Report on the Food and Nutrition Situation
in
Bay, Bakool and Gedo Regions
Somalia
October 19, 2000
Albertien van der Veen, nutritionist, WHO/ORHC1
Index
page
1.
2
2.1
2.2
2.3
3
3.1
3.2
4
5
Background
Nutrition situation
Nutrition Surveillance
Selective Feeding Programmes
Health
Food Situation
Food security
General Food Distribution
Conclusions
Recommendations
Annex 1:
Annex 2:
Summary of Nutrition Surveys
Health and Supplementary Feeding Programmes
2
3
3
4
6
8
8
9
11
12
References
1
Office of the Humanitarian Co-ordinator for the Drought in the Horn of Africa
1.
Background
The objective of this report is to provide an overview of the food, nutrition and health
situation in Bakool, Gedo and Bay Regions of Somalia, the humanitarian response thus
far, to outline existing problems and to provide recommendations for action. The
methodology for this assessment consisted of a study of various survey and assessment
reports of non-governmental organisations (NGOs), the Food Security Assessment
Unit, and United Nations (UN) agencies. This was followed by field visits to Gedo and
Bay. Information was gathered from UN agencies and NGOs active in these areas.
The humanitarian response in Somalia is co-ordinated by the Somalia Aid Coordination Body (SACB), in which UN agencies and NGOs work together. At field
level, SACB participants in some areas also work with local government authorities.
Drought response interventions have heavily relied on data collected and analysed by
the Food Security Unit (FSAU) and the Famine early warning system (FEWS) 2
published monthly. To further improve programme planning, early detection and
response, a health information system, which incorporates the already existing system
of nutrition surveillance, and an outbreak detection system were launched earlier this
year.
Bakool, Bay and Gedo regions are located in the north western part of southern
Somalia. The total population is an approximate 1,1 million, but estimates vary. All
regions were severely affected by drought in 1999, following floods in 1997/1998.
The drought, compounded by conflict, displacement and lack of public services, left a
substantial part of the population highly food insecure. By the end of 1999,
approximately 400,000 people in the three regions combined were considered in need
of relief food assistance. A famine alert was issued for Bakool in January 2000.
A number of rapid assessments were conducted in February 2000. An assessment in
Bakool documented both the diversity and the severity of food insecurity. An UNICEF
nutritional assessment in Rabdure town found a global malnutrition rate of 30 percent,
including 6 percent severe malnutrition. Another UNICEF nutrition survey in Wajid
town showed a 21 percent global malnutrition rate, and a severe rate of 3 percent,
despite major WFP food distributions in both districts. Also in Gedo Region, an interagency mission in February found high food insecurity among poor agro-pastoralists
who, as a result, were reducing their consumption levels to below minimum
requirements. Nutrition surveys conducted during the period December 1999-April
2000 revealed levels of malnutrition varying from 14% to 24%.
Following the gu rains, the situation rapidly improved, despite the fact that food aid
deliveries till June were well below planning figures. Results from the only postharvest nutrition survey thus far carried out are expected soon. In view of a reasonable
to good harvest, improved (safe) water availability and decreasing morbidity, the
general expectation is that the nutrition situation is improving.
2
FSAU is funded by the EC and FAO; FEWS is funded by USAID.
2
2
Nutrition Situation
2.1
Nutrition Surveillance
There is no comprehensive nutrition surveillance system in Somalia, but the FSAU
attempts to monitor trends in nutrition by collecting anthropometric data from some 30
to 35 nutrition surveillance sites. Virtually all data are collected in mother and child
health (MCH) clinics, mainly in those supported by INGOs and the International
Federation of the Red Cross (IFRC). Staff has been trained in the past in proper
measuring and recording, but problems continue with the quality and usefulness of
these data. A major constraint is uneven coverage among and within districts, biased
heavily towards more urban areas, where most MCH clinics are located. In addition,
data are usually3 only collected of children attending MCH clinics, resulting in an overrepresentation of sick children. With a view to increase the quality of data gathering,
FSAU has recently secured funding to strengthen the nutrition surveillance system.
Representative data are available from nutrition surveys carried out regularly by
UNICEF. Since July 1999 UNICEF, sometimes in conjunction with NGOs, has
conducted some 10 surveys in the regions worst affected by the drought. In addition,
ACF and MSF B have collected anthropometric information. With the exception of
rapid assessments, surveys have been random cluster surveys. In accordance with good
practice, most surveys also collected data on underlying causes of malnutrition, in
particular morbidity and, to a lesser extent, food insecurity (refer to sections 2.3 and
3.1). A Nutrition Working Group, based in Nairobi, analyses survey results (including
the methodology used) and provides recommendations on further data collection.
Results from UNICEF surveys indicate persistent high levels of malnutrition, ranging
from 17% to 30%. In the period May-July 2000 findings showed malnutrition rates of
21,5% in Belet Hawa District (Gedo), 17,2% in Baidoa District and 22,4% in Bur
Hakaba District (both in Bay region). Severe malnutrition was 3.5%, 3% and 4,1%
respectively. These rates are somewhat lower than last years’, but not significantly so
(please refer to Annex I for an overview of nutrition surveys). Also, because surveys
carried out in 1999 only covered towns, comparison is not straightforward. Results
from the only post-harvest nutrition survey, thus far carried out in 2000, are expected
soon.
A nutrition survey carried out by ACF, in April 2000, in Luuq (Gedo region) revealed a
malnutrition rate of 14,9% among residents of Luuq town and 20,0% among IDPs
residing in camps. ACF also conducted several rapid nutrition surveys using MUAC in
three areas with potential nutritional problems. Global acute malnutrition rates as
defined by MSF and SACB4 were 44,3%, 15,6%, 10,3% and 5,7%. Also using MUAC,
rapid assessments carried out by MSF B in the Bakool region in May revealed
malnutrition rates of 23% in Rabdure, 20% in El Berde, 19% in Wajid to 16% in
Tieglow. Due to the sampling methodology and the small sample sizes, results of these
3
4
In some areas, also mobile teams collect anthropometric data.
MUAC cut-off points vary among organisations.
3
rapid assessments are not representative. Neither can results be compared to results
from UNICEF surveys, because MUAC was used instead of weight for height.
In the absence of base-line data –preferably by season– it is difficult to ascertain to
what extent malnutrition levels found by ACF and UNICEF differ from levels normally
found at the peak of the hunger season in Somalia. Interpretation is further complicated
by the fact that, in line with international recommendations, malnutrition is presently
measured in Z scores, which result in systematically higher rates (30%-60% depending
on the sample characteristics) than weight for height as percentage of the median used
in pre-war Somalia.
2.2
Selective Feeding Programmes
With a few exceptions, supplementary feeding (SF) in Somalia is provided through
MCH clinics. In the past, UNICEF operated many MCH clinics, but at present its role
is largely in support of NGOs. While many MCH clinics are assisted by INGOs, some
have also been handed over to (new) national NGOs. UNICEF continues to provide
blended food (and other inputs). As of August 2000, supplementary food was provided
in some 22 MCH clinics, that is in approximately 40% of all clinics supported by
UNICEF in the south and central zone of Somalia. Of these, seven are in Bay, three in
Bakool and five in Gedo (see annex II for an overview). ACF provides supplementary
feeding in Luuq, presently in one location, but with plans to extent to at least two more
sites, possibly five. Trocaire, in addition to malnourished screened in MCH clinics,
also provides supplementary food to malnourished displaced children in the outskirts of
Belet Hawa and children screened by its mobile teams in the rural areas.
All rations consist of 10 kg of blended food per beneficiary per month. Recommended
medical treatment consisting of EPI (or at least measles vaccination), micro-nutrient
supplementation, treatment of intestinal parasitosis, and systematic treatment of
infections with oral antibiotics is undertaken throughout, facilitated by the fact that
most supplementary feeding is linked to MCH.
Overall numbers of malnourished children receiving supplementary feeding in MCH
clinics have shown little variation during the last year(s), ranging from less than 100 to
more than 1000 per MCH. Re-admissions frequently account for over half of the new
admissions, suggesting limited impact. In addition, there is some doubt whether the
official policy of using internationally accepted criteria for admission and discharge is
adhered to. A recent re-screening by UNICEF in Baidoa town, for instance, revealed
that out of more than 3,000 children registered as supplementary feeding beneficiaries,
only 1,320 (44%) actually qualified. In addition, UNICEF, Trocaire and others report
that there is duplication in areas where catchment areas of supplementary feeding
programmes overlap. Findings from nutrition surveys also suggest that the number of
children receiving supplementary feeding is often much higher than would be expected
on the basis of malnutrition rates. At the same time there is evidence that, in some
areas, supplementary feeding coverage among malnourished children is extremely low.
In Belet Hawa, coverage, according to Trocaire, remains a modest 18% (as compared to
10% last year), despite efforts to improve coverage by strengthening out-reach
4
activities carried out by a mobile team. UNICEF nutrition surveys unfortunately do not
assess the coverage of feeding programmes.
In order to increase impact, UNICEF and WFP have linked supplementary feeding to
distribution of family food rations in Baidoa town for the period July-September 2000.
Preliminary results indicate a spectacular decrease in malnutrition. However, because
the pilot period5 coincides with a period of overall improvement in the food security
situation and water availability, as well as a period of decreased morbidity, it will be
difficult to draw unambiguous conclusions. For instance, in three MCH clinics in Gedo
and non-pilot districts in Bay, visited by the mission, the number of malnourished
children had also declined substantially during the last six weeks.
Supplementary feeding is restricted to children. Pregnant and lactating women, both
caretakers and others, receive routine micro-nutrient supplementation in the MCH, but
no supplementary food, even if malnourished.
Despite an overall average severe malnutrition rate of more than 4%, which, in the
surveyed areas, roughly corresponds to some 4,000 children below five years of age,
there are only two therapeutic feeding centres (TFCs) in the three regions combined.
ACF opened a TFC in Luuq (Gode region) in March 2000, while MSF B has initiated
health care services including a therapeutic feeding centre in Hudur (Bakool region) in
May of this year. Statistics from ACF indicate that after the initial two months, the
number of new admissions has stabilised at around 70 per month, with increasing
importance of areas outside Luuq and its IDP camps. Admissions are not restricted to
malnourished children, but include older children and adults. Performance indicators
suggest that mortality and defaulting rates have declined sharply after the first two
months. However, a substantial number of attendants continues to be discharged after
60 days, failing to meet discharge criteria, normally due to underlying illness. For
instance in August, nearly 30% of the new admissions consisted of (confirmed) cases
of tuberculosis or kala-azar. Information from MSF B similarly confirms that diseases
account for a significant number of cases of severe malnutrition.
Where there are no TFCs, severely malnourished receive high-energy biscuits (HEB),
provided by UNICEF, in addition to blended food. These biscuits6 are a nutritious,
high-energy food, easy to transport and requiring little preparation. Because the
biscuits are sweet, they are generally very acceptable to children. However, HEB have
a number of disadvantages. Their protein content of 14-15% is much too high for
severely malnourished children and may, in fact, cause a clinical deterioration in this
group. In addition, in order to avoid the risk of the biscuits contributing to dehydration
there is a need to ensure safe water. Lastly, there is the risk that, because the biscuits
represent a highly valued commodity, they will end up on the market place and/or be
shared with other household members rather than being used as intended; this is a
particular risk if HEB are distributed in dry selective feeding programmes. In summary,
the provision of HEB is not an appropriate strategy to cure severely malnourished.
5
6
The project was scheduled to start in March, but was postponed for various reasons.
HEB were originally designed as a temporary nutritional supplement prior to the mobilisation of
a general food ration, especially for mobile and/or displaced populations lacking cooking
utensils.
5
2.3
Health
Evidence from nutrition surveys suggests that –as elsewhere– high morbidity, due to in
particular diarrhoeal diseases, acute respiratory infections (ARI) and –to a lesser
extent– malaria and measles have negatively impacted on the overall nutrition
situation7. UNICEF surveys indicate that the number of children suffering from a
diarrhoeal episode during the two weeks prior to the survey ranged from 17 to 43%. In
Baidoa district, however, only 13% of the surveyed children had experienced diarrhoea,
as compared to more than 30% in Baidoa town the previous year. This improvement
was attributed to an extensive water rehabilitation programme. The number of under
fives with ARI two weeks prior to the survey varied from 17 to 56%. ACF also
reports, that during screening in El Bon (Gedo) in July 2000, many cases of diarrhoeal
diseases and ARI were either seen by the team or reported by parents. Other diseases
reportedly were measles, conjunctivitis and splenomegaly, thought by the team to be
malaria8. Interestingly, in neighbouring Yurkut, where malnutrition was much lower,
the only main disease children were reportedly suffering from was malaria.
More systematic information on morbidity as underlying cause of malnutrition is
expected to become available shortly from a new health information and surveillance
system, devised jointly by UN agencies including WHO, and almost 20 NGOs. The
system aims to collect nutrition and health data, including information on morbidity
and immunisations, from health facilities by means of a standardised monthly reporting
form. In May, an outbreak detection system was also launched. This system is based
on 17 sentinel sites, which should be providing weekly information on measles,
meningitis, cholera, bloody diarrhoea, and any other outbreaks, to allow early detection
and response.
Mortality is not recorded systematically in the region, and very few agencies have
included questions on mortality in their nutrition surveys. ACF in April 2000 reported
an under five mortality rate of 6,6/10.000/day in the IDP camps in Luuq and
5,8/10.000/day in Luuq town, suggesting an extremely alarming situation. Similar
alarming rates of 6,0/10.000/day and 6,7/10.000/day were found in two villages near
Luuq. Rapid assessments, carried out in July, indicated that in other towns under five
mortality was 5,8/10.000/day and 3,2/10.000/day respectively. Mortality rates among
persons over five in these two towns were 0,6/10.000/day and 0,7/10.000/day, strongly
suggesting that nearly all excessive deaths were among children under five. Data were
collected retrospectively through household interviews. This method is prone to recall
bias and may result in an over-estimate of mortality due to a variety of reasons, such as
inclusion of deaths, which in fact occurred prior to the recall period, or counting people
who do not belong to the household as defined by the surveyors. Retrospective
mortality figures therefore, that cannot be crosschecked with verifiable information
such as clinical records or grave counts, should be treated with extreme caution.
Measles were the primary cause of mortality, in case causes were recorded. Other main
causes were malaria, malnutrition and diarrhoea. This is in line with information
7
8
And, vice versa, morbidity has increased because of high levels of malnutrition.
Splenomegaly is a common symptom of malaria, but also of certain other diseases, such as
kala-azar.
6
available from nutrition surveys regarding morbidity and measles vaccination coverage.
Although measles mass vaccination campaigns are carried out regularly (UNICEF
conducted nine campaigns in these regions during the last year), coverage and
frequency seem insufficient to reduce transmission. Data show that coverage between
and within districts varied considerably, ranging from less than 10% to more than 60%.
In particular among IDPs and in rural areas coverage was low. The number of children
who had received a vitamin A supplement9, however, was in some areas much higher
due to the fact that vitamin A is also provided during the polio national immunisation
days (NID). The new NID rounds scheduled for October and November are expected
to further increase vitamin A coverage.
There are presently 12 NGOs active in the health sector. These include eight
international NGOs (ACF, AMREF, Cordaid (previously Memisa) IMC, IFRC/SRCS,
MSF, Trocaire and WVI) and four Somali NGOs. The latter focus on MCH, usually in
clinics handed over by UNICEF. Coverage of health facilities is uneven among the
three regions, partly reflecting (past) insecurity. Please refer to annex II for details.
Gedo boosts three functioning hospitals10 in Belet Hawa (supported by Trocaire), Luuq
(supported by AMREF) and Garbaharey (supported by Cordaid) respectively. All three
hospitals provide a full range of health services, including treatment of tuberculosis
(DOTS). TB treatment in Belet Hawa, where defaulting is as little as 2%, includes
patients from Kenya in an agreement between MSF Spain in Mandera (Kenya) and
Trocaire. The latter in turn, refers severely malnourished children to the therapeutic
feeding centre operated by MSF.
There is no hospital in Bakool, while the referral hospital in Baidoa (the capital of the
Bay region) functions on a skeleton basis only, due to lack of support. Voluntary staff
cares for emergency cases. This includes providing treatment in case of epidemics,
notably (each year recurring) cholera. Laboratory facilities supported by WHO are
presently set up however, and WVI is scheduled to start TB treatment in October.
Although not typically in response to the drought, but as a result of improved security
the number of health care facilities has considerably increased during the last year. In
particular in Bay, where WVI and IMC have resumed previous activities in (primary)
health care, coverage in the rural areas is rapidly improving, although gaps continue to
exist and catchment areas vary considerably in size. A weaker point is that many
Somali NGOs and some INGOs such as IMC, (no longer) provide regular out-patient
services, leaving a gap in the health care for adolescents and adult males. In Bakool,
health coverage in general remains poor in every respect.
9
10
Standard provided during measles mass vaccination campaigns.
With the exception of the hospital in Belet Hawa, functioning has been with interruptions due to
security and/or funding reasons.
7
3.
Food Situation
3.1
Food Security
The FSAU and FEWS collect and analyse climatic, agricultural, economic, and
household data to track vulnerability and provide early warning. As of May 2000
information is published in a joint monthly report. The combination of activities
carried out by the FSAU11, which includes among others detailed crop assessments four
times a year, data provided by the FEWS and ad hoc interagency assessments to areas
of concern, ensures timely and regular information on the food security situation
throughout the country. Information is also used to estimate how many people require
food assistance. In April under the best case scenario for food security the number of
people requiring food assistance would (continue to) be 750,000 during the period
May-July and drop thereafter during the period August December to 525,000. For the
mid case scenario these numbers would be 929,000 and 1,2 million respectively, while
under the worse case scenario a total number of 1,147,400 vulnerable people would be
in need of food aid, increasing to 1,4 million during the last five months of the year.
During the prolonged dry jilaal period from the end of 1999 until late April Gedo,
Bakool and parts of Bay Regions (and Northern Hiran) were considered the worst
drought-affected areas of Southern Somalia, accounting for over half of the people in
need of food assistance. Almost total failure of the 1999/2000 deyr (secondary) season
harvest in most rain-fed sorghum-growing areas resulted in extreme food insecurity in
these regions. Deyr production in the Bakool Region was estimated at only 5% of the
post-war average. During the first three months of the year, drought-affected
populations in northern Gedo, Bay and Bakool moved in a number of different
directions, including into Ethiopia, in search of land for cultivation, opportunities for
employment and the sale of bush products, and food distributions. At the end of April
people started returning to their areas of origin in expectation of rain and planting.
Food security at household level, at the time, was precarious as well, as can be
concluded from nutritional surveys.
ACF in April 2000, reported that households in villages near Luuq were consuming
only one meal a day, consisting of tea, meat, maize and edible wild grasses. The
primary source of food at the time was purchase from the market with cash derived
from casual farm labour. Only a few families reportedly had benefited from free food
distribution by CARE in February (50 kg per family). By contrast, 100% of the
households interviewed as part of a rapid assessment carried out in Yurkut in July had
received 50 kg of cereals in May, while almost one third had received a subsequent
second ration. All households claimed that their last harvest had been in 1997 and only
one third owned animals. In El Bon, only 17% of the households owned livestock,
while about 60% had profited from general food distribution. Households were
employing a variety of coping mechanisms such as the consumption of wild plants, outmigration, sale of firewood, charcoal, daily labour and petty trade. In all villages and
towns surveyed, a substantial number of families had a history of displacement.
11
Many FSAU field monitors are (senior) agronomists of the former Somalia Ministry of
Agriculture, living in their home areas.
8
UNICEF nutrition surveys do not cover household food security. The original
intention12 was to link these surveys to food security assessments carried out by the
FSAU, but the FSAU, for various reasons, has provided thus far only for one survey the
food security context.
FSAU/FEWS reports indicate that by the end of June the situation had improved in
many areas with good prospects for the 2000 gu (main) cropping season. Improved
security in many agricultural areas of southern Somalia reportedly facilitated farming
activities and population return. At regional level, cereal production forecasts expected
to be well above post-war average in Bakool (50%), Bay (24%) and just above average
in Gedo (5%)13, despite limited seed distribution. In Bakool only 16 percent of the
estimated seed requirements were met, while in Bay Region the supply was 35 percent
below estimated needs. Field reports from July confirmed June’s relatively good
forecasts. Subsequently the worst case scenario for food security and food aid was
ruled out.
In August a good harvest in many areas started to reduce prices by nearly 50%, in
among others Baidoa. Term of trade started to improve and one local quality goat
traded more than two bags (137 kg) of sorghum, as compared to 53 kg in June14. By
September terms of trade further improved with one goat buying 193 kg in Baidoa.
Overall, the 2000 gu harvest was the second largest in the post war period, yielding
20% more than on average. This is however nearly 40% lower than the pre-war
average. In particularly among agro-pastoralists in Bay, food availability and food
security improved dramatically, minimising the need for further food assistance. Also
in Bakool, where agro-pastoralists rely heavier on livestock, rains were good. In view
of serious asset loss and in order to recover livestock levels and production limited food
needs remain however, especially among recently returned residents who had outmigrated during the drought. In Gedo, although food security is normal, pasture was
very dry and the in majority pastoralist population continues to move their livestock to
neighbouring Bakool and Bay.
3.2
General Food Distribution.
The main agencies delivering food aid for general distribution in Somalia are WFP,
CARE and ICRC. During the first five months of the year more than 75% of the
estimated food aid requirements were provided. However, the most food insecure
regions of Bakool, Bay and Gedo received on average less than 40% due to repeated
security incidents. Discrepancies between districts varied considerably, ranging from
4% to 75% in Gedo and 24% to 80% in Bakool. In June and July, with improved
security, actual distribution in both Gedo and Bakool was more or less according to
need. Overall in the pre-harvest period distributions in all regions except in Bay were
12
13
14
UNICEF and FSAU to this end signed a letter of agreement in 1999.
On average, this forecast was however 38% below the historical average (1982-1988).
Terms of trade in Somalia throughout seem to have remained substantially better than in some
of the drought affected areas in Ethiopia. In Wollo for example, it was not unusual to trade as
little as 20 kg of cereals for one goat.
9
equal to requirements. In August and September, in line with recommendations from
SACB to reduce food aid deliveries in response to crop harvests, agencies distributed
much less than planned.
Neither the FSAU nor food agencies systematically track to which extent people from
regions neighbouring Kenya and/or Ethiopia benefit from free food aid distributions in
these countries. WFP monitors report however, that during the period June-August,
when free food distribution in the Somali region of Ethiopia gained momentum, people
from Bakool moved to Ethiopia, in particular Kelafo in Gode Zone. Pastoralists from
Gedo reportedly benefited from free food distribution in Liben Zone. During this
period food from Ethiopia, including oil distributed by ICRC and (I)NGOs, was sold on
various Somali markets. By September food from Ethiopia was no longer seen
however15.
In April WFP switched from relief to rehabilitation, mainly providing food as food for
work (FFW). Only in Bakool free food was distributed in July to some 10,000
families, consisting of 50 kg of cereals and 10 kg of pulses (yellow split peas) per
family16. CARE also mainly provides food as FFW. Only in Gedo some 650 MT of
free food was distributed in June and about 700 MT in September.
WFP’s current FFW caseload consists of on average approximately 10,000 families of
whom about 30% urban. Numbers vary however and have also been as low as about
4,500 in August. CARE’s caseload has been and will remain for the rest of the year
approximately twice as high. Activities carried out under FFW include works of
infrastructure, rebuilding of houses, construction of shallow wells, berkeds and so on.
WFP intend to replace about 20% of the food by other material inputs such as building
materials. For women’s groups, the agency is presently piloting kitchen gardening
FFW projects in Baidoa and Wajid with plans to extend to other districts17. With a
view to further improve household food security through FFW, experts also recently
have assessed the potential for plant nurseries, model farms and so on under FFW.
Stocks and pipeline of both WFP and CARE are sufficient to meet FFW and limited
free food requirements till the end of the year.
Both CARE and WFP FFW rations consists of 90 kg of cereals, 10.8 kg of pulses and
3.6 litres of oil per family. With an assumed average family size of 6, this corresponds
to 500 g of cereals, 60 g of pulses and 20 g of oil per person per day, meeting full
energy and protein requirements, but less successful in meeting micro-nutrient needs, in
particular of the most vulnerable under fives. These however, if need be can benefit
from substantial supplementary blended food provided by MCH clinics.
15
16
17
This does not necessarily imply that people no longer profit from Ethiopian free food
distribution. Marketing of cereals is simply not profitable at present, while oil distribution by
ICRC and possibly also NCA has ceased.
Part of the families received two rations.
FAO also launched in February a project to improve food security through home gardening in
other parts of Southern Somalia.
10
4
Conclusions
Results from nutrition surveys indicate persistent high levels of malnutrition. However,
in the absence of comprehensive base-line data –preferably by season– it is difficult to
ascertain to what extent malnutrition levels measured prior to the harvest are abnormal
for Somalia. Interpretation is also complicated by the fact that, in line with
international recommendations, malnutrition is presently measured in Z scores, which
result in systematically higher rates than weight for height as percentage of the median,
used in pre-war Somalia.
Despite a long history of supplementary feeding provided through MCH clinics, little is
known about the impact of this intervention. Recent screening by UNICEF suggests a
substantial inclusion error. Data about exclusion is virtually non existent. This might
well be substantial, given that the average severe malnutrition rate in surveyed areas is
more than 4%. Obviously, attendance in the only two therapeutic feeding centres in the
three regions consists of only a small minority of the 8,000 severely malnourished
under fives this rate roughly translates into18.
Mortality is not systematically recorded, but some data suggest that under five
mortality earlier this year was alarmingly high. Measles were the primary cause, while
other main causes were malaria, malnutrition and diarrhoea. This is in line with
information available from nutrition surveys regarding morbidity and measles
vaccination coverage. Although measles mass vaccination campaigns are carried out
regularly coverage and frequency are insufficient to reduce transmission.
The combination of activities carried out by the FSAU, data provided by the FEWS and
ad hoc interagency assessments to areas of concern, ensures timely and regular
information on the food security situation throughout the country. Much less is known
about household food security. The original intention to link UNICEF nutrition
surveys to food security assessments carried out by the FSAU, thus far, has not
materialised. This is a lost opportunity, because regular data collection by the FSAU is
insufficiently dis-aggregated to link anthropometric data to (household) food security.
Despite security constraints, actual food distribution matched requirements in all
regions except Bay. This can be attributed to various drought alarms and timely
response. However, many agro-pastoralists, which are dependent on rain fed crop
production and have experienced displacement, remain vulnerable due to the
cumulative effects of three consecutive years of asset depletion and livelihood stress in
much of the three regions.
Results from the only post-harvest nutrition surveys thus far carried out are expected
soon. In view of a reasonable to good harvest, improved (safe) water availability and
decreasing morbidity, the general opinion is that the nutrition situation has improved.
18
Or 4,000 in the areas surveyed by UNICEF. Assuming that the severe malnutrition rate does
not differ substantially in areas not surveyed, the number of severely malnourished in the three
regions combined would be roughly 8,000.
11
4.
Recommendations
Nutrition
 Strengthen nutrition surveillance by collecting anthropometric data from sentinel
sites following standard methods that include the analysis of underlying factors
such as morbidity, care and household food security.
 Further extend the role of the nutrition working group based in Nairobi by:
1.
Compiling into a data-base of information on surveys and interventions
2.
Encouraging agencies to seek technical assistance prior to nutrition surveys in
order to ensure consistent data collection and reporting
3.
Provide timely feed-back on nutrition surveys submitted for analysis.
 Improve data collection from supplementary feeding programmes by encouraging
agencies and (UNICEF) implementing partners to (more systematically) report on a
monthly basis standardised summary indicators including defaulting rates and
average length of stay so that programmes can be monitored and technical support
given when needed.
 Carry out a comprehensive impact study of supplementary feeding in MCH clinics.
 Systematically, as part on nutrition surveys, assess supplementary feeding
coverage.
 Critically review the use of high energy biscuits for the treatment of malnourished
and if need be, replace by more appropriate and/or effective means.
Health
 Explore possibilities to link measles vaccination to polio eradication (WHO).
 Boost malaria control by the provision of appropriate drugs to be provided for free,
means to prevent malaria and the logistics to effectively implement such a
programme at regional level
 Advocate among international agencies to intensify coverage of health services, in
particular in the Bakool Region and by Baidoa hospital.
Food
 Develop efficient and effective mechanisms to monitor population movements to
neighbouring countries and a method to systematically exchange this information
with relevant humanitarian agencies in these countries.
 In Ethiopia, re-assess beneficiary caseloads in the Somali region bordering
Southern Somalia and intensify distribution monitoring (DPPC/WFP).
 Consider, in areas with persistent high malnutrition rates, to replace pulses by
blended food in food for work and free food distribution during the pre-harvest
period.
12
ANNEX I
NUTRITION SURVEYS 1999 – 2000
Location
Date of
survey
Bay region
Baidoa
August
town
1999
Baidoa
July 2000
District
Burhakaba
August
town
1999
Burhakaba
June 2000
District
Bakool region
Hudur
September
town
1999
Hudur
May
town
2000
Rabdure
February
town
2000
Rabdure
May 2000
town
Wajid
March
District
2000
Wajid
May
town
2000
El Berde
May
Town
2000
Tieglow
May
town
2000
Gedo Region
Bardera
December
town
1999
Belet Hawa May
2000
Luuq
April
2000
Qorbolo
Amarayle
village
El Bon
village
Yurkut
village
19
April
2000
April
2000
July
2000
July
2000
Agency
Sample
size
Methodology
UNICEF
903
30 clusters
UNICEF
909
30 clusters
UNICEF
905
30 clusters
UNICEF
904
30 clusters
UNICEF
910
30 clusters
MSF B
103
UNICEF
498
Rapid
assessment
30 clusters
909
Rapid
assessment
30 clusters
MSF B
UNICEF
MSF B
Rapid
assessment
Rapid
assessment
Rapid
assessment
MSF B
MSF B
UNICEF
903
30 clusters
UNICEF
905
30 clusters
ACF
780
508
78
ACF
53
ACF
192
ACF
64
30 clusters
exhaustive
Rapid
assessment
Rapid
assessment
Rapid
assessment
Rapid
assessment
ACF
Nutrition Indicators19
W/H <-2 Z score + oed
21,6%
W/H <-2 Z score + oed
17,0%
W/H <-2 Z score + oed
28,0%
W/H <-2 Z score + oed
22,4%
W/H <-3 Z score + oed
6.1%
W/H <-3 Z score + oed
3,0%
W/H <-3 Z score + oed
6.0%
W/H <-3 Z score + oed
4,1%
W/H <-2 Z score + oed
22,7%
MUAC <125mm
27%
W/H <-2 Z score
30,0%
MUAC <125mm
23%
W/H <-2 Z score
21,0%
MUAC <125mm
19%
MUAC <125mm
20%
MUAC <125mm
16%
W/H <-3 Z score + oed
7,2%
MUAC <110mm
W/H <-2 Z score
23,05
W/H <-2 Z score
21,5%
W/H <-2 Z score
Town
14,9%
IDPs
20,0%
MUAC <125mm
10,3%
MUAC <125mm
5,7%
MUAC <125mm
44,3%
MUAC <125mm
15,6%
W/H <-3 Z score
5,5%
W/H <-3 Z score
3,5%
W/H <-3 Z score
Town
1,9%
IDPs
4,2%
MUAC <110mm
0%
MUAC <110mm
0%
MUAC <110mm
8,9%
MUAC <110mm
3,1%
W/H <-3 Z score
6,0%
MUAC <110mm
W/H <-3 Z score
3,0%
MUAC <110mm
MUAC <110mm
MUAC <110mm
Global malnutrition expressed in % weight for height (W/H) with a Z score < -2 + oedema
Severe malnutrition expressed in % weight for height (W/H) with a Z score < -3 + oedema
Global malnutrition expressed as Mid Upper Arm Circumference (MUAC) < 125 mm + oedema
Severe malnutrition expressed Mid Upper Arm Circumference (MUAC) < 110 mm + oedema
13
ANNEX II
Health Facilities and Supplementary Feeding
Hospital
TB
OPD/MCH
Bay
DMO
IMC
Baidoa (1)
Baidoa (1)
Dinsor (1)
SRCS
(Baidoa)
WVI
Bakool
MSF B
Baidoa (2)
Berdale (1)
Qansadere (1)
Burhakaba (1)
Trocaire
UNICEF
Health Posts
Baidoa
(40)
Berdale
(16)
Dinsor
(21)
QansaDere (17)
SF
Baidoa
Baidoa
Dinsor
(1)
(1)
(1)
Baidoa
Berdal
Q dere
(2)
(1)
(1)
Burhakaba (10)
El Berde (1)
Huddur (1)
El Berde (1)
Huddur (1)
Rabdure (1)
Tiegelow (1)
Wadjid (1)
IMC
THA
WHA
Gedo
AMREF
BDHC
Cordaid
MCH
Luuq
Luuq
Luuq
(1)
Garbaharey
Garbaharey
Belet Hawa
Belet Hawa
Garbaharey(1)
Burdhubo (1)
Belet Hawa(1)
Dolo
(1)
El Berde ( 1)
El Berde
(1)
Tiegelow (1)
Wadjid
(1)
Luuq
(16)
Bardere (1)
Garbaharey
Burdhubo
Belet Hawa
Dolo
(6)
(4)
(9)
(4)
Luuq
(1)
Bardere
(1)
Garbaharey (1)
`
BeletHawa (1)
Dolo
(1)
Bardere (1)
14
References
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Anthropometric Survey, Luuq Town and IDP Camps, Somalia, 16-20 April 2000, ACF.
FEW Bulletin March-June 2000, USAID.
Inter-agency Assessment Gedo Region, Food Security Findings, FSEA Focus, Nairobi.
Monthly Food Security Report for Somalia, Issues June-August 2000, FSAU/FEWS,
Nairobi
Nutrition Data from MCH Facilities in Bay, Bakool and Gedo Regions, UNICEF Baidoa.
Nutrition Survey Report Baidoa Town, Bay Region, Somalia, UNICEF, August 1999.
Nutrition Survey Report Baidoa District, Bay Region, Somalia, UNICEF, July 2000
Nutrition Survey Report Bardera Town, Gedo Region, Somalia, UNICEF, December 1999.
Nutrition Survey Report Belet Hawo district, Gedo Region, Somalia, UNICEF, May 2000
Nutrition Survey Report Burhakaba Town, Bay Region, Somalia, UNICEF, August 1999.
Nutrition Survey Report Burhakaba District, Bay Region, Somalia, UNICEF, June 2000.
Nutrition Survey Report Hoddur Town, Bakool Region, Somalia, UNICEF, September
1999.
Nutrition Survey Report Rabdure Town, Bakool Region, Somalia, UNICEF, February
2000.
Nutrition Survey Report Wajid District, Bakool Region, Somalia, UNICEF, March 2000.
Nutrition Update, May 2000, FSAU, Nairobi
Nutrition Update, June 2000, FSAU, Nairobi
Nutrition Update, July 2000, FSAU, Nairobi
Rapid Nutritional Assessment around Luuq, Gedo Region, July 2000, ACF.
Rapid Nutritional Assessment, Gedo Region, April 2000, ACF.
Somalia Complex Emergency/Drought Situation Report #1, 2000, USAID/BHR/OFDA.
Somalia Health Update, WHO, 18 July 2000.
TB Newsletter, Somalia, Volume 1, issue 3 and issue 4, WHO
UNICEF Somalia Review Aug 2000.
15