Nutrition in urban areas

Protection objectives

• To ensure refugee populations in urban areas have access at all times to safe and nutritious food, sufficient to maintain a healthy and active life.
• To respect the right to food and the right to health.
• To ensure refugees receive appropriate treatment for moderate acute malnutrition (MAM) and severe acute malnutrition (SAM).
• To ensure adequate protection, promotion and support for breastfeeding of infants and young children are available, that infants and young children have access to adequate complementary feeding and that infants younger than 6 months who are not breastfed have access to alternative food that is appropriate and adequate.

Underlying principles and standards

Note that UNHCR has developed a comprehensive public health strategy that applies to emergency and non-emergency operations in camp and out-of-camp settings. In urban settings, UNHCR aims to integrate refugees into national services, and therefore UNHCR and its partners should apply national public health and nutrition standards where these exist and are appropriate.

Sphere, Management of malnutrition standard 2.1: Moderate acute malnutrition. Moderate acute malnutrition is prevented and managed.

Sphere, Management of malnutrition standard 2.2: Severe acute malnutrition. Severe acute malnutrition is treated.

Sphere, Micronutrient deficiencies standard 3: Micronutrient deficiencies. Micronutrient deficiencies are corrected.

Sphere, Infant and young child feeding standard 4.1: Policy guidance and coordination.Policy guidance and coordination ensure safe, timely and appropriate infant and young child feeding.

Sphere, Infant and young child feeding standard 4.2: Multi-sectoral support to infant and young child feeding in emergencies. Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that minimises risks, is culturally sensitive and optimises nutrition, health and survival outcomes.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 1. Addresses the prevention of under-nutrition and micronutrient deficiencies through the provision of access to food, cash and/or vouchers to the general population, and special nutritional products for vulnerable groups, as well as promotion of and support to adequate infant and young child feeding and care practices.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 2. Sets standards for treating acute malnutrition that ensure quality treatment and adequate coverage.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 4. Guides an effective food security and nutrition response in emergencies.

UNHCR and Save the Children, Infant and Young Child Feeding in Refugee Situations: A Multi-Sectoral Framework for Action. 2018. Provides guidance on how to consider the particular vulnerabilities of children under 2 and pregnant and nursing mothers in a multitude of sectors.

Protection Risks

In emergency refugee operations, protection, food security and nutrition are closely linked.

• If refugees living in urban areas cannot obtain enough food, they are likely to become food insecure and malnourished and may adopt unsafe coping mechanisms that endanger their security.
• If refugees are not screened for acute malnutrition, or malnutrition programmes are not available, individuals with acute malnutrition will not be identified or treated, making it more likely that they will die or that their nutritional status will deteriorate.
• If infants and mothers who have difficulty breastfeeding do not receive assistance and skilled support, those infants are at greater risk of serious malnutrition and death.
• If programmes do not promote and support good feeding and caring practices for infants and children younger than 24 months, infants and young children are more likely to become malnourished and to die.

Other risks

Refugees in urban areas face additional indirect or long term risks if they do not have access to sufficient food or treatment for malnutrition.

• Security may be compromised, by riots, demonstrations, or violent behaviour.
• Refugees may take risks to acquire food, or adopt unsafe coping strategies. These may adversely affect feeding and care (including breastfeeding) of infants and young children.
• Malnourished individuals may suffer long-term effects, such as impeded growth or development.

Key decision points

Wherever required, UNHCR and WFP should provide appropriate food assistance, including fortified foods, to refugees in urban areas.

Treatment programmes for acutely malnourished refugees, and support services and facilities for infant and young child feeding, should always be available to refugees living in urban areas. UNHCR should encourage the authorities to grant refugees access to national services, where these are available and adequate. Where they are not, UNHCR should collaborate with the Ministry of Health, UNICEF, WFP and other relevant actors to establish new services or improve those that exist, for the benefit of both refugee and host populations.

Where individuals require help to breastfeed or infants younger than six months need alternative foods to breast milk, appropriate services and support must be made available.

Public health and nutrition interventions must always be:

• Evidence-based. Activities should be planned and implemented, based on the findings of the initial assessment.
• Needs-based. Interventions should be scaled and resources should be allocated to meet the needs of the population.
• Technically sound. Services should be based on current scientific evidence and operational guidance, and implemented by skilled staff.
• Impact oriented. UNHCR promotes the primary health care approach, which ensures that essential health services address the health and nutrition needs of the entire population.
• Priority-based. Emergency nutrition interventions and services should be prioritised to achieve maximum impact across the population. Interventions to address immediate health risks, such as disease outbreaks and malnutrition, must be priorities.
• Integrated. Avoid setting up costly parallel services. Assist the national health system to extend its services to refugees.

Key steps

• Establish strong co-ordination with the Ministry of Health (MOH), NGOs, UNICEF, WFP and other relevant actors to ensure refugees are integrated into available national nutrition services. In urban areas, UNHCR will need to rely even more on available services than in camp and camp-like settings.
• Ensure refugees have access to information and know where services are available and are able to voice their opinions.
• Ensure that all needs are covered and referrals between services and individual follow-up are assured, given that urban settings sometimes have more complex service delivery structures.
• Make sure that all refugees living in urban areas have adequate access to food. To prevent their nutritional status from deteriorating, assist them to be self-sufficient or provide (temporary) food assistance.
• Conduct regular nutrition surveys to monitor the situation. Either include urban refugees in national/regional nutrition surveys, or conduct specific nutrition surveys that observe UNHCR's Standardised Expanded Nutrition Survey (SENS) guidelines. During an emergency, nutrition surveys should be conducted bi-annually or annually, depending on the level of malnutrition, the risk of deterioration, and available resources.
• Where the nutrition situation is of concern, continue to screen for acute malnutrition among refugees, both to monitor levels of nutrition and identify individuals who need treatment. If the host community is screened, make sure that refugees are included.
• All refugees living in urban areas should be able to access programmes for treating moderate and severe acute malnutrition. Refugees should preferably be included in national programmes where these exist. Where they do not, UNHCR should encourage and support the creation of services that will benefit both refugees and the host community. Programmes should align with principles of CMAM (community-based management of acute malnutrition) and be linked to national health and nutrition services.
• To treat severe acute malnutrition (SAM), inpatient and outpatient services should be available to refugees, wherever possible through national programmes, in collaboration with the Ministry of Health and UNICEF.
• To treat moderate acute malnutrition (MAM), outpatient services should be provided, linked to national programmes; WFP should provide the food products required.
• To tackle malnutrition effectively and identify individuals who are malnourished, it is crucial to inform the community about malnutrition and engage the population in efforts to improve nutrition.
• During emergencies, infant and young child feeding (IYCF) programmes help to save the lives of numerous vulnerable infants and young children and play a key role in preventing malnutrition and micronutrient deficiencies. Refugees living in urban areas should have access to services that compare with those available to the host community, preferably by their inclusion in national programmes in collaboration with the Ministry of Health and UNICEF. Where services do not exist or are inadequate, UNHCR and partners should encourage their creation or improvement. Programmes should protect, promote and support exclusive breastfeeding for infants younger than 6 months, and combine appropriate complementary feeding for older infants and children with continued breastfeeding.
• Where the diet of pregnant and lactating women (PLW) lacks nutrients, it may lead to pregnancy complications, maternal mortality, low birth weight infants and lower concentrations of certain nutrients in the breastmilk. PLW should be able to access relevant services in the host community. Where such services do not exist, UNHCR should encourage their establishment, in collaboration with the Ministry of Health, UNICEF and other relevant agencies.
• Micronutrient deficiencies are mainly prevented through food security programmes. Where a population receives food assistance, a suitable micronutrient-fortified food should be included in the general ration; blanket provision of complementary food for children or other vulnerable groups may be needed. It is also vital to control diseases, notably respiratory infections, measles, and parasitic infections like malaria and diarrhoea that deplete micronutrient stores. The provision of water and appropriate sanitation facilities is essential. Where relevant, refugees should be integrated in national malnutrition prevention and treatment programmes.
• Refugees with specific needs who require assistance to access or use nutrition services should be supported and prioritised.
• Apply an age-gender diversity perspective and use community based approached in assessments, response analysis and programme implementation.

Key management considerations

Where refugees live in urban areas side by side with host communities, early coordination and collaboration with the government, NGOs, UNICEF, WFP and other partners is especially important. UNHCR must ensure that refugees have access to adequate food, programmes to treat and prevent acute malnutrition, and infant feeding support. UNHCR should encourage the integration of refugees in national programmes and services to which their host communities have access.

Where national services do not exist or are inadequate, UNHCR and UNICEF should encourage their creation or improvement, to the benefit of both refugees and the host community. When national programmes are overwhelmed by exceptional need, for instance during food or nutrition emergencies, UNHCR and partners must establish additional services and provision to complement national programmes.

Given that UNHCR has an overall accountability for the refugee response, UNHCR should ensure that public health or nutrition staff are available as soon as possible to support the assessment, relevant public health and nutrition strategy and support the operational response. In situations where malnutrition is a severe problem, UNHCR should deploy nutrition staff directly.

Though the preferred option is to integrate refugees within national services, it must be recognized that challenges may arise. For instance, the services delivered may be uneven, programmes may lack staff, access may be difficult (because of distance, for example), data may be lacking, and oversight of refugee access and nutritional status may be weak.

Infant feeding programmes must respect the UNHCR´s standard operating procedure on breast milk substitutes (BMS). UNHCR actively discourages inappropriate distribution and use of BMS, which are not to be included in general or untargeted distributions, and are only provided to specific infants after a professional assessment. UNHCR does not accept unsolicited donations of BMS. Inappropriate handling of milk products can negatively affect feeding practices and increase infant morbidity and mortality.

Resources and partnerships

The inputs required to set up and implement a nutrition response in urban areas depend on the nature of the emergency and the degree to which refugee needs can be met by available national programmes and services. Initially, an experienced public health officer, with nutrition experience should be present to assess the situation and need. If it is found that a comprehensive nutrition response is necessary, the inputs below will be required.

Staff

• A trained UNHCR public health officer, with knowledge of nutrition, to coordinate the response.
• An experienced nutritionist from UNHCR or standby partner to lead the nutrition response in cases of severe under-nutrition, ensuring that refugees are integrated in available national services, or that services are created or improved;
• Community outreach workers to provide support in the community and nutrition/health assistants to staff nutrition centres, from UNHCR or partner organisations. In some cases, staff will be available in sufficient numbers; however, after a refugee influx, staff may need to be recruited or trained.

Partners

• If it is necessary to establish new services or to strengthen existing services, nutrition partners must be identified in partnership with the Ministry of Health, UNICEF and WFP, to screen for malnutrition, implement nutrition programmes, and conduct nutrition surveys.
• Predictable partnership agreements must be established with relevant NGOs (international and national) and UN agencies such as WFP and UNICEF.