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Syria

Contents

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Field Articles113 WFP’s emergency programme in Syria

118 WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management

122 Experiences and challenges of World Vision's programming in Northern Syria

126 Postscript

127 Non-food cash voucher programme in Northern Syria Northern Syria

128 GOAL’s food and voucher assistance programme in Northern Syria

133 Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria

Views138 Coordinating the response to the Syria

crisis: the southern Turkey cross border experience

WFP beneficiary in damascus; WFP/Abeer Etefa

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OverviewWFP has had a continued presence in Syria foralmost 50 years, providing more than US$500million worth of food assistance into the countrythrough development and emergency operations.Prior to the current conflict, WFP, togetherwith its partner organisation the Syrian ArabRed Crescent (SARC), responded to emergencyfood needs following consecutive droughts, as-sisted in the implementation of school feedingprogrammes and provided assistance to Iraqirefugees seeking sanctuary in Syria. In October2011, WFP launched an emergency operationto provide relief food assistance to affected fam-ilies, in what was then a localised conflict.Initially targeting 50,000 beneficiaries, the op-eration was rapidly scaled up as the conflictspread over the following months. Over time,WFP modified the composition of the food bas-ket, in response to changes in the availabilityand accessibility of individual commodities. Ablanket supplementary feeding programme(BSFP) for young children was developed fol-lowing concerns over declining nutritional in-dicators. Ready-to-eat food rations were providedfor newly displaced families without access toalternative sources of food or cooking facilities.

In 2013, WFP gradually scaled up its response,reaching close to 3.4 million beneficiaries acrossall 14 Syrian governorates. WFP expanded itsnetwork of local non-governmental organisations(NGOs) beyond SARC to enhance its capacityand reach to meet rapidly growing needs. As ofJune 2014, a total of 27 partners support the de-livery and distribution of WFP food assistance.ese include SARC, 25 local NGOs, and oneinternational NGO (the Aga Khan Foundation)working in Hama governorate. rough theirlong established presences and extensive localnetworks, WFP’s partner organisations, localauthorities and community leaders mobilisedto help ensure and organise the safe delivery ofassistance. Each partner has been selected toensure their compatibility with WFP’s mandateand with the principles of the UN Global Com-pact1 and the WFP Code of Conduct.

Considerable efforts to strengthen local ca-pacity have been made throughout 2013 includingsupplying crucial equipment and providingtraining on warehouse management, safe dis-tribution practices, and programme monitoring.While allocation to partners varies on the basisof needs, capacity and access, on average ap-proximately 55% of total food rations are allocatedto SARC, while the remaining 45% are distributedby the NGO partners. SARC implements dis-tributions through its branches and sub-branches,or through local charities in locations where ithas no presence.

e number of WFP staff in country hasgradually increased to over 200; the majority ofthese are national staff. WFP and local partnersare currently implementing three main schemes –general food distribution, BSFPs for young chil-dren and ready-to-eat rations. e latter aredistributed to newly displaced families withlimited access to food or cooking facilities duringthe initial days of their displacement. In late2014, two additional components were added:a school feeding programme to encourage regularattendance in school and distribution of foodvouchers to promote dietary diversity for pregnantand breastfeeding mothers.

e number of WFP staff in country hasgradually increased to over 200; the majority ofthese are national staff. WFP and local partnersare currently implementing three main schemes –general food distribution, BSFPs for young chil-dren and ready-to-eat rations. e latter aredistributed to newly displaced families withlimited access to food or cooking facilities duringthe initial days of their displacement. In late2014, two additional components were added:a school feeding programme to encourage regularattendance in school and distribution of foodvouchers to promote dietary diversity for pregnantand breastfeeding mothers.

WFP’semergencyprogrammein Syria

WFP establishes the ration type in consultation with partners, according to nutrition consider- ations,local preferences and procurement capacity. The ration is then approved by the relevant governmentauthorities. Targeting criteria are also established in consultation with partners, based on thefollowing vulner- ability criteria:

• Persons and households that have been displaced and have little or no income for food• People located in or near areas subject to armed activities with little or no income for food• Persons and households hosting a displaced family with little or no income for food• Poor people in urban and rural areas affected by the multiple effects of the current events and who have little or no income for food.

Box 1 WFP’s targeting approach

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Field Articles .............................................................

By Rasmus Egendal andAdeyinka Badejo

Rasmus Egendal hasmore than 20 years ofexperience ininternationaldevelopment andhumanitarian aidassistance. Currently

he is serving as Deputy Regional EmergencyCoordinator for WFP’s Emergency Responsein Syria and neighbouring countries.

Adeyinka Badejojoined WFP in 2001and is currentlyDeputy CountryDirector for WFP inSyria. Previously, sheserved as a WFP

Programme Officer in Afghanistan,Zimbabwe, Sudan and in Rome andundertook field work in Pakistan, Palestine,Tanzania, Egypt, Cambodia, Nepal andAfghanistan.

The authors gratefully acknowledge thecontributions of Sarah Gordon-Gibson,Regional Programme Manager, WFP Syriaand neighboring countries; Lourdes Ibarra,Head of Programme, WFP Syria; YasmineLababidi, Nutrition Programme Assistant;and Nicoletta Grita, Reports Officer.

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Needs assessment in November 2013A WFP/FAO Joint Rapid Food Needs Assessmentwas conducted in November 2013 in Syria, incollaboration with the Ministry of Agricultureand Agrarian Reform and the Ministry of SocialAffairs. It indicated that some 9.9 million peoplewere estimated to be vulnerable to food insecurityand unable to purchase sufficient food to meetbasic needs. Of these, some 6.3 million were es-timated to be particularly exposed to the effectsof conflict and displacement and in critical needof sustained food assistance. A severe reductionin agricultural production, combined with con-straints in marketing available produce, as wellas weakened import capacity to meet domesticdemands, have increasingly limited food avail-ability over time. Compounding the devastatingeffects of the conflict, exceptionally low levels ofrainfall during the 2013/2014 winter season con-ditions impacted food production in 2014 andfurther exacerbated Syria’s humanitarian crisis.Furthermore, inflation, high commodity pricesand growing rates of unemployment significantlyreduced household purchasing power. Foodsand fuels have been severely hit by price inflationparticularly in northern governorates. On theother hand, prices have actually dropped in somesouthern governorate areas. As available resourceshave been depleted over time and resilience

weakened, households have increasingly resortedto negative coping strategies including a reductionin both the quantity and quality of food consumed,a decrease in dietary variety, withdrawing childrenfrom school and selling assets.

General food distribution (GFD)TargetingWFP’s GFD targets the most vulnerable house-holds across all 14 governorates. WFP establishthe target for each governorate on the basis ofavailable needs assessment as well as consultationwith partners (see Box 1). e assistance pri-oritises displaced households who have losttheir main source of income, as well as poorcommunities hosting a large number of displacedfamilies. Each household receives a food basketsufficient to feed a family of five for one month.e monthly family food basket consists of avariety of commodities such as rice, bulgurwheat, pasta, pulses, vegetable oil, sugar andsalt. In 2014, the food basket was revised from1680 kcals to provide up to 1,920 kcal per personper day. is increase was effected as WFP’sprogramme monitoring findings suggested thatfamilies were increasingly less able to accessadditional food from alternative sources, mostlyrelying on the GFD. e quantity and composi-tion of the basket has been subject to changesdepending on commodity availability and pipelinestatus. Figure 1 presents the target and reachedpopulations up to July 2014. In August 2014,food distributions reached over 4.1 millionpeople, or 98% of the month’s target.

ChallengesDistributions are conducted on a monthly basisin order to balance meeting the immediate foodneeds of beneficiaries with logistical challengesassociated with such wide-scale activity acrossinsecure areas. In 2013, widespread insecurityrestricted access to many areas of the country,preventing the distribution of assistance at theplanned scale. Particularly in the north, escalatinginfighting among multiple armed groups closedaccess routes and deadlocked assistance to Al-Hasakeh for most of the year, to rural Aleppofrom August 2013 and eastern Aleppo city fromSeptember 2013. By November, the entire north-east was cut off as routes to Ar-Raqqa and Deir-ez-Zor were also blocked by continuous clashes.Haphazard access narrowed the scope of moni-toring activities which could not be conducted

Figure 1: WFP planned and reached general food distribution beneficiaries

4.504.003.503.002.502.001.501.000.500.00

January February March April May June July

Planned Reached

4.253.6 3.7 4.1 3.7

3.3 3.4 3.6

4.25 4.25 4.25 4.25 4.25 4.25

in Ar-Raqqa, Deir-ez-Zor and Quneitra for theentire year. Furthermore, shiing patterns ofactive conflict prevented WFP teams fromvisiting the same sites each month, obligingthem to rotate distributions among locationsas security conditions permitted. Access con-straints continued into 2014 as the crisis becamemore protracted. WFP planned and ‘reached’general food distribution beneficiaries are shownin Figure 1 (Jan – July 2014).

Food assistance to millions of civilians trappedin besieged locations, including an estimated800,000 in Rural Damascus, remained sporadicdespite unrelenting appeals for unhinderedaccess. Al-Hasakeh is one of the hardest gover-norates to reach with humanitarian assistance.e continued closure of border crossings, activefighting in neighbouring governorates andradical armed groups blocking passage of trucksseverely disrupted overland food deliveries sinceJuly 2013. As needs in the governorate continuedto grow and food security of affected populationsdeteriorated, on three instances WFP was com-pelled to resort to costly but necessary emergencyairlis as the only means to deliver food to thetargeted 227,170 civilians. e first airlis wereconducted in December 2013 when 6,025 foodrations for 30,000 people were airlied fromErbil to cover just 13% of the monthly require-ments. rough the second round of airlis,conducted between February and March 2014,WFP was able to deliver just over 16,000 rationsout of a planned 32,500 to support 80,000 peoplein the governorate. ese were suspended inmid-March aer Turkish authorities grantedthe long awaited greenlight for the passage of10,000 food rations into Al-Hasakeh throughNusaybeen on the Syria-Turkey border. Howeverfrom April 2014, the governorate was onceagain cut-off from access. As a result, in July2014, a third round of airlis was implementedfrom Damascus. A total of 10,000 family foodrations for 50,000 people and 3,000 ready-to-eat rations to support the immediate needs ofnewly displaced families were delivered. DuringJanuary 2014, 17,500 people were assisted with3,500 ready-to-eat rations in Homs and RuralDamascus.

Each monthly cycle is typically completedover the course of 45 days, due to access con-straints and extended dispatch cycles. WFP has

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Syrian refugeesgo shopping withe-vouchers

In areas like Homs and DierEzzor, WFP in partnershipwith the Syrian Arab RedCrescent (SARC) conductsdoor-to-door fooddistributions.

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continuously had to make adjustments to theration due to funding and supply chain issues.is has resulted in reductions in ration size.ere have been many constraints to providinga full ration including delays in procurement,inspection and quality issues that delay approvalin country and insufficient pledges from donors.To date (September 2014), cash flow problemshave been mitigated by the use of WFP’s internaladvance funding mechanism, which have allowedborrowing against future contributions. Howeverinadequate funding commitments have becomea severe constraint (see later).

In April 2013, WFP added wheat flour tothe food basket in response to widespread wheatflour and bread shortages. Targeting 70% ofWFP’s planned beneficiaries, the flour is providedto households living in areas where the effectsof the conflict have decreased availability andreduced milling and bakery capacities, to theextent that target beneficiaries are reliant uponWFP wheat flour distributions to meet theirbread needs. For the beneficiaries that receivefortified wheat flour, the food basket providesapproximately 80% of daily caloric requirements.e food basket satisfies approximately 52% ofminimum daily caloric needs for those residingin areas not targeted by wheat flour distributions,In areas where home baking is common, wheatflour is distributed directly to beneficiaries,while in other locations, wheat flour is suppliedto functioning bakeries through SARC and otherpartners. Governorates that do not receive wheatflour include Damascus, Tartous and Lattakiadue to availability of bakeries. Governoratesthat receive 100% of wheat flour include RuralDamascus, Hama, Idleb,Ar-Raqqa, Al-Hassakeh,Deir ez-Zor and Dar’a. All remaining recipientgovernorates receive 70% of wheat flour. osethat do not receive flour do not get any additionalitems.

MonitoringWFP have common monitoring tools and plat-forms in the region, as well as dedicated moni-toring staff, although monitoring has been weakin Syria (only 15% coverage for 2013) due to in-security and access constraints. However, by

Fuel distributionIn response to anticipated harsh winter conditionsduring 2013/14, WFP provided emergency fuelsupport to vulnerable families with limitedaccess living in collective IDP shelters, in part-nership with UNHCR. A total of 58 collectiveshelters in Homs, Hama and Damascus weresupplied with 100,000 litres of fuel to coverheating requirements for four months while10,000 heat-retention Wonder-bags® were dis-tributed to families unable to cook WFP foodrations. A total of 2,500 Wonder-Bags® (out of4,100 dispatched), were distributed to familiesin rural Damascus, Damascus and Idleb whileover 24,000 litres of fuel were supplied to the 58targeted collective shelters.

Voucher scheme targeting pregnantand lactating (PLW) womene October 2013 Humanitarian Needs Overview(HNO) estimated that 300,000 PLWs across thecountry were at risk of micronutrient deficienciesand required nutrition support, as well as im-proved awareness of appropriate feeding practices.In addition, WFP’s monitoring findings illustratedthat access to and consumption of fresh produce(such as fruits, vegetables and animal protein)by families, including PLW, was very limited,increasing their vulnerability. Hence, WFP in-troduced a targeted voucher-based nutritionprogramme to complement the GFD ration andimprove dietary diversity for pregnant and lac-tating women. Lauched in July 2014, the pilotis targeting initially 3,000 women in Homs andLattakia cities. Beneficiaries receive vouchersto the value of US$23 to purchase fresh products,including vegetables, fruit, meat and dairy prod-ucts, which are not part of the general foodration. It is planned to target up to 15,000women as this programme is fully rolled out.

School feedingAn estimated 2.3 million children in Syria areno longer regularly attending school or havedropped out completely. As part of the UNICEF-led ‘Lost Generation’ strategy to improve accessto learning and facilitate a return to normalcy,in 2014, WFP introduced a school feeding pro-gramme targeting some 350,000 children in fourcritically affected governorates, including RuralDamascus, Homs, Tartous and Aleppo. e firstphase of the project was launched in July 2014,

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Syrian refugeesgo shoppingwith e-vouchers

WFP beneficiaries in Syria

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January 2014, WFP was able to augment itsmonitoring capacity by engaging third-partymonitors who are able to access locations WFPstaff cannot. is has led to an improvement ofthe monitoring coverage to 41% of distributionlocations. WFP monitors all accessible distri-butions by examining the process of beneficiaryverification and the performance of cooperatingpartners. Beneficiary satisfaction with the dis-tribution procedures is also monitored. Bothfemale and male beneficiaries are consulted inthe process. Shop monitoring examines the re-demption of vouchers, type of commoditiespurchased, prices charged as well as beneficiaryand shopkeeper satisfaction with the overallprocess. Beneficiary monitoring examines house-hold outcome indicators including food con-sumption scores, dietary diversity and the variouscoping mechanisms used.

Monitoring data allowed comparison of ben-eficiary and non-beneficiary households andfindings indicated poorer dietary diversity ofthe latter – especially with regard to access tofruits, vegetables, meat and dairy products.

Prevention of acute malnutrition In March 2013, a BSFP was initiated to providenutrition support to young children, prioritising240,000 children aged 6-59 months. In 2014,over 189,000 children at risk of malnutritionwere provided with nutrition support, includingthose in hard-to reach areas in Hama and RuralDamascus for the first time in months. Twoprogramme variations (using different products)have been employed in different governorates.Implemented in partnership with the Ministryof Health and UNICEF, one scheme providesmonthly rations of Plumpy’Doz® (a nutritionalsupplement for children) to children aged 6-59months living in internally displaced persons(IDP) collective shelters. Since September 2013,three NGOs in partnership with WFP extendedthe feeding programme beyond official IDP col-lective shelters to reach vulnerable children re-siding in host communities in Tartous, Homsand Hama. Under the second BSFP variant, thesupplementary product Nutributter® for the pre-vention of micronutrient deficiencies is beingdistributed to children aged 6-23 months livingin collective shelters and among host communitiesin the northern governorates of Syria.

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targeting schools in critical districts in RuralDamascus and Tartous. During the first phase,up to 100,000 elementary school children aged6-12 years received daily rations of fortified datebars, conditional on attendance. e programme,which was initially implemented in summerschools, has been transferred to regular schoolswhen classes resumed in September.

Inter-UN coordinationWFP has had a Memorandum of Understanding(MoU) with UNICEF in Syria, since January2013, whereby both agencies have committed,through joint programming, to scale up nutritioninterventions to address malnutrition, as wellas to tackle micronutrient deficiencies and pro-mote the population’s nutrition status. Accord-ingly, WFP currently focuses on the preventionof acute malnutrition (using Plumpy’Doz), whileUNICEF focuses on its treatment (usingPlumpy’Sup and Plumpy’nut). In addition, bothagencies collectively focus on the prevention ofmicronutrient deficiencies (using Nutributterand micronutrient powder). A key challengefor both organisations has been the lack ofcurrent nutrition data to guide programming,due to access constraints to certain areas. WFP’sprogramme for PLW complements the supportalready provided by UNICEF, WHO and theUnited Nations Population Fund (UNFPA), in

the form of micronutrient supplementation andreproductive health services. rough the Nu-trition Sector Working Group, led by UNICEF,nutrition assessments are conducted to updatethe nutrition situation as well as define nutritionstrategies.

LogisticsLogistical needs inside Syria are continuouslychanging due to the fluidity of the security andaccess situation on the ground, and require ahigh degree of flexibility in planning. In thiscontext, a complex chain of delivery underpinsthe implementation of these programmes.

WFP imports food into Syria through theprimary supply corridors of Beirut and Tartous,while the use of Lattakia port was also increasedduring 2013. In addition, a fourth corridorthrough Jordan has been activated in July 2014following the adoption of UN Security CouncilResolution (UNSCR) 2165 . WFP retains thecapability to rapidly adjust its use of availablecorridors in response to changes in the operatingenvironment. Accordingly, the expansion of ad-ditional corridors through Turkey is also underuse, thanks to UNSCR 2165.

Upon arrival in Syria, food commodities areassembled in five storage and packaging facilitiesstrategically located in Safita, Lattakia, Homsand Rural Damascus. To avoid assembling thefood basket on-site under challenging securityconditions, food is packaged prior to dispatch,thus mitigating the risks of losses and ensuringthat each family receives the adequate fooditems. Each packaging facility produces up to10,000 food rations every day, which are thendispatched by over 1,000 trucks each month togovernorates allocated to each centre accordingto respective strategic advantages. Facilities inSafita, Lattakia and Homs offering a good stagingpoint to cover the requirements of central andnorthern governorates, while facilities in Dam-ascus serve the southern governorates. is al-location maximises the efficiency of food dis-patches while reducing travel times, thus miti-gating exposure of cargo to security threats.

Once packaged, the family food rations aredispatched to secondary storage points insideSyria and delivered to WFP partners on thebasis of monthly allocation plans. In some cases,WFP purchases pre-packed rations which aretransported by suppliers directly at the handover

points to partners inside Syria, without beingprocessed through WFP facilities. Wheat flourmilling is undertaken outside of the country, inMersin and Beirut. Subsequently, bagged wheatflour is shipped respectively to Syrian ports ortrucked to Damascus. For transport inside Syria,WFP utilises existing commercial transport set-tings, encouraging local capacities where possible.Previously working with one single transportpartner, WFP contracted five additional transportcompanies in September 2013 to increase itsdelivery capacity and respond to the growingneed for humanitarian assistance within thecountry. Each transporter is allocated specificareas on the basis of a previously establishedpresence in certain parts of the country. ismaximizes WFP’s ability to deliver to all locations.For specific areas where surface access can besporadic and the humanitarian situation par-ticularly dire, contingencies for airli of life-saving supplies are arranged.

Food distributions take place at final distri-bution points (FDPs) agreed upon with partners.Due to the instability of security conditions onthe ground, the number of FDPs and their lo-cations vary from month to month, as partnersmay no longer be able to perform distributionsin previously accessible locations, or beneficiariesmay be unable to reach planned distributionsites.

Activation of the Logistics ClusterFollowing the recommendation of the UN Re-gional Emergency Coordinator for the SyriaEmergency, the Logistics Cluster was activatedin January 2013 to support overall logistics co-ordination and provide services to humanitarianactors responding to the emergency in Syria.e Logistics Cluster, led by WFP, fills logisticsgaps in emergencies on behalf of the humanitariancommunity, whilst also providing a platformfor coordination and sharing of key logistics in-formation among partners. As such, it providesfree-to-user services to its humanitarian partners,including dedicated warehousing space for in-ter-agency cargo, as well as transport servicesthroughout Syria. In addition, the Cluster ensuressupport for inter-agency convoys to deliver as-sistance to the most vulnerable communities inotherwise inaccessible parts of the country. eLogistics Cluster offers also humanitarian flightsto Qamishli, on a cost-sharing basis.

Furthermore, the Logistics Cluster has es-tablished a logistics coordination forum in Dam-ascus, Beirut and Amman. Over 30 organisations(UN agencies, NGOs, INGOs, and donor agen-cies) regularly attend meetings where participantsdiscuss logistics bottlenecks and develop commonsolutions for improved humanitarian response.In addition, the Cluster produces regular logisticsinformation products including situation reports,maps, assessments, meeting minutes, snapshotsand flash updates on the Syria Logistics Clusterwebpage, and shares them via a Cluster mailinglist. As of June 2014, a total of 17 organisationswere benefiting from the Logistics Cluster services

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Kindergarten student receivesnutritional support

A Syrian boy collects hisfamily’s monthly rationof rice, flour, pasta,beans, vegetable oil,sugar and yeast.

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for their operations inside Syria. As additionalorganisations are allowed to work in Syria, thenumber of service requests has been increasing.Accordingly the Cluster has been rapidly scalingup its operations, and continues to be ready toexpand further if required.

In 2014, WFP logistics in close coordinationwith procurement and shipping units, updatedthe Concept of Operations for the Syria Opera-tion’s Supply Chain and put in place measuresto mitigate pipeline breaks and ensure timelyarrival of commodities in Syria. Arrangementswith suppliers now ensure a readily availablestock of food commodities for immediate pur-chase upon receipt of funds by WFP. Additionally,procurement will be conducted solely withinthe Mediterranean, significantly acceleratinglead times for the arrival of food in the country.

Risks to staff safety continue to representthe greatest threat to sustaining WFP operationsin the country. Should the security environmentdeteriorate further, WFP may be forced to reduceits footprint inside the country by deployingboth national and international staff to workfrom alternative locations. Remote managementplans have been developed, including the in-creasing use of WFP’s Lebanon and Jordanoffices if necessary.

Ongoing challenges and lessonslearntWFP’s ability to deliver and distribute adequatefood is affected by access restrictions and shrink-ing humanitarian space. However, WFP continuesto work with the UN Country Team and partnersto maintain a presence on the ground, implementactivities and continuously advocate for unhin-dered humanitarian access.

WFP, and hopefully the Syrian population,have benefited from a clear WFP operationalstrategy at the outset. Recognising the politicalnature of the crisis and that high levels of inse-

curity were going to prevent WFP from operatingas normal, the decision was taken early on toadopt a pragmatic and opportunistic approach.WFP began its Syria emergency operation in2011 and was the first organisation to launchan emergency operation without the full approvalof the Syrian government, gradually buildingon its programming base to expand the hu-manitarian space through engagement and ne-gotiation. is has been a slow process requiringpersistence. Although at first and for manymonths it was only possible to work throughSARC, WFP were gradually allowed to engagewith more local NGOs and were not shut downas a result. WFP did not control the modusoperandi but found that they could expand hu-manitarian space in a way that was acceptableand met needs of millions of people, includingother organisations working on behalf of theconflict affected population. WFP has workedthrough numerous local partners since theyhave better access to most of the governorates.is has been a very positive development andhas effectively changed the landscape of civilsociety in Syria by investing in building up ca-pacity of national agencies.

While working in Syria, WFP have had totread carefully with regard to the cross-borderprogramme from southern Turkey as this expandedwith an increasing number of agencies basingthemselves in Gaziantep and Antakya in southernTurkey. With mounting criticism of the UN’slack of engagement in the cross-border programme,WFP began engaging with INGOs involved incross-border work in early 2013 and sent anumber of staff to liaise with the NGOS andACU in order to focus on information manage-ment and nurture mutual understanding. iswas followed by the deployment of a Global FoodSecurity Cluster lead to work with NGOs doingcross-border work and to improve collaboration.is was a slow consensus and trust building ex-ercise leading to the establishment of systems forsharing information about programming fromsouthern Turkey and Damascus.

In May 2014, additional measures to improveoperational coordination and joint planningwere taken. is involved constructing a jointforward looking plan that indicated where therewere operational overlaps and engaging in dis-cussions with partners about how to decide on‘who does what, where’. Another meeting washeld in July 2014 where an action plan wasagreed for cross-border programming from

Turkey, Jordan and programming from Dam-ascus, looking at the whole of Syria. A key chal-lenge for all stakeholders is how to determinenumbers in need.

Adoption of UNSCR 2165 on 14th July hashad a positive impact in enabling WFP use themost direct route to reach cut-off communities.All WFP programming, including cross-borderand cross-line, is now managed from Damascus.ere are no WFP cross-border operations man-aged from Turkey or Jordan. is position hasbeen taken in order not to undermine the man-date under UNSCR 2165. is has made pro-gramming harder in one sense as there are com-plex discussions and negotiations with the SyrianGovernment but WFP is gradually overcomingchallenges related to fragmented and uncoordi-nated responses. While information about INGOprogramming is treated confidentially, any WFPcross-border programming from Turkey isplanned from Damascus and the government isinformed accordingly through the office of theHumanitarian Coordinator. An unexpected con-sequence of the UNSCR 2165 has been an in-creased readiness of the Government of Syriato facilitate cross-line convoys, a welcome de-velopment for WFP. is may partly reflect thebattle for hearts and minds as the threat of ISISappears to have increased.

Against the backdrop of these positive hu-manitarian and political ‘sea-changes’ is a loomingresource crisis affecting WFP, who will effectivelybe running out of money for this and otherprogrammes in the region in late 2014, resultingin dramatic scaling back of programming . iscould not be happening at a worse time aswinter approaches. e irony is that in August2014, WFP managed to reach almost 4.1 millionSyrians in Syria, the highest number since theemergency response began in 2011. In October,WFP hopes to still reach 4.25 million Syrians incountry but will provide a food basket with a40% reduction of the planned caloric requirement.WFP will do everything it can to advocate andstrengthen resource mobilisation efforts in orderto avoid a reduction of WFP assistance.

For more information, contact: Rasmus Egen-dal, email: rasmus.egendal@wfp.org +962 798947301 or Adeyinka Badejo, email:adeyinka.badejo@wfp.org

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3 http://www.theguardian.com/global-development/2014/ sep/18/world-food-programme-cut-aid-syria

WFP working with theSyrian Arab Red Crescent(SARC) Packaging FoodBefore Distribution

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Three years into a brutal crisis,the protracted conflict in Syriahas had an immensely negativeimpact on essential living con-

ditions of the Syrian population. Access tobasic services and commodities such asfood, livelihoods, safe drinking water, san-itation, education, shelter and health carehas been compromised. is in turn hasincreased the populations’ vulnerability topoverty, violence, food and nutrition inse-curity, and disease. e volatile nature ofthe crisis has created unpredictable andunstable living conditions for the population.e ongoing conflict has caused forceddisplacement, socioeconomic limitations,insecurity and a lack of access to basicservices. Coupled with recurrent droughts,the conflict has significantly affected foodsecurity and livelihoods and thus, has ad-versely impacted nutritional status, especiallyin children under 5 years; an already vul-nerable population. More specifically, chron-ic poor dietary diversity, inadequate/im-proper infant, young child and maternalfeeding practices, as well as geographicaland gender inequalities have heightenedthe risk of malnutrition in children underfive years.

According to the Syrian Family HealthSurvey (2009), conducted prior to the crisis,the nutritional situation of children underfive years of age was poor, with an estimated23% of them being stunted, 9.3% wastedand 10.3% underweight. Exclusive breast-feeding rates stood at 42.6% while the pro-portion of newborns introduced to breast-feeding within the first hour was 42.2%1.Micronutrient deficiencies were also record-ed in pre-crisis Syria in 2011, presenting arisk for sub-optimal growth among children;for example, anaemia prevalence among0-59 month old children was 29.2%2, whilethere was an 8.7% Vitamin A deficiencyrate3 and 12.9% iodine deficiency preva-lence4. Neonatal mortality rates, infantmortality rates and under-five mortalityrates stood at 12.9/1000, 17.9/1000 and1.4/1000 respectively5.

Coordinating responsee confluence of factors and lack of soliddata on the nutritional status alerted thehumanitarian community to the possibilitythat cases of malnutrition in Syria weregoing undetected. is prompted interna-

WHO responseto malnutritionin Syria: a focuson surveillance,case detectionand clinicalmanagementBy Hala Khudari, Mahmoud Bozo andElizabeth Hoff

Hala Khudari, WHO TechnicalOfficer at WHO Syria, joined WHOin 2011 and is a BSc (Nutrition andDietetics) and MSc in Nutritiongraduate from the AmericanUniversity of Beirut. For the last 3years she has helped develop the

WHO nutrition response programme in Syria.

Mahoud Bozo is a nutritionexpert/ paediatrician and a WHOconsultant since Nov 2013. He haswidespread experience inresearch in paediatricgastroenterology and nutritionand was former general

coordinator of paediatrics in MOH Syria (2005-2012).

Elizabeth Hoff was appointedWHO representative in Syria inApril 2014 (acting representativeJuly 2012 – April 2014). She hasmore than two decadesexperience in Africa, the MiddleEast, Asia and Eastern Europe and

previously was coordinator for resource mobilisation andexternal relations under the Emergency RiskManagement and Humanitarian Response departmentin WHO HQ, Geneva.

We wish to express our sincere appreciation for thesupport and input from WHO’s information managementteam and field staff for their feedback, commitment andresponsiveness to build up the information provided.Special thanks go to Dr. Ayoub Al-Jawaldeh, NutritionRegional Advisor, for his invaluable technical supportand guidance, in addition to the publication office at theEastern Mediterranean Regional Office.

1 WHO/MOH, Syrian Family Health Survey, Syria, 2009.2 Ministry of Health, Nutrition surveillance system

report, Syria, 2011.3 Ministry of Health, Vitamin A deficiency Study, MOH,

19984 Ministry of Health, Study on Iodine deficiency

prevalence in Syria, MOH, 2006.5 See footnote 1

tional organisations and national counter-parts to address the prevention, detectionand treatment of emerging malnutritioncases. With the establishment of the Nu-trition Sector Working Group headed byUNICEF and the Ministry of Health (MOH)in the second quarter of 2013, whichemerged as a result of expanded nutritionactivities and increased nutrition partnersin the field, the response to malnutritionhas gradually been strengthened. is hasbeen realised through the involvement ofkey UN agencies including the World HealthOrganisation (WHO), UNICEF and theWorld Food Programme (WFP) and keynational authorities and implementing part-ners including the MOH, Ministry of HigherEducation (MOHE), as well as internationaland national non-governmental organisa-tions (NGOs) such as International MedicalCorps, Action Against Hunger (ACF) andthe Syrian Arab Red Crescent (SARC).ese stakeholders have scaled up theirresponse by adopting a holistic strategicapproach that covers i) preventative mi-cronutrient supplementation; ii) screeningfor and referral of malnutrition cases; andiii) outpatient and inpatient treatment ofacute malnutrition. WHO’s response hasfocused on strengthening screening of chil-dren under five years for malnutrition andhospitalised care of complicated cases ofsevere acute malnutrition (SAM).

Scaling up WHO nutritionactivitiesRevitalising the NutritionSurveillance SystemPrior to the conflict, in 2009, a nationalnutrition surveillance system was establishedto report on acute and chronic malnutritionof children under 5 years visiting healthfacilities for their routine immunisation.e system extended to providing parentswith information and a service to monitorchild growth. However, with the conflictdriven damage to the health system andthe consequential shortage in nutritionpersonnel, the national nutrition surveillance

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system has suffered from a reduction in thequality of nutrition service provision and dete-rioration in reporting and monitoring. With anexpected increased number of acute malnutritioncases, and a scarcity of nutrition services, therewas a concern that malnutrition cases weregoing undetected.

In order to understand the impact on overallnutrition related morbidity and mortality, de-tection and reporting on cases would need tobe improved. In order to enhance the detectionof malnourished children and fill the informationgap, WHO is collaborating with the MOH andother partners to improve and strengthen theNutrition Surveillance System. Between Apriland July 2014, twelve health centres from 12governorates were selected to pilot a modifiedsurveillance system. is modification encom-passed revised reporting and monitoring toolsand providing trained human resources. epilot governorates were selected using twocriteria: (i) conflict-impacted areas (Daraa,Homs, Aleppo, Rural Damascus, Idlib, Quneiteraand Deir-ez-zor) and (ii) densely populatedareas with high numbers of Internally DisplacedPersons (IDPs) (Damascus, Tartous, Latakia,Hama and Sweida). Coverage rates of nutritionsurveillance, capacity of human resources, avail-

ability of physical space, and equipment needswere also assessed and evaluated within thepilot timeframe. Aside from the pilot centres,nutrition surveillance was also started up againin the highly conflict-affected governorate ofAr-Raqqa, through the coordinated efforts ofWHO field staff.

Numerous constraints were reported by thepilot nutrition surveillance centres. e lack ofhuman resources, space, equipment and telecom-munication-reporting utilities were cited as chal-lenges by a number of Governorates. ese ob-stacles were especially evident in the case ofDeir-ez-Zor, with a significantly under-staffedhealth centre, where the single health providerpresent was only able to take mid-upper armcircumference (MUAC) measurements of 300U5 children per month.

One aim of the pilot was to test the effective-ness of the capacity building trainings conductedon anthropometric measurement techniques in-cluding weight, height and MUAC and the re-porting system. is included assessment of thetools and flow of data and adequacy of referralsand standardised management following com-munity based management of acute malnutrition(CMAM) and WHO 2013 protocols. e findingsof the pilot have demonstrated what changes

World HealthOrganisation Syrian Arab Republic: Revitalised Nutrition Surveillance Centres Map 1

Health District

Nutrition Surveillance Centres

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need to be effected for the next phase of the nu-trition surveillance strengthening which aimsto expand to 10 health centres within each gov-ernorate including enhancing capacity, provisionof supplies and equipment and reporting tem-plates and tools. e expansion began in mid-July when a team of health workers from 20centres in Damascus and Rural Damascus weretrained. By mid-October, 105 surveillance centreswere following the improved surveillance system(see Map 1).

By the end of 2014, it is anticipated thatmore than 115 health centres will be integratedinto national surveillance system. In 2015, anumber of NGOs will be integrated into theprogramme in order to reach more children inaffected and hard-to reach areas. e regularand accurate flow of information through month-ly paper-based published reports shared withWHO and centrally with the MOH by mainnutrition offices at the directorates of health inthe governorates. Reports include cases of mal-nutrition in children under five years across thecountry that will be analysed and utilized tomonitor prevalence and trends, and more im-portantly early detection of cases and referralfor treatment.

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A step towards success: activesurveillance in Aleppo Governoratee surveillance system in the northern Gover-norate of Aleppo has set a high standard andmany ways been exemplary. As one of the mainthe population centres in Syria, Aleppo city wasonce considered the industrial heart of the coun-try. It is surrounded by large rural areas thathave been severely affected by violent conflictfor over 2 years. Huge population displacement,food shortages and economic losses are someof the many hardships Aleppo Governorate in-habitants have faced, making families and es-pecially their children more susceptible to mal-nutrition. With a very active surveillance team,screening for malnutrition was optimised notonly through screening cases entering facilitiesbut also via mobile teams visiting shelters forthe internally displaced in the city and conductingreferrals for cases in need of treatment.

Since the start of 2014, the surveillance inAleppo has consistently reported on cases fromfour health centres in four health districts inthe governorate of Aleppo (the numbers availableso far are limited to specific locations in thegovernorate, are not statistically representativeand therefore not included here). In the monthof August, 12 facilities have been activated in

urban and rural areas of Aleppo. ese facilitiesare expected to screen an approximate 4000children per month. In locations experiencingintermittent violence like north Aleppo, due tothe security situation, some health centres stopreporting when the security situation is dire.is varies the total number of centres reportingfrom month to another with a typical differenceof 1-2 centres.

Referral of detected cases and hospitalcare of complicated cases of severe acutemalnutrition (SAM) e implementation of the pilot phase of themodified Nutrition Surveillance System led toan increase in the detection of cases of malnu-trition requiring treatment and confirmed mor-bidity and mortality due to nutrition relateddisease. Data collection and analysis on SAM isstill ongoing; the full report will be out by early2015. is increase highlighted the importanceof establishing a solid referral system for spe-cialised treatment to reduce associated mortalityand morbidity.

Since January 2014, WHO has supportedthe establishment of Stabilisation Centres (SC)for the management of SAM in hospitals acrossthe country in line with WHO’s SAM Manage-

6 World Health Organisation, Training course on the management of severe malnutrition, WHO/NHD/02.4, 2009

Syrian Arab Republic: Stabilisation CentresMap 2World HealthOrganisation

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ment Protocol, updated in 2009 and 2013. So asto not create parallel systems within hospitals,these centres have been integrated within pae-diatric departments at the main public hospitals.Support to these SCs has been extended in threemain areas, (i) building the capacity of thehealth workforce, critical for effective SAMmanagement and treatment (ii) filling gaps inmedicines, medical supplies and equipment fortreatment of complicated SAM, e.g. anthropo-metric equipment, antibiotics, minerals, vitaminsand F100, F75 formulas and (iii) providing tech-nical support for treatment protocols and re-porting. To date, over 350 health professionalsfrom MOH, MOHE and private hospitals inDamascus, Rural Damascus, Homs (includingHoms city and Tadmor), Hama, Aleppo, Idlib,Lattakia, Deir-ez-zor, and Quneitera have beentrained on the WHO SAM Management Protocoladopting best practice techniques and foodsafety measures6. Additionally, systemised re-porting through a developed hospital reportingtemplate, has been initiated in collaborationwith MOH.

As of August 2014, SCs in hospitals were es-tablished in nine governorates with MOH and

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local NGOs. Centres within the public hospitalsare available in Damascus (2), Aleppo (1), Hama(1), Lattakia (1), Qutaifeh in Rural Damascus(1), Homs (1-Tadmor), Quneitera (1), Sweida(1), Deir-ez-Zor and Idlib (1) (see Map 2). Eightof these centres have received SAM cases inDamascus, Aleppo, Lattakia, Idlib, Deir-ez-Zor,Sweida and Hama. In cities where public healthfacilities have been significantly damaged suchas Homs, Deir-ez-Zor (Boukamal), Dara’a andAr-Raqqa, cases are referred to private or NGOhospitals.

Reports from Damascus, Homs, Dara’a, Aleppo,Latakia, Hama and Deir-ez-Zor have been re-ceived on complicated cases of SAM requiringurgent medical attention. In the case of Hama,over a period of three months (April-July), 42cases of complicated SAM were admitted incomparison to six cases admitted betweenJanuary and March before the establishment ofthe SC. Further expansion of SCs to all gover-norates is planned with the aim to situate atleast one centre per governorate to manage thecaseload of SAM cases requiring hospitalisedcare. Future centres will be located in hospitalsin Deir-ez-Zor (Deir-ez-Zor city), Dara’a, Tartous,Sweida, Qamishli, and Hassakeh.

Mainstreaming Infant and Youngchildren feeding promotionInfant and young child feeding (IYCF) andbreastfeeding promotion has been prioritizedand mainstreamed within most nutrition supportactivities. In Syria before the crisis, the rate ofsix-month exclusive breastfeeding had been con-sistently low (approximately 43%). Without theproper support of health staff and communitybased initiatives, lactating mothers have beenstruggling during the crisis with initiating breast-feeding. In many cases, due to displacementand overcrowded living conditions compoundedby conflict-related distress, mothers lose confi-dence in the quantity and quality of their breast-milk, stopping breastfeeding all together andresorting to other practices. During an obser-

vational mission in early 2013, doctors and mid-wives reported an increasing number of womenwho wished to breastfeed their infants, mainlybecause they could not afford infant formula.Due to the short stay in health facilities followingdelivery, help with initiation of breastfeedinghad been insufficient. Also during 2013, WHOreceived numerous requests from NGOs sup-porting populations in need including the dis-placed to provide breast-milk substitutes likeinfant formula. ese requests were not supportedas they counteract WHO/UNICEF global guid-ance to promote exclusive breastfeeding; instead,WHO focused on promoting optimal IYCFpractices. Requests for infant formula over 2014significantly decreased.

A capacity building and programme-strength-ening project was identified as an essential ele-ment to promote breastfeeding at the health fa-cility and community level with the aim ofraising awareness among lactating mothers inboth displacement shelters and host communities.Since early 2014, WHO has conducted five train-ings for more than 190 doctors and healthworkers from Aleppo, Damascus, Rural Dam-ascus, Quneitera, Sweida, Homs, Derezzor,Hama, Latakia, Hassakeh, Tartous and Daraain cooperation with the MOH-primary healthcare department. Trainings covered the impor-tance of breastmilk, its constituents, techniqueson initiation of breastfeeding and its benefitsfor both child and mothers.

Breastfeeding promotion has been streamlinedacross all WHO nutrition activities. It has beenincluded in all training courses conducted onnutrition surveillance allowing surveillancehealth workers to conduct breastfeeding con-sultations for concerned visiting mothers. Datacollection on breastfeeding rates will also be in-cluded through the nutrition surveillance systemin the upcoming months, providing informationfor analysis of trends and further investigationson causal factors of the changes to breastfeedingrates. As yet, no assessment has been conductedto investigate any links between breastfeedingstatus and acute malnutrition.

Preventative micronutrientsupplementationEqually important to strengthening treatmentcapacity, preventative measures against micronu-trient deficiencies have also been scaled up bynutrition working group partners through blanketdistribution of ready-to-use supplementary foods(RUSF). WHO has also contributed to this ini-tiative through the distribution of micronutrientsfor children and mothers during immunisationcampaigns and in health facilities. In 2014, upto 900,000 children and 7500 adults were providedwith micronutrient supplementation.

The way forwardDuring the second half of 2014, WHO will befurther enhancing its nutrition activities across

Baby girl admitted to WHO supportedSC who was sucessfully treated anddischarged 12 days later

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four main areas: 1) Further strengthening of the nutrition sur-veillance system will be achieved through con-ducting decentralised trainings on nutritionsurveillance to expand the re-activation of nu-trition surveillance in 10 health centres inLatakia, Tartous, Idleb, Hama, Dara’a and Homs.Efforts will also be made to improve data entry,collection and reporting through strengthenedoperational capacity and procedures at the nu-trition surveillance centres.

2) Distribution of supplies to SCs to improveand enhance treatment of admitted SAM cases.In order to expand geographical coverage, WHOis drawing on NGO and private sector capacitiesacross the country. NGOs operating hospitalswill be trained and supported with in-kind do-nations to also be able to treat detected compli-cated SAM cases.

3) Mainstreamed IYCF activities through ex-tensive trainings for health workers in the healthcentres providing nutrition surveillance, allowingthem to deliver key messages to mothers on theimportance of breastfeeding and complementaryfeeding. Furthermore, two courses of trainingof trainers will be implemented to decentraliseIYCF trainings across the country, contributingto raising the awareness of mothers visitinghealth centres or hospitals, or residing in dis-placement shelters or the host community.

4) Strengthened coordination with the NutritionWorking Group partners will be crucial in en-hancing a coordinated referral process fromsurveillance centres, outpatient and inpatienttreatment centres. Nutrition sector partners in-cluding MOH and SARC predominantly sup-ported by UNICEF have worked to establishOutpatient erapeutic Programmes (OTPs) inhealth centres to include the follow up andmanagement of both SAM and MAM (moderateacute malnutrition) cases. Additionally, preven-tative nutrition services and blanket supple-mentation has been supported by WFP. eseefforts have been strongly coordinated and con-tinue to be through regular Nutrition sectormeetings and bilateral meetings with UN sisteragencies to bridge programmes and fill in gapsworking towards a holistic CMAM approach.

WHO in coordination with nutrition sectorpartners has scaled up its nutrition response tohelp alleviate nutrition insecurity from a healthperspective, aiming to provide quality nutritionservices at health facilities to prevent, detectand treat cases of malnutrition and related mor-tality and morbidity. Efforts continue to obtaina clearer picture of the prevalence of malnutritionacross the country. Halting the increase of mal-nutrition prevalence during the protracted Syriancrisis is crucial for children’s health, well-beingand physical and cognitive development.

For more information, contact: Hala Khudari,WHO Technical Officer - khudarih@who.int

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Emma Littledike has been the Health andNutrition Manager for World VisionInternational on the Northern Syriaresponse since September 2013. She wasthe Nutrition Sub-Working Group LeadFebruary to May 2014.

World Vision International (WVI)set up offices in southern Turkeyin May 2013 and began work inJarabulus and Manbij, Aleppo

governorate in response to the escalating violencein Syria and reports of large scale internal dis-placement. is article describes their experiencesin supporting nutrition and related primaryhealthcare programming to internally displacedpersons (IDPs) between May 2013 and April2014.

Current IDP situation (May 2014)e total number of IDPs in Jarabulus is currentlyestimated at 22,875 and the total catchment pop-ulation is approximately 68,000. e total numberof IDPs in Manbij is estimated at 115,518 withan estimated catchment population of over 1million. In Jarabulus, the camps are managed byan independent Syrian individual with strongrelationships in the community. Informal campshave been established in collective communityspaces such as schools and unfinished buildings.ere are a greater number of informal camps inManbij than Jarabulus. Organised and establishedcamps in Manbij are managed by other INGOs.e majority of IDPs at the camps are fromHoms, Hama and within Aleppo governorates.

Early needs assessmentAt the time of initial assessment by WVI, onlybackground nutrition data from Syria was avail-able. Pre-crisis, Syria had a high global acutemalnutrition (GAM) prevalence of 9.3%, stunting(23%) and underweight (10.3%). Micronutrientdeficiencies in children 0-59 months were alsoprevalent: 29.2% anaemia, 8.7% Vitamin A de-ficiency and 12.9% iodine deficiency1 Pre-crisisinfant and young child feeding (IYCF) practices

were poor. National figures show a low initiationof breastfeeding within the first hour of birth(42.2%) and low exclusive breastfeeding amongstinfants < 6 months (42.6%) (national survey,2009)2. e percentage of children under 2 yearswho are not breast-fed is estimated at 10%.(2009)3. According to national data from 2006,the timely complementary feeding rate for chil-dren 6-9 months was 36.5% and the proportionof children 6-11 months who received the rec-ommended minimum number of complementaryfoods per day was 20.8%4.

In May 2013, an observational rapid area as-sessment was conducted by WVI in JarabulusDistrict, Aleppo governorate, Northern Syriato determine the need for and nature of healthand nutrition interventions. e assessmentteam was made up of members of WVI’s GlobalRapid Response Team. e target populationfor the assessment comprised internally displacedpersons (IDPs) living both in one camp andamongst the host community (four additionalcamps were later established to meet the needsof the increased number of IDPs arriving). epriority needs voiced by the IDP and host com-munity during the rapid assessment in Jarabulus,Aleppo governorate were access to health servicesfood, shelter and improved water, sanitation andhygiene (WASH) facilities for the camp residentsand town inhabitants. Access to breast milk sub-stitutes was also reported as a major issue.

Programme responsePrimary health service supportWVIs immediate priority was to establish supportto primary health care services. Health serviceswere limited, consisting of a number of privatedoctors and a Qatari Red Crescent Field Hospital.

e Syrian Arab Red Crescent clinic had notfunctioned for a while. IDPs could not afford tovisit the private doctors and the camp managementwas unable to cover the cost of medicines forthe residents. In conjunction with the local lead-ership, including the health committee, a smallprimary health care centre (PHC) was establishedin June 2013 next to the main camp in the area.A paediatrician, midwife and two nurses werehired to provide services, while a communitymobiliser was hired to conduct health and nu-trition assessments, to provide psychosocial sup-port to women and to counsel on optimal IYCFin all the collective centres. An English andArabic speaking coordinator linked expatriateand Syrian staff. All staff were qualified withinthe Syrian health system and selected withsupport from the local council and the healthcommittee, who approved all appointees. Initially,expatriate staff visited the projects biweekly forongoing training and support, but once theborder was closed to expatriates in July 2013, allsupport, supervision and training was doneeither remotely through phone or skype access,or at the nearest border crossing on a bi-monthlybasis. Few Syrian staff could cross the border tomeet with management staff as this was timeconsuming and had to be well planned due tothe busy work schedules in the field and theneed to keep services running. Lack of identifi-cation documents was also an issue.

Experiences andchallenges ofprogramming inNorthern Syria

By Emma Littledike and Claire Beck

Claire Beck is the Global EmergencyHealth, Nutrition and WASH TeamLeader for World Vision International.

Measuring height during the WVI supportedanthropometric assessment

1 Revised Syria Humanitarian Assistance Response Plan (SHARP), Syrian Arab Republic, January- December 2013

2 Syrian Family Health Survey, 20093 Figure estimated from area graphs in Trends in Infant

Feeding Patterns, January 20094 Multiple Indicator Cluster Survey, Syrian Arab Republic,

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Building IYCF and SAM treatmentcapacitySupports to IYCF and SAM treatment capacitywere also provided. A planned IYCF trainingfor all health and water, sanitation and hygiene(WASH) staff was postponed due to insecurityin the field. Instead, two doctors crossed theborder for accelerated two day training. eywere equipped with training materials andtechnical guidelines in Arabic language, andequipment to replicate it back in Syria duringthe aernoons when the clinic was closed.In practice, they could only deliver part ofthe training due to clinical demands. Guidanceon the treatment of severe acute malnutrition(SAM) was also provided through technicalresources and discussion. is proved sufficientfor the paediatrician to begin treating acutelymalnourished children who came to the clinic,rather than referring them for treatment atthe hospital, which was 45 minutes travel byroad and not always secure. F75 and F100were made using locally available ingredientsas commercial product was not available (seelater for issues around supplies). Until then,the few children that presented at the clinicwith SAM had complications and were referredto the hospital for medical treatment whereno nutrition support was provided.

e initial rapid assessment was observa-tional; it was not possible to collect data onfeeding practices. Informed by background(national) data, all health staff were sensitizedto the importance of exclusive breastfeeding.However the demand for BMS was high fromthe IDP and vulnerable host community.ere was no BMS programme at the timealthough infant formula was available to pur-chase locally (see later under ‘challenges’).As a result of consultation with the governinggroup, WVI adapted the organisation’s Women,Adolescent and Young Child Space (WAYCS)model and instead of having separate dedicatedspaces for women and children, an alternativemore culturally appropriate approach wasdecided upon which was to set up WAYCSwithin clinic facilities. Staff began to holdsmall meetings for women in one of the clinicrooms to support them in breastfeeding andcomplementary feeding. It meant, however,that it was harder to include husbands andwider family in these sessions. To help over-come this, staff made tent-to-tent visits andcollection centre visits to all pregnant andlactating women to provide support and ed-ucation.

Further nutrition assessmentsWhen WVI programmes began in June 2013,there were no current nutrition data available.By August 2013, two rapid mid upper armcircumference (MUAC) assessments had beenconducted by two INGOs among children inIdleb and Ar raqqa governorates in northernSyria. Both found low prevalence rates ofSAM (<0.4%) and moderate acute malnutrition(MAM) (<2.4%). Both assessments had lim-itations. e larger rapid assessment in Arraqqa5 was conducted alongside a measles

vaccination campaign making it difficult toensure quality data collection and the majorityof children measured were <12 months. erapid assessment in Idleb on 4,230 childrendid not provide enough information on thesampling methodology and household selec-tion to determine how representative it was.

Given these limitations and the report of30 cases of severe and moderate acute mal-nutrition to clinics between June and December2013, WVI undertook an anthropometricsurvey amongst IDPs in Jarabulus district,Aleppo governorate on 20th – 24th December2013. Both weight-for-height z score (WHZ)and MUAC were assessed. Given the opera-tional constraints, training on anthropometricassessment was compromised and relied onguidance documents, video links and a surveyleader (paediatrician) with research experiencein nutrition and anthropometric assessment.e assessment was carried out during a diffi-cult time (snow and conflict) and the method-ology had to be adapted to survey accessibleareas. e prevalence of acute malnutritionwas again found to be low: 2.6% global acutemalnutrition (GAM), 0.5% SAM and 8.1%underweight (low weight for age). Prevalenceof stunting was 22% (7.7% severe). A photo-graph of each child’s measurement was takenand examined for accuracy; the main limitationwas an inaccurate adjustment for clothingweight (see images).

In September 2013, a joint scoping missionwas carried out by the Global NutritionCluster (GNC) Rapid Response Team (RRT)consultant in Northern Syria to assess thenutrition situation.

Scaling up services: small scaleneeds, large scale challengesCase management of SAMWhilst the prevalence of SAM was low, therewas a need for small-scale treatment capacity.Existing capacity was weak given lack of train-ing and low exposure of staff to WHO treat-ment protocols. e majority of in-patientfacilities did not follow WHO protocols andused intravenous fluid as one of the maintreatment methods for children with SAMand complications. Exceptions were specialisedchildren’s hospitals in Aleppo and Damascusthat are part of the Syrian Ministry of Health(MoH) and which follow WHO treatmentprotocols. In Syria, there was no commerciallyproduced F100 or F75 available so locallyprepared F75/F100 was used instead. An ex-ample of case management of a SAM case isgiven in Box 1.

In general, community based managementof acute malnutrition is being explored butthere is no community health worker networkin existence so cases are being managed by aselect few INGOs at their supported inpatientand outpatient facilities across the country.WVI is the only external (INGO) health

An infant presented to the clinic with acutewatery diarrhoea having already receivedtreatment with antibiotics and oral rehydrationsalts (ORS) from a private physician. The child hada history of chronic diarrhoea and had beenformula fed since birth (never breastfed). The childhad a WHZ <-3 and MUAC 11cm at 9.5 months ofage. The infant showed signs of marasmus anddehydration. He had a fast pulse and dry hair. Hisweight on presentation was 5.5kg (a weightrecorded at the private clinic was 6kg).

The staff began treatment by stopping the courseof antibiotics, given the lack of evidence for theinfection diagnosed. For the first two days,ReSoMAL solution was provided (5ml/kg =30mlevery half an hour). This was prepared as 5%Dextrose, 1.8g of sodium chloride and 1.5g ofpotassium chloride in one litre of water. F100 wasalso given and it was prepared as: 80g powderedfull fat milk, 45g olive oil, 50g cane sugar, 1gpotassium chloride, 0.5g magnesium citrate, 2mgcopper acetate and 20mg of zinc acetatedissolved in 1 litre of boiling water and set to cool.The F100 was given to the child in 60ml dosesevery 2 hours. Vitamin A was also given for 2 days.The clinic staff reported that they cannot prepareF75 as there is no skimmed milk.

On the fourth day they gave the child Bactrimsyrup and on the 8th day, gave iron. The childrecovered and then maintained his pre-hydrationweight (6kg) during this stabilisation period.

During the following 10 days, the quantity of F100was increased and under supervision, heproceeded to gain weight at a rate of 15g/kg/day(90g/day). For another 20 days, the child wasmanaged at home with increased F100; his fatherwas capable of preparing F100. The child’s weightincreased to 8kg and MUAC increased to 12.5cm.He was discharged on lactose free milk until oneyear of age and then transferred to full fat milk(reconstituted NIDO). The child now drinks fullcream milk, one boiled egg, and fruit daily. Hereturns to the clinic for regular weigh in.

Box 1 Treatment of a case of SAM

Severe acutely malnourishedchild on admission at PHC inAleppo governorate

Severe acutelymalnourishedchild aer 3weeks treatment

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Source: INGO worker

5 The actual number of children measured is not confirmed.

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Field Article

of time required to submit and get feedbackfrom applications.

Access to health care: the role of theprivate sectorIn Manbij city, Aleppo governorate, there are289 doctors working privately providing highquality care. IDPs are not able to pay the com-mercial prices for treatment at private clinics.Many primary and secondary clinic health carestaff provide free consultations or a negotiatedlower payment rate but given financial and timeconstraints, they are only able to see a smallnumber of patients per day. WVI has recentlyembarked on a 1 year pilot of a small-scalehealth care voucher system using the privatesector to provide quality services to IDPs whohad little or no household income (April 2014 –31st March 2015).

e pilot targets children under 5 years inselect areas of Manbij. ey will receive a voucherentitling them to one consultation at any privateclinic and medicine from a pharmacy over the12 month project period. At WVIs primaryhealthcare facilities in Jarabulus and Manbij,children under 5 years have the highest propor-tion of respiratory tract infections, gastrointestinaldiseases and acute malnutrition. ey are alsothe most vulnerable group to acquire diseaseswith outbreak potential such as acute jaundicesyndrome, acute watery diarrhoea, polio andmeasles.

e caregiver presents the voucher to an ac-credited primary or secondary healthcare providerthat they select, along with the eligible child’sIDP registration card. Aer the consultation,the provider then submits a claim to the agencyto obtain reimbursement for the services providedwith all required paperwork, including detailedpatient records. If the healthcare provider issuesa prescription, the caregiver can obtain medicinefrom an accredited pharmacist by presenting italong with the voucher and the eligible child’sIDP registration card.

Healthcare providers will receive an inductionon the voucher system detailing the beneficiaryage group eligible to receive treatment, recordsrequired for verification and how they can claim.Additionally, a number of vouchers will beissued from the agency’s PHCs in Manbij to pa-tients in need of quality secondary healthcaretreatment from specialist doctors.

A demand-side financing scheme such asthis is expected to reduce financial barriers toaccess and therefore should improve utilisationof health facilities by IDPs. Since the voucherscheme allows the caregiver to choose theproviders, this should encourage quality healthcare services through increased competition inthe market. Targeting children under 5 yearsshould also reduce the possibility of voucherselling and misuse. By design, revenue earnedby a health facility from IDPs is directly pro-portional to the number seen. erefore, thisscheme should enhance the quality and quantityof targeted private healthcare services. WVIwill monitor quality of consultations randomly

to ensure clinics signed up to the scheme areproviding adequate services.

BMS supplies and supportAs reflected in the early needs assessment, thedemand for BMS was high from the community;a reflection of its common use. Uncontrolledand untargeted distributions of BMS remaincommon, however determining the extent towhich this is happening is extremely difficult,especially given the response is managed remotely.Some actions have been taken at coordinationlevel to try and minimise risks (see postscript).

e need for support with safe artificialfeeding was identified as particularly importantin areas receiving large supplies of BMS. Infor-mation, Education and Communication (IEC)materials (posters and flyers) were provided toall agencies on how to prepare formula safely.ere was one observational report of infantformula being distributed into cups from a largetank / container and handed out so in additionto the IEC, the working group also identifiedthe need for safe feeding kits to be distributed.

Infant formula availability in the markets inSyria has been very sporadic and prices arehigher than before the conflict. It is not affordablefor IDPs and vulnerable host communities.Prices range from $7-10 for 1kg in Jarabulusand Manbij when it is available. A small amountis available in pharmacies but it is not enoughto meet the needs of the communities. It is alsoavailable in some markets. Currently (May 2014)there is almost none available. WVI has notprocured infant formula as the programmingfocus was on breastfeeding support and pro-curement and transport of medicines and suppliesfrom Turkey has been a huge challenge.

provider in our operational areas in NorthernSyria.

Due to cultural norms and medical hierarchy,it is also proving difficult for humanitarian agen-cies to support in-patient facilities to improvethe treatment of SAM with training and support.Designated in-patient referral facilities need tobe identified in each governorate and there is arequirement for training events inside Syria tobe delivered by a highly qualified consultant.Many health personnel that are both employedby the regime, working independently or for anINGO are unable to cross the border into Turkeywithout a passport. Travel to Aleppo to acquirea passport carries substantial safety risk. eneed was therefore identified for a strong distancelearning training package comprised of narratedvideos in Arabic that could be stored on USBsand disseminated in-country. Whilst this is in-ferior to practical ‘on the job’ training at in-patient facilities, it is perhaps the only way toimprove treatment, particularly in areas withpoor access such as Deir ez zor and Homs.

Of note, we have seen a higher caseload ofmalnutrition cases in the past two months.ere have been around 30 cases of malnutrition(24 moderately malnourished and six severelymalnourished) identified at the clinics.

erapeutic food supplies Establishing a supply of therapeutic and sup-plementary feeding products has been prob-lematic. Our agency could find no local equiva-lents of RUTF in Turkey and acquiring therapeuticfeeding products from reputable suppliers hasbeen difficult. e customs cost to import prod-ucts is excessive. For example, an RUTF orderworth $650 carried a customs clearance cost of$5000 on top of a $1500 shipment cost. Increasingthe order quantity did not improve the cost effi-ciency. Our agency managed to find a supplierwho helped to secure customs clearance free ofcharge as a one-off gesture of support. Howeversupplies had to be shipped straight into Syria(since the agency was not registered in Turkeyand so goods could not be stored in-country).us it was not possible to share the supplieswith other Turkey-based INGOs and SyrianNGOs as planned. Border closures further pre-vented staff sending supplies back to Turkey toshare with other agencies. Importing and storingproducts in Turkey requires agencies to be reg-istered as organisations undertaking medicalactivities. A number of agencies are not yet reg-istered, despite their efforts, due to the length

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Medical examination at aprimary health centre inAleppo governorate

Ingredients formaking F100

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Field Article

InnovationsRemote training deliveryere have been many challenges in deliveringtraining, such as lack of Arabic speaking trainersavailable in Turkey, border closures preventingtravel, and limitations on the number of partic-ipants at venues. A training of trainers reliesupon staff prioritising delivering training in-country which may not be feasible dependingon the area, workload and available resources.is led WVI to develop a distance learningpackage in the style of Khan Academy videos6.Also, WVI has worked with a regionalGNC/UNICEF IYCF consultant to produce aharmonised translated IYCF training packageusing training materials from many NGO nu-trition actors working in the region. A series ofvideos on all nutrition topics, particularly IYCF-E and nutrition in emergencies, will be producedon USBs for distribution to all NGOs and passedonto Syrian health staff. Pre- and post-trainingtests are also being developed and added to theUSBs so that agencies can check and verify thatthe staff have watched the videos and understoodthe content. Given the high turnover of medicalstaff in many areas, this also ensures that trainingnew staff is not an additional burden.

DiscussionRemote management led to the development ofrobust data collection mechanisms which wereset up in the early stages of the programme inSeptember. A Health Information ManagementSystem (HMIS) was developed to monitor con-sultations for all morbidities including malnu-trition. e HMIS automatically calculates in-cidence, prevalence and case fatality rates pergeographic area. Data can be cross checked withpatient records. Data entry is simple for fieldstaff and data collation is automatic. ere is aneed for a standardised database system whichcan be used by all INGOs and Syrian NGOsand patient ID cards. Given the difficulties withensuring a consistent supply of medicines, es-tablishing a strong pharmacy system is also in-tegral to provide inventory reports and determineneeds ahead of time. e HMIS and pharmacysystem combined enabled us to produce anannual forecast of pharmaceutical products re-quired per clinic on a monthly basis, takingseasonal fluctuations in morbidities into con-sideration. In addition to data management sys-

tems, beneficiary feedback mechanisms werealso important to ensure quality of service pro-vision. Putting these standardized systems intoplace in each project early was essential to gainan indepth understanding and provide a greaterlevel of support.

Remote management calls for strong andconsistent communication via telephone dailyat designated times, and regular trainings (inTurkey, online and in Syria). Given access toprogrammes was not feasible, the building ofhealth worker managerial skills became asintegral as health technical guidance, particularlyfor Health Coordinators in each location. Pro-vision of training about humanitarian standardsand regulations was also critical given all healthstaff had no prior experience of working on ahumanitarian programme. Creativity was criticalto ensure staff received quality training giventhe difficulties with border closure and lack ofpassports. Training delivery was through avariety of methods including Webex, trainingof trainers, videos and contracting Syrian con-sultants. Trainings are oen conducted in alarge community space and videoed for thebenefit of new staff who may join in the future.

Effective contingency planning was anotherimportant lesson learned, given conflict and es-calations in fighting have led to hibernation(temporary suspensions of activities) and borderclosures. ese factors have complicated bothmovement of staff into and out of Syria and dis-tribution of medical and therapeutic food sup-plies. e temporary cessation of clinic activitieshad a huge impact on the population as thereare no other health providers. We learned thatdetailed contingency planning is essential. Sup-plies need to be pre-positioned and stored ap-propriately and staff need to have completedsecurity training and be thoroughly briefed onsecurity standard operating procedures.

Given the difficulties with procurement forunregistered agencies and transportation of sup-plies amidst border closure, early hire of amedical procurement specialist is essential tosupport supply chain establishment and man-agement. e hiring of pharmacists within Syriato dispense medicines to patients and manageand plan stock from an early stage was also es-

sential. Our INGO has procured drugs fromTurkey and within Syria. Sourcing drugs fromwithin Syria can be a challenge for staff sincenot all pharmacies have the amount in stockthat is required, forcing them to visit manytimes and buy piecemeal. Research also needsto be conducted evaluating the quality of medi-cines and supplies available for purchase insideSyria. WVI has developed an assessment toolto gain more information about production,regulation and gauge the opinion of Syrian phar-macists and health staff about the quality ofmedicines. Procurement and distribution of es-sential primary health care medicines acrossthe border has posed significant challenges.Supplies have had to be sent out with biscuitshipments and once across the border, trans-porting them within areas affected by conflictto the project sites has been extremely difficult.

A thorough understanding of the situationin terms of health staff and facilities existing inthe areas and resources available is very important.Establishing an ambulance was a real challengegiven there were no equipped suitable vehiclesfor use. A large van, which had been badlydamaged and abandoned in the conflict, wasdonated by local authorities and refurbishingand fixing the vehicle was a major effort. Pro-curement of specialist ambulance equipmentfrom Turkey was also extremely time consumingand problematic. Both of these factors led to atime delay in the establishment of ambulanceservices which was not anticipated at the be-ginning of the programme. Gaining knowledgeof the health care system generated the idea forvoucher provision instead of the establishmentof more clinics which may not be sustainable. Itwas deemed more effective for a larger numberof doctors to remain in their private clinics andbenefit from supplementary pay to treat IDPsthan for a smaller number to give up their workfor a position at a WVI clinic which may not beable to run sustainably. An indepth assessmentof the capacity of all private clinics and phar-macists is currently being conducted.

For more information, contact: Emma Littledike,email: Emma.littledike@hotmail.co.uk

6 https://www.khanacademy.org/

MUAC measurement during the WVIsupported anthropometric assessment

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Clinic staff outside one of the primary health centres in Jarabulus

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Postscript

The Global Nutrition Cluster (GNC) secondeda Rapid Response Team (RRT) Nutrition con-sultant to the Syria response for a three

month period (13 Dec 2103-13 Feb 2014) to pro-vide technical, strategic and coordination supportto the Northern Syria Nutrition Sector response. Onher departure, I was appointed as interim NutritionCluster Coordinator for a two month period to stopgap the lack of data and information on the nutri-tion situation. This appointment was on a volun-tary basis, in addition to a busy full time jobmanaging three large health and nutrition pro-grammes for World Vision International (WVI).

In this role I have led weekly meetings and tried tobuild an evidence base for the nutrition situation.A key task in my role as coordinator was to evalu-ate critically existing data on the nutrition situation(e.g. review three anthropometric assessment sur-veys in Aleppo, Arraqqa and Idleb (see earlier arti-cle)) and emerging from this, to advocate for andhelp support securing more nutrition information,especially in areas where accessibility, food secu-rity and humanitarian assistance were poor. Duringmy tenure, a lead partner and survey methodology(SMART) was eventually agreed for a representa-tive SMART nutrition survey in each governorateand a purposive sample in sub-districts that weremore likely to have malnutrition1. The survey isnow underway in Idlib (May 2014) and other gov-ernorates will be surveyed post Ramadan.

There is a need to improve nutrition surveillancethrough clinics, community spaces and communityworkers. This is particularly important in areaswhere there is very little humanitarian support andfor areas dependent on food assistance that can beaffected by hibernation (when agencies have tosuspend activities due to conflict) and border clo-sure. Camps also need to screen new arrivals thatmay have travelled from highly food insecureareas. Many health actors do not record malnutri-tion in their health monitoring systems and fewcases of malnutrition are reported amongst healthpartners (this may be due to low caseload and/orlow awareness at management or field level). AMid Upper Arm Circumference (MUAC) screeningpackage with guidance materials and a trainingvideo is in development to help address this. Theaim is to disseminate the screening kit to all actorsand all community stakeholders and to offer onlinesupport to practice measurements via WebEx orSkype video. The cascade training of trainer’smodel is not far reaching enough in this context.Provision of a screening package such as this,whilst not ideal, could be a partial solution to theproblem of poor access. Referral facilities also needto be identified and incorporated into the screen-

ing package and they in turn, require training inthe treatment of severely malnourished cases.There is also a need to incorporate data collectionon underlying causes of malnutrition into all multi-sector rapid surveys to gather more information oncamp and host community needs. A multi-sectorassessment is currently in planning (May 2014).

A major coordination challenge has been aroundthe management of breastmilk substitutes (BMS),including around untargeted distributions to thepopulation. To try and gain more information, in mycoordination role, I advocated for inclusion of ques-tions about BMS distribution in all general rapidsurveys being conducted. A BMS distribution indi-cator was subsequently included in the ResponsePlan. Awareness amongst actors of the OperationalGuidance on infant and younfgchild feeding inemergencies (IYCF-E)2 and the International Code ofMarketing of Breast-Milk Substitutes3 was improvedthrough handouts and making resources availableon the google drive established for the working nu-trition sub-group.

Sourcing therapeutic food supplies has been prob-lematic (see earlier article which reflects the issueswell under ‘challenges’).

Nutrition coordination in itself has been challeng-ing in this context. Nutrition is not considered asufficiently important issue to be a stand-alonesector as there is no evidence of acute malnutri-tion. This has led to the formation of a nutritionsub-group in the health working group. Howeverparticipation and engagement of agencies in thenutrition sub-group has been minimal. There arevery few nutrition experts in-country and only sixagencies implementing nutrition activities. Manystructured sessions had to be postponed becauseof poor attendance. All agencies were regularlysent agendas, meeting presentations and technicalguidance documents to ensure they were sup-ported with adequate resources.

The focus of coordination on nutrition has been onassessments, management of acute malnutritionand on IYCF. The degree of scale up needed forthese nutrition interventions is unclear due to lackof current data on acute malnutrition prevalenceand IYCF practices. While there are cases of SAM re-ported, the number of reporting facilities andcatchment populations is unknown. We suspectthere may be high levels of SAM cases in specificpockets of the country with poor access to fooddistribution and humanitarian support.

Additional significant nutrition problems are stunt-ing and micronutrient deficiencies which have re-ceived little programming attention. There is a

need to build a solid evidence base and to focus onprevention activities in the immediate future.Syrian agencies have much greater access andneed greater technical support from internationalNGOs to programme according to the needs theyare witnessing in their areas of operation. In theimmediate term, more nutritionists are anticipatedto arrive to contribute expertise to the nutritionworking group that may encourage participation.

My coordination time would have benefitedgreatly from more support with obtaining suppliessuch as ready to use therapeutic food (RUTF), safefeeding kits (for infants using BMS) and anthropo-metric equipment. Given the nature of the Syria re-sponse, the usual support of UNICEF with regard tosupplies was not available. More support in secur-ing Arabic speaking trainers would also havehelped enable trainings. It is questionable whethera working group lead can be effective withoutgood resource provision.

My coordination role has now ended and nutritionis incorporated into the health working group.There are advantages to this, as it allows nutritionissues to be discussed repeatedly with a largergroup of actors for which it should be a concern.Integration into the health working group has ledto increased attention and nutrition now com-prises a substantial part of the new annual re-sponse plan. By July 2015, primary health facilitieswill improve screening and referral through stan-dardised nutrition service packages. Treatment ofacute malnutrition according to WHO protocolswill be improved at designated health facilities.Access to support on IYCF practices will be im-proved through the training of focal points.Children and pregnant and lactating women willaccess micronutrients from targeted supplemen-tary or fortified foods, supplements or multiple-mi-cronutrient preparations. Encouraging themainstreaming of nutrition activities into othersectors will also be very important. I continue toplay an active nutrition role supporting with up-dates, discussion points and technical support toagencies on a voluntary basis.

For more information, contact: Emma Littledike,email: Emma.littledike@hotmail.co.uk

Postscript Stop-gapping nutrition coordination for the Syria responseBy Emma Littledike

is is a personal account of the experiences of Emma acting to stop-gap nutritioncoordination around the cross border operations into Syria from Turkey.

1 A specialist agency developed a database ranking areas by likelihood of higher prevalence of acute malnutritionusing food security and health data from the Syrian Integrated Needs Assessment (SINA)

2 An international policy guidance endorsed by the World Health Assembly. Available at: http://www.ennonline. net/resources/6

3 Access the full Code at: http://ibfan.org/the-full-code

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Field Article

The war in Syria is now in its thirdyear and having displaced over fourmillion Syrians internally - with over2 million fleeing their country to Jor-

dan, Lebanon, Iraq and Turkey - there is no endin sight. In Northern Syria, over 200,000 Syriansare living in internally displaced population(IDP) camps, namely Atmeh, Qah, Karameh,Aqqrabat, Bab-Al- Hawa and Al-Salham, while35,000 people are living in non-camp settingsin villages.1

Provision of assistance to such a large numberof displaced people in camps with inadequateinfrastructure is a challenge to humanitarianorganisations. Most of the emergency responseinvolves in-kind distributions of food and non-food items. ese interventions have been effec-tive in saving lives and preventing a further de-terioration in the humanitarian situation. How-ever, the approach has several drawbacks, in-cluding the fact that it is a huge logistical burdenand time consuming activity -from procurementto stocking and transporting commodities todistribution. is is made all the more difficultin conflict affected areas. Also, it disempowersthe affected population as it does not providethem with the ability to decide what commoditiesthey want or prefer. With the aim of mitigatingthese problems, a pilot voucher programme wasdesigned and implemented by an internationalnon-governmental organisation (INGO) in oneof the IDP camps.

Overview of voucher programmeis involved voucher distribution and thearrangement of two market days at which tospend the vouchers. e programme was im-plemented over one month. e programmewas informed by a needs assessment and marketassessment (1 week) by the INGO, followed byvendors’ selection and beneficiary registrationbefore implementation.

e needs assessment involved four focusgroup discussions (FGD) to understand theIDPs’ need for non-food items. e FGDs wereconducted with men, women, young boys andyoung girls. ey indicated that the top threepriorities were hygiene items, clothing, andkitchen items. e preference was for Syrianmade items that met their social and culturalvalues, such as scarves, long skirts, specificshampoos and detergents. Based on the identifiedneeds, market prices were collected for themajor items and maximum prices were agreedwith the vendors that would apply for the twomarket days. is was undertaken to protectthe value of the vouchers that was based on thefindings of the market assessment. Findingsfrom the market and price assessments wereshared with both vendors and beneficiaries. e

arrangement was governed by a signed memo-randum of understanding with the INGO officeto keep the price as agreed or constant. An ex-ception was if vendors wished to sell at a lowerrate (while maintaining quality) to attract buyers,they were free to do so. Beneficiaries had alsothe right to negotiate on price in order to buymore items. Either way, better deals could bemade for the same quality of product. e agree-ments also included clauses on the respect ofhumanitarian principlesand using an agreedupon stable exchange rate of Syrian Pound (SP)to United States Dollar (USD). Field monitoringand support was undertaken by the field staff.

Vendors were identified from nearby Syriancities and their capacity to meet the identifiedneeds was assessed. Twelve vendors were selectedto participate in the market day to create enoughcompetition to lower the prices, however onlyseven were able to participate. e five vendorswho did not participate pulled out at the lastminute; no reasons were given but may havebeen due to security issues or lack of sufficientstock.

ImplementationA total of 420 IDP households benefited fromthe pilot programme in the camp. Each householdwas provided with 12 vouchers, worth 12,000SP (69 USD). e vouchers had denominationsof 3,000, 1,500, 600 and 300 SP, to provide moreflexibility in shopping for smaller or bigger items.

Two market days were selected and agreedon with the beneficiaries and vendors. e ven-dors trucked their goods to the camps on theagreed dates and the camp leaders were respon-sible for securing a space for the market placeand for crowd control. e INGO staff monitoredall activities during both market days and pro-vided guidance when needed. At the end of thefirst market day, the vendors packed their re-maining items and carried them back to their

home towns. With a better understanding ofwhat the IDPs wanted to buy, the vendors in-creased the amount and the diversity of theitems they brought to the second market day.

Feedback

A rapid post distribution survey was conductedwhich found that all 420 households had spent100% of their vouchers. e top three purchasedcommodities were hygiene materials, plasticmats, and clothing (see Figure 1). Beneficiariesindicated that they were highly satisfied withthe programme and commented that it was thefirst time in two years that they were able to dotheir own shopping. ey were pleased to regaintheir ability to make their own decisions aboutwhat to purchase for their families. Howeverthey commented that the price of goods hadrisen sharply over the past years due to loss ofSP value. Some of the beneficiaries observedthat prices were three times higher comparedto what they used to pay in their hometowns acouple of years ago. Overall, the pilot programmewas appreciated by the beneficiaries because itgave them the opportunity to choose goods de-pending on their needs, the goods were fromSyria, the suppliers were Syrian, and the responsetime between the need assessment and themarket days was very short. ere was nosecurity problem and no complaints were reg-istered from the beneficiaries or the vendors.To date (May 2014), the programme has notbeen repeated but the team is preparing to scaleup the voucher system to other camps.

Conclusionse voucher programme was a speedy responseto the camp IDPs and the best way to addresstheir basic needs. Satisfaction among the bene-ficiaries was very high mainly due to a highlevel of participation (involving the beneficiaries)during the needs assessment, the market as-sessment and consultations at various levels.Also, use of local suppliers (Syrian) who areknown by the community and part of the sameculture helped to supply materials that fit to thecontext and cultural values of the IDP’s. evoucher system has proven to be applicable inan IDP camp setting. It was implementedquickly in an emergency context to addressbasic needs of the IDP’s, and carried lower risksdue to the requirement for less logistic activitiesand low visibility of the approach.

Above all, the voucher approach empowersbeneficiaries and respects their dignity as itgives them the right to choose how they meettheir needs, which is fundamental principle ofthe humanitarian charter.

Non-food cash voucher programmefor IDPs in Northern Syria By an international NGO

Written April 2014

1 Turkey and Syrian refugees: the limits of hospitality. http://www.brookings.edu/research/reports/2013/11/14-syria-turkey-refugees-ferris-kirisci-federici

Plastic mats

Hygiene materials

Clothing

Kitchen items

Figure 1: NFI voucher spending in SyrianIDP camp

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Field Article

ContextGOAL’s response to the Syria crisis began inNovember 2012. To date, it has provided vitalfood and non-food aid to over 300,000 benefi-ciaries through both direct distributions andvoucher programming in Idlib and Hama Gov-ernorates, Northern Syria, in addition to in-creasing access to water for over 200,000 peoplein northern Idlib.

GOAL Syria currently receives funds fromfour donors (OFDA, FFP, UKAID and ECHO1).Under OFDA, GOAL implements voucher-basedand in-kind Non-Food Items (NFIs) and win-terisation support. FFP funding provides FamilyFood Rations (FFR) and support to bakerieswith wheat flour alongside a voucher-based sys-tem for the most vulnerable households to accessbread. A UKAID grant focuses on improvedaccess to safe water, hygiene and sanitation andimproved food security through a mixed-resourcetransfer model combining dry food distributionswith Fresh Food Vouchers (FFV). Finally, IrishAid and ECHO support unrestricted vouchersand cash for work to increase access to foodand NFIs in areas with safe access to functionalmarkets.

At the time of writing (May 2014), GOAL’sfood assistance programme is reaching upwardsof 240,000 direct beneficiaries each month.Monthly unrestricted (food and NFI) vouchersare targeting 5,790 people, expanding to a total13,200 direct beneficiaries each month fromJune 2014, while voucher-based assistance tomeet winterisation needs reached over 72,000people during winter 2013/14. Funding has alsobeen secured to expand voucher-based assistanceto increase access to inputs required for theprotection and recovery of livelihoods and toinclude food production.

GOAL’s Food Security programme imple-mentation and design has been informed by

various assessments and studies completed overthe past six months. ese include a Food BasketAssessment (August 2013), Emergency MarketMapping and Analysis (EMMA) studies on mar-kets for wheat flour and vegetables (January2014) and dry yeast, rice and lentil (May 2014),a Food Security Baseline (December 2013) andMulti-sector Needs Assessment (January 2014).Design and implementation also continue to beinformed by ongoing Post Distribution Moni-toring (PDM) of all programme activities.

Programming context, includingchallenges due to access and securitye protracted conflict has resulted in urgent,humanitarian needs across Syria. e UnitedNations (UN) estimates that the conflict hasdisplaced at least 6.5 million people withinSyria, with a further 2.5 million refugees inneighbouring countries2. A combination ofdirect and indirect factors has led to in excessof 9.3 million people classified as in need ofhumanitarian assistance. With reference to aidrequired per sector, the Syria Integrated NeedsAssessment (SINA) found the highest numberof people in need across the sub-districts sur-veyed were in need of food assistance, with anestimated 5.5 million people food insecure inassessed areas of northern Syria, including 4.9million in moderate need and 590,600 in acuteor severe need3.

Resulting in displacement, reduced accessto livelihoods and market disruption, in additionto the direct loss of life and damage to infra-structure, the protracted conflict continues to

By Hannah Reed

Hannah Reed is theformer AssistantCountry Director forProgrammes inGOAL’s SyriaProgramme. She hasover 10 years of

experience in the humanitarian anddevelopment sector, working in Boliviaand the Fairtrade Foundation, beforejoining GOAL in 2011. Since joining GOAL,Hannah has worked in the field andsupport offices in GOAL’s Sudan, Haiti andSyria programmes.

With thanks to Hatty Barthorp, GOAL’sGlobal Nutrition Advisor, and AlisonGardner, Nutrition Consultant, for theirtechnical support.

1 US Office for Disaster Assistance; US Food for Peace; UK Aid Department for International Development (UK), European Commission Humanitarian Office

2 UNOCHA Syrian Humanitarian Bulletin Issue 44, 27 February– 12 March 2014

3 Syria Integrated Needs Assessment, December 2013

Crowds gather as an aid delivery arrives at a GOALoffice in Idlib Governorate, Northern Syria

Dav

y Ad

ams/

GO

AL,

Nor

ther

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ria, 2

013

GOAL’s foodand voucherassistanceprogrammein NorthernSyria

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Field Article

impact negatively on the ability of affectedpopulations to meet basic food and otherneeds without assistance. Increased relianceon coping strategies reduces householdresiliency and results in increased imme-diate and sustained humanitarian need.

In tandem, the operational and securitycontext continues to present challengesto the impartial and safe delivery of hu-manitarian aid. An increasingly fracturedopposition force and changes in powerdynamics requires continual operationaladjustments to ensure aid can pass freelythrough check-points held by differentand continually changing factions. Highlyfluid changes within the opposition move-ment are accompanied by an increasingtrend of Government military action inopposition-held areas of northern Syria,resulting in continued population dis-placement and a highly insecure opera-

4 Fresh Food vouchers were distributed with dry food rations over this period, and only in areas where local markets will sustain a voucher-based approach

5 A household survey was conducted in August 2013, using convenience sampling of 607 randomly selected households in GOAL’s operational areas. The sample covered 82% beneficiaries (of non-food aid) and 18% non-beneficiaries and a mix of rural and urban areas. Data were then triangulatedthrough in-depth interviews in the same districts. The ‘NutVal’ tool was used for analysis of nutrient composition, while secondary data from FSLWG and OCHA, WFP documents were also referenced. In terms of limitations, some areas were inaccessible to the data collection team due to security constraintswhile challenges were also experienced with regards to respondents’ ability to recall daily food intake.

6 Of which the average households sampled had 0.46 household members aged two years and younger, and 0.90 household members aged between three and five years.

7 Possible answers were: never since Ramadan, more than once per week, and everyday

Figure 1: Sources of food accessed by respondents

100%

80%

60%

40%

20%

0%Rice Bread Pulses Eggs Olives Vegetables Oil Tea SugarFresh

dairyproducts

Own productionPurchased from local shop/market

Food AidGift from relative/neighbour

Figure 2: Current intake of common food items

Canned Meat

Fresh Chicken

Fresh Fish

Fresh meat

Beans

Pasta

Fruits

Lentils

Flour

Bulgar

potatoes

Milk

Eggs

Fresh milk Products

Rice

Vegetables

Bread

Oil

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%Never since Ramadhan More than one time per week Everyday

tional environment for aid agencies. De-terioration in security in areas of Syriaclose to the border with Turkey, have alsoresulted in periodic and oen prolongedborder closures (notably in January 2014)which in turn prevent and/or delay cross-border delivery of aid to conflict-affectedpopulations in Syria.

Assessments which informed thefood kit designe designs of GOAL’s Family Food Ration(FFR) and complementary fresh foodvouchers4 for distribution from Autumn2013 up to early Summer 2014, were in-formed by GOAL’s Food Basket Assess-ment5 (and supporting assessment of freshfood availability on local markets) com-pleted in August 2013. e survey objec-tives were to obtain information on dietquantity, diet diversity, feed frequency,food availability, nutritional deficiencies

and access to produce an evidence base and recommendationsfor the contents of GOAL’s FFR, and to reassess the profile ofGOAL beneficiaries, including household size and compositionof the household.

Key survey findings were: • Percentage of households with at least one household

(HH) member with specialised nutritional require-ments: children aged 5 years and younger (66%6), elderly(15%), Pregnant and Lactating Women (PLW) (30%), and members with chronic illness or disability (27%).

• Average monthly income per HH is SYP 7,279 ($29) while average monthly expenditure on food per HH wasreported as SYP 9,265 ($37).

• Ratio of HH member contributing to income to dependent HH members = 1:4

Figure 1 shows that the primary source of all food groupswas purchase from local markets. e average monthly foodexpenditure reported exceeds average monthly income, sug-gesting a high risk of food insecurity in the absence ofassistance to access food, and a need to rebuild livelihoodsto increase income levels.

To assess current dietary diversity, respondents were alsoasked how oen they consumed food items from a specifiedlist of foods common in Syria (see Figure 2). Ramadan was 3weeks before the household survey7. e results (Figure 2)reveal very low levels of dietary diversity with the populationheavily reliant on bread and vegetables. e main additionalfoods consumed (eaten more than once a week) were othercereals, such as rice, bulgur and pasta, as well as lentils.Results of the assessment in terms of the % RecommendedDaily Allowance (RDA) for kilocalories and micro- andmacro-nutrients showed that households were able to meetan average of 900 kilocalories per person per day withoutassistance. e % RDA met without assistance was high forvitamin A (91%) and Vitamin C (92%) and low for protein(49%), fat (41%), iron (24%) and iodine (15%).

Design of different food kits and resultingoperational difficultiesIn response to these findings, GOAL designed two types offood ration. e FFR included tahini, raisins, fava beans andchick peas for distribution in areas without functioningmarkets, and therefore not receiving vouchers to access freshfood. In areas with safe access to functioning markets, adual-transfer food assistance package was distributed thatincluded both a dry food ration and vouchers to access food(see Figure 3 for nutrient composition including % RDA).

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Field Article

All food assistance was designed to meet atarget of 2,400 kcals p/d adjusted from theSphere standard (2,100 kcal p/p/d) by an addi-tional 300 kcals p/d in order to meet increasedcalorific requirements during the winter period.For areas targeted by direct distribution of dryfood rations only, GOAL designed two types offood kit – a full FFR and a reduced FFR. elatter was provided where targeted beneficiarieswere also receiving a daily bread ration (457kcal per person per day (pppd) via bread vouch-ers) under complementary GOAL programming;in this instance, the FFR contained reducedquantities of pasta, rice and bulgur wheat. Forboth FFR types, full and half kits were also pro-vided, designed to ensure the RDA pppd wasmet and allocated according to household size.

In practice, disruption to border crossingsresulted in frequent delivery of only one type offood ration. is disrupted distribution as itwas necessary to wait for delivery of contingentsof all food ration specifications to cross theborder. Otherwise, distributing food kits to allregistered households in any given village atdifferent times had the potential to create securityissues.

Modified food assistance modalityGiven the unreliability of border crossings, thedesign of food kits has been greatly simplifiedfor the next round of food security programmingwith one type of half kit only. Households willreceive between one and three half kits eachmonth depending on household size. A repeatof the Food Basket Assessment is planned forearly June 2014 to inform the final specificationsof the FFR. is will focus specifically on the %RDA currently met by targeted groups withoutassistance, and will ensure the RDA per personper day is met in terms of calorific and nutrientrequirements. It is expected that the % meetingthe RDA without assistance will have declinedsince August 2013, due to:• Continued trend of price increases in food

items

• Reduced purchasing power as conflict affected households deplete remaining savings, and

• Disruption to livelihood activities pre-conflict and the corresponding decrease in income generation capacity for much of thepopulation.

GOAL’s assessments in 2014 demonstrate a trendof decreasing food security within populationswithout access to regular food assistance. Table1 shows average Household Food ConsumptionScores (FCS) for populations surveyed in GOAL’soperational areas during October 2013, December2013 and January 2014.

Table 1 demonstrates progressive deteriorationin household food security across targeted areas,with a striking increase in the number of femaleheaded households ranked with a ‘poor’ FCS(82%) in January 2014 when compared to maleheaded households surveyed at the same timeand in the same areas (40%). A sharp declinecan also be seen in January 2014 figures whencompared to the % of female headed householdsranked with poor FCS in October (2%) andDecember 2013 (14%).

Food security is undermined by the type ofincome source, with the majority of householdssurveyed currently relying on irregular jobs(44%), the sale of personal assets (29%), assistancereceived from relatives (17%) and previoussavings (7%)8. is represents a worrying trendas there are only a finite number of assets thatmay be sold or savings that may be utilised. Onaverage, irregular jobs only generated USD $65/ 9,724 Syrian Pounds (SYP) in the month priorto the survey, compared to the sale of personalassets (the highest source of income reported)which generated an average of USD $415.5 /SYP 62,018 over the same period.

Correspondingly, the average monthly ex-penditure on food alone across the sample wasUSD $81/SYP 12,105 significantly higher thanthe average income generated by irregular jobs,

which represents the most common source ofincome referenced. Households also reportedthat most of their income was not generated byjobs or livelihoods but by the use of copingstrategies; 22% of the income source was throughthe sale of personal assets, whereas a further22% was credit – strategies which are not sus-tainable9. Sixty eight per cent of householdssurveyed also reported outstanding debt, with72% of these reporting that credit obtained hadbeen used to purchase food. Other coping strate-gies identified to meet food needs include relyingon less preferred or less expensive food (62%),taking on credit (29%), limiting portion sizes(25%), borrowing food (19%), and taking childrenfrom education to work (17%) or sendingchildren or other family members to live withrelatives (15%)10.

Recent surveys, reinforced by EmergencyMarket Mapping & Analysis (EMMA) studieson critical markets for tomatoes, potatoes, riceand lentils, reinforced the trend that food remainsavailable in areas with functioning markets (seeFigure 4). However, food remains inaccessibleto many households in these areas due to reducedlivelihood options and the widening gap betweenhousehold expenditure and income.

Change of GOAL direction to includevoucher programming Given that access as opposed to availability rep-resents the critical barrier to households meetingbasic food needs without assistance, GOAL willexpand the current FFV modality to includevouchers for both dry and fresh food in thenext phase of food security programming. isrecognises increased flexibility afforded by amarket-based approach in areas with functionalmarkets and when compared to direct distribu-tions alone, reducing reliance on border crossingsand the transportation of food rations when re-

Table 1: Trends in Household Food Consumption Score (FCS)

Average Male headed households Female headed households

Oct-13 Dec-13 Jan-14 Oct-13 Dec-13 Jan-14 Oct-13 Dec-13 Jan-14

% households scored ‘acceptable’ 43% 22% 15% 40% 23% 15% 58% 43% 18%

% households scored ‘borderline’ 50% 47% 42% 56% 48% 45% 40% 43% 0%

% households scored ‘poor’ 7% 31% 43% 4% 28% 40% 2% 14% 82%

Figure 3: GOAL mixed modality Food Assistance package: % RDA met by dry food ration and fresh food vouchers

Food items Energy Protein Fat Calcium Iron Iodine Vit. A Thiamine Riboflavin Niacin Vit. C

Current consumption (kcals) 900 26 19 220 6 25 557 1 0 13 30

Dry rations (kcals) 1212 38 31 94 11 251 26 1 0 15 4

Fresh foods (kcals) 184 11 7 139 1 20 591 0 0 5 20

Total 2296 75 57 454 19 295 1173 1 1 32 55

Required ration (adjusted for winterisation) (kcals) 2400 53 46 430 26 161 613 1 2 16 32

% of requirements supplied by current consumption 37% 49% 41% 51% 24% 15% 91% 60% 24% 80% 94%

% of requirements supplied by dry rations 51% 71% 69% 22% 44% 155% 4% 74% 20% 95% 13%

% of requirements supplied by fresh foods 8% 21% 15% 32% 5% 12% 96% 19% 15% 29% 62%

% of total requirements met 96% 141% 124% 105% 73% 183% 191% 152% 59% 204% 169%

8 Needs Assessment in northern Idlib, January 2014, GOAL.9 See footnote 810 See footnote 8

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Field Article

lying only on direct distributions. is approachalso recognises beneficiary preference for vouch-ers. A dual resource transfer approach also pro-vides maximum operational flexibility, with theoption to increase or decrease the ration of as-sistance provided via vouchers and via directdistributions in response to changes in marketsystems or in the security context.

is approach has been informed by GOAL’sunderstanding of market systems developedthrough EMMAs on critical markets for dryand fresh food, and by experience to date withfresh food vouchers and in addition to ongoingunrestricted and NFI voucher programming.Food assistance will be delivered through monthlyfood voucher distributions in areas which willsustain a market-based approach, and throughdry food rations in areas without safe access tofunctioning markets.

e use of vouchers – when market systemspermit – also seeks to ‘do no harm’ both to localmarkets and to livelihoods, by avoiding the po-tentially negative impact of large volumes ofimported food goods being distributed in areaswhere markets continue to function11.

GOAL welcomes the formation of a CashBased Response Technical Working Group (CashTWG) for actors implementing the cross-borderresponse in northern Syria. GOAL is participatingactively on the working group and has recentlypresented GOAL’s voucher process (outlinedbelow) in response to requests from other mem-bers. e Cash TWG has been formed to supportlesson learning and exchange of best practicewith reference to cash and voucher based pro-gramming in northern Syria and to improvecoordination. With a market-based approachto assistance, it is critical that actors coordinateto ensure a ‘Do No Harm’ approach is appliedto local markets. is will mitigate against therisk of ‘flooding’/crashing local markets shouldthere be a significant and uncoordinated increasein voucher-based programming by other actors,reliant on the same markets, within the sametimeframes.

Details of the voucher programmedesign Food vouchers will build on GOAL’s establishedvoucher modality, taking the form of printed,cash-based vouchers distributed on a monthlybasis and exchangeable for food items only atselected and registered traders.

Following an assessment by GOAL field staffof trader’s stock and capacity to restock and to

gauge willingness to engage with the conditionsof GOAL’s voucher scheme, traders sign a contractwith GOAL to participate in the voucher scheme.is includes a commitment on the part of thetrader only to redeem agreed items for GOALvouchers exchanged by beneficiaries, namelydry and fresh foods for food security interventions(see Box 1 for decision making regarding vouchersrelated to infant feeding)12. Punitive measuresare in place and communicated to traders re-garding infractions to the stated terms of thecontract. is includes temporary moving topermanent exclusion from the voucher schemeif substantial evidence exists that vouchers havebeen exchanged for items outside the scopeagreed by GOAL with traders and stipulated onthe vouchers, in addition to other breaches ofthe contract signed.

Food vouchers are eligible for one monthand redeemed for food by beneficiaries in arange of registered shops. Lists of shops partic-ipating and the prices charged for key foodgoods are distributed to beneficiaries with vouch-ers. Participating shops are also required todisplay the agreed price list in their outlets toreduce the risk of voucher beneficiaries beingpunitively charged for goods purchased withvouchers. Prices for food goods exchanged withvouchers are set in line with average marketprices for these goods, and are not intended tobe ‘cheaper’ than the same good purchased inthe same markets by non-beneficiaries and usingcash. GOAL vouchers continue to incorporatea series of security features13, while a rigoroussystem of checks ensure only the selected familiesreceive and redeem the vouchers; that the vouch-ers are used for NFIs only; that the traderscannot increase prices arbitrarily and that any

complaints are quickly relayed to GOAL for in-vestigation14.

Shopkeepers redeem vouchers with GOALstaff on a weekly basis and are reimbursed for thevalue of food items exchanged for vouchers. ereare currently over 200 outlets registered withGOAL’s voucher scheme offering a wider rangeof food and NFIs. GOAL is currently providingfresh food assistance to upwards of 10,000 house-holds each month via a voucher-based modality.Initial assessments and demand from traders notcurrently registered demonstrate that scope existsto expand further the food voucher scheme underthe proposed modification.

Both breastfeeding and use of breastmilksubstitutes (BMS) – typically infant formula –is common in the population. In the January2014 Needs Assessment, in nine sub-districts(Armanaz, Badama, Darkosh, Harim, Janudiyeh,Kafr Takharim, Maaret Tamsrin, Qourqeen, andSalqin) of Idlib Governorate, 25% of respondentsreported infants 0-5m were being fed milk (reg-ular, tinned, powdered or fresh animal milk), afurther 17% of infants 0-5m were being fedinfant formula and 41% reported other foods/liq-uids. ree-quarters (75%) of respondents alsoreported breastfeeding their infant. Various diffi-culties with breastfeeding were reported, suchas too stressed to breastfeed (13%) and inadequatematernal food intake (29%).

Access to breastfeeding support and to BMSsupplies for mothers is very limited in our targetpopulation. An international non-governmentalorganisation (INGO) is running an IYCF pro-gramme in just five of the 134 villages thatGOAL currently operates in, though this maybe expanding which may bring more opportunities

11 The EMMA on rice and lentil critical markets completed in May 2014 by GOAL suggested that large-scale influxes of these food types via aid agency distributions may be impacting local markets systems for these commodities

12 Note that shopkeepers include a strict ban on the exchangeof vouchers for alcohol, cigarettes, infant formula and powdered milk. GOAL programme and M&E staff will continue closely to monitor shopping periods to ensure contractual requirements are met, and including that NFIs are not exchanged for food vouchers. The ban on exchange of vouchers for infant formula and powdered milk is in line with GOAL’s policy of safeguarding children and the international Operational Guidelines for Infant Feeding in Emergencies (2007) which state that “infant formula should only be targeted to infants requiring it, as determined from assessment by a qualified health or nutrition worker trainedin breastfeeding and infant feeding issues” See Box 1 for more considerations around infant formula/powdered milk exclusion from the voucher scheme.

13 There are two serial numbers, one is random and one is computer generated and therefore unpredictable. Each

voucher has a hologram which is GOAL-specific, patented and only produced in one factory in Turkey. There is a different colour for each batch of vouchers. Watermarks are incorporated into the design, which are very difficult to forge and there is also a complex pattern on the surface and exact measurements of the font. Replication of vouchers is therefore extremely difficult.

14 This system includes: price setting with participating shopkeepers prior to each round of distributions with price lists then displayed in participating outlets; the use of ‘shopkeeper books’ to register beneficiary names, ID numbers and voucher numbers against the items these are exchanged against; careful selection of shopkeepers against established accessibility and stock level criteria followed by signatures of contracts agreeing to abide by the terms and conditions of GOAL’s voucher scheme; and clearly defined shopping and voucher redemption periods to guarantee close monitoring by both programmes staff and GOAL’s M&E team to ensure guidelines are adhered to and to reduce the risk of unauthorised duplication or use of GOAL vouchers.

Figure 4: Principal source of food* for households surveyed in northern Idlib, January 2014

Bought in market Food aid Gift No source of food Private production Other (Specify)

First Second Third

88%

55%

26%12%

31%19%

2%15% 11%

35%

1% 3% 1% 2%

*Respondents could give up to three sources of food ranked in order of importance as principalle source of food.

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Field Article

to collaborate. Infant formula is expensive; the price of infantformula has risen significantly through the crisis. Untargeteddistribution of infant formula (ready-to-use and powderedproducts) is happening in the northern governorates (source:GNC scoping mission, Sept 2013); one INGO is collaboratingwith a number of these to minimise risks.

On balance, it was decided that GOALs vouchers anddry rations should not include a BMS as we do not have thecapacity or relevant partnerships established to ensure ap-propriate targeting and also provide the requisite level ofsupport/guidance to mothers. e hygiene-sanitation con-ditions are poor and access to safe water is a problem.Households still have a certain level of income from varioussources, whereby GOAL FSL project is trying to protectassets and the income generation pot’, by providing accessto as replete a diet as possible. We excluded BMS to reducethe risk of families choosing BMS or other powdered milksover breastfeeding. ose who are dependent on BMS stillhave the potential to buy from local markets, as a greaterproportion of their personal income would be available tospend on ‘essential items’, given the food/vouchers providedby GOAL. In January 2014, the predominant expenditurefor all households remained food, followed by health, waterthen fuel.

Lessons learnt on voucher programming so farand vision for future.To date, GOAL’s experience with voucher-based programmingdemonstrates that this is an appropriate and effective modalityto increase access to basic needs for populations in northernSyria with safe access to functional markets. PDM demon-strates that targeted distribution of vouchers affords greaterflexibility to beneficiaries than direct distributions (whichis of particular relevance to address the needs of womenand children) whilst simultaneously strengthening localmarkets, as evidenced by positive feedback from marketactors. A recent survey of shopkeepers participating inGOAL’s voucher scheme found that 100% reported thatthey would like to sign future agreements with GOAL. Inaddition, a recent rapid assessment found that 88% of keyinformants surveyed who were aware of GOAL’s vouchersystem believe it has a positive impact on the market, while71% of shopkeepers interviewed who were familiar withthe system stated that they would be very interested in par-ticipating. An average of 93% of beneficiaries stated that thefrequency of vouchers was appropriate to their needs, while81.5% of beneficiaries responded that they were satisfiedwith the range of shops available to them.15

GOAL will therefore continue to increase access to foodand other basic needs through a voucher-based modality, asthe preferred option in areas with safe access to functionalmarkets. is will be supported by continued direct distri-butions of food assistance when security or market capacitydoes not permit a market-based approach. rough continuedemphasis on robust monitoring of the impact of assistanceon food security, and on market impact of modalitiesemployed, GOAL will scale up the use of vouchers inpreference to direct distributions.

For more information, contact: Vicki Aken, Country Di-rector, GOAL Syria, email: vaken@goal.ie

Both breastfeeding and use ofbreastmilk substitutes (BMS) – typicallyinfant formula – is common in thepopulation. In the January 2014 NeedsAssessment, in nine sub-districts(Armanaz, Badama, Darkosh, Harim,Janudiyeh, Kafr Takharim, MaaretTamsrin, Qourqeen, and Salqin) ofIdlib Governorate, 25% of respondentsreported infants 0-5m were being fedmilk (regular, tinned, powdered orfresh animal milk), a further 17% ofinfants 0-5m were being fed infantformula and 41% reported otherfoods/liquids. Three-quarters (75%) ofrespondents also reported breastfeeding their infant. Various difficultieswith breastfeeding were reported,such as too stressed to breastfeed(13%) and inadequate maternal foodintake (29%).

Access to breastfeeding support andto BMS supplies for mothers is verylimited in our target population. Aninternational non-governmentalorganisation (INGO) is running an IYCFprogramme in just five of the 134villages that GOAL currently operatesin, though this may be expandingwhich may bring more opportunitiesto collaborate. Infant formula isexpensive; the price of infant formulahas risen significantly through thecrisis. Untargeted distribution of

infant formula (ready-to-use andpowdered products) is happening inthe northern governorates (source:GNC scoping mission, Sept 2013); oneINGO is collaborating with a numberof these to minimise risks.

On balance, it was decided that GOALsvouchers and dry rations should notinclude a BMS as we do not have thecapacity or relevant partnershipsestablished to ensure appropriatetargeting and also provide the requisitelevel of support/guidance to mothers.The hygiene-sanitation conditions arepoor and access to safe water is aproblem. Households still have acertain level of income from varioussources, whereby GOAL FSL project istrying to protect assets and the‘income generation pot’, by providingaccess to as replete a diet as possible.We excluded BMS to reduce the risk offamilies choosing BMS or otherpowdered milks over breastfeeding.Those who are dependent on BMS stillhave the potential to buy from localmarkets, as a greater proportion oftheir personal income would beavailable to spend on ‘essential items’,given the food/ vouchers provided byGOAL. In January 2014, thepredominant expenditure for allhouseholds remained food, followedby health, water then fuel.

15 PDM Irish Aid Vouchers Rounds 1 and 2

Decision making around exclusion of infant formula and milkpowder from the voucher scheme and food distributionBox: 1

Families receiving food assistance from GOAL

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Field Article

Pre-war food and nutritionsituationAl-Raqqah governorate is in the Northof Syria and has Al-Raqqah city as itscapital. e governorate is divided intothe three districts of Tal-Abyad, Al-Tawrah and Al-Raqqah. Tal-Abyad dis-trict was estimated to have around200,000 inhabitants, of which around40,000 were internally displaced popu-lations (IDPs) (March 2013). ere areno official collective centres or campsin Tal Abyad district. e IDPs live withhost families or in empty buildings ormakeshi accommodation with limitedprotection from weather conditions.

Pre-war, before March 2011, the maineconomic activity in Al-Raqqah gover-norate was agriculture, with the Euphratesas an important source of water for irri-gation2,3. In combination with importsfrom neighbouring countries, food avail-ability generally met the needs of thegrowing population. With fixed pricepolicies from the government, staplefood was accessible for all. e agricul-tural sector was hit hard by the watercrisis that peaked in 2008, which in-creased unemployment and reducedlocal food production. e event coin-

cided with external economic factorsand neo-liberalisation policies drivingup prices of food, fertilisers and energy.ese developments caused many Al-Raqqah farmers to move from theirlands to the southern cities, in the hopeof finding a job4,5,6.

Undernutrition was a problem inpre-war Syria, reflected in 9.7% of chil-dren under five years underweight fortheir age, 2.3% wasted7 and 29% stunted8.Underweight and wasting were reportedto be more prevalent in Al-Raqqah gov-ernorate, with the 6-11 months age groupmostly affected9. In Al-Raqqah gover-norate, there were no specific protocolsor programmes in place for the treatmentof moderate and severe acute malnutri-tion. Since the outbreak of the conflict,agricultural production has been furtherhampered by insecurity limiting accessto fields and markets, as well as the highprice of fuel10. Moreover, the region ex-perienced damage to its irrigation canals(10%)11. Shortages of food, due to limitedproduction as well as import problems,have been regularly reported and theprices of bread and other food have sig-nificantly increased12.

By Maartje Hoetjes, Wendy Rhymer, LeaMatasci-Phelippeau, Saskia van der Kam

Maartje Hoetjes is a Medicalmember of the MSF emergencyteam, currently working in SouthSudan. She worked as MedicalCoordinator in Syria fromFebruary to November 2013.

Wendy Rhymer started workingwith MSF-OCA in 2007 as a nurse/midwife and was MSF medicalcoordinator for Northern Syriafrom December 2013 to May2014. Wendy was interviewed by the ENN in early May 2014.

Lea Matasci-Phelippeau ispsychologist and worked in Syria as mental health officer. He is currently working as Mental Health Officer in SouthKivu, Democratic republic of the Congo, for MSF OCA.

Saskia van der Kam is thenutrition expert of MSF inAmsterdam.

The authors gratefully acknowledge the work ofMedecins Sans Frontieres Operational Centre inAmsterdam (MSF OCA), the team MSF OCA in Syria andVanessa Cramond, Emergency Manager (Medical) atthe Emergency Support Desk at MSF-OCA.

Sections of this publication are part of Maartje Hoetjes’dissertation for a Masters in International Health1.

1 Hoetjes, M. The impact of armed conflict on health in Al-Raqqah governate, Syria. KIT/RoyalTropical Institute: August 2014

2 Masri A (2006) Country Pasture/Forage Resource Profiles. Rome.

3 Goodbody S, del Re F, Sanogo I, Segura BP (2013) FAO/WFP crop and food security assessment mission to the Syrian Arab Republic. Damascus.

4 Nasser, R; Mehchy, Z; Ismail AK (2013) Socioeconomic roots and impact of the Syrian crisis. Damascus.

5 International Crisis Group (2011) Popular protest in North Africa and the Middle East (IV):the Syrian people’s slow motion revolution. Brussels/Damascus.

6 Rifat H, Ismail KA, Nawar AH (2010) Syrian Arab Republic Third National MDGs Progress Report.

Emerging cases ofmalnutritionamongst IDPs in TalAbyad district, Syria

Damascus.7 Wasted defined as acute malnourished with

weight-for-height <-2 z score. This includes moderate (MAM) and severe acute malnutrition (SAM)).

8 Stunting defined as Height-for-Age <-2 z score9 UNICEF (2008) Syrian Arab Republic Multi

Indicator Cluster Survey: 2006. Geneva, Switzerland

10 The wheat production of 2013 showed a decline of 40% compared to the trend of the previous 10 years and the livestock sector in Syria has significantly reduced. Source: See footnote 2.

11 See footnote 2.12 Hoetjes M (2014) The impact of armed conflict

on health in Al-Raqqah governate , Syria

Small market in a town located in Idlib area, Syria

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MSF operations in Northern SyriaMédecins Sans Frontières Operational CentreAmsterdam (MSF OCA) has been working inNorthern Syria, Al-RAqqah governorate, Tal-Abyad district, since February, 2013. Medicalprogrammes include inpatient paediatrics, aswell as general outpatient services for adultsand children. Services also include antenatalcare, postnatal care, sexual and gender basedviolence care, family planning, as well as routineimmunisation. e mental health programmeincludes individual and group counselling ses-sions, psycho-educational sessions and outpatientpsychiatric care. e nutrition programme in-cludes inpatient therapeutic feeding and ambu-latory therapeutic feeding care. Expanded Pro-gramme of Immunisation (EPI) support hasbeen provided to outlying villages. Donationsof emergency medicines and medical suppliesto other facilities in the surrounding area arealso provided.

Until May 2014, the expatriate team includedtwo Medical Doctors, two Nurses, a MentalHealth Officer, a WASH (Water, Sanitation andHygiene) officer, a Project Coordinator and aLogistician. To this date, 78 Syrian national staffwere working with MSF, either directly orthrough a partnership with the national hospitalin both medical and non-medical positons.When MSF OCA first began working in NorthernSyria, the expatriate staff were able to live andwork alongside the national staff. In January,2014, with significant changes in the leadershipof the area, a major security incident and closureof the border crossing from Turkey into Syria,MSF withdrew expatriate staff from Syria and

switched to a remote management style of work-ing. National Staff were then supported by ex-patriate staff in Turkey via phone, email andskype. With regards to the nutrition programme,this meant that with each admission, the Syrianmedical doctor would call the expat medicaldoctor responsible and discuss the patient’s con-dition and treatment plan. ese patients werefollowed up by the expat daily, via phone callswith the on duty physician. Trainings for nationalstaff doctors and nurses were conducted viaemailed power point and skype, and proved tobe successful even with this unusual method ofmanagement. In May 2014, MSF closed the pro-gramme completely (see discussion for moredetails).

Nutrition situation 2013 In March 2013, an exploratory mission by MSFfound no cases of acute malnutrition. Two monthslater, in May 2013, a mid-upper arm circumference(MUAC) screening was included as part of ameasles vaccination campaign (including childrenfrom 9 months old to five years). is was un-dertaken to update information on the nutritionalstatus of the IDP community given their situation(displacement, lack of income), a recent measlesoutbreak and anecdotal reports that that mothershad difficulties finding appropriate food (infantformula) for their children.

e MUAC screening found a 0.6% prevalenceof global acute malnutrition (GAM). irtyeight cases (0.1%) of severe acute malnutrition(SAM) were identified amongst 34,997 childrenscreened (see Table 1). e vast majority of theidentified cases were children younger than 1

Table 1: MUAC screening during vaccination campaign, May, 2013, Tal Abyad district, Syria

MUAC <115 mm 115-<125 mm 125-<135mm >135 mm TotalNumber 38 180 1,161 33,618 34,997

% 0.1% 0.5% 3.3% 96.1% 100%

Table 2: MUAC screening in mobile clinics, 3rd August - 21st September, 2013

MUAC <115 mm 115-<125 mm 125-<135mm >135 mm TotalNumber 3 2 29 637 671

% 0.4% 0.3% 4.3% 94.9% 100%

Table 3: MUAC screening in inpatient clinics, 1st July -15th September, 2013

MUAC <115 mm 115-<125 mm 125-<135mm >135 mm TotalNumber 16 8 22 383 429

% 3.7% 1.9% 5.1% 89.3% 100.0%

Figure 1: Family size

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13 Matasci-Phelippeau L (2013). Nutrition status of IDP population in Tal Abyad district

year of age. e highest numbers and percentagesof malnourished were found in the Central area,with the majority in Tal Abyad town. In thecity, the malnourished cases were clustered. Per-centages of children with a MUAC <125mmranged from 0-10% per area in the city. emost common explanation for malnourishedchildren with no underlying medical issues wasthat caregivers had no money to purchase infantformula. Seven medical cases were childrenwith “a hole in the heart” (a congenital heartdefect). MUAC screening by mobile clinics wasalso used as a way of monitoring the trend inthe population. is showed no increase in mal-nutrition (see Table 2). MUAC screening fromJuly to September 2013 of children attendingthe inpatient clinic did not show an alarmingnumber of malnourished (Table 3).

Despite the low number of malnourishedcases identified in the vaccination campaign,an increasing number of malnourished caseswere attending in the mobile clinics in betweenApril and May 2013. is triggered the openingof an Ambulatory erapeutic Feeding pro-gramme (ATFP) at the end of May 2013, followedby an Intensive erapeutic Feeding Centre(ITFC, inpatient facility) at the beginning ofJuly 2013. Since the start of the programme, thenumber of admissions has increased slightlyweek by week. In order to have a better pictureof the factors affecting the nutritional statusamongst the Tal-Abyad population, MSF un-dertook a small qualitative survey among themost vulnerable populations in the Tal-Abyadregion of Syria in August 2013.

Qualitative surveye surveyed population was IDPs living inschools in the Tal Abyad region13. A total of 39persons were interviewed, all women, abouttheir living circumstances and food security.e data were collected using a questionnaireadministered by MSF staff working with themobile clinics. e data covered a period betweenmid-August and mid-September 2013.

Family compositionFigures 1 shows the family size amongst thosesurveyed. e average family size was 5.9 with79% (n=30) having 3-7 family members. emajority of the families (84% (n=32)) had oneor two children aged 5 years or under (seeFigure 2). Twenty two families (58%) had oneor more children younger than 12 months (onefamily had two children under this age).

Availability and access to foodAll but one interviewed woman (n=38/39) re-ported that a wide range of food was stillaccessible at local markets. However, for someof the women (n=9), access to markets was noteasy since they live 10-15 km away. Public trans-portation is expensive (100 Syrian Pounds);most walk long distances to reach the market,sometimes arriving too late to find the items

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Field Article

they need as the market starts early in the morn-ing. Culturally, men are supposed to do theshopping. Only women with ‘special circum-stances’ (widows, divorced) are ‘allowed’ to goout shopping. Married women should not leavethe house regularly. ose interviewed reportedthe major problem affecting people’s nutritionis that prices continue to rise and there is a lackof money due to unemployment (see Table 4).is has a direct influence both on the quantityand quality of food that can be purchased.

Almost 100% of the respondents reportedhaving received at least one donation of foodand non-food items (NFI) from different actors(Turkish Red Crescent (TRC), Qatari Red Cres-cent (QRC), Saudi Arabia, local court, privatedonations). Most of them, however, stressedthat donations occur sporadically and they needregular donations. Mothers spontaneously ex-pressed fears for their children, in particularlack of fresh milk, since this item is neverincluded in food donations. Infant formula milkis generally available but the prices are veryhigh; mothers simply cannot afford it. e onlyitem that was received on a regular basis byIDPs living in some of the schools was freebread, donated by different armed groups. IDPsliving in one of the schools reported receivingfree rice regularly.

Meal frequencyBefore the war, Syrians used to have three mealsper day (breakfast, lunch and dinner). esurvey investigated the number of meals IDPsare currently eating each day. As Figure 3 shows,52% of the women interviewed (n=20/38) re-ported that their families are having the usualnumber of meals, 16% are having only twomeals (n=6/38) and one third of the familiesare eating more than three meals (n=12/38) perday. In response to the question “do you oenfeel hungry?” almost 75% (n=29/39) of thoseinterviewed replied “yes”. Unfortunately, meal

quantity could not be ascertained. However,since three-quarters of respondents reportedoen feeling hungry, it can be inferred thatthose who are still having three meals (or more)are actually eating smaller quantities of food.

Diet diversificationIn Syria, all the family usually eats together,unless there are guests or in the case of a specialevent, when women and children eat separately.e diet pre-crisis was varied and mainly com-posed of grains (bread, rice, bulgur, etc.), veg-etables (soup, salads, etc.), beans (chick peas inhummus and falafel, lentil soup, etc.), dairyproducts (yoghurt, milk, cheese) meat and eggs.e survey revealed that people’s current dailydiet is generally composed of grains (bread,spaghetti, rarely rice) and vegetables (73% ofadults, 63% of children). Only two people re-ported eating dairy products (milk, yoghurt).Meat and eggs are scarce and not consumed butbeans and lentils are part of the diet. For someIDPs, the variety of food is even more limited;seven people reported that adults are only eatinggrains, with five people saying that the same istrue for their children. In some cases, adults arefavouring their children (n=6/33), by givingthem the available vegetables and/or milk. In asmall number of cases (4/33) the opposite istrue, and parents report eating more vegetablesthan their children.

Infant nutrition and breastfeedingpractices

“ And mothers should breastfeed theirchildren two complete years for those who

want the breastfeeding to be complete”(Qu’ran, 2nd verse, Al Bqarah, 233:37)

Breastfeeding is a practice accepted and evenpromoted by the holy Qu’ran. In fact, in “Islamicinstruction, mothers are entitled a monthly pay-ment from their husbands to breastfeed theirchildren14”. Breastfeeding was also used some-times as a social regulator; if a mother breastfedanother baby in addition to her own baby, theywould become “brothers of milk”. Marriagewould therefore be forbidden between the twochildren in later life in a culture where intra-fa-milial marriages are still common. Also, accordingto custom, the parents of a woman who hasbeen breastfed can ask for a larger dowry thanif she was not breastfed.

However, according to national staff, usingformula milk became the new “fashion” in pre-war Syria. ere are several possible ‘cultural’reasons for this: people started to think thatformula milk was better than mother’s milk,some (urban) women started to have concernsabout preserving the beauty of their breast andmen who refused formula milk for their wivesfelt they might be perceived as mean. All thesefactors have meant that duration of breastfeedinghas been decreasing and that some mothershave not breastfed at all. Furthermore, Syrianmothers also believe that babies benefit fromwater, water and sugar, a local type of “sheepclear butter”, or tea in addition to breastmilk.Exclusive breastfeeding was and is still far frombeing a generalised practice. ese findings aresupported by a UNICEF survey which showedthat less than half of infants were exclusivelybreastfed at birth in 2006; in Al-Raqqah, theexclusive breastfeeding rates was estimated evenlower, only 26.5%15.

In the past decade, many efforts were madeby the Ministry of Health (MoH), in collaborationwith UNICEF, to provide breastfeeding educationand promote exclusive breastfeeding for the first6 months. According to data collected byUNICEF, from 2007 to 2011, 43% of womenexclusively breastfeed during the first 6 months,and 25% continued partial breastfeeding untiltheir baby was 2 years old. According to thedata collected in the MSF survey, 68% (n=26/38)of the women interviewed reported that theywere currently breastfeeding. Among them, 20had babies aged < 12 months and four of themreported exclusively breastfeeding. When askedif infant formula was available, only three mothersreplied affirmatively. For the majority of women,infant formula had become too expensive.

Health and sanitationLack of access to good quality water was thesecond most common complaint amongst re-spondents aer lack of access to food. e sur-veyed IDPs got their water supply from threedifferent sources: city water (tap), water trucking,and wells (See Figure 5). Out of the 39 peopleinterviewed, 49% (n=19) complained aboutwater quality, mainly saying that it is “bad”,“dirty” or “salty”. Only one respondent complainedthat there was “not enough” water. Despite this,only 3/39 stated that they were boiling water.

Figure 4: Breastfeeding practice, Syria 2006 (UNICEF)

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Table 4: Average price increase betweenpre-war and August 2013

Food Average price increase %BreadOil

+ 233 %+ 294 %

Flour + 424 %

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Figure 3: Meal frequency

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Field Article

ITFC in the paediatric ward in Tal Abyad hospitalfrom July 2013. Out of an estimated under 5population of 30,000 in Tal Abyad, the team ex-pected 10-15 admissions per month for com-plicated SAM (0.5%).

Between July 2013 and April 2014, malnu-trition was the principal reason for 5.3% of alladmissions in the in-patient paediatric ward. Inthe same period, SAM was the main cause ofmortality (21%) in the ward, followed by respi-ratory tract infection (RTI) and accidental in-toxication (drinking petrol, cleaning solutions)(both 10.5%). All deaths due to malnutritionoccurred amongst infants under 6 months. isdoes show an important trend compared withthe mortality profile before the conflict, whenmalnutrition did not appear in the under-five’smortality profile.

All patients under 5 years, presenting toeither the paediatric inpatient facility or theoutpatient facility, are screened for malnutrition.Children whose MUAC is below< 135 mm areassessed using weight-for-height z score (WHZ).All children are also assessed for oedema. Anychild with WHZ <-3 or oedema is admitted.Patients are admitted to the inpatient ward(which is within the paediatric inpatient facilityin the national hospital) and a caregiver ispresent from admission to discharge. Usually

this caregiver is the mother, although sometimesan alternative female family member is designatedto stay. MSF ITFC nutritional guidelines arefollowed, which include the use of F-100, F-75and Ready to use erapeutic Food (Plumpy’nut)as needed. In the ATFC, patients are seen andassessed by the nutrition nurse in the outpatientdepartment on a weekly or bimonthly basis,depending on the condition of the patient.

To date, the majority (75%) of cases havebeen direct admissions to the inpatient feedingprogramme. Between July and December 2013,70 children were admitted to the ITFC of which36% (n=25) were younger than 6 months. FromJanuary to April 2014, 49 patients were admittedto the ITFC of which 59% were younger than 6months. is indicates that the malnutritionwas a larger problem in Tal Abyad district thancould have been expected based on surveillancedata, which does not include this age-group.According to the ITFC medical staff, the majorityof the children included in the programme wereinfants < 12 months. e team identified anumber of contributing factors to malnutritionin these infants: a low rate of exclusive breast-feeding, significant use of infant formula inrecent years, escalating prices and decreasedavailability of infant formula and inappropriatefeeding (e.g. use of animal milk) when infantformula unavailable.

MSF market surveys showed a tremendousincrease in prices of infant formula, from apre-conflict price per can of 300SYP to 1500SYPin September 2013 and 1700SYP in February,2014; more than a 500% increase.

Programming challengesAt the outset, there was some resistance fromthe doctors and nurses to follow the MSFnutrition protocols. As these staff members hadlimited or no experience with malnutrition,there was a belief that the patient was sick dueto other reasons, and therefore only needed in-terventions such as intravenous fluids and an-tibiotics. But with training, we were able tochange this to a certain extent.

All issues related to breastfeeding and re-lactation were a challenge, in particular:• Given the culture of using infant formula,knowledge of breastfeeding among staff and pa-tients was very low. Some mothers had notbreastfed at all or had stopped two or threemonths ago, although their children were stillunder the age of 6 months. In this age group,the options for therapeutic feeding includebreastmilk, therapeutic milk and infant formula.Relactation is a difficult process, even with ex-perienced health professionals providing adviceand support, and mothers who are committedto the process. As exclusive breastfeeding wasnot a common practice amongst most womenand the staff, there was limited drive to persistwith relactation.

• When these children reached their targetweights and were ready for discharge, the problempresented that many of the mothers had not yet

Lack of fuel was a main reason for this. ethird most common complaint (7 people men-tioned it) was poor hygiene due to overcrowding.Hygiene supplies were included in donationsbut again, this happened too sporadically.

ese findings support observations duringthe assessments in the IDP collective centres inJune/July 2013 where the MSF team concludedthat the IDP’s living there suffer from skin dis-eases, such as scabies, lice and ringworm. Fur-thermore, 80% of the IDPs interviewed reportedsuffering from diarrhoea, due to bad hygieneand water quality. Following the findings of theJune/July 2013 assessment, MSF launched awater and sanitation intervention in the mostaffected schools and started up mobile clinicstargeting the collective centres.

Nutrition programmeDoctors and nurses in Syria have not beentrained on how to diagnose and treat malnutritionand protocols and guidelines were not in placeto support the medical practitioners, as malnu-trition was not common. is gap in medicalcare was one of the reasons for MSF to intervenegiven the cases of malnutrition identified in theMUAC screening. MSF began by integratingAmbulatory erapeutic Feeding Centre (ATFC)services into outpatient clinic activities at thebeginning of June 2013. MSF also supported an

Ambulance in front of an advanced medicalpost supported by MSF in Idlib area, Syria

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achieved exclusive breastfeeding and thereforewould need to resort to giving infant formula.In ATFP where children are followed up aerhaving been treated in the inpatient ward, MSFonly provides breastfeeding advice and support,and does not give a supply of infant formulafollowing the general international policy. isle many families in the difficult position ofagain trying to acquire infant formula, as noother local or international non-governmentalorganisation in the area was providing this topatients. e motivation to come to the ATFCfor follow up was low as nothing other thanadvice was provided.

• Occasionally infant formula was suppliedthrough the ATFC, but the team saw this as anexception. If mothers thought that they couldreceive formula milk, it would have underminedall the hard work that was done in the ITFC tomotivate mothers to stimulate and restartbreastfeeding. Moreover, the fear was that MSFwould be overrun by mothers requesting infantformula.

• e time that expats were on-the ground wasnot sufficient to train staff fully on breastfeedingpromotion, and remote support to breastfeedingwas a challenge as locally there was virtually noexperienced person on the ground. Predominantlymale staff were unable to give breastfeeding sup-port, as only female staff are able to discuss andassist patients with breastfeeding. Most of thefemale staff had never breastfed before. Alsomidwives had minimal experience teaching pa-tients about breastfeeding.

• Although many breastfeeding videos wereavailable, as well as pamphlets/books, due tocultural considerations, these materials weredeemed too sensitive to use with patients in theprogramme although some were useful to trainthe national staff. A training plan was developedwith the help of an experienced Save the Childrenstaff but the security situation prevented imple-mentation.

e supply of therapeutic foods and itemswas problematic. It was difficult for agencies toaccess international supplies of these foods andagencies were unable to procure comparablenutritional supplies locally. ere was a rupturein the supply of F100 milk in January, 2014 sothat MSF was required to purchase infant formulalocally as an interim measure to use in therapeuticfeeding programmes.

Finally, the defaulter rate of the therapeuticfeeding programme was high (30% to 50% ofthe exits) both for the inpatient and outpatientprogrammes. Some of the reasons for defaultare not unusual for a feeding programme; theseincluded the fact that some of the patients wereIDPs, and their families were moving to anotherlocation and that sometimes the caregiver wasunable to stay with the patient in the hospital,due to other responsibilities at home. However,what was reported most commonly with regardsto patient default was that the parents did notunderstand or value the care being provided totheir children. Due to a lack of understandingof malnutrition, there was distrust that therapeuticmilk would be sufficient to support these patients.Also, once patients under 6 months were trans-ferred from the ITFC to the ATFC and no longerwere being given therapeutic milk or infant for-mula, mothers questioned the need to comeweekly for weight and physical assessment.

DiscussionDespite difficulties in active case finding andscreening, the number of acutely malnourishedwas higher than expected. e initial assessmentand the surveillance did not indicate the im-portance of malnutrition in the Syrian IDP andhost community. is can be partly explainedby the large proportion of infants younger than6 months amongst admissions, as these generallyare excluded from screening and communityassessment.

Reasons for acute malnutrition in infantsappear to be a low rate of breastfeeding, lack ofclean water, lack of resources to buy infantformula milk and physical exhaustion of themother. Treatment of malnourished infantsworks in the short term, but aer dischargefrom the inpatient ward, a dilemma arises. MSFdid not supply infant formula for use at home,but the families would face the same difficultieswith feeding their babies as an alternative referralor support system was lacking. MSF activelylobbied other agencies for such support butnone was forthcoming. Overall MSF recognisedthe importance of breastfeeding in these cir-cumstances and organised breastfeeding pro-motion and individual support as much as pos-sible given the challenging circumstances.

Despite concerns about the general food se-curity, this did not manifest itself in the nutritionalstate of older children or the general population.However, it was quite visible in very young agegroups, who need high quality foods, includinga source of milk or other foods of animal origin.

As food security and dietary diversity is lowand there are no signs of improvement, MSF

considered blanket selective feeding for all chil-dren, as well as improving hospital food andlobbying for more food aid and humanitariansupport. However two major constraints ham-pered implementation of these activities. Tal-Abyad is situated in a rebel controlled area inthe north of Syria. is meant denial of regularcross-line support through UN coordinatedfood aid or nutritional support as this neededgovernment permission. Importation of foodsby MSF was not straightforward either. Fur-thermore, a significant security event involvingMSF staff meant that expatriate staff were phys-ically withdrawn from Syria in February 2014;this meant that new programme elements, likethe roll out of breastfeeding promotion andsupport, could not be properly implemented.

Conclusions and recommendations e Syrian context is relatively new for MSF,therefore we would like to share some lessonslearned. In the immediate term, to address theneeds and challenges we have identified, weconsider that:

ere is an urgent need for unrestrictedaccess to people in need throughout Syria andunhindered cross border activities.• Nutrition assessment and surveillance

systems should include infants younger than 6 months, and be alert to potential changes in the under one year age group.

• ere is an urgent need to supply infant formula to babies whose mothers have not been breastfeeding and therefore have a limited or lack of milk supply, and who are unable to afford or find infant formula for their babies.

• Medical professionals should be trained on breastfeeding to help educate pregnant women and to provide skilled support to establish breastfeeding and overcome diffi-culties. ere is a need to explore the use of medications to assist women in increasing their milk supply. Strengthened individual support should be complemented by a breastfeeding community awareness cam-paign focusing on the need to breastfeed exclusively for the first 6 months of age, targeting not only mothers but their familiesand the community.

• Management of acute malnutrition (likely requiring training), vaccination and target-ing the top three illnesses should be inte-grated into normal paediatric health care structures.

• Blanket selective feeding programmes pro-viding high quality foods to young childrenand PLW and better quality general food distributions could prevent further deterio-ration of the nutritional status.

e MSF programme in Tal Abyad has beenclosed since May 2014; leaving very few agenciesaddressing malnutrition in Northern Syria. ereis an urgent need for others to secure accessand step up their nutrition support activities inNorthern Syria.

For more information, contact: Maartje Hoetjes,email: Maartje.Hoetjes@oca.msf.org

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Backgrounde onset of the conflict in Syria, which resultedin the establishment of government and oppo-sition controlled areas (the latter are predomi-nantly in northern Syria), has meant that todate (April 2014), the humanitarian responsehas largely been administered through two sep-arate and uncoordinated programming ap-proaches1. Firstly, humanitarian agencies basedin the Syrian capital Damascus, work throughthe consent of the Syrian Government and withthe Syrian Arab Red Crescent (SARC). Secondly,agencies administering services into northernSyria do so largely through programming plannedand coordinated from southern Turkey. is isreferred to as the cross border programme2 andwas initiated in the early months of the crisis bya number of diaspora Syrian based agenciesand international non-governmental organisa-tions (INGOs) with support from a small numberof humanitarian donors. e coordination ex-perience from the cross-border programme hashighlighted a number of lessons learnt and chal-lenges for the humanitarian sector. Coordinationand planning for nutrition programming, inparticular, appears to have been a casualty ofsome of these challenges. is is the main focusof this views piece.

Coordination in the absence of acluster mechanism Within Syria, the Damascus based UN agenciesopted for sectoral coordination with UN clusterlead agencies working with a government co-lead. For nutrition, UNICEF as the cluster leadagency has been ‘double hatting’ providing tech-nical input, as well as a crucial coordinationrole. In the opposition controlled areas of Syriahowever, there has not been any official UN co-ordination presence. In southern Turkey, thenational and INGOs involved in the cross borderprogramme established a coordination mecha-nism known as the NGO Forum, which sharedinformation as best it could between operationalagencies(largely INGOs). A joint rapid assessmentmission into northern Syria (JRAM) carriedout in January 2013 was an NGO Forum ledinitiative. e formation of the Assistance Co-ordination Unit (ACU)3 in November 2012

brought another prominent player in cross-border programming and it was hoped that thisstructure would take on operational coordination.However, a number of internal challenges pre-vented ACU from taking on this role. In addition,OCHA arrived in southern Turkey in February2013 with a mandate to promote coordinationof information management and needs assess-ments of the cross border programme. is en-gagement led gradually to the establishment ofIASC4- like coordination mechanisms. e efficacyof this mechanism was challenged by the lack ofcluster activation in Syria at that time, the con-straints faced by UN agencies for their direct in-volvement in a response that was clearly opposedby the Syrian Government, as well as a lack ofbuy-in by INGOs to coordination by a UNagency (OCHA) that was not itself operationalin the cross-border programme. Despite thesechallenges, there was an increased call for morecoordination, in particular between programmingfrom Syria and programming across the southernborders of Turkey into northern Syria.

To date (April 2014), UN agencies presentin southern Turkey have largely (with some ex-ceptions and to varying degrees) had to operatean information ‘firewall’ system between theircross border coordination work and their oper-ations based in Damascus. ere were two mainreasons for this. e first was the risk of theSyrian Government finding out about UN cross-border activities from southern Turkey, whichcould jeopardise their work in Governmentcontrolled areas of Syria, i.e. the Syrian Gov-ernment may place restrictions on UN agenciesworking both sides of the divide or even stoptheir activities altogether. e second was thepotential risk to programming activities andstaff involved in the cross-border programme ifinformation was shared with Damascus basedprogramming staff and government counterparts5.

e UN therefore effectively adopted an ‘in-direct support’ modus operandi for southernTurkey. OCHA in coordination with globalcluster lead UN agencies, INGOs and donors,set up working groups for each sector. Most of

these working groups were co-chaired betweenINGOs and UN agencies or cluster representatives(without cluster activation) and the majority ofthem had dedicated coordinators, funded bydonors, to chair and steer the group’s work. eworking groups replaced the NGO Forum andprovided a far more effective space for technicalcoordination within sectors – especially aroundinformation sharing and certain elements ofoperational coordination. e membership ofthe working groups was extended to cover awider range of partners, including Turkish andSyrian NGOs which fed into a broader coordi-nation architecture, including an inter-sectorworking group, as well as a strategic, decision-making body with key representatives of thehumanitarian community to provide overallleadership for the response.

However, major challenges remain due tothe absence of an official mandate for strongerUN operational involvement6. As a result, UNagencies provide support and guidance on hu-manitarian standards, training and planning ofhumanitarian programmes in support of NGOoperations. WFP, in particular, has managed touse its regional hub in the capital of Jordan,Amman, as a forum for information sharing,thus overcoming to some extent the firewallingconstraint7. According to many stakeholders in-

Coordinating the response to the Syria crisis:the southern Turkey cross border experience

is views piece was developed by the ENN based on eight key informant interviews with donors, UNagencies and INGOs carried out during an ENN visit to southern Turkey in early April 2014, subsequentfollow-up by email and meetings with OCHA Geneva and the Global Nutrition Cluster in June 2014. Allcontributors have seen various dras but requested to be anonymous.

Note that this views piece reflects the experiences up to April 2014 (with some updates related to UNResolutions). Other developments in the coordination mechanisms may have taken place since this time.

1 See later for updates in this regard with respect to UN Resolution 2165.

2 At the time of writing, programming across other borders, such as from Iraq and Jordan, existed but at much smaller scale and are not covered in this views piece.

3 Created in November under the initial leadership of Suhair al-Atassi, a vice president of the National Coalition for Syrian Revolutionary and Opposition Forces

4 Inter Agency Standing Committee5 Some INGOs have also adopted a similar approach, i.e.

basing themselves in Damascus and not implementing cross-border programming.

6 This situation has changed since the adoption of Resolution2165, later in this article and footnote 9.

7 Subsequent and further actions by WFP to coordinate and align cross border and cross line operations following Resolution 2165 are shared in an article in this 48th edition of Field Exchange. Of particular note, all WFP operations in Syria, whether cross border or cross line, are now planned from Damascus.

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terviewed during the course of the ENN visit,this has resulted in better ‘gap’ analysis by WFP,its implementing partners and the food securitysector in general. e lack of operational in-volvement of the UN in southern Turkey for thecross border programme has meant that imple-menting agencies do not have access to financingmechanisms such as the Emergency ResponseFund (ERF) or stocks of non-food items (NFI)and medicines. Furthermore, the absence of thecluster mechanism has also meant that there isno agency identified in the role as provider oflast resort – a key feature of the IASC clustermechanism and important to ensure accounta-bility to both beneficiaries and to donors.

ere are ongoing tensions for many agenciesworking on cross-border programming who be-lieve that OCHA and the UN agencies couldhave operated more effectively. One view is thatOCHA interpreted its role as one of reportinginformation rather than coordinating the mean-ingful assessment and analysis of informationand the mapping of key gaps to ensure moreequitable access to food and non-food assistance.An opposite view from within the UN family isthat the refusal of many INGOs to share infor-mation with the UN has made it impossible todo meaningful assessments and analysis. WhilstNGOs have been advocating for better coordi-nation, there have been sensitivities and dynamicswith OCHA that have continued to constrainstrengthened coordination. To some degree,personality clashes have been a part of thisproblem yet other sectors, notably education,food security and child protection have donewell, highlighting that sectoral coordinationwith concomitant donor support can lead toenhanced coordination even in the most chal-lenging situations. is, however, has not beenthe experience thus far with the nutrition sector.

e firewalling of information between thecross-border programme in southern Turkeyand the Syria programme has meant that southernTurkey based INGOs have had little informationabout programming being coordinated and im-plemented from the Damascus side, while agen-cies in Damascus do not know what is beingplanned and implemented cross border8. As aresult, there have been examples of duplicationof aid where the so called cross-line programmeinto northern Syria has been implemented inareas where NGOs operating from southernTurkey have already worked. In addition, thereare also concerns that areas exist where boththe cross-line and cross border programme havenot reached areas in need.

e passing of UN Resolution 2139 in Feb-ruary 2014 raised expectations about greaterfreedom to share information amongst all stake-holders, as well as opening up more bordercrossing points from southern Turkey. Howeverdevelopment in this regard needed the subsequentResolution 21659 – considered a “breakthroughin efforts to get aid to Syrians in need10” – withthe first UN convoy which crossed into Syriafrom Turkey through the Bab al-Salam bordercrossing on 24th July 2014. Food, shelter materials,

household items and water and sanitation suppliesfor approximately 26,000 people in Aleppo andIdleb Governorates were transported. e Syrianauthorities were notified and more convoys an-ticipated. Nonetheless, at the time of interviewing(April 2014) there was still considerable mistrustbetween INGOs working in southern Turkeyand the UN agencies. Although INGOs anddonors understood why the UN agencies haveoperated in the way they have, there is con-structive criticism about how they could havecombined the maintenance of their ‘safe’ positionin Damascus whilst working more effectivelywith agencies in southern Turkey. is has beenreferred to as the ‘anonymisation of the response’and links to a widespread view that the UNagencies could have reached out more to INGOs,found better ways to share information (perhapsusing the WFP regional hub model) and alsoconnected more fully with Syrian NGOs workingcross border. Syrian agencies are increasinglybecoming involved in the working groups butthis greater engagement has been a slow process.ere is also a strong view amongst the donorsand INGOs interviewed that as the UN is non-operational, their legitimacy for coordinationis intrinsically diminished and that the UNshould have been clearer from the start aboutwhat they could, or could not do. INGOs anddonors have therefore been lobbying to have anINGO co-chair on the inter-sectoral workinggroup in order to strengthen operational coor-dination. However, OCHA have been unable togrant this request as this arrangement wouldnot be in line with IASC guidelines.

Nutrition sector coordination andleadershipMany actors working in southern Turkey are ofthe view that there has been an absence of lead-ership around nutrition programming and co-ordination. is has meant that there has beena lack of thorough sectoral analysis of the mainnutrition problems faced within Syria andamongst the refugees. Added to this has beenthe limitation of the global benchmark for defin-ing a nutrition emergency, which requires highor increasing levels of GAM for funding to beactivated. In essence, donors wanted to see ahigher GAM before agreeing to a dedicated nu-trition working group and programme of funding.Whilst there are examples of low GAM and nu-trition cluster activation in emergencies such asHaiti and the Philippines, the donor focus inthe Syrian crisis has been largely confined toother sectors such as WASH (water, sanitationand hygiene) and child protection. ere is nodoubt that the Syrian crisis has lacked a well-articulated and coherent analysis of nutritionrisk and needs and this has constrained thelevel of attention to the sector.

Between September 12th and 20th 2013, theGNC undertook a scoping mission to “assessthe nutrition context and potential nutritioninformation-sharing mechanisms within thehumanitarian response for northern Syria”. Itwas undertaken by a two person team – onemember of the GNC Rapid Response Team(RRT) and a nutritionist seconded from an

INGO. It was prompted by a lack of informationand data about ‘nutrition in emergencies’ pro-gramming in northern Syria and by concernsregarding lack of understanding regarding infantand young child feeding (IYCF) in this context.It identified that coordination on nutritionneeded to be enhanced, with particular emphasison IYCF. Suggestions were made regarding po-tential coordination structures and systems.Subsequently, from mid December 2013 to mid-Feb 2014, a GNC RRT member (hosted by anINGO) was deployed “to provide coordination,technical and information management support”on nutrition to the cross-border Turkey basedoperation. Whilst inroads in raising the profileand engagement on nutrition between agencieswas reported,11 the profile of nutrition remainedhugely constrained and was essentially shortlived given the short term nature of the deploy-ment. e mission placed considerable emphasison IYCF (particularly breastfeeding support) asa priority issue for response and the need for anutrition survey to establish whether acute mal-nutrition was a problem. Many stakeholdersdisagreed with these recommendations and alsofelt that the three month period should have re-sulted in more robust nutrition data and analysisto inform programming.

e absence of nutrition data in northernSyria has been a constant anxiety for imple-menting agencies that are aware of high levelsof food insecurity and lack of access to healthcare and clean water for many internally displacedpeople and in the besieged areas. A nutritionsub-group has recently been set up as part ofthe health working group for the cross-borderprogramme and is working to provide theanalysis and programming recommendationsneeded for the nutrition sector. However, thereare very few agencies involved directly in nutritionprogramming and added to this, the absence ofa UN agency presence in the nutrition sub grouphas reduced the level of authority typicallyneeded to influence donor financing allocationsand their response.

A question is raised as to how, in a ‘level 3’emergency, which is in its fourth year, there isnot a standalone nutrition sector working groupin southern Turkey with a lead agency providingcredible assessment and analysis of the overallnutrition situation. ere is also a related questionas to why the GNC was not enabled to sustain apresence in southern Turkey in order to providecoordination for nutrition analysis and opera-tional planning for the cross border programme.

8 See footnote 79 Resolution 2165, unanimously adopted by Council

members on 14 July, authorised the United Nations and ourpartners to use routes across four additional border crossings with Turkey, Jordan and Iraq. The resolution also authorised the establishment of a monitoring mechanism to confirm the humanitarian nature of supplies brought through those crossings points. Available at: http://unscr.com/en/resolutions/2165 

10 Under-secretary-general for humanitarian affairs/ emergency relief coordinator Valerie Amos, executive director of the WFP Ertharin Cousin and Executive Director of UNICEF Anthony Lake, Statement on Security Council Resolution 2165 on humanitarian access in Syria.

11 GNC End of Mission Report (Feb, 2014)

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