Niger has suffered from chronic malnutrition, rooted in structural vulnerabilities, for several decades. A series of environmental and economic shocks has further exacerbated these vulnerabilities, resulting in high levels of acute malnutrition among children under five. Elevated levels of mortality, particularly among children, are also evident. During 2005, the under-five mortality rate was 4.1 per 10,000 per day, and the crude mortality rate was 1.5 per 10,000 per day. In two regions of the country, under-five mortality rates were above the emergency threshold of two per 10,000 per day. Based on the findings of a recent evaluation, and using UNICEFs framework for the causes of child malnutrition, this article outlines the structural roots of Nigers crisis, and provides a brief synopsis of the lessons learned for UNICEF.
The causes of malnutrition
In general, the basic causes of child malnutrition at the national and regional level are rooted in the availability of resources (human, structural, financial), formal and informal infrastructure and national and regional government polices. The underlying causes of malnutrition, acting at the household and community level, encompass several broad areas: care practices, social and cultural expectations, health services and health environment and food access and food availability.
The prevalence of exclusive breastfeeding among infants under four months in Niger is extremely low (reportedly only 2% in 2000). It is recognised that support for exclusive breastfeeding is a priority intervention for child survival. In addition, there is very little awareness amongst communities and families about the consequences of malnutrition for children and Nigers patriarchal society means that women often do not have access to or control of food supplies. Low education and early marriage among women are additional gender-related factors that impact on nutritional status.
Health facilities to cope with malnutrition are generally weak and under-resourced. The capacity of local health workers to treat and prevent malnutrition and associated illnesses is low. Vaccination against measles is inadequate (below 60%), and user fees mean that more than half the population are excluded from health services (an estimated 63% of the population lives on less than a dollar a day, and UNDPs Human Development Report in 2005 ranked the country last out of 177). Unusually high millet and sorghum prices in regional markets, combined with an earlier fodder deficit caused by drought and a severe locust infestation in some pastoral areas, exerted further pressure, and resulted in many livestock-dependent households facing a sharp decrease in purchasing power for food commodities. In 2005, purchasing power was reported to be less than a quarter of its 2004 level, and was weakest in the agro-pastoral and pastoral zones of Niger.
It is generally accepted that food access, rather than food availability, is the critical factor. The importance of non-food causes of malnutrition needs to be emphasised, and underlines the need for complementary initiatives in health, water, sanitation, feeding practices and care sectors. For many malnourished children, food support will undoubtedly contribute to their nutritional status, but it will not be enough to maintain nutritional status in the long term if these other factors are not addressed.
Early warning, surveillance and assessment
In September 2004, the IASC Working Group on Early Warning Early Action (EW/EA) recommended strengthening national and local early warning in Niger, including incorporating malnutrition data into analyses and strengthening the analysis of the impact of rising market prices for grain. Although surveys conducted late in 2004 and throughout 2005 consistently reported high levels of acute malnutrition, these findings did not trigger timely and appropriate action in terms of both treatment and preventive interventions. This was arguably due to a lack of in-country capacity to collect, analyse and interpret data, and an inability to raise nutrition as a key priority with the government, donors and partner agencies.
Establishing a nutritional surveillance system in Niger that can provide timely information and is appropriate to national capacities and needs will be a challenge, including for UNICEF. This system would need to identify temporal changes (i.e. seasonal periods of malnutrition), distinguish relative vulnerability among different livelihood groups and combine food security and nutritional data. It would also need to be child-centred, and take due account of childrens nutritional status.
From 2006, UNICEF plans to undertake twice-yearly national nutrition surveys. Data will need to be appropriately disaggregated to account for regional differences. Technical and logistical support has been provided for the early-warning system, to ensure that nutritional indicators are incorporated into the system and analysed on a monthly basis. UNICEF and its partners will also need to ensure that the surveillance system explicitly leads to programmatic action, which in turn will need to be measured in results.
Vulnerability analysis: the need for a broader framework for understanding malnutrition
As late as May 2005, analyses still focused on the production and availability of grain staples at the expense of other indicators, such as changes in the import and export regulations governing grain, market prices, access to food and malnutrition. Other factors such as lack of access to health services, cultural practices and gender inequality were inadequately incorporated into the national vulnerability analysis and subsequent programming. Furthermore, analyses failed to identify which population groups were at relatively greater risk, and why. In view of existing resource constraints, this analysis could have been extremely useful for prioritising action. The problem of persistent indebtedness among vulnerable groups must also be highlighted, especially given the continuing deterioration of livelihood systems. Information should be analysed from a long-term perspective, taking into account earlier trends, previous crises and a systematic comparison of different livelihood groups coping strategies, as well as chronic vulnerabilities.
A broader regional analysis of the problem of malnutrition is critical for more effective strategy development in the future. A comprehensive analysis and understanding of the risks associated with changes in regional cross-border trade regulations should inform priorities for programming, as well as advocacy. Similar patterns of vulnerability are occurring elsewhere in the region, for instance in Burkina Faso and Mauritania. UNICEF has developed an inter-agency proposal for West and Central Africa which focuses on addressing both acute and chronic malnutrition; strengthening early-warning systems including nutritional surveillance systems, developing a regional approach to the treatment of severe and moderate malnutrition using a decentralised community-based approach, establishing adequate supplies and stockpiles of emergency nutrition commodities, addressing infant and young child feeding and strengthening national nutrition policies to reflect emergency nutrition and other child survival activities.
Strengthening and retaining emergency and development capacity
Separating humanitarian and developmental efforts potentially sets up a false dichotomy between normality and crisis, obscuring the fact that many people live perpetually close to the edge of crisis. In situations of chronic vulnerability, where populations have reduced capacity to cope with shocks, crises are more likely to recur. In Niger, UNICEF and its partners did not adequately articulate and advocate for a strategy that included both mitigation and emergency response interventions.
UNICEF and its partners should recognise that earlier interventions such as strengthening peoples livelihoods, developing national capacity for emergency response and advocating for improved access to social services and markets are critical interventions in countries where chronic vulnerability exists. UNICEF and others must respond, not only to the existing malnutrition crisis, but also to the factors that predispose people to crisis, and the underlying causes. While UNICEF cannot undertake responsibility for all interventions addressing the underlying causes of malnutrition, UNICEF should ensure that the analytical framework that it applies in surveillance and early warning sufficiently measures these underlying causes. Subsequently, UNICEF is obligated to undertake strategic advocacy that is based on evidence, and where possible design and implement programmes that address these underlying causes.
It is equally important that UNICEF retains adequate emergency response capacity (financial, human, technical and logistical) to address nutritional crises, however localised, in countries such as Niger. In particular, high-calibre staff specifically equipped with skills in emergency as well as public health nutrition should be retained in-country, to recognise when there is a deterioration in the nutritional situation, to develop and build national capacities and to advise and support timely responses. This would include the resources and capacity to address chronic underlying causes such as inadequate feeding practices (which may be exacerbated in crises) as well as priority public health interventions, including measles and malaria campaigns.
In August 2005, a strategy to address the problem of acute malnutrition in the context of chronic vulnerability was implemented. Supported by the UNICEF Regional Office for Western Africa and Headquarters, the Niger Country Office has played a more effective and decisive role by assuming a greater technical, leadership and coordination function in nutrition through its support to the Ministry of Public Health, and in cooperation with NGOs. UNICEF now has technical nutrition staff based in Niger as well as in the regional office to support strategic changes at the policy and programme levels.
Existing UN coordination mechanisms in Niger, such as the UN Country Team, were slow to acknowledge the severity of the crisis. Coordination between the UN and the government, as well as coordination within UN agencies, was weak. Funding constraints prevented WFP from fulfilling some of its commitments as outlined in a global MOU between UNICEF and WFP, specifically in undertaking large-scale emergency supplementary feeding programmes. The relatively late implementation of general and supplementary feeding contributed to greater numbers of severely malnourished children requiring treatment in therapeutic feeding programmes.
Close collaboration and coordination between the different UN and other agencies in Niger is critical, especially in the area of nutrition. An adequate UN response in a nutritional crisis requires that UN agencies work collaboratively, with well-defined responsibilities (UNICEF for surveillance, treatment of malnutrition, infant feeding and Vitamin A; WFP for food aid; FAO for food security; WHO for health). UNICEF, as the lead UN agency for nutrition, needs to ensure that policies and programme priorities are based on a framework that engages and holds accountable each of these agencies (including UNICEF itself) for effectively addressing and preventing malnutrition in emergencies. To a large extent, the specific roles and responsibilities of UN agencies have been clarified. In March 2006, UNICEF assumed the coordination of technical support for the treatment of malnutrition, WFP will provide food for supplementary feeding programmes (SFPs) and WHO will coordinate and implement complementary health initiatives; UNICEF will continue to supply nutrition and drugs for the management of severely malnourished children. Although a significant step forward, this clarification of responsibilities, this clarification is not necessarily applied at the country level across all emergencies.
Strengthening and developing national capacity
UNICEF needs to establish a long-term approach to strengthening emergency nutrition capacity within the Niger government. The strategy in Niger will require more than intermittent training workshops, and will need to be sustained over a long period. It should focus on leadership skills as well as technical competencies within national structures, and it should focus on achieving greater ownership of nutrition surveys and surveillance findings, incorporating emergency nutrition policies into broader public health policy and advocating for the abolition of user fees for essential health services. It should also consider advocating for access to locally produced low-cost therapeutic foods and complementary foods for young children. Overall, UNICEF should support, and should be accountable to, specific capacity development results and outcomes within Nigers government and other national structures. As UNICEF strengthens its own capacity in emergency nutrition, it should be better positioned in the medium term to strengthen the governments capacity. Neglecting to do so will only lead to inadequate national capacity and over-reliance on (often inadequate) international capacity in future crises in Niger.
Strategic advocacy is a critical component of UNICEFs emergency response. In Niger, however, relatively greater emphasis was placed on short-term advocacy, rather than strategic policy advancements. While retaining a focus on children, UNICEF and its partners must work to ensure that rigorous, evidence-based assessments are used to inform and develop a country-based advocacy strategy for immediate and long-term change. These assessments are crucial not only for informing agencies about context-specific priorities, but also for gaining consensus among partners, including national authorities, over the severity of the situation and the need for a scaled-up response. Evidence-based advocacy in Niger is also required to raise the profile of nutrition in general; achieve greater cohesion between interventions addressing chronic and acute causes; win broader recognition of the various causes of malnutrition (not just related to food); revise and change health policies that support more equitable health services; ensure that social, cultural and gender-related causes are consistently addressed; and make certain that changes in cross-border (regional) trade regulations have minimum negative effects on peoples access to food. Advocacy must be sustained and systematically communicated to all stakeholders, including the government, the broader UN family and internally within UNICEF, as well as with donors and regional actors.
The chronic and devastating nature of the malnutrition crisis in Niger poses significant challenges for humanitarian aid agencies, including UNICEF. An approach which encompasses a meaningful shift in policy, programming and advocacy strategies is needed. Significant progress has been achieved by the humanitarian community in recent months to address the crisis in Niger, but the problem of chronic vulnerability and high levels of chronic and acute malnutrition persists. Greater efforts are required to understand and respond to this chronic vulnerability.
Annalies Borrel (email@example.com) and Lauren Rumble work in the Humanitarian Policy and Advocacy Unit in UNICEFs Office of Emergency Programmes, New York. Until recently, Gillian Mathurin was also a member of the team. Significant inputs into this article were made by UNICEFs Regional Office in West Africa, the Country Office in Niger and the Nutrition Section at UNICEF Headquarters.