doi:10.1136/bmj.323.7315.740 
 2001;323;740-742 BMJ
  
André Griekspoor and Steve Collins 
  
 assistance?
are Sphere minimum standards for humanitarian 
Raising standards in emergency relief: how useful
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Education and debate
Raising standards in emergency relief: how useful are
Sphere minimum standards for humanitarian assistance?
AndrØ Griekspoor, Steve Collins
International humanitarian agencies have recently
developed a set of standards governing the implementa›
tion of relief programmes.
1
The Sphere standards were
developed in response to concerns about the quality and
impact of humanitarian assistance and are analogous to
those set for healthcare services in developed coun›
tries.
23
Although the standards have been generally wel›
comed, concerns have been raised about their use.
45
One worry is that the main measures apply only to ideal
situations in relief camps and that standardisation will
prevent relief workers from adapting in more complex
situations. Another fear is that politicians could use the
standards to obscure their responsibilities to tackle the
underlying causes of emergencies. Finally, the indicators
could foster unrealistic expectations while ignoring con›
straints. This could lead to unjustified adverse publicity,
liability, and reprisals.
67
In this article we describe the
standards and assess their usefulness by considering the
application of nutritional standards in the 1998 famine
in Sudan.
Development of standards
The Sphere project is a consortium of the inter›
national humanitarian community set up to establish
what is technically and normally possible for relief
operations.
8
More than 700 people from 228 relief
organisations in 60 countries considered ideas on
good practice over three years. The results were
published in a handbook in January 2000.
1
The Sphere
handbook contains a humanitarian charter and
minimum standards, accompanied by key indicators
for five sectors of disaster response: water supply and
sanitation, nutrition, food aid, shelter and site manage›
ment, and health services. The charter recognises the
basic right to assistance of people affected by disasters,
enshrined in international law. It highlights the legal
responsibility of states to guarantee these rights. The
standards are formulated as principles or objectives,
and the box gives examples of standards on nutrition.
The key indicators are quantified indices to measure
fulfilment of the standards.
Famine in Sudan, 1998
The 1998 famine in southern Sudan was another cata›
strophic episode in the continuing civil war.
9
In January
1998, during a period of severe drought, a resurgence
of fighting around the government held towns of Wau
and Gogrial displaced about 130 000 people. This
destroyed any remaining coping mechanisms and pre›
cipitated intense famine. Deliberate manipulation by
the warring parties aggravated the desperate situation.
By imposing a succession of flight bans and allowing
access to only a few sites, the Sudanese government
concentrated relief efforts in a few villages. Insecurity
on both sides of the frontline restricted movement of
aid workers and forced teams to evacuate periodically.
Displaced people who had gathered together had no
access to clean water, sanitation, or health facilities and,
despite relief efforts, had grossly insufficient quantities
of food. Malnutrition combined with epidemics of
diarrhoea killed tens of thousands of people.
To have an impact in such a resource depleted
situation, relief programmes must ensure that most of
the population has access to minimum life sustaining
requirements: sufficient general food rations, adequate
water, sanitation, and basic health care. Unless these
basic requirements are met, additional selective
feeding programmes, aimed at providing special food
for those with malnutrition, cannot produce a lasting
decrease in mortality.
Summary points
In January 2000, the Sphere project published the
first handbook describing minimum standards
and related key indicators applicable to
emergency relief programmes
The handbook aims to stimulate learning and
accountability by measuring process and outcome
The standards and key indicators are minimum
values for beneficiaries but cannot always be used
as planning objectives by humanitarian agencies
Assessment of performance of single agencies
must take into account the general context of the
emergency, particularly resource availability,
access, and interventions by others
Use of technical standards must be accompanied
by an obligation on states to respond to
humanitarian emergencies and guarantee the
rights of populations
MØdecins Sans
FrontiŁres,
Amsterdam,
Netherlands
AndrØ Griekspoor
head of the
monitoring and
evaluation unit
Valid International,
Oleuffynon,
Llanidloes, Powys
SY18 6PJ
Steve Collins
director
Correspondence to:
A Griekspoor, 148
Impasse du Saugy,
01210 Ornex,
France
griekspoora@who.ch
BMJ 2001;323:740–2
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Relief programmes for areas affected by drought will
usually include feeding centres. Supplementary feeding
centres provide moderately malnourished people with a
weekly ration of enriched blended cereal flour to take
home, whereas therapeutic feeding centres provide
severely malnourished people with 24 hour inpatient
care. Inpatients receive therapeutic milks tailored to
their individual metabolic needs, as well as intensive
medical and nursing care and systematic broad
spectrum antibiotic and antihelminthic drugs.
10
Most of the humanitarian relief for the 1998 famine
was provided by Operation Lifeline Sudan, an umbrella
group comprising the United Nations and international
and national non›governmental organisations. As in
many major emergencies, the World Food Programme
provided general rations. MØdecins Sans FrontiŁres
Holland set up two therapeutic feeding centres in Wau,
which had a population of 150 000, and supported the
town’s hospital. It also ran therapeutic and supplemen›
tary feeding centres and supported primary healthcare
centres in Panthou, Ajak, and Tieraliet, three villages of
5000›10 000 people controlled by the Sudan People’s
Liberation Army (figure).
Were Sphere standards met?
Sphere recognises that factors outside the control of
humanitarian agencies affect their ability to meet mini›
mum standards of service provision. Four prerequisites
need to be met: everyone involved in humanitarian
assistance should share a common goal; there should
be access to the afflicted population; sufficient funds
should be available; and everyone should be commit›
ted to meet minimum standards.
In Sudan during 1998, none of these underlying
assumptions were met. The humanitarian crisis and
the response were highly orchestrated by the Sudanese
governments and the Sudan People’s Liberation Army.
Access was severely restricted. The flight restrictions
flouted international humanitarian law that obliges
states to agree to the provision of humanitarian assist›
ance.
11 12
Large amounts of relief grain were diverted to
the military so that the general ration remained well
below requirements.
13
Adequate donor funding was
available only after June, when pictures of starving
children appeared on Western television. In our
experience, these findings are not abnormal in large
scale complex emergencies.
The relief intervention aimed to provide the great›
est amount of good for the greatest amount of people.
However, the needs were overwhelming and the
resources were grossly inadequate. The utilitarian
principle conflicted with the desire to provide
minimum levels of individual care described by the
Sphere key indicators. MØdecins Sans FrontiŁres did
not have the capacity to tackle the underlying problem
of inadequate food distribution. Therefore, in consulta›
tion with Operation Lifeline Sudan, it implemented
selective feeding programmes while advocating
improvements in the general ration. Although it
realised that this intervention would have limited
impact if the wider problems were not tackled, it
believed that solidarity and advocacy were important
reasons justifying an intervention. MØdecins Sans
FrontiŁres therefore established a field presence know›
ing that it was unrealistic to meet all Sphere’s process
and outcome key indicators (tables 1 and 2 ).
MØdecins Sans FrontiŁres’ solution to this problem
was to make admission criteria more stringent but
maintain a high level of care. For example, the
therapeutic feeding centres admitted only children
who were less than 60% of their weight for height
instead of the usual level of 70%. Because the centres
admitted only the most severely malnourished
children, recovery rates inevitably fell below the
indicated norm of 75% after two months. The coverage
of the feeding programmes in all locations was low,
varying from 10% to 33%.
An evaluation of the programme concluded that
the intervention could have had greater effect if
MØdecins Sans FrontiŁres had deviated further from
the Sphere standards.
14
It suggested that triage
methods, prioritising less intensive treatment for those
having better survival chances, would have been more
Examples of Sphere standards for emergency
nutrition interventions
Standard 1: assessment
Before any decisions are made about a programme,
aid workers must demonstrate understanding of the
basic nutritional situation and conditions that may
create a risk of malnutrition
Standard 2: response
If nutritional intervention is required, the problems
must be clearly described and the strategy for response
documented
Standard 3: monitoring and evaluation
The performance and effectiveness of the nutrition
programme and changes in the context must be
monitored and evaluated
Standard 4
The public health risks associated with moderate
malnutrition are reduced
Standard 5
Mortality, morbidity, and suffering associated with
severe malnutrition are reduced
Khartoum
Tieraliet Ajak
Wau
River Nile
White Nile
Blue Nile
Panthou
Sudan
Chad
Libya
Egypt
Ethiopia
Red
Sea
Kenya
Democratic Republic
of the Congo
Central African
Republic
0 km 300
Location of humanitarian relief operation by MØdecins Sans
FrontiŁres, Holland
Education and debate
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cost effective.
15
Large scale feeding centres with
reduced quality of treatment for individuals would
have freed up capacity to increase the coverage of the
programme. For example, not providing intravenous
rehydration would have avoided staff wasting time try›
ing to find parenteral access for patients with little
hope of survival. A triage strategy could have achieved
lower overall mortality by accepting higher death rates
among the most severely malnourished.
Such decisions are extremely difficult and require
considerable experience and professional acumen.
The Sphere handbook does not help in these
dilemmas. As Sphere does not include an indicator for
programme coverage, small intensive programmes
with low death rates but low coverage and therefore
low impact seem more effective than large less
intensive programmes with higher death rates but
higher coverage and impact. This omission should be
corrected in subsequent editions of the standards.
Conclusions
The Sphere handbook defines minimum service
standards from the perspective of beneficiaries.
However, the assumptions behind these standards,
such as unhindered access and adequate resources, are
rarely met during large scale humanitarian emergen›
cies. Such constraints restrict the effectiveness of all
humanitarian interventions. This case study shows that
trying to adhere to preset indicators when needs are
overwhelming compared with the available capacity
for response could promote inappropriate planning.
The Sphere nutritional key indicators emphasise indi›
vidual cure rates rather than overall impact at the
population level. Triage is needed to obtain an optimal
balance between quality of individual care and
coverage of the programme. Relief workers must be
prepared to define innovative approaches aiming at
the highest effect possible with the given resources.
The need for triage of entire populations is a sad
comment on the state of the “global village.” It reflects
a failure of politicians and governments to meet their
humanitarian responsibilities. Campaigns to point out
these obligations under international humanitarian
law, as emphasised in the humanitarian charter, must
be reinforced. The Sphere handbook must be used as a
whole and not just as a technical reference. This mini›
mises the scope for politicians to divert attention away
from underlying political failures by scapegoating
humanitarian agencies for not meeting technical
standards.
The success and immediate uptake of Sphere by
humanitarian agencies, donors, and the media has its
dangers. It is vital that agencies attempt to uphold
standards of interventions and that they are account›
able to donors, the media, and to those afflicted by dis›
aster. Nevertheless, in the absence of other tools,
politicians and the media might be tempted to judge
agencies solely on adherence to Sphere’s indicators. A
simple comparison of figures could lead to naive
assessments. The standards should be seen as
references when judging the performance of single
agencies. The wider humanitarian community and
media need to understand that achievements must be
analysed within their context, taking into account avail›
able resources, access, and interventions by others.
Competing interests: None declared.
1 The sphere project: humanitarian charter and minimum standards in disaster
response. 1st ed. Oxford: Oxfam, 2000.
2 Harrel›Bond B. Imposing aid: emergency assistance to refugees. Oxford:
Oxford University Press, 1986.
3 Relief and Rehabilitation Network. The joint evaluation of emergency assist›
ance to Rwanda: study III. Principal findings and recommendation. London,
Overseas Development Institute, 1996. (RRN paper 16.)
4 Gostelow L. The Sphere project: the implications of making humanitar›
ian principles and codes work. Disasters 1999;23:316›25.
5 Open letter, written by representatives of Action Contre le Faim, Institute
de l’Humanitaire, MØdecins Du Monde, MØdecins Sans FrontiŁres France
and Groupe Urgence RØhabilitation et DØveloppement. Paris, September
10, 1998. www.urd.org (debates, accessed 15 August 2001).
6 The Sphere project conference report, London, 3 December, 1998.
www.sphereproject.org (accessed 14 Feb 2000.)
7 Buzard N. Benchmarks, sticks or carrots? Differing perceptions of the role
of standards. Relief and Rehabilitation Network Newsletter 1998;12:13›4.
8 The Sphere project. www.sphereproject.org (accessed 14 Feb 2000).
9 Keene D. Making famine in Sudan. Field Exchange 1999;6 (Feb):6›7.
10 MØdecins Sans FrontiŁres. Nutrition guidelines. 1st ed. Paris: MSF, 1995.
11 Universal Declaration of Human Rights 1948. Articles 3 and 5
www.un.org/Overview/rights.html (accessed 10 June 2001)
12 Protocol additional to the Geneva conventions of 12 August 1949, and
relating to the protection of victims of international armed conflicts (pro›
tocol 1). Articles 69 to 71. http://www.unhchr.ch/html/menu3/b/
93.htm (accessed 10 June 2001).
13 Danida, Ministry of Foreign Affairs. Report on the evaluation of Danish
humanitarian assistance to Sudan, 1992›98. Vol 7. Sudan. Copenhagen:
Danida, 1999:42.
14 Collins S. MSF in catastrophe: Evaluation report of the MSF Holland
programmes in Bahr El Gazal and western upper Nile in 1998. Amsterdam:
Monitoring and Evaluation Unit, MSF Holland, 1999. (Evaluation series
No 9.)
15 Briggs SM, Leong M. Classic concepts in disaster medical response. In:
Leaning D, Briggs SM, Chen LC, eds. Humanitarian crises. Cambridge,
MA: Harvard University Press, 1999:69›80.
(Accepted 18 June 2001)
Table 1 Key indicators for supplementary feeding programmes
Panthou Tieraliet Ajak
No increase in levels of severe malnutrition or no increase in
number registered in therapeutic feeding centres
No Yes Yes
Surveillance systems established to monitor nutritional trends Yes Yes Yes
Programme objectives reflect understanding of causes and
identified target groups
Yes Yes Yes
Staff trained in principles of feeding infants and young children Yes Yes Yes
Clearly defined and agreed criteria for closing the programme No No No
Table 2 Key indicators for therapeutic feeding centres
Panthou Wau
Mortality rate <10% in 1›2 months No* Yes*
Recovery rate >75% in 1›2 months No* No*
Default rate <15% in 1›2 months No* No*
Mean daily weight gain >8 g/kg per person No* No*
Nutritional and medical care based on clinically proved therapeutic care
protocols
Yes Yes
Staff patient ratio >1:10 Yes Yes
Discharge criteria include non›anthropometric (clinical) indices Yes Yes
Staff able to feed and care for patients Yes Yes
*Admission criterion was <60% weight/height, but these indicators were developed for <70%weight/height.
Endpiece
The final quip
You know that I’m at death’s door. But the trouble
is that I’m afraid to knock.
Said by Somerset Maugham (1874›1965) to his
nephew, Robin Maugham, in 1965. Maugham
qualified at St Thomas’s Hospital Medical School
but never practised.
Submitted by Fred Charatan, retired geriatric
physician, Florida
Education and debate
742 BMJ VOLUME 323 29 SEPTEMBER 2001 bmj.com
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