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