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ANNEX A Proposal Project title Emergency Nutrition Program DRC (PUNC) The project aims to document and address Democratic Republic of Cong (DRC)’s nutritional crisis through SMART One line summary of project surveys and appropriate multisectoral interventions in order to reduce mortality and morbidity linked to severe acute malnutrition, as well as addressing the root causes of undernutrition Start/end dates 01/01/2018 – 31/06/2019 Organisation name Action Against Hunger Polly Arscott Primary contact person, email Senior DFID Relations Manager and phone number T: +44 (0)20 8293 6190 P.Arscott@actionagainsthunger.org.uk Secondary contact person, Luc BELLON email and phone number Country Director Email: dp@cd-actioncontrelafaim.org Tel: + 243 81 880 7320 Context 1. Please give your assessment of the humanitarian emergency and how it is likely to develop over the funding period. Please limit to three succinct bullets. DRC is one of the world’s poorest countries, ranked 176th out of 188 according to Human Development Index (UNDP 2015 and 2016) and has one of the world’s highest undernutrition burdens. The Humanitarian Response Plan (HRP) estimates that 1 in 10 individuals living in the country (7.5 million people) will be in need of humanitarian assistance in 2018 because of complex crisis combined with prolonged structural deficiencies. 1 in 10 children dies before reaching the age of five in DRC, representing one of the highest rates in the world. Of these deaths, an estimated 45% is due to malnutrition. According to the humanitarian needs overview (HNO) 2017-19, the predicted caseload of acute malnutrition victims in DRC is 4.1 million people in 2017, 4.3 million in 2018 and 4.4 million in 2019. 1.9 million children are expected to suffer from severe acute malnutrition (SAM). More than 80% of Standardized monitoring and assessment of relief and transition (SMART) surveys conducted by Action Against Hunger, UNICEF and COOPI in the past 12 months confirmed severe nutrition crisis in the provinces of Tshopo, Kasai Central, Kasai, Kasai Oriental, Haut-Lomami, Kwilu and Kwango. SMART surveys, conducted between July 2016 and February 2017 showed alarming rates of malnutrition, with Global Acute Malnutrition (GAM) as high as 16,4%, SAM up to 6,5%. The HNO 2016 also identifies Maniema, North Kivu, Kongo-Central and Haut-Katanga as most affected provinces. The last Integrated phase classification (IPC) shows severe food insecurity, including in Kasai Region (five provinces) and Tanganyika, and signs of a dramatic increase of SAM cases in these areas are observed. Chronically understaffed and often poorly trained, national health staff faces significant challenges in responding to these emergencies. The authors of the National Strategic Nutrition Plan (NSNP) estimated that less than 15% of SAM cases are able to access adequate therapeutic treatment in a health facility. Limited resources jeopardize the Minister of health (MoH)’s ability to implement quality services for the integrated management of severe malnutrition. An estimated 50% of under-nutrition cases result from diarrhoea or other water borne diseases caused by poor Action Against Hunger – PUNC III Proposal //DRAFT// p. 1 water quality, insufficient sanitation or unhygienic conditions, while only 48.7% of the population has access to safe drinking water and less than 1 out of 5 has access to latrines. This vicious cycle linking illness, under-nutrition, and diarrhoea creates a drastic increase in malnutrition rates. The structural poverty coupled with acute aggravating factors including repeated epidemics and cycles of violent conflict, resulting in a chronic emergency context, induces recurrent and chronic nutrition crises. The areas most affected by nutritional crises are also those with the poorest access to safe drinkable water and sanitation facilities. According to the survey done by UNICEF in 2014 in the Kasai region, the rate of access to drinking water is less than 20% while less than 10% of the population have access to adequate facilities (see Annex 8) Since 2016, the DRC is subject to severe and increasing political, economic and social instability. The local currency has lost half of its value and is being artificially stabilized. The government in place has not undertaken the elections that were due before December 2016, and is thus seen as illegitimate by opposition leaders. Social unrest has led to gruesome conflicts in the Kasai region for the first time in 60 years. Signs of similar tensions are now being observed in other provinces such as Bas Congo, Haut Uele or Equateur. These factors indicate that the situation nationwide will at best remain the same, or worsen. In both cases, there will be direct negative consequences on the nutritional conditions of the population. Kwango province is located in the southwest of the country, on the border with Angola. This area is experiencing recurring nutritional crises. During 2016, it has shown to be one of the worse affected areas in terms of SAM. In the past 12 months, 10 out of 14 health zones have been either in a situation of nutritional alert or confirmed nutritional crises. SMART surveys, conducted between July 2016 and February 2017 showed alarming rates of malnutrition in the province, ranging from a Global Acute Malnutrition (GAM) rate of 13,3% up to 16,4% and reaching rates of up to 6,5% Severe Acute Malnutrition (SAM). Action Against Hunger considers that these rates, in a context which is neither conflict nor natural disaster affected, are the symptoms of wider vulnerabilities. 2. What is the proposed form of assistance (in-kind, cash or combination) and location of the proposed intervention? Please provide a map. The proposed project will respond directly to the needs created by malnutrition, following the identified priorities of intervention (GAM > 10% and/or SAM > 2%), considering aggravating factors for prioritization, and in line with the DRC wash in nutrition (WiN) strategy and the National Nutrition Working Plan. The approach will be two-pronged: (i) life-saving intervention in acute nutrition crises; (ii) addressing the root causes of malnutrition in selected areas where nutritional crises are recurrent, through a medium to long-term approach. The life-saving intervention will Make a diagnosis of the severity of the nutritional situation in the targeted health zones. Essentially provide in-kind assistance through the provision of Ready-to-use-therapeutic foods (RUTF), medicines and water, sanitation and hygiene (WASH) inputs (WiN kits) for beneficiaries as well as anthropometric, WASH and other supplies for health centres and families whose members are suffering from SAM. The distribution of WIN kits to the household with SAM patients clearly plays a lifesaving role. According to a study conducted by Action Against Hunger in DRC in 2014, for six months period, access to safe water (water treatment at home level) decreases the time of treatment by 4 days and promotes a rapid weight gain (see Annex 8). These results were confirmed by similar studies done by Action Against Hunger in Chad and Pakistan in 2015 (see Annex 1). The studies showed that access to drinking water, soap and hygiene sensitization campaign improves the cure rates to 10% (Chad) and 22% (Pakistan). They determined the importance of promoting access to WASH services as a part of the standard nutrition treatment of SAM children without medical complication, in areas with difficult or no access to clean drinking water and adequate sanitation facilities. In addition to the curative aspect, lessons learned from the past PUNC programs and a CERF funded project in Tshikapa, showed that: - The distribution of hygiene kits to the SAM children households is a factor in mobilizing mothers to screen their children. Action Against Hunger – PUNC III Proposal //DRAFT// p. 2 - Improvement of hygiene conditions in the health facilities increases attendance at health centres - There is a considerable Impact on the occurrence of waterborne diseases amongst the hygiene kits beneficiary households. The rate of diarrheal diseases is reduced by more than 50% compared to the overall situation of the intervention area (lesson learned from the project funded by the CERF funds in Tshikapa). A regular technical monitoring and hygiene promotion campaign will be conducted throughout the intervention in the health centres (health staff) and households benefiting from WASH kit by community volunteers and Action Against Hunger’s team. Targeted populations will also benefit from sensitization sessions on health and hygiene practices, improved food consumption and crop cultivation. Training will be provided to health staff regarding treatment of SAM cases, as well as administrative management. Continuous technical support of health personnel by Action Against Hunger team will complement formal training and ensure good practice assimilation as well as quality treatment throughout the intervention Implement basic rehabilitation of health centres, including water storage, latrines and solid waste disposal facilities. Cash will be provided to support health structures to provide improved services, free of charge for the patient as well as to support training and supervision activities. Feasibility studies to support nutritional resilience: Over the past 20 years, Action Against Hunger has treated severe malnutrition where it is most acute in DRC. Doing so, we have been sending emergency teams repeatedly to the same areas. The re-occurrence of nutritional crisis proves that an emergency intervention alone will not curb the trend of increasing nutrition vulnerability. That is why, in parallel to the nutrition emergency activities, Action Against Hunger proposes to draw out the modalities of an intervention that can address and strengthen local resilience to malnutrition (for a definition of resilience, see Annex 7– external evaluation, p.67). Our experience in the country allows us to make the following initial assumptions: 1) It is possible to support local resilience mechanisms to address root causes of malnutrition over a period of around three to four years 2) Addressing the victims of severe acute malnutrition is an entry point to addressing vulnerabilities at large. In other words, the majority of those vulnerable to malnutrition are also the most vulnerable of the area. 3) Local state institutions will not become any more stable or efficient in the coming years, which means that for an intervention to have any structural impact on the nutrition security, it will have to address coping and resilience capacities at household level also. 4) Strengthening resilience requires providing adaptive support which allows individual and households to strengthen their respective capitals - whether economic, physical, social, or knowledge based capital – according to their needs. In this sense, unconditional cash distribution is arguably the most adaptive aid modality. The proposed model proposed will be based on the verification of these assumptions. To do so, Action Against Hunger will conduct studies in a specific area where the prevalence of Severe Acute Malnutrition is above the emergency threshold. The studies will be grouped in two types. Socio-Economic Analysis will be looking at market structures, market prices, availability of goods and services, quality and quantity of existing stakeholders, mapping of existing nutrition related services and will pay particular attention on the agricultural sector. Malnutrition Root Cause analysis: looking at household level practices and behavior, food and dietary diversity, the cost of diet, economic household analysis, access to health and nutrition related services. Both thematic analysis will determine the vulnerabilities and barriers local populations face in accessing economic, physical, social, knowledge based and institutional capital. Action Against Hunger – PUNC III Proposal //DRAFT// p. 3 Geography The location of the proposed intervention is nation-wide. The targeted areas will be identified according to alerts provided by the national surveillance system (SNSAP) (annex 6 ). The alerts will be confirmed through a SMART survey, conducted by Action Against Hunger or any other actor. In certain cases, measurable evidence provided by organisations and partners will be considered to deploy emergency interventions directly without a SMART survey. The feasibility studies will be conducted in the Kwango Province. In 2016 and 2017, three quarters of the Kwango Province was under confirmed nutritional crisis. It benefited from an emergency nutrition intervention since the beginning of 2017 conducted by Action Against Hunger and COOPI in 6 Health Zones. One intervention conducted by Action Against Hunger in Kahemba was prolonged from 6 to 12 months because the admission rates remained too high and acute malnutrition prevalence were still above emergency thresholds. The studies will assess the best configuration for a multiyear project addressing the root causes of malnutrition, and reducing the general vulnerability of the people living in the area. 3. What is your current field/regional presence? Please specify if this is your ow!n or a partner. Time and location in country: Action Against Hunger is present in DRC since 1997. It currently has 1 main coordination office in Kinshasa, 4 permanent bases (Kananga, Tshikapa, Kalomba, Goma), and temporary bases facilitating emergency interventions in three provinces (Kwilu, Kwango, Tshopo) Number of staff: 204 national staff and 18 international staff Sectors: Nutrition, WASH, Food Security and Livelihoods Budgets: annual budget of the DRC mission in 2017 is 9,7 million GBP. Project outline 4. What activities will be undertaken? Please limit to five bullets. LIFE-SAVING INTERVENTION: Conducting SMART surveys in order to confirm nutritional crisis and disseminating and publishing the reports: In coordination with the national coordination committee, SMART surveys will be deployed country wide to document the nutritional situation in health districts which are in alert, according to the national surveillance system (SNSAP) or information by clusters or partners. Using, whenever possible, new technologies (Open Data Kit) for improved data quality, SMART surveys will be conducted within a timeframe of 10 weeks from the decision to be deployed to the validation. Treatment of patients suffering from severe acute malnutrition: With an initial capacity building of health care professionals, management teams and community health workers, the management of severe acute malnutrition will be integrated into the national Health System with an average coverage of 15 catchment areas per zone. Action Against Hunger will necessary provide nutritional, medical, anthropometric supplies to ensure high quality treatment that follow international (SPHERE) and national performance standards (based on the national protocol) and WASH supplies to health centres and distribution to beneficiaries according to the national Wash-in-Nut strategy. Organisation and support of the surveillance system through Community Health Volunteers active screening and monitoring of children under 5 nutritional status by their parents in hard to reach areas (MUAC parents). Creation and animation of Infant and young child feeding (IYCF) support groups and/or care groups as well as nutrition education and cooking demonstration in health centres and communities. FEASIBILITY STUDIES TO SUPPORT NUTRITIONAL RESILIENCE The studies will be conducted in three phases. An international consultant will be hired as an Analysis Coordinator, and will supervise all phases. The analysis methodology is designed (estimated 2 months): The scope of both analysis will call upon existing methodologies, which will be adapted and merged into two studies. These will Action Against Hunger – PUNC III Proposal //DRAFT// p. 4
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