Effective joint programming in The Gambia: Targeting the same communities at the same time to reduce malnutrition

Effective joint programming in The Gambia: Targeting the same communities at the same time to reduce malnutrition

Undernutrition is a major public health problem in The Gambia, especially among women of reproductive age and young children. Chronic malnutrition has remained static for the last decade or so, with a stunting prevalence of 24.5% of children under five; and under five wasting levels of 11% (2013) [1]. To achieve a greater impact on reducing undernutrition, The Gambia joined the Scaling Up Nutrition (SUN) Movement in 2011 and has focused on a multi-sectoral, multi-stakeholder approach to improve malnutrition in these vulnerable groups.

 

UN Network in The Gambia

The UN Network (UNN) in the country comprises five core agencies: Food and Agriculture Organization of the United Nations (FAO); International Organization for Migration (IOM); World Food Programme (WFP); World Health Organization (WHO); and United Nations Children’s Fund (UNICEF), which chairs the platform. While there has been an understanding among UN agencies in The Gambia that nutrition programming is most effective when it addresses both the immediate and underlying causes of malnutrition, the multi-sector approach was given a huge boost by a multi-agency programme − ‘Post Crisis Response (PCR) − designed to help hard-hit regions recover from a food and nutrition insecurity crisis peak in 2015. The PCR brought together three UN Network members − FAO, UNICEF and WFP − to implement a wide range of activities under a Co-Delegation Agreement in the spirit of UN joint programming and improved coordination.

Women with sacks_Gambia

 

Tackling undernutrition in rural communities

The PCR is an €11.4 million EU-funded intervention that took place between January 2017 and December 2019. The programme was designed to help communities ‘bounce back’ from a cumulative effect of shocks, both agricultural and non-agricultural, that were having a negative impact on food and nutrition security. The PCR’s overall objective was to contribute to the reduction of stunting and wasting among children 0-24 months in food-insecure households in rural communities in four regions in The Gambia: North Bank Region, Lower River Region, Central River Region and Upper River Region.

Map_Gambia

 

Different roles for UN agencies

FAO coordinated and facilitated the implementation of the project with support from UNICEF and WFP. Each agency was responsible for a different aspect of programming. FAO led on interventions aimed at improving household food security through cash for work interventions and support to agricultural production. UNICEF was responsible for health-related programming to promote optimal nutrition and care practices with a focus on the first 1,000 days (between a woman's pregnancy and her child's second birthday). WFP provided preventive support for moderate acute malnutrition (MAM). Implementing partners included the Ministry of Health, Ministry of Agriculture, the National Nutrition Agency, The Gambia Red Cross Society and NGOs (Catholic Relief Services, Action Aid International etc.)

A private company, Gambia Horticultural Enterprise, was provided with knowledge and skill enhancement through Hazard Analysis and Critical Control Points (HACCP) training as well as other essential equipment to support local production of fortified blended cereal.

 

Catalyst for closer collaboration 

A formal contract as well as a Memorandum of Understanding (MoU) was signed between the three UN agencies that clearly specified the funds allocated to each of them and their responsibilities and activities. All agencies reported on financial expenditure in the period reporting and the final donor report.

According to the UN agencies involved in the PCR, the joint implementation approach resulted in an effective programme based on a set of mutually reinforcing activities and more efficient use of available resources. For example, UNICEF and WFP conducted joint screening for MAM and Severe Acute Malnutrition (SAM). The MAM and SAM children with no complications were referred to health workers and registered into the Community-based Management of Acute Malnutrition (CMAM) programme. SAM children with complications were referred to facilities for specialized treatment.

As part of efforts to integrate interventions for maximum impact, FAO supported the households of children who were found to be malnourished with vegetable seeds and fertilizer. These families grew and produced vegetables that were consumed by households and the excess produce sold to provide income for other family needs. Joint nutrition education was conducted for health workers and village support groups in the communities to create awareness on infant and young child feeding (IYCF) best practices, using locally available food products. A comprehensive package of social and behavioral change communication (SBCC) was covered jointly by UNICEF and WFP.  This initiative used the national MoH/NaNA IYCF toolkit materials for nutrition care practices and hygiene education sessions at health facility level, as well as nutrition education and counselling at community level. 

SBCC_Gambia

WFP Country Director, Wanja Kaaria, confirmed that “the first driver for UN agency collaboration was joint funding, but the SUN UN Network was an existing platform that we leveraged. Having a good working platform has allowed us to forge and strengthen that joint approach.”

“The PCR was designed to provide a holistic multi-sectoral programme for addressing FSN and [to do this] sustainably,” Wanja reported. “This meant covering all angles, from community engagement and support to smallholder farmers, and including safety net support for the most vulnerable. Different agencies covered various components – the programme was designed to allow for such synergies.” 

 

Coordinating mechanisms

Good coordination and regular communication between the UN partners proved essential, especially as each agency had different organizational structures and decision-making procedures. The UN Network served as a point of convergence. The three UN agencies involved in the PCR held monthly inter-agency meetings as Technical Working Groups (TWGs), as well as regular meetings with their government partners. UN agency joint activities included development of workplans through the TWGs; targeting of beneficiaries through joint screening; joint implementation; and joint supervision and monitoring of interventions. There was a project steering committee, chaired by the Ministry of Health or his delegate at ministerial level, to provide oversight, direction, and supervisory support to the programme. The integrated management of acute malnutrition (IMAM) technical working group quarterly meeting, supported by UNICEF, ensured effective coordination and knowledge sharing, and provided an opportunity to discuss progress and challenges in the treatment of acute malnutrition programme.

The National Nutrition Agency (NaNA) under the office of the Vice President is the coordinating agency for the implementation of all nutrition programmes in the country. NaNA leads and coordinates the development and validation of nutrition education materials, and provided technical expertise in training health professionals on the management of SAM. Both NaNA and the Ministry of Health worked closely with UNICEF and WFP on developing IYCF practices, including community engagement on SBCC, in a process that reflects strong national ownership.

The Department of Agriculture (DoA) was in charge of implementing agriculture-related activities in the programme, including input distribution and technical training related to farmer field schools. Frontline DoA extension workers benefitted from training and are now able to carry out extension services on improved technological packages. The project also involved NGOs, notably Catholic Relief Services, Action Aid International in The Gambia (AAITG), and United Purpose in the operation and management of the Savings and Internal Lending Community initiatives, and The Gambia Red Cross Society took part in the lean season blanket supplementary feeding for the prevention of stunting. For a sustainable supply of micronutrition rich fortified foods, Gambia Horticultural Enterprise partnered with WFP for the local production of fortified blended cereals.

Gardening_Gambia

 

Programme results

UNICEF and WFP undertook screening exercises as a joint effort, in collaboration with NaNA, MoH and the Gambia Red Cross Society. The active nutrition screening campaigns were a key activity within the nutrition component of the PCR programme, reaching about 67,329 children (6-59 months). This enabled early detection of MAM and SAM cases: depending on status (complicated or uncomplicated), SAM cases were either referred to outpatient clinics (the Outpatient Therapeutic Programme) and children with complications were subsequently referred for inpatient treatment. MAM children identified during the active screening were provided with food supplements. Screening was undertaken at the onset of the lean season months (March to May) and based on WFP’s beneficiary registration and monitoring system in all provincial regions, involving approximately 1516 villages. There was a consistent decline in children identified with MAM and SAM as programme implementation progressed

Following the training of mothers on MUAC screening in some communities by UNICEF, community screening was also conducted monthly and children referred to the community health nurse for further assessment, supplementation and/or treatment if needed. Mothers/caregivers were also oriented on IYCF and healthy diets. Community MUAC training was initiated through the PCR programme, and is now being mainstreamed in current nutrition interventions, one of the critical elements of sustainability and building resilience in communities to withstand future nutrition shocks.

Table of results: PCR Programme

PCR Table_Gambia

 

Challenges to working together

Despite the programme’s extensive reach (see Table 1), UN agencies reported that the efficiency of the PCR programme was variable. The project steering committee did not meet quarterly as planned due to frequent changes in top management at the MOH, the chair of the committee, and the busy calendars of committee members. Management structures between the three UN agencies were appropriate and effective, but multi-sector, multi-agency coordination mechanisms did not always function adequately. After a slow start (the PCR took one year to begin implementation), efficiency was boosted through more integrated and joint activities. However, some pipeline breaks occurred for the nutrition products, and SBCC materials were distributed later than planned. Nevertheless, the reported overall budget disbursal by end November 2019 was greater than 90% for all three agencies, despite delays caused by different agency reporting requirements.

 

Lessons learnt and next steps

WFP’s Country Director, Wanja Kaaria, confirmed that joint UN programming can be challenging due to issues of aligning resources at the same time and coordinating project cycles between different agencies. “Yet the PCR really showed what we can achieve when agencies have concerted efforts in the same region targeting the same communities at the same time – and with multi-sectoral engagement. It really contributed to reducing malnutrition.” Furthermore, PCR stakeholders felt that the partnership arrangement had built synergies between the three partner agencies due to effective day-to-day collaboration and communication on the programme’s activities under each agency. 

The PCR programme in The Gambia was able to successfully unite UN agencies on food and nutrition security agenda, with complementary and specific technical expertise and mandates, along with relevant Government ministries. The legacy of this joint approach is a renewed commitment to working together with new challenges: the UN network team meets quarterly to discuss programme implementation in their various agencies and also join NaNA in SUN meetings to provide technical advice. Thanks in part to the close working collaboration and effort established by the PCR, the UNN and The Gambia Government came together to release a joint statement on COVID-19 and food and nutrition security, outlining critical actions that need to be coordinated to prevent and mitigate the impact of COVID-19 on the country’s most vulnerable population groups.

 

Footnotes

[1] https://globalnutritionreport.org/resources/nutrition-profiles/africa/western-africa/gambia/#profile

[2] SMART survey (2015) https://www.unicef.org/gambia/sites/unicef.org.gambia/files/2018-11/The%20Gambia%20National%20Nutrition%20Survey%202015.pdf

[3] MICS survey (2018) https://www.unicef.org/gambia/sites/unicef.org.gambia/files/2019-12/Gambia%202018%20MICS.pdf

 

Photo Credits:

WFP/Gambia

WFP/Dawda Samba

WFP/Thomas Kimaru