Report on the Food and Nutrition Situation in Bay, and Regions

October 19, 2000

Albertien van der Veen, nutritionist, WHO/ORHC1

Index page

1. Background 2 2 Nutrition situation 3 2.1 Nutrition Surveillance 3 2.2 Selective Feeding Programmes 4 2.3 Health 6 3 Food Situation 8 3.1 Food security 8 3.2 General Food Distribution 9 4 Conclusions 11 5 Recommendations 12

Annex 1: Summary of Nutrition Surveys Annex 2: Health and Supplementary Feeding Programmes 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 Co- ordination 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 inter- agency 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 post- harvest 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 over- representation 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 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 In some areas, also mobile teams collect anthropometric data. 4 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 (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 The project was scheduled to start in March, but was postponed for various reasons. 6 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 And, vice versa, morbidity has increased because of high levels of malnutrition. 8 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 Standard provided during measles mass vaccination campaigns. 10 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 , 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, out- migration, 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 out- migrated 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 UNICEF and FSAU to this end signed a letter of agreement in 1999. 13 On average, this forecast was however 38% below the historical average (1982-1988). 14 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 of Ethiopia gained momentum, people from Bakool moved to Ethiopia, in particular 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 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. 16 Part of the families received two rations. 17 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 Agency Sample Metho- Nutrition Indicators19 survey size dology Bay region Baidoa August UNICEF 903 30 clusters W/H <-2 Z score + oed W/H <-3 Z score + oed town 1999 21,6% 6.1% Baidoa July 2000 UNICEF 909 30 clusters W/H <-2 Z score + oed W/H <-3 Z score + oed District 17,0% 3,0% Burhakaba August UNICEF 905 30 clusters W/H <-2 Z score + oed W/H <-3 Z score + oed town 1999 28,0% 6.0% Burhakaba June 2000 UNICEF 904 30 clusters W/H <-2 Z score + oed W/H <-3 Z score + oed District 22,4% 4,1% Bakool region Hudur September UNICEF 910 30 clusters W/H <-2 Z score + oed W/H <-3 Z score + oed town 1999 22,7% 7,2% Hudur May MSF B 103 Rapid MUAC <125mm MUAC <110mm town 2000 assessment 27% Rabdure February UNICEF 498 30 clusters W/H <-2 Z score W/H <-3 Z score town 2000 30,0% 6,0% Rabdure May 2000 MSF B Rapid MUAC <125mm MUAC <110mm town assessment 23% Wajid March UNICEF 909 30 clusters W/H <-2 Z score W/H <-3 Z score District 2000 21,0% 3,0% Wajid May MSF B Rapid MUAC <125mm MUAC <110mm town 2000 assessment 19% El Berde May MSF B Rapid MUAC <125mm MUAC <110mm Town 2000 assessment 20% Tieglow May MSF B Rapid MUAC <125mm MUAC <110mm town 2000 assessment 16% Gedo Region December UNICEF 903 30 clusters W/H <-2 Z score W/H <-3 Z score town 1999 23,05 5,5% Belet Hawa May UNICEF 905 30 clusters W/H <-2 Z score W/H <-3 Z score 2000 21,5% 3,5% Luuq April ACF W/H <-2 Z score W/H <-3 Z score 2000 780 30 clusters Town 14,9% Town 1,9% 508 exhaustive IDPs 20,0% IDPs 4,2% Qorbolo April ACF 78 Rapid MUAC <125mm MUAC <110mm 2000 assessment 10,3% 0% Amarayle April ACF 53 Rapid MUAC <125mm MUAC <110mm village 2000 assessment 5,7% 0% El Bon July ACF 192 Rapid MUAC <125mm MUAC <110mm village 2000 assessment 44,3% 8,9% Yurkut July ACF 64 Rapid MUAC <125mm MUAC <110mm village 2000 assessment 15,6% 3,1%

19 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 MCH Health Posts SF Bay DMO Baidoa (1) Baidoa (1) IMC Baidoa (1) Baidoa (40) Baidoa (1) Dinsor (1) Berdale (16) Dinsor (1) Dinsor (21) QansaDere (17) SRCS Baidoa (2) Baidoa (2) Berdale (1) Berdal (1) Qansadere (1) Q dere (1) WVI (Baidoa) Burhakaba (1) Burhakaba (10) Bakool MSF B El Berde (1) Huddur (1) IMC El Berde (1) El Berde ( 1) El Berde (1) Huddur (1) Rabdure (1) THA Tiegelow (1) Tiegelow (1) WHA Wadjid (1) Wadjid (1) Gedo AMREF Luuq Luuq Luuq (1) Luuq (16) Luuq (1) BDHC Bardere (1) Bardere (1) Cordaid Garbaharey Garbaharey Garbaharey(1) Garbaharey (6) Garbaharey (1) Burdhubo (1) Burdhubo (4) ` Trocaire Belet Hawa Belet Hawa Belet Hawa(1) Belet Hawa (9) BeletHawa (1) Dolo (1) Dolo (4) Dolo (1) UNICEF Bardere (1)

14 References

· 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 , 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.

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