International Migrants Day 2017

The answer to bridging the development-humanitarian divide when addressing malnutrition in fragile contexts:
Longer-term and multi-sectoral funding approaches

Members of the SUN Movement Executive Committee, CEO of Medical Teams International (MTI), Martha Newsome, and Permanent Secretary of the Office of the Prime Minister, Christine Guwatudde Kintu, highlight what they have learned by working together in Uganda with partners to support over one million refugees which the country hosts today.

Uganda joined the Scaling Up Nutrition Movement in 2011 and is a key pilot country for implementing the Comprehensive Refugee Response Framework (CRRF), which provides support to both refugees and host communities, alike, in seven districts across the north western and southwestern regions of Uganda. Medical Teams International (MTI) is a key health implementing partner which provides health and nutrition services to 700,000 refugees and 300,000 Ugandans –including community mobilisation and operation of 27 supplemental feeding centres (SFC), 27 outpatient therapeutic care centres (OTC), and six inpatient therapeutic care centres (ITC).

Uganda recently welcomed its millionth South Sudanese refugee – an amount that has tripled since 2015, from 480,000, to 1.3 million in 2017. At the height of the influx in May 2017, Uganda received as many as 5,000 refugees each day, via its borders – the majority (82%) of whom were women and children.[1]

Uganda is breaking new ground by integrating a focus on refugees within their National Development Plan II, and prioritising development interventions for those that have fled conflict. Yet, the massive influx greatly impacts the implementation of this plan, particularly in the northern region, as the level of acute malnutrition is reaching emergency levels. With a significant shortfall in the funding available, the government and partners such as MTI are finding it difficult to meet the essential needs of the growing number of refugees. In addition, host communities and refugees are found in poor districts of the country, that are both overstretched and increasingly vulnerable, as long-term support mechanisms to address nutrition become less predictable.[2] As support wanes from the international community, Uganda is experiencing a 70 per cent funding gap of its USD 674 million budget needed to meet the needs of refugee women, men and their families, and host communities. The budgeted monthly food requirement alone is USD 21 million.

Food security fragility in the southwest region

Despite a strong national nutrition programme, MTI data in two settlements in the southwest (Nakivale and Oruchinga), show that the host population is at an even higher risk of malnutrition than refugees. In Nakivale, the rates were at 37.9, 36.2 and 28 per cent (amongst refugees) and at 42 per cent for the host community, respectively, between 2013 to 2015.  In Oruchinga, stunting rates were at 34.8 per cent, 40.7 per cent and 30 per cent (for refugees), with a very high rate of 58 per cent (for the host community)”.[3]  Although refugees in this region have been resettled here for over five years, we believe these high rates are partly due to significant food insecurity from prolonged droughts resulting in crop failure. Host communities may not be accessing the general food distributions, as WFP has had to reduce the monthly rations provided by 25 per cent. Another key factor is the issue of climate change and unstable weather patterns, causing areas that have typically been food secure with diverse crops to now become food insecure. Increased droughts combined with the steady arrival of refugees —as many as 500 per day currently 1— have caused significant barriers in executing the Uganda Nutrition Action Plan, developed in alignment with the Scaling Up Nutrition Movement’s multi-sectoral and multi-stakeholder approach.

Situation of emergency in the northwest region

In the north, acutely malnourished children needing intensive nutrition services continue to arrive in Uganda. These needs present a great challenge, considering the extremely limited resources in the area, as health centres in the districts are only prepared to care for 500 malnourished children from both host and refugee communities and there are 3,000 (and rising) girls and boys in need of immediate assistance. This leaves the host communities with inadequate attention and services, further perpetuating the crisis. A recent report on Global Acute Malnutrition (GAM) progressions in the Rhino Camp and Adjumani show a progressive deterioration in its nutrition status, and the GAM of Bidibidi was reported at 7.6 per cent, just above the 5 per cent emergency threshold. The anaemia burden is also of significant concern, with rates in all three settlements of more than 40 per cent. [4] Additionally, we have found that Moderate Acute Malnutrition (MAM) cases of adolescents and people with chronic illnesses must be addressed, as supplementary feeding is only targeting pregnant and lactating mothers and children 5 and under.

As refugees are likely to stay in Uganda for many years, it is difficult to address the nutritional needs of refugees and the host population using current funding instruments and commitments that are designed for short-term humanitarian interventions.[5] Supplementary feeding programmes helps to reduce high levels of malnutrition in the short-term, but there is still a need to address high levels of chronic malnutrition in these districts and the strain on nutrition services for local clinics that must care for these acutely malnourished girls and boys who enter. As we are beginning to see, this added pressure of the refugee population will likely destabilise the fragile economic situation of these districts, causing an overall decline in the nutrition status of the whole population.

Therefore, this situation underscores the need to make good on our collective Grand Bargain Commitment from the Humanitarian Summit – where donors and aid organisations committed to bridge the development and humanitarian divide and “provide more un-earmarked money, and increased multi-year funding to ensure predictability and continuity in humanitarian response”.[6]

The Comprehensive Refugee Response Framework would ultimately allow this Grand Bargain to be realised through the hybrid mechanism of a multi-year strategy, yet funding continues to come in annual allotments.  MTI experiences this strain and its limitations, as we continue to operate under one year ‘typical’ humanitarian allocations in areas where long-term solutions are significantly needed, yet largely unaddressed.

In consideration of addressing nutrition in countries like Uganda who find themselves burdened from taking in unprecedented amounts of refugees, we recommend the following solutions:

• New longer-term (2-3 year), multi-sectoral “hybrid” funding mechanisms that offer both short and long-term solutions to malnutrition that can be implemented concurrently (i.e. feeding programmes targeting vulnerable groups and multi-sectoral approaches to reducing chronic malnutrition). These solutions should alleviate and address immediate relief-driven needs of both populations, as well as consider the longer-term implications of malnutrition – while investigating its roots. Special attention should also be given to chronic malnutrition and preventable deaths for children under age five and their mothers (with a focus on curbing stunting, anaemia reduction, malaria prevention and MCH activities). In this specific case of Uganda, traditional annual methods of funding have proved inadequate as programmes are grossly underfunded with a shortfall of 70 per cent (as stated above). Whilst most donors have pledged to fund their traditional pipelines, there is still little money to fund the gap for development interventions;

• A strategy to care for host and refugee needs, alike, as the “normal practice”, considering a more comprehensive approach that alleviates the strain on the receiving districts and looks at the nutritional needs of the entire population as well as considers refugee livelihoods (tying into the UN Durable Solutions approach);

• A focus on increased unity between civil society, the government and stakeholders. Escalating refugee crises such as these demand an enlightened governance, where there is commitment and willingness, at the government level, for increased engagement and support to collaborate with responders to best meet needs.

Martha Newsome,
CEO of Medical Teams International (MTI)

Christine Guwatudde Kintu,
Permanent Secretary of the Office of the Prime Minister

[1] Office of the Prime Minister
[2] ReHoPE
[3] FSNA 2016
[4] Refugee FSNA Report Dec 2016
[5] UNHCR – unrefugees.org
[6] Agenda for Humanity