Targeting the vulnerable: a review of the necessity and feasibility of targeting vulnerable households

This article examines whether it is possible to target vulnerable households within a geographically defined area. It looks first at the justification for targeting and then reviews recent practical experience in actually trying to reach vulnerable groups. As complex emergencies increasingly last longer, strategies to target vulnerable households are common in the protracted phase of the emergency. While this is often necessary because of a decline in resources, it is not always justified by an improvement in nutritional status or food security of the beneficiary population. Common target groups are the poor and the malnourished, but in complex emergencies these are not always the most vulnerable. Moreover, recent practical experience has shown considerable difficulties in targeting the poor. Methods to target the poor rely on community-based relief committees, whose priorities are not necessarily the same as those of external agencies. This paper gives examples of such targeted assistance programmes in Kenya, south Sudan and Tanzania. The paper concludes that situations where targeting vulnerable households is justified and feasible are extremely limited. It is suggested that if targeting has to be done because of scarce resources, this should be done on a geographical basis and on the basis of nutritional status. Case-study material shows that it is essential to understand the political determinants of vulnerability and to design methods that will reach the most vulnerable.     

Zimbabwe's Child Supplementary Feeding Programme: a re-assessment using household survey data

In 1992-3 and 1995-6, Zimbabwe used a Child Supplementary Feeding Programme (CSFP) to combat child malnutrition during drought-induced emergencies. Previous evaluations of the CSFP relied on routine administrative data and key informant interviews and made only cursory use of available household survey data. These evaluations concluded that the CSFP was effective in preventing an increase in malnutrition among children under five, especially in 1992-3. The more-detailed analysis of household surveys provided in this article suggests that CSFP coverage was generally patchy and disappointingly low, especially in 1995-6. There is little evidence that children from poor or nutritionally vulnerable households got preferential access to supplementary feeding. The CSFP failed to feed many malnourished and nutritionally vulnerable children even in areas where the programme was operating. Household survey evidence suggests that the CSFP's impact on nutritional status was likely marginal, especially in 1995-6.     

Malnutrition and Poverty in the Early Stages of Famine: North Darfur, 1988–90

In this article we report findings on the relationship between malnutrition and poverty during a period of acute food insecurity in Darfur, Sudan. Children of rich and poor families were equally likely to be malnourished, which is explained in terms of people's responses to the threat of famine. This finding has important implications for targeting interventions in the early stages of famine. Appropriate interventions at the early stages of famine are livelihood and income support to the most vulnerable. The entitlement theory of famine causation assumes that the poor are most vulnerable, and become malnourished and die during famines. In this article we show that this assumption does not hold. Even though poverty is the root cause of malnutrition, it does not follow that anthropometric status can be used to target individual poor families, or even that targeting the poor is appropriate in famine situations.     

Nutritional response to the 1998 Bangladesh flood disaster: Sphere minimum standards in disaster response

In this study we use a cross-sectional survey to evaluate the nutritional response to the 1998 Bangladesh Flood Disaster by 15 relief agencies using standards developed by the Sphere Project. The Sphere Project is a recent attempt by agencies around the world to establish universal minimum standards for the purpose of ensuring quality and accountability in disaster response. The main outcomes measured were resources allocated to disaster relief types of relief activities and percentage of agencies meeting selected Sphere food aid and nutrition indicators. Although the process of nutritional response was measured, specific nutritional and health outcomes were not assessed. This review found that self-reported disaster and nutritional resources varied widely between implementing agencies, ranging from US $58,947 to $15,908,712. The percentage of resources these agencies allocated to food aid and nutritional response also varied, ranging from approximately 6 to 99 per cent of total resources. Agencies met between 8 and 83 per cent of the specific Sphere indicators which were assessed Areas in which performance was poor included preliminary nutritional analysis; beneficiary participation and feedback; disaster preparedness during non-emergency times; monitoring of local markets and impact assessment. Agencies were generally successful in areas of core humanitarian response, such as targeting the vulnerable (83 per cent) and monitoring and evaluating the process of disaster response (75 per cent). The results here identify both strengths and gaps in the quality of humanitarian response in developing nations such as Bangladesh. However, they also raise the question of implementing a rights-based approach to disaster response in nations without a commitment to meeting positive human rights in non-disaster times.     

Epidemiological assessment of food aid in the Bosnian conflict, 1994-97

Surveys in emergency settings are important for the accountability of food aid. Four household surveys conducted between 1994 and 1997 measured the performance of the Bosnia food aid programme, covering a random sample of clusters in Bosnia and Herzegovina and the Republica Srpska. The team calculated coverage, exclusion and inclusion errors, programme misses, and under-supply. Despite intended universal coverage from 1994-96, 15, 19, and 31 per cent, respectively, did not receive food across the three-year time frame. Households categorised as vulnerable were somewhat more likely to receive food. Programme misses were rare, whereas under-supply fell from 30 per cent in 1994 to four per cent in 1997, as the availability of other food increased. Extrapolation suggested that 61 per cent of the food distributed did not reach households. The programme introduced priority categories for targeting in 1997, yet nearly one-half of the highest priority households did not receive food. Incomplete coverage and weak targeting were related to political constraints.     

The Impact of a Reduced and Uncertain Food Supply in Three Besieged Cities of Bosnia-Hercegovina

Nutritional status and household food security were longitudinally monitored in three besieged cities of Bosnia-Hercegovina (Sarajevo, Zenica and Tuzla) during the winter and spring of 1993 to 1994. The objectives were to provide early warning of a deterioration in the food and nutrition situation and identify particularly vulnerable groups so that action could be taken to prevent potential undernutrition and target resources to the most needy. Before the cease-fire, which came into effect at the end of February 1994, trends in various indicators (weight loss, decline of household food stocks, rising food prices, reduction in food aid distribution, sale of possessions) suggested that the situation was deteriorating. Access to food improved as a result of the cease-fire, however, which was reflected in improvements in indicators of food security and weight gain. The impact of, and response to, the food emergency differed between individuals, households and locations; the elderly were found to be more nutritionally vulnerable than children or adults, households with the least access to resources were the most food insecure, while the city of Zenica appeared to be particularly hard hit. The findings show the effects of an uncertain and reduced food supply on a previously well-fed healthy population in an industrialised country. The value and constraints of an Early Warning System set up to monitor trends in an emergency in a European context are discussed.     

Coping with drought and food insecurity in ethiopia

In this article I examine the impact of drought on farm households in Ethiopia and their response to crisis conditions. I ask whether every household in a community is equally affected by drought and what households do to mitigate the effects of drought and associated food insecurity. Information on production, income and food consumption is disaggregated by agroecological zone (highland and lowland), and by socioeconomic strata (relatively wealthy versus poor). Such detailed analysis permits an improved understanding of why the poor are much more vulnerable than the wealthy to drought and associated famines and why they need to be more effectively targeted by relief and development interventions. In a world of limited public resources for crisis intervention, such understanding is crucial to the design of improved policies and projects for reaching people most at risk.     

Ageism: A Factor in the Nutritional Vulnerability of Older People?

Unlike other population groups, the rights, needs and contributions of older people in developing countries are not well understood. With the absence of information about how to assess the nutritional status and vulnerability of older people, HelpAge International joined forces with the London School of Hygiene and Tropical Medicine in the early 1990s to launch a research programme. Seven years later some of the basic questions can now be answered but there remains much more to do.
Although older people are increasingly acknowledged as a vulnerable group in emergencies, NGO responses often fail to meet their needs. The question is whether there are real difficulties in service adaptation or whether ageism is one of the greatest barriers to the provision of appropriate services for older people.     

Ageism: a factor in the nutritional vulnerability of older people?

Unlike other population groups, the rights, needs and contributions of older people in developing countries are not well understood. With the absence of information about how to assess the nutritional status and vulnerability of older people, HelpAge International joined forces with the London School of Hygiene and Tropical Medicine in the early 1990's to launch a research programme. Seven years later some of the basic questions can now be answered but there remains much more to do. Although older people are increasingly acknowledged as a vulnerable group in emergencies, NGO responses often fail to meet their needs. The question is whether there are real difficulties in service adaptation or whether ageism is one of the greatest barriers to the provision of appropriate services for older people.     

Targeting vulnerability after the 2005 earthquake: Pakistan's Livelihood Support Cash Grants programme

The 7.6 magnitude (Richter scale) earthquake that struck northern Pakistan on 8 October 2005 was devastating. This paper gauges success in targeting vulnerable families during the transition from relief to reconstruction through cash assistance provided by the Livelihood Support Cash Grants (LSCG) programme. Families without a male member, with a disabled male member aged between 18 and 60 years or with more than five children, defined as vulnerable, were provided with USD 50 per month for six months via a bank transfer. The LSCG scheme enrolled around 750,000 families and selected 267,402 vulnerable families to whom it disbursed a total of USD 86.95 million. Using a community‐based survey, this paper assesses leakage and under‐coverage (exclusion). Approximately 30 per cent of families received the cash grant. However, only one in two was eligible for the benefit, and one in two deserving families was excluded. This is a matter of grave concern.     

Vulnerable groups*

As a rule, refugees arrive in their host country with a bare minimum of possessions; in this respect every refugee can be classified as vulnerable. However, a certain category is especially at risk, namely those persons who would be considered vulnerable in a "normal society." These people are doubly in need of assistance, firstly, inasmuch as they are refugees and secondly, insofar as they are vulnerable. If these refugees can be helped to overcome (or at least reduce) their handicaps, they can begin to become self-reliant and form an active, productive parts of their community, rather than remaining an extra burden to an already vulnerable part of the society in their country of asylum. Whilst their able-bodied companions work in the fields or the towns, part of this category can be trained and usefully employed in sectors of work that do not require great mobility or physical fitness (such as handicrafts, trade, teaching and services)..     

Surveillance of the Health and Nutritional Status of Rohingya Refugees in Bangladesh

Early in 1992, Bangladesh experienced an influx of Burmese refugees, reaching a total of 263,000 by May. As the health and nutritional status of the refugee population was reportedly poor, a need was felt to collect dependable data through epidemiological surveillance, on which interventions could be based. The nutritional and health status of children was dramatically poor in all camps surveyed and a deterioration was expected in the coming monsoon. Several problem areas could be identified. Based on these findings it was possible to undertake appropriate action and to avert threatening calamities. Epidemiological surveillance is an important monitoring tool to provide reliable data on the health and nutritional status of refugee populations and to help the organizations involved to prioritize and evaluate their actions.     

Implementing cash for work programmes in post-tsunami Aceh: experiences and lessons learned

Cash for work (CFW) programmes are utilised in various disaster and emergency contexts and were a prominent component of the tsunami response in Aceh province, Indonesia. This paper describes Mercy Corps' CFW programme, discusses CFW implementation experiences and provides key recommendations for similar programmes in future emergencies. For the majority of CFW participants and their households, CFW was the only source of household income and 93 per cent of household incomes were attributable to it. The CFW programme empowered displaced populations to return to their communities; 91 per cent of participants indicated that CFW facilitated their return. Other reported psychosocial benefits included providing productive activities and giving communities an opportunity to work together. Mercy Corps' experience in Aceh demonstrates that cash disbursements can be safely delivered in a widespread manner in emergencies, and that when implemented on a short-term basis, can have positive impacts at the individual and community level.     

The 1998 Flood in Bangladesh: Is Different Targeting Needed During Emergencies and Recovery to Tackle Malnutrition?

Bangladesh suffered the century's worst flood during July-October 1998 and appealed for assistance. To provide information for appropriate interventions to tackle nutritional problems, a rapid assessment survey was conducted to look at the nutritional situation, problems encountered by the community, their coping mechanisms and rehabilitation priorities in six rural areas. The survey was repeated after four months to measure the outcome of activities during the flood and the necessity for future assistance. There were 3,048 children measured in both surveys (1,597 and 1,451). The sample of most interest was a sub-group of 180 children present in two previous independent surveys. The analysis found that while moving from the crisis period to post-flood phase there was evidence of a 'crossover phenomenon' in the recovery pattern of nutritional status. Sixty-eight per cent of the children who were malnourished (WHZ < -2SD) during the crisis period (18 per cent) recovered enough to cross the cut-off point and became normal after four months. Another 8 per cent of children (9 per cent of all normal) who were normal during the crisis period, after four months had deteriorated to be malnourished. Thus, despite there being a shift in the overall distribution of nutritional status, there has been another shift that reduced the net effect. Subsequent episodes of diarrhoea, access to food and loan burden had also influenced the recovery pattern of the children's nutritional status as evident from the statistically significant associations. These findings raise questions about targeting acute malnutrition during emergencies, and using the same criteria during both the crisis and rehabilitation phases.     

Humanitarian information systems and emergencies in the Greater Horn of Africa: logical components and logical linkages

Natural and man-made emergencies are regular occurrences in the Greater Horn of Africa region. The underlying impoverishment of whole populations is increasing, making it more difficult to distinguish between humanitarian crises triggered by shocks and those resulting from chronic poverty. Shocks and hazards can no longer be seen as one-off events that trigger a one-time response. In countries that are both poor and exposed to frequent episodes of debilitating drought or chronic conflict, information needs tend to be different from the straightforward early warning/commodity accounting models of information systems that have proven reliable in past emergencies. This paper describes the interdependent components of a humanitarian information system appropriate for this kind of complex environment, noting the analytical links between the components and operational links to programme and policy. By examining a series of case studies from the Greater Horn region, the paper demonstrates that systems lacking one or more of these components will fail to provide adequate information--and thus incur humanitarian costs. While information always comes with a cost, the price of poor information--or none--is higher. And in situations of chronic vulnerability, in which development interventions are likely to be interspersed with both safety nets and emergency interventions on a recurrent basis, investment in improved information is a good investment from both a humanitarian and a financial viewpoint.     

Rural residents and choice of building earthquake-resistant house: results of a choice experiment study

Rural settlements, especially in developing countries, are disproportionally vulnerable to natural hazards due to both biophysical and social vulnerability. Building hazard-resistant houses requires a thorough understanding of hazards and institutional and financial resources. However, it is equally important for planners and policymakers to know how rural residents make the tradeoff between various housing attributes when provided with the resources such as low-interest housing construction loans. In this study, we use a choice experiment (CE) to examine rural households' preference for earthquake resistance when building houses. A total of 300 households from randomly selected villages in central districts of Guilan Province in Iran were recruited for a CE study in which they had to choose between a number of houses that differed in terms of the required construction loan, resistance to earthquakes, size, and exterior and interior designs. Our results show that the average resident preferred larger houses with better exterior and interior designs to more earthquake-resistant houses, and is willing to spend more on these attributes than earthquake safety. These results indicate that rural households are willing to receive loans to improve their houses but that this does not translate into more earthquake-resistant houses.     

The impact of drought on production, consumption and nutrition in southwestern kenya

In this paper I compare the effects of the 1984 drought on agricultural production, income, food consumption, and nutrition of farm and non-farm households in South Nyanza District, Kenya. Survey work covered the period 1984 to 1987. It was the late arrival of the long rains in spring 1984, rather than an absolute shortfall in rain, that caused most of the fluctuations in agricultural production. Agricultural households who were least affected by the drought were able to cope by increasing the amount of cultivated land and by relying more on coarse grain production. Coping strategies for the landless households in South Nyanza were more limited and this group of households therefore experienced greater fluctuations in income between the drought and non-drought periods than did most types of agricultural households. Surprisingly, changes in food consumption between the drought and non-drought periods were small for most households. In spite of differences in production, food availability and incomes, however, the health and nutritional status of pre-school-aged children was not significantly different in the two time periods. Differences in health and nutritional status appear to be influenced more by community-level health and sanitation factors than by differences in agricultural production and incomes in drought and non-drought years.     

Supporting breastfeeding in emergencies: protecting women's reproductive rights and maternal and infant health

Women have the right to support that enables them to breastfeed. Supporting breastfeeding in emergencies is important because artificial feeding places mothers and children at risk. In emergencies, artificial feeding is dangerous to the infant, difficult and requires substantial resources. In contrast, breastfeeding guards infant health. It is also protective against postpartum haemorrhage, maternal depletion, maternal anaemia and closely spaced births and should therefore concern not only nutritionists, but also those involved in reproductive health. However, it is common for women's ability to breastfeed to be undermined in emergencies by the indiscriminate distribution of breast-milk substitutes and the absence of breastfeeding support. Controlling the distribution of breast-milk substitutes, providing supportive environments, and appropriate medical and practical assistance to breastfeeding women safeguards the health and well-being of mothers and babies. Greater collaboration between the nutrition and reproductive health sectors is required to promote best practice in protecting breastfeeding women and their children in emergencies.     

Mother's body mass index as a predictor of infant's nutritional status in the post-emergency phase of a flood

Maternal nutritional status is a determinant of child health. This paper studies the association between a mother's body mass index (BMI) and her infant's nutritional status over a one year time frame after the 1998 flood crisis in Bangladesh. The paper uses secondary analysis of data collected from 757 households in seven rural areas of Bangladesh affected by the 1998 flood using multiple-stage probability sampling techniques (n = 143). Logistic regression models were employed to investigate the predictive impact of maternal BMI on infant's nutritional status after controlling for a range of child and maternal factors. An underweight mother was a significant factor with regard to the risk of infants suffering stunting (odds ratio (OR) = 4.45, 95 per cent confidence interval (CI) = 1.04-18.94) and being underweight (OR = 3.51, 95 per cent CI = 1.02-12.05) a year later, but not wasting (OR = 2.09, 95 per cent CI = 0.51-8.67). The findings suggest that there is a post-emergency link between maternal and infant nutritional health.     

Are non‐poor households always less vulnerable? The case of households exposed to protracted civil war in Southern Sudan

Civil wars in Africa are now the leading contributory cause of vulnerability of rural communities. Understanding vulnerability during civil war is critical for humanitarian response and post-conflict rehabilitation planning. The lack of understanding of vulnerability has led existing studies to make sweeping generalizations, either by equating the dynamics of vulnerability during civil wars with vulnerability in other risk events, or by projecting people in the 'war zones' as unable to cope and subsequently becoming vulnerable. This paper is an attempt to gain a more nuanced understanding of the dynamics of vulnerability during protracted civil war. It shows that during civil war the non-poor are not necessarily less vulnerable than poor households. The idea that people caught up in civil war are all vulnerable is not supported by the findings of this paper. It shows that the 'standard' pattern of vulnerability to drought is similar to that during exogenous counter-insurgency warfare, while a different pattern of vulnerability to endogenous shocks is identified.