Technical Series Nutrition Situation Post Deyr 2008/09

Technical Series Report No V. 16 February 20, 2009

Nutrition Situation Post Deyr 2008/09

Food Security Analysis Unit - Somalia Box 1230 Village Market Nairobi, Kenya Ph: 254-20-3745734 Fax: 254-20-3740598 Web site: www.fsausomali.org Email: [email protected]

Technical and Funding Agencies Managerial Support

European Commission

Acknowledgement

FSAU would like to thank the twenty partner agencies for their participation and support in this seasonal nutrition assessments and analysis. These crucial assessments would not have been possible without the technical participation and timely logistical support provided by our partners. The assessments and integrated analysis would not have been possible without the dedication and expertise of the FSAU’s Nairobi and field based nutrition analysts.

Participating partners United Nations Children’s Fund (UNICEF), Ministry of Health and Labor (MOHL), Ministry of Health (MOH), World Food Program (WFP), World Health Organization (WHO), Horn Relief, Somalia Red Crescent Society (SRCS), Muslim Aid, Mercy USA, Co-operative Di Svil- lupo International (COSV), AFREC (African Rescue Committee), World Vision International (WVI), International Medical Corps (IMC), Gedo Health Consortium (GHC), CARE, Action Contre La Faim (ACF), Intersos, Merlin, Save the Children (UK), Concern Worldwide, MSFB, MSFH, MSF-CH, COOPI.

FSAU Technical Series Report No V. 16 iii Issued February 20, 2009 TABLE OF CONTENTS

1. EXECUTIVE SUMMARY 1

2. NUTRITION ANALYSIS IN SOMALIA 5

3. REGIONAL NUTRITION ANALYSIS 7 3.1 Gedo Region 7 3.2 Lower and Middle Juba Regions 10 3.3 Bay and Bakool Regions 13 3.4 Central Regions 16 3.5 Hiran Region 18 3.6 Lower and Middle Shabelle Regions 19 3.7 Northeast Regions 20 3.8 Northwest Regions 26 3.9 Urban Nutrition Analysis 31 4. DEVELOPMENT OF CASELOAD ESTIMATES OF ACUTELY MALNOURISHED CHILDREN IN SOMALIA 34 5. PLAUSIBILITY CHECKS 36 6. APPENDICES 38 6.1: Somalia Livelihood Zones 38 6.2 Progression of Estimated Nutrition Situation Deyr 06/07 - Deyr 08/09 39 6.3 Somalia Median Estimates of Acute Malnutrition 2001 - 2007 40 6.4 Nutrition Assessment Tools Post Deyr ‘08/09 41

LIST OF TABLES

Table 1 Somalia IPC Rural, Urban & IDP Populations in Crisis, Jan – Jun ’ 2009 4 Table 2 Nutrition Situation Categorisation Framework 5 Table 3 Summary of Key Nutrition Findings in Gedo Region 8 Table 4 Summary of Key Nutrition Findings in Middle and Lower Juba 11 Table 5 Summary of Key Nutrition Findings in Bakool Region 15 Table 6 Summary of Key Nutrition Findings in Central Regions 17 Table 7 Summary of Key Nutrition Findings in Hiran Regions 18 Table 8 Summary of Key Nutrition Findings in Middle and Lower Shabelle Regions 20 Table 9 Summary of Key Nutrition Findings in Northeast Regions 22 Table 10 Summary of Key Nutrition Findings in Northwest Regions – Golis, Gagaab, Sool Plateau, Karkaar, Coastal Deeh, Nugal Valley 24 Table 11 Summary of Key Nutrition Findings in Northwest – W. Golis/Guban; Sool Plateau 27 Table 12 Summary of Key Nutrition Findings in Northwest – E. Golis of Sanaag 28 Table 13 Summary of Key Nutrition Findings in Northwest – Hawd, Nugal Valley livelihood zones 29 Table 14 Summary of Key Nutrition Findings in Northwest Agropastoral livelihood zone 30 Table 15 Summary of Key Nutrition Findings in IDPS in Hargeisa, Burao 30 Table 16 Summary of Key Nutrition Findings in Bossaso Urban 32 Table 17 Summary of Nutrition Assessments, October-December 2008 35 Table 18 Plausibility Checks 37

LIST OF MAPS

Map 1 Estimated Nutrition Situation, January 2008 2 Map 2 Rural IPC Populations, Jan – Jun ’09 4 Map 3 Urban and IDP IPC Populations, Jan – Jun ’09 4 Map 4 Distribution of Estimated Caseloads of Acutely Malnourished Children, Jan’09 34

FSAU Technical Series Report No V. 16 iv Issued February 20, 2009 LIST OF FIGURES

Figure 1 Rates of Global and Severe Acute Malnutrition (WHZ) from surveys conducted in Oct.-Dec.’08 1 Figure 2 Summary of findings from Nutrition Assessments conducted in Gu ’08 and Deyr ’08/09 1 Figure 3(a) Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Gedo Region (1995-2006) 7 Figure 3(b) Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Gedo Region (2007-2008) 7 Figure 4 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Juba Valley 2001-2008 10 Figure 5 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Bakool Region 2001-2008 13 Figure 6 Number of admission in the ACF Wajid CBTC 2007-2008 14 Figure 7 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Bay Region 2000-2008 14 Figure 8 Bay Agro-Pastoral HIS Nutrition Trends for 2008 15 Figure 9 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Central Regions 2000-2008 17 Figure 10 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Hiran Region 2000-2008 18 Figure 11 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Shabelle Valley 2007-2008 19 Figure 12 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Northeast Regions 2000-2008 21 Figure 13 Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Northwest Regions 2001-2008 26 Figure 14 Kulmiye MCH HIS Nutrition Trends for 2008 27 Figure 15 Badhan MCH HIS Nutrition Trends for 2008 28 Figure 16 Garadag MCH HIS Nutrition Trends for 2008 28 Figure 17 Lasanod Daami MCH HIS Nutrition Trends for 2008 29

SPECIAL ARTICLES

Analysis of Nutrition Data (2007-2008) Comparing the New Who Anthro 2006 Standards and the Nchs 1978 Population References 9

Meta Data Analysis of Nutrition Surveys, 2001-2008 12

Supporting Breastfeeding for a Healthy Family 25

Case Study: A Family in Bossaso Idp Camp, February, 2009 33

FSAU Technical Series Report No V. 16 v Issued February 20, 2009 LIST OF ACRONYMS

ARI Acute Respiratory Tract Infections ACF Action Contre La Faim AFLC Acute Food and Livelihood Crisis CARE Canadian Relief Everywhere CMR Crude Mortality Rate (Retrospective) COSV Co-operatione Di Svillupo International CTC Community Therapeutic Care FSAU Food Security Analysis Unit FEWSNET Famine Early Warning System Network GAM Global Acute Malnutrition GHC Gedo Health Consortium HE Humanitarian Emergency HIS Health Information System IDP Internally Displaced persons LQAs Lot Quality Assurance LZ Livelihood Zone MCH Maternal and Child Health Center MOH Ministry of Health MOHL Ministry of Health and Labour MT Metric Tonne MUAC Mid Upper Arm Circumference NCHS National Center for Health Statistics PWA Post War Average SAM Severe Acute Malnutrition SRCS Somalia Red Crescent Societies SD Standard Deviation SFP Selective/Supplementary Feeding Program U5MR Under Five Mortality Rate (Retrospective) WHO World Health Organization of the United Nations WFP World Food Program of the United Nations WHZ Weight for Height Z Scores

FSAU Technical Series Report No V. 16 vi Issued February 20, 2009 Forward

This nutrition situation technical series report is a new publication of the Food Security Analy- sis Unit (FSAU). The FSAU biannual seasonal technical series reports have always included an integrated analysis of all sectors including nutrition, however given the scale of nutrition information available, a separate publication was deemed appropriate. Therefore, this report does not replace the seasonal technical series report rather complements it, with a specific focus on nutrition information. The FSAU Post Deyr ’08/09 Technical Series report, will be released in the coming weeks and provides a detailed analysis by region and by sector of the integrated food security situation.

FSAU Technical Series Report No V. 16 vii Issued February 20, 2009

1. EXECUTIVE SUMMARY

The findings of the FSAU, FEWSNET, and partners’ post Deyr ‘08/09 seasonal assessment confirm that there is an ongoing and sustained Humanitarian Crisis in Somalia, with 43% of the total population of the country, or around 3.2 million people, in need of emergency livelihood and life-saving assistance at least until June 2009. A failed state since the early 1990s, Somalia has had recurring humanitarian emergencies over the last 18 years and is a country characterized by chronically high rates of acute malnutrition above emergency levels, and chronic levels of food insecurity among the rural population. The ongoing humanitarian crisis, however, is unique in that the crisis is widespread; not only are 1.2 million rural people in crisis, nearly two-thirds of those in crisis, or 2 million people, are urban poor and internally displaced populations (IDPs) (Map 2 & 3 and Table 1).

One of the driving factors behind the current emergency is a macro-economic crisis, driven by a significantly devalued Somali Shilling and hyperinflation of basic food and non-food items. This macro-economic crisis is exacerbated by months of increased conflict that have internally displaced more than 1 million people throughout the country. Furthermore, the Deyr ‘08/09 season rains (Oct.-Dec. ‘08) were below normal. This not only deepened an already severe ongoing drought and pastoral humanitarian emergency in the central regions, but has resulted in another year of below normal annual cereal production and an overall annual cereal availability deficit of 120,000MT.

Nutrition Situation Overview Figure 1: Rates of Global Acute and Severe Acute At least 200,0001 children under five years of age are malnutrition (WHZ) from surveys conducted known to be acutely malnourished in Somalia at the cur-! in Oct.-Dec. ’08 30

rent time, of which 60,000 are estimated to be severely 7"# 89) :);<* => )?>@AB 50C !"# 89) :);<* => )?>@AB .C 25 malnourished. These numbers represent 1 in 6 children executive summary

as acutely malnourished and 1 in 20 as severely 20 malnourished, numbers which will have a devastating impact on the long term economic development of the 15 country (Map 4). These proportions remain similar to the 10

Gu ’08, but are elevated from the Deyr ’07/08 numbers 5 (Appendix 2). Due to population density, a third of these children are in the Shabelle regions, followed by Central 0 and Bay regions. Of greatest concern is the deteriorating nutritional situation in central regions, where there are an estimated 10,000 children in need of immediate therapeutic care, yet ongoing insecurity prevents them from accessing this care. These figures have been estimated Figure 2: Summary of findings from Nutrition Assessments conducted in the Gu ’08 and Deyr ‘08/09 based on the nutrition surveys conducted in the recent Deyr (Oct-Dec ’08) season and extrapolated as neces- 30 sary, using median rates, and cover 83% of the <5yrs 25

population, excluding non crisis areas in the northwest 20 and northeast regions. 15

An integrated analysis of the nutrition information2 col- 10 lected from July to December 2008 indicates a varied yet 5

sustained crisis in the nutrition situation throughout the 0 country (Map 1). Repeated illness in children, limited access to basic services and poor child care practices

continue to underpin the chronic nutrition crisis in most GAM WHZ Gu GAM WHZ Deyr SAM WHZ Gu SAM WHZ Deyr of the Somali populations.

A total of 17 representative nutrition assessments were conducted by FSAU and partners from October to December 2008 (Figure 13). From these assessments, eight reported global acute malnutrition (GAM) rates below the emergency threshold of 15%, three reported rates between 15-19.9%, with the remaining six reporting rates >20%.

1 These numbers are based on nutrition survey data and extrapolations; and refer to the WHO GS, 2006 2 The analysis was conducted on a range of nutrition information collected from July-December 2008 including 17 detailed nutrition surveys by FSAU and partners (13 using SMART methodology, 2 by LQAs and 2 exhaustive), 100 Health Facilities, Rapid MUAC assessments conducted in 126 sites (NW: 64, NE:18, Hiran:12, Bakool:10, Bay: 10, Juba (Kismayo IDPs):12, data from partners on feeding centres, SHC/WHO bul- letins on morbidity and Acute watery diarrhoea Updates and other secondary data 3 Nutrition survey results reported using NCHS values for GAM and SAM, WHO GS figures presented in summary tables.

FSAU Technical Series Report No V. 16 1 Issued February 20, 2009 Map 1: Estimated Nutrition Situation January 2009 SO ALIA ESTIMATED N

CA UU A 43°0'0"E 46°0'0"E 49°0'0"E "

12°0'0"N Alula 12°0'0"N QANDA A " ZE AC " !( AASQORA " Gulf of Aden Kandala Zeylac Bosaso DJIBOUTI UGHA E " Lughaye Badhan Awdal BERB ERA Erigavo Iskushuban !( Berbera BAKI Baki ISKUSHUBA N Borama " " El Afwein Sanag Bari SHEIKH CEE A WE N Woq. Galbeed " Sheikh " GEBI E "Gabiley Bender Beila Hargeisa! QARDHO BANDARBE A ! " " OWDWE NE !( " Gardo Odweine Burco Taleh XUDUN A EEX Caynaba " "

Togdheer CA NABO Xudun "

9°0'0"N Sool 9°0'0"N

Buhodle !(Garowe BUUHO E Lasanod

E Nugal " Eyl Burtinle BUR E " District Capital " Coastline ARIIBAN International Boundary " GA DOGO Jariban ETHIOPIA Goldogob Regional Boundary Galkayo District Boundary !( River

CABUDWA Q " CADAADO " Adado Mudug Abudwaq Hobyo 6°0'0"N 6°0'0"N

Dusa Mareb HOB O " Indian Ocean Galgadud CEE BARDE " El Bur Haradhere CEE BUUR XARA RDHEERE El Barde Belet Weyne " "

Rab huu e Bakol " DOO OW Rab-Dhuure Hudur Hiran A EEG OW " El Der Dolo BU O BUR O CEE DHEER LEGEND UUQ WAA ID " " BE E XAA WO " " ADAN ABAA " Tieglo " Luuq Wajid Bulo Burti Nutrition Situation Aden Yabal A A AQSI Belet Hawa "

executive summary Jalalaqsi Acceptable Garbahare Baidoa!( Adale Alert Gedo QANSAX DHEE RE M. Shabelle " BUUR HA KABA CEE WAQ " CADA E Qansah Dere Jowhar " 3°0'0"N Wanle Weyne WAN A WE N El Waq " Insufficient data but likely Bay Balad DIINSO R " BA CAD BAARDHEERE Bur Hakaba to be Alert " " Afgoye AGOOE! Serious Bardera Dinsor !Banadir!( L. Shabelle Insufficient data but likely QOR OO E Kurtun Warrey Qoryoley Sakow SAAKOW " KUR UNWAARE !! to be Serious " Marka M. Juba Critical SAB A A E Sablale "

BARA AWE Insufficient data but likely Buale " Brava to be Critical

Jilib Very Critical Afmadow A M ADOW IIB " " Projected Trend (January - July '09) Insufficient data but likely Potential to Improve to be Very Critical AMAAM E "Jamame L. Juba Uncertain IDP Phase 0°0'0" Potential to Deteriorate Serious Kismayo !( Critical

Badhadhe Very Critical ADHAADHE " The Nutrition Situation is analysed using a range of nutrition ± indicators from direct and indirect sources from July to Dec '08: nutritional surveys (Oct-Dec '08), health fac lity data, rapid MUAC assesments, selective feeding centre data, health reports 4020 0 40 80 120 160 43°0'0"E 46°0'0"E and others K lometers Datum: WGS84, Data Source: FSAU, 2006 Admin. layers: UNDP, 1998

Food Security Analysis Unit - Soma ia http://www.fsausomali.org P.O. Box 1230 Vi lage Market, Nairobi, Kenya Email: [email protected] tel: 25 -20-37 573 fax:25 -20-37 0598 FSAU s managed by FAO. The boundaries and names on these maps do not imply offic al endorsement or acceptance by the Un ted Nat ons. The regional & Distr ct boundaries reflect those endorsed by the Government of the Republ c of Somalia in 1986.

FSAU Technical Series Report No V. 16 2 Issued February 20, 2009 The rates of severe acute malnutrition (SAM) were also unacceptably high with six surveys reporting above 4%, six between 2-4% and the remainder below 2%. However, crude and under five-year mortality rates remained below the respective emergency thresholds of 2 and 4 deaths per 10,000 population per day for all the assessments, but elevated levels were reported in the Golis/Guban assessment in the northwest regions, Bossasso IDPs, Hawd livelihood, Shabelle Riverine and Juba region surveys. The rural areas of most concern illustrated in red in the map are the Golis/ Guban livelihood zones (Appendix 1) in the northwest regions, the Hawd Livelihood in the Central regions bordering Ethiopia, Bakool region and Gedo regions. For IDPs, their nutritional situation is also of great concern, with the highest rates of acute and severe malnutrition in 2008 reported in Bossasso IDPs in December. Other protracted IDP populations in Galkayo, Garowe, Hargeisa, Berbera and Burao are also facing chronically high levels of acute malnutrition, undoubtedly exacerbated by the urban food price crisis, given their reliance on purchase for food access.

Food Security Situation Overview

Urban Food Security Crisis The growing urban food security crisis is widespread throughout Somalia, affecting roughly 25% of the total urban population, or 705,000 people. Of this total, 565,000 are in Acute Food and Livelihood Crisis (AFLC), requiring emergency livelihood support and 140,000 are in Humanitarian Emergency, requiring both emergency livelihood and life saving assistance. Additionally, there are 1,021,000 new IDPs from the increased conflict over the last two years, plus 275,000 protracted IDPs, who are equally affected by the food price crisis. Urban poor food access is severely constrained as people struggle to meet their basic food and non-food needs in the face of record high food prices. Prices of imported rice and local cereals increased between 230% and 350% from early 2008. These price increases are significantly greater than global cereal price increases. Although prices declined from Oct.

’08, providing some benefits, they are still 450-780% above normal. The average cost of the urban poor minimum executive summary expenditure basket needed for survival has more than doubled in the last year, while the purchasing power of the poor is significantly below normal. Incomes have not kept pace with rising food and non-food prices.

With income unable to match basic food and non-food price increases, the urban poor have had to seek additional financial support, in the form of cash gifts, loans and remittances, to meet their basic food needs. By Dec. ‘08, financial assistance was covering between 15-35% of the cost of a minimum survival basket of goods. Poor households have switched to cheaper local cereals, skipping whole meals and borrowing food from neighbours. The percentage of urban poor households employing one or more of these distress coping mechanisms increased from 32% in Oct. ’07 to 59% in Oct. ’08. The increased inability to cope has resulted in reduced levels of dietary diversity, as 20-60% of the poor urban households were reported to have consumed less than four food groups per day in Oct. ’08. If the situation does not improve, urban populations will exhaust many of their coping options. Already urban poor households are deeply indebted and becoming more impoverished, thus increasing their vulnerability to shocks and further crises.

Pastoral and Agro-pastoral Rural Crisis The rural crisis is more severe in that more than half or 650,000 people are in Humanitarian Emergency (HE), requiring emergency livelihood and life saving interventions. Another 565,000 are in Acute Food and Liveli- hood Crisis (AFLC), requiring emergency livelihood support. The largest concentrations of rural populations in crisis are in the south (68%) and central regions (26%). Most of the rural populations in crisis are agro-pastoralists (48%) and pastoralists (41%). The severity and depth of the rural crisis is greatest in the Galgadud, Mudug, Hiran and Middle Shabelle regions, where 50-70% of the total rural population is in crisis and where the number in HE exceeds the number in AFLC. The central regions are suffering from one of the worst droughts in recent history following successive seasons of rain failure. The impact of the drought is further exacerbated by the hyperinflation in food prices, increased conflict, and the presence of 200,000 IDPs in the region. The viability of pastoral livelihoods is threatened as livestock production is very poor and herds are significantly below baseline levels due to death and high off-take.

Internally Displaced Populations in Crisis Increased civil insecurity is leading to distressed population movement both internally and cross-border. Since July ’08, it is estimated that the number of IDPs has increased from 870,000 to 1,021,000 (UNHCR, January 9, ’08), in addition to more than 275,000 protracted IDPs. Livelihood options are limited and food access has deteriorated for many IDPs, worsened by the ongoing macro-economic crisis. Social support systems are overburdened and there is limited access to basic services.

For a full report on the Food Security Situation analysis see the FSAU Food Security and Nutrition Brief (February 11, 2009) and the Technical Series Report Post Deyr ‘08/09 Analysis.

FSAU Technical Series Report No V. 16 3 Issued February 20, 2009 Integrated Food Security Phase Classification Maps

Table 1 provides the estimated number and proportion of the population (UNDP 2005 figures) categorized to be in Acute Food and Livelihood Crisis or Humanitarian Emergency by region. For more information, Food Security and Nutrition Brief, February 11, 2009 and the Technical Series Report Post Deyr ‘08/09 Analysis at www.fsausomali. org, or contact FSAU: [email protected].

Map 2: Rural IPC Populations, Jan – Jun’09 Map 3: Urban IPC Populations, Jan – Jun’09

Table 1: Somalia Food Security Situation Analysis: Post Deyr '08/09 Population Numbers, January - June 2009 executive summary Urban in Acute Rural in Acute UNDP 2005 UNDP 2005 UNDP 2005 Urban in Rural Total in AFLC and Food and Food and Region Total Urban Rural Humanitarian Humanitarian HE as % of Total Livelihood Crisis Livelihood Crisis Population Population Population Emergency (HE) Emergency (HE) population (AFLC) (AFLC) North Awdal 305,455 110,942 194,513 10,000 20,000 0 0 10 Woqooyi Galbeed 700,345 490,432 209,913 10,000 5,000 0 0 2 Togdheer 402,295 123,402 278,893 55,000 10,000 20,000 0 21 Sanaag 270,367 56,079 214,288 20,000 10,000 5,000 0 13 Sool 150,277 39,134 111,143 15,000 0 5,000 0 13 Bari 367 638 179 633 202 737 80 000 0 25 000 0 29 Nugaal 145,341 54,749 75,860 25,000 20,000 0 0 31 Sub-total 2,341,718 1,054,371 1,287,347 215,000 65,000 55,000 0 14 Central Mudug 350,099 94,405 255,694 30,000 60,000 0 80,000 49 Galgaduud 330,057 58,977 271,080 15,000 45,000 10,000 165,000 71 Sub-total 680,156 153,382 526,774 45,000 105,000 10,000 245,000 60 South Hiraan 329,811 69,113 260,698 20,000 65,000 5,000 135,000 68 Shabelle Dhexe (Middle) 514,901 95,831 419,070 30,000 65,000 0 165,000 50 Shabelle Hoose (Lower) 850,651 172,714 677,937 65,000 70,000 15,000 55,000 24 Bakool 310,627 61,438 249,189 25,000 80,000 0 45,000 48 Bay 620,562 126,813 493,749 35,000 5,000 0 0 6 Gedo 328,378 81,302 247,076 30,000 60,000 0 35,000 38 Juba Dhexe (Middle) 238,877 54,739 184,138 25,000 10,000 0 0 15 Juba Hoose (Lower) 385,790 124,682 261,108 45,000 10,000 0 0 14 Sub-total 3,579,597 786,632 2,792,965 275,000 365,000 20,000 435,000 31 Banadir 901,183 901,183 - 30,000 - 55,000 - 9 Grand Total 7,502,654 2,895,568 4,607,086 565,000 535,000 140,000 680,000 26

Distribution of populations Assessed and Contingency Population in AFLC and HE Number affected % of Total population in crisis Assessed Urban population in AFLC and HE 705,000 9 22% Assessed Rural population in AFLC and HE 1,215,000 16 38% Estimated number of new IDPs (UNHCR, Protection Cluster, Jan. 9, '09) 1,020,000 14 32% Estimated number of protracted IDPs 275,000 4 9% Estimated Rural, Urban and IDP population in crisis 3,215,000 43 100.0%

FSAU Technical Series Report No V. 16 4 Issued February 20, 2009 2. Nutrition Analysis in Somalia

The Nutrition Surveillance Project of the Food Security Analysis Unit has been operational in Somalia since 2000. From that time the nutrition project has been the main source of nutrition information in Somaila. In an effort to illustrate the nutrition situation in a manner helpful for response agencies and donors, the project has developed over the years, a format for analyzing the nutrition situation, which results in a cartographical output. The development of this analysis framework, below, although led by the FSAU Nutrition team, has also involved a consultative process with many nutrition partners in the region including, WHO, UNICEF, WFP, ACF, CONCERN, SCUK, IMC and WV. This came out of an identified need for a type of tool to describe the nutrition situation creating a contextual analysis rather than focus on prevalence estimates and thresholds, which is traditionally the case in nutrition analysis.

This framework forms the basis for the nutrition situation classification and theEstimated Nutrition Situation map and is based on international thresholds, where available, and contextually relevant analysis where not available. There are three sections to the analysis framework, A. Core/ Anthropometry Related Information, B. Biochemical Indicators and C. Risk/Underlying Factors. A minimum of 2 anthropometric indicators are required to make an analysis with the supporting non anthropometric indicators. Information only from the current season is used and when sufficient data is not available, this is illustrated through slash marks on the map. However historical data is used for overall contextual analysis and for projections.

Twice per year, in line with the seasonal assessments post Gu (April – June) and post Deyr (October-December), the nutrition team develops an updated nutrition situation analysis at livelihood level by region and by IDP settlement. The overall analysis is consolidated into the Estimated Nutrition Situation Map. The analysis framework, below, is considered a working document, and will be updated and refined as new information and guidance becomes available. The nutrition situation, presented by region over the coming pages has been developed using this framework (Table 2).

Table 2: Nutrition Situation Categorisation Framework nutrition analysis A. Core/Anthropometry Related Information

Reference Indicators Acceptable Alert Serious Critical Very Critical 10 to<15% 15 to<20% >/=20% or or where there has (or where there has Global Acute Malnutrition1 (Or where there has 5 to <10% usual been a significant been a significant (WHO Reference) <5% a significant increase range and stable increase from season- increase from season- from seasonally adjusted ally adjusted previous ally adjusted previous previous surveys) surveys) surveys) 3 to <4% 4 to <5% >/=5% SAM2 (WHZ) (or where there has (Or where there has (WHO to advice on thresholds) been a significant a larger significant <0.5% 0.5 to <3% increase from season- increase from season- Oedema – proportion of cases, ally adjusted previous ally adjusted previous trends in numbers surveys) surveys) 1 to <2 /10,000/day 2 – 5/10,000/day CMR3/10,000/day <0.5/10,000/ Include information Include information as Include information as 0.5 to <1/10,000/day day as to the main causes to the main causes and to the main causes and and likely progression likely progression likely progression Under five years mortality rates <1/10,000/day 1-1.99/10,000/day 2-3.9/10,000/day 4 to <10/10,000/day >/=10/10,000/day 10-14.9% >15% MUAC4 Rapid Assessment <5% with increase or where there has been Or where there has (% <12.5cm) from seasonally ad- <5% 5-9.9% a significant increase a significant increase Ref: FSAU Estimates 5To be usted previous rapid from seasonally adjust- from seasonally adjusted confirmed assessments ed rapid assessments rapid assessments Adult MUAC - Pregnant and Lactating women TBC – based on historical analysis from nutrition surveys conducted in Somalia – ongoing in FSAU (% <23.0cm, Sphere 2004) Chronic malnutrition/ stunting6 <10% 10 to <20% 20 to <40% >40% (HAZ) Low numbers of High with significant Very low num- Low numbers of acutely malnourished High levels and stable increasing numbers HIS7 Nutrition Trends bers of acutely acutely malnourished children from previous numbers of acutely in >2 rounds of acutely (Ref: HIS) malnourished for area and stable months but increasing malnourished children’s malnourished children children (seasonally adjusted) in >2 rounds (season- (seasonally adjusted) from screening ally adjusted) Sentinel8 Site Trends Low levels and one High levels of mal- Increasing levels levels of children identified as Very low and round indicating nourished children Increasing levels with based on two rounds acutely malnourished (WHZ), Ref: stable levels ncrease (seasonally and stable (seasonally increasing trend (seasonally adjusted) FSAU SSS adjusted) adjusted) B. Biochemical Indicators Reference Indicators Acceptable Alert Serious Critical Very Critical

Vitamin A9 <2% >/=2 to 10 to <20% >/=20%

Iron Deficiency Anaemia10 40%

Iodine11 (Median urinary iodine concentration in school age 100-199 50-99 20-49 <20 children mm/lt)

FSAU Technical Series Report No V. 16 5 Issued February 20, 2009 C. Risk / Underlying Factors Reference Indicators Acceptable Alert Serious Critical Very Critical Poor dietary diversity12 for population <5% 5 to<10% 10 to <25% 25 to <50% >50% (<4 food groups) AWD 1 case Outbreak not contained and/or in non endemic area – Disease Outbreaks13: Normal levels, imited access to treatment: (seasonally adjusted) seasonally Measles 1 case Frequency of reported outbreaks of AWD &, adjusted, Review CFR for AWD >2% rural malaria and measles, data in relevant Malaria – doubling of CFR for AWD >1% urban context cases in a 2 week period in hyper endemic AWD – duration exceed >6 wks areas in the South – using RDT’s Acute Food Famine/ Humani- Generally Food Generally Food Humanitarian Food Security14 Situation - current IPC status and Livelihoods tarian Catastro- Secure Insecure Emergency Crisis phe Meal Frequency15 in addition to breastfeeding >25% 20-25% 5-19.9% <5% <20% ). 6-8 months old16 2-3 <2 i). 9 months old & above 3-4 <3 Breastfeeding Practices17 i). Exclusive BF for 6 mths 90% and above 50-89% 12-49% 0-11% ii). Complementary Feeding introduced at 6 95% and above 80-94% 60-79% 0-59% months reference mmunization & Vitamin A Supplementation Coverage18: Measles– >95% 80-94.9% <80% Campaigns

Vitamin A – one dose in last 6 months) Cam- >95% 80-94.9% <80% paigns - Population have access to a sufficient quantity of water for drinking, cooking and personal 100% TBC TBC TBC TBC and domestic hygiene – min 15lts/person/day Reduced access Access to humanitar- Limited access to Affected pop with access to formal/informal Should not be to humanitarian Negligible or no ian interventions for humanitarian sup- services: health services, etc Is this useful? necessary support for most access most vulnerable port for majority vulnerable Selective Feeding 19 / Programmes Available Availability of therapeutic/ supplementary feeding Should not be Access for most programmes/ services and referral systems. None available necessary vulnerable Coverage – access to available services, coverage of availability of services – Is this useful?

Key Points: i) To make a statement on the nutrition situation, a minimum of two Core indicators and two risk / underly- nutrition analysis ing factors are recommend ensuring a reliable analysis. ii) The overall classification of the nutrition situation for a given area is done taking into account historical nutrition and contextual data. Triangulation of all indicators is also undertaken. iii) It is not necessary for all the indicators to fall into one category, in fact this will rarely happen, the idea is to look at the bigger picture in terms of where the indicators are currently, where they have come from and where they are likely to go to make the overall statement of the situation. iv) Where possible, nutrition information should be analysed at livelihood level and not at administrative level, this is the case in Somalia. v) The references or cut offs used for GAM, SAM, CMR and Immunization coverage are consistent with the international ranges. However, for many of the other indicators, agreed international ranges/ thresholds for each categorisation are lacking. As such, the various ranges have been developed following analysis of available nutrition data from Somalia. vi) Other contexts may need to refine certain indicators such as dietary diversity and MUAC, currently they are based on the historical analysis from FSAU vii) Further inclusion of indicators relating to, displacement and population concentration for displacement are required. viii) The age of the data needs to be considered and ideally should be from the current season. If the data is from an earlier season this needs to be considered in the overall analysis and may affect the results. ix) This tool should only be used by nutrition experts who have the ability to critically evaluate and contex- tualize nutrition information

FSAU Technical Series Report No V. 16 6 Issued February 20, 2009 3. REGIONAL NUTRITION ANALYSIS Figure 3 (a): Trends in levels of Acute Malnutrition (WHZ<-2 or oedema) Gedo Region, 1995-2006

3.1 Gedo Region 30%

Gedo Region in southwest Somalia comprises six districts; Luuq, Dolo, Belet Hawa, Garbaharey, El Wak, 15% and Bardera. The main rural livelihood zones in this region are: Dawa Pastoral, Juba Pump Irrigation Riverine, 0% Southern Agro-pastoral, and Southern inland Pastoral (See Livelihood Zones Map Appendix 1). Luuq IDPs Luuq Town Town Luuq Town Luuq Bardera Town Town Bardera Town Bardera Gedo Region B/Hawa District B/Hawa District Bardera District Luuq District Post Gu ‘08 Overview Burdhubo District Gedo region has been adversely affected by the cumulative Nov-95 Dec-99 Dec-99 Apr-00 Apr-00 May-00 Sep-00 Oct-02 Oct-04 Mar-06 Apr-06 effect of the extended human conflict and recurrent natural Figure 3 (b). Trends in levels of Acute Malnutrition disasters. This has consequently resulted in the disruption1 (WHZ<-2 or oedema) Gedo Region, 2007-2008 of livelihood systems, including loss of livestock and crop failure, which has led to a persistent emergency situation in parts of the population. According to the FSAU Integrated

Food Security Phase Classification, parts of the region 30%

has persistently faced a Humanitarian Emergency (HE) 15%

situation since 2004. 0% regional nutrition analysis

The FSAU Post Gu ’08 assessment indicated a further Gedo Riverine Gedo Riverine deterioration in the food security and nutrition situation Gedo Pastoral Gedo Pastoral Gedo Pastoral Gedo Agropastoral Gedo Agropastoral Gedo

with the number of people in Humanitarian Emergency Apr-07 May-08 Dec.08 Apr-07 May-08 Apr-07 May-08 or Acute Food and Livelihood Crisis increasing from an estimated 45,000 people in Jan. ’08 to 130,000 in Aug. ’08. The deterioration was more severe in northern Gedo, particularly affecting the urban, Dawo-Pastoral, Southern Agro-pastoral and Juba pump irrigation riverine livelihoods. The worsening food security situation was largely due to several seasons of below average rains leading to poor or failed crop, depletion of rangeland resources, low livestock productivity, reduction in herd sizes and livestock out-migration. Hyperinflation and high food prices also impacted negatively on the food security in the region. Likewise, the nutrition situation in the region had also remained unstable, with all assessments conducted in the region since 1995 recording global acute malnutrition rates (GAM) above the emergency threshold of 15%. The the most recent livelihood-based nutrition assessments conducted in May ’08 recorded a Very Critical nutrition situation with GAM rates of >20% in the pastoral and riv- MUAC measurement, FSAU Oct’08 erine livelihoods and a Critical situation in agro-pastoral livelihood with a GAM rate of 18.8%. Figure 3b indicates the trends of acute malnutrition since 1995.

Current Situation

Food Security In the current Post Deyr’08/09 analysis season, the rural population in northern Gedo is classified inHumanitarian Emergency while southern Gedo is in Acute Food and Livelihood Crisis phase. In general, the number of people in Humanitarian Emergency has increased to 34,376 and those in the Acute Food and Livelihood Crisis to 60,000. The classification is linked to the cumulative effect of the current and past rainfall performances and the impact on different livelihoods, including cereal and livestock production as well as the impact of market forces and civil insecurity. The FSAU Post Deyr ’08/09 analysis indicates that parts of Gedo region received poor rainfall resulting in average water availability and pasture conditions and poor cereal production: 38% of Post-War Average. Pasture condition in the Dawa Pastoral areas is poor, leading to livestock migration to the riverine areas. The in-migration of livestock from Elwak, Kenya, also suffering from poor rainfall is expected to create excessive pressure on water and pasture conditions in Gedo region. The overall livestock body condition in the region is average, while milk production from livestock is low. The poor cereal and low milk production is in no doubt affecting cereal and milk availability and access, ultimately influencing the nutrition situation.

FSAU Technical Series Report No V. 16 7 Issued February 20, 2009 Integrated analysis of information from nutrition assessments conducted in Gedo in Dec ’08, health information and feeding facilities’ data indicates a Very Critical nutrition situation in all livelihoods in the region. The nutrition assessment in the pastoral livelihood recorded a GAM rate of 25.4% (21.8 – 29.0) while LQAS assessment identified 46 children out of the 198 assessed as acutely malnourished which, based on LQAS decision rule, indicates that the acute malnutrition rate in the riverine community is >20%.These results indicate a Very Critical nutrition situation and a sustained crisis in pastoral and riverine livelihoods when compared with Post Gu ’08’s findings. The nutrition assessment results from the agropastoral populations show a GAM rate of >20% however the data was of insufficient quality after carrying out plausibility checks using Epi-ENA software, likely due to reduced supervision due to insecurity. For this reason, the point prevalence of the survey is not reported but an integrated analysis of the assessment data, health and feeding facility data shows that the nutrition situation of agropastoral community likely to have deteriorated from Critical levels recorded during Post Gu ‘08 to a likely Very Critical situation in Post Deyr’08/09 (Table 3 and Figure 3).

Table 3. Summary of Key Nutrition Findings in Gedo Region Riverine (LQAS33x6; Pastoral (N=831) Agropastoral (=705) N=198) Indicator Results Outcome Results Outcome Results Outcome Global Acute Malnutrition (WHZ<-2 or 25.4 L kely to be Very Critical >20% >20% Very Critical oedema) (21.8 – 29.0) Very Critical Severe Acute Malnutrition (WHZ<-3 or 6.6 Very Critical NA NA NA NA oedema) (4.8– 8.7) Oedema 0.3 (0.0 – 0.7) Alert NA NA NA NA Admission trends at TFPs/SFPs (Gedo High and and High and and High and Critical Critical Critical – Aug-Dec‘08) increasing increasing fluctuating 19.8 Acute malnutrition by MUAC (<12.5 cm 13.0 (N=831) Very Critical Critical NA NA or oedema in nutrition surveys) (N=705) Proportion of malnourished non pregnant 1.6 0.3 Acceptable Acceptable NA Acceptable women (MUAC≤18.5 cm) (N=318) (N=334) Proportion of malnourished pregnant 30.1 32.0 Very Critical Very Critical NA NA women (MUAC<23.0). (N=113) (N=78) Crude Mortality Rate per 10,000 per 0.69 0.69 Alert Alert NA NA day (retrospective for 90 days) (0.34 – 1.37) (0.39 – 2.20) Under five mortality rate per 10,000 per 0.99(0.44 – 1.15 (0.33 – 3.88) Alert Alert NA NA day (retrospective for 90 days) 3.60) High levels High levels and High levels and HIS Nutrition Trends(Aug-Nov’08) Critical Critical and fluctuat- Critical increasing increasing ing Poor household dietary diversity (< 4 24.0 38.1 37.3 Critical Critical Critical food groups) (12.1 – 35.8) (25 – 51.2) (20.7 – 54.0) Disease trends (seasonally adjusted) Outbreak Outbreak - None Outbreak Morbidity refers to the proportion of -None Morbidity – 61.2 Critical Serious -None Critical children reported to be ill in the 2 weeks Morbidity– 12.3 RDT – 4.8 Illness – 40.4 prior to the survey RDT – 0.7 Vitamin A – Vitamin A – Vitamin A – 47.3 Critical Seri- Critical Immunization Status 25.4 74.2 Alert Measles – 63.4 ous Critical regional nutrition analysis Measles 20.4 Measles 74.2 Food Security situation AFLC/HE Very Critical AFLC/HE Very Critical AFLC/HE Very Critical Meal frequency consumption 6-8 months –(2-≥3 times/day ) 89.6 Acceptable 100.0 NA Acceptable NA >8 months- - (3-≥4 time/day) 46.0 Critical 61.2 Households with access to safe water 2.9 Very Critical 0.5 Very Critical 6.0 Very Critical Households with access to health 57.6 Serious 14.7 Very Critical 94.0 Acceptable services Wide spread low Wide spread Wide spread Civil Insecurity Situation Critical Critical Critical intensity low intensity low intensity Overall Situation Analysis Very Critical Likely to be Very Critical Very Critical

The worsening nutrition situation is partly attributed to the cumulative effects of seasons with poor crop harvests and low milk production and the resultant decline in food availability and access at the household. Other factors that have affected food access are hyperinflation, leading to increased food prices and civil insecurity. The ongoing civil insecurity has disrupted delivery of health and nutrition-related assistance to the affected population by humanitarian agencies. Notably, the suspension of such activities like food distribution in northern Gedo, scaling down of mobile outreach activities by NGO which identify acutely malnourished and ill children for appropriate referral, have had a negative impact on the nutrition situation. Other potential factors influencing the nutrition situation include the chronic issues of poor child care and feeding practices and limited access to basic human services such as health, sanitation and safe water. These factors often lead to high morbidity and corresponding high levels of acute malnutrition. Diarrhoea is particularly associated with high acute malnutrition rates in the region. The key nutrition findings in these areas which form the basis of the analysis on the nutrition classification outcome are provided above in Table 3.

FSAU Technical Series Report No V. 16 8 Issued February 20, 2009 Analysis of nutrition data (2007-2008) comparing the new WHO Anthro 2006 standards and the NCHS 1978 population references

The National Centre for Health Statistics (NCHS) population references from 1978 have been the main dataset for which nutrition surveys results are compared to and reported against. However, following a comprehensive review of the uses and interpretation of these references conducted by WHO in the early 90’s, the need for new population standards was recognised. This was considered given several concerns with this dataset, including the fact that the children were predominantly white and bottlefed. Consequently, WHO conducted a multi country study, collecting primary growth data and related information on 8,440 healthy breastfed infant and young children from diverse ethnic and cultural settings. The six participating countries were USA, India, Norway, Oman, Ghana, and Brazil. This study demonstrated similarity in growth patterns of children across the world’s regions.

In June 2008 a meeting was held in Geneva with participation from all the relevant UN agencies and NGO and the GS were endorsed for use in emergency settings for both reporting the nutrition situation and for admission criteria. However, it was recognised that there are significant implications due to the increased proportions of severely malnourished cases identified. Severe Acute Malnutrition Rates (Deyr’08) Based on WHO Anthro 2006 vs NCHS 1977

SAM - NCHS 1977 SAM - WHO 2006

0 Hawd Elberde Gedo AP AP Gedo Hargeisa Burao IDP Burao IDP Garowe IDP Garowe IDP Galkayo IDP Galkayo IDP shabelle IDP shabelle IDP Bosasso IDP Bosasso IDP Shabelle IDP Shabelle IDP Juba Riverine Juba Riverine Juba Pastoral Juba Pastoral Berbera Town Town Berbera Hiran Riverine Gedo Riverine Gedo Pastoral Gedo Pastoral Hawd Pastoral Addun Pastoral Addun Pastoral Shabelle Riverine Shabelle Riverine Juba Agropastoral Juba Juba AgroPastoral Juba Hiran AgroPastoral Hiran Bakool AgroPastoral Bakool Guban Golis Pastoral Sool plateau Pastoral shabelle-Agropastoral Shabelle Agropastoral Shabelle Cada le-Shabelle Pastoral

Apr 08 May'08 Jun'08 Oct'08 Nov 08 Dec 08

The FSAU nutrition project conducted preliminary comparative analysis of data sets from 67 nutrition assessments conducted in 2007-2008 using both the WHO 2006 and the NCHS 1978 population references. Up to December 2008, following the Standing Committee on Nutrition recommendation, FSAU has primarily reported the prevalence’s of wasting, stunting and underweight using the NCHS references while also including the estimates based on the new WHO standards in all reports. Findings indicate that, for most assessments, the prevalence rates for global acute malnutrition (GAM) based on weight for height z score (WHZ) do not show a significant difference, though the WHO Anthro 2006 show relatively slightly higher rates. However, the rates of severe acute malnutrition (SAM) have shown a near double relative increase with the new reference population standards (See figure above).

These results are in line with similar analysis from other countries and continue to highlight the need for discussion and guidance on the implementation of the new standards and the resulting impact on response and resource allocation.

FSAU, with partners, plan the official roll out and implementation of the WHO Growth Standards (GS) in 2009 in Somalia, this means that from March 2009, all nutrition surveys will report the main prevalence estimates using WHO GS, while also referring to the NCHS results. Further the acutely malnourished caseload estimated for Somaila, have also been developed using the WHO GS and a sensitization meeting with non technical partners (donors, senior UN and INGO managers) will be held in early March to discuss the reasons behind the shift to the WHO GS and the implications for response and resources. More information can be found on the WHO website on http://www.who.int/childgrowth/software/en/

FSAU Technical Series Report No V. 16 9 Issued February 20, 2009 3.2 Lower and Middle Juba Regions

Middle and Lower Juba in South of Somalia have a combined total of seven districts namely Sakow, Buale, Jilib (in M. Juba), Jamame, Afmadow, Kismayo and Badhadhe (in L. Juba). These have been categorised into three rural livelihood zones: the pastoral (the Southern Inland and Southeast Pastoralists), agropastoral (Lower Juba and Southern Agro-pastoralists) and pure farmers (Riverine community).

Post Gu ‘08 Overview The food security and nutrition situation in the Juba regions have varied over time, mainly linked to rainfall performances and the resultant impacts on different livelihoods. Heavy rainfall in the Juba regions or in the Ethiopian highlands often results in floods that devastate crops cultivation in the riverine areas, but later benefits the riverine communities from fishing opportunities from the flood waterDesheks) ( and recession crops. The agro-pastoral communities who rely on rain-fed agriculture are totally dependent on rainfall performance as do the pastoralists, whose livelihood is greatly influenced by pasture conditions and water availability for their livestock.

The FSAU Post Gu ‘08 analysis classified the food security in Juba regions into different phases. In Middle Juba, the situation showed deterioration with about 36,000 of rural and 25,000 of urban populations faced with AFLC. In addition, 7,000 people from Buale, Jilib and Sakow riverine areas who were earlier classified in AFLC in Post Deyr’07/08 had deteriorated to HE in Gu ’08. The worsening situation was a result of poor rainfall and the ensuing poor cereal (sorghum/maize) production ranging from 3% of PWA in Sakow to 21% of PWA in Buale. On the other hand, the food security situation in Lower Juba region showed some improvement with an estimated 15,000 people who were faced with HE in Post Deyr’07/08 progressing to AFLC in Gu ’08. Overall, the numbers of people who were faced with AFLC from urban and rural populations in Lower Juba were 25,000 and 45,000 respectively. The improvement was attributed to average rainfall; good cereal (maize) production with 96% of PWA in Jamame and Badhadhe and 113% of PWA in Kismayo; increased labour opportunities and improved rangeland and livestock body conditions.

The integrated nutrition analysis at that time also showed mixed results in the regions. A sustained Serious nutrition situation was recorded in the pastoral livelihood and an improvement from Critical to Serious nutrition situation noted in the riverine zone. However, the likelihood of the nutrition situation of the riverine community deteriorating was acknowledged at the time due to worsening food security indicators and the eventual affect on food intake. In the agropastoral livelihood, the situation deteriorated from Serious to Critical levels in Gu ’08. Figure 4 shows the trend of acute malnutrition from 2001 to 2008.

Current Situation Figure 4: Trends in levels of Acute Malnutrition (WHZ There are currently no populations in HE in the Juba <-2Z scores or oedema) Juba Valley 2001 - 2008 regions, while a combined total of 90,363 people in both 30% regions are faced with Acute Food and Livelihood Crisis (AFLC). The current FSAU Post Deyr ’08/09 food security analysis indicates a mixed rainfall outcome in Juba regions, regional nutrition analysis with parts recording near normal rainfall while others, 15% particularly in Middle Juba, receiving poor rains. As a result, water availability and pasture condition is poor in both pastoral and agropastoral areas but good in riverine areas. This has led to the early migration of livestock from 0% Jan.01 Jan.01 Jun.07 Jun.08 Jun.07 Jun.08 Jun.07 Jun.08 Apri.01 Apri.01 Dec.07 Dec.08 Dec.07 Dec.08 Dec.07 Dec.08 pastoral and agro-pastoral zones to riverine areas and Jo- May.03 May.04 May.06 rey of Badhadhe district. The livestock body condition is J'me Buale/Sakow Ksm Afm Juba pastoral Juba Agro-pastoral Jil b Riverine Juba Riverine average with high prices while milk production is average to good in the regions. The overall cereal production is 20% and 30% of PWA in Lower and Middle Juba regions respectively.

However, there was an off-season maize production estimated at 1,650MT mainly from Jamani amd also there will be an off-season projection estimated 7,500MT that will be harvested in late March, eraly April. This will improve income options through increased labour opprotunities.

The integrated Post Deyr ’08/09 nutrition situation analysis indicates an improvement in the agro-pastoral population from Critical levels recorded in Post Gu ’08 to a Serious phase currently. Sibling takes care of a baby FSAU, Dec ‘08

FSAU Technical Series Report No V. 16 10 Issued February 20, 2009 The pastoral population remain in the Serious phase, as recorded in Gu ‘08, based on findings from the Dec ’08 nutrition assessment which recorded a GAM rate of 14.9% (11.2-19.4) and a SAM rate of 2.4% (1.3-4.2). The relatively better, though still Serious, nutrition situation among the pastoral and agropastoral communities in Juba regions could be attributed to good milk availability and access from the livestock from within the regions, as well as from those in-migrating from other regions. The communities are, therefore, benefiting from both the consumption and sale of healthy livestock and livestock products, including milk, milk products and meat. Drawing water from a shallow well, FSAU, Dec’08 The riverine community recorded a GAM rate that is within Serious levels, but due to a high severe acute malnutrition rate of 4.2 % (2.5 – 7.1) that included 13 (1.8%) cases of oedema, therefore the situation is classified asCritical. This shows deterioration from the Serious levels reported in Gu ’08. It is, therefore, worth pointing out that interventions required in the riverine livelihood should include strategies tailored to rehabilitate and prevent kwashiorkor among children. The riverine communities nevertheless are benefiting from off-season crops from cultivation of the Desheks which were replenished with flood water, increased access to fish from flooded areas and also from the increased farm labour opportunities. These factors are expected to mitigate the nutrition situation. The nutrition situation of Kismayo IDPs is in a sustained Critical phase since the Deyr’07/08 with 12% of the 1386 children assessed in Janu-

ary’09 being acutely malnourished (MUAC<12.5 cm or oedema). regional nutrition analysis

In Juba regions, high morbidity and the chronic problem of poor child care practices, limited access to safe water and lack of sanitation and health facilities remain key factors aggravating the nutrition situation. The ongoing conflict in the two regions is also likely to impact negatively on the nutrition situation, especially through the disruption of humanitarian activities such as provision of health and selective feeding services. The key nutrition findings in these areas, which form the basis of the analysis on the classification outcome, are provided in Table 4.

Table 4. Summary of Key Nutrition Findings in Middle and Lower Juba Regions Pastoral (N=720) Agropastoral (=713) Riverine (N=732) Indicator Results Outcome Results Outcome Results Outcome Global Acute Malnutrition (WHZ<-2 or 14.9 (11.2 – 19.4) Serious 13.9 (8.3-19.5) Serious 10.9 (8.8-13.5) Serious oedema) Severe Acute Malnutrition (WHZ<-3 or 2.4 (1.3– 4.2) Alert 2.9 (0.5-5.4) Alert 4.2 (2.9-6.0). Critical oedema) Oedema 0.2 (0.0 – 0.7) Alert 0.5 (0.0-1.1) Alert 1.8 (1.0 – 0.7) Serious Low numbers with Low numbers with Admission trends at TFPs/SFPs Low number with de- Serious slight increase in Serious decreasing admis- Serious (Juba– Aug- Dec ‘08) creasing admission admission sion

Acute malnutrition by MUAC (<12.5 cm or Very Criti- 11.9 (N=720) Critical 23.0 (N=713) Very Critical 19.1 (13.0 – 25.3) oedema in nutrition surveys) cal Proportion of acutely malnourished non 1.3 (N=302) Acceptable 0.3 (N=306) Acceptable 0.6 (N=311) Acceptable pregnant women, (MUAC≤18.5 cm) Proportion of acutely malnourished preg- Very Criti- 28.0 (N=82) Very Critical 31.4 (N=86) Very Critical 37.5 (N=96) nant women (MUAC<23.0). cal Crude Mortality Rate per 10,000 per day 0.90 (0.51 – 1.58) Alert 1.19 (0..83 – 1.75) Serious 1.08 (0.68-1.71) Serious (retrospective for 90 days) Under five mortality rate per 10,000 per 1.82 (1.10 – 3.01) Alert 2.27 (1.5-3.45) Serious 3.27 (CI 1.97-5.39) Serious day (retrospective for 90 days) Low and decreasing Low with slight Low and decreas- HIS Nutrition Trends(Aug-Nov’08) Serious Serious Serious trends increasing trends ing trends Poor household dietary diversity (< 4 food 6.2 (0.0 – 13.8) Alert 8.6 (0.9 – 16.3) Alert 12.6 (5.1 – 20.1) Serious groups) Disease trends (seasonally adjusted) Outbreak - None Outbreak - None Outbreak - None Morbidity refers to the proportion of chil- Morbidity– 58.5 Critical Morbidity – 51.3 Critical Morbidity – 60.2 Critical dren reported to be ill in the 2 weeks prior RDT positive – 5.1 RDT positive – 3.4 RDT positive – 8.8 to the survey Vitamin A Supplementation Status Vitamin A -42.9 Critical Vitamin A 47.5 Critical Vitamin A 60.2 Serious Measles Vaccination Status Measles - 44 Critical Measles -53.4 Critical Measles -71.4 Serious Food Security situation BFI Alert BFI Alert BFI Alert Meal frequency consuming 6-8 months (2-≥3 times/day) 94.0 Acceptable 78.4 82.9 Acceptable Serious ≥9 months (3-≥4 times/day) 73.5 74.6 62.3 Limited spread low Limited spread low Limited spread low Civil Insecurity Situation Serious Serious Serious intensity intensity intensity Households with access to safe water 35.7 Critical 16.9 Critical 30.0 Critical Households with access to health 49.9 Critical 62.6 Critical 49.3 Critical services Overall Situation Analysis Serious Serious Critical

FSAU Technical Series Report No V. 16 11 Issued February 20, 2009 Meta Data Analysis of Nutrition Surveys, 2001-2008

Since the collapse of the Somali Central Government in 1991, the country has faced a series of natural and man-made disasters1. These have led to the disruption of livelihood systems, poor provision of basic services and erosion of social care networks. The UNFAO’s Food Security Analysis Unit (FSAU) nutrition project undertakes regular nutrition surveillance in Somalia and consequently has developed a central repository for data for nutrition surveys conducted since 2000. FSAU has, subsequently, conducted a meta analysis of the data from nutrition surveys conducted coun- trywide in 2000-2007 as a reference for analyzing trends to highlight patterns in seasonality, explore causal factors and understand more clearly the impacts of shocks on the populations nutritional status.

Findings from the 2000-2007 meta data analysis indicate a Map A. Somalia Median Estimates of Stunting median global acute malnutrition2 rate of 15.8%, with a median Malnutrition 2001 - 2007 severely malnourished rate of 2.6%, these rates highlight chronic emergency levels (Appendix 6.3). Stunting median rates, an indicator of long term cumulative effects of inadequate food intake and poor health conditions, is estimated at 23.1%, serious levels according to WHO standards. The median underweight malnutrition is estimated at 31.7%, critical levels according to WHO. The south, central and parts of the northeast regions are the worst affected areas, with Bay region in particular being faced with Critical median levels of wasting, stunting and underweight (Maps A and B). Of note however, is that although this data provides insightful information about the nutrition situation in Somalia over time and in different population groups, birth related records are not readily available in Somalia and age data is mainly estimated through recall, thereby possibly impacting on the precision of stunting and underweight levels.

The median rates for 2008, in which an aggregate of 30 nutrition survey data sets were assessed have indicated an overall deterioration in acute malnutrition with median wasting levels at 18.4%, yet stable levels for stunting at 23.7% and underweight at 31.7%. The current situation therefore, remains of great concern. The contributing factors to this chronic critical situation include sub optimal child care feeding and health seeking practices and behaviours3, poor access to safe water (only 20% of the population have access), poor sanitation Map B. Somalia Median Estimates of Underweight facilities (a paltry 28.5% of the population have access), lack Malnutrition 2001 - 2007

meta data analysis of a functional health system for basic primary health care services (for example measles immunization status estimated at 35%)4 while humanitarian agencies’ efforts to provide such services are hampered by recurrent insecurity. Available data on care practices of young children indicate alarming practices in breast/complementary feeding and treatment of childhood illnesses.

The impact of a series of droughts, coupled with extended civil unrest, frequent population displacement, a macro economic crisis and frequent disease outbreaks underscore this current situation. By contrast, the regions in the northwest region, that has enjoyed greater political stability, improved food and livelihood security and significantly better access to health services and public health environment in general, reports significantly lower levels of acute malnutrition.

The report includes an analysis of the nutrition data by livelihood and by season as well as causal analysis to explore the underlying causes of this crisis, to inform better response in the long term. (Detailed information available in the FSAU’s Meta Data Analysis Report, coming in April 2009, check website for details from April 2009, www.fsausomali.org).

1 Floods and droughts, poor governance, armed conflict, and collapse of institutions/infrastructure 2 Based on WHZ and NCHS 1977 reference 3 See the FSAU September 2007 report on Knowledge, Attitude and Practices on Infant and Child Feeding in Somalia 4 Source: FSAU nutrition surveys database (n=105) from 2000 to 2007

FSAU Technical Series Report No V. 16 12 Issued February 20, 2009 3.3 Bay and Bakool

Bay and Bakool regions comprise of two predominant livelihoods systems; the agro-pastoral and pastoral. These are further sub-divided into three livelihoods zones, (1) Southern Inland Pastoral, (2) Southern Agro-pastoral and (3) Bay Bakool Agro-pastoral - High potential sorghum (Appendix 1).

Bakool Region

Post Gu’ 08 Overview According to Post Gu ’08 analysis, an estimated 145,000 agro-pastoralists and pastoralists in the region were either in Acute Food and Livelihood Crisis (AFLC) or Humanitarian Emergency (HE). This was a 12% increase from the total number of people previously in AFLC or HE (from April - June ‘08). In addition, a total of 25,000 urban poor were in AFLC. The deterioration was mostly attributed to poor rainfall which had resulted in complete crop failure in all livelihoods (5% of PWA), significant deterioration in vegetation conditions (pasture and browse), acute water shortage and decreased herd sizes from December ’07. Deterioration was also attributed to huge livestock migration to Bay and Lower Shabelle regions and low livestock milk production. Levels of social support (zakat) in the form of cereal donations also reduced significantly as a result of the crop failure. The deterioration in food security was also attributed to sharp increases in local cereal and imported commodity prices, as well as a dry Jilaal ‘08 season, which compounded the effects of previous successive below average seasonal rains.

The three Gu ‘08 nutrition assessments conducted in Figure 5: Trend in levels of acute malnutrition (WHZ< -2 regional nutrition analysis Bakool Agropastoral and Pastoral livelihoods reported or oedema ) in Bakool region 2001- 2008 Very critical levels of malnutrition (Figure 5). The nutri- 30.0 tion assessment conducted in April ’08 in Wajid district by ACF reported a GAM rate of 22.3% (18.2 - 26.4) 25.0

and SAM rate of 2.5% (1.3 - 3.7) while the nutrition as- 20.0 sessment in Bakool Agropastoral conducted by FSAU 15.0 & IMC in July 2008, recorded a GAM rate of 25.2% (22.1 – 28.6) and SAM rate of 3.8% (2.6 – 5.6). Bakool 10.0

Pastoral livelihood reported Very Critical levels of acute 5.0

malnutrition with a GAM rate of 24.2% (18.5 – 29.7) and 0.0 Jul'00 Jul 08 Oct'01 Oct'03 Jan'06

a SAM rate of 2.8% (1.2 – 4.4) and indicated deterioration Apr 08 Apr 08 Jan.0 Jan.06 Aug'00 Feb.07 Dec 06 Apr 0 Nov.'07 Nov.'07 Nov.'07 Nov.'07 Sept'03 Sept'02

from the Critical situation in the Deyr ’07/08. Figure 5 Jan.06 (IDP) Waj d Huddur Elberde Rabdure Tieglow Bak AgroP Bak Past Bak shows the trend of acute malnutrition from 2001-2008 AgroP in Bakool region.

Current situation

Bakool region shows a mixed picture with some areas in the pastoral and agropastoral livelihoods showing deterioration in the food security situation, while others show improvements. The affected livelihoods in Humanitarian Emergency HE have declined from 80,000 to 45,000 people while those in Acute Food and Livelihood Crisis (AFLC) have increased to 105,000 (urban and rural). This is an increase of 18% from the total number of people previously in either AFLC or HE in the Gu ‘08 (from July – Dec. ’08).

Bakool Agropastoral Livelihood Areas Although there was no Deyr cycle nutrition assessment conducted in Bakool Agropastoral livelihood zone due to insecurity preventing access, nutrition information from other sources is used to estimate the most likely nutrition classification phase. A rapid MUAC assessment (n=400) conducted in Dec ’08 in Huddur and Tieglow Districts have reported a high (22%) proportion of acutely malnourished children with MUAC<12.5cm or oedema and 3.5% with MUAC<11.0cm or oedema. Bakool region is partially covered with selective feeding centres: Supplementary Feed- ing Program (SFP), Stabilisation Centre (SC) and Community Therapeutic Centre (CTC) services in Wajid Tieglow and Elberde districts. The selective feeding data admissions of severely and moderately malnourished children shows high numbers with fluctuating trends in Wajid and Tieglow districts over the last two months.

The health facilities data has shown high levels and increasing numbers of acutely malnourished children in the last three months. Poor sanitation and lack of safe drinking water predisposes the community to water borne illnesses. High morbidity cases such as diarrhoea and ARI were noted and associated with the sustained high malnutrition in Bakool Agropastoral livelihood. Due to lack of sufficient data the nutrition situation is classified aslikely to be Very Critical, indicating no change from the Gu.

FSAU Technical Series Report No V. 16 13 Issued February 20, 2009 Bakool Pastoral Livelihood Zone No Deyr cycle nutrition assessment was conducted in Figure 6: Number of admission in the ACF Wajid CBTC the Bakool Pastoral livelihood zone due to insecurity 650 preventing access, thus nutrition information from other 600 550 sources was used for analysis of the nutrition situation. 500 A rapid MUAC assessment (n=600) conducted in Dec 450 400 ’08 in Elberde, Rabdhure and Huddur Districts reported 350 a high (16.6%) proportion of acutely malnourished 300 children with MUAC<12.5cm or oedema and 3.1% with 250 200 MUAC<11.0cm or oedema. SFP are available in the 150 main towns but are limited in the rural areas. SFP data 100 50 in the feeding centres shows high levels of admissions. 0 The TFC and OTP feeding centres in Wajid have shown high numbers of admission with increasing trend since August ’08, this can be explained for two reasons. ACF shifted from using the NCHS to WHO reference standards in August 2008 which increased the proportion of children identified as severely malnourished and expanded outreach activities. Figure 6 shows the trends in numbers of admissions in the ACF Wajid Community Based Therapeutic Care (CBTC)

In Elberde district, two facilities are used to provide supplementary feeding: Elberde MCH in Elberde town and Qura- jome health outpost. Data from these facilities shows increasing numbers of acutely malnourished children screened and admitted to the supplementary feeding program in the last six months. Therefore the nutrition situation has been classified as likely to be Very Critical in Bakool Pastoral livelihood zone.

Bay Region

Post Gu ‘08 Overview Following an average cereal production in Bay in the Gu ’08 (93% of PWA), the food security situation improved among the agro-pastoralists in Berdale and Mowlimaad, and, as a result, their level of crisis reduced from HE to AFLC. The total number of Bay’s rural population in AFLC was 15,000 in Gu’ 08, a 92% decrease from the total previously in AFLC or HE Deyr ‘07/08. The majority of those in crisis were located in Baidoa district. Rural populations outside of Baidoa district were classified asBorderline Food Insecure (BFI). With regards to Bay’s urban populations, the food security situation had improved. The total number of Bay’s urban population now in AFLC was about 35,000, a 49% decrease from the people previously in AFLC or HE in the same period.

The most recent nutrition assessment conducted in Bay agro-pastoral livelihood zone was in July’ 08 but unfortu- nately the quality of the data was not of sufficient standard to publish. However the HIS data shows high levels and increasing numbers of acutely malnourished children, as well as an increase of admission in SFP and therefore the

regional nutrition analysis nutrition situation in Bay region was classified as likely Critical. Figure 7 shows the trends of acute malnutrition from 2001-2008 in Bay region. Figure 7: Trend in Levels of Acute malnutrition (WHZ <-2 or Oedema) in Bay 2000 - 2008 Current situation The food security situation of the agro-pastoralists in Bay 25

region, during June – Dec.’08, has improved to 45,000 20 (urban and rural) in AFLC due to near or to above nor- 15 mal crop production in previous seasons as well as the recovery of their livestock herd size. The majority of the 10 remaining rural population in Bay region is Borderline 5 Food Insecure (BFI). These people remain vulnerable to shocks that can negatively impact on their food security 0 and livelihood status. Qansahdere Berdalle Dinsor Baidoa Burhakaba Bay Agro- past

FSAU Technical Series Report No V. 16 14 Issued February 20, 2009 Bay Agro-pastoral Livelihood Zone Figure 8: Bay Agro-pastoral HIS Nutrition Trends for 2008 Due to civil insecurity, a nutrition assessment could not be carried out in the Bay Agro-pastoral livelihood zone. 45 40 Therefore nutrition information from other sources was 35

used for the nutrition integrated analysis. A rapid MUAC 30

assessment conducted in December ‘08 (n=1226) indi- 25

cated a high (17.7%) proportion of acutely malnourished % Malnourished 20

children with MUAC <12.5 cm or oedema and 2 % with 15 MUAC<11.0cm or oedema. The HIS data from health 10 facilities shows an increasing trend and a high proportion 5 0 of acutely malnourished children in Baidoa, Berdale and Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Qansadhere District. Figure 8 shows Bay Agro-pastoral 2008 HIS nutrition trends for 2008. SFP services are available, but limited in rural areas, SFP data in the feeding centres shows high levels of admissions. This health and nutrition information indicates the nutrition situation in Bay region to be classified aslikely to be Critical.

A summary of the nutrition information from Bay and Bakool used for the integrated analysis of the nutrition situation is provided in Table 5.

Table 5: Key Reference Indicator Findings Outcome Bakool Pastoral Livelihood Zone

MUAC (N= 600 Sites = 7) <11 cm = 3.1 <12.5 cm = 16.6 Very Critical regional nutrition analysis Data indicates high and but stable numbers of acutely HIS Nutrition Trend Critical malnourished children Poor; no milk available, high prices of cereals, reduced Poor Dietary Diversity Serious meal consumption per day Disease Outbreaks No outbreak Alert Immunization Status Very low Very Critical Access to Health Services Limited Health services in the area Critical Selective Feeding Programmes Limited Serious Overall Situation Analysis: Likely to be Very Critical Bakool Agro-pastoral Livelihood Zone MUAC (N= 400 Sites = 3) <11 cm = 3.5 <12.5 cm = 22 Very Critical Data indicates high numbers and increasing trend of HIS Nutrition Trend Critical acutely malnourished children Poor; no milk available, high prices of cereals, reduced Dietary Diversity Serious meal consumption per day Disease Outbreaks No out-break Alert Immunization Coverage Very low Critical Access to Health Services Available, but limited Serious Selective Feeding Programmes Very limited Critical Overall Situation Analysis: Likely to be Very Critical Bay Agro-pastoral Livelihood Zone MUAC (N= 1226 Sites = 10) <11 cm = 2 <12.5 cm = 17.7 Very Critical Data indicates High and stable trend of acutely malnour- HIS Nutrition Trend Serious ished children Satisfactory, some milk available, mainly or preferred Dietary Diversity Alert cereals consumed- sorghum AWD out-break was reported in Qansahdhere and Dinsor Disease Outbreaks Critical Source, IMC, Nov-Dec’08) Immunization Coverage Very low Very Critical Access to Health Services Limited except in Baidoa, Burhakaba Serious Selective Feeding Programmes Limited, although available for Baidoa and Dinsor Serious Overall Situation Analysis: Likely to be Very Critical

3.4 Central and SouthEast

Central and southeast Somalia comprises of six regions namely: Galgadud, South Mudug, Hiran, Lower Shabelle, Middle Shabelle and Benadir. About 13 livelihood zones1 are found in the area generally consisting of riverine, agro-pastoral, pastoral and urban (Appendix 1).

Post Gu ’08 Overview The FSAU Post Gu ’08 food security analysis indicated deterioration since the Deyr ‘07/08 in the food security and humanitarian situation in Central, Hiran and Shabelle regions. In Central, the number of people in Humanitarian Emergency (HE) and Acute Food and Livelihood Crisis (AFLC) increased by 64% and 24% respectively due

1 Addun Pastoral, Hawd Pastoral, Southern Inland pastoral, Hiran Agropastoral, Hiran Riverine, Coastal Deeh, Central Regions Agropastoral, Southern Agropastoral, Lower and Middle Shabelle Agropastoral rain fed, Lower and Middle Shabelle Agropastoral Irrigated, Shabelle River- ine, South East Pastoral and Urban livelihood zones.

FSAU Technical Series Report No V. 16 15 Issued February 20, 2009 to complete rain failure during Gu ’08 and two previous successive seasons of poor rainfall. In Hiran, the number of people in HE and AFLC had doubled, the worst affected being the agropastoral and urban poor livelihoods. This was attributable to five consecutive seasons of rain failure that disrupted the people’s livelihoods. In the Shabelle regions, the number of people in HE and AFLC increased significantly, with 48% of the affected population in Middle Shabelle (indicating a doubling since Deyr ‘07/08) and 52% in Lower Shabelle. This deterioration was the result of delayed and poor Gu ’08 rains and previous below-average crop production, due to floods and poor irrigation infrastructure and river embankment in addition to displacement caused by continued civil insecurity.

The integrated nutrition situation analysis conducted by FSAU and partners in the Post Gu ’08 indicated all livelihoods in Galgadud and South Mudug to be in a persistent Critical situation with exception of the Coastal Deeh, where the situation was in a sustained Serious phase. The nutrition situation in the Cowpea Belt remained Serious, although food security indicators showed deterioration. In Hiran region, the nutrition situation remained persistently Critical for the riverine population in Gu’08 while the agropastoral areas deteriorated to Critical from the Serious situation in the previous Deyr ’07/08 season, mainly due to unfavourable food security indicators and limited humanitarian access. Even though there was insufficient data to make a definite classification in the pastoral areas of Hiran, integrated analysis estimated the nutrition situation likely to be Critical. Shabelle Agropastoral and the IDPs in the Afgoye Cor- ridor and Merka also sustained a Critical nutrition situation and was linked to a deteriorating food security situation and the continued influx of IDPs. However, in the Shabelle Riverine, there had been some sustained improvement from the previous Critical in Gu ’07 to Serious in Post Deyr ’07/08 through to Post Gu ’08, possibly due increased humanitarian interventions as well as increased access to fish, fruits and vegetables.

Central Regions (Galgadud and South Mudug)

Current Situation

Food Security According to FSAU Post Deyr ’08/09 Integrated Analysis, the overall food security situation in the drought-affected Central (Galgadud and Mudug) regions has deteriorated even further since Gu ‘08. The depth of the crisis is severe, with an estimated 350,000 rural pastoralists and agropastoralists and 55,000 urban inhabitants in either AFLC or HE. More than half the total population of the two regions is in crisis. Furthermore, there are another 200,000 IDPs, a result of increased civil insecurity in the Shabelles and within the parts of the central regions.

The number of people in HE increased in the Addun, Hawd, Coastal Deeh and the Cowpea Belt LZs, and there is an early warning of a moderate risk of deterioration in terms of the Boiled Maize (Ambulo), a number of people in HE before the end of June ’09. Since Gu ’08, the number of people in common diet in times of HE has increased by 41% (from 117,000 to 165,000) in Galgadud and by 27% (from 55,000 distress, FSAU, Dec. ‘08

regional nutrition analysis to 80,000) in southern Mudug. This deterioration is due to poor Deyr ‘08/09 rainfall performance, which deepened the drought, and widespread civil insecurity, which led to increased numbers of IDPs (increase of 5,000 people). Of particular concern is the recent displacement from Dhusamareb and Guricel towns, resulting from increased fighting between religious groups in those areas. In the agro-pastoral areas of the Cowpea Belt, there was a complete crop failure during the Deyr ‘08/09 season, which compounded the effects of previous successive below average seasons. Cereal prices are at record high levels and the highest in all of Somalia.

Nutrition The FSAU Post Deyr ’08/09 integrated nutrition analysis indicates a very alarming nutrition situation in the two main pastoral livelihoods in the central regions. The Hawd pastoral livelihood has deteriorated to Very Critical from the Critical phase in the Post Gu ’08, as predicted. This deterioration is due to a combination of factors, including the continuing food security crisis, ongoing displacement, a severe and as of yet uncontrolled Acute Watery Diarrhoea (AWD) outbreak, and a complete lack of access to basic services and humanitarian assistance for the affected populations. The Addun pastoral livelihood has reported a persistent Critical nutrition situation, with risk to deteriorate further, due to worsening food security indicators and lack of humanitarian assistance. The current analysis estimates 10,000 severely malnourished children less than 5 years of age in Galgadud and Mudug regions, who are at risk of death if they do not receive the appropriate treatment. However due to shrinking humanitarian space, essential life saving operations have scaled down and their needs are not being met.

Repeat representatives assessments conducted in Nov’08 reported GAM rates of 20.8% (14.9-26.8) and 18.4% (12.7- 24.2) in the Hawd and Addun Pastoral areas respectively. These rates indicate a deterioration in the Hawd and similar rates in Addun from the Apr’08 assessments conducted in the region which reported GAM rates of 19.3% (15.6-23.0) and 18.4% (14.9 – 21.8) in the Hawd and Addun livelihoods respectively (Figure 9). These areas currently have limited

FSAU Technical Series Report No V. 16 16 Issued February 20, 2009 access to food (due to rain failure from four consecutive Figure 9: Trends in Levels of Acute Malnutrition seasons, high inflation and exchange rates and increased (WHZ<-2 or oedema) in Central Regions (2001-2008) food prices among other factors), host a large population of displaced persons and face situations of civil insecu- 30 rity, which have hindered humanitarian interventions that were in place during the Deyr ‘07/08. Humanitarian

operations have either been scaled down or closed in these % 15 areas due to deteriorating security situation.

The suspension, in November 2008, of Supplementary 0 Feeding Programmes (SFP) in Dusamareb and Guriel Sep.04 Dec.07 Aug.01 Nov.07 Jun.08 Nov.08 Nov.07 Jun.08 Nov.08 Dhusamareb District Eldhere Hawd Pastoral Addun Pastoral by ACF, following a serious security incident, resulted District in over 4,000 moderately malnourished children being discharged prematurely and compounded with irregular food distributions, are also likely to exacerbate an already worsening humanitarian situation. Further field reports have indicated an Acute Watery Diarrhoea (AWD) outbreak in Abudwak district by November 2008, reportedly yet to be contained.

The key nutrition findings in Addun, Hawd and Cowpea belt areas, which define the classification outcome, are provided in Table 6 below. regional nutrition analysis Table 6. Summary of Key Nutrition Findings in Central Regions Agropastoral -Cow- Hawd Pastoral (N=776) Addun Pastoral (N=640) pea Belt Indicator Results Outcome Results Outcome Results Outcome 20.8 Very 18.4 Global Acute Malnutrition (WHZ<-2 or oedema) Critical N/A N/A (14.9-26.8) Critical (12.7 - 24.2) 5.8 Very 3.8 Severe Acute Malnutrition (WHZ<-3 or oedema) Serious N/A N/A (3.2-8.4) Critical (2.0-5.4) 0.5 0.0 Accept- Oedema Alert N/A N/A (0.0-1.0) able 21.8 Very 18.8 Global Acute Malnutrition (WHO 2006) Critical N/A N/A (18.9-24.0) Critical (15.7 - 21.0) 7.0 Very 6.1 Very Criti- Severe Acute Malnutrition (WHO 2006) N/A N/A (5.2-8.9) Critical (4.2-8.1) cal Acute malnutrition by MUAC (<12.5 cm or 8.5 3.9 oedema in Rapid Assessments or nutrition as- Serious Alert N/A N/A sessments) Crude Mortality Rate per 10,000 per day (retro- 0.98 0.63 Alert Alert N/A N/A spective for 90 days) (0.87-3.60) (0.32-1.26) Under five mortality rate per 10,000 per day 1.80 1.94 Alert Alert N/A N/A (retrospective for 90 days) (0.87-3.60) (0.88-4.26) High (>20%) but High (>20%) but Low but HIS Nutrition Trends Critical Critical Serious stable stable increasing AWD Outbreak AWD Outbreak No Out- Disease trends (seasonally adjusted) Morbidity – 54.4 Very Morbidity – 39.2 break Morbidity refers to the proportion of children re- Critical Serious RDT positive – Critical RDT positive – ported to be ill in the 2 weeks prior to the survey 12.5 6.8 Vitamin A Supplementation Status :6mths recall Vitamin A – 44.6 Very Vitamin A – 46.1 Very Criti- N/A N/A Measles Vaccination Status Measles -15.7 Critical Measles -23.8 cal Admission trends at TFPs/SFPs (ACF, Dusa- High and increas- High and increas- Critical Critical N/A N/A mareb – Jan-Jun ‘08) ing ing Poor household dietary diversity (< 4 food 7.7 15.3 Alert Serious N/A N/A groups) (0.0 – 16.4) (6.5 – 24.1) 8.4 Very Households with Access to water 29.1(13.9-44.3) Critical N/A N/A 0- 18.3) Critical Households with sanitation facilities 57.7(43.5-71.8) Serious 55.1(38.9-71.3) Serious N/A N/A Food Security situation AFLC (High risk) Critical AFLC Serious AFLC Serious Wide- Widespread and Widespread and spread Civil Insecurity Situation Critical Critical Critical high intensity high intensity and high intensity Likely to be Serious Critical with risk to further Overall Situation Analysis Very Critical with risk to deterio- deterioration ration

Note: Other information on the central livelihoods are given in the northeast region.

FSAU Technical Series Report No V. 16 17 Issued February 20, 2009 3.5 Hiran Region

Current Situation

Food Security The overall food security situation in Hiran region has been deteriorating since Gu ‘08. Consequently, the number of people in HE in rural areas has increased from 113,000 people to 135,000 people, which is an increase of 19%. The number of people in both AFLC and HE has also increased since Gu ’08 and currently stands at 200,000, rep- resenting 75% of the region’s rural population, with approximately 68% in HE and 32% in AFLC. Factors that have contributed to the serious deterioration include poor crop production, resulting from below normal Deyr ‘08/09 rains (67% of the LTA), recurrent conflict in both urban and rural areas, and disruption of trade and economic activities. Cereal production is estimated at 4,500MT, which is 188% of Deyr ‘07/08 production, 67% of PWA (1995-2007) and 89% of the 5-year average (2003-2007). The majority of this production (75%) is from Beletweyn district, which benefited from pump irrigation and depressed seasonal river wadi( ) irrigated crop production. The worst affected livelihood zone is the agro-pastoral LZ, where 75,000 people are now in HE and 37,000 in AFLC. This is followed by Riverine LZ, where 27,000 people are in HE. Compared to Dec. ’07 and Dec. ’08 prices, and the 5-year average, cereal prices increased, but show a declining trend from July ‘08 to Dec. ’08. A fourth consecutive season of crop failure in both Buloburti and Jalalaqsi district led to a significant food deficit in the majority of rural and urban communities. Moreover, a lack of income earning opportunities, a reduced number of marketable animals and continuous repayment of accumulated debts continue to curtail both urban and rural households’ ability to buy food.

Nutrition Pastoral, Agropastoral and Riverine Livelihood Figure 10: Trends in Levels of Acute Malnutrition Zones (WHZ<-2 or oedema) in Hiran region (2000-2008) The nutrition situation for all the livelihoods in Hiran in- 30.0 dicates a likely sustained Critical phase since the Gu ’07. Although there is a lack of representative survey data to make a definite classification, due to insecurity prevent- 15.0 ing access, the existing data suggests that the situation % is unlikely to have changed from the Gu ’08. Screening data from health facilities continues to indicate high

numbers of acutely malnourished children, with mixed 0.0 trends: declining in agropastoral, stable in pastoral and Jul.03 Apr.00 Apr.00 Jun.02 Jun.08 Jun.08 Mar.07 Mar.07 Mar.07 Mar.07 Mar.07 increasing in the riverine, indicating the relative risk of Nov.07 Nov.07 Belletweyne District B/weyne Hiran Agropastoral Hiran Riverine deterioration among the riverine population. Data from Town INGO run Selective Feeding Programmes in Buloburti also show an increasing number of admissions. Hiran has been faced with 4-5 consecutive seasons of rain failure that, together with high food prices and displacement, has contributed to poor food access in most households. regional nutrition analysis The analysis is consistent with findings from historical nutrition survey data conducted in the region (Figure 10) which highlight a historical nutritional vulnerability. Two nutrition assessments conducted in June ’08 reported GAM rates of 15.9% (10.4-21.4) and 17.7% (13.3 – 22.1) in Hiran Agropastoral and Hiran Riverine respectively, both indicating a Critical nutrition situation. The sustained likely Critical nutrition situation in Hiran is mainly attributed to unfavourable food security indicators and limited humanitarian access.

The key nutrition findings in Hiran region which form the basis of the analysis on the classification outcome are provided in Table 7 below.

Table 7. Summary of Key Nutrition Findings in Hiran Region Hiran Agropastoral Hiran Riverine Hiran Pastoral Indicator Results Outcome Results Outcome Results Outcome Acute malnutrition by MUAC (<12.5 18.5 17.5 9.3 cm or oedema in Rapid Assessments Very Critical Very Critical Serious N=200; 2 sites N=200; 2 sites N=400; 4 sites or nutrition assessments) High(>10%) but High (>15%) and High (>15%) HIS Nutrition Trends Serious Very Critical Critical declining increasing and stable Admission trends at TFPs/SFPs High and increasing Critical High and increasing Critical N/A N/A (Mercy USA, Buloburti – Jul-Dec ‘08) Food Security situation HE/AFLC Critical HE/AFLC Critical HE/AFLC Critical Widespread Widespread and Widespread and Civil Insecurity Situation Critical Critical and high Critical high intensity high intensity intensity Overall Situation Analysis Likely to be Critical Likely to be Critical Likely to be Critical

FSAU Technical Series Report No V. 16 18 Issued February 20, 2009 3.6 Lower and Middle Shabelle REGIONS

Food Security The food security situation in the Shabelle regions (Middle and Lower Shabelle) is mixed, with the Lower Shabelle region showing some improvement, and the Middle Shabelle region experiencing further deterioration. In the Shabelle regions, a total of 465,000 people are in a state of HE and AFLC, with an early warning level of Watch in Lower Shabelle and a moderate risk in Middle Shabelle over the coming six months; this is a 21% decrease since post Gu ’08. Of the total affected, 235,000 people are in HE (11% decrease since July ’08) and 230,000 are in AFLC (28% decrease since Gu ’08).

In Middle Shabelle, of the 260,000 people that are in AFLC or HE, 67% are agro-pastoral; 7% are riverine; 10% are pastoral, and 12% are urban poor. In Lower Shabelle, the majority, or 40%, of those affected are urban poor; 36% are agro-pastoral; 10% are riverine; and 4% are pastoral. There is a further deterioration for rural populations in Middle Shabelle due to a number of factors, including a severe Deyr ’08/09 rainfall deficit, following poor Gu ’08 rainfall, four seasons of below normal crop production, high input costs, persistent hyperinflation and a severe depletion of pasture, which caused livestock out-migration. In addition, escalated civil insecurity has led to a greater IDP influx from urban towns to the regions’ rural areas, which continues to strain already limited rural resources. Household food stocks have depleted due to consecutive crop failure. In Lower Shabelle, although the Deyr ‘08/09 crop production is below average (36% of PWA), the food security situation improved due to a combination of Gu ’08 seasonal cereal production (33,000MT), Deyr ‘08/09 production (13,000MT), and a significant off-season crop harvest in Oct. ’08 (18,500MT). regional nutrition analysis Nutrition The nutrition situation has shown improvements in the Figure 11. Trends in Levels of Acute Malnutrition agropastoral and IDP (Merka-Afgoye corridor) popula- (WHZ<-2 or oedema) in Shabelle Valley (2007-2008)

tions of Lower and Middle Shabelle, from Critical in Gu 30.0 ’08 to Serious in the Deyr ‘08/09. The riverine population is in a sustained Serious phase since the Gu ’08 (Figure 11). Humanitarian interventions (including food and cash

transfer, and increased access to safer water and sanita- % 15.0 tion), a favourable off-season harvest and the riverine population’s access to fish, fruits and vegetables have likely mitigated the previous critical nutrition situation.

0.0 Nevertheless, high incidences of morbidity and civil May.07 Nov.07 May.08 Nov.08 May.07 Nov.07 May.08 Nov.08 Nov.07 May.08 Nov.08

insecurity remain aggravating factors to the sub-optimal Shabelle Riverine Shabelle Agropastoral Shabelle IDP nutrition situation. Of concern are the sustained elevated number of oedema cases, especially among the IDPs (1.0%) and riverine (1.1%) populations, and the continuing displacement of vulnerable households out of Mogadishu, placing burden on host communities.

Three nutrition assessments were conducted in Nov ’08 among the IDPs in the Merka – Afgoye corridor, agropastoral and riverine population groups in Middle and Lower Shabelle regions. Findings indicate a Serious nutrition situation in all the assessments with GAM rates of 12.3% (9.7-15.5) in the IDPs; 12.5% (10.6-14.6) in the agropastoral and 10.8% (8.6-13.5) in the riverine areas. The findings show some improvement from the May ’08 assessments, when GAM rates of 15.0% (11.5-18.4); 18.1% (14.4-21.8) and 13.7% (9.6 -17.7) were reported in IDPs, agropastoral and riverine respectively.

An area of notable concern is Walanweyne district where HIS data has shown very high numbers of acutely malnourished children screened at the local MCH in the last six months of 2008. This situation is explained by unfavourable food security factors and limited access to humanitarian interventions due to a volatile civil security situation. Walanweyne is predominantly a sorghum growing area. During the Deyr ’08/09, the district faced a crop failure producing a meagre 150 MT of sorghum, which is 3% of Deyr ‘07/08 production (5630 MT); 3% of 1995-2007 Post War Average (6050 MT) and 2% of (2003-2007) 5 year average (6106 MT). The low production and high demand from other areas caused a decrease in availability and accessibility of sorghum in the market. The area also faced declining milk production after animals that migrated from other areas depleted the available pasture generated from the previous unusually good Hagaa (July-Sept. ’08) rains.

In Mogadishu, the nutrition situation is likely to be Very Critical based on an integrated analysis of key outcome evidence, with no notable change over the last two years. HIS data from health facilities indicates very high numbers (>20%) but stable for the previous six months period under review (Source: HIS data July-Dec ’08) and SFP/ TFC data indicates high and steadily increasing new admissions in ACF-managed centers in Hodan and Forlanini.

FSAU Technical Series Report No V. 16 19 Issued February 20, 2009 (Source: ACF, Mogadishu – Jul-Dec ’08). ACF has since shifted from using the NCHS to WHO reference standards for their admission criteria, which partly explains the sharp increase in number of admissions.

The key nutrition findings in these areas which form the basis of the analysis on the classification outcome are provided in Table 8.

Table 8. Summary of Key Nutrition Findings in M & L Shabelle Regions Shabelle IDPs (N=667) Shabelle Agropastoral (N=681) Shabelle Riverine (N=638) Indicator Results Outcome Results Outcome Results Outcome Global Acute Malnutrition (WHZ<-2 or 12.3 12.5 10.8 Serious Serious Serious oedema) (9.7 – 15.5) (10.6 – 14.6) (8.6 – 13.5) Severe Acute Malnutrition (WHZ<-3 or 2.8 2.2 2.5 Alert Alert Alert oedema) (1.7 – 4.8) (1.3 - 3.6) (1.4 – 4.4) Oedema 1.0 (0.2 – 1.9) Serious 0.4 (0.0 – 1.0) Alert 1.1 (0.0 – 2.3) Serious Global Acute Malnutrition (WHO 2006) 12.4 (9.4 – 16.3) Serious 13.1 (10.7 – 15.8) Serious 10.7 (8.4 – 13.4) Serious Severe Acute Malnutrition (WHO 2006) 5.2 (3.3 – 8.2) Serious 4.4 (3.1 - 6.2) Serious 3.3 (2.2 – 4.9) Serious Acute malnutrition by MUAC (<12.5 cm or oedema in Rapid Assessments or nutrition 9.7 (6.7 – 12.8) Serious 6.8 (4.3 – 9.2) Serious 9.4 (5.9 – 12.9) Serious assessments) Proportion of acutely malnourished non 0.3 0.3 1.7 Acceptable Acceptable Alert pregnant women (MUAC≤18.5 cm) (N=288) (N=312) (N=301) Proportion of acutely malnourished preg- 16.7 13.2 17.6 Critical Critical Critical nant women (MUAC<23.0). (N=90) (N=76) (N=74) Crude Mortality Rate per 10,000 per day 0.70 0.91 1.01 Alert Alert Serious (retrospective for 90 days) (0.37 - 1.34) (0.16 - 1.34) (0.66 - 1.55) Under five mortality rate per 10,000 per 1.69 1.78 2.15 Alert Alert Serious day (retrospective for 90 days) (0.90 - 3.17) (1.05 - 2.98) (1.17 - 3.94) High (>15%) but High (>15%) but HIS Nutrition Trends High (>15%) but stable Critical Critical Critical stable stable Vitamin A – 56.1 Vitamin A – 57.1 Vitamin A – 51.1 Immunization Status Critical Critical Critical Measles -57.6 Measles -32.7 Measles -52.7 Disease trends (seasonally adjusted) No Outbreak No Outbreak AWD Outbreak Morbidity refers to the proportion of chil- Morbidity – 47.8 Serious Morbidity – 37.7 Serious Morbidity – 48.9 Critical dren reported to be ill in the 2 weeks prior RDT positive – 0.8 RDT positive – 0.6 RDT (+ve) – 0.1 to the survey Poor household dietary diversity (< 4 food 4.0 7.6 2.4 Acceptable Alert Accept-able groups) (1.0 – 7.0) (2.5 – 12.7) (0.0 – 4.9) Household access to latrine 89.0 (79.0 – 99.0) Alert 28.8 (15.0-42.6) Very Critical 48.1 (34.4-61.9) Critical 74.5 11.0 27.5 Very Criti- Household access to safe drinking water Alert Very Critical (59.0 – 90.1) (1.4-20.6) (14.4-40.7) cal Food Security situation HE Critical HE Critical HE Critical Widespread and high Widespread and high Widespread and Civil Insecurity Situation Critical Critical Critical intensity intensity high intensity Overall Situation Analysis Serious Serious Serious

3.7 Northeast RegionS

regional nutrition analysis Northeast regions (Bari, Nugal and North Mudug) are predominately pastoral with eight livelihood zones1, most of which also cut across the different zones of Northwest and Central regions (Appendix 1).

Post Gu ’08 Overview The FSAU Post Gu ’08 analysis classified the pastoral livelihood zones of Hawd and Nugal in northeast regions in AFLC with moderate risk to deterioration. This was a deterioration from the Borderline Food Insecure (BFI) phase in the Post Deyr ’07/08. Prolonged dry conditions (Jilaal ’08), increased food and non food commodity prices, poor Gu seasonal rains, out-migration of livestock, water and pasture unavailability, reduced livestock production and declining terms of trade were the main factors limiting access to dietary intake and directly contributing to the worrying nutrition situation in the area. In Bari region, pastoralists in Sool, Dharoor, Gagaab and Coastal livelihood zones, as well as Addun and Coastal Deeh in Eyl, Jariban and Galkayo districts had sustained the Borderline Food Insecure (BFI) phase since the Post Deyr ’07/08, however there was an early warning the situation could deteriorate. This was due to abnormal in-migration from Hawd and southern Addun, poor rangeland conditions, limited pasture and water availability, and declining terms of trade. The Somalia Health Cluster Bulletin (July ’08) also reported acute watery diarrhea cases in Barghal district of Bari region with 109 reported cases and 7 related deaths as of July 30th 2008. The total number of people in HE or AFLC in Bari and Nugal reached 140,000 of which 130,000 were from urban communities. Of these 82 % were in ALFC and 18 % were in HE.

The integrated nutrition situation analysis of the Post Gu ’08 classified the northern districts of Bari regions as Serious, with the remaining districts as Alert. Of great concern however, were the protracted IDPs in Bossasso,

1) Coastal Deeh; 2) Nugal Valley Pastoral; 3) Addun Pastoral; 4) Hawd Pastoral; 5) Sool- Sanaag Plateau Pastoral; 6) East Golis Pastoral/ Frankincense, 7) Karkaar Pastoral; and 8) Gagaab Pastoral.

FSAU Technical Series Report No V. 16 20 Issued February 20, 2009 Garowe and Galkayo classified in a Very Critical phase with no change from Post Deyr ’07/08. Nevertheless, the results were consistent with historical data on nutrition surveys conducted among IDP and rural populations in the northeast region. The Hawd and Addun livelihoods of Mudug and Nugal regions remained in a sustained Critical nutrition situation, with no improvement from Deyr ’07/08 situation.

Current Situation

Food Security The FSAU Post Deyr ’08/09 analysis has classified the pastoral livelihood zones of Hawd, and adjoining parts of Addun in Northeast regions in a sustained Acute Food Security Livelihoods Crisis (AFLC) but with deterioration from the Gu ’08. The Nugal Valley which was classified in AFLC in the Gu ’08 has improved and now categorised as Borderline Food Insecure (BFI). However, the Addun pastoralists have deteriorated to AFLC phase, with moderate risk to deterioration. These areas currently have limited access to food due to three successive poor rains, leading to poor pasture and water, and subse- Mothers queue for services at Galkayo TFC quently out-migration of livestock to Somali region of Ethiopia and Golol in the northern part of Hawd Dec. ‘08 regional nutrition analysis livelihood in Eyl district.

Reduced access to cereals and milk, linked to hyperinflation and reduced number of viable animals for sale are the main factors limiting dietary intake and contributing to the worrying nutrition situation in the area. The number of people in AFLC or HE increased to 195,000 (from 120,000) of which 130,000 are from urban communities in Nugal, Bari and north Mudug regions. Pastoralists from Sool, Karkaar, Gagaab/Golis and Coastal livelihood zones, are still in a sustained Borderline Food Insecure phase since the Post Deyr ’07/08. These areas had 2-3 consecutive normal rains with good water and pasture. In October 2008, the sub coastal areas of Iskushuban district experienced freezing rains which reportedly Spring water for human consumption, Beyla-Dhudo, killed large numbers of livestock. FSAU, Dec ‘08

Nutrition Figure 12: Trends in levels of Acute Malnutrition (WHZ<-2 Based on findings from 21 nutrition assessments con- or oedema) in Northeast regions 2002-2008 ducted by FSAU & partners from 2002 -2008 (Figure 12a), the nutrition situation of both rural & urban 25.0

population in the northeast was been consistently 20.0 below emergency threshold of 15 % until 2006. Fol- 15.0 lowing the deterioration of the food security situation in the Hawd, Addun and the Coastal Deeh in 2007, 10.0

the nutrition situation deteriorated and levels of acute 5.0 malnutrition exceeded the emergency threshold of 15%. The situation of IDPs in Galkayo, Garowe and 0.0 Hawd Hawd Hawd Addun Addun Addun Dan/Eyl

Bossaso has been different from that of the rural com- Burtinle/D Allula/K/Isk Allula/K/Isk Allula/K/Isk Nugal Val ey Jer banTown Coastal Deeh Galkayo Town Town Galkayo Town Galkayo Town Galkayo Goldgob Town Town Goldgob Ga dogob town

munities, with the rates of acute malnutrition levels Goldogob Distr ct Goldogob Distr ct consistently exceeding the emergency threshold, due Apr02 Ju 02 Dec02 Dec02 Mar03 Feb0 Apr0 Apr0 Sep0 Aug05 Aug05 Sep06 Nov06 Nov06 May07 Oc 07 Oct07 May08 May08 Nov08 Nov08 to their high vulnerability to livelihood shocks.

The integrated nutrition situation analysis of the Post Deyr ’08/09 indicates no major changes in the nutrition situation in most of the livelihoods of the northeast region from the Post Gu’08, except for Hawd pastoral livelihood of Mudug and Nugal regions which has deteriorated from Critical in the Gu’08 to Very Critical in Post Deyr ’08/09. The nutrition situation of Addun pastoral livelihood has remained Critical since Post Gu ’08, with risk to deteriorate. Of great concern, are the protracted IDPs and poor urban population in Bossaso town, where the nutrition situation is

FSAU Technical Series Report No V. 16 21 Issued February 20, 2009 currently classified asVery Critical, with no change from Post Gu ’08. Conversely, there is a slight improvement in the nutrition situation of the Garowe IDPs from Very Critical during the Post Gu’08 to Critical in the Deyr ‘08/09. The poor nutrition situation among the Hawd and Addun pastoral and among the IDP population is mainly attributed to high morbidity rates, poor access to a diverse diet, and lack of safe water and sanitation facilities.

The lack of an established livelihood system in the IDP population, and the general limited access to basic needs and services, exacerbate the compromised nutritional status of this population. Given that the majority of the IDPs rely on purchase for access to food, the current macroeconomic crisis leading to inflated food prices is a further shock on this already vulnerable population. The Coastal Deeh and Nugal valley livelihoods of Mudug, Nugal and Bari regions are in a sustained Serious nutrition situation, with no improvement from Post Gu’08 situation. Sool plateau & Karkaar livelihood zones are in a sustained Alert nutrition phase since the Post Gu ’08. The Golis & Gagaab Livelihood zones are likely to have improved since Gu ’08 from Serious to Alert due to favourable food security indicators. The key nutrition findings in these areas which form the basis of the analysis on the classification outcome are provided in Table 9.

Table 9. Summary of Key Nutrition Findings in Northeast Regions Hawd Pastoral (N=776) Addun Pastoral (N=640) Bossaso IDPs (N=774) Garowe IDP (N=431) Indicator Results Outcome Results Outcome Results Outcome Results Outcome Global Acute malnutrition 20.8 18.4 27.9 Very Criti- Very Critical Critical 17.4 Critical (WHZ<-2 or oedema) (14.9-26.8) (12.7-24.2) (24.3-31.9) cal Severe Acute Malnutrition Very Criti- 5.8 (3.2-8.4) Critical 3.8 (2.0-5.4) Serious 7.6 (5.3 – 10.8) 4.4 Critical (WHZ<-3 or oedema) cal Oedema 0.5(0.02-1.01) Alert 0.5 (0.02-1.01) Alert 0.9 Alert 0.3 Alert Global Acute Malnutrition 21.8 18.8 Very Critical Critical (WHO 2006) (18.9-24.0) (15.7 - 21.0) Severe Acute Malnutrition 7.0 6.1 Very Criti- Very Critical (WHO 2006) (5.2-8.9) (4.2-8.1) cal Proportion acutely malnour- 0.34 1.7 ( 0.3-3.2) 0.5(0.0 – 1.3) Accept- N/A ished non pregnant women Acceptable (0.0 -.03) Acceptable N=289 able (MUAC≤18.5 cm) N=293 Proportion of acutely mal- 23.8 21.7 Very Criti- 40.8 Very Criti- nourished pregnant women (10.9-36.7) Very Critical (9.7-33.4) N/A cal (27.7 – 53.9 cal (MUAC<23.0). N=84 N=51 Crude Mortality Rate per 0.63 Very Criti- 0.93 (0.59-1.45) Alert Alert 3.05 (1.80 – 5.12) N/A 10,000 per day (0.32-1.26) cal Under five mortality rate per 1.94 1.04 10,000 per day retrospective 1.80(0.87-3.69) Alert Alert Alert N/A (0.88-4.26) (0.63 – 1.72) for 90 days High (>10%) but High (>10%) but Low (<10%) but Low (<10%) HIS Nutrition Trends Serious Serious Alert Alert stable stable stable but stable Vitamin A:44.6 Vitamin A-46.1 Very Criti- Vitamin A:53.1 Very Criti- Immunization Status Very Critical N/A Measles 15.7 Measles: 23.8 cal Measles: 67.3 cal

300 AWD, Outbreak: Morbidity 54.4 Morbidity:39.2 CFR=2.7 None regional nutrition analysis Disease out breaks / RDT positive Critical RDT positive Critical Morbidity 58.4 Critical Morbidity:47.3 Critical Morbidity Malaria 12.5 Malaria : 6.8 RDT positive for Diarrhoea;: Malaria: 5.8 20.9 Admission trends at TFPs/ High and High and in- SFPs (MSFB, Galkayo – Jan- Critical N/A Critical N/A increasing creasing Dec’08) Poor household dietary diver- Very Criti- 7.7 (0.0-16.4) Serious 15.3 (6.5-24.1) Critical 33.9(24.0 – 43.8) 18.3 Critical sity (< 4 food groups a day) cal Households with Access to 29.1(13.9-44.3) Critical 8.4 Very Criti- 48.3 Serious N/A safe water 0- 18.3) cal (32.5-64.2) Households with sanitation 41.1 57.7(43.5 -71.8) Serious 55.1(38.9-71.3) Serious Serious N/A facilities (26.8-56.6) AFCL-moderate AFCL-moderate HE –Moderate HE -moderate Food Security situation Serious Serious Critical Critical risk risk risk risk

Limited mag- Limited mag- Limited mag- Limited mag- Civil Insecurity Situation nitude and low Serious nitude and low Serious nitude and low Serious nitude and low Serious intensity intensity intensity intensity

Very Critical with risk to Critical with risk to, Overall Situation Analysis Very Critical Critical deterioration deterioration

Hawd and Addun Livelihood Zones The nutrition situation of the Hawd livelihood of Mudug and Nugal regions has deteriorated from Critical in the Gu ’08 to Very Critical in Post Deyr ’08/09 while the Addun livelihood zone remains Critical since the Post Gu’08, with risk to deterioration. Assessments conducted in Nov ’08 reported GAM rates of 20.8% (14.9-26.8), with a SAM rate of 5.8% (3.2-8.4) and 0.5% (0.02-1.01) oedema cases in the Hawd population. In the Addun population, the GAM

FSAU Technical Series Report No V. 16 22 Issued February 20, 2009 rate was 18.4% (12.7-24.2) with a SAM rate of 3.8% (2.0-5.4) and no oedema case reported (See Table 14). When compared to previous nutrition assessments conducted in the Gu ’08, when the Hawd pastoral livelihood reported a GAM rate of 19.3% (15.6-23.0) and SAM rate of 2.3% (0.9-3.8) and the Addun reported a GAM rate of 18.4% (14.9- 21.8 ) and SAM rate of 2.8% (1.2-4.4) with one (0.2%) oedema case, analysis indicates a continuing deterioration from Critical to Very Critical levels of acute malnutrition in the Hawd, and a sustained Critical nutrition situation in the Addun Pastoral population, respectively. These areas currently have limited access to food (due to poor rains, out-migration of livestock, less viable animals for sale, and declining terms of trade).

Poor access to health services and low coverage of health programmes in both livelihoods are still worrying and require close monitoring. The proportion of households consuming milk was notably low for pastoral communities reported at 44.4 % and 39.8 % among the Hawd and Addun populations respectively. The worsening nutrition situation could be attributed to low milk consumption and generally poor dietary diversity resulting from the impact of the poor rains, high food prices, and reduced access to productive assets with the chronic problems of poor access to safe water and sanitation facilities, limited access to health services and poor child feeding practices driving the underlying crisis. A severe AWD outbreak in Hawd livelihood is also a significant contributor to this crisis.

IDP of the Northeast: Galkayo, Bossaso and Garowe The nutrition situation of the protracted IDPs in Bos- saso town is classified as Very Critical with no change from the situation in Post Gu’08, while the Garowe IDPs showed a slight improvement from Very Critical in post regional nutrition analysis Gu’ 08 to Critical in the Deyr ’08/09.

Admission trends at TFPs in Galkayo from Jan - Dec’08 indicates high and increasing numbers (> 500) of acutely malnourished children in the last quarter. These admission are not only from Galkayo but also from neighbouring regions and across the border from Ethiopia.

The Bossaso nutrition assessment, conducted in October 2008, reported a GAM rate of 27.9% (24.3–31.9) and a A berkad with water Jariban, Mudug, SAM (WHZ<-3 or oedema) rate of 7.6% (5.3-10.8) with seven (0.9%) oedema cases. Analysis indicates a Very FSAU, Dec. ‘08 Critical nutrition situation and deterioration when compared with the previous assessment conducted in November 2007, which reported a GAM rate of 23.3% and a SAM rate of 4.9%. In addition, there was an outbreak of acute watery diarrhoea (AWD) reported in Bossaso with 300 cases of AWD and a Case Fatality Rate of 2.7% between 6th Sept and 31st October’08 (WHO, Oct ’08). An exhaustive nutrition assessment using weight-for-height scores among the Garowe IDPs conducted in December’08 reported a GAM rate of 17.4 % with a SAM rate of 4.4 % indicating a Critical nutrition situation with slight improvement when compared with the previous assessment conducted in the Gu ’08, that reported a GAM rate of 22.6% and a SAM rate of 1.5%. High morbidity, especially diarrhoea; low immunization status; poor household dietary diversity and poor access to sanitation and safe water are the main contributory factors of the very worrying nutrition situation among the IDPs in Bossaso and Garowe.

East Golis (Bari)/Gagaab/Kakaar; Sool Pla- teau; Coastal Deeh and Lower Nugal Liveli- hood Zones The nutrition situation in Sool plateau and Karkaar Pas- toralists of Bari and Nugal regions has been Alert since the post Gu’ 08. Data from rapid MUAC assessments in 5 sites of Sool plateau indicates a low proportion of children (3.4%) with MUAC <12.5cm or oedema while 2 sites from the Karkaar livelihood reported no child with MUAC <12.5cm or oedema. In the East Golis (Bari) and Gagaab Pastoral livelihood zones, the nutrition situation is likely to be in the Alert phase. This indicates an improvement from the Serious nutrition situation in the Post Gu ’08. Integrated analysis of data from rapid MUAC assessments (in only three sites) indicates no children with a MUAC <12.5cm or oedema. The posi- A sibling takes care of a child FSAU, Dec. ‘08

FSAU Technical Series Report No V. 16 23 Issued February 20, 2009 tive improvements of the nutrition situation can be attributed to improved food security indicators. In the Coastal Deeh and Lower Nugal Livelihood zones, the nutrition situation remained Serious with no significant change since the Post Gu ’08. Although a rapid MUAC assessment in 7 sites indicates a low proportion of children (5.3%) with MUAC <12.5cm or oedema, health facility data indicates a low proportion (5.3%) but increasing trend of acutely malnourished children. Dietary diversity is also poor in this livelihood and milk consumption negligible, compro- mising their nutrition situation.

There have been no disease outbreaks reported in this period. Health services are available in urban towns but limited in the rural areas. It is imperative to continue to monitor the key food security and nutrition indicators to detect any changes that may occur which may result in deterioration in the nutritional situation of the population. This is more so because the population remains vulnerable, due to chronic risk factors such as poor child care feeding practices, poor sanitation, and inadequate supply of clean drinking water, high morbidity and limited access to health facilities in the area. Table 10 provides a summary of findings on the key reference indicators used in the integrated analysis of the situation in Coastal Deeh & lower Nugal livelihood zones).

Table 10: Summary of Results Golis, Gagaab Sool plateau, Karkaar, Coastal Deeh and Lower Nugal Livelihood Zones

Key Reference Indicator Findings Outcome

Sool plateau & Karkaar LZ MUAC : <12.5 cm =3.4 , <11 cm=0.2 Sool plateau: (N=436; No. of sites = 5), Alert Karkaar (N=111; No. of sites = 2 ) MUAC: <12.5 cm = 0.0 Oedema None Data indicates a low (<10%) and stable trend of acutely HIS Nutrition Trend Alert malnourished children Low consumption of fruits and vegetables , high prices Dietary Diversity Serious of cereals.

Disease Outbreaks None reported Acceptable

Access to Health Services Limited Health services in the area Critical

Selective Feeding Programmes Very limited Very Critical

Overall Situation Analysis: Alert East Golis, Gagaab Livelihood Zones MUAC (N=113; no. of sites = 3) <12.5 cm = 0.0 Alert Data indicates a low (<10%) and stable trend of acutely HIS Nutrition Trend Alert malnourished children Dietary Diversity some milk available, high prices of cereals Serious Disease Outbreaks None reported. Acceptable Access to Health Services Overall limited health facilities in the area, Serious regional nutrition analysis Selective Feeding Programmes Limited Critical

Overall Situation Analysis: Likely to be Alert due to insufficient data

Coastal Deeh & lower Nugal Livelihood Zones

Coastal Deeh (N=302; no. of sites = 4) MUAC: <12.5 cm = 5.3 <11 cm= 0.3 Serious Nugal Valley (N=212 ; no. of sites = 3) MUAC: <12.5 cm = 6.2 <11 cm=1

Oedema None Data indicates a low (10%) but increasing trend of HIS Nutrition Trend Serious acutely malnourished children No milk available, high food costs, Low consumption Dietary Diversity Serious of fruits and vegetables Disease Outbreaks None reported Acceptable

Access to Health Services Limited health services in the area Critical

Selective Feeding Programmes Very limited Very Critical

Overall Situation Analysis: Serious

FSAU Technical Series Report No V. 16 24 Issued February 20, 2009 Supporting Breastfeeding for a healthy family

The nutrition assessments conducted by the FSAU Nutrition Surveil- lance project and partners in Somalia for the last nine years, together with the Knowledge Attitude and Practices study conducted in Septem- ber 2007, indicate suboptimal infant and child care practices (including breastfeeding) throughout Somalia as a major contributing factor to the high incidences of common illnesses, including diarrhoea. The information collected report that, on average, breastfeeding commences on day 4 of life, due to the views that colostrums is toxic and in its place infants are given sugary water. Other harmful practices such as intro- duction of other fluids and solid food like water and porridge before 6 months, are routinely practiced throughout Somalia. Given the public health significance of these practices contributing to the nutritional crisis in Somalia, FSAU, in collaboration with UNICEF, has constantly advocated (in meetings, publications and through spearheading the production of IEC materials for Somalia) on the importance of appropriate breastfeeding and the need to support breastfeeding mothers and their children, socially, environmentally and financially.

During the World Breastfeeding Week in August 2008, FSAU, in collaboration with UNICEF, published a poster with the following key messages supporting breastfeeding. These messages were based on the theme of the international breast feeding week of Go for Gold – which referred to the Beijing Olympics, held the same month. : Source: UNICEF Somalia 2008

Why should I breastfeed my baby? breastfeeding Breastmilk is a complete food for infants up to 6 months; it protects your baby against diseases like diarrhoea, and also promotes recovery when sick. Breastfeeding helps your baby develop physically and intellectually- hence your baby is a winner!

Is the first yellow milk, colostrum good for my baby? Yes, this special milk is high in nutrients and antibodies which help to keep your baby healthy. It is easy to digest, and helps to clear your baby’s digestive system, easing passage of stools. To benefit from colostrum, put your baby to the breast within the first hour of life.

Is breast milk enough for my young child - I am afraid that my baby will starve on breast milk alone? Breastmilk alone is adequate to quench thirst, satisfy hunger and promote growth of your baby from birth to 6 months. You don’t need to give any other food or fluid, not even sugary water at this age, breast milk is enough!

How long should I breastfeed my child? According to Koran ‘Juz 2:233 surah al-BAQARAH’ mothers should breastfeed for first two years. Continue feeding your baby on breastmilk alone up to the age of 6 months, then gradually introduce appropriate complementary foods while continuing with breastfeeding up to the age of two years or beyond.

I am too busy looking after livestock, fetching water, looking for food. How can I continue breastfeeding? Family members and friends need to assist breastfeeding mothers with some of the household chores that com- pete with breastfeeding. Breastfeeding can be successfully combined with other commitments in life, for example by carrying the baby close to the breast when working.

What contribution can a father give to support breastfeeding? A father can support by continually showing love and appreciation to a breastfeeding wife, and helping her with her work so she can have time to breastfeed the baby.

What is clear in Somalia is the significance of religion in influencing practices. As illustrated above, the Koran does contain very positive messages in relation to child care and breastfeeding; therefore any opportunities agencies have to work with religious leaders on promotion of good practices for breastfeeding, should be encouraged for long term behaviour change.

Other related publications by FSAU include ‘Breastfeeding for a healthy community’, ‘Breastfeeding for a healthy family’, and “Somali Knowledge Attitudes and Practices towards child care and health seeking behaviours, 2007” all of which can be downloaded from the FSAU website, www.fsausomali.org

FSAU Technical Series Report No V. 16 25 Issued February 20, 2009 3.8 Northwest Region

The northwest regions (Awdal, Galbeed, Toghdeer, Sool Figure 13: Trends in levels of Acute Malnutrition and Sanaag) comprise of seven livelihood zones: The (WHZ<-2 or oedema)in Northwest Regions 2001-2008 30% pastoral i.e Hawd, Guban (Coastal), West Golis, Sool/ Sanaag Plateau and Nugal Valley and the agropastoral zones: Northwest Agropastoral and Togdheer Agropas- toral (Appendix 1).

15% Post Gu ’ 08 Overview The FSAU Post Gu ‘08 analysis classified the food security situation in the West Golis, Guban, and northwest

agro-pastoral (Awdal and Galbeed region) livelihood 0% Sahil Sool Togdheer Sool Huddun Togdheer Sool Guban/ Sool Harge sa Berbera Burao Burao Hargeisa Burao zones to be Borderline Food Insecure (BFI), with the Reg on Plateau Region P ateau District Reg on Plateau Go is P ateau IDPs IDPs IDPs IDPs DPs IDPs May 02 May 03 Aug 03 Jun 200 July 05 Jun 06 Aug 2006 Oct 2008 Oct 2008 Sep 2007 Sep 2007 Sep 2007 July 08 Dec 08 Dec 08 remaining areas in the Acute Food and Livelihood Crisis (AFLC). The Post Gu ’08 integrated nutrition analysis indicated a deterioration in the nutrition situation in most of the northwest livelihood zones. The Hawd, East Golis of Sanaag, Sool Plateau, West Golis and Guban livelihood zones were classified as Critical, while the Golis of Awdal region was classified as Alert. Nugal Valley and northwest and Togdheer agro-pastoral were classified asSerious . The nutrition situation in the northwest region historically has mostly been below emergency thresholds (GAM <15%) apart for the IDPs, (Figure 13).

Current Situation

Food Security The FSAU Post Deyr ’08/09 analysis has classified the, Sool Plateau, Nugal Valley, Hawd and Togdheer Agropas- toral as Borderline Food Insecure, while West Golis, East Golis (Sanaag, including Gebbi Valley), Guban and northwest agropastoral (Awdal/Galbeed region) deteriorated from BFI and are identified as being in Acute Food and Livelihood Crisis (AFLC). The current Post Deyr ’08/09 nutrition situation indicates a deterioration in the West Golis/Guban livelihood zones from Critical to Very Critical. In the Nugal Valley pastoral, the northwest and Toghdeer agro-pastoral livelihood zones, the nutrition situation remains Serious. An improvement of the nutrition situation was noted in Gebbi Valley of East Golis, and the Hawd livelihood zones from Critical to Serious. The Sool Plateau livelihood zone also improved from Critical to Alert with the main factors contributing to this improvement including improved food security indicators such as good rain performance, adequate pasture and humanitarian interventions in the area. The nutrition situation among the Hargeisa and Burao IDPs showed improvement from a Very Critical nutrition situation during the Post Gu ’08 to Serious and Critical classifications respectively. There was insufficient nutrition data on the Berbera IDPs to confidently define a nutrition situation classification; this area has been prioritized for nutritional assessment in April 2009.

regional nutrition analysis Nutrition Sool Plateau Livelihood Zone of NW The Post Gu ’08 integrated nutrition analysis classified Sool Plateau of Sool and Sanaag region as Critical. The drought conditions during the Gu ’08 resulted in the out migration of livestock eastwards to the neighbouring Bari region, thereby limiting the household consumption of milk and meat and reducing income. The current integrated nutrition analysis of the Post Deyr ’08/09 (Table 11), classifies the nutritional situation of the livelihood as Alert. A nutrition assessment conducted in the area in the month of October 2008, indicated a global acute malnutrition (WHZ<-2 or oedema) rate of 9.9% (6.9-13.0) and severe acute malnutrition (WHZ<-3 or oedema) rate of 0.5% (0-1.1), with one (0.2%) case of oedema. The improvement is mainly attributed to the good September and October 081 rain performance, leading to increased access to food, water and income in the area. Findings2 indicated a considerably high proportion of the household’s reportedly consuming milk (65.9%) and meat (30.6%). Humanitarian interventions - food aid and cash distributions by relief agencies during the last few months, and the control of diarrhoea outbreaks in the area have also positively contributed to the improved nutritional situation in the area. Although an improvement in the nutritional situation in the area has been observed, the vulnerability of the region, to natural shocks e.g. drought, necessitate continued close monitoring of the situation.

West Golis/ Guban Livelihood Zone The integrated nutrition analysis indicates the West Golis/Guban livelihood zones to be the only area in the northwest region with a marked deterioration in the nutrition situation from Critical in the Post Gu ‘08 to Very Critical in the Post Deyr ’08/09. (See key reference evidence in Table 11). A nutrition survey conducted in October 2008 reported a global acute malnutrition (WHZ<-2 or oedema) rate of 20.7% (15.3-26.2), and a severe acute malnutrition (WHZ<-

1 Food Security and Nutrition brief November 2008 2 FSAU Nutrition Survey October 2008

FSAU Technical Series Report No V. 16 26 Issued February 20, 2009 3 or oedema) rate of 2.4% (1.4-3.5). This is the first nutrition survey to be conducted in this livelihood zone and it confirms the worrying nutrition situation identified during the Post Gu ‘08 rapid nutrition assessments. The poor nutrition situation is mainly attributed to the precarious food security situation, following economic and natural shocks and high morbidity rates. The area depends on the Hays rainfall which comes annually in January. In January 2008, the Hays rains failed totally, causing prolonged Jilaal (dry spell) which resulted in abnormal out migration of livestock southwards toward the Hawd plains. This was followed by freezing rains that left large numbers of livestock dead. As a result, meat and milk consumption declined.

The nutrition survey conducted in October 2008 revealed that the household dietary diversity based on the 24 hour recall period was Critical, with almost one quarter (23.6%) of the assessed households consuming a poorly diversified diet (<4 food groups a day). In addition high morbidity rates (37.4%), especially diarrhoea (28.6%) affected the nutrition situation of the children in the area. Therefore, the integrated nutrition analysis classified the nutritional situation of the livelihood as Very Critical. The lack of adequate safe water for human consumption and inappro- priate disposal of human waste leaves the population vulnerable to morbidity, which has a direct correlation with acute malnutrition.

Table 11 West Golis/Guban (N=535) Sool Plateau (N=593) Indicator Results Outcome Results Outcome Global Acute Malnutrition (WHZ<-2 or oedema 20.7 (15.3-26.2) Very Critical 9.9 (6.9-13.0) Alert Severe Acute Malnutrition (WHZ<-3 or oedema) 2.4 (1.4-3.5) Alert 0.5 (0-1.1) Alert Global Acute Malnutrition (WHZ<-2 or oedema WHO 22.3 (17.2-28.4) Alert 9.9 (7.2-13.7) Alert reference standards regional nutrition analysis Severe Acute Malnutrition (WHZ<-3 or oedema) WHO 6.6 (4.4-9.7) Alert 0.8 (0.4-2.0) Alert reference standards Oedema 0.19 (0-0.57) Alert 0.2 (0-0.5) Alert Acute malnutrition by MUAC (<12.5 cm or oedema in 8.0 (6.6 – 12.9) Alert 3.9 (1.6-6.1) Acceptable Rapid Assessments or nutrition assessments) Proportion of acutely malnourished non pregnant 3.1 (0.9 – 5.3) 2.8 (0.5 – 5.2) Acceptable Acceptable women (MUAC≤18.5 cm) (N=324) (N=320) Proportion of acutely malnourished pregnant women 17.1 (N=41) Critical 18.6 (N=43) Critical (MUAC<23.0). Crude Mortality Rate per 10,000 per day (retrospective 1.05 (0.65-1.68) Serious 0.64 (0.35-1.18) Alert for 90 days) Under five mortality rate per 10,000 per day (retrospec- 1.06 (0.52-2.14) Alert 1.64 (0.88-3.04) Alert tive for 90 days) Stable and low HIS Nutrition Trends Stable and low numbers Alert Alert numbers Vitamin A – 46.9 Vitamin A – 47.7 Immunization Status Critical Critical Measles - 43.0 Measles -36.6 Disease trends (seasonally adjusted) Morbidity refers Morbidity – 37.4 Morbidity – 23.3 to the proportion of children reported to be ill in the 2 Critical Critical weeks prior to the survey

Households with access to safe water 55 (38.5-71.4) 41.7 (22.8-60.5) Poor household dietary diversity (< 4 food groups) 23.6 (14.2-33.0) Serious 23.7 (15.0-32.3) Serious Food Security situation AFLC Serious BFI Alert Prevailing structural Unstable disrupted Civil Insecurity Situation Acceptable Alert peace tension Overall Situation Analysis Very Critical Alert

East Golis Livelihood Zone, Sanaag The East Golis (of Sanaag) livelihood zone (Appendix 1), also shows a pecarious nutrition situation according to the Post Deyr ‘08/09 integrated nutrition analysis. Analysis of rapid MUAC assessments data from 8 sites (n=820) indicates a very high proportion (27.4%) of children with MUAC <12.5cm or oedema. Additionally, the HIS data for the area indicates high numbers and an increasing trend of acutely malnourished children screened at health facilities (Figure 14). An integrated analysis of nutrition, health and food security indicators (Table 12) indicate that the nutrition situation in this livelihood is Very Critical. During the Post Gu ’08, the area’s nutrition situation was not defined as there was insufficient data at the time to Figure 14: Kulmiye MCH HIS Nutrition Trends for 2008

draw a conclusive nutrition situation classification. Cur- 14 rent analysis identifies the factors contributing to the nutrition situation as: reduced food, specifically milk 12 and meat access and intake (due to the failure of the Post 10

Deyr ’08/09 rains in the area which led to out-migration 8 of livestock southwards to the Hawd), high prices of food 6

commodities, in addition to poor access to clean water, Malnourished % appropriate sanitation and health facilities. Morbidity, 4

especially diarrhoea (increased cases noted in Erigavo 2 and Rugay towns), is a major contributing factor given 0 the correlation between acute malnutrition and diarrhoea. Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sept 08 Oct 08 Nov 08 Dec 08

FSAU Technical Series Report No V. 16 27 Issued February 20, 2009 Equally important is the mountainous terrain of this livelihood which limits access and humanitarian interventions in the area. The area has been prioritized for a nutrition assessment early in 2009.

Table 12: East Golis Of Sanaag Livelihood Zone

MUAC (N= 820 Sites = 8) <11 cm = 7.7 <12.5 cm = 27.4 Very Critical Data indicates high numbers and increasing trend of acutely malnour- HIS Nutrition Trend Critical ished children Poor; no milk available, high food costs and reduced frequency of meals Dietary Diversity Serious reported Disease Outbreaks Increased cases of diarrhoea in Ruagay and Erigavo Serious Immunization Status Very Low Very Critical Available in Erigavo, but limited in other areas, interventions are also limited Access to Health Services Critical as physical access is very poor in the livelihood zone Selective Feeding Programmes Very limited Very Critical Overall Situation Analysis: Very Critical Gebbi Valley of Sanaag Livelihood Zone MUAC (N= 1121 Sites = 11) <11 cm = 0.9 <12.5 cm = 6.2 Serious Data indicates low numbers and increasing trend of acutely malnourished HIS Nutrition Trend Serious children Has improved in the livelihood, apart from the areas towards the east Dietary Diversity neighbouring Nugal Valley and East Golis, where there is no milk available Serious and reduced meal frequency Disease Outbreaks None Acceptable Immunization Status Very Low Very Critical Access to Health Services Limited Serious Selective Feeding Programmes Limited, although have received cash relief interventions Serious

Overall Situation Analysis: Serious

Gebbi Valley in East Golis Sanaag, shows an improvement from the Post Gu ’08 nutrition situation classification of Critical to Serious after the Post Deyr ‘08/09 integrated nutrition analysis. The analysis of data from rapid nutrition assessments from 11 sites on 1121 children 6-59months indicates 6.2% of the assessed children with MUAC of <12.5cm or oedema. Information from the health facilities in the area indicates a high and increasing trend of acutely malnourished children (Figure 15). In other parts Figure 15: Badhan MCH HIS Nutrition Trends for 2008 of East Golis and Upper Nugal Valley livelihoods, access to milk, meat and income has reduced as the Deyr rains 14.0 in these areas were poor, leading to the out migration of 12.0 livestock. However, the rest of the livelihood received 10.0 adequate rainfall and the population are able to access some milk and income, improving their dietary diver- 8.0

sity. Another contributing factor to the improvement of 6.0 % Malnourished Malnourished %

regional nutrition analysis the nutritional situation in the area is the humanitarian 4.0 interventions (cash relief) that have been received. The chronic issues affecting the nutritional situation in the 2.0

area i.e. inadequate health services, poor sanitation, sub 0.0 optimal child feeding and care practices and morbidity Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sept 08 Oct 08 Nov 08 Dec 08 and low immunization status, still remain a challenge and should be responded to. Figure 16: Garadag MCH HIS Nutrition Trends for 2008 45 The Hawd and Nugal Valley Livelihood Zone of 40 the Northwest 35 Currently the nutrition situation of the Hawd and Nugal 30 Valley pastoralists is classified as Serious. The Hawd 25 has shown an improvement from the Post Gu ’08 in- 20 % Malnourished tegrated nutritional analysis, when it was classified as 15 Critical, while the Nugal Valley remains Serious and 10

stable. MUAC data recorded from 1148 children in 12 5

sites of the Hawd livelihood indicates 7% of the assessed 0 children with MUAC measurements <12.5cm. Data from Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sept 08 Oct 08 Nov 08 Dec 08 the health facilities indicate low and decreasing numbers of acutely malnourished children (Table 13). The main factors contributing to the improved nutrition situation in the Hawd include; increased milk and meat consumption and income due to the good Deyr rains in September and October 08, causing in migration of livestock to the area.

FSAU Technical Series Report No V. 16 28 Issued February 20, 2009 According to food security reports3, rains in the Hawd Figure 17: Lasaanod Daami MCH HIS Nutrition Trends of Hargeisa failed. This has led to out migration and for 2008 reduced access to income and milk in the area. Although 14 there has been an improvement, the area remains vul- 12 nerable. Poor sanitation, lack of adequate clean water, 10 morbidity, low immunization coverage and limited health 8

facilities remain a challenge and are chronic underlying 6 % Malnourished Malnourished %

factors affecting the nutrition situation. Close monitor- 4 ing of the nutrition situation of this population group 2 remains crucial. 0 Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sept 08 Oct 08 Nov 08 Dec 08

Table 13: Key Reference Indicator Findings Outcome Hawd Livelihood Zone MUAC (N=1148 Sites = 12) <11 cm = 0.3 <12.5 cm = 7.0 Serious Oedema None Data indicates a low and decreasing trend of acutely malnourished chil- HIS Nutrition Trend Alert dren Dietary Diversity1 Improved from past season, however milk availability is still low Alert Disease Outbreaks Cases of diarrhoea and measles have been reported in the area Serious Immunization Status2 Low Very Critical Access to Health Services Limited Health services in the area Critical Selective Feeding Programmes Very limited Critical

Overall Situation Analysis: Serious regional nutrition analysis Nugal Valley Livelihood Zone MUAC (N= 982 Sites = 9) <11 cm = 1.0 <12.5 cm = 9.4 Serious Data indicates high and increasing trend of acutely malnourished children Critical in Upper Nugal, HIS Nutrition Trend But low and decreasing number of acutely malnourished children in Lower Alert Nugal Improved from previous season, in Lower Nugal and there is low milk avail- Dietary Diversity Serious ability however it is still poor in Upper Nugal, with no milk availability Increased cases of diarrhoea were noted in Huddun district but have so Critical Disease Outbreaks far been contained Immunization Status Low Critical Overall limited health facilities in the area, Upper Nugal has more acces- Access to Health Services Critical sible health facilities Selective Feeding Programmes Very Limited Very Critical Overall Situation Analysis: Serious

The nutrition situation in Nugal Valley livelihood zone is Serious according to the Post Deyr ‘08/09 integrated nutritional analysis. Findings on anthropometric measurements of 982 children 6-59months from 9 sites indicate the proportion with MUAC <12.5cm as 9.4%. The health facility data and the food security indicators, however, from upper and lower Nugal Valley depict different situations. The health facilities in upper Nugal Valley (Figure 16) show a recent high and increasing trend of acutely malnourished children and increased cases of diarrhoea. Food security indicators also show that the area has not received rainfall, and the population are out migrating southwards. On the other hand the health facilities in lower Nugal Valley show low and decreasing numbers of acutely malnourished children (Figure 17). The area has received adequate rains and the population has access to milk, meat and income from its sales. Therefore, although the livelihood’s nutrition situation remains as Serious, upper Nugal Valley is likely to deteriorate and will require close monitoring.

3.8.5 Agro-pastoral Livelihood Zone of Northwest The nutrition situation in the northwest (Galbeed/Awdal) and Togdheer/ Sahil agro-pastoral livelihoods remains Serious since the Post Gu ’08. The integrated nutrition analysis of data from the rapid MUAC nutrition assessments from 15 sites in the Galbeed/Awdal agro-pastoral and 9 sites from the Togdheer/Sahil Agro-pastoral indicates that <10% of the assessed children had a MUAC of <12.5cm or oedema (Table 14). Information from health facilities indicate low and stable numbers of acutely malnourished children. No disease outbreaks were noted in the area, however in the Togdheer/Sahil agro-pastoral cases of measles were reported. Qualitative information gathered on the dietary diversity of the households indicates low milk consumption and reduced meal frequency. The food security indicators for both agro-pastoral livelihood zones, except for Gebiley district indicate insufficient rainfall, reduced milk consumption and crop production below average4. It is imperative to carry on closely observing the key food security and nutrition indicators to detect any changes that may occur resulting in a deterioration of the nutritional situation of the population. In addition to the food security risk factors, the population also remains vulnerable to chronic risks namely poor child care and feeding practices, low immunization coverage, poor sanitation, inadequate supply of clean drinking water, morbidity and limited access to health facilities in the area.

3 FSAU Post Deyr’08/09 Presentation in the FSERD meeting, January 30th, 2009 4 FSAU Post Deyr 08/09 Technical Series

FSAU Technical Series Report No V. 16 29 Issued February 20, 2009 Table 14: Summary of Results of Northwest Agro-pastoral LHZs Key Reference Indicator Findings Outcome Agro-pastoral (Galbeed/Awdal) Livelihood Zone MUAC (N= 1223 Sites = 15) <11 cm = 2.5 <12.5 cm = 7.4 Serious HIS Nutrition Trend Data indicates low numbers of acutely malnourished children Alert Poor Dietary Diversity Poor; no milk available, high food prices, reduced meal frequency Serious Disease Outbreaks None reported Acceptable Immunization Status Low Critical Access to Health Services Limited Serious Selective Feeding Programmes Limited in the area Serious Overall Situation Analysis: Serious Agro-pastoral (Togdheer/Sahil) Livelihood Zone MUAC (N= 618 Sites = 9) <11 cm = 2.6 <12.5 cm = 7.4 Serious HIS Nutrition Trend Data indicates a low but stable trend of acutely malnourished children Serious Dietary Diversity Poor; no milk available, high food prices, reduced meal frequency Serious Disease Outbreaks Cases of measles were noted in the area and treated Critical Immunization Status Low Critical Access to Health Services Very Limited in the area Very Critical Selective Feeding Programmes Limited Serious Overall Situation Analysis: Serious

IDPs of Northwest: Hargeisa and Burao IDPs The nutrition situation of the populations in Hargeisa and Burao IDP settlements has improved from Very Critical in the Post Gu ’08 integrated nutritional analysis to Serious and Critical respectively. Analysis of rapid nutrition assessments data from 9 sites in Hargeisa IDPs indicates a global acute malnutrition (WHZ <-2 or oedema) rate of 13.6% (10.7-16.7) and a severe acute malnutrition rate (WHZ <-3 or oedema) of 2.4% (1.4-3.5). In Burao IDP settlements, an exhaustive nutrition assessment was conducted among children 6-59 months. A total of 337 children were assessed, the GAM (WHZ <-2 or oedema) was 15.0% and the SAM (WHZ <-3 or oedema) reported was 0.7%. (Table 15). Morbidity data was also collected during the assessments among the Hargeisa and Burao IDPs with the proportion of children that had suffered from one or more illnesses in the two weeks prior to the assessment reported at 20.5% and 18.1% respectively.

Table 15; Key Reference Indicator Findings Outcome IDPs of Hargeisa Global Acute Malnutrition (WHZ<-2 or oedema) 13.6 (10.7-16.7) Serious Severe Acute Malnutrition (WHZ<-3 or oedema) 2.4 (1.4-3.5) Alert Global Acute Malnutrition (WHZ<-2 or oedema) WHO 14.3 (11.5-17.5) Serious reference standard Severe Acute Malnutrition (WHZ<-3 or oedema) WHO 3.9 (2.6-5.9) Serious reference standard Data indicates high numbers and increasing trend of acutely HIS Nutrition Trend Critical malnourished children

regional nutrition analysis Morbidity (two weeks recall): 20.5 Critical Poor Dietary Diversity Poor; high food prices and reduced meal frequency Serious Disease Outbreaks Increased cases of diarrhoea noted in Daami settlement Acceptable Overall Situation Analysis: Serious IDPs of Burao Global Acute Malnutrition (WHZ<-2 or oedema) 15.0 Critical Severe Acute Malnutrition (WHZ<-3 or oedema) 0.7 Alert Global Acute Malnutrition (WHZ<-2 or oedema) WHO 16.1 Critical reference standard Severe Acute Malnutrition (WHZ<-3 or oedema) WHO 3.6 Serious reference standard Data indicates high numbers and decreasing trend of acutely malnour- HIS Nutrition Trend Critical ished children Disease Outbreaks (Morbidity) 18.1 Critical Dietary Diversity Poor; high food prices and reduced meal consumption per day Serious Disease Outbreaks Increased Cases of diarrhoea noted Alert Overall Situation Analysis: Critical

The data from health facilities in Hargeisa showed a high and increasing number of acutely malnourished children, while the data from the Burao health facilities showed a high but decreasing trend of acutely malnourished children. In both IDP settlements, there were no outbreaks reported, although in Daami settlement of Hargeisa and in Burao there were increased cases of diarrhoea, which have so far been contained. Continued high food prices resulting in reduced food consumption at the household level, high morbidity rates and other risk factors such as low immunization coverage, poor feeding and child care practices, lack of adequate clean water, and poor sanitation are risk factors that are likely to exacerbate the precarious nutrition situation.

FSAU Technical Series Report No V. 16 30 Issued February 20, 2009 The main contributing factor to the slight improvement of the nutrition situation is likely to be the establishment of supplementary and therapeutic feeding and outreach programmes in Burao and Hargeisa. However the situation still warrants continuing interventions. At the time of the assessment, a ‘Child Health’ campaign was on going in the whole region of the northwest, conducted by the Ministry of Health and Labour (MOHL) in collaboration with UNICEF. The activities included screening, de-worming, vaccinating and distribution of vitamin A supplementation to all children 6-59 months; this is a positive step to mitigate the risk factors of acute malnutrition. It is important to continue, expand and commence (in areas that have not began) such relevant interventions to rehabilitate acutely malnourished children. These efforts should also be supported by long term interventions such as improved child care and feeding practices and provision of water and proper sanitation facilities. ______1 FSAU Post Gu July 08 Rapid Field Assessment 2 UNICEF Somaliland EPI Coverage Survey June 08 indicated measles coverage 29.4% and Vitamin A 20.8%

3.9 Urban Nutrition Analysis

To assess the impact of the food price crisis on nutritional status of urban households, FSAU initially assessed anthropometric indicators as a component of the quarterly urban assessment. Mid Upper Arm Circumference (MUAC) was assessed in over 10,000 children over the two rounds in March and June from over 50 sites. The results indicated a varied picture without any strong correlation with the food security analysis. This is in line with many recent reports including ACF1 and WFP2, where the implications of the increased food prices on urban populations are more likely to be manifested through other indicators, such as micronutrient deficiencies as a result of reduced dietary regional nutrition analysis quality. However, the lack of clear correlation could also be linked to a further constraint of the need for representative samples when assessing anthropometric status, which, when monitoring over fifty sites, on a quarterly basis, proves difficult. Therefore the need for other more simple tools that could also be sensitive in assessing the impact of the urban food prices at the household level without the need for large samples, were required. (For a full report on the urban food security analysis see FSAU Technical Series report, Post Deyr ‘08/09 analysis).

As a result, FSAU reviewed the indicators assessed and for the October and December analysis, assessed dietary diversity and coping strategies employed at household level. The results also indicated similar trends to what was reported in the ACF study, where households chose less nutritious food, significantly reducing animal protein sources, relying predominantly on cereal and oils to meet their calorific needs. Overall the numbers of household consuming less than four food groups per day3, ranged from 20% to 60%, the most affected regions also those reporting the highest increases in food prices. Other coping strategies reported were skipping of meals, borrowing food or eating in neighbours houses. The overall number of households employing at least one of these coping strategies had increased from 32% in October 2007 to 59% in October 2008.

Urban health centre data and feeding centre data on trends in acute malnutrition were also assessed and ranged from low and stable (in Awdal, Nugal and parts of Sool regions) to high and increasing trends in Berbera, Erigavo and Beletweyne. An Acute Watery Diarrhoea (AWD) outbreak was reported in Huddun and Abudwaq and malaria outbreak reported in Elbur. These factors need to be considered when analysing the nutrition data. Findings on rapid MUAC (proportion <12.5cm) indicated 16.4%, 5.5% and 11.8% of assessed children in Huddun, Saarmanyo and Erigavo (Sool and Sanag) as acutely malnourished. Bossaso Urban LQAs assessment (Nov’08) recorded a GAM rate of 15-19.9%. Integrated analysis of the urban data indicates the situation to be Very Critical in Gedo, Awdal (Lawyaddo and Garbo) and Berbera in Galbeed; Critical in Toghdeer, Huddun and Bossasso, and likely to be Critical in Mudug, Galgadud, Hiran, Bakool– except for Wajid. Other urban centres, including those in Juba regions are either in the Serious, Alert or likely to be Serious phases.

More detailed studies were conducted in two main urban towns, Bossaso in the northeast region and Baidoa in the South. Results are presented below.

Bossaso Urban An LQAS nutrition survey was conducted in the Bossasso urban population in November 2008, following concerns that the nutrition situation may have deteriorated with the increasing food prices. Bossasso urban had already been identified from the PostGu ’08 analysis as having larger proportions of the poor in Humanitarian Emergencies based on an analysis of the minimum expenditure basket (See FSAU Post Gu 08 Technical Series for more information) The results from the LQAS study reported a GAM rate falling between 15-19.9% (WHZ<-2 or oedema) indicating a sustained Critical nutrition situation (Table 16).

1 Feeding Hunger and Insecurity, Briefing Paper, January 2009, ACF 2 Sight and Life Magazine, issue No 2/2009, “Nutrition in the Perfect Storm’ 3 FSAU defines <4 food groups in 24 hrs as a poorly diversified diet. FSAU uses theAO, F FANTA 24hr recall tool to assess dietary diversity.

FSAU Technical Series Report No V. 16 31 Issued February 20, 2009 Table 16: Summary of Results of Bossaso Urban Key Reference Indicator Findings Outcome Bossaso urban N=198 GAM ( LQAS study, Nov’08 n=198) 15-19.9 Critical SAM 0.5 Alert Oedema 0.5 Alert Proportion acutely malnourished non pregnant women 1.3(0.0 – 3.91) Acceptable MUAC≤18.5 cm) Proportion of acutely malnourished pregnant women 19.1 (12.2 – 35.9) Critical (MUAC<23.0). Data indicates high numbers and increasing trend of HIS Nutrition Trends Critical acutely malnourished children Measles: 63.7 Alert Immunization Status Vitamin A : 91.1 Serious Morbidity 7.9 Disease trends (seasonally adjusted Critical AWD:300 cases and C FR=2.7%,WHO,Oct’08) Admission trends at TFPs/SFPs (ACF, Bosaaso – Jan- Data indicates high numbers and increasing Critical Dec’08) Poor household dietary diversity (< 4 food groups) 5.2 ( 0.6-9.8), high food prices. Alert

Access to Safe water 57.3 Serious Access to health Services 38.5 Critical Food Security situation AFLC-Moderate risk Critical Civil Insecurity Situation Overall Situation Analysis: Critical

The worrying situation is largely attributed to the increasing food insecurity as a results of the increased food prices and exacerbated by the morbidity, especially the outbreak of AWD, which was significantly associated with acute malnutrition as well as the reported cause of high mortality. Measures to increase purchasing power of the urban poor populations are essential to improve household food security and allow families to access other vital non food commodities such as school fees, health care and fuel.

Bay and Bakool Urban Areas The Bay and Bakool urban assessment conducted in October 2008 reported that the majority of the poor households in Bay and Bakool are in crisis, apparently relying on less preferred food, borrowing, credits and reduced number of meals in a day to minimize the household expenditure on food and non food items. Comparing October 2007 to the situation in October 2008, the situation had deteriorated with more severe coping strategies noticeable in 2008. These include decrease in expenditure; increasing regional nutrition analysis family members out migrating for work and food; sale of productive and domestic assets; skipping an entire day without food and seeking for more Weight Measurement FSAU, Oct. ‘08 remittances. The nutrition data also indicates this stress with a Critical situation requiring close monitoring.

The assessment reported that about 75% of the assessed households consumed a poorly diversified diet (three or fewer food groups in a day) in a 24 hour recall period prior to the assessment. The mean dietary diversity score was 1.2 (SD=05.5), the main food consumed was, not surpris- ingly, sorghum Most of the households (75%) reportedly purchased their daily food supplies, while the remaining proportion of households bartered for their food supplies (25%). Half (50%) of the adults apparently consumed two meals per day while three-quarters (75%) of the children under five years consumed three meals.

In Baidoa specifically, the selective feeding centre in- Height measurement FSAU, Oct. ‘08 dicate high and stable levels of admissions to selective feeding centres. Similarly, health facility data from Baidoa IDP settlements indicates high and stable levels in admissions.

FSAU Technical Series Report No V. 16 32 Issued February 20, 2009 Case study: A Family in Bossaso IDP Camp, FebRUARY, 2009

Dheeraad Cumar Cali, 35, has resided with her husband Hersi and nine children in Raf iyo Raho settlement of Bossaso IDP camp since 1999, when they were displaced from Mogadishu as a result of civil insecurity. Prior to the civil war, Hersi worked as a soldier, but was incapacitated from working five years ago following a bullet injury, which still affects him today. Therefore, he is currently unable to contribute significantly to the upkeep of his family, leaving Dheeraad as the main breadwinner. Her main source of income is through casual labour, mainly cleaning of households, supplemented with shoe-shining by her son. The family occasionally access relief assistance from local food distributions with the remaining of their food purchased.

Their youngest son, Mohamed, is a healthy well nourished 42 month old and was breastfed for two years. Mohamed, as well as all the children are fully immunized, while Dheeraad has completed five TT doses. Despite this, the family have faced setbacks as a result of their precarious living situation in the IDP settlement. In May 2008, Dheeraad lost two of her children following an outbreak of Acute Watery Diarrhoea. However, the family continues to cling to hope for the rest of the family and Dheeraad continually accesses the MCH facilities for her surviving children when they are ill.

Dheeraad is, however, very concerned about access to safe water and sanitation facilities. The household uses two 20-litre containers of water a day,

each costing between 2000 – 3000 case study Somali Shillings (SSh). The compound in where Dheeraad lives, constitutes of 11 households residing in poor shelters (see photo) all of whom utilise two pit latrines for human waste disposal at a cost of Ssh 5000 a month. Despite understanding the negative impact of poor sanitation, the costs of water and sanitation services limit appropriate hygiene practices, thereby contributing to poor personal and environmental Dheeraad’s clean compound, Bossaso IDP camp hygiene. However, Dheeraad tries to FSAU, Oct. ‘08 keep her family, house and compound clean.

Dheeraad recommends an improvement in availability of safe water, decent housing conditions and improved access to health services to curb poor health and malnutrition within the camp. While she and her family remain optimists for the future, she wants her story and that of all the IDPs in Bossaso told, to highlight their needs.

The IDP populations remain some of the most nutritionally vulnerable populations in Somaila and with current estimates of over 1 million of the population displaced; they represent a significant proportion of the population. In 2008, the highest rate of acute malnutrition recorded was in Bossaso camp at 27.9%, with an alarming rate of severe malnutrition at 7.4%. The IDPs need fully integrated and sustainable programmes aimed at improving access to basic services including health, nutrition, WASH and education as well as livelihood opportunities to increase their resilience to future shocks.

Interview conducted by Khalif Nouh, FSAU Nutrition Focal point based in Bossasso.

FSAU Technical Series Report No V. 16 33 Issued February 20, 2009 4. Development of Caseload Estimates of Acutely Malnourished Children in SomalIa

FSAU, in collaboration with nutrition cluster partners, in 2008 began to illustrate the distribution of estimates of acutely malnourished children in Somaila. The objective of this was to highlight to response agencies and donors the needs in different parts of the countries, and move away just from the situation analysis also considering the impact of population density in determining response needs. Map 4 illustrates the total caseload based on the most recent nutrition assessments in a given area, and where surveys are not available extrapolations are made using median rates specific to the region as appropriate. This has meant that the current map developed by FSAU has estimated the caseload of malnourished children of approximately 83% of the population from 6months to 5 years in Somalia.

Given the lack of nutrition data in the non crisis rural areas in the northwest and north east regions, these areas have not been included. As regional assessments are planned in both these regions in the Gu 09 cycle, it is anticipated that a full caseload of the entire reference population can be developed in the Gu 09 map. Population figures from the UNDP 2005 settlement survey are used, as the standard reference for Somalia.

The map, therefore illus- Map 4: Distribution of Estimated Caseloads of Acutely malnourished Children, Jan. ’09 trates the distribution of the total estimated caseload 43 0'0"E 46 0'0"E 49 0'0"E

of acutely malnourished 2 5% 2 0%

children and the regional 12 0'0"N 12 0'0"N importance which relates Gulf of Aden !( to population density. For example the Deyr 08/09 Awdal !( nutrition cycles estimated Sanag Bari approximately 200,000 Woq. Galbeed GAM: Estimated Percentages ! !( children 6-59months as of Total Caseload of Acutely Malnourished Children under 5 years in Somalia by Region Togdheer acutely malnourished of Sool

SAM: Estimated Percentages 9 0'0"N which 60,000 are severely of Total Caseload of Severely Malnourished Children under !( malnourished. 5 years in Somalia by Region Severity Scale Nugal <10% 10-20% >20% The distributions of acutely Protracted IDPs

malnourished children are 4 0% 4 0% illustrated in blue, with !( Mudug the highest proportion of the 200,000 children in 18.0% 16.0%

Shabelle regions, at 34.5%, SAM 6 0'0"N followed by Central at 18% and so on. For the severely Galgadud malnourished children of GAM

6 0% 6 0% the total 60,000, the highest 7 0% 8 0% LEGEND proportions are also in the Bakol Nutrition Situation Shabelles at 34% followed Hiran Acceptable by Central at 16% and so 7 0% 9 0% !( Alert caseloads of acutely malnourished children on. Bay M. Shabelle 3 0'0"N Insufficient data but likely Gedo 12.0% 11.0% 34.5% 34.0% to be Alert The indicators used are Banadir! !( LEGEND Serious L. Shabelle Insufficient data but likely based on the WHO Growth ! to be Serious M. Juba Critical

Standards 2006, <-2 WHZ KENYA Insufficient data but likely and/or oedema for GAM to be Cri ical

and <-3 and/or oedema for 9.0% 10.0% Very Critical SAM. FSAU also computes Insufficient data but likely ± to be Very Critical IDP Phase the caseload by region and 020 0 0 80 120 160 0 0'0" Serious district using the WHO GS L. Juba !( Ki ometers Critical WHZ, NCHS WHZ, and Very Cri ical MUAC (<12.5cm, <11.5cm *These numbers are derived using nutrition survey data from the most recent surveys from 2008. Where recent surveys have not been conducted in crisis areas, median rates have been app ied. and <11cm). For more infor- These numbers represent 83% of the total <5years population in 43 0'0"E 46 0'0"E Somalia, as they do not include rural populations in the north mation please contact west and north east regions due to lack of data.

[email protected]. Food Security Analysis Unit Somalia http://www fsausomali org P.O. Box 1230 V llage Market, Nairobi, Kenya Ema l: sauinfo@ sau.o .ke tel: 25 -20-37 573 ax 25 -20-37 0598 FSAU s managed by FAO, funded by EC, the Government of Norway and USA D. FSAU Partners are FEWS NET, WFP, FAO, UNOCHA, SCF-UK, UNICEF, CARE, UNDP The boundaries and names on these maps do not imply official endorsement or acceptance by the Un ted Nat ons. The regional & D strict boundares ref ect those endorsed by the Government of the Republic of Soma ia in 1986.

FSAU Technical Series Report No V. 16 34 Issued February 20, 2009 (0885-3.04) (0.87-3.60) (0.90-3.17) R / M 5 U 10,000/day 1.06 (0.52-2.14) 1.64 3.05 (1.08-5.12) - -

1.80 1.94 (0.88-4.26)

(1.05-2.98) 1.78 2.15 (1.17-3.94) 2.15 N/A 1.69

1.15 (0.33-3.88) - 0.99 (0.44-3.60)

3.27 (1.97-5.39) 2.27 (1.5-3.45) 1.82 (1.1-3.01) (0.37-1.34) R/ C M 10,000/day 1.05 (0.65-1.68) 0.64 (0.35-1.88) 1.04 (0.63-1.72) - -

0.98 (0.58-1.45) 0.63 (0.32-1.26)

0.91 (0.16-1.34) 1.01 (0.66-1.55) 1.01 N/A 0.70

0.69 (0.34-1.37) - 0.69 (0.39-2.20)

1.08 (0.68-1.71) 1.19 (0.83-1.75) 1.19 0.90 (0.51-1.58) caseloads of acutely malnourished children caseloads of (4.2-8.1) (5.2-8.9) M based on SA WHO 2006 <-3 Z scores/ Oedema (%) 6.6 (4.4-9.7) 14.0 (10.9-17.7)14.0 0.8 (0.4-2.0) - - 7.0 6.1 4.4 (3.1-6.2) 3.3 (2.2-4.9) N/A 5.2 (3.3-8.2) 10.8 (8.3-14.0) - - 5.3 (3.3-8.5) 4.2 (1.1-11.3) 4.0 (2.6-6.2) M based on GA WHO 2006 <-2 Z scores or oedema (%) 22.3 (17.2-28.4) 28.9 (25.5-32.6) 9.9 (7.2-13.7) - - 21.8 (18.9-24.0)21.8 18.8 (15.7-21.0) 13.1 (10.7-15.8)13.1 10.7 (8.4-13.4) 10.7 N/A 12.4 (9.4-16.3) 27.4 (23.7-31.6) - - 12.8 (9.3-17.4) 14.3 (8.7-19.9)14.3 15.0 (11.5-19.4) M based on SA NCHS <-3 Z scores/ Oedema (%) 2.4 (1.4-3.5) 7.6 (5.3-10.8)7.6 0.5 (0.0-1.1) 0.5 4.4

5.8 (3.2-8.4) 3.8 (2.0-5.4)

2.2 (1.3-3.6) 2.5 (1.4-4.4) N/A 2.8 (1.7-4.8) 6.6 (4.8-8.7) - -

4.2 (259-7.1) 2.9 (0.5-5.4) 2.4 (1.3-4.2) M based on GA NCHS <-2 Z scores or oedema (%) 20.7 (15.3-26.7) 27.9 (24.3-31.9)27.9 9.9 (6.9-13.0) 15-19.9 17.4

20.8 (14.9-26.8) 18.4 (12.7-24.2)

12.5 (10.6-14.6) 10.8 (8.6-13.5) 10-14.9% 12.3 (9.7-15.5) 25.4 (21.8-29.0) >20

10.9 (8.8-13.5) 13.9 (8.3-19.5) 14.9 (11.2-19.4) Sample Size 535 774 593 201 431 776 640 681 638 205 667 831 198 >20 705 732 713 720 Date of Nutrition Survey Oct’08 Nov’08

Oct’08 Nov’08 Dec’08

Nov’08 Nov’08

Nov’08 Nov’08 Nov’08 Nov’08

Dec’08 Dec’08 Dec’08

Dec’08 Dec’08 Dec’08 ctober-December 2008) O , UNICEF, SRCS, UNICEF, MOH , Unicef, Mercy COSV, , GHC, SRCS, WFP , GHC, SRCS, WFP , GHC, SRCS, WFP sau sau sau sau sau Participating Agencies FSAU, Unicef, MOHL FSAU, UNICEF, MOHFSAU, UNICEF, FSAU, Unicef, MOHL, WFP, Horn Relief FSAU, Unicef, MOH FSAU, UNICEF, SRCSFSAU, UNICEF, MOH F F USA, Intersos, SRCS, Zam- zam, Muslim Aid F F F FSAU, Unicef, Afrec, WVI, Mercy USA, SRCS ummary Nutrition of Assessments ( able 17: S able 17: Region/ Livelihood Northwest & Northeast Regions Guban/West1. Golis 3. Bossaso IDPs 2. Sool Sanaag plateau 4. Bossasso Urban (LQAs) 5. Garowe IDPs (Exhaustive) FSAU, MOH Central Regions 6. Hawd Pastoral 7. Addun Pastoral7. Shabelle Regions 8. Shabelle Agropastoral 9. Shabelle Riverine 10. Shabelle10. Riverine (LQAs) 11. Shabelle IDP11. (Merka/Afgoye) Gedo Region 12. Gedo12. Pastoral 13. Gedo13. Riverine(LQAs) 14. Gedo14. Agropastoral Juba Region 15. Juba15. Riverine 16. Juba16. Agropastoral 17. Juba Pastoral 17. T

FSAU Technical Series Report No V. 16 35 Issued February 20, 2009 5. PLAUSIBILITY CHECKS

In FSAU the use of plausibility check has taken root since early 2007. The procedure has made it possible to check the quality of anthropometric data collected and by so doing improve the data quality. FSAU uses the checks on the latest available software of ENA1 to evaluate the quality of the assessments and publishes only those that meet the quality standards. The explanation of the different quality checks are provided below, with Table 18 outlining the results of the Deyr ’08/09 cycle of assessments.

The current version of ENA also provides an overall percentage for the quality of the surveys. Results of <5% indicates very good quality, results 5-10% indicates good quality, results 10-15% indicates poor results, but still of publishable levels, 15-25% indicates poor and questionable publishable quality and >25% illustrates very poor quality that should not be reported. Therefore, when reporting survey results, FSAU will only report those with a result <15%. However, given FSAU focuses on wasting for reporting, errors in age are considered only for underweight and stunting indicators.

Digit preference (DP) for weight and height: Indicates how accurately children were weighed and when done correctly there shouldn’t be any digit preference. This normally occurs when enumerators round to the nearest cm/ kg or half cm/kg. The signs; +, ++, +++ indicate if there was any DP for a number and if it was, mild, moderate or severe, respectively.

Standard Deviation (SD) of WHZ: Indicates whether there was a substantial random error in measurements. In a normal distribution the SD is equal to +1, but should lie between 0.8 and 1.2 Z score. SD increases as the proportion of erroneous results in the dataset increases.

Skewness of WHZ: This is a measure of degree of asymmetry of the data around the mean. A normal distribution is symmetrical and has zero skewness and should lie between +1 or -1. Positive skewness indicates a long right tail and negative skewness indicates a long left tail.

Kurtosis of WHZ: This demonstrates the relative peakedness or flatness compared to a normal distribution. The normal distribution has zero kurtosis and surveys should lie between +1 and -1. Positive kurtosis indicates a peaked distribution, while negative is a flat one.

Percent of flag: Flags are measurement, that are highly unlikely to occur in nature and are therefore highlighted by measurements’ software. These incoherent measurements should be corrected or discarded prior to analysis, 0% flags is ideal but should be less that 2-3% of children measured. plausibility checks Age distribution: This allows for a view of the representativeness of the sample, and should be similar to the distribution within the population. Age bias is of particular concern for anthropometry. As the younger age group (6-29) are more likely to acutely malnourished than older age group (30-59), this means under representation of the younger age group may give lower prevalence than the actual one and vice versa. The age ratio allows a view of this relationship and should be between 0.78 and 1.18 with an ideal ration of 0.98.

Sex ratio: Allows a view of the representativeness of the sample and should be similar to the distribution within the population. This should not vary too much from the expected sex ratio and should lie between 0.8 and 1.2

Table 18 provides a summary of findings on plausibility checks for nutrition assessments conducted in the Deyr ‘08/09

1 Emergency Nutrition Assessment www.nutrisurvey.net/ena_beta

FSAU Technical Series Report No V. 16 36 Issued February 20, 2009

(p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) (p<0.05) Pois- son dist WHZ-2 Excl p Good Good Good Good Good Good Good Good Good Good Good Good

-0.02 0.08 0.00 0.06 0.13 -0.02 - 0.11 -0.02 -0.06 - 0.15 0.13 0.06 Kurtosis WHZ Excl # Good Good Good Good Good Good Good Good Good Good Good Good

(-0.01) 0.04 0.16 0.3 (-0.21) 0.28 0.13 (-0.01) 0.13 0.17 0.04 0.09 - Skew ness WHZ Excl # Good Good Good Good Good Good Good Good Good Good Good Good

0.99 1.06 1.04 1.07 0.96 1.08 1.11 0.99 1.07 1.07 0.98 1.01 plausibility checks Dev WHZ Standard Dev WHZ Excl SD Good Good Good Good Good Good Good

13 6 Good 8 Good 15 17 18 31 13 34 9 Good 8 Good - - - Dig pref score - height Incl # Accept able Accept Unaccept able Unaccept able Accept Accept

6 6 Poor 6 Poor 6 2 Dig pref score - weight Incl # Good 4 Poor Good 5 Accept Good 4 Poor Accept Accept Good 4 Poor Accept Good 5 Poor 6 Poor 7 Good Good chi square) (Significant chi square) (p=0.000) (p=0.394) (p=0.003) (p=0.009) (p=0.000) (p=0.424) (p=0.000) (p=0.000) (p=0.353) (p=0.000) (p=0.001) ------Overall Age distrib Incl p Unaccept able Unaccept able Unaccept able Good Unaccept able Unaccept able Good Unaccept able chi square) (Significant chi square) p=(0.073) Poor Sex ratio Overall Sex ratio Incl P Good p=(0.829) Good p=(0.937) Accept Good p=(0.190) Poor Good p=(0.416) Good p=(0.502) Good p=(0.862) Poor (p=0.005) Good 5 Good p=(0.829) Poor p=(0.039) Good p=(0.515) Good p=(0.342) Good p=(0.333) Poor subjects) (% of in-range subjects) 0.80% 1.60% 2.30% 5.90% 1.50% 2.90% 2.80% 0.80% 3.40% 1.60% 1.70% 0.90% issing/ M Flagged data Incl % Good Good Good Poor Good Accept Accept Good Accept Good Good Good Category Category Category Category Category Category Category Category Category Category Category Category able 18: Plausibility 18: able Checks Criteria Bosasso IDP Addun Hawd Juba A/ Pastoral Juba Riverine Juba Pastoral Gedo Pastoral Gedo Riverine Gedo A/ Pastoral Shabelle A/Pastoral Shabelle Riverine Shabelle IDP T

FSAU Technical Series Report No V. 16 37 Issued February 20, 2009 6. APPENDICES 6.1: Somalia Livelihood Zones

41°0'0"E 44°0'0"E 47°0'0"E 50°0'0"E

Calula 12°0'0"N

DJIBOUTI Gulf of Aden Qandala

Zeylac Bossaaso Lughaye AWDAL Ceerigaabo Las Qoray/Badhan Baki Berbera SANAG Iskushuban Borama Ceel Afweyne Sheikh BARI Gebiley W. GALBEED

Hargeysa Qardho Burco Owdweyne Xudun Caynabo Talex Bandar Beyla TOGDHEER SOOL 9°0'0"N 9°0'0"N Laas Caanood Buuhoodle Garowe Legend Eyl /" NUGAL Country capital Burtinle International boundary

Regional boundary Jariiban ETHIOPIA Goldogob District boundary Galkacyo n a e River c O Coastline n Cadaado MUDUG ia d Hobyo n Cabudwaaq I 6°0'0"N 6°0'0"N

Dhusa Mareeb

GALGADUD Harardheere Ceel Barde Beled Weyne Ceel Bur BAKOOL Livelihood zones Rab-Dhuure HIIRAN Addun Pastoral Mixed sheep & goats, camel Xudur Awdal border & coastal towns Petty trading, fishing, salt mining Ceel Dheere Dolo Bay-Bakool Agro-Pastoral High potential sorghum Cattle, camel Tayeglow Bulo Barde Luuq Wajid Central regions Agro-Pastoral Cowpea, sheep & goats, camel, cattle Aden Yabal Coastal Deeh Sheep

appendix Beled Hawa Jalalaqsi Dawo Pastoral Shoats, cattle, camel Baydhaba Garbaharey Cadale East Golis Pastoral Frankinncense Jowhar M. SHABELLE Fishing Qansax Dheere Gagaab Pastoral Frankincense 3°0'0"N Wanle Weyne GEDO BAY Guban Pastoral Sheep, goats & camel Ceel Waq Bur Hakaba Balcad Hawd Pastoral Camel, sheep & goats Afgoye Hiran Agro-Pastoral Baardheere Dinsor /" BANADIR Hiran riverine Sorghum, maize, cattle & shoats MOGADISHU Qoryoley Juba pump irrigation Tobacco, onions, maize Sakow Kurtun Warrey Marka Kakaar-Dharor Pastoral Sheep, goats, camel M. JUBA L. & M. Shabelle Agro-Pastoral Irrigated Maize/Sorghum & cattle Sablale L. SHABELLE L. & M. Shabelle Agro-Pastoral rain-fed Maize,cowpeas, sesame & cattle Bu'aale Lower Juba Agro-Pastoral Maize & cattle KENYA Hagar Brava North-West Agro-Pastoral Sorghum, cattle North-West Valley Agro-Pastoral Irrigated vegetables, shoats Afmadow Jilib Nugal Va ley Pastoral Sheep & camel Potato zone & vegetables Shabelle riverine Maize, fruits & vegetables Jamaame L. JUBA Sool-Sanag Plateau Pastoral Camel, sheep & goats

0°0'0" South-East Pastoral Cattle, sheep & goats Kismayo Southern Agro-Pastoral Camel, cattle, sorghum ± Southern Juba riverine Maize, sesame, fruits & vegetables Southern coastal pastoral Goats, cattle 020 40 80 120 160 200 Badhadhe Southern inland pastoral Camel, sheep & goats Kilometers Togdheer Agro-Pastoral Sheep, goats & vegetables Urban West Golis Pastoral Goats camel sheep Datum: WGS84 41°0'0"E 44°0'0"E 47°0'0"E Data Source: FSAU, 2002 admin. layers: UNDP, 1998

Updated: April, 2006 Food Security Analysis Unit - Somalia http://www.fsausomali.org P.O. Box 1230 Vi lage Market, Nairobi, Kenya Email [email protected] tel 254-20-3745734 fax 254-20-3740598 FSAU is managed by FAO, funded by EC and USAID. FSAU Partners are FEWS NET, WFP, FAO, UNOCHA, SCF-UK, UNICEF, CARE, UNDP The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. The regional & District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986.

FSAU Technical Series Report No V. 16 38 Issued February 20, 2009 6.2 Progression of Estimated Nutrition Situation Deyr 06/07 - Deyr 08/09

Deyr ‘06/07 Gu ‘07 12°0 0 N 12°0 0 N 12°0 0 N A u 12°0 0 N DJIBOUTI Gulf of Aden Gulf of Aden A ula DJIBOUTI ) Kandala Zey ac Zeylac Bosaso Kandala ughaye ughaye Bosaso Badh n Awdal E igavo skushuban Iskushuban Awdal Bad an Be be a ) Bo ama Baki Sanag Be be a Sanag E igavo El A we n Bari o amaBaki Sheikh El A we n She kh Bari Woq Galbeed Woq Galbeed Gab ley Ha ge sa Gab ey Ga do ) Ga do Odweine Bende Bei a Ha geisa Odweine Bu co Bu c Bende Bei a Caynaba Xudun aleh Caynaba Xudun Togdhee Togdheer aleh Sool Sool 9°0 0 N 9°0 0 N 9°0 0 N 9°0 0 N

Buhod e asanod Ga o e asanod Buhodle ) Ga ow Eyl Nugal N gal Bu t n e Bu t nle Eyl

ETHIOPIA ban iban Goldogob ETHIOPIA G dogob Galkayo Ga kayo )

Adado Mudug Adado Hobyo Mudug 6°0 0 N 6°0 0 N 6°0 0 N 6°0 0 N ndian Ocean Dusa Ma eb ( Dusa Ma eb Indian Ocean Galgadud Be et We ne Galgadud Ha adhe e Ha adhe e El Ba de El Bu El Ba de Belet Weyne ( El Bu Bakol Bakol ab-Dhuu e Hudu ab Dhuu e Hudu Hiran Hiran El De ) El De Do o Bulo Bu ti Dolo LEGEND Wa id eg o Bu o Bu t uuq uuq Wa d eglo Nutrition S tuation Aden abal Aden abal let Hawa a alaqsi LEGEND B et Hawa a alaqs Insuf ic ent Data Ga baha e Ba doa Ada e Ga baha e Baidoa Nutrition Situation ( M Shabelle Insuf ic ent Data but ikely Gedo M Sh belle G do owha to be crit cal Qansa De e owha 3°0 0 N Wanle Weyne Qan a De e El Waq No Data 3°0 0 N Wan e Weyne Ada e Bay El Waq Bay Alert Bu Hakaba Balad Alert Bu Hakaba Ba ad Ser ous A goye A goye Ba de a Din o Qo yoley Banadir Ba de a D ns Qo yo ey Banadir( Crit cal Mogad shu ( L Shabelle Serious Mogad shu Sakow Sakow L Shabelle Very Critical Ku tun Wa ey Ma ka ( Ku tun Wa ey Ma( ka

KENYA Critical M Juba KENYA IDP Concen ration areas Sabla e M Juba Sab a e Bua e prior to January 2007 B ava Very Critical Bua e Pro ected rend ( an un '07) B ava Pro ected rend ( uly Dec '07) IDP Concen ration areas Po ential to Improve IDP Concentration Areas Potent al to Improve after January 2007 A madow i ib i ib Uncertain A madow he nut i ion si uat on is ana ysed using a ange o Uncer ain nut it on ind cato s om di ect and indi ect sou ces /" ( Po ential to De er orate National Cap tal Potent al to Dete iorate om anua y o u y nut t on su veys sen inel s tes L Juba amame ama e heal h ac l ty data ap d MUAC assesmen s Coastl ne L Juba se ect ve eed ng cent e data health epo ts and othe s 0°0 0 Interna ional Boundary 0°0 0 K smayo Kismayo Coas line ± Regional Boundary Interna ional Boundary Badhadhe 00 00 0 0 0 D str ct Boundary Badhadhe ± Regional Boundary D strict Boundary R ver 00 0 0 0 0 0 a m W 4 R ver 3°0'0 E 6°0 0 E a a e A 2 a m W 4 A m a e s 99 3°0 0 E 6°0'0 E a a e A 2 e a 2 7 A m a e s 99

Deyr ‘07/08 Gu ‘08 3°0'0 E 6°0'0 E 9°0'0 E 12°0 0 12°0 0 12°0 0 12°0 0 Alu a A ula Gulf of Aden DJIBOUTI ( Kandala Kandala Gulf of Aden e ac Bosaso Zey ac Bosaso DJIBOUTI ughaye ughaye Badh n Bad an Awdal Awdal E gavo Iskushuban Be be a Be be a Baki ( Bo ama Baki Sanag Bo ama Bari El A wein Sanag Bari El A wein E gavo Iskushuban She kh Woq Ga beed She kh Woq Galbeed Gab ey Bende Bei a Gab ley Ha ge sa Ha g ( ( Odweine Ga do Ga do Bende Bei a Odweine Bu co aleh Caynaba C ynaba Togdheer Xudun a eh Togdhee Xudun Bu c Sool

9°0 0 N Sool 9°0 0 N 9°0 0 N 9°0 0 N

Buhod e Ga o e Buhod e asanod Ga owe asanod (

Nugal Nugal appendix Eyl Eyl Bu t n e Bu t nle

ban iban ETHIOPIA ldogob o dogob Ga kayo Ga kayo ETHIOPIA (

Adado Adado Mudug Mudug Hobyo Hobyo 6°0 0 N 6°0 0 N 6°0 0 N 6°0 0 N

Dusa Ma eb Dusa Ma eb Indian Ocean Indian Ocean Galgadud Galgadud Ha adhe e El Bu Ha adhe e El Ba de Belet Weyne El Ba de Belet Weyne El Bu Bakol Bakol LEGEND Rab-Dhuu e Hudu Hiran ab Dhuu e Hudu Hiran El De Nutrition S tuation Do o El De Dolo Bu o Bu t eglo uuq Wa d eglo uuq Wa id Bulo Bu ti No data Aden abal Aden abal Be et Hawa nsuff cient data but like y et Hawa a alaqs a alaqsi LEGEND Ga baha e Baidoa Ada e o be cr tical Ga baha e Ba d a Ada e ( Nutrition Situation Gedo M Shabelle A ert Gedo M Shabelle Qansa De e owha Qansa De e owha No data 3°0 0 N Wanle Weyne 3°0 0 N Wan e Weyne El Waq El Waq Ser ous Bay Ba ad Bay Bu Hakaba Bu Hakaba Ba ad Alert A goye Crit cal o e Ba de a Din o Ba de a D nso Qo yo e Banadir Serious (Banadi( Mogad shu L Shabelle Very Cr tical Sakow Ku un Wa ey Qo yoley Sakow L Shabelle Critical Ma ka Ma( ka IDP Phase Ku tun Wa ey M Juba KENYA M Juba Sabla e Ser ous Sab ale DP Phase Bua e Bua e B ava Serious B ava Crit cal Very Cr tical Critical l b A madow A madow i ib e e T e a a - ) e e Te - eeme ) he Nut i ion S tua ion is analysed us ng a ange o Very Crit cal nut it on ndicato s om di ect and ndi ect sou ces otent al o Imp ove o ent al to Imp ove om uly to Dec 08 nut i ional su veys sent nel si es henut itonstuaton s anaysedusnga angeo amame heal h aci ity data ap d MUAC assesments se ec ive ama e Unce tain L Juba Unce ta n L Juba nut t on nd ca o s om di ect and ndi ect sou ces eed ng cent e data health epo ts and othe s 0°0 0 0°0 0 otent al o Dete io ate om uly o Decembe nut it on su veys sentinel s tes o ent al to Dete o a e Kismayo Dist ct Cap tal Kismayo hea th ac l ty data apid MUAC assesmen s ( select ve eeding cent e da a hea th epo ts and o he s Coastl ne

Badhadhe n e national Bounda y Badhadhe Coas l ne n e natonal Bounda y Regional Bounda y ± Reg onal Bounda y ± Dist ct Bounda y 00 0 0 0 0 0 Dist ict Bounda y 00 0 0 0 0 0 Rive 3°0 0 E 6°0'0 E 3°0'0 E 6°0'0 E Rive am W 4 aa e A 2 a m W 4 a e A e 9 A m a e s 99

Deyr ‘08/09 1 1 Alu a ( Kanda a Gulf of Aden Bosaso DJIBOUTIZ ac ughaye Badhan Awdal E igavo Is ushuban Baki ( Be be a Bo ama El A we n Sanag Bar Woq. Galbeed Sheikh Gab ley Bende Be la Ha geisa!! ( Ga do Odwe ne Bu co a eh Caynaba Togdheer Xudun 9°0 0 N 9°0 0 N Sool

Buhodle Ga owe asanod ( Nuga Eyl Bu inle Dist ict Cap tal Coast ine n e na ional Bounda y a iban ETHIOPIA o dogob Reg onal Bounda y Galkayo Dist ict Bounda y ( Rive

Adado Mudug Abudwaq Hobyo 6°0 0 N 6°0 0 N

Dusa Ma eb Indian Ocean Galgadud El Bu Ha adhe e El Ba de Belet Weyne Bakol

Rab Dhuu e Hudu Hiran Do o El De LEGEND ieg o uuq Wa id Bu o Bu i Nutrition Situation Aden abal et Hawa ala aqsi Acceptable Ga baha e Baidoa Adale ( Gedo M. Shabelle Alert Qansah De e owha 3°0 0 N Wan e Weyne El Waq Insufficient data but l kely Bay Balad Bu Hakaba to be Alert A goye Serious Ba de a Dnso !!Banadir( L. Shabelle Insuffic ent data but likely Sakow Ku tun Wa ey Qo yo ey Ma!! ka to be Serious Cr tical M. Juba Sab ale Bua e Insuffic ent data but likely B ava to be Critical

i b Very Critical A madow ee Te a a - 9) Insuffic ent data but likely otential to mp ove to be Very Cr tical amame L. Juba Unce ta n IDP Phase 0°0 0 otential to De e io ate Serious K smayo ( Cr tical

Badhadhe Very Critical he Nut t on S tua ion s ana ysed using a ange o nut t on ind cato s om di ect and indi ect sou ces om u y o Dec 08 ± nut t ona su veys (Oct Dec 08) heal h ac i y data ap d MUAC assesmen s se ect ve eed ng cent e data hea h epo ts 00 0 0 0 0 0 3°0'0 E 6°0 0 E and othe s am W 4 aa e A 2 A m a e s 99

FSAU Technical Series Report No V. 16 39 Issued February 20, 2009 6.3 Somalia Median Estimates of Acute Malnutrition 2001 - 2007 appendix

FSAU Technical Series Report No V. 16 40 Issued February 20, 2009 6.4 Nutrition Assessment Tools Post Deyr ‘08/09

FSAU POST DEYR ASSESSMENT 2008 Rapid Nutrition Assessment Guidelines

INSTRUCTIONS FOR USE

Overview: Rapid assessment tools are essential in countries with high vulnerability to shocks where populations are at risk of malnutrition. This is particularly relevant in Somalia with recurrent shocks such as ongoing conﬂ ict and natural disaster (drought, ﬂ ooding, etc). They provide a means of identifying in a very short space of time areas of risk of malnutrition, the need for a more detailed assessment such as a nutrition survey and the need for emergency interventions.

Criteria: This tool aims to be used in situations where concern has been raised over the nutritional situation, such as recent displacement, or previously inaccessible areas becoming accessible, or additional shocks such as ﬂ oods, drought, or where there is insufﬁ cient time to conduct a more detailed assessment etc. In addition if an agency has phased out of an area and wants to monitor if there is a need to re establish programmes then this can be used. This tool can be used in an assessment lasting from a few hours to a few days depending on the size of the team and the level of information available. In addition it can be used for one or more villages/camps again depending on the time and size of team available.

Team: The tool should only be used by experienced and trained nutrition staff. At a minimum at least one experienced nutritionist should lead the assessment and where necessary can train community health workers on the ground on the day if the size of the assessment area and population warrants many staff members. However for the Post Deyr Assessment all Nutrition Field Analysts will the appendix only one using this tool. Each of you in your location will then administer the tool fully by yourself in order to ensure consistency and high quality data. The tool is designed so that this it is feasible for one person to conduct this.

Methodology: -

1) ANTHROPOMETRIC DATA The most appropriate method for determining nutritional status in a rapid assessment is by using MUAC both for children from 6 months to 5 years, checking for oedema and if there is sufﬁ cient time and staff and a concern then also for pregnant and breast feeding mothers. In addition to nutrition, key informant interview and focus group discussions need to be held to gather additional information of health, food security, water and sanitation, child care practices and security where relevant.

Unlike nutrition surveys the sampling does not have to be done in a statistically signiﬁ cant way. However the following steps have been identiﬁ ed to give a rough estimate of the nutritional situation using MUAC: A tally sheet to record the results is attached

1 Children 6 – 59 months can also be roughly estimated to measure between 65-110cm. Therefore in order to reduce the time identifying the correct age, which is not always easy, a pole can be made marked with the 65 of both 65 and 110cm for ease of selection. These poles have been provided with the lower mark indicating 65cm and the upper 110cm. Only children measuring between the two marks should be included in this assessment.

2. On arrival in the location initially estimate the total number of the households in the village/ camp/ town through discussions with the sheikhs/ camp leaders: • If the total number of households is less than 110 - go to ALL households and measure the MUAC of the ALL children aged 6 months -5 years (65-110cm) • If the total number of households is >100 – randomly select 110 children 6 – 59 months – this can be done by going to the centre of the village, tossing a pen in the air and following the following the direction of the pen to the outside edge of the village. Then traveling from one edge of the village to the other opposite edge and measure ALL the children in the households to your right along that direction or line.

FSAU Technical Series Report No V. 16 41 Issued February 20, 2009 • If 110 children are not reached when you get to the edge of town/village then change direction and follow a different line from the edge of town and repeat this until a total of 110 children are measured. This will ensure the new arrivals on the outskirts of towns are included as well as those in the centre – this is relevant with the recent displacement from the ﬂ oods

1. MUAC must only be taken on the LEFT arm 2. All children should also be checked for oedema - if a case is suspected then this MUST be conﬁ rmed by the nutrition analyst. It is essential that all staff are well trained in checking for oedema. 3. To avoid repeating a measurement on the same child when there are more than one measur- ers - a marker pen can be used to leave a visible small mark on the child once measured such as on the top of the left hand. 4. During this walk, observations on the living conditions, food availability and preparation, asset ownership, water and sanitation facilities etc should be taken into consideration which can then be discussed when holding an informal FGD or KI interview

Reporting of Anthropometric Data: Reports should be short and should be released within a few days of the rapid assessments especially if the situation is of concern. A draft template has been attached in Annex 2 and outlines the key areas to be covered in the report. When reporting on the nutritional status, it is essential to report BOTH the absolute numbers and % of each cut off point in MUAC. However the numbers MUST NEVER BE REPORTED IN % GLOBAL ACUTE MALNUTRITION or % SEVERE ACUTE MALNUTRITION. This classifi cation can only be reserved for a statistically signifi cant nutrition surveys otherwise the fi gures may be quoted out of context and therefore misinterpreted. Reports must always state the methodology, the tools used and that this is a rapid assessment therefore cannot be interpreted in a statistically signifi cant manner. Where necessary if the rapid assessment is indicating an area of concern recommendations for a more detailed assessment such as a nutrition surveys should be made. A sample is in Annex 3.

2) Other Data on underlying causes appendix Information should also be included on other factors that can affect nutrition such as health, child care practices, water and sanitation. Our food security colleagues will already be collecting food security data through a focus group so we don’t need to. Ideally this other data should be collected through a focus group where women are present and IDP’s if there is displacement into that location. Therefore rather than establish a new focus group on arrival complete the anthropometric data collection then join the focus group and ask your questions at the end. In addition if you have any other points that are not included and that you feel will affect nutrition and are relevant please do add as they will contribute to the overall analysis

FSAU Technical Series Report No V. 16 42 Issued February 20, 2009 Annex 1 - Tally Sheet for MUAC Screening Children 6 – 59 months. – Please just use one sheet per village and one tick per child. For ease of completion please group the children into ten so the ﬁ rst ten measured the results should be in the ﬁ rst box the second 10 in the second row etc (see Annex 3 for an sample)

Screening Data / Rapid Assessment Tool - Children under 5 years Name Village:______Date:______Name of Screener:______

Children under 5years ( MUAC only to be measured on children 6 months and above or 65-110cm lying (65-84.9cm or standing for the 85 cm in height and above)

Child Group <11cm 11-12.4cm 12.5- >/=13.5 Oedema Clinical signs 13.4cm (65-110) of malnutrition <65cm (oedema or marasmus Child 1 - 10

Child 11 – 20

Child 21 – 30 appendix Child 31 – 40

Child 41 – 50

Child 51 – 60

Child 61 – 70

Child 71 – 80

Child 81 – 90

Child 91 – 100

Child 100-110

TOTAL

FSAU Technical Series Report No V. 16 43 Issued February 20, 2009 Annex 2 - Report Summary Table These questions should be asked in the focus groups discussion. Please join the food security team once you have completed the anthropometric component rather than setting up a separate group but make sure there are women present and actively contributing and displaced if appropriate

Interviewer Name

Date of Assessment Region District Village

Recent Displacement If Y what numbers and whether this is in or out Y / N displacement from this location What was the main cause for the displacement? When did the majority arrive?

Information available of the current nutritional status (previous surveys, feeding centre statistics, health centre data etc) SOCIAL CARE ENVIRONMENT Shelter conditions for the majority If displacement any immediate concerns on child care practices? Please below (please circle) 1) Good 2) Basic but reasonable 3) Very Poor HEALTH SITUATION Any recent incidence of Acute Watery Diarrhoea in Y / N this location?

If yes, Please describe how the incidence of Acute Minimum / Moderate / Severe Watery Diarrhoea has affected nutrition status of Comment children in the last month, circle minimum moder- appendix ate or severe

Recent Out- Are the Health services Can communities Are there any Health Top 3 illnesses for <5yrs breaks? functioning (do they access the health Services Available have staff drugs etc) services

1) Y / N Y / N 2) If N how close is near- Y / N Y / N If Y what? 3) est (km) If N why not? WATER

What water storage Describe the quality of this water (pls List the main sources Do families have sufﬁ cient quantities containers are being ask to see the water then circle then of drinking water for drinking during the day? (circle) used by the majority option most appropriate) - please list 1) Reasonable Y / N 2) Unclean If N why not? 3) Not sure SANITATION List the main sanitation facilities used now by List any concerns the community may have about the sanitation, such the community as the impact of the recent ﬂ oods

FSAU Technical Series Report No V. 16 44 Issued February 20, 2009 Nutrition Programmes SFC (Location, Agency, Nos of TFC / CTC (Location, Agency, Nos of List the closest nutrition pro- admissions) admissions) grammes available for referral if malnourished cases are identi- ﬁ ed and the agency that oper- ates and where possible recent trends in admissions if a nutrition worker from a feeding centre is available to speak with.

Summary of Nutrition Status: - Children 1 to 5years MUAC (cm) Nutritional status N= ( % ) >13.4cm 12.5cm to 13.4cm At risk of Malnutrition 11.0cm to 12.4cm Moderate Malnutrition < 11.0 cm Severe Malnutrition Oedema Severe Malnutrition CONCLUSIONS - To be completed by Nutrition Analyst once all the data has been collected from the village, add additional paper if necessary Main Problems Identiﬁ ed: (summarise the key ﬁ ndings)

Conclusion: Think about all the information collected and decide whether the nutrition situation is: i). very critical, ii). Critical, iii). Serious iv). Alert. how many people are affected, is

the situation likely to deteriorate. appendix

Sample - Screening Data / Rapid Assessment Tool - Children under 5 years Name Village: El Eak Date: 15th December 2006 Name of Screener: Mohamed Ibrahim

Children under 5years ( MUAC only to be measured on children 1 year and above or 65-110cm standing) Clinical signs of Child Group <11cm 11-12.4cm 12.5-13.4cm >/=13.5 Oedema malnutrition <1yr 1 Child 1 - 10 1 1 1 1 1 1 1 1 1

Child 11 – 20 1 1 1 1 1 1 1 1 1 1

Child 21 – 30 1 1 1 1 1 1 1 1 1 1 Child 31 – 40 1 1 1 1 1 1 1 1 1 1 Child 41 – 50 1 1 1 1 1 1 1 1 1 1 Child 51 – 60 1 1 1 1 1 1 1 1 1 1 Child 61 – 70 1 1 1 1 1 1 1 1 1 1 Child 71 – 80 1 1 1 1 1 1 1 1 1 1 Child 81 – 90 1 1 1 1 1 1 1 1 1 1 Child 91 – 100 1 1 1 1 1 1 1 1 1 1 Child 100-1101111111111 TOTAL 510187250

Summary of Nutrition Status: - Children 6-59 months MUAC (cm) Nutritional status N= 110 (100 % ) >13.4cm 72 (65.5%) 12.5cm to 13.4cm At risk of Malnutrition 18 (16.4%) 11.0cm to 12.4cm Moderate Malnutrition 10 ( 9%) < 11.0 cm Severe Malnutrition 5 ( 4.5%) Oedema Severe Malnutrition 5 (4.5%)

FSAU Technical Series Report No V. 16 45 Issued February 20, 2009 NUTRITION ASSESSMENT HOUSEHOLD QUESTIONNAIRE, 2008

Household Number ______Date______Team Number ______C l u s t e r N u m b e r ______Cluster Name ______District: ______

Q1-7 Characteristics of Household Q1. Household size1 ?______Q2. Number of children less than 5 years (0-59 months)? ______Q3. Sex of household head2? 1=Male 2=Female Q4a . How long has this household lived in this locality? 1= Resident 2=IDP<3 months 3=IDP March ’07 4=IDP before 2007 b. Are you hosting any recently (in the last 6 months) internally displaced persons? 1= Yes 2= No

c. If yes, Number of persons ______d. If yes, what is the impact of IDPs on the household? 1=Receive food aid 2=Increased income for the household 3=Less resources available 4= Other

Q5. Does household have mosquito net? _____ 1= Yes 2= No Q6. If yes, ask to see the net: _____ 1= GFSOM label 2=Other type 3= Not seen Q7. What is the household’s main source of income? 1= Animal & animal product sales 2= Crop sales/farming 3= Trade 4= Casual labour 5= Salaried/wage employment 6= Remittances/gifts/zakat 7= Others, specify ______

Q8-11 Feeding and immunization status of children aged 6 – 59 months in the household. Q8 Q 9 Q10 Q11 First Name Age How many times do Has child been (months) you feed the child in Has child been Vaccinated against Has the child (besides breast

appendix a day provided with Vita- measles? ever been given (if child is more milk)? min A in the last 6 1=Yes polio vaccine than 24 months months? 2= No orally? old, skip to Q9) 1= 1 time (show sample) 2=2 times 3=-3 times 1=Yes 1=Yes 4= 4 times 2= No 2= No 5= 5 times

1Number of persons who live together and eat from the same pot at the time of assessment 2One who controls and makes key decisions on household resources (livestock, assets, income, and food), health and social mat- ters for and on behalf of the household members.

FSAU Technical Series Report No V. 16 46 Issued February 20, 2009 Q12-23 Anthropometry and morbidity for children aged 6 – 59 months in the household

Q23 Q22 Q21 Q16 Q17 Is the child Where did you seek Q15 Diarrhea1 Q18 Did the child currently Q19 Q20 healthcare assistance Q12b Q13 Q14 MUAC in last two Serious ARI2 sleep under a registered Febrile illness/ Suspected when child was sick? (If Q12a Weight (cm) weeks (Oof Wareen/ mosquito net in any of suspected Measles4 yes in Q20 – 24) Sex Oedema Height (cm) (kg) Wareento) in the last night? the feeding Malaria3 in the in last one First Age To the near- last two weeks centres ast two weeks month 1=No assistance sought Name To the near- To the est tenth of 2=Own medication 1=Male 1=yes est tenth of nearest a cm 1= SFP 1=Yes 1=Yes 3=Traditional healer 2=Female 2= No a cm tenth of 1=Yes 1=Yes 2= TFC 2= No 2= No 4 = Sheikh / Prayers a kg 1= Yes 2= No 2= No 3= OTP/CTC 5=Private clinic/ (>6 mo) 2= No 4= Other Pharmacy 5=None 6= Public health facility

24: Anthropometry (MUAC) for adult women of childbearing age (15-49 years) present at the household

Received Illness Physiological Tetanus vac- in last 14 Age MUAC status Sno Name cine? 1=Pregnant days? If Codes for adult illnesses (years) 1= Yes (cm) 2= Non pregnant yes, what 2= No illness? 0= None 1= ARI appendix Mother: 1 2=Diarrhoreal 3=Malaria/ febrile 4=Joint 5=Urinal 6=Organ 7=Anaemia 8= Reproductive 9=Other, specify

FSAU Technical Series Report No V. 16 47 Issued February 20, 2009 Q 25 Food Consumption & Dietary Diversity Twenty four-hour recall for food consumption in the households: The interviewers should establish whether the previous day and night was usual or normal for the households. If unusual- feasts, funerals or most members absent, then another day should be selected. Food group consumed: What foods groups did Did a member of *Codes: members of the household consume in the past 24 your household 1= Own production 6=Borrowed hours (from this time yesterday to now)? Include any consume food from snacks consumed. any these food 2=Purchases 7=Gathering/wild groups in the last 3=Gifts from friends/ 8=Others, specify___ 24 hours? relatives 4=Food aid 9=N/A 5=Bartered Type of food 1=Yes What is the main source of the dominant food 0= No item consumed? (Use codes above)? 1. Cereals and cereal products (e.g. maize, spaghetti, rice, caanjera, bread)? 2. Milk and milk products (e.g. goat/camel/ fermented milk, milk powder)? 3. Sugar and honey? 4. Oils/fats (e.g. cooking fat or oil, butter, ghee, margarine)? 5. Meat, poultry, offal (e.g. goat/camel meat, beef; chicken or their products)? 6. Pulses/legumes, nuts (e.g. beans, lentils, green grams, cowpeas; peanut)? 7. Roots and tubers (e.g. potatoes, arrowroot)? 8. Vegetables (e.g. green or leafy vegetables, tomatoes, carrots, onions)? 9. Fruits (e.g. water melons, mangoes, grapes, bananas, lemon)? 10. Eggs? 11. Fish and sea foods (e.g. fried/boiled/roasted ﬁ sh, lobsters)? 12. Miscellaneous (e.g. spices, chocolates, sweets, beverages, etc)?

Q26 In general what is the main source of staple food in the household? (*Use codes in 29 above) ______

appendix Q27 Total number of food groups consumed in the household: ______Q28 How many meals3 has the household had in the last 24 hours (from this time yesterday to now)? 1= One 2=Two 3= Three

Q29 – Q30 Cereal Consumption

Q29 How much cereal did you consume in the household since this time yesterday? ______units.

Q30 Is this amount usual for the household for this time of the year? 1 = Yes 2 = No

Q30b If No, how does the amount change? 1 = Increase 2 = Decrease

Q30c When would this amount change? 1 = When there is poor harvests 2 = When there are reduced income so need to sell 3 = Other times (mention) ______

Q31-32 Access to water (quality and quantity) Q31a What is the household’s main source of drinking water? 1 = Tap/ piped water 2= Tanker truck 3= Tube well/ borehole 4= Spring 5= Bottled water 6= rooftop rainwater 7= Surface water (river, stream, dam, pond, open well; water catchments; berkad, etc) Q32 Is water treated at the: a) source? 1= Yes 2= No b) storage level? 1= Yes 2= No Q32c If treated, what is the method of treatment? 1= Boiling 2= Chlorination 3= straining/ﬁ ltering 4= Decanting/ letting it stand and settle 5= Other, specify

3 A meal refers to food served and eaten at one time (excluding snacks) and includes one of the three commonly known - breakfast, lunch and supper/dinner

FSAU Technical Series Report No V. 16 48 Issued February 20, 2009 Q 33 Access to Health Care Q33 Do you have access to a health facility? 1 = Yes 2 = No Q33b If yes, do you use it? 1 = Yes 2 = No Q33c If not, why not? 1 = Too expensive 2 = Too far 3 = Not enough time 4 = Insecurity 5 = Other

Checked by supervisor (signed): ______

1 Diarrhoea is deﬁ ned for a child having three or more loose or watery stools per day 2 ARI asked as oof wareen or wareento. The three signs asked for are cough, rapid breathing and fever 3 Suspected malaria/acute febrile illness - the three signs to be looked for are periodic chills/shivering, fever, sweating and sometimes a coma 4 Measles (Jadeeco) a child with more than three of these signs– fever and, skin rash, runny nose or red eyes, and/or mouth infection, or chest infection appendix

FSAU Technical Series Report No V. 16 49 Issued February 20, 2009 URBAN ASSESSMENT HOUSEHOLD QUESTIONNAIRE, 2008 HHNO:

Household Size ______Date______Enumerator: ______Name of Town ______Section: ______

Q 1 Food Consumption & Dietary Diversity

Twenty four-hour recall for food consumption in the households: The interviewers should establish whether the previous day and night was usual or normal for the households. If unusual- feasts, funerals or most members absent, then another day should be selected.

*Codes: Did a member of your household Food group consumed: What foods groups did members of consume food from any these food 1= Own production 5=Bartered the household consume in the past 24 hours (from this time groups in the last 24 hours? yesterday to now)? Include any snacks consumed. 2=Purchases 6=Borrowed 7=Gather- 1=Yes 3=Gifts from friends/ relatives 2= No ing/wild 4=Food aid 8= N/A What is the main source of the dominant food item con- Type of food sumed? (Use codes above)? A1. Cereals and cereal products (e.g. maize, spaghetti, rice, caanjera, bread)? A2. Milk and milk products (e g. goat/camel/ fermented milk, milk powder)?

A3. Sugar and honey? A4. Oils/fats (e.g. cooking fat or oil, butter, ghee, margarine)? A5. Meat, poultry, offal (e.g. goat/camel meat, beef; chicken or their products)? A6. Pulses/legumes, nuts (e.g. beans, lentils, green grams, cowpeas; peanut)? A7. Roots and tubers (e.g. potatoes, arrowroot)? A8. Vegetables (e.g. green or leafy vegetables, tomatoes, carrots, onions)? A9. Fruits (e.g. water melons, mangoes, grapes, bananas, lemon)? A10. Eggs? appendix A11. Fish and sea foods (e g. fried/boiled/roasted ﬁ sh, lobsters)? A12. Miscellaneous (e.g. spices, chocolates, sweets, beverages, etc)? Q2. In general what is the main source of staple food in the household? (*Use codes in 29 above) ______Q3 Total number of food groups consumed in the household: ______

Q4 How many meals1 did the adults (18+ years) in this household eat in the last 24 hours (from this time yesterday to now)? 1= One 2=Two 3= Three

Q5 How many meals did the children (<5 years) in this household eat in the last 24 hours (from this time yesterday to now)? 1= One 2=Two 3=Three 4=N/A

Q6. Coping and coping strategies During the PAST YEAR, have here been times when you did not have enough money to buy food or cover other essential expenditures (health, 1 = Yes 2 = No (skip) cooking fuel, school etc.)? During the PAST Year (October If yes, how did your household manage to put food on the table Now (In October 2008) 2007) last year? And how has your household managed to put food on the table this year? 2 = No 1 = Yes (skip to 2008) 1 = Yes 2 = No B1 Rely on less preferred and less expensive food 1 = Yes 2 = No 1 = Yes 2 = No B2 Borrow food, or rely on help from friends or relatives 1 = Yes 2 = No 1 = Yes 2 = No

B3 Purchase food on credit, incur debts 1 = Yes 2 = No 1 = Yes 2 = No

B4 Limit portion size at meals 1 = Yes 2 = No 1 = Yes 2 = No B5 Restrict consumption by adults in order for small children to eat 1 = Yes 2 = No 1 = Yes 2 = No

B6 Reduce number of meals eaten in a day 1 = Yes 2 = No 1 = Yes 2 = No

B7 Skip entire days without eating 1 = Yes 2 = No 1 = Yes 2 = No

1 A meal refers to food served and eaten at one time (excluding snacks) and includes one of the three commonly known - breakfast, lunch and supper/dinner

FSAU Technical Series Report No V. 16 50 Issued February 20, 2009 B8 Purchase food on credit 1 = Yes 2 = No 1 = Yes 2 = No

B9 Consume seed stocks held for the next season 1 = Yes 2 = No 1 = Yes 2 = No

Decrease expenditures for fertilizer, pesticide, fodder, animal B10 1 = Yes 2 = No 1 = Yes 2 = No feed, vet. Care….

B11 Sell domestic assets (radio, furniture, fridge, TV, carpet…) 1 = Yes 2 = No 1 = Yes 2 = No

Sell productive assets (farm implements, sewing machine, B12 1 = Yes 2 = No 1 = Yes 2 = No motorbike, land…)

B13 Sell more animals than usual 1 = Yes 2 = No 1 = Yes 2 = No

B14 Decrease expenditures for health care 1 = Yes 2 = No 1 = Yes 2 = No

B15 Take children out of school 1 = Yes 2 = No 1 = Yes 2 = No

B16 Seek alternative or additional jobs 1 = Yes 2 = No 1 = Yes 2 = No

Increase the number of members out-migrating for work and/ B17 1 = Yes 2 = No 1 = Yes 2 = No or food

B18 Increase in the amount of remittances received 1 = Yes 2 = No 1 = Yes 2 = No

Mortality Questionnaire, March 2007

Household No: _____ Date: ______Team No: ____ Cluster No: ____ Enumerator’s Name: ______

No. 1: First Name 2: Sex 3: Age 4: Born since 5: Arrived since __ 6: Reason 7: Cause of appendix (1=M; (yrs) __ / 12/ 2007 / 12/ 2007 for leav- death 2=F) ing a) How many members are present in this household now? List them.

b) How many members have left this household (out migrants) since Dec __, 2007? List them

c) Do you have any member of the household who has died since Dec __, 2007? List them

Codes Reason for migration Cause of death 1= Civil Insecurity 6= Hospitalised 1= Diarrhoeal diseases 6= Anaemia 2= Food Insecurity 7= In boarding school 2= ARI 7= Birth complications 3= Employment 8= Grazing/herding 3= Measles 8= Accident/ killed/ physical 4=Divorce/ Married away 9= Other, specify 4= Malaria injuries 5=Visiting 5= STD/ HIV/AIDS 9= Hunger/starvation 10= Other, specify

FSAU Technical Series Report No V. 16 51 Issued February 20, 2009 Summary*

Total U5 Current HH Members Arrivals during the Recall period Number who have left during Recall period Births during recall Deaths during recall period * For Supervisor Only

FOCUS GROUP DISCUSSION GUIDE Village: ______Supervisor: ______Cluster No. ______

Food Consumption and Feeding Practices

1. What is the common staple diet you are likely to ﬁ nd in households currently? (List the types of foods consumed, their composition and how they are prepared)

Meal Foods Composition Method of preparation Breakfast Lunch Supper

2.a) For how long (duration) do mothers generally breastfeed their babies in this community?

b) What are the common foods normally given to children below 2 years in this community? How many times per day? (Specify ingredients)

appendix Common foods Age when introduced Ingredients Number of times given Water Sugar solution Cows/camel/goat mi k Semi solid foods( porridge and others) Solid foods (caanjera, rice, spaghetti),

3. At the moment, what meals are given to children 0-2 years and how many times per day? (Specify ingredients)

Common foods Ingredients Number of times given Water Cows/camel/goat mi k Semi solid foods( porridge and others) Solid foods ( caanjera, rice, spaghetti),

4. Has there been any change in food consumption (diets) in the last three months? Specify and give reasons for change if any. ______

5. What constraints do households (women) normally face in providing adequate food for their families? In terms of:

Effective breast feeding and child feeding Food acquisition & preparation Food processing, preservation & storage Food service and sharing/rations

FSAU Technical Series Report No V. 16 52 Issued February 20, 2009 6. What would you say is the level of current availability and accessibility of the following foods? Foods Codes: 1= Absent/none 2= Low 3=medium 4= High Availability Accessibility Meat Goat milk Cow milk Camel milk Spaghetti Beans/ peas Wheat Rice Maize Sorghum Sugar Cooking oil Potatoes Fish

7. In the past 30 days, if there have been times when people did not have enough food or money to buy food, which of the following coping strategies did they use? (Select based on relevant livelihood system)

Pastoralist Livelihood 1= Yes 2=No Coping strategy a Reduce home milk consumption and sell more of milk produced? b Consume less preferred cereals

c Borrow food on credit from another household (Aamah)? d Reduce number of meals per day? e. Reduce the portion size/quantity consumed at meal times (Beekhaamis)?

f. Rely on food donations (gifts) from the clan/community (Kaalmo)? appendix g Consume weak un-saleable animals (caateysi)? h. Send household members to eat (for food) elsewhere?

i Skip (go an) entire days without eating (Qadoodi)? j Beg for food (Tuugsi/dawarsi)? k Rely on hunting for food (ugaarsi)?

Agro-pastoralist Livelihood 1= Yes 2=No Coping strategy a Shift from high priced cereal varieties to low price cereal varieties? b. Shift from high quality cereals to low quality cereals (from osolo to obo)?

c. Borrow food on credit from shop (Deyn)? d Borrow food on credit from another household (Aamah)? e Reduce home milk consumption and sell more of milk produced? f. Reduce the number of meals in a day by adults?

g. Stop all home milk consumption and sell all mi k produced? h Rely on food donations (gifts) from the close relatives (Qaraabo)? i Rely on food donations (gifts) from the clan/community (Kaalmo)? j Skip (go an) entire days without eating (Qadoodi)?

k. Community identiﬁ ed your household as in need of food and ﬁ ves support? (Qaraan) l. Send household children to live or eat with relatives (elsewhere)?

Riverine Livelihood Coping strategy 1= Yes 2=No a. Shift to less preferred foods (e.g. white maize to yellow maize)? b. Reduce the portion size/quantity consumed at meal times (Beekhaamis)? c. Consume poor quality foods (unsafe or spoilt)? d. Reduce number of meals per day by one (e.g. from three to two)?

e. Consume wild foods and ﬁ sh from the river? f. Consume immature crops (fruits or cereals)?

g. Reduce number of meals per day by two (e.g. from three to one)? h. Feed particular members (elderly, children) at the expense of other household members?

FSAU Technical Series Report No V. 16 53 Issued February 20, 2009 i. Consume seeds meant for future planting? j. Borrow food for consumption (to be repaid in future – in kind)? k. Eat prohibited/ unacceptable foods (an mal skins, grass, roots, clotted blood, tree leaves, wart- hogs etc)?

Fishing Livelihood Coping strategy 1= Yes 2=No a. Consume low quality fi sh and fi sh parts? b. Increase number of family members going fi shing (to increase catch)? c. Reduce portion size of meals? d. Decrease fi sh consumption and increase consumption of non- fi sh items?

e. Reduce number of meals per day? f. Borrow or purchase food on credit? g. Rely on gifts (donations) of food? h. Consume only non- ﬁ sh items (no ﬁ sh consumption)?

i. Consume left-over or thrown away ﬁ sh (left on beach, market, etc)? . Beg for food (Tuugsi/dawarsi)? k. Reduce food intake of adults (relative to children)?

l. Skip (go an) entire days without eating (Qadoodi)? m. Consume recognised health hazard ﬁ sh?

Urban Livelihood Coping strategy 1= Yes 2=No a. Shift to less preferred (low quality, less expensive) foods (from osolo to obo)? b. Limit the portion/quantity consumed in a meal (Beekhaamis)? c. Take fewer numbers of meals in a day?

d. Borrow food on credit from the shop/market (Deyn)? e. Borrow food on credit from another household (Aamah)? f. Restrict consumption of adults in order for small children to eat?

g. Rely on food donations from relatives (Qaraabo)? h. Rely on food donations from the clan/community (Kaalmo)? i. Seek or rely on food aid from humanitarian agencies?

. Send household members to eat elsewhere?

appendix k. Beg for food (Tuugsi/dawarsi)? l. Skip entire days without eating (Qadoodi)? m. Consume spoilt or left-over foods

8. a) Have there been any population or animal movements in the past 3 months? If yes from where to where?

b) Have there been any reported animal deaths in the village? If yes what was the extent of this problem?

9. Water, Sanitation and hygiene a) What is the main source of water for people in this village? b) Is drinking water treated at point of supplies and/or at point of use? c) What is the average distance to the water point? d) On average how much water is used by each person/day? e) How many people on average share a water point/source?

f) How far away is the latrine from the water source for the majority? g) How many people on average share a toilet/latrine facility? h) How are children faeces disposed of? i) Do households have soap for body, utensils and clothes washing? ) How is prepared food stored/kept by most households

10. Prices of major foods (ﬂ our, rice, milk, sugar, etc) and other essential commodities (water, cooking fuel, etc) for the village Price/unit in SSH (Exchange rate- 1US$ = SSH) Item/material In August 2007 Now (November 2007)

FSAU Technical Series Report No V. 16 54 Issued February 20, 2009 11. What are the main sources of income for most households in order of priority? ……………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………

12. What are the common illnesses in this village among children and adults?

illnesses Possible causes/reasons Children Adults

13. Find out if there has been any formal support in this village in the last 3 months

Type of support/ programme Agency Targeted group (beneﬁ ciaries)

Data collection form for Malaria

Date GPS Coordinates North Name of

Cluster No appendix the Village East Name of medical

person of the team

Treated for Have ac- Do you Slept under Fever last 2 Age Sex malaria in past 2 cess to/ use the net last RDT result days? weeks? own a net? net? night?

1=POSITIVE In MONTHS if < 1 yr 1 = Male 1=Yes 1=Yes 1=Yes No Name 1=Yes 2=NO 1=Yes 2=NO 2=NEGATIVE In YEARS if ≥ 1 yr 2 = Female 2=NO 2=NO 2=NO 3=INVALID

FSAU Technical Series Report No V. 16 55 Issued February 20, 2009