Factors Influencing Persisted High Global Acute Malnutrition Among IDP Camps in Puntland

UNICEF Field Office NEZ

Rapid Assessment of IDP settlements of Bosaso, Garowe, Galkayo and Gardo, April 2018

ABBREVIATIONS

ANC antenatal Care ARI Acute Respiratory Infections AWD Acute Watery Diarrhea C4D Communication for Development CBO Community Based Organizations CHW Community Health workers EPI Expended Program on Immunization FCS Food Consumption Scores FSNAU Food Security and Nutrition Analysis Unit GAM global Acute Malnutrition HHS Household Hunger Scores IDPs Internally Displaced peoples IEC Information Education Communication ISDP Integrated Services for Displaced Persons IYCF Infant and Young Child Feeding MCHN Maternal and Child Health and Nutrition MDM Medicins De Monde MOH Ministry of Health MSF Medecins Sans Frontieres MUAC Mid Upper Arm circumference NGOs Non-Governmental Organizations NUWACO Nugal Water Company OPD Outpatient Department ORS Oral Rehydration Salt OTP Outpatient therapeutic Program I

PNC Postnatal Care PSA Puntland Students Association RI Relief International RR Risk Ratio SAM Severe Acute malnutrition SC Stabilization Center SCI Copying Strategies Index SDRA Social Development and Research Association SIAs supplementary Immunization Activities SRCS Somali Red Crescent society TSFP Targeted Supplementary Feeding Program UNICEF: United Nations Children’s Fund WFP World Food Program WHO World Health Organization WVI World Vision

TABLE OF CONTENTS

Table of Contents Abbreviations ...... I Table of Contents ...... III List of Tables ...... IV List of Figures ...... IV 1 Introduction ...... 1 1.1 Objectives ...... 1 2 Data Collection Methods ...... 2 3 Main Findings and Results ...... 3 3.1 Somalia 2016 IYCN Study ...... 3 3.2 Rapid Assessment of the Bosaso IDPs...... 4 3.2.1 Results of Recent Assessments Among Bosaso IDPs ...... 4 3.2.2 Rapid Assessment Summary Findings Among Bosaso IDPs ...... 5 3.3 GALKAYO IDPs ...... 11 3.3.1 Recent Nutrition Assessment Results Among Galkayo IDPs ...... 11 3.3.2 Nutrition Causal Analysis Among Galkayo IDPs (SAGE 2014) ...... 12 3.3.3 Summary Rapid Assessment findings among Galkayo IDPs ...... 12 3.4 Garowe IDPs ...... 18 3.4.1 Recent Nutrition Assessment Results Among Garowe IDPs ...... 18 3.4.2 Summary Rapid Assessment Findings Among Garowe IDPs ...... 19 3.5 Gardo IDPs...... 26 3.5.1 Recent Nutrition Assessment Results Among Gardo IDPs ...... 26 3.5.2 Nutrition Casual Analysis Among Gardo IDPs (SAGE 2014) ...... 27 3.5.3 Summary for the Rapid Assessment Among Gardo IDPs ...... 27 3.5.3.7 Social awareness activities ...... 29 4 conclusion...... 33 5 Recommendations...... 34 6 References ...... 35 7 Annexes ...... 36 7.1 Annex I: Rapid Assessment Timelines ...... 36

III

7.2 ANNEX II: Nutrition Situation Among Bosaso IDPs ...... 37 7.3 ANNEX III: Nutrition situation among Galkayo IDPs ...... 38 7.4 Annex IV: Nutrition Situation among Garowe IDP Camps ...... 39 7.5 Annex V: Nutrition Status Among gardo IDPs ...... 40 7.6 Annex VI: Casual analysis on morbidities among Galkayo and Qardo IDPs...... 41 7.7 Annex VII: Casual analysis on health programs (Galkayo) ...... 42 7.8 annex VIII: Casual Analysis on Water and Sanitation ...... 42 7.9 ANNEX IX: Focus Group Discussions ...... 43 7.10 ANNEX X: Key Informants/Observations Check list ...... 45

LIST OF TABLES

Table 1: Information Collected during Rapid Assessment among NE IDPs ...... 2 Table 2: Status of key IYCN Indicators ...... 3 Table 3: Information collected from Bosaso IDPs during the Rapid Assessment ...... 4 Table 4: Summary Responses of FGDs Among Bosaso IDPs during the Rapid Assessment ...... 7 Table 5: Information collected from Galkayo IDPs during the Rapid Assessment ...... 11 Table 6: Summary Responses of FGDs Among Galkayo IDPs during the Rapid Assessment ...... 14 Table 7:Information Collected from Garowe IDPs During the rapid Assessment ...... 18 Table 8: Summary Responses of FGDs Among Garowe IDPs during the Rapid Assessment ...... 22 Table 9: Information collected from Gardo IDPs During the Rapid Assessment ...... 26 Table 10: Summary Responses of FGDs Among Gardo IDPs during the Rapid Assessment ...... 29

LIST OF FIGURES

Figure 1: GAM and SAM trends among Bosaso IDP Camps, 2012 -2017 ...... 4 Figure 2: GAM and SAM trends among Galkayo IDPs, 2012 - 2017 ...... 11 Figure 3: GAM and SAM trends among Garowe IDPs, 2012 to 2017 ...... 18 Figure 4: Garowe OTP Admissions, Jan to Dec 2017...... 18 Figure 5: GAM and SAM trend among Gardo IDPs, 2012 to 2017 ...... 26

1 INTRODUCTION

Internally displaced persons (IDPs) are among the most vulnerable groups with the highest global acute malnutrition (GAM). The alarming high rate of malnutrition among IDPs can be attributed to various complex set of factors and causes that may include: poor housing conditions, poor environmental sanitation, limited awareness on health, nutrition and sanitation issues, inadequate food intake, lack of access to adequate health services, lack of access to clean water, proper sanitation service, poverty, etc.

According to a brief paper of Feinstein international center of Tufts University, USA, the prevalence rates of global acute malnutrition (GAM)regularly exceed the emergency threshold of >15 percent of children with acute malnutrition in many countries in emergency situation such as Somalia, despite ongoing humanitarian interventions1

IDPs in the NEZ of Somalia are among those groups with persisted critical acute malnutrition in recent years, where the GAM rate is mostly higher than the emergency threshold of 15 percent. Despite different humanitarian interventions on health, nutrition, food security and sanitation, there is no tangible improvement and the level of malnutrition remains very high.

To better understand the possible common factors that are influencing this sustained malnutrition level among N.E. Somalia IDPs, UNICEF Field Office in North East Zone, in collaboration with the Ministry of health (MOH) Puntland, planned and led a rapid qualitative assessment, to further assess the situation and facilitate the development of an intervention plan focusing on identified gaps in terms of health, nutrition, Education, C4D, water and sanitation.

Data collection for the UNICEF led rapid assessment have been conducted from 13 to 20th March 2018, with the collaboration of number of partner organizations. During this period total of 26 focus group discussions (FGDs) and 58 key informant interviews were done. Quantitative secondary information from studies done by different partners were also used.

With the triangulation of available secondary information, the rapid assessment results are emphasizing the requirement to put in place an integrated intervention approach on all relevant sectors of health, nutrition, WASH, Education and C4D.

1.1 OBJECTIVES

1. To assess and understand the major possible aggravating factors that may cause the persisted global acute malnutrition among IDP camps in Puntland; 2. Conduct a qualitative assessment to complement the previously conducted quantitative studies and surveys for a better understanding of the situation in the IDPs camps; 3. To identify existing gaps in services provided to IDPs.

1 Helen Young and Anastasia Marshak, January 2018, Persistent global Acute Malnutrition, USA. 1

2 DATA COLLECTION METHODS

Qualitative methods have been used to gather required information and to complement the quantitative studies which have been collected in recent years by different partners, the RA process collected information using the following methods:

A. Focus Group discussions: In each IDP camp focus group discussions have been carried out. Priorities were given to the camp committee and groups of mothers to understand the ongoing health and nutrition interventions, as well as attitudes and behaviors of the camp residents on health, sanitation and child care issues. B. Key Informant Interview: Two to three key informant interviews were conducted in each site and specific selection criteria have been set, including that the key informant should be a person who can provide detailed information on health, nutrition, sanitation or education. C. Observations: Interview teams have also observed the status and available services in the camp, covering availability of health services, schools, latrines, camp sanitation status, garbage collection and open defecation. D. Secondary Information: quantitative secondary information are used to complement this RA, therefore, reference has been made to: the 2016 IYCN study, Food security and Nutrition Analysis Unit (FSNAU) seasonal analysis, MOH feeding data, Nutritional Casual analysis study which was conducted by SAGE in 2014.

Led by UNICEF joint team, partners from MOH, SCI, WVI, WFP, MDM, SRCS, ISPD, HADO, CARE and PSA, have participated at different stages in the data collection process in IDP settlements of Bosaso, Galkayo, Garowe and Gardo from 13th to 20th March 2018, and collected information during the rapid assessment as shown in table 1

Table 1: Information Collected during Rapid Assessment among NE IDPs

SN IDP Sites Information Collected FGD Key Informants 1 Bosaso 10 20 2 Galkayo 12 18 3 Garowe 8 12 4 Gardo 6 8 Total 26 58  Participants of focus group discussions were mothers who have children, fathers or members of camp committees.  Key informants were mainly people who have information on Health, Nutrition, Sanitation and education like health workers, committee members and school teachers

3 MAIN FINDINGS AND RESULTS

3.1 SOMALIA 2016 IYCN STUDY2 In early 2016, FSNAU with the financial support of UNICEF conducted Infant and Young Child Nutrition (IYCN) study, and the table below shows some of the key results recorded.

Table 2: Status of key IYCN Indicators

Indicators Infant and Young child feeding status National Puntland South/central Somaliland Timely Imitation of 80 84 75 89 breastfeeding (BF) 0 – 23 months Exclusive Breastfeeding 33 39 21 56 Continue breastfeeding up 46 52 39 56 to one year Continue breastfeeding up 15 22 12 18 to two years Minimum meal Frequency 69 71 66 74 (6 – 23 months old) Minimum dietary 15 9 21 7 diversity(6 – 23 months old) Minimum acceptable diet 9 7 11 6 (6 – 23 months old) Consumption Iron rich 48 42 60 22 foods (6 – 23 months old)

Breastfeeding: 2016 IYCN study is showing that the early initiation of breastfeeding and exclusive breastfeeding levels are 84 and 39 percent in Puntland respectively, while continuing breastfeeding up to one year (12 to 15 months) is 52 percent; and only 22 percent continue breastfeeding up to two years (20 to 23 months). Nearly half of mothers stop breastfeeding before one year.

2 FSNAU, 2016, Somalia Infant and Young Child Nutrition Assessment 3

3.2 RAPID ASSESSMENT OF THE BOSASO IDPS

Table 3: Information collected from Bosaso IDPs during the Rapid Assessment

Bosaso has hosted the highest S/N IDPs camps Information Collected number of IDPs and refugees in NEZ. FGD Key Presently, there are 28 settlements Informants inside Bosaso, and most of them 1. Tawakal 1 2 2. 55bush 1 2 came from south and central 3. Absame -A 1 2 Somalia due to security issues while 4. Buulo- mingis -A (Town) 1 2 there are also refugees from Yemen 5. Shabeele-B 1 2 and Ethiopia. Out of 28 settlements 6. Buulo-mingis-B 1 2 total of 10 camps were covered 7. Biyo Kulule B 1 2 during the rapid assessment, where 8. Girible 1 2 one focus group discussion and two 9. Ajuran -A 1 2 key informants were conducted in 10.Buulo-elay B 1 2 each camp, resulted in 10 FGDs and 11. Total 10 20 20 key informants (see table 3).

3.2.1 Results of Recent Assessments Among Bosaso IDPs3

Figure 1: GAM and SAM trends among Bosaso IDP Camps, 2012 -2017

25 GAM and SAM trends among Bosaso IDPs FSNAU post Deyr 2017 20.6 GAM SAM 20 19.8 18.6 shows serious level 17.3 17.2 16.8 17.3 15 14.7 (14.7%) of Global Acute 13.5 13.2 12.5 10 Malnutrition (GAM) 5 4.4 4.3 4.7 among Bosaso IDP 3.8 2.8 2.9 3.1 2.9 3.7 2.3 0 1.5 settlements, indicating improvement from the critical levels observed in Gu’ 2017 (18.6%) and Deyr 2016 (17.3%). Similarly, it shows that Severe Acute Malnutrition (SAM) is (2.3%), indicating improvement from the critical level (4.5%) reported in Gu’ 2017 but similar to the serious result (3.7%) that was seen in Deyr 2016. High morbidity level has also been reported in all the three seasons, and 20 percent of children assessed in Deyr 2017 survey were reported sick prior to two weeks of the assessment, while higher morbidity trend was also recorded during Gu’ 2017 (35%).

3 FSNAU, 2018, Deyr 2017 Nutrition Situation 4

3.2.2 Rapid Assessment Summary Findings Among Bosaso IDPs

3.2.2.1 Access to Health Services Most of Bosaso IDP settlements are in eastern side of the city and have only one health center (Isniino), while the other seven health facilities are either inside the town or for IDPs in other corners of the town, therefore, some of the camps have difficulties on accessing health care service as their homes/camps are quite far from the health center and it takes around 30 minutes to reach the health center, at the same time the health center they are visiting is very busy and they have to wait hours to access services due to long queues.

This health center provides different health services mainly for mothers and children but cannot cover the health needs of all the settlements in the east side of the town, therefore establishment of additional health centers or outreach activities are very important to cover this gap in health services. The common morbidities that are frequently seen among Bosaso IDP camps are Acute Watery Diarrhea (AWD), Malaria and Malnutrition. Most of the parents first try to manage diarrhea cases at home by giving Oral Rehydration Salt (ORS) but if the child is in severe condition, He/she will usually be transferred to the hospital or health center.

3.2.2.2 Nutrition Interventions There are some ongoing nutrition interventions that include maternal and child health and nutrition (MCHN), as well as OTP programs through mobile teams, but there are no fixed sites. The assessment team has also realized that nutrition products are not properly utilized at household level.

The previous nutrition interventions of TSFP and OTP, by SCI, have ended during January 2018, SCI was the only organization doing TSFP intervention among IDP camps of Bosaso. No ongoing TSFP interventions were reported, while OTP services are not sufficient.

There is a stabilization center (SC) inside Bosaso hospital, and it was observed that the majority of the admitted children came from IDP families, where diarrhea was the main complication and associated with malnutrition cases of most of the admitted children.

There are community health workers (CHW)/volunteers who frequently and weekly conduct screening activities; using mid-upper arm circumference (MUAC), and transfer malnourished children to health facilities. Periodic health and nutrition education activities were also conducted inside the camps.

3.2.2.3 Child Care Practices Majority of the people know that exclusive breastfeeding is very crucial during the first 6 months of the child’s life but mostly not practiced, due to the fact that most of mothers leave very early every day for casual work activities and return very late in the afternoon, and therefore the child may not get proper adequate feedings.

3.2.2.4 Access to Safe Water Main water source for majority of the settlements were barkeds which are managed by elders and most of them could be reached easily since they are all inside the camps. Water is trucked from boreholes around Bosaso and each household uses an average of 100 liters a day, using jerrycans of 20 liters, and

5 each jerrycan is costing 2,000 Somalia shillings. Water treatment at household level have not been reported and some of the barkeds are not protected, while contamination is most likely happen at household level.

3.2.2.5 Access to Latrines Most of the people did not have access to latrines in majority of IDP settlements of Bosaso and open defecation have increased due to two main reasons:

1. Most of the latrines were not properly planned at the beginning and were designed as temporary latrines, most of them were dug less than two meters deep, and within very short time the pit became full. 2. Each 100 households were sharing one block, consisting of around 10 latrines; there is lack of ownership by the community, no one is responsible of repairing services, therefore, most of them become useless within few months due to lack of maintenance.

Although many people were not using latrine, however, most of the people were found to be aware of the importance of using latrines, and that open defecation can lead to outbreak of communicable diseases, like AWD.

3.2.2.6 Use of Hygienic Items

Beside that most of the interviewed people were stressing the benefits on using soap during the critical times, majority of households do not use hygienic items during the critical time (like soap or ash), which needs further awareness and behavioral changes.

3.2.2.7 Environmental Sanitations Poor environmental sanitations were observed, as hills of garbage were seen in majority of the camps and most of the settlements do not have garbage disposal bits.

3.2.2.8 Social Mobilization Activities

Bosaso IDPs have community health workers (CHWs)/volunteers who conduct nutrition screening activities, using Mid upper arm circumference (MUAC) on weekly basis, and then transfer malnourished children to the hospital or health centers. They also frequently undertake health and nutrition educations in all the IDP camps. This needs to be developed to ensure that all the CHWs are properly trained and can provide clear and appropriate messages. In addition to the awareness conducted by the CHWs, the use of other communication channels is also important to promote health, nutrition and sanitations.

3.2.2.9 Education Elders and interviewees have reported that they have only one school serving for all the IDP camps located at the eastern side of Bosaso, and it is quite far to some camps, at same time as this school is busy, it does not promotes health and nutrition, so the elders have proposed to train the teachers and encourage them to participate in promotion activities for health, nutrition, hygiene and sanitation.

Table 4: Summary Responses of FGDs Among Bosaso IDPs during the Rapid Assessment

01 Can you explain what are the Diarrhoea, malaria , malnutrition, skin diseases, common cold common diseases that affect are most common diseases in this camp. children under five years in this camp

02 What do you do if the child gets  We use ORS, which has been received from MCH and if diarrhoea? there is deterioration we refer to the MCH/ Hospital.

03 How is the access to health services  We have access to the Health centers and receive services, in the camp? What kind of health it is near to our Camp. services can be found? What are the  60% of the IDPs population are living east side of the town, conditions? Are they accessible for and there is only one Health center for these camps (Isniino everybody? health center), and it is located at the west corner of these IDPs.  We have limited access/difficulty to this Health center ( sniino HC ). Buulo-mingis, Shabeele-B, Shirikow IDPs walk about 30 to 45 minutes to reach the health center.  Our sick people and old aged people from these IDPs have limited access to this Health center.  We receive services including vaccinations, delivery, nutrition services for children, MHN services, diarrhea treatments etc.

04 Can you tell about exclusive  We know the importance of exclusive breastfeeding for breastfeeding? And how long should children below 6 months, but due to mother’s work load a mother continue breastfeeding for exclusive breastfeeding is not effectively adopted/practiced. the child?  Most of IDPs mothers are bread-winners for family, they go and away from children long hours for casual work in the town, looking for survival.  We buy infant formula milk from business shops in the IDP camps and start feeding with children while they are below six months of age.  There are still some mothers who practice exclusive breastfeeding and start complimentary feeding later.  Mothers continue breastfeeding up to 18 months of age but they stop breastfeeding very soon, if mother becomes pregnant.

05 Do you know any ongoing nutrition  Yes, there are mobile nutrition teams who come to the interventions in your camp? camps and screen/admit children supported by different organizations (SCI, CARE and MDM)  Yes;

 No If yes what type of  All TSFP services were stopped in December 2018 and four interventions OTP sites were also closed due to funding gap.  OTP  Mobile teams provide only nutrition services but no Health  TSFP and EPI activities.  MCHN  Micro nutrition supplementations

Others (specify)

06 Are you aware of any one doing  Yes; there are community nutrition workers/volunteers screening activities at household from the respective villages and they do routine screenings level in your camp? If yes who and at household level using MUAC tape, supported by SCI and how frequently? (Show MUAC tape MDM for understand

07 1. What are the major sources of  We use public berkeds inside the IDP camps (100%). drinking water for the camp (  All HHs depend on water trucking from boreholes in or For Interviewer: please estimate around the town with high cost and some people cannot the proportion of community afford to pay. that use in each source)?  Community organized small committees manage berkeds and charge fee to consumers for maintenance.

 Households use plastic jerrycans to fetch water from berkeds, costing 2000 Somali shillings per 20 liter.

08 What are the main challenges to get  The biggest challenge we face is the issue of water drinking water in this camp? availability, sometimes, pipelines break.  High cost of 2000 Shilling per Jerrycan.

09 Do majority of the people have  No, most of our camps have no access to latrines. access to latrines? If not what are  public toilets were constructed as one block of 10 latrines the main challenges for not accessing for 100 households, but most of them are not in use because and how do you think this problem the pit is full. can be addressed  Latrine construction was poor as the pit was dug very short in deep.  No one responsible for the maintenance of latrines

10 Can you tell about the importance of  Yes. latrine is important and open defecation can result using latrines than open health consequences. defecations?  Open defecations result diarrhea, cholera and other illness.  Our Community/households are aware about the importance of using latrines to prevention diseases.

11 How and where do you dispose  Garbage is gathered in open places around the camp on garbage? Who is managing the weekly basis, then community burns after months. garbage? Do you pay for garbage  There is no one managing the garbage collection and collection disposal points.  People individually collect the garbage and dispose it in an area where even animal and children have access to reach, which can have negative impacts.  Community do not pay on garbage collection and disposals.

12 Do you think there is relationship  Yes. There is Somali slogan that says, “disease is same between garbage and disease? (If distance to you as distance of the garbage”. yes) what is that relationship? How  Garbage is the source of the diseases, it attracts the can be managed garbage? bacteria/insects that causes the germs.  If garbage is not properly managed/controlled flies and other germ carrier insects grow in it and affects to the neighboring people.

13 Do majority of the people in the  No, Due to lack of soap in our households, catchment wash their hands with  We use ash to clean hands and sometimes we use plain soap at critical times? ( If yes) what hand washing with water, without soap. hygiene items do they use for hand  Households are aware that handwashing is a method of washing? (if not) why not washing disease prevention. hands at critical times?

14 Can you explain if there is any  Yes, effective handwashing prevents diseases relations between hand washing  Human hands have always contacts with germs/bacteria and diseases and usually are contaminated, if not washed with soap. .

15 Did you get awareness on health,  Yes. We received messages relating to health, nutrition and nutrition and sanitations during the sanitation from the health staff in health centers or from the last three months? And If yes from community nutrition volunteers. which sources?  Our community receive key messages on hygiene and sanitation promotions from community nutrition workers  A. health staff and health facilities but there is no distribution of materials  B. community volunteers/social like leaflets. mobilizers  We didn’t receive IEC materials to help us to understand  C. Relatives/neighbors better.  D. Mass media  Community Sensitization meeting  E. Mobile SMS

16 Are there any community  Yes. There are community nutrition volunteers, community groups/volunteers/ CBOs, etc. in this elders, Water committees, gender violence groups, IYCF community? If yes, what volunteers and mostly support the implementation of nutrition programs. are they doing?

17 Is there school in the camp? (If yes)  Yes, we have schools in or around the camp. what is the role of school teachers in  No, we do not have schools, we share one school which community health education serve for all camps in the east side of the town. activities, did you see any teacher  Most of IDPs are in east of the town and share only one telling about nutrition? What is the school in Biyo-Kulule Camp supported by SCI and some IDPs relationship between the school and have no access or have difficulty to reach it. the camp activities?  No there is no any topics to nutrition or health education given to students by the school.  Role of the teachers in health education is almost zero.

18 What roles can school play in  If the schools are supported with the relevant materials, enhancing camp community teachers can streamline nutrition information with school education for promotion of better sessions for the students. nutrition practices?_  If teachers are trained on nutrition and health education effectively, they can provide messages to the community.  Teachers are credible people in the community, they have respect and their information can be taken seriously.  School/teachers can participate mobilization and sensitization meetings

3.3 GALKAYO IDPS

Table 5: Information collected from Galkayo IDPs during the Rapid Assessment

On 20th March 2018, UNICEF and S/N IDPs camps Information Collected MOH with the collaboration of FGD KII Save the children (SCI) Relief International (RI), Social 1. Tawakal 2 3 Development and Relief Association (SDRA), Somali Red 2. Salaama One and Two 2 3 Crescent Society (SRCS) 3. Halabooqad 2 3 Medecins Sans Frontieres (MSF) and Shadeedley Organization 4. Orshe 2 3 conducted rapid nutrition assessment in IDP settlements of 5. 2 3 Danwadaag Galkayo. Six settlements were 6. Taalacad 2 3 assessed through focus group discussions and key informant Total 12 18 interviews as well as observations on the overall status of nutrition, health, sanitation and education. Three out of the six assessed camps were IDPs who had previously migrated from South and Central Somalia, while the other three camps were recently arrived pastoral destitute due to prolonged drought, and majority of them came from the Somalia region in Ethiopia.

3.3.1 Recent Nutrition Assessment Results Among Galkayo IDPs

Figure 2: GAM and SAM trends among Galkayo IDPs, 2012 - 2017

FSNAU Dayr 2017 nutrition assessment is showing global acute malnutrition of 21.8 percent (see figure GAM and SAM trends among Galkayo IDPs 2), showing sustained critical 25 GAM SAM 21.6 21.8 malnutrition and similar to 19.4 20.2 20 17 16.5 16.9 Gu’ 2017 (21.6%) and Gu’ 15 16.515.1 2016 (16.9%), severe acute 15 malnutrition is also showing 10 critical level (4.8%) and not 4.4 4.7 4.8 3.1 4.1 different from Gu’ 2017 5 2.5 2.9 2.5 2.6 1.7 (4.1%),but deteriorated 0 compared to Gu’ 2016 2012 2013 2013 2014 2014 2015 2015 2016 2016 2017 2017 (3.1%). Morbidity level is Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr also very high and nearly half of assessed children (47.1%) reported sick two weeks prior the assessment; this can be one of the major

11 aggravating factors of persisted high malnutrition level. According to SAGE nutrition casual analysis conducted in Galkayo IDPs in 2014, a significant statistical association have been seen between the morbidity and malnutrition, specially diarrhea, pneumonia and fever (see table 7).

3.3.2 NUTRITION CAUSAL ANALYSIS AMONG GALKAYO IDPS (SAGE 2014)

3.3.2.1 Morbidity 129 out of 841 assessed children were sick prior two weeks of the assessment, and this shows that there are significance associations between malnutrition and morbidities, specially diarrhea, Pneumonia, Fever and the overall morbidities (P <0.05). Although in general measles negatively affects the nutrition status of the children, this data has not shown any association between malnutrition and measles.

3.3.2.2 Health Interventions

Vitamin A supplementation and measles vaccine are among the key interventions that can mitigate nutrition situations, but Galkayo IDPs assessment has not shown any statistical association between malnutrition and these interventions (P>0.05)

3.3.2.3 Water and Sanitation

Generally lower prevalence of child morbidity has been observed among households with access to latrines (statistically significant, p=0.025); and those treat drinking water (Statistically very significant (P<0.0001), The associations were mostly not statistically significant (p>0.05) between child morbidity and hand-washing at critical times and use of soap for hand-washing and access of water from protected source.

3.3.3 Summary Rapid Assessment findings among Galkayo IDPs

3.3.3.1 Access to Health Care

Only two camps of Salaama one and Halabooqad have health centers providing different services that include outpatient treatments, antenatal and postnatal cares, immunizations, growth monitoring etc. Tawakal IDP camp has also health post providing some basic health service but the remaining three assessed IDPs do not have health facilities, however, six mobile teams supported by Medecins Sans Frontieres (MSF) and Save the Children (SCI) were working in all the visited IDP camps, who were providing integrated health and nutrition services. Most of the settlements that do not have health facility were the recently arrived pastoralists due to recurrent droughts.

3.3.3.2 Nutrition Interventions

The only reported ongoing nutrition intervention was outpatient therapeutic Program (OTP), which is supported by UNICEF (through partner organizations) and MSF, but no Targeted Supplementary Feeding Programs (TSFP) activities were seen. Because of the persisted global acute malnutrition among Galkayo IDPs, in which recent assessments are showing critical status, implementation of TSFP service is very 12 crucial to focus on moderate acute malnutrition and complement with the current ongoing OTP activities which are only focusing on severe malnutrition.

3.3.3.3 Child Care Practice

Limited knowledges of optimal feeding practices were also noted, especially exclusive breastfeeding, which need efforts to raise the knowledge and awareness of the community to promote positive behavior on child care practices.

3.3.3.4 Access to Safe Water

There are number of boreholes available in some IDP settlements owned as private and powered by generators or solar panels and borehole owners sell one jerrycan of water (20 liters) for 4,000 to 6,000 Somali shillings, a price that cannot be afforded by very poor households.

Danwadaag IDP camp has two water kiosks supported by UNICEF and NRC. An unprotected shallow well is being used by some IDP families. Higher cases of diarrhea were reported from this camp, which are most likely caused by using water from the unprotected shallow well.

3.3.3.5 Access to Latrines

A big gap exists in regards to access of latrines, specially the recently arrived pastoral destitute, who mainly migrated from the Somali region in Ethiopia, and open defecation practices were common.

3.3.3.6 Environmental Sanitations

No proper garbage and solid management system have been observed inside or around the camps.

3.3.3.7 Education

Education is another area with extreme gap, specially the recently established camps who do not have schools.

Table 6: Summary Responses of FGDs Among Galkayo IDPs during the Rapid Assessment SN Questions Responses

1 Can you explain what are the common Measles, Malaria, diarrhea, Malnutrition, ARI, and chicken diseases that affect children under five box. years in this camp

2 What do you do if the child gets  Give ORS or lemon if Diarrhea and refer. diarrhea?  Give orange or salt plus sugar and take to hospital.  Take to the MCH to get ORS

 Refer to hospital

3 How is the access to health services in  Yes, there is health center in the camp (Halabooqad) the camp? What kind of health and everybody have access. services can be found? What are the  There are mobile teams providing health services conditions? Are they accessible for (Tawakal). everybody?  Yes, we have access to health services and everybody have right for health (Salama).  No MCH, no hospital but we receive weekly mobile health services (Danwadaag).

4 Can you tell about exclusive  Six months for breast milk and according to the breastfeeding? And how long should a Qur’an to continue up to 2 years. mother continue breastfeeding for the  Child have right for breastfeeding to protect the child? diseases.  Exclusive breastfeeding, is 0 to six months and continuation is for 2 years.  Continuation of breastfeeding is up to 12 months

5 Do you know any ongoing nutrition  Only OTP and MCHN activities are going on interventions in your camp?

 Yes;  No If yes what type of interventions  OTP  TSFP  MCHN  Micronutrition supplementations

Others (specify)______

6 Do you aware any one doing screening  Yes, there is weekly screening activities activities at household level in your  Yes, some organizations are doing bi-weekly camp? If yes who and how frequently? screenings. (Show MUAC tape for understand):  Yes, there is one trained person who do screening activities in this camp  No screening activities in this camp (Tawakal)

7 2. What are the major sources of  Major source of water is pipe water drinking water for the camp (For  Pipe water provided by private company Interviewer: please estimate the  Pipe water, kiosks and shallow wells. proportion of community that use  Shallow wells and kioskis (Salama) in each source)?  Berkeds and shallow wells (Orshe).  It is tape from Halabooqad but insufficient (Danwadaag)

8 What are the main challenges to get  Water Shortage (Danwadaag) and water points are drinking water in this camp? far from the households  Water price is too high

 Need bigger tankers

9 Do majority of the people have access  Yes, majority of the people use latrines but there are to latrines? If not, what are the main some people who do not have. challenges for not accessing and how  No latrines for most of the people and there is open do you think this problem can be defecation addressed  Most of the people do not have access, because they cannot build latrines.  No, because latrine pits are full and we cannot build new latrines.  There are only 10 latrines with no water, and latrine pit is already full in some of them.  There are few latrines and most of them are not in use currently

10 Can you tell about the importance of  If no use of latrines diseases will spread using latrines than open defecations?  Use of latrine can prevent diseases, while open defecations lead to diseases.  It is good and save environment because open defecation is danger.  No open defecation, use of latrine means no disease.  To improve the sanitation and the health of the community.

11 How and where do you dispose  No garbage disposal system, no one manages. garbage? Who is managing the  We dispose to the assigned area. garbage? Do you pay for garbage  We dispose to an open area and then burn. collection  We collect garbage, but we do not have materials to use for collection.

12 Do you think there is relationship  Yes, when the garbage is near, disease is near. between garbage and disease? (If yes)  Yes, there is direct relation between garbage and what is that relationship? How can be diseases. managed garbage?  Yes, garbage causes diseases and we need to manage the garbage, and conduct awareness activities.  No relation

13 Do majority of the people in the  No, because of lack of awareness and water catchment wash their hands with soap shortages. at critical times? (If yes) what hygiene  No because of the knowledge. items do they use for hand washing?  Yes, we use soap and shampoo at the critical times. (if not) why not washing hands at  Majority are not practicing but some people use critical times? hand washing with soap or ash.  Yes, there is enough water and hand washing practices in Orshe camp.

14 Can you explain if there is any relation  There is direct relationship, if people do not wash between hand washing and diseases their hands, they will get bacteria and will lead to disease.  Hands carry bacteria, if washed people are safe from bacteria, if not they might get diseases.  If you do not practice hand washing, you will be at risk of disease.  The relation is, if you do not wash your hands there is likelihood of disease occurrence.

15 Did you get awareness on health,  Yes, from health staff nutrition and sanitations during the  Yes, from health staff and volunteers. last three months? And If yes from  Yes, from health staff and mass media which sources?  No, we did not receive any messages on health and nutrition.  A. health staff

 B. community volunteers/social mobilizers  C. Relatives/neighbors  D. Mass media  Community Sensitization meeting 16

 E. Mobile SMS

F. Other (specify)

16 Are there any community  No, there are no community groups/volunteers groups/volunteers/ CBOs, etc. in this  Yes, they do screening of malnutrition community? If yes, what  Yes, they conduct campaigns on hygiene promotion.  Yes, we have one trained girl, who conduct are they doing? screening activities.

17 Is there school in the camp? (If yes)  Yes, there is primary school what is the role of school teachers in  No there is no school (Tawakal and Danwadaag) community health education  Yes, we have school and it have good relationship activities, did you see any teacher with community and participates awareness telling about nutrition? What is the campaigns. (Orshe) relationship between the school and the camp activities?

18 What roles can school play in  Yes, some nutrition sessions are given to students enhancing camp community education  They can participate awareness activities on health for promotion of better nutrition and nutrition practices? _

3.4 GAROWE IDPS Table 7:Information Collected from Garowe IDPs During the rapid Assessment

SN Main sites Sub site Information Collected Most of the IDPs in Garowe located FGDs Key Informants in two main areas of Jowle and 1 Jilab Jilab 1 2 3 Jilab. Each main camp is sub- 2 Jilab Jilab 2&3 2 3 divided into smaller camps. Jowle 3 Jowle Banaadir 2 3 camps are overcrowded with poor 4 Jowle Jiingadaha 2 3 housing and sanitation conditions, Total 8 12 while most of camps in Jilab have better housing conditions with better access to latrines. Majority of IDPs came from south and central Somalia, but there are number of destitute families who lost their livestock due to recurrent droughts and they migrated to Garowe.

3.4.1 Recent Nutrition Assessment Results Among Garowe IDPs

Figure 3: GAM and SAM trends among Garowe IDPs, 2012 to 2017

According to GAM and SAM trends among Garowe IDPs GAM 25 21 FSNAU Dayr 19.6 19.5 20 19.9 19.2 2017 20 17.7 17.6 15.8 15.7 14.3 Nutrition 15 analysis, the Global Acute 10 5.5 4.4 4.3 4.9 malnutrition 3.7 3.9 4.1 3.8 3.1 5 1.9 2.9 (GAM) is 17.6 (13.2 -23.1), 0 showing 2012 Deyr2013 Gu2013 Deyr2014 Gu2014 Deyr2015 Gu2015 Deyr2016 Gu2016 Deyr2017 Gu2017 Deyr sustained critical malnutrition and similar to the previous two seasons of Gu’ 2017 (19.9%) and Deyr 2016 (17.1%). Severe Acute Malnutrition (SAM) is at serious level of 3.1 (1.8 -5.2), indicating an improvement from the critical result of Gu’ 2017 (4.9%) but similar to post Deyr 2016 serious level of SAM (3.1%).

Morbidity is high and 18.8 % of children were reported sick prior two weeks of the assessment, while vitamin A supplementation and Measles vaccinations were 64.1 and 64.5 percent respectively (See table 11 for details).

Figure 4: Garowe OTP Admissions, Jan to Dec 2017 18

Number OTP and SC admissions in Garowe district, 2017 1200 1022 1044 1000

800

600 529 505 452 442 415 400 302 298 312 178 140 200

0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

This is data from the health facilities in Garowe, which serves IDPs only, and it indicates an increased admissions trend during the last quarter of 20174.

3.4.2 Summary Rapid Assessment Findings Among Garowe IDPs

3.4.2.1 Access to Health Services

There are two health centers providing different health service for Garowe IDPs, that include, Outpatient Department (OPD), Expanded Program on Immunization (EPI), Antenatal care (ANC) and Postnatal care (PNC), nutrition service including growth monitoring, severe malnourished cases management and outpatient therapeutic program (OTP). In addition, awareness messages to promote health, nutrition and sanitation are provided. Awareness messages are given only to those visit the health centers.

These services are free and are accessible to majority of the people, though some IDPs feel that they are quite far from the health centers, at the same time, the working hours for health facilities are only during the day, and no services are available during the night.

Most common diseases reported among under five years children were : Acute Watery diarrhea (AWD), Acute respiratory Infections (ARI), Pneumonia, Measles, malnutrition and dysentery. Majority of the households seek medical care from the health facilities, but some families try first to treat the child at home, using traditional treatments.

3.4.2.2 Nutrition interventions

Save the Children (SCI) was implementing Targeted Supplementary Feeding Program (TSFP) but this activity has ended two months ago, leaving a gap in terms of TSFP services. UNICEF currently supports the

4 Ministry of health 2017, Garowe district OTP and SC admissions. 19

OTP and MCHN programs through partner organizations, as well as Iron (at the facility) and vitamin A supplementations (during immunization campaigns).

Most of mothers are not aware of the proper use of plumpy-nut, and majority of them give it to all the children in the family, rather than giving it to severely malnourished child as treatment.

3.4.2.3 Child Care Practices

Majority of parents leave in the morning for casual labour activities, and only children remain at home. The infants and young children do not get proper adequate feeding and care since mothers are away from home for long hours.

The 2016 IYCN assessment shows an exclusive breastfeeding rate of 39 percent in Puntland and 33 percent at national level, both rates are below the global nutrition targets of exclusive breastfeeding (50%). Since the IYCN study consists of whole population including pastoral and urban, the rate of exclusive breastfeeding for IDPs is likely to be much lower, and the majority of key informant interviews and other qualitative information indicate that a child is given water with sugar within few days after delivery, and receives milk feeding during the second or third months after birth.

3.4.2.4 Access to safe water

The main water source for most of the IDPs camps is kiosks which are run and managed by Nugal water company (NUWACO). People mainly use jerrycans of 10 to 20 liters, and one jerrycan of 20 liters is costing 2,000 Somali shillings. People were complaining that the water from the kiosks are very salty and difficult to drink, moreover, kiosks are closed sometimes, especially in the evening, where number of camps may not have alternative water source.

The second water source for the IDPs is the Biyocade open well, which is about 20km southeast of Garowe where water tankers supply the private barkeds that sale 5,000 shilling per jerrycan of 20 liters. Biyocade well is less salty than the water from kiosks but it is an open well and not protected, therefore it cannot be considered as safe unless treated/cleaned at the Barked or household level.

Usually each family uses an average of three to four jerrycans of 20 liters per day, and the price is 2,000 for kiosks and 5,000 for Biyocade open well per jerrycan. The distance to the source of the water is not far and closer than 500 meters, but the cost looks very expensive to poor families,

Activities to improve the quality of drinking water were not observed. In early 2017, after the outbreak of Acute Watery Diarrhea (AWD) in Garowe IDP camps, there was distribution of aqua tablets for households, an intervention that had ended few months ago.

3.4.2.5 Access to latrines

Access to latrine was among the biggest challenges observed. There are few latrines available inside the camps, and the number of latrines are quite less than the number of households. In some camps, up to 10 families are using one toilet, while there was no proper digging in some latrines, and are less than 2

20 meters deep. The pit became full and out of use within a very short period. Challenges on latrine access were very common in Jowle IDP camps but some of the camps in Jilab have better access to latrines.

3.4.2.6 Environmental Sanitations

Poor environmental sanitation has been observed in majority of the settlements, specially Jowle zone. However, situation of the environmental sanitation in majority of Jillab settlements was better compared to Jowle. Overall only two camps reported that they have garbage disposal sites, while reaming visited camps were disposing the garbage around the settlements. Garowe municipality collects garbage once or twice a year and transport it to the main disposal site, which is around three kilometers away from the camps.

3.4.2.7 Use of hygienic items.

Although it has been reported that number of families are using soap/ash at the critical times, still majority of households are using only water with no other hygienic items for hand washing, which require more behavioral change activities.

3.4.2.8 Social awareness activities.

Currently no effective social mobilization and awareness activities were observed, specially, at household level, but IEC materials were seen on the walls of health centers, with focus on sanitation, health and nutrition, while the only other social mobilization activity undertaken is on immunizations during the SIAs.

School teachers give few awareness messages on sanitation at the school for students only and there is no active community based organizations (CBO) or volunteers working inside the camps and the only available active members are camp committees, who mainly work on conflict resolutions and support NGOs for the implementation of some interventions.

Education

Majority of IDPs have schools with four to five teachers, and almost half of them are female teachers. Schools are providing some awareness messages to students on sanitation as well as few sessions on health are in school curriculum, but the school enrollments are quite low and nearly half of the school age children in the camps are not going to school.

Table 8: Summary Responses of FGDs Among Garowe IDPs during the Rapid Assessment

SN Questions Responses

1 Can you explain what are the common Measles, diarrhea, Malnutrition, ARI (specially pneumonia) diseases that affect children under five and malaria years in this camp

2 What do you do if the child gets  Give ORS or lemon if Diarrhea and refer diarrhea?  Give lemon, sugar or rice water and take to MCH  Give zinc and ORS  Take to health center and to hospital if severe  Take to private clinic or sometimes to health center or hospital

3 How is the access to health services in  Health facilities are quite far from this camp and the camp? What kind of health services difficult to reach it for the children and aged can be found? What are the conditions? people Are they accessible for everybody?  There is health center that provides different services include immunizations, OPD treatments, delivery, growth monitoring, rehydration, and nutrition interventions.  All the people can access and MCH staff conduct home visits for those cannot come.

4 Can you tell about exclusive  Due low family income, mothers go for casual breastfeeding? And how long should a labor and do not get enough time to breastfeed mother continue breastfeeding for the  Mothers cannot breastfeed exclusively, because child? they are away from the child most of the day for casual activities.  Most of mothers give the baby water with sugar within 40 days after birth.  Breastfeeding is continued from 3 to 12 months only and very few people continue after 12 months.  Breastfeeding helps child’s health and growth, so mothers continue breastfeeding if they do not get pregnant  Child is given milk two to three months after birth (mainly milk powder)

5 Do you know any ongoing nutrition  OTP and MCHN are going at the health centers, no interventions in your camp? mobile OTP services   Yes; TSFP activities are done once a month

 No If yes what type of  Health facilities are providing MCHN, OTP and iron interventions supplementations, while vitamin A  OTP supplementation is done only during the  TSFP campaigns  MCHN  No mobile teams doing interventions and the  Micronutrition supplementations ongoing activities are OTP and MCHN at the  Others (specify)______facility

6 Do you aware any one doing screening  SCI was doing screening before but they stopped activities at household level in your last year (September 2017). camp? If yes who and how frequently?  There are no CBOs/volunteers doing screening, (Show MUAC tape for understand): but SCI conducts once a month  There are no ongoing screening activities now.  SCI conducts once for every three months. But not at household level  Screening activities were going on before, but not seen during the last three months

7 What are the major sources of drinking  Most of households use NUWACO kiosks but few water for the camp (For Interviewer: families use purified water. please estimate the proportion of  70% use kiosks while the remaining 30% use community that use in each source)? Barkeds  NUWACO kiosks and Al-naciim purified water.  Use water trucked from Biyo-cade shallow well

8 What are the main challenges to get  Main challenge is land ownership, and we cannot drinking water in this camp? build barkeds..  Water is very salty and difficult to drink  Water is costing and difficult to most of the camp households, since has been trucked from a far place.  Water kiosks are available only during the day and not working during the night.  Sometimes kiosks are closed by the water company.  Most people use plastic jerrycans for drinking water which are not clean.

9 Do majority of the people have access to  No, land owners refused to build latrines for some latrines? If not, what are the main camps. challenges for not accessing and how do  The pit is full for most of latrines, then cannot be you think this problem can be addressed used.  No, only few households have latrines.

 No, the IDP residents of this camp (Jilab 3) were pastoralists originally and were here since June 2017, so no latrines constructed so far.  Yes, all the households have latrines (Jillab 1) but the pit is very small and might become full within very short period.

10 Can you tell about the importance of  Latrine is good for the sanitation, and will lead to using latrines than open defecations? better health and nutrition.  Everybody knows the importance of using latrines for the hygiene and health of the family.  Latrine is good for the health, environment, security and reduces the spread of the diseases.  Good for the privacy, dignity and the health  Open defecation can result poor sanitation and spread of diseases.

11 How and where do you dispose garbage?  Garbage is disposed in to the dry stream near the Who is managing the garbage? Do you camp, and it is burned one time in every one to pay for garbage collection two years by the municipality.  Disposed it around the camp, but sometimes people of the camp collect and burn, it is not paid  Garbage is bothering all the IDP households  Disposed around the camp, and no one manages and even garbage from the town is disposed to here sometimes

12 Do you think there is relationship  Yes, and the availability of dumping site is very between garbage and disease? (If yes) important. what is that relationship? How can be  It can result morbidities like skin diseases. managed garbage?  Yes, because garbage is the source of flies and other insects which can result spread of diseases  Yes, it can result diseases like Diarrhea.

13 Do majority of the people in the  Yes, they wash their hands with soap or ash at the catchment wash their hands with soap at critical times. critical times? (If yes) what hygiene  People wash their hands but mostly do not use items do they use for hand washing? (if soap, either they may not have the soap, or there not) why not washing hands at critical are issues need more awareness. times?  Soap is mainly used for the cleaning of clothes only  There is hand washing but sometime water used for hand washing may not be clean.

14 Can you explain if there is any relation  If no hand washing, it can result diseases. between hand washing and diseases  If there is no handwashing, the hands themselves will contaminate the food, and then result disease.  Diarrhea is mainly caused by lack of handwashing.  Any bacteria to stomach is from the hands

15 Did you get awareness on health,  The last time we got awareness was June 2017. nutrition and sanitations during the last  Yes, the camp committee have done social three months? And If yes from which mobilization activities. sources?  No, we did not receive any messages on health  A. health staff and nutrition.  B. community volunteers/social  Health staff conduct awareness activities if there is mobilizers an outbreak.  C. Relatives/neighbors  D. Mass media  Community Sensitization meeting  E. Mobile SMS

F. Other (specify)

16 Are there any community  No, there are no community groups/volunteers groups/volunteers/ CBOs, etc. in this  No, the only organized available group is camp community? If yes, what committee, no other social groups are they doing?  Yes, they were there before, but they are not working now.

17 Is there school in the camp? (If yes)  Yes, we have school, and teachers give some what is the role of school teachers in awareness messages on hygiene and sanitation to community health education activities, students. did you see any teacher telling about  Yes, we have school but it does not have any other nutrition? What is the relationship role than teaching. between the school and the camp  We do not have school in this camp (Jilab 3) but activities? there is school in Jilab 1 which is far from us.

18 What roles can school play in enhancing  Yes, school can control the hygiene of the students camp community education for and they can also give messages on sanitation and promotion of better nutrition practices? _ hygiene.  No, there is no other role.  Schools can promote sanitation, health and nutrition.  They can contribute up to a level in which the student can influence household practices.

3.5 GARDO IDPS

Table 9: Information collected from Gardo IDPs During the Rapid Assessment

SN Sites Information Collected Most of the IDPs in Gardo located at the FGDs Key Informants southern side of the town, specially the three 1 Shabeelle 2 3 major IDP settlements of Shabelle, Bulo-qodax 2 Bulo-Qodax 2 2 and New camp. Majority of IDPs came from 3 New Camp 2 3 south and central Somalia, but there are Total 6 8 number of destitute families who lost their livestock due to recurrent droughts and then moved to Gardo.

3.5.1 Recent Nutrition Assessment Results Among Gardo IDPs

Figure 5: GAM and SAM trend among Gardo IDPs, 2012 to 2017

25 According to FSNAU 21.7 GAM and SAM trends among Qardho IDPs 21.9 Dayr 2017 Nutrition GAM SAM 19.4 20 18.5 analysis the Global Linear (GAM) Linear (SAM) 14.9 15.2 Acute malnutrition 14 (GAM) is 21.9, 15 12.2 12.6 11.1 10.4 among Gardo IDPs, 10 which indicates sustained critical 5.6 4.9 3.2 malnutrition level 5 2.8 2.2 2.3 2.7 1.7 1.8 1.1 1.9 from the previous two seasons, where 0 similar result have 2012 2013 2013 2014 2014 2015 2015 2016 2016 2017 2017 Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr been reported. Severe Acute Malnutrition (SAM) is at serious level of 2.7 percent, compared to post Deyr 2016 (2.3%) alert level of SAM (see table 13 for details)

children reported sick prior to the assessment, were very high (43.9%) while vitamin A supplementation (42.2%) and Measles vaccinations (21.4%), were very low. One of the reasons for low health interventions (Vitamin A supplementation and Measles vaccination) may likely due to the fact that no health facility is located inside the camp, and IDPs only have the option to go to facilities inside the town.

3.5.2 Nutrition Casual Analysis Among Gardo IDPs5 (SAGE 2014)

3.5.2.1 Morbidity

Though diseases are among the key immediate causes of malnutrition, no statistical association has been noted among Gardo IDPs.

3.5.2.2 Health Interventions

Those who had received measles vaccine doses were nearly half times RR=0.55; (0.36-0.84) less likely to be acutely malnourished among Qardho IDPs.

The associations between acute malnutrition and other health programmes (Vitamin A supplementation) did not however, show statistical significance (see table 14 for details)

3.5.2.3 Water and Sanitation

Generally lower prevalence of child morbidity observed among households with access to protected water (statistically significant, p=0.033); and households treat drinking water (statistically very significant, p=0.000), The associations were not statistically significant (p>0.05) between child morbidity, hand-washing and use of soap for hand-washing (See table 15 for details)

3.5.3 Summary for the Rapid Assessment Among Gardo IDPs

3.5.3.1 Access to Health Services

No health centers inside Gardo IDPs, but UNHCR has recently built a health center in shabelle IDPs which is not functioning yet, however, majority of IDP camps go to Hingood Health center which is about three to four kilometers away from the camps. They receive different free health services such as Outpatient Department (OPD), Expanded Program on Immunization (EPI), Antenatal (ANC) and Postnatal (PNC) cares. Nutrition service and awareness messages on health, nutrition and sanitation are provided at this facility.

These services are free but health centers are quite far from the camps, which may prevent IDPs from seeking key services (like immunizations) and visit only when the child is very sick.

Most common diseases reported among under five years children were: Acute Watery diarrhea (AWD), Acute respiratory Infections (ARI), specially Pneumonia, Measles, malnutrition and diarrhea.

3.5.3.2 Nutrition interventions

5 SAGE, 2014, Nutrition Casual Analysis Among IDP Camps in Gardo 27

HADO organization with the support of WFP, is carrying some nutrition interventions of Targeted Supplementary Feeding Program (TSFP). The health facilities provide MCHN program, however, no OTP intervention has been noted and the last one ended on 21st January 2018.

Vitamin A supplementation activities are mostly combined with the supplementary Immunization Activities (SIAs),

3.5.3.3 Child Care Practices

Most of parents leave from the camps at the morning for casual labour activities, and only children remain at home, this indicates that the infants and young children may not get proper / adequate feeding and care, since the mother is away from the home for long hours.

Though most of those interviewed were aware about the importance of exclusive breastfeeding, however, it is not practiced; and majority of key informant interviews and other qualitative information have shown that the new born baby is given water with sugar within few days after delivery.

Access to safe water

Almost all the Gardo IDP camps get water from water storage tanks, and the original source of the water is boreholes inside Gardo town.

People mainly use jerrycans of 20 liters capacity, and family uses an average of four to five jerrycans per day, where one jerrycan of 20 liters is costing 3,000 Somali shillings, thus this make it difficult for very poor households to have access. Apart from the high cost, there were no major challenges on water availability are reported.

Though people are getting water from protected source, contamination still can take place at household level.

3.5.3.4 Access to latrines

Majority of families in Gardo IDPs use either communal or household toilets, but due to the quality of toilets at least one third of them are not used currently because most of them have less than 2 meters deep pit and become full within very short period. Open defecation practices have been reported, specially by children.

3.5.3.5 Environmental Sanitations

Two out of the three camps visited have garbage disposal bit, while Buloqodax camp, do not have disposal site, but they gather and burn garbage every Friday, therefore, no garbage has been seen inside most of the camps in Gardo.

3.5.3.6 Use of hygienic items.

Although it has been reported that number of families are using soap/ash at critical times, still majority of households are using only water with no other hygienic items for hand washing, which requires behavioral change.

3.5.3.7 Social awareness activities

There is no effective social mobilization and awareness activities, specially at household level, but there were very few volunteers who were trained by CARE and they do not conduct regular awareness activities on sanitation, health and nutrition. Social mobilization activities on immunization is undertaken only during the SIAs.

3.5.3.8 Education

Majority of IDPs have schools with four to five teachers, and almost half of them are female teachers. Schools are providing some awareness messages to students on sanitation and few sessions on health, but the school enrollment is quite low and nearly half of the school age children in the camps are not going to school.

Table 10: Summary Responses of FGDs Among Gardo IDPs during the Rapid Assessment

SN Questions Responses 1 Can you explain what are the common Measles, diarrhea, Malnutrition, ARI diseases that affect children under five years in this camp 2 What do you do if the child gets diarrhea?  Give ORS if Diarrhea and refer  Take to the nearest health center if severe  Ake to private clinic or health center 3 How is the access to health services in the  Health facilities are quite far from the camp? What kind of health services can camps and nearest health center is up to be found? What are the conditions? Are three kilometers they accessible for everybody?  There is new building for health center but not functioning yet  Mobile teams come sometimes with TSFP 4 Can you tell about exclusive  Exclusive breastfeeding is for up to six breastfeeding? And how long should a months but majority of mothers due not mother continue breastfeeding for the practice. child?  Most people are aware about EBF but not practices  Most of mother give water with sugar within 40 days  Breastfeeding is mainly continued up to 12 months only.

 Mothers stop breastfeeding if they get pregnancy.  Milk is given to the child within two to three months after birth

5 Do you know any ongoing nutrition  Previously SCI was doing OTP activities but interventions in your camp? stopped on 21st January 2018  Yes;  No  With support of WFP HADO NGO is doing If yes what type of TSFP activities interventions  There is also ongoing MCHN activities at  OTP health centers.  TSFP  No OTP activities at the moment  MCHN  Micronutrition supplementations Others (specify)______6 Do you aware any one doing screening  Yes, HADO NGO conducts periodic activities at household level in your screening to identify malnourished camp? If yes who and how frequently? children (Show MUAC tape for understand): 7 3. What are the major sources of  100% of IDPs use water from tankers drinking water for the camp ( For around the camps, and water is trucked Interviewer: please estimate the from boreholes inside Gardo town proportion of community that use in each source)?

8 What are the main challenges to get  No major challenges regarding the access drinking water in this camp? of water  Very poor households are feeling quite expensive as 20 liters jerrycan is 3,000 Somali shillings 9 Do majority of the people have access to  Yes latrines? If not what are the main  Each latrine is shared by three households, challenges for not accessing and how do and the bit becomes full within short time, you think this problem can be addressed as it was dug not more than 2 meters deep.  Nearly half of the latrines are not working now 10 Can you tell about the importance of  Yes, if latrines are used, it will reduce using latrines than open defecations? disease transmissions.  Open defecation can result diseases like Cholera  It is very important for health, dignity and privacy

11 How and where do you dispose garbage?  It is collected and burned Who is managing the garbage? Do you  Gather in open grounds and then burn on pay for garbage collection weekly basis  Dispose to a garbage pit, and not paid  There is disposal pit which was dug by CARE but currently it is full. 12 Do you think there is relationship between  Yes, as children play around the garbage, garbage and disease? (If yes) what is that it can easily result diseases relationship? How can be managed  Yes, it can result many diseases include garbage? skin diseases  Yes it can lead diseases like diarrhea. 13 Do majority of the people in the  Yes, they wash their hands with soap at catchment wash their hands with soap at the critical times critical times? ( If yes) what hygiene  It is mixed, some people wash only with items do they use for hand washing? (if water while others use soap. not) why not washing hands at critical  Most people wash their hands with only times? water.

 Majority are using water only, but there are increasing number using soap or ash.  Hand washing is common, but majority are not using soap, people are aware about the importance, but not practice 14 Can you explain if there is any relations  If no hand washing, there could be between hand washing and diseases bacteria that may lead to a disease.  Hand is the main transmitter of many diseases.  Yes, like diarrhea 15 Did you get awareness on health, nutrition  No, we did not get any information and sanitations during the last three promoting health, nutrition and sanitation months? And If yes from which sources? in last three months  A. health staff  Yes, we have seen one-time community  B. community volunteers/social mobilizers, promoting sanitation hygiene, mobilizers health and nutrition  C. Relatives/neighbors  We have seen TASS promoting only issues  D. Mass media related to protection, but not on health,  Community Sensitization meeting nutrition and sanitation  E. Mobile SMS F. Other (specify) 16 Are there any community  No, there are no community groups/volunteers/ CBOs, etc. in this groups/volunteers community? If yes, what  The only organized group are camp are they doing? committee who supports aid distributions and health education.  IDP committee conducts some awareness

17 Is there school in the camp? (If yes) what  Yes, but this camp (Buulo-qodax) have is the role of school teachers in only one room for school which is not community health education activities, enough and the other schools are far from did you see any teacher telling about the camp. nutrition? What is the relationship  Teachers give some awareness message between the school and the camp on sanitation to students activities?  There is no relations between the school and camp activities  Yes, there is school but their role is only educating the student.

18 What roles can school play in enhancing  Yes, it can play specially areas of health camp community education for promotion and sanitation of better nutrition practices? _  It can play good role in camp activities specially nutrition practices  They can give awareness on nutrition if trained  Yes, specially sanitation

4 CONCLUSION.

Taking into consideration the findings of this qualitative rapid assessment and the available secondary quantitative information, it could be stated that numerous factors exist to influencing the persistence of high level of malnutrition in the IDPs camps in Puntland which include:

Access to Latrines: Majority of the adult people were using latrines before, but as more and more latrines are not in use, this will likely increase open defecation practices. this challenge has been observed in the majority of IDP camps in Bosaso, Garowe, Galkayo and Gardo.

Poor solid waste and garbage management system: except for Gardo IDPs camps, the majority of the IDPs camps have no proper waste management systems or sustainable ways of garbage collection and disposal.

Access to Safe water: Although majority of the IDP camps in Puntland have reported that they get water from protected source, water can be contaminated easily at home, and there are no evidence that water is boiled at household level. The only reported method of water treatment in some facilities (mainly Garowe and Gardo) was aqua tablets distributed last year, but majority of the households do not have it now.

Morbidity and lack of access to health care: There are some very common morbidities that can negatively affect nutrition status including diarrheal diseases, pneumonia and measles. Health facilities are also quite far from some camps in Bosaso, Galkayo and Gardo, a factor that prevent children from getting access to early treatments.

Child Care practices: children do not get proper feeding and care due to mother’s workload and limited knowledge.

No or very limited TSFP: In almost all the IDPs camps visited, nutrition interventions of Targeted Supplementary Feeding Programs (TSFP) were either nonexistent, limited or completely stopped.

Less focus on Immediate and Underlying Causes: The current nutrition interventions are mainly focused on treating acute cases of malnutrition, but the influencing factors of the malnutrition are rarely targeted.

Limited social mobilization Activities: There are some perceptions and behaviors that may negatively affect child’s nutritional status, for example most people were saying that mother’s milk is not enough for the first six months of the child’s life, which could be one of the reasons for low rate of exclusive breastfeeding.

5 RECOMMENDATIONS.

1. Water and Sanitations:

A. Address the issue of not in use latrines and set SOPs for future implementation of any new latrines for IDP camps, to ensure that deeper latrines are dug for future sustainability and quality toilets. B. Think sustainable method of water treatment at household level, to reduce possible use of unsafe water. C. Establish proper community based solid waste management system to collect and dispose garbage

2. Health and Nutrition:

A. Operationalize the recently constructed health center for Gardo IDPs, to facilitate better access to health services for children and mothers. B. Established new health facilities for populated IDP camps that are quite far from the health centers, (mainly in Bosaso and Galkayo) C. Promote proper IYCF practices, especially exclusive breastfeeding and complementary feeding practices.

3. Education. A. Train teachers to participate in health, nutrition and sanitation promotions B. Consider the possibility of adding health, nutrition and sanitation sessions in the school program. C. Build schools for the recently established IDP camps (Mainly Galkayo)

4. Communication for Development.

A. Establish community groups/volunteers that can conduct house to house social mobilization activities and promote health, nutrition, sanitation and education activities. B. Train health workers on interpersonal communication skills to deliver the messages effectively. C. Conduct periodic community sensitization meetings. D. Develop a PCA on C4D, covering all the IDP camps in Puntland and addressing all the social mobilizations gaps on health, nutrition and sanitation.

5. WFP Supported TSFP: WFP should urgently start its support to the implementation of Targeted Supplementary Feeding Programs (TSFP) in all IDPs camps in Puntland. 34

6 REFERENCES

1. Helen Young and Anastasia Marshak, January 2018, Persistent global Acute Malnutrition, USA.

2. FSNAU 2016, Somalia Infant and Young Child Feeding and Nutrition study

3. World health Organization, 2010, indicators for infant and young child feeding practices, Geneva Switzerland.

4. Food Security and Nutrition Analysis Unit (FSNAU) Deyr 2017 Nutrition Presentation

5. SAGE, 2014, Nutrition Casual Analysis Among IDP Camps in Gardo

6. Ministry of health 2017, Garowe district OTP and SC admissions

7 ANNEXES

7.1 ANNEX I: RAPID ASSESSMENT TIMELINES

SN Dates Activity Responsible

04-05/03/2018 Desk Review UNICEF

06/03/2018 Discussion with MOH UNICEF & MOH

6-8/03/2018 Development of tools for data collection UNICEF & MOH

09 – 11/03/2018 Contact with the regional team and review UNICEF, MOH, Karkaar of tools health team 12/03/2018 Data Collection for Garowe IDPs MOH, UNICEF SCI & WVI

13 -14/03/2018 Data Collection for Galkayo IDPs MOH, UNICEF, MSF, SRCS, RI, SDRA and Shadeedley 14 – 15/03/2018 Data Collection for Gardo IDPs MOH and UNICEF

20/03/2018 Data Collection for Bosaso IDPs UNICEF, MOH,

18/03 – 11/04 Data Analysis and Report Writing, UNICEF, MOH, CARE, SCI, presentations and developing action points MDM, SRCS, HADO, ISPD, WFP and SRCS

7.2 ANNEX II: NUTRITION SITUATION AMONG BOSASO IDPS

Deyr 2016 Gu 2017 Deyr 2017 INDICATOR (N=712) (N=684) (N=654)

Plausibility 12% 4% 12

17.3 (13.7- GAM (WHZ<-2 or oedema - WHO/UNICEF 18.6 (15.5-22.1) 14.7% (12.3-17.4) 21.5)

SAM (WHZ<-3 or oedema - FSNAU 3.7 ( 2.5- 5.4) 4.5 (3.1-6.6) 2.3% ( 1.5- 3.5)

Oedema 0.0 0.0 0.0

Mean Weight-for Height Z (WHZ scores) -0.95±1.09 -1.08±1.03 -0.97±0.99

DEFF WHZ<-2 1.79 1.13 1.0

MUAC (<12.5 cm or oedema) -FSNAU 8.1 ( 5.3-10.9) 9.7 (6.6-11.3) 10.2% ( 8.1-12.8)

Severe MUAC (<11.5cm) - FSNAU 2.5 ( 1.4- 3.8) 2.0 (1.0-3.1) 2.1% ( 1.1- 4.0)

Stunting (HAZ-2) - WHO/UNICEF 17.5 (12.6-23.9) 18.5 (14.6-23.3) 21.1% (16.1-27.1)

Under weight (WAZ-2 - WHO/UNICEF 19.2 (15.3-23.8) 24.2 (20.7-28.2) 22.1% (18.1-26.7)

Admitted with GAM<-2 15.8

Crude death Rate 0.12 (0.04 – 0.38) 0.56 (0.27-1.15) 0.06 (0.01 – 0.24)

Under 5 death Rate 0.27 (0.06 -1.13) 0.59 (0.17-2.02) 0.11 (0.01 -0.83)

NUTRITION SITUATION Critical Critical

Risk/Underlying Factors

Morbidity 19.4 35.0 20.0

Vitamin A 94.9 83.4 57.0

Measles 86.4 82.4 76.3

FCS 22 25 TBD

HHS 34 16 TBD

CSI 23 29 TBD

Source: FSNAU 2017

7.3 ANNEX III: NUTRITION SITUATION AMONG GALKAYO IDPS INDICATORS Gu 2016 (n= 707) Gu 2017 (n= 747) Deyr 2017 (N= 866)

Plausibility 8 % 1 % 11% GAM (WHZ<-2 or oedema – WHO /UNICEF 16.9(14.3-19.8) 21.6 (18.8-24.6) 21.8% (18.1-26.0)

SAM (WHZ<-3 or oedema – FSNAU 3.1(2.1-4.7) 4.1 (2.6 – 6.5) 4.8% ( 3.2- 7.3)

Oedema 0.3 0 0

Mean Weight-for Height Z (WHZ scores) -0.90±1.10 -1.12±1.09 -1.13±1.10

DEFF WHZ<-2 1.00 1.00 1.86

MUAC (<12.5 cm or oedema) – FSNAU 6.0(4.5-7.9) 10.3 (7.1 – 14.7) 11.5% ( 8.6-15.3) 0.6(0.2-1.4) 2.5 (1.4 – 4.4) 1.9% ( 1.1- 3.3) Severe MUAC (<11.5cm) – FSNAU

Stunting (HAZ-2) - WHO/UNICEF 15.6(13.1-18.4) 13.7 (9.0 – 20.1) 14.6% ( 9.6-21.6) 16.9(14.3-19.8) 20.9 (16.3 – 26.4) 20.3% (16.1-25.3) Under weight (WAZ-2 - WHO/UNICEF

Admitted With GAM<-2 4.8

Crude death Rate 0.08(0.03-0.27) 0.07 (0.02-0.30) 0.21 (0.12-0.37) Under 5 death Rate 0.00 0.0 (0.0-0.0) 0.40 (0.17-0.92)

NUTRITION SITUATION Critical Critical Critical

Risk/Underlying Factors Morbidity 36.7 45.7 47.1

94.1 Vit A Sup. 91.2 83.7 89.2 Measles Vac. 91.6 80.4

HHS 21 TBD FCS 6.0 28 TBD

CSI 29.6 44 TBD Source: FSNAU 2017

7.4 ANNEX IV: NUTRITION SITUATION AMONG GAROWE IDP CAMPS

INDICATOR Deyr’ 2016 Gu’ 2017 Deyr 2017

(N=838) (N=772) (N=723)

14% 6% 4%

GAM (WHZ<-2 or oedema - WHO/UNICEF 17.7 (14.2-21.8) 19.9 (16.5-23.9) 17.6 (13.2-23.1)

SAM (WHZ<-3 or oedema – FSNAU 3.1 ( 1.8- 5.2) 4.9 (3.5-7.0) 2.9 ( 4.7- 9.5 )

Oedema 0 0.1 0

Mean Weight-for Height Z (WHZ scores) -0.94±1.13 -1.14±1.04 -1.05±1.01

DEFF- WHZ <-2 1.99 1.53 1

MUAC (<12.5 cm or oedema) – FSNAU 10.5 ( 7.8-13.1) 8.8 (6.8-11.3) 6.7% ( 5.1- 8.8)

Severe MUAC (<11.5cm) – FSNAU 2.0 ( 1.2- 3.2) 2.0 (1.3-3.2) 2.2% ( 1.4- 3.5

Stunting (HAZ-2) - WHO/UNICEF 12.8 ( 9.6-16.8) 16.4 (12.5-21.3) 9.7% ( 7.1-13.2 )

Under weight (WAZ-2 - WHO/UNICEF 17.2 (12.9-22.6) 23.3 (18.9-28.4) 15.3% (11.9-19.5 )

Admitted with GAM 14.2

Crude death Rate 0.16 (0.06 – 0.43) 0.35 (0.15-0.80) 0.27 (0.11-0.65)

Under 5 death Rate 0.36 (0.11 -1.11) 0.75 (0.28-2.01) 0.29 (0.06-1.32)

NUTRITION SITUATION-I WHO/UNICEF Critical Critical Critical

Risk/Underlying Factors

Morbidity 34.1 33.4 18.8

Vit A 94.7 95.1 64.1

Measles 95.8 91.5 64.5

FCS 9 (poor to borderline) 6 (poor to borderline) TBD

HHS 39 (severe to moderate 13 (severe to TBD hunger) moderate hunger)

CSI 23 40 TBD

Source: FSNAU 2017

7.5 ANNEX V: NUTRITION STATUS AMONG GARDO IDPS

INDICATORS Deyr’2016/17 Gu 2017 Deyr’ 2017

(N=646) (N=689) (N-630)

Plausibility 12% 10% 3

GAM (WHZ<-2 or oedema - WHO/UNICEF 15.2 19.4 21.9%

SAM (WHZ<-3 or oedema – FSNAU 2.3 3.2 2.7%

Mean Weight-for Height Z (WHZ scores) -1.06±0.88 -1.19±0.89 -1.14±0.97

DEFF WHZ<-2 1.00 1.00

Oedema 0 0 0.3

MUAC (<12.5 cm or oedema) – FSNAU 10.7 17.2 22.0%

Severe MUAC (<11.5cm) – FSNAU 0.6 2.6 1.6%

Stunting (HAZ-2) - WHO/UNICEF

Under weight (WAZ-2 - WHO/UNICEF 11.0 16.3 15.9%

Admitted with GAM<-2 28.6

Crude death Rate 0.29 0.45 0.45

Under 5 death Rate 0.47 1.02 1.06

NUTRITION SITUATION- WHO/UNICEF Critical Critical Critical

Risk/Underlying Factors

Morbidity 39.3 55.3 43.7

Vit A 62.0 40.6 42.2

Measles 87.9 43.1 21.4

65 (poor to 9 (poor to TBD FCS borderline) borderline)

42 (severe to 22 (severe to TBD HHS moderate hunger) moderate hunger)

24 62 TBD CSI

Source: FSNAU 2017

7.6 ANNEX VI: CASUAL ANALYSIS ON MORBIDITIES AMONG GALKAYO AND QARDO IDPS. Variables Proportion Statistics Dependen Independe Group N % RR (95% CI) P Value t nt Wasting Morbidity Galkayo Yes 60 21.4 1.733 (1.27 – 3.59) 0.001* (WHZ <-2 (129) No 69 12.3 Z Qardo Ye 44 20.6 1.181 (0.809 – 1.724) 0.388 scores/Od No 43 17.4 ema Diarrhea Galkayo Yes 30 24.0 1.736 (1.209 – 2.492) 0.004* N= 841 No 99 13.8 Qardo Ye 34 22.4 1.304 (0.888 – 1.915) 0.178 No 53 17.4 Pneumonia Galkayo Yes 20 25.6 1.795 (1.1.84 – 2.721) 0.008* No 109 14.3 Qardo Ye 10 18.2 0.949 (0.523 – 1.722) 0.863 No 77 19.2 Fever Galkayo Yes 50 21.6 1.671 (1.213 – 2.302) 0.002* No 79 13.0 Qardo Ye 20 18.0 0.933 (0.594 – 1.466) 0.763 No 67 19.3 Measles Galkayo Yes 10 20.8 1.388 (0.781 – 2.469) 0.277 No 119 15.0 Qardo Ye 7 30.4 1.663 (0.869 - 3.18) 0.148 No 80 18.3 Source: SAGE 2014

7.7 ANNEX VII: CASUAL ANALYSIS ON HEALTH PROGRAMS (GALKAYO)

Variables Location Proportion Statistics Dependen Independent Group N % RR (95% CI) P Value t Wasting Vitamin A Galkayo Yes 118 15.9 1.248 (0.663 – 2.349) 0.485 (WHZ <-2 Supplementation No 9 12.7 Z Gardo Yes 70 17.7 0.688 (0.434 -1.091) 0.122 scores/Od No 17 25.8 ema Measles Galkayo Yes 115 15.8 1.190 (0.670 – 2.116) 0.548 N= 841 Vaccination No 11 13.3 Gardo Yes 67 16.9 0.550 (0.360 – 0.841) 0.008* No 20 30.8

7.8 ANNEX VIII: CASUAL ANALYSIS ON WATER AND SANITATION

Variables Proportion Statistics Independent Dependent Group N % RR (95% CI) P Value Morbidity Access to Galkayo Protected 94 39.3 0.568 0.033* Protected Not 9 69.2 (0.383 –0.843) Water protected Gardo Protected 94 39.3 0.568 0.033* Not 9 69.2 (0.383 0.843) protected Access to Galkayo Latrine 95 39.6 0.594 0.060 latrine No Latrine 8 66.7 (0.386 0.912) Gardo Latrine 95 39.6 0.594 0.060 No Latrine 8 66.7 (0.386 –0.912) Treat Galkayo Treat 4 11.1 0.242 0.000** Drinking Not Treat 99 45.8 (0.095 –0618) Water Gardo Treat 4 11.1 0.242 0.000** Not Treat 99 45.8 (0.095 0.618) Soap Galkayo Soap 51 36.4 0.785 0.109 present for No Soap 52 46.4 (0.584 1.055) hand Gardo Soap 51 36.4 0.785 0.109 washing No Soap 52 46.4 (0.584 –1.055)

7.9 ANNEX IX: FOCUS GROUP DISCUSSIONS

RAPID ASSESSMENT ON THE MAJOR CONTRIBUTING FOCTORS OF PERSISTED HIGH- LEVEL MALNUTRITION AMONG IDP CAMPS IN PUNTLAND IDP Camp: ______District: ______Region: ______Date: ______

1. Can you explain what are the common diseases that affect children under five years in this camp?______2. What do you do if the child gets diarrhea? ______3. How is the access to health services in the camp? What kind of health services can be found? What are the conditions? Are they accessible for everybody? ______4. Can you tell about exclusive breastfeeding? And how long should a mother continue breastfeeding for the child?______5. Do you know any ongoing nutrition interventions in your camp?  Yes;  No If yes what type of interventions  OTP  TSFP  MCHN  Micronutrition supplementations  Others (specify)______

6. Do you aware any one doing screening activities at household level in your camp? If yes who and how frequently? (Show MUAC tape for understand): ______

7. What are the major sources of drinking water for the camp ( For Interviewer: please estimate the proportion of community that use in each source)? ______8. What are the main challenges to get drinking water in this camp? ______43

9. Do majority of the people have access to latrines? If not what are the main challenges for not accessing and how do you think this problem can be addressed?______

10. Can you tell about the importance of using latrines than open defecations? ______11. How and where do you dispose garbage? Who is managing the garbage? Do you pay for garbage collection?______12. Do you think there is relationship between garbage and disease? (If yes) what is that relationship? How can be managed garbage? ______13. Do majority of the people in the catchment wash their hands with soap at critical times? ( If yes) what hygiene items do they use for hand washing? (if not) why not washing hands at critical times? ______

14. Can you explain if there is any relations between hand washing and diseases?______15. Did you get awareness on health, nutrition and sanitations during the last three months? And If yes from which sources?  A. health staff  B. community volunteers/social mobilizers  C. Relatives/neighbors  D. Mass media  Community Sensitization meeting  E. Mobile SMS  F. Other (specify)______

16. Are there any community groups/volunteers/ CBOs, etc. in this community? If yes, what are they doing?______17. Is there school in the camp? (If yes) what is the role of school teachers in community health education activities, did you see any teacher telling about nutrition? What is the relationship between the school and the camp activities? ______18. What roles can school play in enhancing camp community education for promotion of better nutrition practices?______

7.10 ANNEX X: KEY INFORMANTS/OBSERVATIONS CHECK LIST

ASSISSING THE MAJOR CONTRIBUTING FOCTORS OF PERSISTED HIGH-LEVEL MALNUTRITION AMONG IDP CAMPS IN PUNTLAND

IDP Camp: ______District: ______Region: ______Date: ______

Role key informant in the community______

19. How is the access to health services in the camp? What kind of health services can be found? What are the conditions? Are they accessible for everybody? ______

20. Is there any ongoing nutrition interventions in your camp?  Yes;  No If yes what type of interventions  OTP  TSFP  MCHN  Micronutrition supplementations  Others (specify)______21. Did mothers /caregivers understand the importance and how to use of the products given to the malnourished children? And what the mother/caregiver do when she/he receives this product? ______

22. What are the major sources of drinking water for the camp (estimate the proportion of community that use in each source)?  Pipe water:______ Kiosks:______ Protected well:______ Tanker:______ Barked (Water reservoir):______ Un protected well:______ Other (specify)______

23. What are the main challenges to get save drinking water in this camp? ______

24. Do people have containers for fetching water and separate containers for storing drinking water? 45

Yes No  A. What size and number per family (containers for fetching water or/and storing drinking water)? ______

 B. What type of container is generally used?______

25. Do households pay water in this camp, (If yes) how much per jerry can ______(SoSh)

26. How far is the water source from the majority of the households? ______

27. What is the average amount of water that each household can collect per day? (e.g Liters or jerrycans)______

4. Do people do anything to improve the quality of their drinking water? Yes No If yes, which treatment method(s) are used? select all that apply  A) Chlorination  B) Sedimentation  C) Simple sand filtration  D) Cloth filtration  E) Boiling or Sun exposure  F)Aqua tab  F) Other (specify): ______28. Do majority of the people use latrines?  Yes  No If not why not______

29. Where do the people dispose the faeces of children? ______

30. Do majority of the people in the catchment wash their hands with soap or ash at critical times?  Yes  No If not why not?______

31. Are there any community groups/volunteers/ CBOs, etc. in this community? If yes, what Aretheydoing?______32. Do community in this camp get awareness messages on nutrition, health and sanitation, if yes from which sources:______

33. Is there any functioning school in this camp? ______(If yes) are there female teachers teaching in your school? (estimate school age children enrolled in the School and how many of the students are girls)______

34. Is there any health, hygiene, sanitation and nutrition related topics in the school curriculum ______

B) Observations

Observe Yes No Remarks 1 Are majority of the people using latrines 2 Is there open defecations practices 3 Are households using hygiene items (like soap) 4 Is there garbage inside the camp 5 Is there accessible functioning health facility around the camp 6 Do people use the health facility 7 Are there on-going nutrition intervention activities? 8 Is there any outreach services: trained CHW/VNW who screen refer and follow up malnourished children in the camp Take following information from the health facility monthly report (HMIS)

SN Diseases Sep. 17 Oct. 17 Nov. 17 Dec. 17 Jan. 18 Feb. 18 1 Diarrhea 2 Measles 3 Pneumonia 4 Total children screened 5 Moderate malnutrition 6 Severe malnutrition

Any other observations/remarks:______