions, where food is available whenever it’s needed, not only on certain weeks or days of the month.

But this is difficult to achieve in most areas in Darfur, given the limited number of international and national nongovernmental organizations present. It takes months for INGOs, for example, to receive permits to work in Sudan, and they have to submit separate permit requests to work in Darfur, which can tack on several more weeks or months.

This lack of sufficient staff on the ground is one of the reasons World Vision had to resort to a schedule in Nyala for its nutrition interventions. Staff members in charge of distributing “supercereal plus” and ready-to-use therapeutic food in Diraige are also responsible for it in Nyala’s New Serif and Otash camps. That often leaves the organization with just one staff member manning each site.

It’s a huge task, Ahmed said, and one that can be overwhelmingly challenging during what he describes as the hunger season, usually between the months of May and September. It’s during this period that admissions at the center increases, leaving a huge disparity in staff to beneficiary ratio.

So World Vision decided to engage the very community it serves. In Diraige, for example, it selected 25 community workers, trained them on behavior change communication, screening for children at risk of or suffering from malnutrition and in conducting home visits for further information dissemination. Five of the community health workers are site-based to assist the lone World Vision staff member.

In exchange, the community health workers receive food from WFP.

The decision helps fill the gap in ground staffing capacity, promotes service decentralization — which also helps prevent crowding at the nutrition center — and helps boost household monitoring.

Prost noted community health workers are crucial components of the response.

“These are people who are in daily contact on a daily basis with mothers,” he said. “They can feedback to us what are the main constraints for mothers to come and use our services, but they can also help mothers identify when there’s a problem.”

WFP is now looking to community health workers to be the service providers of its micronutrient powders. This has already taken place in some of the camps in West Darfur, and Prost shared the agency has recently gotten approval from the Ministry of Health for national scale up.

Understanding as a recipe to success

How much donors and the government are involved — and understand — the dynamics on the ground have a huge impact on nutrition interventions, too.

For example, with behavior change communication, Prost argued it’s difficult to see significant change in a short period of time.

“These are interventions that have to go for over three, four, five to 10 years to really see a difference,” he said.

Communicating that to donors, however, can be difficult, he added, as most of WFP’s donors in Sudan are “very much emergency donors” that expect results within six to 12 months.

In Diraige camp for example, three community health workers are in charge of checking up on each caregiver in a household to make sure they are informed of the latest schedules at the center. But even with that setup, some mothers continue to miss the schedules.

Donors such as the European Commission’s Humanitarian Aid and Civil Protection Department, whose priorities in the country include nutrition interventions, appear to understand the complexities. Clement Cazaubon, one of ECHO’s field experts in Sudan, told Devex how different variables like age, education level, cultural belief, community support, and the available health care system, for instance, play a role in changing a mother’s behavior when feeding her 6-month-old child. Food for children that young should only be breast milk, but some mothers already give them water, which in some cases may be contaminated, and other types of “inappropriate food.”

“It’s hard, it takes important time and necessitates joint efforts,” he told Devex.

But he also said that “although results can vary widely, we do believe that these messages need to be delivered, even in a short time frame, and in particular during emergencies, when we see good practices being abandoned due to stress and a changing environment.”

Another issue is funding. Organizations favor unearmarked funding for nutrition activities so they can use the money as they see it fit, be it for nutrition-specific interventions such as the procurement of micronutrient powders, or nutrition-sensitive interventions like helping the community build a hafir, which in turn could help get more people in the community to be more nutrition-aware.

Some donors are already providing this flexibility, to some extent. ECHO, for instance, is earmarking funding for specific geographical areas and sectors. In Darfur, its support for WFP on general food distributions cover food assistance and short-term livelihood support. But WFP can choose how to spend the amount and the modality through which to spend the money, such as in-kind food versus e-voucher or cash-based food assistance, conditional or unconditional.

But what Prost hopes for all actors involved in fighting malnutrition in the country is to understand that a child’s nutritional well-being is very much a lifestyle issue rather than just about food consumption, or health. It’s a multisectoral issue that doesn’t fall just under a country’s health or agricultural ministry, for example.

“It has to do with not only what people eat, how people behave, how people interact, how people are assisting each other. It has to do with social networks,” Prost pointed out.

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About the author

  • Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.