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

Technical Series Report No VI. 25 September 11, 2009

Nutrition Situation Post Gu 2009

Food Security and Nutrition Analysis Unit - Somalia Box 1230, Village Market Nairobi, Kenya Tel: 254-20-4000000 Fax: 254-20-4000555 Website: www.fsnau.org Email: [email protected]

Technical and Funding Agencies Managerial Support

European Commission FSNAU Technical Series Report No VI. 25 ii Issued September 11, 2009 Acknowledgement

FSNAU would like to thank all partner agencies for their participation and support in the Gu ’09 seasonal nutrition assessments and analysis. From April until July 2009 a total of 33 nutrition surveys were conducted, 80 health centres visited and nearly 12,000 children measured in rapid assessments. Without the support and expertise of 15 local NGO, 12 International NGO, 2 Local Authorities and 3 UN agencies, this would not have been possible. A sincere note of thanks and appreciation also goes to the FSNAU nutrition team based in Somalia and Nairobi who work under such difficult conditions yet continue to produce such high quality professional work.

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-UK, Mercy USA, Co-operative Di Svillupo 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, AID organization, Social Development and Research Association (SDRA), Norwegian Church Aid (NCA), Africa Muslim Aid, HIRDA, Green Hope, Degares, Goolyome Relief And Development Organization (GREDO), Somalia Aid Foundation (SAF), Economic Independence Research Group (EIRG), APD, Juba Foundation, WRRS, JCC, VDO, PCDDO, Intercare Development Association (ICDA), Jubaland Charity Center (JCC).

Mahad Sanid

FSNAU Technical Series Report No VI. 25 iii Issued September 11, 2009 TABLE OF CONTENTS 1. EXECUTIVE SUMMARY 1

2. DEVELOPMENT OF CASELOADS OF ACUTELY MALNOURISHED CHILDREN IN SOMAILA 6

3. NUTRITION ANALYSIS IN SOMALIA 8

4. REGIONAL NUTRITION ANALYSIS 10 4.1 Gedo Region – Pastoral, Agro-Pastoral And Riverine Livelihood Zone 10 4.2 Lower and Middle Juba Regions – Pastoral, Agro-Pastoral and Riverine Livelihood Zone 14 4.3 Bay and Bakool Regions 16 4.4 Lower and Middle Shabelle Regions 20 4.5 Central Somalia: Galgadud and Mudug Regions (Addun, Hawd and Deeh Pastoral; and Cowpea Belt) 23 4.6 Hiran Region – Pastoral, Agro-Pastoral and Riverine Livelihood Zone 26 4.7 Northeast Regions 29 4.8 Northwest Regions 38 4.9 Urban Nutrition analysis 46

5. GUIDANCE FOR USE OF THE PLAUSIBILITY CHECKS 49

6. APPENDICES 52 6.1: Somalia Livelihood Zones 52 6.2 Progression of Estimated Nutrition Situation Deyr ’06/07 - Gu ’09 53 6.3 Nutrition Assessment Tools Post Gu ‘09 54

LIST OF TABLES

Table 1: Timeline of activities for Gu 2009 Nutrition Situation Analysis 1 Table 2: Somalia Integrated Food Security Phase Classification, Population Numbers, July - December 2009 5 Table 3: Nutrition Situation Categorisation Framework 8 Table 4: Summary of Key Nutrition Findings in Gedo Region 12 Table 5: Summary of Key Nutrition Findings in Middle and Lower Juba Regions 16 Table 6: Summary of Key Nutrition Findings in Bay and Bakool Regions 19 Table 7: Summary of Key Nutrition Findings in M. and L. Shabelle Region 22 Table 8: Summary of Key Nutrition Findings in Central Regions 25 Table 9: Summary of Key Nutrition Findings in Hiran Region 28 Table 10: Summary of Key Nutrition Findings in Northeast Regions 31 Table 11: Summary of Key Nutrition Findings in Northeast Regions 32 Table 12: Summary of Key Nutrition Findings in IDPs-Northeast Regions 34 Table 13: Summary of Key Nutrition Findings in IDPs-Northeast Regions Qardho IDPs (Exhaustive) N=478 35 Table 14: Summary of Results Sool plateau and Lower Nugal Livelihood Zones 36 Table 15: Sool Plateau of Sool and Sanaag Region Livelihood Zone 39 Table 16. Summary of Key Nutrition Findings in West Golis/Guban, East Golis of Sanaag region and Gebbi Valley 41 Table 17: Key Reference Indicator 42 Table 18: Nugal Valley Livelihood Zone 43 Table 19: Summary of Results of Northwest Agro-pastoral LHZs 43 Table 20: Summary of Key Nutrition Findings of the North West IDPs Hargeisa, Burao and Berbera 45 Table 21: Summary of Key Findings, Rapid Urban Nutrition Assessments, June - July 2009 47 Table 22: Summary of Nutrition Assessments (April - July 2009) 48 Table 23: Plausibility Checks 50

FSNAU Technical Series Report No VI. 25 iv Issued September 11, 2009 LIST OF MAPS

Map 1: Estimated Nutrition Situation, July 2009 2 Map 2: Somalia Integrated Food Security Phase Classification, Rural Populations, July - Dec. ‘09 5 Map 3: Somalia Integrated Food Security Phase Classification, Urban Populations, July - Dec. ‘09 5 Map 4: Estimated Nutrition Situation, July 2009 6 Map 5: Gedo Region Livelihood Zones 10 Map 6: Juba Regions Livelihood Zones 14 Map 7: Bay and Bakool Regions Livelihood Zones 17 Map 8: Shabelle Livelihood Zones 20 Map 9: Central: Livelihood Zones 23 Map 10: HiranRegion Livelihood Zones 26 Map 11: North West Livelihood Zones 38

LIST OF FIGURES

Figure 1: Median Rates of Global Acute Malnutrition, Gu ’09 2 Figure 2: Median Rates of Stunting & Underweight, Gu ’09 2 Figure 3: Global Acute and Severe Acute Malnutrition Gu ’09 (April - July) WHOGS <-2WHZ & <-3WHZ and /or oedema 3 Figure 4: Comparing GAM rates, Household milk consumption and milk prices of the Deyr 08/09 and the Gu 09 7 Figure 5: Trends in levels of Acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Gedo Region , 2002-2009 10 Figure 6: Trends in levels of Acute Malnutrition (WHZ <-2Z scores or oedema,WHO 2006) in Juba Regions 2003 – 2009 14 Figure 7: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) in Bakool region 2002- 2009 17 Figure 8: Bakool agro-pastoral SFP admission 18 Figure 9: Trend in levels of acute malnutrition (WHZ< -2 or oedema , WHO 2006) in Bay region 2002- 2009 18 Figure 10: Cholera outbreak in Bur-hakaba WVI 19 Figure 11: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) in Shabelle region 2002- 2009 21 Figure 12: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) in Central region 2002- 2009 ) 24 Figure 13: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) in Hiran region 2002- 2009 26 Figure 14: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) in Northeast region 2002- 2009 30 Figure 15: MCHs in Sool Plateau, January 2008 - July 2009 36 Figure 16: Stunting Prevalence by Regions in Somalia (2001 - 2008) 37 Figure 17: Trend in levels of acute malnutrition (WHZ< -2 or oedema, (WHO 2006) in Northwest region 2002- 2009 38 Figure 18: Dhahar and Hingalool MCH Nutrition Trends Jan-Jun 2009 39 Figure 19: Badhan and Hadaftimo MCH Nutrition Trends Jan-Jun 09 41

SPECIAL ARTICLES

Trends in Pastoral Malnutrition - The Case of West Golis/Guban Livelihood Zones, Somaliland 7 Somalia National Micronutrient Malnutrition Study: Field Experiences 13 Piloting the Trials of Improved Practices (Tips) in Somalia 37 Stunting Trends in Somalia: The Case of Bay Region 37 Breast Feeding is the Best Feeding Method for Healthy Growth and Development (World Breastfeeding Week 2009) 51

FSNAU Technical Series Report No VI. 25 v Issued September 11, 2009 LIST OF ACRONYMS

ARI Acute Respiratory Tract Infections ACF Action Contre La Faim AFLC Acute Food and Livelihood Crisis BFI Borederline Food Insecure CARE Canadian Relief Everywhere CMAM Community Management of Acute Malnutrition CMR Crude Mortality Rate (Retrospective) COSV Co-operatione Di Svillupo International CTC Community Therapeutic Care FAO Food and Agricultural Organixation of the United Nations FSNAU Food Security and Nutrition 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 Sampling 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 OTP Out pateint Therapuetic Programme PWA Post War Average SAM Severe Acute Malnutrition SRCS Somalia Red Crescent Societies SD Standard Deviation SFP Selective/Supplementary Feeding Program TIPS Trials of Imporved Practice 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

FSNAU Technical Series Report No VI. 25 vi Issued September 11, 2009 Forward

This nutrition situation technical series report is a recent publication of the Food Security and Nutrition Analysis Unit (FSNAU). The FSNAU 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 FSNAU Post Gu ’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.

FSNAU Technical Series Report No VI. 25 vii Issued September 11, 2009 FSNAU Technical Series Report No VI. 25 viii Issued September 11, 2009 1. Executive Summary

An integrated analysis of the nutrition information from the Gu‘ 09 season indicates a varied yet alarming situation throughout the country (See Map 1). Civil insecurity in Mogadishu leading to on-going population displacement, the severe and deepening drought conditions in Central regions, parts of the South and in the northwest regions and the continuing elevated commodity prices, are the key driving factors in the current analysis. High morbidity, disease outbreaks, limited access to basic services, and poor child care practices further underpin the chronic nutrition crisis faced by the Somali populations. Generally breastfeeding starts on day five of life and children often born already low birth weight and stunted are then offered solids and fluids prematurely. Beliefs and practices of treating childhood illness often results in delayed treatment, meaning a much higher burden of morbidity and mortality than necessary. This translates into a major nutrition crisis manifested in the short term through acute malnutrition and longer term though stunting. Both of these conditions have a devastating impact on the economic potential and development of the population.

The current situation analysis estimates1 285,000 acutely malnourished children of which 70,000 are severely malnourished, representing one in five and 1 in 20 of all children, respectively, under 5 years of age in Somalia. A further 84,0002 pregnant women are also estimated to be acutely malnourished, which has a negative impact on the growth of the unborn child, leading to low birth weight, stunting and developmental delay. FSNAU and partners conducted a total of 34 representative nutrition surveys to date in 2009 (see Table 1 for timeline). Of these, and referring to the WHO Growth Standards, 6 reported rates of global acute malnutrition2 (GAM) <15%, 12 reported rates in the 15-20% range, with the remaining 16 reporting rates >20%. The median rate of global acute malnutrition (GAM) for all 34 surveys was 19%, an increase from 17% from the last round of comparable surveys. Rates of severe acute malnutrition remained high in many parts, with a median rate of 4.5% for all 34 surveys. However, crude and under five years mortality rates, remained below the respective emergency thresholds of 2 and 4 deaths per 10,000 population per day, with the exception of alert levels (CMR of 1-2/10,000day and U5MR of 2-4/10,000/day) reported in 4 surveys (Shabelle agro-pastoral, Juba agro-pastoral and Riverine and Gedo agro-pastoral). 70% of these acutely malnourished chil-

dren are in South and Central regions, Table 1. Timeline of activities for Gu 2009 Nutrition Situation Analysis executive summary the area’s most affected by insecurity and I. NUTRITION SURVEYS GU 2009 April-July 2009 limited humanitarian space. 1. Guban/West Golis June ‘09 2.East Golis June ’09 South & Central regions: The sustained 3. Gebi Karkar June ‘09 4. Hargeisa IDP (small sample cluster survey) April ‘09 Critical and Very Critical nutrition situ- 5.Burao IDP (Exhaustive survey) April.’09 ation in South and Central Somalia con- 6. Berbera IDP (Exhaustive survey) April ‘09 tinues to highlight the impact of years of 7. Qardho IDP ( Exhaustive survey) July.’09 civil war on the population’s ability to deal 8. Bossaso IDPs July.’09 with shocks. Without appropriate access 9. Bossasso Urban (Small sample cluster survey) July.’09 10. Garowe IDPs (Exhaustive survey) July.’09 to basic health services, children start life 11. Galkayo IDP (Exhaustive survey) July.’09 vulnerable, and common childhood ill- 12. Hawd Pastoral May’09 ness like respiratory infections and diar- 13. Addun Pastoral May’09 rhoea can be fatal. The widespread lack of 14.Cowpea belt May’09 15. Coastal Deeh (Small sample cluster survey) May.’09 safe water and improved sanitation further 16. Mudug Region May.’09 increase the risk of diarrhoeal disease, 17. Galgadud Region May.’09 which is currently widespread. Children 18. Hiran Pastoral (small sample cluster survey) April’ 09 are fed a predominantly cereal and oil 19. Hiran Agro-pastoral April ‘09 based diet, missing the essential micro- 20. Hiran Riverine April’09 21. Beletywene District April’09 nutrients and proteins essential for health, 22. Shabelle Agropastoral May’09 growth and development. During times 23. Shabelle Riverine May’09 of crisis, even these foods are limited and 24.. Shabelle IDP (Merka/Afgoye) May’09 exacerbated by all the other underlying 25. Adale District May.’09 factors, high levels of acute malnutrition 26. Gedo Pastoral July’09 27. Gedo Riverine July ’09 are prevalent. Although levels of acute 28.. Gedo Agropastoral July ’09 malnutrition are currently high all over 29. Juba Riverine July’09 the country, the very high stunting of 30. Juba Agropastoral July’09 30% in the South and Central regions 31. Juba Pastoral July’09 compared to the 10% reported in the 32. Bay Agro-pastoral June’ 09 33.Bakool Agro-Pastoral June’ 09 northwest, further illustrates the chronic 34.Bakool Pastoral June’09 nature of this crisis. With the ever shrink- HEALTH FACILITY REVISITS / HIS DATA Jan’09 and June’09 ing humanitarian space, the nutrition RAPID NUTRITION ASSESSMENTS: URBAN & RURAL June/July’09 situation here remains in crisis with a poor FSNAU & PARTNERS NUTRITION ANALYSIS August 2nd – 9th, 2009 FSNAU NUTRITION TEAM MEETING August 10th-11th, 2009 outlook for the coming months. NUTRITION SITUATION VETTING MEETING August 17th, 2009 FSNAU PRESS RELEASE August 24th, 2009 FSNAU FOOD SECURITY AND NUTRITION BRIEF RELEASE September 9th, 2009 FSNAU NUTRITION TECHNICAL SERIES REPORT RELEASE September 11th, 2009

1 When applying the national median rate of 19% for GAM and 4.5% for SAM (WHO GS)

2 Numbers estimated from 2009 surveys- median rates of MUAC <23cm of 22.4% in pregnant women

FSNAU Technical Series Report No VI. 25 1 Issued September 11, 2009 Map 1: EstimatedSOM NutritionALIA - E Situation,STIMATE JulyD N 2009UTRITION SITUATION JULY 2009

CALUULA "

Alula QANDALA " ZEYLAC " (! LAASQORAY Gulf of Aden " Kandala Zeylac Bosaso DJIBOUTI LUGHAYE " Lughaye BERBERA Badhan Awdal (!" BAKI Baki Berbera ISKUSHUBAN " " Borama Sanag Iskushuban El Afwein Bari Erigavo SHEIKH CEEL AFWEYN Woq. Galbeed " Sheikh " GEBILEY G" abiley (! QARDHO BANDARBEYLA Hargeisa " " OWDWEYNE (! Gardo " Bender Beila Odweine Burco Caynaba XUDUN TALEEX " " Xudun Taleh Togdheer CAYNABO " ^ Sool Buhodle Lasanod (!Garowe BUUHOODLE "

EYL Nugal " " Eyl District Capital Burtinle BURTINLE Major Road " Coastline JARIIBAN International Boundary " GALDOGOB Jariban " ETHIOPIA Goldogob Regional Boundary Galkayo District Boundary (! River

CABUDWAAQ " CADAADO " Adado Mudug Abudwaq Hobyo

Dusa Mareb HOBYO " Indian Ocean Galgadud CEEL BARDE " El Bur Haradhere El Barde CEEL BUUR XARARDHEERE Belet Weyne " "

Rab Dhuure Bakol "

DOOLOW Rab-Dhuure Hiran " Hudur TAYEEGLOW Dolo " El Der BULO BURTO CEEL DHEER WAAJID " " BELET XAAWO LUUQ " ADAN YABAAL " " Tieglo Bulo Burti " Luuq Wajid Aden Yabal JALALAQSI Belet Hawa " Jalalaqsi Garbahare Ba(!idoa Adale Gedo QANSAX DHEERE M. Shabelle " BUUR HAKABA CEEL WAQ " CADALE " Qansah Dere Wanle Weyne Jowhar " LEGEND WANLA WEYN El Waq " Bay Balad DIINSOOR " BAARDHEERE Bur Hakaba BALCAD " " Nutrition Situation Afgoye AFGOOYE Bardera " (! Dinsor L. ShabelleBanadir Acceptable QORYOOLEY Sakow Kurtun Warrey Q" oryoley SAAKOW KURTUNWAAREY " " Marka Alert M. Juba Sablale SABLAALE " Serious BARAAWE Buale " Brava Critical executive summary Jilib Afmadow AFMADOW " JILIB Very Critical " Projected Trend (July - December'09) Potential to Improve JAMAAME J" amame Hot Spot for Very Critical L. Juba Uncertain ^ (! Potential to Deteriorate IDP Phase Kismayo Serious

Badhadhe Critical BADHAADHE " Very Critical The Nutrition Situation is analysed using a range of nutrition ± indicators from direct and indirect sources from Jan to July '09: nutritional surveys (Apr-July'09), health facility data, rapid 40 20 0 40 80 120 160 MUAC assesments, selective feeding centre data, health reports Kilometers and others

Food Security and Nutrition Analysis Unit - Somalia http://www.fsnau.org P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-4000000 fax:254-20-5000555 FSNAU is managed by FAO. 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.

Figure 1: Median Rates of Global Acute Malnutrition, Gu ’09 Figure 2: Median Rates of Stunting & Underweight, Gu ’09

25 40 Stunting Underweight GAM SAM 35 20 30

25 15 20

10 15

10 5 5

0 0 All (excl All (incl Sth Central All (excl All (incl Sth Central IDP IDP) IDP) NW (excl NE (excl (excl IDP) IDP IDP) IDP) NW (excl NE (excl (excl IDP) IDP) IDP) IDP) IDP)

FSNAU Technical Series Report No VI. 25 2 Issued September 11, 2009 Northern regions Figure 3: Global Acute and Severe Acute Malnutrition Gu ’09 (April - In the northwest region, there is a mixed July) WHOGS <-2WHZ & <-3WHZ and /or oedema

picture with notable recovery to Serious 30% from the previous Very Critical situation in the western Golis Guban, as a result of in 25% migration of livestock, increasing access to 20% milk and increased access to humanitarian support. This recovery is to a lesser degree 15% in the eastern parts, likely due to less positive food security and basic service indicators 10%

there. In the other areas there has been no 5% significant change from theSerious situation in the Post Deyr ‘08/09, however localized 0% areas of higher concern are apparent in the agro-pastoral parts of Galbeed, in southern

Togdheer, and in Sool Plateau linked to a GAM <-2WHZ+/-oed SAM<-3WHZ+/-oed combination of water crisis increasing diarrhoeal disease and increasing household food insecurity. Given the population density, even without Very Critical rates of acute malnutrition, 20% of all acutely malnourished Somali children reside in the northwest, therefore integrated efforts to meet their needs are key. In the northeast region, analysis of the nutrition situation is also providing a mixed picture, though overall a deterioration from 6 months ago. Critical rates of acute malnutrition are now being reported in East Golis, Guban & Karkar with Serious rates and risk of deterioration in Nugal valley. The sustained Critical rates in Hawd and Addun highlight the concerning nutrition situation in the northeast and the elevated needs.

IDPS

The IDP populations continue to be the most nutritionally vulnerable group, even in areas of relative peace in the executive summary northern regions. The median GAM rate at 20% is higher than for the national rate and with a median SAM rate of 4.8% and the highest stunting levels at 36%, the increased vulnerability of the IDPs is apparent. However it is notable that one of the lowest rates of GAM reported so far in 2009, is in the IDP camps of Afgoye and Merka, likely linked to large scale and sustained access to appropriate humanitarian services. This illustrates that the nutrition situation can improve in the presence of appropriate quality and quantity of care.

Based on the above highlighted aggravating factors, coupled with the prevailing insecurity which limits humanitarian access, the nutrition vulnerability is likely to persist and potentially deteriorate unless a combination of emergency nutrition interventions, adequate integrated humanitarian response and capacity strengthening of current and new nutrition stakeholders is undertaken alongside improved humanitarian access. Major contributing factors to the chronic nutrition crisis are the lack of safe water and sanitation facilities, both of which contribute to widespread diarrhoea in young children. Coverage in rural areas of Somalia stands at just 11.3%, and only 12.6% for sanitation. In many areas of the country, people are living on the equivalent of just one bottle of contaminated water a day, and using the cover of a tree or bush as a toilet. Water and sanitation interventions have been relatively poorly funded in 2009, when compared with other sectors such as food and health, and yet poor water and sanitation is often the underlying causes of many health and nutrition related illness in emergencies. The deteriorating health and nutrition status of the population is confirmation of a water and sanitation sector that is outpaced by the increasing needs of populations affected by drought, conflict and displacement. Unless a concerted effort is made to rectify the poor water and sanitation situation in Somalia, very little sustained health improvements will be ever be realised.

Food Security Overview

The findings of the FSNAU, FEWSNET, and partner postGu ‘09 seasonal assessment confirms thatSomalia faces its worse Humanitarian Crisis in eighteen years, with half of the population or an estimated 3.64 million people in need of emergency livelihood and life saving assistance at least until December 2009. This signals a serious deterioration in the food security and nutrition situation from earlier this year. Most of the 3.64 million people in crisis or 75% of the population are concentrated in south and central Somalia. Of increased concern is that the escalating fighting and conflict is occurring in the same areas that are recording the greatest problems of food access and malnutrition. This will not only place additional burdens on the people already in crisis, but will also make it difficult for humanitarian relief to reach the populations most in need of assistance. Given the context of an escalating civil war, FSNAU issues an early warning for an even further deterioration in the humanitarian situation depending on the extent of the fighting in the coming weeks and months.

The people currently in humanitarian crisis include 1.4 million rural people affected by a severe drought, 655,000 urban poor who continue to struggle with very high food and non-food prices, and 1.3 million internally displaced people (IDPs) who are fleeing from the fighting and conflict (Map 2, 3 and Table 2). The key driving factors of the current humanitarian crisis are severe drought, very high food and non-food prices and increased conflict forcing massive displacement of population.

FSNAU Technical Series Report No VI. 25 3 Issued September 11, 2009 Deteriorating Humanitarian Emergency (HE) in the Central Regions The epicentre of the humanitarian crisis is in Mudug, Galgadud, Hiran and Bakool regions of south and central Somalia, where there is a two and a half year ongoing drought. The depth of the crisis in these areas is severe, with up to 65% of the total population in crisis, of which most, or 73%, are in Humanitarian Emergency. The drought has intensified following five consecutive seasons of rain failure. Livestock herds are decimated and destitute pastoralists are gathering in main villages and towns in search of assistance. The nutrition situation is alarming, as most pastoral and agropastoral livelihoods in these areas are classified asCritical, with a risk to deterioration. The nutrition situation is worse for Bakool pastoralists, who are classified asVery Critical. The contributing factors are the acute food insecurity situation, ongoing displacement, and high morbidity burden coupled with a complete lack of access to basic services for the affected populations.

Increasing Number of Internally Displaced Populations (IDPs) The number of internally displaced people (IDPs) has increased significantly since the January, from 1 million to now 1.3 million people, a twenty-five percent increase in six months. Most of the new IDPs are fleeing conflict and violence and are concentrated in the Shabelle and central regions. Nutrition surveys confirm that IDP populations are highly vulnerable, as IDPs consistently record higher median rates of global acute malnutrition rates, 20% compared to the non-IDP rates of 18%.

Continuing Food Insecurity for the Urban Poor A significant number of urban poor continue to be in crisis struggling to meet basic their survival needs despite the declin- ing food prices and improving wages. Nearly a quarter (23%) of the total urban population or 655,000 people are in need of humanitarian assistance. This is a slight decline from the figure of 705,000 people inDeyr ‘08/09. Out of the total people in crisis, 520,000 urban poor are in Acute Food and Livelihood Crisis (AFLC) requiring emergency livelihood support, while 135,000 urban poor are in Humanitarian Emergency (HE) requiring livelihood and life saving emergency assistance.

Emerging Drought and Acute Food and Livelihood Crisis (AFLC) in Northern Pastoral Areas There is an alarming deterioration in the food security and nutrition situation of the pastoral and agropastoral communities in the north, caused by an emerging drought after 2-3 consecutive seasons of below normal rainfall. These areas are suf- fering from consecutive seasons of severe water shortages, stressed livestock migration, high livestock off-take and high debt levels. The situation is now deteriorating further, as indicated by increased malnutrition rates reaching the emergency level threshold of 15% in some areas. An estimated 255,000 people are identified in Acute Food and Livelihood Crisis, while another 25,000 are in Humanitarian Emergency. Unlike south and central Somalia, humanitarian access to these regions is good, therefore it is critical that these areas receive appropriate levels of emergency livelihood support and nutrition response, to prevent a further deterioration into Humanitarian Emergency.

Normal Crop Production and Improving Food Access in Some Areas of the South The Gu ’09 cereal production in southern Somalia is the second highest in the last seven years and is near the Post-War average Gu production (102% of PWA). Most of the cereals, however, were produced in three regions of Lower Shabelle (51%), Bay (27%), and Middle Juba (14%). There is a also a significant off-season cereal production in Lower Juba, Middle Juba and Lower Shabelle due to above normal Hagaa showers. The main contributing factors to the good production in these three regions include a combination of near normal rainfall levels (Gu rains and Hagaa), above normal off-season executive summary production, improved irrigation systems (in Lower Shabelle), increased access to water, as well as significant increases in cultivated area in Lower Shabelle and Middle Juba. Food access has improved for most farmers in Bay, Lower Sha- belle, and Juba regions due to improved own crop production, as well as improved agriculture labor opportunities and high wage rates.

Implications for Response

Humanitarian Access • Actions to increase humanitarian space and safety to ensure that the growing number of people in need receive assistance.

Emergency Humanitarian Assistance: To Save Lives • Targeted to areas and livelihood groups identified in Humanitarian Emergency (HE) • Targeted to areas and livelihood groups identified with Critical and Very Critical nutrition status • Increased attention to areas where past/current needs exceed response. • Scale-up in HE areas continuing to deteriorate (i.e. Central, Hiran, M. Shabelle, and Bakool). • Targeted to IDP and Urban populations identified in HE and with high rates of malnutrition. • Targeted to populations at high risk to HE areas in the north (Togdheer Agropastoral and Sool Plateau Pastoral).

Emergency Livelihood Support: To Save Livelihoods and Prevent Deterioration to HE • Targeted to areas and livelihood groups in Acute Food and Livelihood Crisis (AFLC) • Targeted to populations in HE, to complement life saving interventions. • Scale-up of emergency livelihood support for populations in AFLC in the south (Middle Shabelle, Gedo, and Bakool). • Increase emergency livelihood support to populations identified in AFLC in the northern drought affected areas. • Targeted to poor urban populations who continue to be identified in AFLC

FSNAU Technical Series Report No VI. 25 4 Issued September 11, 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, refer to the Food Security and Nutrition Brief, September 8, 2009 and the upcoming Technical Series Report Post Gu ‘09 Analysis at www.fsnau.org, or contact FSNAU: [email protected].

Map 2: Somalia Integrated Food Security Phase Map 3: Somalia Integrated Food Security Phase Clas- Classification, Rural Populations, July - Dec. ‘09 sification, Urban Populations, July - Dec. ‘09 executive summary

Table 2: Somalia Integrated Food Security Phase Classification,Population Numbers, July - December 2009 Urban in Acute Rural in Acute Urban in Rural Total in AFLC UNDP 2005 Total UNDP 2005 Urban UNDP 2005 Rural Food and Food and Region Humanitarian Humanitarian and HE as % of Population Population Population Livelihood Crisis Livelihood Crisis Emergency (HE) Emergency (HE) Total population (AFLC) (AFLC) North Awdal 305,455 110,942 194,513 5,000 25,000 0 0 10 Woqooyi Galbeed 700,345 490,432 209,913 55,000 30,000 0 0 12 Togdheer 402,295 123,402 278,893 55,000 75,000 20,000 5,000 39 Sanaag 270,367 56,079 214,288 20,000 75,000 5,000 15,000 43 Sool 150,277 39,134 111,143 15,000 35,000 5,000 0 37 Bari 367,638 179,633 202,737 80,000 0 25,000 0 29 Nugaal 145,341 54,749 75,860 25,000 15,000 0 5,000 31 Sub-total 2,341,718 1,054,371 1,287,347 255,000 255,000 55,000 25,000 25 Central Mudug 350,099 94,405 255,694 30,000 40,000 0 110,000 51 Galgaduud 330,057 58,977 271,080 15,000 35,000 10,000 200,000 79 Sub-total 680,156 153,382 526,774 45,000 75,000 10,000 310,000 65 South Hiraan 329,811 69,113 260,698 25,000 55,000 5,000 160,000 74 Shabelle Dhexe 514,901 95,831 419,070 25,000 60,000 0 160,000 48 (Middle) Shabelle Hoose 850,651 172,714 677,937 35,000 50,000 10,000 5,000 12 (Lower) Bakool 310,627 61,438 249,189 25,000 65,000 0 70,000 52 Bay 620,562 126,813 493,749 20,000 5,000 0 5,000 5 Gedo 328,378 81,302 247,076 30,000 80,000 0 40,000 46 Juba Dhexe (Middle) 238,877 54,739 184,138 10,000 5,000 0 0 6

Juba Hoose (Lower) 385,790 124,682 261,108 20,000 10,000 0 0 8 Sub-total 3,579,597 786,632 2,792,965 190,000 330,000 15,000 440,000 27 Banadir 901,183 901,183 - 30,000 - 55,000 - 9 Grand Total 7,502,654 2,895,568 4,607,086 520,000 660,000 135,000 775,000 28

Assessed and Contingency Population in AFLC and HE Number affected % of Total population Distribution of populations in crisis Assessed Urban population in AFLC and HE 655,000 9 18% Assessed Rural population in AFLC and HE 1,435,000 19 39% Estimated number of new IDPs-updated 1st Sept 2009 (UNHCR) 1,275,000 17 35% Estimated number of protracted IDPs 275,000 4 8% Estimated Rural, Urban and IDP population in crisis 3,640,000 49 100.0%

FSNAU Technical Series Report No VI. 25 5 Issued September 11, 2009 2. Development of Caseloads of Acutely Malnourished Children in Somaila

FSNAU, in collaboration with nutrition cluster partners, in 2008 began to illustrate the distribution of estimates of acutely malnourished children in Somaila. The objective being to highlight to response agencies and donors the needs in different parts of the countries, and move away just from the situation analysis to also consider the impact of population density in determining response needs.

The map illustrates the total caseload based on the most recent nutrition assessments in a given area, and where recent survey data are not available extrapolations are made using median rates specific to the region as appropriate. This has meant that the current map developed by FSNAU has estimated the caseload of malnourished children of 100% of the population from 6months to 5 years in Somalia. Population figures from the UNDP 2005 settlement survey are used, as the standard reference for Somalia.

The map, therefore, illustrates the distribution of the total estimated caseload of acutely malnourished children and the regional importance which relates to population density. To explain, the Gu ’09 nutrition cycles estimated approximately 285,000 children 6-59months as acutely malnourished of which 70,000 are severely malnourished in the total population. These figures are derived using the national median rate of 19% for global acute malnutrition and 4.6% as the median severe acute malnutrition rate, from the thirty four representative surveys conducted in 2009.

The distributions of the 285,000 Map 4: EstimatedDISTRIBUTION O FNutrition ESTIMATED* CSituation,ASELOADS OF AJulyCUTE L2009Y MALNOURISHED CHILDREN, JULY 2009 (100%) acutely malnourished children are illustrated in blue, and the

20% 16% distributions of the 70,000 (100%) !( severely acutely malnourished DJIBOUTI children are illustrated in red. For Awdal !( example 21% of the 285,000 acutely Sanag Bari Woq. Galbeed !( malnourished children reside in !( KEY the Shabelle regions, followed by GAM: Estimated Percentages of Total Caseload of Acutely Togdheer Malnourished Children under Sool 20% in the 5 northwestern regions. 5 years in Somalia by Region ^ 7% 6% SAM: Estimated Percentages !( of Total Caseload of Severely caseloads Neither of these areas report a Very Malnourished Children under 5 years in Somalia by Region Nugal NE/NW Critical nutrition situation (>20% Protracted IDPs Severity Scale GAM) yet due to the population <10% 10-20% >20% density, the absolute numbers of 3.0% 3.0% acutely malnourished children are !(

very significant. For the severely Mudug malnourished children the regions 10.0% 10.0% hosting the majority are again the Shabelles at 22%, followed by Juba Galgadud

regions at 15% and Bay regions B5.0a%ko3l.0% 5H.0%ira6n.0% at 12%. This therefore highlights that the focus should not just be on !( areas of Critical and Very Critical Gedo M. Shabelle 6.0% 7.0% LEGEND nutrition situation but also on the 13.B0%ay12.0% 21.0% 22.0% distribution of these cases. Nutrition Situation Ban!(adir Acceptable L. Shabelle Alert M. Juba The indicators used are based on the Serious Critical WHO Growth Standards 2005, <-2 10.0% 15.0% Very Critical WHZ and/or oedema for GAM and Projected Trend (July - December'09) Potential to Improve Hot Spot for Very Critical <-3 and/or oedema for SAM. FS- L. Juba Uncertain ^ !( Potential to Deteriorate IDP Phase NAU also computes the caseload by Serious region and district using the WHO Critical Very Critical GS WHZ, NCHS WHZ, and MUAC *These numbers are derived using nutrition survey data from the ± most recent surveys from 2009. Where recent surveys have not been conducted in crisis areas, median rates have been applied. (<12.5cm, <11.5cm and <11cm). For 40 20 0 40 80 120 160 These numbers represent 100% of the total <5years population in Kilometers Somalia.

more information please contact Food Security and Nutrition Analysis Unit - Somalia http://www.fsnau.org P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-4000000 fax:254-20-5000555 FSNAU is managed by FAO. [email protected]. 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.

FSNAU Technical Series Report No VI. 25 6 Issued September 11, 2009 Trends in Pastoral Malnutrition - The Case of West Golis/Guban Livelihood Zones, Somaliland

The pastoral livelihood zones of West Golis (goat, camel, sheep) and Guban (sheep, goat, camel) encompass the coastal plains and highlands of Somaliland. As pastoralists, the population mainly rely on the consumption and sale of milk and animal products for subsistence and commercial purposes. Studies conducted amongst other pastoral populations in Eastern Africa have noted the important contribution that livestock milk makes to the energy and nutrient requirements of pastoral populations, especially children. Milk is a good source of high quality protein and micronutrients and an important contributor to the total energy intake of individuals. Subsequently, increasing the intake of milk is protective against wasting as well as stunting in young children1. In a normal dry season, pastoralists migrate within their region in search of pasture and water as they await the seasonal rains. During this normal migration, the entire household will migrate together; hence all the household members will continue to benefit directly from livestock products. In situations whereby the area has experienced consecutive A young girl herding goats in West Golis seasons of rainfall failure resulting in very limited water availability and inadequate pasture, pastoral populations cope through abnormal migration out of their region. Abnormal migration is an extreme coping strategy and often results in families splitting, where the women and children are left behind with a few lactating animals, whilst the adult and adolescent boys move great distances to areas outside their region in search of water and pasture for their livestock. The vulnerable groups left behind consequently experience reduced household access to food, milk and animal products. Household food consumption then reduces with declined income from the sales of milk and animal products. Further, with the limited milk available, market prices for milk rise. This reduced consumption of milk and household income has a direct impact on the nutritional status of the children, as has been observed, in the case of the West Golis/Guban pastoralists.

Prior to the Deyr ‘08/09, animals from the West Golis/Guban livelihood zone had abnormally out migrated to the Hawd livelihood zone in the south, and the Northwest Agropastoral livelihood zones of Awdal and Galbeed regions, due to four consecutive seasons of poor rainfall in the livelihood. Unfortunately, in addition to the harsh climatic conditions in the livelihood, an outbreak of livestock special article disease resulted in high deaths of sheep and goat, reducing livestock holdings. The overall impact was a reduction in household food access and consumption of milk and livestock products. A nutrition survey conducted in October 2008 indicated a global acute malnutrition (rate of 22.3% and a severe acute malnutrition rate of 6.6 %, indicating a Very Critical2 nutrition situation. The proportion of households reported to be consuming milk everyday was only 33%, moreover the cost of milk was high, with 1 litre of milk costing 3,500 SL shillings at the local markets. The overall household dietary diversity was Critical3, whilst the proportion of households consuming at least three meals a day was almost half of the population (47.7%). In addition to the precarious food security situation having a negative effect on the nutritional status of the vulnerable pastoral population, the proportion of children assessed that had reportedly suffered from diarrhoea in October 2008 was high at 28.6%. During periods of water scarcity, the population consume unsafe water predisposing them to diarrhoea and further risk of acute malnutrition. Figure 4: Comparing GAM rates, Household milk The Gu ’09 rainy season, fortunately was normal. The area consumption and Milk prices of the Deyr 08/09 received adequate rainfall which increased water and pasture availability, and prompted the in-migration of livestock back to and the Gu 09 the area. Additionally, livestock from other areas, namely Shiniile and Djibouti also migrated to the West Golis/Guban livelihood zones. This resulted in improved household availability and consumption of milk and animal products. A nutrition survey conducted in June 2009 indicated a marked improvement in the nutrition status of the population, with a global acute malnutrition rate of 13.3%, and a severe acute malnutrition rate of 2.5 %. Household milk consumption had significantly increased, with 60.4% of the households reported to be consuming milk. The price of milk in the local markets had also reduced, with a litre of milk being sold at 1,500 SL shillings, increasing household access. The overall dietary diversity also improved, and only 13.5% of the households reportedly consumed less than 4 food groups a day. Water availability and access also improved in the area, with resultant decline in the incidences of reported diarrhoea, compared to the Deyr ‘08/09.

The Very Critical nutrition situation in the Deyr ‘08/09 also prompted humanitarian interventions in the area. UNICEF, MOHL, World Vision and SRCS implemented selective feeding and health programmes which mitigated the sub-optimal nutrition situation in the livelihood. The Child Health Days also conducted in the region included activities such as immunization, vitamin A supplementation, deworming and screening of children.

The case of the West Golis/Guban is a positive illustration of the importance of milk among the pastoralist populations, and the negative effects of drought on the pastoralist population. Milk availability and consumption has a very significant influence on the nutritional status of the pastoralist population. It also demonstrates the natural ability the pastoral population may have to recover from non cumulative shocks.

1 Milk Matters- A Literature review for the Pastoralist Health and Nutrition Initiative, Mark Myatt et al; November 2008 2 FSNAU Framework for Estimating the Nutrition Situation, Draft 6 February 2008 3 Proportion of households consuming <4 food groups is 25-40% - FSNAU Framework for Estimating the Nutrition Situation,

FSNAU Technical Series Report No VI. 25 7 Issued September 11, 2009 3.Nutrition Analysis in Somalia

The nutrition information component of the Food Security and Nutrition Analysis Unit has been operational in Soma- lia since 2000. From that time the nutrition project has been the main source of nutrition information in Somaila for response actors. 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 cartographi- cal output. The development of this analysis framework, below, although led by the FSNAU 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, a 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 though slash marks on the map. However historical data is used for overall contextual and trends analysis

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 3: Nutrition Situation Categorisation Framework 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, nutrition analysis 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 justed 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 increase (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)

FSNAU Technical Series Report No VI. 25 8 Issued September 11, 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, limited 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% i). 6-8 months old16 2-3 <2 ii). 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 Immunization & 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 quan- nutrition analysis tity 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 / underlying 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

FSNAU Technical Series Report No VI. 25 9 Issued September 11, 2009 4. REGIONAL NUTRITION ANALYSIS

4.1 Gedo Region – Pastoral, Agro-pastoral and Riverine Livelihood Zone

Gedo Region in south west Somalia comprises of six Map 5: Gedo Region Livelihood Zones districts; Luuq, Dolo, Belet Hawa, Garbaharey, El Wak, and Bardera. The region has three main rural livelihood zones namely; pastoral, agro-pastoral and riverine (Juba riverine pump irrigation). The pastoral livelihood is further sub-divided into the Southern Inland and Dawa pastoralists while the agro-pastoral is divided into Southern agro-pastoral and Bay-Bakool high potential agro-pastoralists. (Map 5)

Gedo is one of the regions adversely affected by the cumulative effects of extended conflict and recurrent natural disasters. These have resulted in the disruption of livelihood systems, including loss of livestock and crop failure and culminated in a persistent emergency situation in most parts of the population. According to the bi-annual FSNAU seasonal analysis, northern Gedo has persistently faced a Humanitarian Emergency (HE) crisis since 2004. Similarly, the nutrition situation in the region has remained unstable, with all assessments conducted in the region since 1995 recording Global Acute Malnutrition (GAM) rates above the emergency threshold of 15%. Figure 5 indicates the trends of acute malnutrition (using WHO reference growth standards) in Gedo since 2002. Figure 5. Trends in levels of Acute Malnutrition Historical Overview - Post Deyr ‘08/09 (WHZ<-2 or oedema, WHO 2006) in Gedo Region , 2002-2009 Population GAM- Date WHO'06 Oct.02 30% B/Hawa 22% Oct.04 Luuq D 27% Mar.06 Gedo R 24% Apri.06 Bardera Town 20% The FSNAU Post Deyr’ 08/09 integrated food security 22% Apr.07 Gedo Pastoral May.08 22.80% Dec.08 27% Jul.09 23% Apr.07 Gedo Agropastoral 17% phase classification, indicated that the rural population in May.08 19.00% Dec.08 23.10% Jul.09 20.60% Apr.07 Gedo Riverine 19% May.08 21.80% Dec.08 21.70% Northern Gedo was persistently faced with a Humanitar- Jul.09 12.50% ian Emergency (HE) while southern Gedo was classified 15% in an Acute Food and Livelihood Crisis (AFLC) phase. Approximately, 36,000 people were faced with HE and regional nutrition analysis regional 91,000 people were in AFLC in the entire Gedo region.

These phase classifications were linked to the cumulative 0% 22% 27% 24% 20% 22% 27% 23% 17% 19% effect of the poor rainfall performances and the resulting 22.80% 19.00% 23.10% 20.60% 21.80% 21.70% 12.50% B/Hawa Luuq D Gedo R Bardera Gedo Gedo Gedo Town Pastoral Agropastoral Riverine negative impact on the different livelihoods, including Oct.02 Oct.04 Mar.06 Apri.06 Apr.07 May.08 Dec.08 Jul.09 Apr.07 May.08 Dec.08 Jul.09 Apr.07 May.08 Dec.08 Jul.09 diminished cereal and livestock production as well as the impact of market forces and civil insecurity. According to the FSNAU Post Deyr ’08/09 analysis, parts of Gedo region had received poor Deyr rainfall resulting in average water availability and pasture conditions and poor cereal production estimated at 37% of post-war average. The in-migration of livestock across the Kenya border from Elwak at the time exerted further pressure on the already reduced water and pasture availability in the region. The overall livestock body condition in the region was average, and milk production low. The poor cereal and milk production influenced availability and intake of these food items thus influencing the nutrition situation of the population.

The integrated analysis of data from nutrition assessments conducted in Gedo in December 2008, health information and feeding facilities indicated a Very Critical nutrition situation in all livelihoods in the region. The nutrition assessment in the pastoral livelihood zone recorded a GAM rate of 27.4% (23.7 – 31.6) while a small sample cluster assessment (33X6) among the riverine livelihood identified 46 children out of the 198 assessed as acutely malnourished which, based on LQAS decision rule indicated that the global acute malnutrition rate among the riverine community was greater than 20%. Similarly, the nutrition assessment results from the agro-pastoral populations, reported a GAM rate greater than 20%. The worsening nutrition situation was attributed to reduced access to food due to poor rainfall performances, resulting in low milk production and poor crop harvests; the hyperinflation and disrupted delivery of health and nutrition-related assistance to the affected population by humanitarian agencies; high morbidity; and limited access to basic services including health, safe water and sanitation facilities.

FSNAU Technical Series Report No VI. 25 10 Issued September 11, 2009 Current Situation

Food Security The Post Gu’09 analysis continues to show below normal rainfall performance in Gedo region with poor and near normal Gu rains recorded in northern and southern Gedo respectively. As a result, crop production in the rain-fed agropastoral areas has been adversely affected with the region realizing only 26% of PWA (1995 – 2008) crop production. Livestock production has equally been affected by lack of water and pasture leading to weakened body conditions, below average milk production and out-migration of livestock to other regions, thus reducing milk availability and access as well as income from sale of livestock and other livestock related products. The FSNAU Post Deyr’08/09 analysis indicates that about 110,000 and 40,000 people are currently faced with Acute Food and Livelihood Crisis and Humanitarian Emergenciy respectively.

Nutrition The high vulnerability to acute malnutrition persists in the region due to chronically high morbidity, poor access to diversified diets and basic services. The integrated analysis of information from nutrition assessments conducted in Gedo in July 2009, health information and feeding facilities’ data show a Very Critical nutrition situation among the pastoral and riverine livelihoods and a Critical situation among the agro-pastoral livelihood populations. The nutrition assessment in the pastoral population recorded a GAM rate of 22.6% (18.3 – 27.5) and a SAM rate of 5.4% (3.9 – 7.5) while the riverine regional nutrition analysis assessment reported a GAM rate of 22.9% (18.7 – 27.7) and a SAM rate of 5.6% (3.9 – 8.1). These rates indicate a sustained Very Critical nutrition phase with no change from the situation in the Deyr’08/09, for both the livelihoods. On the other hand, the nutrition assessment conducted among the agro-pastoral livelihood population Assessment Team conducting household interview in reported a GAM rate of 19.9% (17.3 – 22.8) and SAM Dolo town, Gedo,July ‘09 rate of 4.4% (2.9 – 6.6) indicating a Critical nutrition situation. The Deyr ‘08/09 had classified the nutrition situation as likely Very Critical. However, given that the confidence intervals of the GAM rates in the three livelihood-based assessments overlap, and the CDC calculator indicates no significant differences (pr<75%, p>0.05), the nutrition situations in the three livelihoods are statistically not different.

The sustained poor nutrition situation in the region is partly linked to the cumulative effects of seasons of reduced food availability and access due to poorly functioning livelihood systems and poor rainfall performance. The low crop production arising from rain failures and reduction of cultivated land, and low milk access due to weakening livestock body conditions and out-migration of livestock also contribute to poor dietary intake in Gedo region. Current results indicate a Critical1 dietary diversity situation with over 33% of the assessed households consuming poorly diversified diets (≤ 3 food groups). The high morbidity reported, complicated with limited access to health services has also negatively affected the nutrition situation.

Other potential issues influencing the nutrition situation include chronic factors such as poor child care and feeding practices, and limited access to basic human services such as sanitation facilities and safe water, which predispose populations to high morbidity and subsequent high levels of acute malnutrition. Diarrhoea is particularly associated with high acute malnutrition rates in the region. Multi-sectoral responses that address these underlying causes are required in the region. The key nutrition evidence indicators of the analysis on the nutrition phase classification are provided in Table 3.

1 FSNAU Frame work for Estimating the Nutrition Situation

FSNAU Technical Series Report No VI. 25 11 Issued September 11, 2009 Table 4: Summary of Key Nutrition Findings in Gedo Region Pastoral (N=754) Agropastoral (=753) Riverine (N=676) Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status 22.6 19.9 22.9 Global Acute Malnutrition (WHZ<-2 or oedema) Very Critical Critical Very Critical (18.3 – 27.5) (17.3 – 22.8) (18.7 – 27.7) 5.4 4.4 5.6 Severe Acute Malnutrition (WHZ<-3 or oedema) Very Critical Critical Very Critical (3.9– 7.5) (2.9 – 6.6) (3.9 – 8.1) Oedema 0.1 0.4 0.1 Acceptable Acceptable Acceptable (...) (0.1 – 1.3) Global Acute Malnutrition (WHZ<-2 or oedema; 23.0 19.3 23.4 Very Critical Critical Very Critical NCHS) (18.6 – 28.1) (16.5 – 22.3) (19.0 – 28.4) Severe Acute Malnutrition (WHZ<-3 or oedema; 2.7 2.0 2.7 Serious Alert Alert NCHS) (1.8– 3.9) (1.2 – 3.3) (1.6 – 4.5) Acute malnutrition by MUAC (<12.5 cm or 6.6 13.4 13.8 Serious Critical Critical oedema in nutrition surveys) (3.4 – 9.8) (11.1 – 16.1) 9.7 – 17.8) 22.9 34.3 31.2 Stunting (HAZ<-2) Serious Serious Critical (19.0 – 27.4) (30.9 – 37.8) (26.2 – 36.7) 28.6 31.6 31.9 Underweight (WAZ<-2) Serious Serious Critical (23.7 – 33.9) (28.4 – 35.1) (27.3 – 36.8) High levels and High levels and High levels and HIS Nutrition Trends(Aug-Nov’08) Critical Critical Critical stable increasing increasing Admission trends at TFPs/SFPs (Gedo – Jan- High levels and High and Critical Critical High and stable Critical Jun’09) stable increasing Proportion of malnourished registered in SFs 3.5 Very Critical 6.1 Very Critical 2.5 Very Critical

Child Morbidity & Immunization Disease trends (seasonally adjusted) Outbreak – None Outbreak -None Outbreak -None Morbidity refers to the proportion of children Morbidity – 28.4 Critical Morbidity– 45 Critical Illness – 41.4 Critical reported to be ill in the 2 weeks prior to the survey RDT – 0.5 RDT – 0.2 RDT- 1.1 Vitamin A – 88.2 Alert Vitamin A – 69.6 Vitamin A – 82.7 Immunization Status Serious Alert Measles – 91.1 Measles- 66 Measles- 84.2 Mortality N=782 N=790 N=784 Crude Mortality Rate per 10,000 per day 0.77 1.17 0.81 Alert Serious Alert (retrospective for 90 days) (0.45 – 1.30) (0.75 – 1.81) (0.44 – 1.51) Under five mortality rate per 10,000 per day 1.34 3.82 2.90 Alert Serious Serious (retrospective for 90 days) (0.68 – 2.64) (2.20–6.58) (1.67 – 5.0) Women Nutrition & Immunization Status Proportion of malnourished non pregnant women 1.6 0.7 2.4 Acceptable Acceptable Acceptable (MUAC≤18.5 cm) (N=322) (N=439) N=267 Proportion of malnourished pregnant women 26.2 36.2 26.1 Very Critical Very Critical Very Critical (MUAC<23.0). (N=130) (N=130) N=119 Proportion of Women who received Tetanus 81.4 56.6 78.5 Alert Critical Serious Immunization (N=452) (N=569) (N=386) Public Health Indicators N=453 N=473 N=374 Households with access to safe water 13 Very Critical 1.9 Very Critical 32.9 Very Critical Household with access to sanitation facilities 19.2 Very Critical 11.6 Very Critical 46.3 Very Critical

regional nutrition analysis regional Households with access to health facility 64.7 Serious 12.9 Very Critical 55.3 Serious 18.3 16.5 24.4 Proportion who own mosquito nets Very Critical Very Critical Very Critical N=1550 N=1603 N=1349 14.8 13.8 17.6 Proportion who use mosquito nets Very Critical Very Critical N=1550 N=1603 N=1349 Food Security N=453 N=473 N=374 Households with poor dietary diversity (< 4 food 36.9 33.6 36.1 Critical Critical Critical groups) (24.2 – 49.5) (29.4 – 38.1) (23.6 – 48.5) Household’s Main Food Source Purchase: 94.7 62.8 4.5 Serious Own Production 0 Acceptable 34.9 87.2 Acceptable Food aid 1.3 0.2 0 Food security phase AFLC/HE Very Critical AFLC/HE Very Critical AFLC/HE Very Critical Overall Situation Analysis Very Critical Critical Very Critical

FSNAU Technical Series Report No VI. 25 12 Issued September 11, 2009 Somalila National Micronutrient Malnutrition Study: Field Experiences

Somalia is facing a chronic nutrition crisis with rates of acute and chronic malnutrition consistently exceeding emergency thresholds, in some areas for over 10 years. Research into the underlying causes has identified high rates of morbidity as a major driving force behind this sub-optimal nutrition situation. Low immunization coverage, periods of food shortage and poor access to basic social services are aggravating factors. Anecdotal evidence has identified clinical cases of Vitamin A deficiency and Iodine deficiency at community level, however the availability of prevalence data to determine the public health significance of the main micronutrient deficiencies disorders in Somalia is lacking.

It is from perspective that FSNAU in collaboration with UNICEF, WHO, WFP, University College London and Ministries of Health/Labour in Somaliland and Puntland conducted a Micronutrient Malnutrition Study from 19th March to 5th August 2009 in Somaliland, Puntland and South Central Somalia. The aim of the study was to determine the public health significance of the major micronutrient (Vitamin A, Iron and Iodine) deficiencies in the Somali population so as to inform Interviewer collecting information from a mother and advocate for appropriate responses. The study findings will also serve as baseline on the levels of deficiencies of the major micronutrients in Somalia for monitoring response. Analysis of data collected is on-going, and preliminary findings will be shared in November - December 2009. Field experiences and challenges encountered during data collection are summarized below.

Methodology Due to the need to have three representative surveys for Somaliland, Puntland and South Central, in order to appropriately inform response, three cross sectional studies were conducted in sequence. Probability proportional to size was used for the first stage of sampling at zonal level and second level sampling conducted using a combination of maps, segmentation and modified EPI sampling system. The survey involved collection of biological and anthropometric data as well as household and individual level descriptive data. Due to the challenging environment in Somaila, the collection of serum samples is not recommended, therefore the Dry Blood Spot (DBS) technique was applied. The DBS was collected from a finger prick for iron special article and Vitamin A analysis, urine samples were collection for iodine estimation and as salt samples were tested for presence of potassium iodate. Measurement of Haemoglobin and Malaria tests were also performed using a HaemoCue machine and rapid diagnostic test kits (RDT) respectively. Anthropometric measurements were collected on women and children from 0 to 59 months. In addition to the routine household data and individual data on demographics, IYCF, public health environment, information was collected at individual level on dietary diversity. Lab Technician collecting DBS sample Each survey team comprised of 2 enumerators, 2 biological sample collectors, 2 measurers and one team leader. FSNAU Nutrition field analysts served as supervisors with each team having at least one FSNAU staff. A seven day training was undertaken with one day of piloting of the survey tools in each survey area. Actual field work in each zone took about two weeks. A total of 31, 32 and 33 clusters were covered in Puntland, Somaliland and South Central Somalia respectively.

Challenges Somalia is vast and majority of the regions have very poor road networks. Logistical organisation was therefore a major problem. However this was overcome by conducting the survey in phases. Puntland, Somaliland, South Central Somalia were therefore treated as separate phases. Training for the teams was done at the start of every phase with new staff recruited from the respective phase. Logistical problems within a phase were overcome by the teams completing one region at a time until the phase was completed. In Somaliland for example, there were 6 regions and all the 6 teams worked in one region before moving to the next. Thus all the teams were in close reach of supervision and supplies in case of shortage. Teams were also provided with extra supplies for the number of clusters to be covered. A checklist of the supplies with the quantities required were provided to the teams leaders and teams were only released to the field upon satisfying that the exact qualities of supplies had issued. Thuraya satellite phones were provided to team supervisors going to areas out network in areas that permitted their use and also additional supplies such as HaemoCue and weighing scales in the event of a breakage. With the exception of Gerisa and Erigavo clusters in Somaliland where a shortage of essential supplies took over six hours to replenish, though no day was lost, the logistical arrange- ments made ensured smooth running of the survey until completion.

Another major challenge was the recruitment of qualified and dedicated teams for the survey as well as hiring serviceable cars that could access the remote areas of Somalia. This was also overcome by the presence of FSNAU staff in the field who worked in close collaboration with the local authorities from the survey areas. Given FSNAU conducts regular nutritional assessments in Somalia, they were able to identify the strongest enumerators from previous experience. Insecurity was also a major challenge, specifically in South and Central Somalia. In this area both the micronutrient study coordinators as well as FSNAU staff were severely restricted in their movements. To combat this, a thorough training was provided to the teams and pilot testing was repeated for some teams with unsatisfactory performance. Each team was closely supervised at the start of their first cluster which was within reach and only sent off to the remote areas after satisfactory performance. Given South Central Somalia is also ravaged by clan tensions, FSNAU staff ensured that teams were sent to clans and clusters they belonged.

The complexity of the biological sample collection, handling and storage was also a major challenge. This was however overcome by recruit- ing into the survey teams at least two qualified laboratory technicians. The inclusion of the laboratory staff into the teams improved sample collection quality as well as reduced the time taken to cover a cluster. A cluster took on average one and half days. Despite the fact that it was not pronounced, there was felt existence of misconceptions about the biological sample collections in some survey populations. This was similarly overcome through publicity during the official opening of the training where top officials from the Ministry of Health attended and also aired in the zone’s local television and radio stations. The presence of testing facilities and treatment for anaemia and malaria also improved acceptance. In summary the participation of FSNAU staff in the survey that were well versed with the geopolitical situation of Somalia, coupled with quality survey teams, good supply chain management, the presence of Haemoglobin and Malaria testing and treatment and the presence of community leaders with the survey team, contributed to the successful completion of the survey in such a complex environment as Somalia. Given this is the first study of its kind in Somalia and given the very challenging environment, FSNAU wishe to thank all the actors who participated in this incredibly important study!

FSNAU Technical Series Report No VI. 25 13 Issued September 11, 2009 4.2 Lower and Middle Juba Regions – Pastoral, Agro-pastoral and Riverine Livelihood Zone

Middle and Lower Juba in south Somalia have a total of seven districts namely Sakow, Buale and Jilib in Middle Juba, and Jamame, Afmadow, Kismayo and Badhadhe in Lower Juba. The two regions have three rural livelihood zones namely, the pastoral (the Southern Inland and Southeast Pastoralists), agro-pastoral (Lower Juba and Southern Agro-pastoralists) and the riverine communities who are purely farmers. (Map 6).

The food security and nutrition situation in the Juba Map 6: Juba Regions Livelihood Zones regions have varied over time and been linked to rainfall performance and the resultant impacts on the different livelihood systems. Heavy rainfall in the Juba regions or in the Ethiopian highlands often results in floods that devastate crop cultivation, and sanitation in the riverine areas, however, the riverine communities’ later benefit from recession crops from the Desheks and fishing opportunities from the flood waters. 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. The nutrition situation in Juba regions equally, varies across livelihoods with the pastoral population remaining mostly in Serious levels since Gu’07 while in the riverine and agro-pastoral livelihoods, the situation has fluctuated betweenSerious and Critical phases. Figure 6 shows the trends of acute malnutrition in Juba regions since 2003.

Figure 6: Trends in levels of Acute Malnutrition (WHZ Historical Overview - Post Deyr ’08/09 <-2Z scores or oedema,WHO 2006) in Juba The FSNAU Post Deyr ’08/09 integrated food security Regions 2003 - 2009 phase classification analysis reported mixed rainfall 30% outcomes in Juba regions, with parts recording near normal rainfall while others, particularly in Middle Juba, receiving poor rains. Consequently, water availability and pasture conditions were poor both in the pastoral and 15% agro-pastoral areas but good in riverine areas, leading to early out-migration of livestock to riverine areas and Jorey

regional nutrition analysis of Badhadhe district. The livestock body condition was reported as average, while milk production was average 0% Jul.09 Jul.09 Jul.09 Jun.07 Jun.08 Jun.07 Jun.08 Jun.07 Jun.08 Apri.06 Dec.07 Dec.08 Dec.07 Dec.08 Dec.07 Dec.08 May.03 May.03 May.06 May.04 May.06

to good in some areas in the region. The overall cereal Buale/ Kismayo Afmadow Juba pastoral Juba Agro-pastoral Jilib Riverine Juba Riverine Sakow production in the agricultural areas of the two Juba regions was poor, estimated at 20% of PWA in Lower Juba and at 30% of PWA in Middle Juba. During the Post Deyr ‘08/09 season, no one was faced with a Humanitarian Emergency, however, about 90,000 people in both regions were faced with Acute Food and Livelihood Crisis (AFLC).

The integrated Post Deyr ’08/09 nutrition situation analysis indicated an improvement in the agro-pastoral population from Critical levels recorded in Post Gu ’08 to a Serious phase, while the pastoral livelihood was in a sustained Serious phase. The relatively better, though Serious, nutrition situation among the pastoral and agro-pastoral communities in Juba regions at that time was attributed to good milk availability and access from the livestock within the regions, as well as from those in-migrating from other regions. These communities benefited both from the consumption and sale of livestock products, including milk, milk products and meat.

The riverine community recorded a GAM rate that was within Serious levels, but due to a high severe acute malnutrition rate the situation was classified asCritical . The riverine communities were benefiting from off-season crops, increased access to fish from flooded areas and also from the increased farm labour opportunities. The nutrition situation of Kismayo IDPs was in a sustained Critical phase since the Deyr’07/08 with 12% of the, 1386 children assessed in January 2009 being acutely malnourished (MUAC<12.5 cm or oedema).

FSNAU Technical Series Report No VI. 25 14 Issued September 11, 2009 Current Situation

Food Security The FSNAU Post Gu ’09 analysis shows near normal and poor Gu rainfall performance in Middle Juba and parts of Lower Juba regions respectively. In addition, a good Hagaa rainfall is on-going in the two regions. However the poor Gu rainfall performance particularly in parts of Lower Juba has contributed to poor rangeland conditions and low water availability in pastoral and agro-pastoral areas. This prompted early out-migration of livestock to the riverine areas, reducing milk availability and access in the affected areas. The impact of the Gu rains is well reflected in the cereal production, with Middle Juba recording bumper harvest estimated at 210% of PWA, while Lower Juba region has poor cereal harvest. However, due to the on-going good Hagaa rainfall, good off-season cereal production is expected in the two regions.

Nutrition Situation In contrast to the improved food security indicators, the current Post Gu’09 integrated analysis of the nutrition assessments, health information and targeted feeding facilities data, indicates a significant deterioration of the nutrition situation in the pastoral and the agro-pastoral population from Serious recorded in Post Deyr ’08/09 to the current Very Critical. The nutrition assessments conducted in July 2009 recorded respective GAM and SAM rates of 20.6% (16.1 – 26.1) and 6.8% (4.2 – 10.8) in the pastoral livelihood while a GAM rate of 21.7%

(19.0 – 24.7) and a SAM rate of 7.4% (4.8 – 11.2) was regional nutrition analysis recorded among the agro-pastoral population. These show Very Critical nutrition situations and deterioration from the respective GAM and SAM rates of 15.0% (11.5-19.4) and 4.0% (2.6-6.2) in pastoral livelihood and 14.3% (8.7 – 19.1) and 4.2%(1.1 – 7.3) in the agro-pastoral livelihoods recorded in the December 2008 assessments. Using the CDC2 calculator, there is a significant difference (increase) between the respective GAM rates recorded in December 2008 and those recorded in the current July 2009 assessments at a probability of 92.7% (p=0.073) in pastoral and at 95.4% (p=0.046) probability in the agro- pastoral livelihoods.

The deterioration is largely attributed to morbidity related factors especially the outbreak of acute watery diarrhoea since March 2009 across all livelihoods. According to(AWD) the Somali Health Cluster Bulletin3, AWD cases are still prevalent with a total of 736 cases, 82% of An Enumerator taking MUAC measurement of a

whom were children under the age of five years, recorded mother in Juba, July ‘09 in the two regions between 27th June and 31st July 2009. However, given the on-going health responses by WHO and other local NGOs in the regions, including provision of treatment drugs, water chlorination, health education, distribution of soap and campaigns raising awareness on environmental hygiene, the case loads are expected to continue decreasing resulting in an improved nutrition situation. It is in view of these facts that the nutrition situation in the two livelihoods is classified asVery Critical but likely to improve in the coming months.

On the other hand, the riverine population shows an improvement in the nutrition situation from Critical levels recorded six months ago to Serious. The nutrition assessment conducted in July 2009 reported a GAM rate of 12.5% (10.1 – 15.4) and a relatively lower SAM rate of 3.6% (2.2 - 5.9) as compared to the higher SAM rate of 5.1% (3.1 – 8.2) recorded in December 2008. The improvement is linked to increased access to fish, fruits, vegetables and milk (from own livestock as well as those migrating into Juba from other regions), increased income through increased labour opportunities and relatively better access to health services compared to other livelihoods. The nutrition situation of Kismayo IDPs is in a sustained Critical phase since the Deyr’07/08 with 14% of the 1530 children assessed in July 2009 being acutely malnourished (MUAC<12.5cm). Overall, chronic poor child care and feeding practices, limited access to safe water and sanitation facilities as well as health services are, key aggravating factors to the acute malnutrition in Juba regions. Measures to improve and sustain health service delivery, access to safe water and sanitation facilities as well as addressing poor child care practices are recommended in the two regions. The following table highlights the key findings of the nutrition situation analysis.

2 A one-tailed 75% and 2-taile 87.5% probability is considered operationally different between two surveys 3 Somali Health Cluster Bulletin # 25, July 2009

FSNAU Technical Series Report No VI. 25 15 Issued September 11, 2009 Table 5: Summary of Key Nutrition Findings in Middle and Lower Juba Regions Pastoral (N=754) Agropastoral (=753) Riverine (N=676) Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or 20.6 21.7 12.5 Very Critical Very Critical Serious oedema) (16.1 – 26.1) (19.0-24.7) (10.1-15.4) Severe Acute Malnutrition (WHZ<-3 or 6.8 7.4 3.6 Very Critical Very Critical Serious oedema) (4.2 – 10.8) (4.8-11.2) (2.2-5.9). Oedema 0.3 Acceptable 0.9 1.7 Alert Alert (0.1 – 1.6) (0.2 – 3.2) Global Acute Malnutrition (WHZ<-2 or 20.2 19.9 11.3 Very Critical Critical Serious oedema; NCHS) (15.5 – 25.8) (17.3 – 22.8) (8.7 – 14.6) Severe Acute Malnutrition (WHZ<-3 or 2.2 3.2 2.8 Alert Serious Alert oedema; NCHS) (0.9– 5.0) (2.2 – 4.7) (1.6 – 4.8) Acute malnutrition by MUAC (<12.5 cm or 13.1 19.6 14.6 Critical Very Critical Critical oedema in nutrition surveys) (9.6 – 16.6) (14.5 – 24.8) (10.0 – 19.2) 25.1 38.4 41.0 Stunting (HAZ<-2) Serious Serious Critical (19.6 – 31.6) (32.7 – 44.4) (35.6 – 46.5) 25.8 29.5 24.5 Underweight (WAZ<-2) Serious Serious Serious (19.6 – 33.1) (23.2 – 36.8) (19.7 – 30.0) High levels and High levels with High and stable HIS Nutrition Trends(Aug-Nov’08) Critical Critical Critical stable increasing trends trends High number with High numbers with High numbers with Admission trends at TFPs/SFPs (Gedo – increasing trend of Critical increasing trend of Critical increasing trends Critical Jan-Jun’09) admission admission of admission Proportion of malnourished registered in 20.0 Very Critical 33.0 Very Critical 42.6 Critical SFs Child Morbidity & Immunization Outbreak – 204 Outbreak – 314 AWD Outbreak – 214 Disease trends (seasonally adjusted) AWD cases cases reported in AWD cases Morbidity refers to the proportion of children reported in July’09 Very Critical July’09 Very Critical reported in July’09 Very Critical reported to be ill in the 2 weeks prior to the Morbidity– 62 Morbidity – 54 Morbidity – 56 survey RDT positive – 6.5 RDT positive – 1.1 RDT positive – 0.9 Vitamin A -55 Vitamin A 73.2 Vitamin A 69.6 Immunization Status Serious Serious Serious Measles – 66.7 Measles -61.2 Measles -66 Mortality N=672 N=692 N=646 Crude Mortality Rate per 10,000 per day 0.80 0.17 1.19 Alert Acceptable Serious (retrospective for 90 days) (0.45 – 1.43) (0.06 – 0.48) (0.87-1.63) Under five mortality rate per 10,000 per 2.19 0.37 2.62 Serious Acceptable Serious day (retrospective for 90 days) (0.99 – 4.81) (0.08-1.59) (1.71-4.00) Women Nutrition & Immunization Status Proportion of malnourished non pregnant 2.0 0.3 0.4 Acceptable Acceptable Acceptable women (MUAC≤18.5 cm) (N=303) (N=315) (N=274) Proportion of malnourished pregnant women 34.7 52.4 29.6 Very Critical Very Critical Very Critical

meta data analysis (MUAC<23.0). (N=95) (N=168) (N=162) Proportion of Women who received 52.7 Critical 53.0 Critical 67.4 Serious Tetanus Immunization Public Health Indicators N=403 N=478 N=434 Households with access to safe water 58.1 Serious 19.0 Very Critical 36.6 Very Critical Household with access to sanitation 52.4 Serious 44.8 Critical 27.9 Very Critical facilities Households with access to health facility 48.8 Critical 47.7 Critical 56.9 Serious 53.3 32.8 29.5 Proportion who own mosquito nets Serious Very Critical Very Critical N=1306 N=1235 N=1447 52.1 30.8 29.4 Proportion using mosquito nets Serious Very Critical Very Critical N=1306 N=1235 N=1447 Food Security N=403 N=478 N=434 Households with poor dietary diversity (< 4 9.2 8.7 3.5 Alert Alert Acceptable food groups) (3.1 – 15.3) (2.6 – 14.7) (0.7 – 6.2) Household’s Main Food Source Purchase: 78.9 48.1 55.8 Own Production 14.3 Acceptable 47.9 Serious 37.6 Serious Food aid 6.0 2.9 5.1 Food security phase BFI/AFLC Critical BFI/AFLC Critical BFI Serious Overall Situation Analysis Very Critical Critical Very Critical

4.3 Bay and Bakool Regions

Bay and Bakool regions comprise of two predominant livelihoods systems; the Southern Inland Pastoral, largely located in Elberde district (referred herein as Bakool pastoralists); and the agro-pastoral livelihood in Tieglow, Wajid Huddur and Rabdure districts of Bakool, and the four districts (Baidoa, Qansahdhere, Dinsor and Burhakaba) of Bay region (Map 7). The two regions have a high agricultural potential with Bay region serving as the sorghum basket for Somalia.

FSNAU Technical Series Report No VI. 25 16 Issued September 11, 2009 Bakool Region

Historical Overview - Post Deyr ’08/09 Map 7: Bay and Bakool Regions Livelihood Zones According to the Post Deyr’ 08/09 integrated food security phase classification, Bakool region showed a varied situation with some pastoral and agro-pastoral livelihoods showing improvements, and others, showing deterioration in the food security situation. In Bakool region, the total number of people in Humanitarian Emergency (HE) and Acute Food and Livelihood Crisis (AFLC) had decreased by 16% to 45,000 people in HE and 80,000 people in AFLC. The decline was attributed to the good Deyr ‘08/09 rainfall performance in Bakool region that resulted in increased crop production and improved rangeland conditions. The Deyr ‘08/09 crop production was above the post war average (PWA), except in some small pockets. Rangeland and livestock body conditions improved, with medium to high livestock conception rates observed. However, pastoral and agro-pastoral livestock herd sizes remained significantly below baseline levels due to several seasons of dry conditions and high levels of livestock off-take.

In the Deyr ‘08/09 no comprehensive nutrition assessment

was conducted in Bakool agro-pastoral and Bakool pastoral regional nutrition analysis livelihood zones due to civil insecurity in the region, which Figure 7: Trend in levels of acute malnutrition (WHZ< -2 or limited access; however nutrition information from other oedema, WHO 2006 ) in Bakool region 2002- 2009

sources was used to estimate the nutrition situation. A rapid 30.0

MUAC assessment, conducted in Dec’08 in Huddur and 25.0 Tieglow districts, reported a high (22%) proportion of acutely 20.0 malnourished children with MUAC measurements <12.5cm 15.0 (or oedema). Bakool region has selective feeding centres with SFP, TFP and CTC services in Wajid, Tieglow and 10.0 Elberde districts. The admissions of severely and moderately 5.0 acutely malnourished children into selective feeding centres 0.0 Jul 08 Oct'03 Jan'06 Apr 08 Dec 06 Apr 04 Jan.06 Nov.'07 Nov.'07 Nov.'07 Sept'03 Sept'02 showed high numbers of acutely malnourished children with June 09 June 09 Wajid Huddur District Elberde Rabdure District Tieglo Bakool Agropast Bakool Past fluctuating or increasing trends in MCHs within Wajid and IDP District Tieglow districts. The SFP data from the feeding centres showed high levels of admissions of acutely malnourished children, while the TFC and OTP feeding centres in Wajid had shown high numbers of admissions of acutely malnourished children with an increasing trend since Gu ’08. These increased admissions into feeding centres were attributed to expanded outreach activities, and the shift from using the NCHS reference to WHO growth standards in August 2008. The analysis of data from the health information system and feeding facilities in Bakool livelihood zone in the Post Deyr ‘08/09 indicated the nutrition situation was likely to be Very Critical, showing no change from the Gu’08. See Figures 7 which highlights the trends in levels of acute malnutrition from 2003 to current.

Current situation

Food security According to the Post Gu ‘09 integrated food security phase classification, the food security situation in Bakool region has deteriorated in all livelihoods, including the urban areas, since the Deyr ‘08/09. An estimated 160,000 agro-pastoralists, pastoralists and urban population, all together accounting for 52% of the total population of the region are now either in Acute Food and Livelihood Crisis (AFLC) or in Humanitarian Emergency (HE) with an early warning level of Watch over the coming six months (July 09-Dec. 09). The factors contributing to the deterioration in the Gu’09 include crop failure (23% of PWA) due to severe moisture stress at the crop development stage, as well as significant deterioration in vegetation conditions. In addition, water shortages affected pasture conditions and consequently the calving and kidding rates for all livestock species.

Nutrition Bakool Agro-pastoral Livelihood Zone The integrated nutrition situation analysis using data from nutrition assessments conducted in Bakool agro-pastoral in June 09 and information from health and feeding facilities indicates a Serious nutrition situation. This is an improvement from the Very Critical nutrition situation in the Post Deyr ‘08/09. In Bakool region, the agro-pastoral nutrition assessment reported a global acute malnutrition rate (WHZ <-2 or oedema) rate of 14.9% (12.1- 18.3) and a severe acute malnutrition (WHZ <-2 or oedema) rate of 3.4% (2.1-5.4) including one case of oedema, 0.2% based on WHO 2006 growth standards. Given that the confidence intervals of the GAM results from the current and the previous surveys conducted in July 2008

FSNAU Technical Series Report No VI. 25 17 Issued September 11, 2009 where a GAM rate of 25.7% (22.2 – 28.7) was reported Figure 8: Bakool agro-pastoral SFP admission do not overlap, the two surveys are statistically different, 1200 hence illustrating a significant improvement in the nutrition Bakool agro-pastoral SFP admission situation. The improvement is attributed to the positive impact 1000

of humanitarian services that include targeted supplementary 8001200 feeding programmes, general food distribution and relatively 1000 better access to health services. This improvement is also 600800 reflected in the decreasing trends in admissions of moderately 600 malnourished children into supplementary feeding centres 400400 200 in the Bakool agro-pastoral livelihood (Figure 8). The 200 Number of admission retrospective crude and under-five mortality rates of 0.53 Number of admission 0 July Aug Sept Oct Nov Dec Jan Feb Mar Apri May June (0.34 – 0.82) and 0.98 (0.40-2.37) respectively, were below 0 the alert threshold according to the WHO classification. July Aug Sept Oct Nov 2008Dec - 2009Jan Feb Mar Apri May June 2008 - 2009 Bakool Pastoral Livelihood Zone Analysis of data from nutrition assessments, health facilities and feeding centre information, indicates a sustained Very Critical nutrition phase among the Bakool pastoral population. The Bakool pastoral nutrition assessment, conducted in June 2009, reported a high GAM rate of 25.1% (18.6 – 32.8) and a SAM rate of 1.2% (0.5 – 2.6) These results indicate a sustained Very Critical nutrition phase, even when compared to the previous nutrition assessment in April 2008 when a GAM rate of 26.5% (22.5 – 30.5) and a SAM rate of 5.8% (3.6 – 7.9) were reported. The underlying causes of acute malnutrition in the pastoral areas include high morbidity coupled with limited access to health services, safe water and sanitation, and poor child care and feeding practices. The negative impact of these factors are often exacerbated by the frequent seasons of poor rainfall as currently experienced in the area that do not only affect the livestock body conditions and production, but also lead to out-migration of livestock therefore reducing milk access for household members left behind.

Bay Region

Historical Overview - Post Deyr ’08/09 Figure 9: Trend in levels of acute malnutrition (WHZ< -2 or The analysis from the Post Deyr ’08/09 classified the food oedema, WHO 2006 ) in Bay region 2002- 2009 security situation in Bay region as Borderline Food Insecure 30

(BFI), with the exception of areas of northern Baidoa where 25 further deterioration, following consecutive seasons of crop 20 failure was noted. For some agro-pastoral households in these localized areas, the situation deteriorated from the Acute 15 and Food and Livelihood Crisis (AFLC) to Humanitarian 10

Emergency (HE). In Bay region, 4,000, and 1,000 people 5 were in AFLC and HE, respectively. Health information 0 systems (HIS) data had shown high numbers and an increasing Mar'07 Mar'07 Sep'06 Sep'03 May'02 May'07 May'07 Nov.'07 Nov.'07 June 09

trend of acutely malnourished children, as well as increased Qansahdere Berdalle District Dinsor District Burhakaba Burhakaba Bay Agro-past District Pastoral Agro-Pastoral regional nutrition analysis admissions into selective feeding programs. The integrated nutrition situation analysis using information from health and feeding facilities conducted in Bay region in Post Deyr ‘08/09 classified the nutrition situation as likely to be Critical. Figure 9 illustrates the trends of acute malnutrition in Bay region from 2002-2009.

Current situation

Food security The food security situation in the Bay region remains unchanged since the Deyr ‘08/09. Subsequently, most of the rural agro- pastoral communities are still identified asBorderline Food Insecure (BFI), with the exception of Berdalle area bordering Bakool region, which has deteriorated to Humanitarian Emergency (HE) since the Deyr ‘08/09, due to three consecutive seasons of poor rainfall. An estimated 30,000 agro-pastoral and urban population in the region are either in Acute Food and Livelihood Crisis (25,000 people) or Humanitarian Emergency (5,000 people). Improved Gu ‘09 rains in most parts of Bay region resulted in crop production of 106% of the PWA and 167% of the 5- years average, however, this did not contribute much to the already dwindling cereal stock carryover in affected areas. However, most households from the Bay agro-pastoral livelihood zones have cereal stocks for consumption and sales that could last up to 7 months. In Baidoa market, the local quality goat price in July ’09 is 110% higher than 5-year average (2003-2007), although there is a slight decrease when compared to July ’08 (3%) due to higher livestock supply into the market. Nonetheless, the trend of livestock prices is expected to increase until Dec’09, due to the high demand for the Hajj pilgrimage and Ramadan. Prices of cereals have declined from Jan.’09 due to decreased global prices as well as the WFP food aid distributions carried out between Jan.’09 to July ’09. Sorghum prices decreased in July ’09 by 47% when compared to July ’08 (from 11,000/kg to 6,000/kg), nevertheless, this is still significantly higher, by 269%, compared to 5-year average. The decreased cereal prices,as well as increased job opportunities, contributed to increased purchasing power as demonstrated by the improved TOT in July ‘09.

FSNAU Technical Series Report No VI. 25 18 Issued September 11, 2009 Nutrition

Bay Agro-pastoral Livelihood Zone The integrated analysis of information from nutrition assessments Figure 10: Cholera outbreak in Bur-hakaba WVI

conducted in Bay region in June 2009, together with health 80 information and feeding facilities’ data, indicates a Very Critical 70 Cholera outbreak in Bur-hakaba WVI nutrition situation among the agro-pastoral population. The 80 60 70 results indicate a GAM rate of 23.9% (19.2 – 29.4) and a SAM 50 60 rate 5.2% (3.9 - 6.9), including one (0.1%) oedema case. This 40 50 indicates a deterioration in the nutrition situation from the Post 30 40 30 20 Deyr’08/09, when the situation was classified as likely to be Number of cases 20

Number Number of cases 10 Critical. The deterioration is mainly attributed to chronically 10 high morbidity rates, exacerbated by the reduced access to 0 0 humanitarian health and nutrition services provided by national 1/3/09 4/3/09 8/3/09 1/4/09 4/4/09 7/4/09 11/3/09 11/3/09 10/4/09

and international agencies. The persistently poor child care and 20/2/2009 23/2/2009 26/2/2009 4/3/20099/3/2009 14/3/2009 17/3/2009 20/3/2009 23/3/2009 26/3/2009 2/4/200929/3/2009 6/4/2009

20/2/200924/2/200928/2/2009 13/3/200917/3/200921/3/200925/3/200929/3/2009 10/4/200914/4/2009 13/4/4/2009 feeding practices, and the inadequate access to safe water and 2009 2009 sanitation services, has also continued to impact negatively on the nutrition situation of the population. Although the Bay region food security situations is fair, with the area experiencing relatively good cereal availability, the high disease burden, poor dietary quality and very poor access to basic services indentified in the region, are the major underlying causes of malnutrition. (Refer to case study on stunting in Bay region, pg37)

Table 6: Summary of Key Nutrition Findings in Bay and Bakool Regions Bay agro-pastoral (N=882) Bakool Agro- pastoral (N=617) Bakool pastoral (N=686) regional nutrition analysis Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema, 23.9 14.9 25.1 Very Critical Serious Very Critical WHO, 2006) (19.2 – 29.4) (12.1 – 18.3) (18.6 – 32.8) Severe Acute Malnutrition (WHZ<-3 or oedema, 5.2 3.4 1.2 Very Critical Serious Alert WHO, 2006) (3.9– 6.9) (2.1 – 5.4 (0.5 – 2.6) Oedema 0.1 N/A 0.2 NA 0 NA Global Acute Malnutrition (WHZ<-2 or oedema; 22.7 14.6 25.2 Very Critical Serious Very Critical NCHS) (18.7 – 27.3) (11.7 – 18.1) (19.0 – 32.7) Severe Acute Malnutrition (WHZ<-3 or oedema; 3.4 2.3 1.3 Serious Alert Alert (NCHS) (2.1– 5.4) (1.4 – 3.6) (0.6 – 2.9) Acute malnutrition by MUAC (<12.5 cm or 16.3 6.5 19.6 Very Critical Serious Very Critical oedema in nutrition surveys) (13.4 –19.2) (3.7 – 9.3) (13.7 – 25.6) 32.4 32.6 29 Stunting (HAZ<-2) Critical Critical Critical (35.1 – 41.8) (27.2 – 38.5) (22.2 – 36.9) 40.7 30.2 27.4 Underweight (WAZ<-2) Very Critical Critical Critical (35.5 – 46.2) (24.4 – 36.8) (21.7 – 33.9) High levels but High levels but High levels but HIS Nutrition Trends( Jan – June-09) Very Critical Critical Very Critical increasing decreasing increasing High and increasing High and decreasing Low but Admission trends at TFPs/SFPs (Jan-Jun’09) Very Critical Critical Critical trend trend increasing trend 2.8 8.9 33.7 Proportion of malnourished registered in SFs Critical Critical Serious (1.1 – 6.4) (4.2 – 17.4) (26.8 – 41.3) Child Morbidity & Immunization Increasing AWD 74 Disease trends (seasonally adjusted) cases including four Outbreak -None Outbreak -None Morbidity refers to the proportion of children deaths (CFR=5.4%) Very Critical Morbidity– 21.5% Acceptable Illness – 38% Acceptable reported to be ill in the 2 weeks prior to the survey Morbidity 44.6% RDT – 0.1 RDT – 0.3 RDT positive – 1.3 Vitamin A -50.1 Critical Vitamin A - 59 Critical Vitamin A 74.5 Alert Immunization Status Measles – 43.2 Critical Measles - 75.7 Serious Measles- 68.4 Serious Mortality N=3900 N=3560 N=3406 Crude Mortality Rate per 10,000 per day 0.68 0.53 0.61 Alert Alert Alert (retrospective for 90 days) (0.48 – 0.96) (0.34 – 0.82) (0.37 – 0.99) Under five mortality rate per 10,000 per day 1.18 0.98 0.77 Alert Acceptable Acceptable (retrospective for 90 days) (0.62 – 2.16) (0.40–2.37) (0.31 – 1.93) Women Nutrition & Immunization Status Proportion of malnourished non pregnant women 0.7 0.6 2.4 Acceptable Acceptable Acceptable (MUAC≤18.5 cm) (N=285) (N=440) N=327 Proportion of malnourished pregnant women 33.3 8.8 32 Very Critical Serious Very Critical (MUAC<23.0). (N=78) (N=102) N=103 Proportion of Women who received Tetanus 44.2 68.7 70.2 Critical Alert Alert Immunization (34.9 – 53.6) (61.5 – 75.9) (60.1 – 80.4) Public Health Indicators N=534 N=368 N=435 Households with access to safe water 1.7% Very Critical 16.2 Very Critical 9.0 Very Critical Household with access to sanitation facilities 9.4% Very Critical 32.1 Critical 9.2 Very Critical Households with access to health facility 17.5% Critical 47.3 Critical 35.2 Critical Proportion who own mosquito nets 21.2 (N=1515) 62.9 (N=1560) 10.9 (N=1399) Proportion who use mosquito nets 17.7 (N=1515) 50.6 (N=1560) 1.3 (N=1399) Food Security N=534 N=368 N=435 Households with poor dietary diversity (< 4 food 48.6 55.3 60.5 Critical Very Critical Very Critical groups) (38.2 – 59.2) (45.4 – 65.2) (48.5 – 72.5) Household’s Main Food Source Purchase: 60.3% 58.6% 80% Own Production 32.2% 18.3% 4.6% Food aid 1.8% 20.1% 6.4% Food security phase AFLC/HE Very Critical AFLC/HE Very Critical AFLC/HE Very Critical

Overall Situation Analysis Very Critical Serious Very Critical

FSNAU Technical Series Report No VI. 25 19 Issued September 11, 2009 4.4 Lower and Middle Shabelle Regions

Middle and Lower Shabelle Regions comprise of riverine, agro-pastoral and urban livelihoods (Map 8), with a large number of IDPs settling in the Afgoye-Merka corridor as a result of continued insecurity in Mogadishu. The riverine zone is located within 10km of the Shabelle River where maize, sesame and a variety of vegetables and fruits are cultivated, with limited livestock holdings as a result of tsetse fly infestation. Further on is the agro-pastoral zone, which extends 20-40km from the Shabelle River with maize, cowpeas, sesame and fruit cultivation and some livestock holdings as their main means of livelihood. The agricultural potential, as well as the labour and income opportunities in the area, make it a haven for seasonal and vulnerable populations in normal and shock years. This has resulted in a high density population living in this area, aggravated by high in-flow of IDPs from Mogadishu. UNHCR estimates that 524,000 IDP are currently living along the Afgoye corridor as a result of the continuing violence and clashes in Mogadishu.

Historical Overview - Post Deyr ‘08/09

According to the FSNAU Post Deyr ‘08/09 analysis the Map 8: Shabelle Livelihood Zones food security situation showed a mixed picture 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 were classified in the HE and AFLC phases. Of the total affected, 235,000 people were in HE (11% decrease since July ’08) and 230,000 were in AFLC (28% decrease since Gu’ 08). According to the integrated nutrition analysis, there were some improvements in the nutrition situation in the agro-pastoral and IDP (Merka-Afgoye) populations of Lower and Middle Shabelle, from Critical in Gu ’08 to Serious in the Deyr ‘08/09. The riverine population was in a sustained Serious phase since the Gu’08.

Current Situation

Food Security Almost half of the population or 48% of the population in Middle Shabelle is in crisis with 158,000 people in Humanitarian Emergency (HE) and 59,000 in Acute Food and Livelihood Crises (AFLC), with a projected early warning level of Watch up to the December ’09. Agropastoral livelihoods have continued to deteriorate since Deyr ‘08/09, however, the overall numbers in AFLC and HE are slightly reduced since Deyr ‘08/09 (AFLC was 164,000

regional nutrition analysis and HE was 65,000) due to a small improvement in the riverine areas. The urban poor in AFLC is slightly reduced from Deyr ‘08/09 (AFLC was 30,000) to 25,000. Lower Shabelle, in contrast, has a significant improvement in the food security situation for riverine and agropastoral livelihoods, such that the there is now only 5,000 people in HE (53,000 in Deyr ‘08/09) and 50,000 people in AFLC (71,000 in Deyr ‘08/09). Similarly, there is also a significant improvement in the food security situation for the urban poor such that the urban poor in AFLC is 35,000 which is reduced from 65,000 estimated in the Deyr ‘08/09.

The key determining factors of the current food security situation in Middle Shabelle are five consecutive seasons of below average productions due to poor rainfall; limited irrigation and lack of inputs; deteriorated rangeland conditions causing abnormal livestock out-migration; poor livestock body conditions; low milk production; and high livestock off-take. The situation is exacerbated by highly volatile civil insecurity with clan conflict over limited resources, as well as political conflict between opposing groups struggling for power. Gu ’09 regional cereal production is 44% of PWA and 50% of the 5-year average, which is the 3rd lowest in over a decade. Labour opportunities are limited to agricultural activities in riverine areas, while there is a significant reduction in livestock trading due to lack of saleable animals. Poor households are resorting to distress strategies, such as increased charcoal production, collection of firewood/building materials, labour migration to main towns and seeking social support (in-kind food or cash).

Nutrition The nutrition situation has deteriorated in the agro-pastoral population from the previous Serious situation reported in the Deyr ‘08/09 to a Critical situation in the Gu ’09 returning to previous levels where the GAM rate reported above the emergency threshold of 15% (Figure 11). The IDPs (Merka-Afgoye corridor) and riverine populations remained in a sustained Serious nutrition phase. Historically these areas have witnessed an improving trend in nutrition situation, likely attributed to the interventions in the areas, especially among the IDP groups.

FSNAU Technical Series Report No VI. 25 20 Issued September 11, 2009 Outbreaks of disease, such as acute watery diarrhoea, Figure 11: Trend in levels of acute malnutrition (WHZ< -2 or especially in Wanlaweyne and Merka, alongside oedema, WHO 2006 ) in Shabelle region 2002- 2009

outbreaks of measles and cholera in Afgoye and Merka 30.0 in the last few months are likely attributing factors to the deteriorating nutrition situation in the agro-pastoral populations. The impact of the disease outbreaks may

15.0

also have been exacerbated by the looting and subsequent % interruption of delivery of humanitarian interventions in the region. However ongoing humanitarian interventions (including food and cash transfer and other livelihood interventions), a favourable harvest in Lower Shabelle as 0.0

Nov.07 Nov.08 Nov.07 Nov.08 Nov.07 Nov.08 well as improved pasture for livestock and the riverine May.07 May.08 May.09 May.07 May.08 May.09 May.08 May.09 population’s access to fish, fruit and vegetables have Shabelle Riverine Shabelle Agropastoral Shabelle IDP likely mitigated the nutrition situation in the riverine and IDP groups.

Using the WHO 2006 growth standards, the results of nutrition assessments conducted in May 2009 reported a GAM rate of 11.7% (8.8-14.7) among the Shabelle IDPs with a SAM rate of 3.5% (2.0-5.1) including one oedema case (0.2%) which indicates a sustained Serious nutrition

situation from the previous assessments. The 90 days regional nutrition analysis retrospective crude and under-five year mortality rates were 0.50 (0.28-0.88) and 1.00 (0.46-2.19) respectively, both being below the alert thresholds. The recent outbreak of cholera in the Afgoye camps, where 79 cases had been Donkey cart carrying fodder confirmed in early August, alongside an AWD outbreak in Merka in May 2009 – which saw 208 cases with 5 deaths (CFR 2.4), remain of concern and are being monitored through the Somalia health cluster early warning system (EWAS). These outbreaks are reflected in the high number (57.3%) who reported ill in the two weeks prior to the assessment. Furthermore, the recent influx of IDPs into the area could result in additional pressure on the already limited resources and should continue to be observed.

The results for the riverine livelihood from a small sample cluster (33x6 cluster sampling) survey indicates a GAM rate of 10.3% (5.4-15.3) and a SAM of 2.0% (0.1-3.9) with two (1.0%) oedema cases. From the CDC calculator, the result suggest a 90% probability that the GAM>7.5%) indicating a sustained Serious nutrition situation from the previous season. Although the food security indicators remain positive, especially in Lower Shabelle, outbreaks of AWD and cholera in Merka should be monitored in the event that it spreads to the neighbouring riverine region, compromising the nutritional situation of the vulnerable population.

The Shabelle agro-pastoral assessment results displayed a high standard deviation on the weight-for-height z-scores (WHZ) on the plausibility check of EPI-ENA, which fell just beyond the acceptable margins of 1.20 at 1.22 indicating a problem with the overall data quality. Therefore this needs to be considered when interpreting the results. The results indicated deterioration in the nutrition situation with a GAM of 19.6% (14.6-28.8) and a SAM of 8.2% (5.7-11.6). The CDC Calculator recorded a 90% probability that the GAM>15.5%. This Critical situation indicates deterioration from the Serious phase reported six months ago. Given the recent AWD, cholera and measles outbreak and the elevated mortality, the deterioration is likely linked to disease rather than a food security issue. The low number of households with poor dietary diversity (1.2%) confirms that the nutrition situation is more of a public health rather than a food security concern. However, interventions are underway to contain the outbreaks and in the event that it is contained, the nutrition situation will likely improve, especially in Lower Shabelle which has favourable food security indicators.

Mogadishu is likely to be Very Critical showing no change from previous assessments. A rapid assessment conducted in July 2009 reported 17.1% of children with a MUAC less than 12.5cm and 4.8% below 11.5cm (N=1980; 18 sites). HIS data from health facilities confirm the situation, indicating very high numbers (>20%) but stable for the previous

FSNAU Technical Series Report No VI. 25 21 Issued September 11, 2009 six months period under review (Source: HIS data Jan-July ’09). Due to the poor civil security situation, there is a massive displacement within and out-migration of people from Mogadishu town with poor access to water, sanitation and health services into the surrounding regions or IDP camps, causing concern of the spread of diseases in the area. The key nutrition findings in these areas which form the basis of the analysis on the classification outcome are provided in Table 7.

Table 7: Summary of Key Nutrition Findings in M. and L. Shabelle Region IDPs (N=597) Agro-pastoral (=536) Riverine (N=203) Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status 19.6 10.3 Global Acute Malnutrition (WHZ<-2 or oedema) 11.7 (8.8-14.7) Serious Critical Serious (14.6-29.9) (5.4-15.3) Severe Acute Malnutrition (WHZ<-3 or oedema) 3.5 (2.0-5.1 Serious 8.2 (5.7-11.6) Very Critical 2.0 (0.1-3.9) Alert Oedema 0.2 Alert 0.9 Serious 0.1 Alert Global Acute Malnutrition (WHZ<-2 or oedema; 20.0 10.3 9.2 (6.2 – 12.2) Alert Critical Serious NCHS) (15.1-25.4) (5.8-14.9) Severe Acute Malnutrition (WHZ<-3 or 3.5 1.5 (0.4-2.6) Alert Serious 1 Alert oedema; NCHS) (2.4-4.7) Acute malnutrition by MUAC (<12.5 cm or 7.1 13.8 6.3 (4.5-8.3) Serious Serious Critical oedema in nutrition surveys) (4.0-10.2) (8.2-19.4) Stunting (HAZ<-2) 35.0 (28.2-41.7) Serious 37.3 (32-43) Serious 40.9 (32.2-49.5) Very Critical 22.9 34.5 30.5 Underweight (WAZ<-2) Serious Serious Serious (17.0-28.9) (24.1-40.2) (22.5-38.6) High levels and High levels and HIS Nutrition Trends(Jan-June ‘09) High levels and stable Serious Serious Serious stable stable High levels and High levels and Admission trends at TFPs/SFPs (Jan-Jun’09) High levels and stable stable stable Proportion of malnourished registered in SFs 18.6 Critical 6.7 Critical 9.5 Critical Child Morbidity & Immunization Disease trends (seasonally adjusted) Outbreak – Outbreak – Outbreak – Measles, Measles, AWD Measles, AWD AWD, Cholera Morbidity refers to the proportion of children and Cholera and Cholera reported to be ill in the 2 weeks prior to the Critical Critical Critical Morbidity –57.3 survey Morbidity– 47.6 Morbidity– 28.9

RDT – 0.1 RDT – 0.2 Vitamin A – 41.3 Vitamin A – 34.7 Vitamin A – 31.0 Immunization Status Critical Critical Critical Measles – 57.2 Measles- 26.1 Measles- 35.1 Mortality N=581 N=554 Crude Mortality Rate per 10,000 per day 0.50 (0.28-0.88) Alert 1.02 (0.71-1.46) Serious - NA (retrospective for 90 days) Under five mortality rate per 10,000 per day 1 (0.46-2.19) Alert 2.43 (1.48-3.98) Serious - NA (retrospective for 90 days) Women Nutrition & Immunization Status Proportion of malnourished non pregnant 0 9.7 10 Acceptable Acceptable Acceptable regional nutrition analysis women (MUAC≤18.5 cm) (N=292) (N=277) (N=93) Proportion of malnourished pregnant women 1.4 0 0 Acceptable Acceptable Acceptable (MUAC<23.0). (N=71) (N=61) (N=20) 66.1 31.7 58.4 Proportion of Women who received Tetanus (56.6-75.6) Alert (22.2-41.1) Serious (45.2-71.6) Alert Immunization (N=338) (N=113) (N=363) Public Health Indicators N=354 N=333 N=110

Households with access to safe water 85.9 Alert 8.1 Very Critical 19.1 Very Critical Household with access to sanitation facilities 93.1 Alert 27.1 Very Critical 37.2 Very Critical Households with access to health facility 83.8 Alert 28.6 Very Critical 31.8 Very Critical Proportion who own mosquito nets 4.8 (N=1251) 21.2 (N=1235) 26.8 Proportion who use mosquito nets 4.5 (N=1251) - 18.2 Food Security N=354 N=333 N=110 Households with poor dietary diversity (< 4 2.8 Acceptable 1.2 Acceptable 2.7 Acceptable food groups) Household’s Main Food Source 45.2 48.8 54.6 Purchase:

- 47.6 44.4 Own Production

54.5 0.9 0.9 Food aid AFLC/HE – M. AFLC/HE – M. AFLC/HE – M. Shabelle, Shabelle, Food security phase Shabelle, Very Critical Very Critical Very Critical AFLC – L. AFLC – L. AFLC – L. Shabelle Shabelle SHabelle Overall Situation Analysis Serious Critical Serious

FSNAU Technical Series Report No VI. 25 22 Issued September 11, 2009 4.5 Central Somalia: Galgadud and Mudug regions - Addun, Hawd and Deeh Pastoral; and Cowpea Belt

Central Somalia comprises of two regions, namely Galgadud and South Mudug. There are four main livelihood zones, three of which are pastoral which include the Addun, Hawd, and Coastal Deeh and one of which is agro-pastoral, the Cowpea Belt ( Map 9).

Historical Overview - Post Deyr ’08/09 According to the FSNAU Post Deyr ‘08/09 integrated food security phase classification analysis, the situation in Central regions had deteriorated in severity since Gu’ 08 leaving more than half of the population in crisis. An estimated 350,000 rural pastoralists and agro-pastoralists and 55,000 urban inhabitants were either in Acute Food & Livelihood Crisis (AFLC) or Humanitarian Emegency (HE) during the Deyr ‘08/09. This situation was linked to the severe drought occurring in the region as a result of four consecutive seasons of poor rainfall performance, hyperinflation and wide spread civil insecurity that led to an increased number of IDPs in the region.

The Post Deyr ’08/09 nutrition situation in Central regions Map 9: Central: Livelihood Zones indicated an alarming nutrition situation in the two main pastoral livelihoods. The Hawd pastoral livelihood deteriorated to Very Critical from the Critical phase in Post Gu ’08 as earlier predicted, owing to an array of factors including the severe food security crisis, and an outbreak of Acute Watery Diarrhoea (AWD) , both of which were regional nutrition analysis exacerbated lack of access to basic services and wide spread civil insecurity. Addun pastoral livelihood reported a persistent Critical nutrition situation with risk to deteriorate further due to the worsening food security indicators and lack of humanitarian assistance.

Current Situation

Food Security The food security situation in the drought-affected central (Galgadud and Mudug) regions has significantly deteriorated. Since the Deyr ‘08/09, the number of people in Humanitarian Emergency (HE) has increased by 20-21% in all livelihoods of central regions. The severity of the crisis is deepening, such that now 79% of the population of Galgadud and 51% of the population of Mudug are either in Acute Food and Livelihood Crisis (AFLC) or Humanitarian Emergency (HE). Another measure of the increased severity is that now most or 75% of the 440,000 people in crisis are in HE. Of the 440,000 in crisis, an estimated 385,000 are rural pastoralist and 55,000 are urban poor. An estimated 124,000 are in Acute Food and Livelihood Crisis (AFLC) and 319,000 are in Humanitarian Emergency (HE). There is also an overall early warning of a moderate risk to further deterioration before the end of Dec. ’09, depending on the extent of fighting and conflict in the coming weeks and months.

The food security situation continues to deteriorate due to the cumulative impact of successive seasonal rain failures, high food and non-food prices, and increased civil insecurity. Food access is significantly deteriorated in all pastoral livelihoods as the result of extremely deteriorated rangeland conditions (water and pasture) resulting in very poor livestock body conditions; low to none calving/kidding rates for all livestock species; high livestock off-take and declines in livestock herds significantly below baseline; and very few marketable livestock available for selling. Poor pastoralists are now becoming destitute after losing all their livestock and have begun to move to towns and villages in search of support. Agropastoralists have experienced successive crop failure due to high winds at an early cropping stage that wilted the crops, while the crops in the areas that received near normal rains suffered from high pest attacks (Elder district in Galgadud). The current crop failure has compounded the effects of previous successive below average seasons. The situation in central is further exacerbated by resource based conflict in Xaradheere district and clashes between the Local Militia and Al-Shabab in Elder district, causing displacement of population (187,000 IDPs) and halting humanitarian access. Cereal prices are still at high levels compared to other regions and labor opportunities are limited due to low to none agricultural and construction activities. Households continue to rely on distress coping options to access food, such as buying on credit, collecting firewood/building materials, migrating to main town in search of labour and seeking social support (in kind food or cash).

FSNAU Technical Series Report No VI. 25 23 Issued September 11, 2009 Nutrition The Post Gu ’09 integrated nutrition analysis conducted Figure 12: Trend in levels of acute malnutrition (WHZ< -2 or by FSNAU and partners has indicated an alarming nu- oedema, WHO 2006 ) in Central region 2002- 2009 ) trition situation in the two main pastoral livelihoods in 30.0 Central region. The Hawd pastoral livelihood has reported a Critical nutrition situation, with risk of deterioration,

indicating no significant change though from the Very % 15.0 Critical phase in the Post Deyr ’08/09. This situation is attributed to a combination of factors including the chronic food insecurity, ongoing displacement, and high 0.0 morbidity burden coupled with a severe lack of access Jul.03 Jun.02 Jun.08 Jun.08 Mar.07 Mar.07 Mar.07 Mar.07 Nov.07 Nov.07 Nov.07 May.09 May.09 May.09

to basic services and limited humanitarian assistance for Belletweyne District Hiran Agropastoral Hiran Riverine the affected populations.

The Addun pastoral livelihood has reported a persistent Critical nutrition situation, with risk of further deterioration due to the worsening food security indicators and lack of humanitarian assistance. The analysis also indicates that a high morbidity burden and lack of access to services are factors linked to the persistent critical nutrition situation. However, due to shrinking humanitarian presence as a result of a volatile security situation in the Central regions, the affected populations are at increased risk of humanitarian crisis as essential life saving operations have scaled down, increasing the nutritional vulnerability of the population.

The Coastal Deeh pastoral livelihood and the Cowpea Belt agro-pastoral livelihood zone, covering the districts of Eldhere and Haradhere reported a Serious nutrition situation indicating a sustained Serious phase from Post Deyr ‘08/09. Even though in the Cowpea Belt, the Serious phase was sustained based on the Gu’09 integrated nutritition analysis, risk of deterioration is probable given the below normal Gu’09 rains that further threaten their main livelihood.

Four livelihood based nutrition assessments in the Addun, Hawd, Cowpea Belt and Coastal Deeh population groups of Central and Northeast regions were conducted in May 2009. The findings reported GAM rates1 of 17.3% (13.8- 21.5) and 18.0% (13.8-23.1) in Addun and Hawd pastorals respectively. Compared to the rates observed in November 2008, where GAM rate of 18.9% and 21.9% were reported in Addun and Hawd respectively, the situation in Addun remained stable as it was in Deyr ‘08/09 while the Hawd showed slight improvement from Very critical to Critical, although the change was not statistically significant.

In the agro-pastoral Cowpea Belt livelihood, the findings reported a GAM rate of 14.9% (12.4-18.7) indicating a Serious nutrition situation. Even though there is lack of data from a comprehensive nutrition assessment from previous seasons to compare the results with, the situation is consistent with the Deyr ‘08/09 integrated analysis which had predicted a Serious situation with risk to deteriorate. The result of a small sample cluster survey (33x6) in the Coastel Deeh indicated a high probability of GAM rate being above 12.6% (Pr.=0.90). The results indicate a Serious nutrition

regional nutrition analysis situation, again consistent with the Deyr ‘08/09 integrated analysis and similar to the previous nutrition assessment conducted in May 2007 which reported a GAM rate of 15.8% (12.8-19.3.).

Alongside the four livelihoods, two regional nutrition assessments were conducted in Galgadud and Mudug regions at the request of WFP for response analysis and monitoring. In Galgadud, GAM rates of 14.3% (10.3-19.3) were obtained indicating a Serious nutrition situation, consistent with the Post Gu’09 analysis classification of the Cowpea Belt and Coastal Deeh livelihoods.This being the first regional assessment, there were no results to compare it with2. In Mudug region, the assessment results indicated a Critical nutrition situation with GAM rate of 18.3% (15.4-21.6). Albeit there are no regional assessments available for comparison, the results were consistent with the Gu’09 analysis drawn from the livelihood adjusted nutrition analysis for Hawd and Addun pastoral groups.

Overall, the trend analysis as shown in the Figure 12 indicates that the Central regions have a history of chronic nutritional vulnerability, with median wasting estimated at 17.3%. This is attributed to a number of factors including persistent drought that has devastated the population’s livelihoods, limited access to basic services and widespread civil insecurity that has lead to population displacements and also limited humanitarian support activities. This situation has been exacerbated by the hyperinflation amongst other economic factors. The key nutrition findings in Ad- dun, Hawd, Coastal Deeh and Cowpea belt areas, which define the classification outcome, are provided inTable 7.

2 All the GAM rates discussed here are computed using the WHO (2006) growth standards and C.I. => 95% Confidence Interval. 3 Source:FSNAU May-June 2009, Nutrition Update

FSNAU Technical Series Report No VI. 25 24 Issued September 11, 2009 Table 8: Summary of Key Nutrition Findings in Central Regions Agro pastoral -Cowpea Belt Coastal Deeh(N=202) Hawd Pastoral (N=751) Addun Pastoral (N=831) (N=693) (Small sample cluster survey) Indicator Results % Outcome Results % Outcome Results % Outcome Results % Outcome Child Nutrition status Global Acute Malnutrition 18.0 17.3 14.9 >12.6 Critical Critical Serious Serious (WHZ<-2 or oedema) (13.8-23.1) (13.8 - 21.5) (12.4-18.7) (Pr=0.90) Severe Acute Malnutrition 5.5 2.6 3.3 Critical Alert Serious >2.0 (Pr=0.91) Alert (WHZ<-3 or oedema) (3.7-7.9) (1.6-4.4) (2.6-5.4) 0.1 Oedema Acceptable 0.2 Acceptable 0.4 Acceptable 0.5 (>0.01;Pr=0.91) Alert

Global Acute Malnutrition 16.9 15.6 14.7 Critical Critical Serious (>6.6; Pr=0.90) Alert (WHZ<-2 or oedema :NCHS) (12.5-21.4) (11.7 – 19.6) (11.3-20.6) Severe Acute Malnutrition 3.7 1.7 2.2 Serious Alert Alert >0.01;Pr=0.91) Acceptable (WHZ<-3 or oedema:NCHS) (2.0-5.5) (0.5-2.9) (0.1-6.7)

Acute malnutrition by MUAC (<12.5 cm or 7.3 4.9 8.4(1.0-18.1) oedema in Rapid Assessments or nutrition Serious Alert 4.3 Alert Serious >1.6; assessments)

18.1 23.2 20.1 31.7 Stunting (HAZ<-2) Acceptable Alert Alert Serious (0.7-35.5) (19.1-27.3) (16.0-24.1) (15.1-48.3) 19.8 22.1 19.9 26.7 Under weight (WAZ<-2) Alert Serious Alert Serious (10.8-38.9) (18.2-26.1) (8.8-31.1) (16.4-37.1) HIS Nutrition Trends High (>20) and High (>20) and High (>30) and High (>30) and Serious Serious Serious Serious (Jan-July ’09) fluctuating fluctuating fluctuating fluctuating Increased number

Admission trends at TFPs/SFPs regional nutrition analysis N/A N/A of admission in ACF N/A N/A N/A N/A N/A ( Jan-July ‘09) OTP(April-May) 11.0 8.9 17.0 Proportion of malnourished in SFs 8.3 (3.5-18.7) (4.6-29.6) Child Morbidity & Immunization No Outbreak Confirmed measles Disease trends (seasonally adjusted) outbreak in Guriel, 99 No Outbreak Morbidity refers to the proportion of children Morbidity – 37.8 Very Morbidity- Critical cases Alert Critical reported to be ill in the 2 weeks prior to the Critical 40.6 Morbidity – 35.5 Morbidity-17.5 survey

Vitamin A-68.8 Vitamin A – 35.6 Vitamin A – 47.9 Vitamin A – 41.3 Immunization status Critical Critical Measles -68.1 Serious Critical Measles -52.9 Measles -31.5 Measles -46.8 Mortality N=583 N=651 N=571 Crude Mortality Rate per 10,000 per day 0.71 0.55 0.20 Alert Alert Acceptable N/A N/A (retrospective for 90 days) (0.40-1.25) (0.31-0.98) (0.08-0.48) Under five mortality rate per 10,000 per day 0.92 1.36 0.28 Acceptable Alert Acceptable N/A N/A (retrospective for 90 days) (0.48-1.77) (0.67-2.78) (0.07-1.16) Women Nutrition & Immunization Status Proportion of malnourished non-pregnant 0.3 0.5 0.7 1.2 women (MUAC<18.5) (N=340) (N=410) (N=288) (N=84) Proportion of malnourished pregnant women 17.1 19.7 14.3 24.0 (MUAC<23.0) (N=76) (N=71) (N=70) (N=25) 31.5 34.5 45.3 56 Proportion of women who received TT (23.2-39.8) (24.6-44.5) (33.1-57.4) (42.2-69.8) immunization (N=416) (N=481) (N=358) (109) Public Health Indicators N=423 N=501 N=367 N=109 31.0 44.1 28.3 34.9 Household with access to safe water (12.3-49.7) (25.5-62.7) (10.7-45.9) (19.2-50.5) 46.1 45.3 47.4 38.5 Household with access to sanitation facilities (28.6-63.6) (32.3-58.4) (33.8-61.0) (23.5-53.6)

32.9 37.1 27.5 54.1 Household with access to health facility (14.5-51.2) (19.9-54.3) (10.2-44.9) (40.1-68.1) Food Security N=423 N=501 N=367 N=109 Household with poor dietary diversity 18.6 9.2 22.8 Serious Serious 10.3 Serious Critical (< 4 food groups) (11.5 – 25.6) (4.0 – 14.4) (11.4-34.1) Household’s main Food source Purchase 89.7 92.2 79.8 90.9 Own production - 0.4 0.8 - Food Aid 3.5 4.8 15.8 5.4 Food Security phase HE Critical HE Critical HE Critical HE Critical Critical with risk to further Critical with risk to further Serious risk to further Overall Situation Analysis Serious deterioration deterioration deterioration

Note: Other information on the central livelihoods are given in the NEZ

FSNAU Technical Series Report No VI. 25 25 Issued September 11, 2009 4.6 Hiran Region – Pastoral, Agro-pastoral and Riverine Livelihood Zone

Hiran region comprises of three main livelihood groups: the Southern Inland Pastoral covering Mataban and Mahas districts and agro-pastoral and Riverine livelihood zones, both of which cut across Beletweyne, Buloburti and Jalalaqsi districts. Like many other regions in Somalia, Hiran region has not escaped the effects of high inten- sity civil conflict, which has affected people’s means of livelihood. Hiran, located along the frontline, witnessed intense confrontation between the forces and the insurgents before the withdrawal of the Ethiopian forces in the beginning of 2009. Intermittent localised civil conflict, as well as the targeting of aid workers in the region, has continued to hinder humanitarian access. As a border region, it continues to feel the effects of cross-border tensions.

Historical Overview - Post Deyr ’08/09 According to the FSNAU Post Deyr ‘08/09 integrated Map 10: HiranRegion Livelihood Zones analysis, the food security situation in Hiran region deteriorated since Gu ’08. Consequently, the number of people in Humanitarian Emergency (HE) in rural areas increased from 113,000 in the Gu ’08 to 135,000 in the Deyr ‘08/09, while a total of 200,000 faced with both an Acute Food and Livelihood Crisis (AFLC) and HE. Factors that contributed to the serious deterioration included poor crop production, resulting from below normal Deyr ‘08/09 rains , recurrent conflict in both urban and rural areas, and disruption of trade and economic activities.

According to the integrated nutrition analysis conducted in the Post Deyr ‘08/09, the nutrition situation for all the livelihoods in Hiran was classified as sustainedlikely to be Critical phase since the Gu’ 07. Although there was lack of representative survey data to make a definite classification, due to insecurity preventing access, the existing data at the time suggested that the situation was unlikely to have changed from Gu ’08.

Current Situation – Post Gu ’09

Food Security The overall food security situation in Hiran region has continued to deteriorate since Gu ’08. Populations in HE have increased from 135,000 in the post-Deyr ‘08/09 analysis to 160,000 in the Gu ’09. Currently 100% of the poor

regional nutrition analysis agro-pastoral population are in HE as well as 50-75% of the middle-income groups. The riverine has deteriorated even further with 100% of both the poor and middle-income groups in HE. The continued deterioration is as a result of continued seasons of poor rainfall, which has led to another season of crop failure (crop production is at 20% PWA) and limited livestock production and saleable animals, alongside high livestock off-take. Furthermore, poor pasture has resulted in the out-migration of livestock to Lower Shabelle region resulting in poor access to milk in Hiran region, further compromising the nutrition situation of women and children. Decreased income and limited labour opportunities are also having an impact on household income and resulting in further food access stress. This has resulted in signs of distressed coping strategies, such as an increase in charcoal production and migration to main towns.

Nutrition Figure 13: Trend in levels of acute malnutrition (WHZ< -2 or The nutrition situation of the agro-pastoral population oedema, WHO 2006 ) in Hiran region 2002- 2009 in Hiran indicates a deterioration from the Critical situation in the Deyr ‘08/09 to a Very Critical situation, while the riverine and pastoral populations remains in a sustained Critical phase. Historically, the agro-pastoral and riverine populations of Hiran region have usually been just about or above the emergency thresholds of 15% (Figure 13). This is the first comprehensive nutrition assessment conducted in the Hiran pastoral population.

FSNAU Technical Series Report No VI. 25 26 Issued September 11, 2009 Using the WHO 2006 growth standards, the results of the nutrition assessments conducted in April 2009 reported a GAM of 25.5% (19.7 – 31.2) among the agro- pastoral population with a SAM rate of 8.1% (5.6-10.6) including three (0.6%; CI: 0.0-1.5) oedema cases. This indicates a Very Critical nutrition situation and deterioration from the previous Critical phase. However, the respective Crude and under five year mortality rates of 0.64 (0.45-0.90) and 1.41 (0.76-2.61) were below the alert threshold levels of 1/10,000/day and 2/10,000/ day according to WHO classification, though still of concern. Of further concern are the high morbidity Migrating families in Hiran, april 2009 rates experienced in the area, with 51.4% of the assessed children reportedly having fallen ill in the two weeks prior to the assessment. Although there has been no reported outbreak of disease, the area needs to be monitored closely due to the hindrance of humanitarian interventions in the area.

Hiran riverine livelihood reported a GAM rate of 16.9%

(11.5-22.2) and a SAM rate of 4.6% (2.7-6.5) including regional nutrition analysis four (0.7%: 0.0-1.4) oedema cases, which indicates a sustained Critical nutrition. The Crude and U5 mortality rates of 0.36 (0.14-0.95) and 1.61 (0.58-4.45) were below the alert threshold according to WHO classifica- Water collection in Hiran, april 2009 tions, though also elevated from previous surveys and therefore of concern. However, high morbidity rates in the area also need to be monitored as well as the high and increasing trends of acute malnutrition recorded in the health facilities.

Results of the Hiran pastoral small scale assessment reported a point prevalence acute malnutrition rate of 20.2% (14.0-26.4) and a SAM rate of 4.5% (1.5-7.6) that included one (0.5%; CI: 0.0-1.5) oedema cases. Using the CDC Probability Calculator1, the results indicate a higher probability (>16.5%; Pr=0.90)) of falling in the Critical levels of 15.0-19.9%. The Probability calculator also indicates that the SAM rate has high probability (>2.9%, Pr=0.90) of falling between 2.5% and 3.5%. A high admission rate observed in the health centres was most likely as a result of opening new OTP sites, and needs to be monitored.

Deteriorating food security indicators in terms of high prices of food and essential commodities, due to inflation, low productivity and unfavourable terms of trade (TOT), have limited household’s access to food and thereby impacted negatively on consumption. This is illustrated by a significant proportion of the assessed households in the agro-pastoral (18.6%) and pastoral (22.8%) households consuming poorly diversified diets (fewer than four food groups). As a result of the irrigation infrastructure for crop and vegetable cultivation, the riverine population are less reliant on the weather patterns, and have therefore been less affected with 10.3% reportedly consuming a poorly diversified diet. Furthermore, the agro-pastoral and pastoral livelihood groups rely mainly on purchase to source their main food (87.2% and 83.2% respectively), while the riverine also rely on their own production (32.9%) besides purchases (64.0%).

1 Oleg Bilukha and Curtis Blanton, 2008; http://www.ete-online.com/content/5/1/25

FSNAU Technical Series Report No VI. 25 27 Issued September 11, 2009 The key nutrition findings in Hiran region which form the basis of the analysis on the classification outcome are provided in below.

Table 9: Summary of Key Nutrition Findings in Hiran Region

Pastoral (N=198) Agro-pastoral (=518) Riverine (N=540) Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or ≥15 (Pr = 0.95) Critical 25.5 (19.7-31.2) Very Critical 16.9 (11.5-22.2) Critical oedema) Severe Acute Malnutrition (WHZ<-3 or 4.5 (1.5-7.6) Critical 8.1 (5.6-10.6) Very Critical 4.6 (2.7-6.5) Critical oedema) Oedema 0.5 Alert 0.6 Alert 0.7 Alert Global Acute Malnutrition (WHZ<-2 or ≥15 (Pr = 0.98) Critical 24.5 (18.3-30.8) Very Critical 15.9 (11.3-20.6) Critical oedema; NCHS) Severe Acute Malnutrition (WHZ<-3 or 2.5 (0.4-4.7) Alert 3.7 (1.4-5.9) Serious 2.0 (0.7-3.3) Alert oedema; NCHS) Acute malnutrition by MUAC (<12.5 cm or 6.1 (2.5-9.6) Serious 8.7 (4.6-12.8) Serious 10.7 (7.7-13.8) Critical oedema in nutrition surveys) Stunting (HAZ<-2) 28.3 (21.3-35.3) Serious 24.1 (19.6-28.7) Serious 33.7 (25.5-41.9) Serious Underweight (WAZ<-2) 23.2 (16.6-29.9) Serious 29.9 (24.3-35.5) Serious 29.4 (21.4-37.5) Serious High (>10) and High (>10) and High (>10) and HIS Nutrition Trends(Jan-June ‘09) Critical Critical Critical increasing fluctuating increasing Admission trends at TFPs/SFPs ( Jan- High (>20) and fluc- Critical Jun’09) tuating Proportion of malnourished registered 12.5 Critical 5.3 Critical 29.7 Critical in SFs

Child Morbidity & Immunization Disease trends (seasonally adjusted) Outbreak – None Outbreak – None Outbreak – None Morbidity refers to the proportion of Morbidity – 32.3 Critical Morbidity – 51.4 Critical Morbidity – 42.8 Critical children reported to be ill in the 2 weeks RDT - - RDT – 6.6 RDT – 7.3 prior to the survey Vitamin A – 12.6 Vitamin A – 19.3 Vitamin A – 27.4 Immunization Status Very Critical Very Critical Very Critical Measles – 10.2 Measles – 18.8 Measles – 29.1 Mortality - - N=573 N=570 Crude Mortality Rate per 10,000 per day - - 0.64 (0.45-0.9) Acceptable 0.36 (0.14-0.95) Acceptable (retrospective for 90 days) Under five mortality rate per 10,000 per - - 1.41 (0.76-2.61) Alert 1.61 (0.58-4.45) Alert day (retrospective for 90 days) Women Nutrition & Immunization Status Proportion of malnourished non pregnant 1.3 (0.0-4.0) 0.0 0.4 (0.0-1.2) Acceptable Acceptable Acceptable women (MUAC≤18.5 cm) (N=77) (N=266) (N=259)

Proportion of malnourished pregnant 22.7 26.1 16.9 Critical Critical Critical women (MUAC<23.0). (N=22) (N=65) (N=65) regional nutrition analysis Proportion of Women who received Teta- 16.2 (5.5-26.8) 18.7 (12.6-24.9) 28.9 (18.3-39.6) Critical Critical Critical nus Immunization (N=99) (N=331) (N=324) Public Health Indicators N=101 N=320 N=319

Households with access to safe water 5.0 (0.0-10.7) Very Critical 10.7 (0.0-23.3) Very Critical 3.4 (0.0-10.6) Very Critical Household with access to sanitation 8.9 (2.3-15.5) Very Critical 26.4 (12.5-40.4) Very Critical 31.0 (13.6-48.5) Very Critical facilities Households with access to health facility 9.9 (0.5-19.3) Very Critical 24.8 (7.8-41.9) Very Critical 16.0 (1.3-30.7) Very Critical 12.0 19.8 Proportion who own mosquito nets - - (N=1096) (N=1155) 6.8 12.6 Proportion who use mosquito nets - - (N=1096) (N=1155) Food Security N=101 N=320 N=319 Households with poor dietary diversity (< 22.8 (11.4-34.1) Serious 18.6 (11.5-25.6) Serious 10.3 (4.7-16.0) Serious 4 food groups) Household’s Main Food Source Purchase: 83.2 87.4 64.1 Own Production 1.9 10.7 32.8 Food aid 6.9 1.3 0.9 Food security phase AFLC/HE Very Critical AFLC/HE Very Critical AFLC/HE Very Critical

Overall Situation Analysis Critical Very Critical Critical

FSNAU Technical Series Report No VI. 25 28 Issued September 11, 2009 4.7 Northeast Regions

The Northeast region is predominately pastoral with eight livelihood zones namely; the Hawd, Addun Coastal Deeh, East Golis, Gagaab, Kakaar,, Nugal Valley and Sool-Saanag Plateau. Administratively, these fall into three regions: Bari, Nugal and North Mudug. (Map 11).

Historical Overview - Post Deyr ‘08/09 The FSNAU Post Deyr ’08/09 integrated food security phase classification analysis classified the pastoral livelihood zones of Hawd and the adjoining parts of Addun in the Northeast region in a sustained Acute Food Security Livelihoods Crisis (AFLC) with some deterioration from the Gu’08. The Nugal Valley livelihood zone which was classified inAFLC in the Gu’08 improved and was in the Borderline Food Insecure (BFI) phase in the Deyr ‘08/09. Pastoralists from Sool, Karkaar, Gagaab/Golis and Coastal livelihood zones were in a sustained Borderline Food Insecure phase since the Post Deyr ’07/08. These areas experienced 2-3 consecutive seasons of normal rains with good water and pasture. In October 2008, the coastal areas of Iskushuban district experienced freezing torrential rains which killed about 20,000-30,000 heads of livestock, reducing livestock holdings of the pastoralists.

The integrated nutrition situation analysis of the Post Map 11: Northeast Livelihood Zones Deyr ’08/09 indicated no major changes from the Post Gu’08 in most of the livelihoods of the northeast regions, except for the Hawd pastoral livelihood zone of Mudug and Nugal regions which had deteriorated from Critical in the Gu’08 to Very Critical in Post Deyr ’08/09. The regional nutrition analysis nutrition situation of the Addun pastoral livelihood remained Critical from the Post Gu’08. Of great concern, were the protracted IDPs in Bossaso Town in a Very Critical nutrition situation, with no change from the Post Gu’08. Conversely, there was 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 populations and among the IDP population, was mainly attributed to high morbidity rates, poor access to food, safe water and sanitation facilities. The lack of an established livelihood system among the IDP population, and the general limited access to basic needs and services, exacerbated the compromised nutritional status of this population. The Coastal Deeh and Nugal Valley livelihood zones of Mudug, Nugal and Bari regions reported a sustained Serious nutrition situation, with no improvement from Post Gu’08 . Sool Plateau & Karkaar livelihood zones were in a sustained Alert nutrition phase since the Post Gu ’08. The Golis & Gagaab Livelihood zones improved since Gu ’08 from Serious to Alert due to favourable food security indicators.

Current Situation

Food Security The food security situation of the Hawd and Addun Pastoral livelihoods in southern Nugal and north Mudug regions have deteriorated from Acute Food and Livelihood Crisis (AFLC) with moderate risk to Humanitarian Emergency (HE) in Deyr’08/09 to Humanitarian Emergency in Gu ‘09. The total population in crisis in Bari, Nugal and northern Mudug regions is estimated at 210,000, of which 145,000 are urban poor. Of the total population in crisis, 169,900 or 79% are in AFLC and 44,100 or 21% are in HE. There are also 66,000 IDPs in the region that are in need of humanitarian assistance.

The food security situation has deteriorated for the Hawd and Addun Pastoral livelihoods due to another season of poor rainfall. This is now the fourth successive season of poor rainfall (Deyr ‘07/08, Gu ’08, Deyr ‘08/09 and Gu ‘09), which affected pasture and water conditions in Hawd and Addun Pastoral, as well as parts of Coastal Deeh Pastoral in north Mudug and Nugal regions. Poor rangeland conditions, combined with limited options for out-migration (because of poor rangeland conditions throughout the whole of the north and central Somalia), has led to weak and emaciated livestock, low to none calving rates for camels, low milk production and high livestock off-take with herd size of all livestock species well below the baseline levels.

FSNAU Technical Series Report No VI. 25 29 Issued September 11, 2009 Nutrition

Based on findings from 23 nutrition assessments con- Figure 14: Trend in levels of acute malnutrition (WHZ< -2 or ducted by FSNAU & partners from 2002 -2009 (Figure oedema, WHO 2006 ) in Northeast region 2002- 2009 25.0 14), the nutrition situation of both the rural & urban population in the northeast has been consistently been 20.0

below the emergency threshold of 15 % until 2006. Fol- 15.0 lowing the deterioration of the food security situation 10.0 in the Hawd, Addun and the Coastal Deeh livelihood zones in 2007, the nutrition situation deteriorated and 5.0

the levels of acute malnutrition exceeded the emergency 0.0 Hawd Hawd Hawd Hawd Addun Addun Addun Addun Dan/Eyl Karkaar

threshold. The situation of IDPs in Galkayo, Garowe, Allula/K/Isk Allula/K/Isk Allula/K/Isk Golis/Gagab Nugal Valley Nugal Valley JeribanTown JeribanTown Coastal Deeh Coastal Deeh Galcayo Town Town Galcayo Town Galcayo Town Galcayo Alula/K/iskush Goldgb District Goldgb District Qardho District Galdogob town

Bossaso and Qardho has been different from that of the Apr02 Aug02Dec02 Dec02 0ct03 Apr03 Apr04sept04 sept04 Aug05 Aug05 Sep06 Nov06 Nov06 May07 Oct07 Oct07 May08May08 Nov08 Nov08 May09 May09 May09 June09 June09 host communities, with the rates of acute malnutrition consistently exceeding the emergency threshold, due to their high vulnerability.

The FSNAU Post Gu’09 integrated nutrition situation analysis indicates that the Golis/Gagaab and Karkaar Pastoral livelihoods have deteriorated to Critical from Alert and likely to be Alert classification phases in the Post Deyr’08/09. The Nugal Valley livelihood zone has also deteriorated from Serious in the Deyr ’08/09 to a Critical nutrition situation, while the Sool Plateau of Bari region has also deteriorated to Serious from an Alert phase in the Deyr’08/09. The deterioration in the nutrition situation in these livelihood zones is mainly attributed to a combination of factors including unfavourable food security indicators, particularly low milk production, the ongoing water crisis in the region and limited health, safe water MUAC measurement in a recent survey and sanitation facilities. The Coastal Deeh livelihood zone of Nugal and Mudug regions have reported a persistent Serious nutrition situation with potential to deteriorate, mainly owing to the worsening food security indicators identified in theGu ’09. The Addun pastoral livelihood zone of Mudug and Nugal regions reported a persistent Critical nutrition situation, which is likely to deteriorate further also due to worsening food security indicators. However, the nutrition situation in the Hawd livelihood zone of Mudug and Nugal regions has shown slight improvement from Very Critical in the Deyr’ 08/09 to Critical in the Post Gu’09. However, this change is not statistically significant.

regional nutrition analysis Of great concern, are the protracted IDPs and urban poor population of Bossaso town, their nutrition situation is currently classified as Very Critical and Critical respectively with no change from the Post Deyr’08/09. Although there is a marked improvement in the nutrition situation of the Bossaso IDPs, where the GAM and SAM rates have significantly reduced compared to the PostDeyr ’08/09, the nutrition situation still remains Very Critical. Integrated humanitarian interventions contributed to the improvement and mitigated further deterioration of their nutrition situation. The poor nutrition situation amongst the IDP population is due to a combination of factors namely high morbidity burden, reduced access to a diversified diet due to the high and increasing food prices and sub optimal child care and feeding practices. The results are consistent with historical data on nutrition surveys conducted among the IDP population in the northeast region, which highlight the achronic nutritional vulnerabilities.

Hawd and Addun Livelihood Zones The nutrition situation of the Hawd livelihood zones of Mudug and Nugal regions of the northeast has improved slightly from Very Critical in the Post Deyr’08/09 to Critical in the Gu’09. However, statistical analysis between these two surveys indicates no significant difference in the GAM (p=0.22) and SAM rates (p=0.40). The Addun livelihood zone remains Critical from the Post Gu’08, with potential to deteriorate. Assessments conducted in May 2009 among the Hawd pastoral population reported a GAM rate of 18.0 %( 13.8-23.1), and a SAM rate of 5.5 (3.7-7.9) with 0.1% oedema cases. Among the Addun pastoral population, the GAM rate recorded was 17.3 %( 13.8 - 21.5) with a SAM rate of 2.6 ( 1.6-4.4) and 0.2% oedema case reported (Table 10). Compared to the previous nutrition assessments conducted in the Deyr’08/09 when the Hawd pastoral livelihood reported a GAM rate of 21.9% (16.5-28.6), and SAM rate of 7.1% (4.5-10.9) and 0.5% (0.02-1.01) cases of oedema, and the Addun pastoral livelihood zone reported a GAM rate of 18.9% (13.9-25.3) with a SAM rate of 6.1% (3.5-10.8) and no oedema, integrated analysis indicates a slight improvement, though not significant, from Very Critical to Critical levels of acute malnutrition among the Hawd pastoral population, and a sustained Critical nutrition situation among the Addun pastoral population respectively.

FSNAU Technical Series Report No VI. 25 30 Issued September 11, 2009 The retrospective crude and under-five mortality rates across both the Hawd and Addun livelihood zones are below the alert WHO threshold levels These areas currently have limited access to food (due to four successive seasons of poor rainfall, resulting in out-migration or deaths of livestock), low income from livestock sales and limited labour opportunities. The recent outbreak of measles in Galkayo town and some surrounding villages, where 45 cases have been confirmed (WHO, July 2009), coupled with high morbidity, low milk consumption, poor access to safe water and adequate sanitation facilities, limited access to health services in addition to poor child care and feeding practices have aggravated the situation. Nevertheless, dietary diversity was good, with only a small proportion of the households consuming a poorly diversified diet of less than four food groups in a 24-hour recall period, sourced mainly through purchase. Efforts to address the sustained worrisome nutrition situation in central regions, amidst limited access due to insecurity, are challenging, but remain crucial.

Table 10 Summary of Key Nutrition Findings in Northeast Regions Hawd Pastoral Addun Pastoral Coastal Deeh (N=751) (N=831) (N=202) Out- Indicator Results % Outcome Results % Outcome Results % come Child Nutrition status Global Acute Malnutrition 18.0 17.3 >12.6% Critical Critical Serious (WHZ<-2 or oedema) (13.8-23.1) (13.8 - 21.5) (Pr=0.90) Severe Acute Malnutrition 5.5 2.6 >2.0%, Critical Alert (WHZ<-3 or oedema) (3.7-7.9) (1.6-4.4) (Pr=0.91) 0.1 0.2 0.5% Oedema Acceptable Acceptable Alert (>0.01%;Pr=0.91)

Global Acute Malnutrition 16.9 15.6 regional nutrition analysis Critical Critical (>6.6%; Pr=0.90) Alert (WHZ<-2 or oedema :NCHS) (12.5-21.4) (11.7 – 19.6) Severe Acute Malnutrition 3.7 1.7 Accept- Serious Alert >0.01%;Pr=0.91) (WHZ<-3 or oedema:NCHS) (2.0-5.5) (0.5-2.9) able Acute malnutrition by MUAC (<12.5 cm or oedema in 7.3 4.9 8.4(1.0-18.1) Serious Alert Serious Rapid Assessments or nutrition assessments) >1.6%; Stunting (HAZ<-2) 18.1 (0.7-35.5) Alert 23.2 (19.1-27.3) Serious 31.7 (15.1-48.3) Serious 19.8 Under weight (WAZ<-2) Alert 22.1 (18.2-26.1) Serious 26.7 (16.4-37.1 Serious (0.8-38.9) High (<10%) and High (<10%) and High (<10%) and HIS Nutrition Trends(Jan-July ’09) Serious Serious Serious fluctuating fluctuating fluctuating Admission trends at TFPs/SFPs ( Jan-July ‘09) N/A N/A N?A N/A N/A N/A Proportion of malnourished in SFs 11.0(3.5-18.7) N/A 8.9 N/A 8.3 N/A Child Morbidity & Immunization 45 Suspected Disease trends (seasonally adjusted) measles cases in Very Critical No Outbreak Morbidity refers to the proportion of children reported Critical Critical Galkacayo Morbidity- 40.6 to be ill in the 2 weeks prior to the survey Morbidity – 37.8 Vitamin A – 47.9 Vitamin A – 41.3 Vitamin A – 35.6 Immunization status Critical Critical Critical Measles -52.9 Measles -31.5 Measles -46.8 Mortality N=583 N= 651 Crude Mortality Rate per 10,000 per day (retrospec- 0.71 0.55 Alert Alert N/A N/A tive for 90 days) (0.40-1.25) (0.31-0.98) Under five mortality rate per 10,000 per day (retro- 0.92 1.36 Acceptable Alert N/A N/A spective for 90 days) (0.48-1.77) (0.67-2.78) Women Nutrition & Immunization Status Proportion of malnourished non-pregnant women Accept- 0.3 Acceptable 0.5 Acceptable 1.2 (MUAC<18.5) able Very Proportion of malnourished pregnant women 17.1 Very Critical 19.7 Very Critical 24.0 Critical (MUAC<23.0) (7.5-26.7) (9.3-30.1) (7.2-40.8)

31.5 34.5 56 Proportion of women who received TT immunization (23.2-39.8) (24.6-44.5) (42.2-69.8) Public Health Indicators N= 423 N=501 N=109 Proportion of malnourished in SFs 11.0(3.5-18.7) N/A 8.9 N/A 8.3 N/A 31.0 44.1 34.9 Household with access to safe water Critical Critical Critical (12.3-49.7) (25.5-62.7) (19.2-50.5) 46.1 45.3 38.5 Household with access to sanitation facilities Critical Critical Critical (28.6-63.6) (32.3-58.4) (23.5-53.6) Household with access to health facility 32.9(14.5-51.2) Critical 37.1 (19.9-54.3) Critical 54.1(40.1-68.1) Serious Food Security Household with poor dietary diversity 18.6 9.2 22.8 Serious Serious Critical (< 4 food groups) (11.5 – 25.6) (4.0 – 14.4) (11.4-34.1) Household’s main Food source Purchase 89.7 92.2 90.9 Own production - 0.4 - Food Aid 3.5 4.8 5.4 Food Security phase HE Critical HE Critical Critical with risk to further Critical with risk to further Overall Situation Analysis Serious deterioration deterioration

FSNAU Technical Series Report No VI. 25 31 Issued September 11, 2009 Coastal Deeh The Coastal Deeh livelihood zone of Nugal, Bari and Mudug regions has reported a sustained Serious nutrition situation, however with an indication of a likelihood to deteriorate due to worsening food security indicators in the Gu’09 season. The results of the 33X6 cluster survey conducted in May 2009 indicates a high probability that the GAM rate is above 12.6% (Pr.=0.90) and the SAM rate is above 2.0% (Pr.=0.91).These results indicate a Serious nutrition situation, consistent with the Post Deyr’08/09 integrated analysis and the previous nutrition assessment conducted in May 2007, which reported GAM and SAM rates of 15.8% (12.8-19.3) and 2.1% (1.2-3.5) respectively, indicating no significant change in the GAM rate (p=0.78). In the coastal areas, the low access to milk due to limited camel calving, poor access to fishing as a result of the unfavourable monsoon weather and the effects of piracy, coupled with high morbidity, poor household dietary diversity, persistent poor child care and feeding practices, limited access to safe water and sanitation facilities and a lack of health services remain key factors aggravating the nutrition situation in the area (Table 11).

Golis/Gagaab and Karkaar Livelihood Zones The Post Deyr’08/09 integrated nutrition analysis classified the Golis/Gagaab and Karkaar pastoral livelihoods as likely to be Alert and Alert phases respectively. The current integrated nutrition analysis of the Post Gu’09 classifies the nutritional situation of the Golis /Gaagaab and Karkaar livelihood zones as Critical. The deterioration is mainly attributed to below average milk consumption and high morbidity burden. The worsening nutritional situation in the area requires continued close monitoring of the situation.

Table 11: Summary of Key Nutrition Findings in Northeast Regions Golis/Gagaab N= 772 Karkaar N= 603 Bosaso urban 199 Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) 17.9 (14.4-22.0) Critical 15.0(11.4-19.5) Critical 15.2% (Pr=0.90) Critical Severe Acute Malnutrition (WHZ<-3 or oedema) 3.3(1.9-5.8) Serious 3.3(1.9-5.7) Serious >2.6% (Pr=0.90) Serious Oedema 0.5 (0.1-1.6) Acceptable 0.1 Acceptable 0.1 Global Acute Malnutrition (NCHS) 19.1 (15.6-23.1) Critical 14.8 (11.0-19.8) Serious >16.8% (Pr=0.90) Critical Severe Acute Malnutrition (NCHS) 2.0 (1.2-3.2) Alert 1.5 (0.7-3.2) Alert >1.0% (Pr=0.93) Critical Acute malnutrition by MUAC (<12.5 cm or 10.5 1.7 (0.8-3.1) Alert 4.9 (1.9-7.9) Alert Critical oedema in nutrition surveys) 6.5-13.6 Stunting (HAZ<-2) 10.9 (8.6-13.8) Alert t 13.9 (10.7-17.9) Alert 18.1(0.7-35.5) Alert Underweight (WAZ<-2) 17.1 (14.2-20.4) Alert 17.5 (13.3-22.8) Alert 22.115.1-29.2 Serious High (>10%) and HIS Nutrition Trends(Aug-Nov’08) <10% and stable Alert >10 and increased Serious Serious fluctuating Admission trends at TFPs/SFPs N/A N/A N/A N/A Proportion of malnourished registered in SFs 5.3 N/A 4.7 N/A 22.4 Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity: 14.6 (11.9- Morbidity: 12.9 Morbidity – 33.7 Morbidity refers to the proportion of children re- Serious Serious Critical 17.7) (9.2-16.6) ported to be ill in the 2 weeks prior to the survey Vitamin A: 59.9 (55.8- Vitamin A: 69.7 Critical Vitamin A – 73.7

regional nutrition analysis 63.8) (60.8-78.7) Critical Critical Immunization Status Measles -76.4 Measles: 65.0 (61.0- Measles: 66.9 Critical Critical Critical Polio-84.9 68.8) (58.7-75.2) Mortality N= 484 N=620 Crude Mortality Rate per 10,000 per day (retro- 0.35 Acceptable 0.23 Acceptable N/A spective for 90 days) Under five mortality rate per 10,000 per day 1.06 Alert 0.82 Acceptable N/A (retrospective for 90 days) Women Nutrition Status Proportion of malnourished non pregnant women Accept- 6.5 (4.2-9.9) Serious 0.3 Acceptable 0 (MUAC≤18.5 cm) able Proportion of malnourished pregnant women 0 Acceptable 22.4 (10.8-34.0) Acceptable 29.4 V. Critical (MUAC<23.0). Public Health Indicators N= 369 N= 407

Proportion of Women who received Tetanus 55.8 (50.6-60.9) Critical 58.8 (49.8-67.9) Critical 52.9 Critical Immunization Very Criti- Very Critical Households with access to safe water 22.2(18.2-26.9) cal 14.5 (5.2-23.8) 65.6 Serious

Very Critical 100(63.3 shared Household with access to sanitation facilities 47.4 (42.2-52.7) Serious 13.5 (3.4-23.7) Alert latrines 2 – 9 HHs Households with access to health facility 20.3 16.4-24.9) 64.4 (46.3-82.5) 77.1 Food Security Households with poor dietary diversity (< 4 food Accept- 17.1 (13.5-21.4) Serious 14.0 (6.4-21.6) Serious 1 groups) able Household’s Main Food Source Purchase: 96.7 95.5 Own Production 0 0 100 Food aid 0 0 Food security phase BFI BFI Overall Situation Analysis Critical Critical Critical

FSNAU Technical Series Report No VI. 25 32 Issued September 11, 2009 A nutrition survey conducted in June 2009 reported GAM rates of 17.9% (14.4-22.0) with a SAM rate of 3.3% (1.9-5.8) among the Golis /Gagaab pastoral populations. The Karkaar pastoral population reported a GAM rate of 15.0% (11.4-19.5) and a SAM rate of 3.3% (1.9-5.7) (Table 11). These results indicate a Critical nutrition situation in the Golis/Gagaab and Karkaar livelihood zones according to WHO classification. Findings indicate high morbidity rates, especially diarrhoea. Access to sanitation facilities was also very poor, with a large proportion of the households in all livelihoods not having access to appropriate sanitation facilities, predisposing the population to disease, especially diarrhoea that has a direct effect on the nutritional status of individuals. Furthermore, the immunization status of the children assessed among the Golis/Gagaab and Karkaar pastoral populations was Child with measles in Goldogob MCH, FSNAU, low, as was the proportion of households with access May’09. to health facilities. The worrying nutrition situation is mainly attributed to the worsening food security situation, high morbidity rates and lack of access to clean water, proper sanitation and health facilities as well as inadequate targeted feeding programmes and health programmes to support the vulnerable populations. Therefore it is vital to closely monitor the food security and nutrition indicators, as well as to immediately start initiatives to rehabilitate acutely malnourished children, improve accessibility regional nutrition analysis to health and sanitation services and improve child care and feeding practices.

Bossaso Urban An integrated analysis of the nutrition situation of the Bossaso urban population during the Post Deyr ’08/09 indi- catesd a Critical situation. The 33x6 cluster survey conducted in November 2008 reported GAM rates of >14.7% (pr=0.90). Similar results have been observed in a repeat small cluster survey conducted in June 2009, where a GAM rate of >15.2% (pr=0.90), and SAM rate of >2% (pr=91) were reported, indicating a sustained Critical nutrition situation amongst the urban population of Bosasso Town. The overall coverage of all the health programmes namely Vitamin A supplementation, measles and polio vaccination fell below the recommended standards (Sphere, 2004). The proportion of households with access to safe water was poor. Although all households have access to sanitation facilities, 63.3 % of them share the facilities between 2-9 households. The worrying nutrition situation is largely attributed to morbidity, such as the high levels of reported suspected measles, low vaccination and vitamin A supplementation coverage (<80%) and poor household food insecurity caused by hyperinflation

FSNAU Technical Series Report No VI. 25 33 Issued September 11, 2009 IDPs of the Northeast: Bossaso, Garowe, Galkayo and Qardho The nutrition situation has shown significantly high levels of acute malnutrition among the protracted IDPs of Bossaso, Garowe, Galkayo and Qardho towns and is currently classified as Very Critical with no change from the Post Deyr’08/09.

Four representative nutrition assessments conducted among the IDPs of Bossaso, Garowe, Galkayo and Qardho towns of Bari, Nugal and Mudug regions in July 2009, indicate a Very Critical nutrition situation among all the IDPs assessed, with GAM rates of 21.4% (18.8-24.1) and SAM rates of 4.8 % (3.0-6.5) among the Bossaso IDPs; GAM rates of 20.0% and SAM rates of 4.6 % among the Galkayo IDPs; GAM rates of 24.5 % and SAM rates of 6.5 % among the Garowe IDPs and GAM rates of 20.1% and SAM rates of 5.2 % among the Qardho IDPs (Table 12). The findings show no improvement from the November 2008 assessments, with the exception of Bossaso IDPs which showed marked improvement with a significant, change from the high GAM rates of 28.8% (25.5 – 32.6) and high rate SAM of 14.0% (10.9 – 17.7) reported (p<0.05).

Table 12. Summary of Key Nutrition Findings in IDPs-Northeast Regions Bossaso N = 924 (Exh) Galkayo N= 3114 (Exh) Garowe N= 460 Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) 21.4 (18.8-24.1) V. Critical 20.0 V. Critical 24.5 V. Critical Severe Acute Malnutrition (WHZ<-3 or oedema) 4.8 (3.0-6.5) Critical 4.6 Critical 6.5 V. Critical Oedema 0 Acceptable 0.2 Acceptable Global Acute Malnutrition (NCHS) 20.7 (17.8-23.6) V. Critical 17.8 Critical 23.5 V. Critical

Severe Acute Malnutrition (NCHS) 1.8 (0.8-2.8) Alert 2.1 Alert 1.7 Alert Acute malnutrition by MUAC (<12.5 cm or 16.3 11.7 Very Critical Critical 14.8 Critical oedema in nutrition surveys) (13.7-18.9) Stunting (HAZ<-2) 35.8(30.8-40.9) Critical 43 Critical 38.5 Critical Underweight (WAZ<-2) 34.5 (30.4 – 38.6) Critical 38.3 Critical 35.4 Critical HIS Nutrition Trends(Aug-Nov’08) >10% Critical N/A N/A N/A N/A Admission trends at TFPs/SFPs N/A N/A N/A N/A N/A N/A Proportion of malnourished registered in SFs 21.1 N/A 21.2 N/A 46.7 N/A Child Morbidity & Immunization Increased Measles Disease trends (seasonally adjusted) suspected caseas outbreak in Morbidity 57.4 Morbidity refers to the proportion of children of measles Critical GAlkacyo-45 Critical Measles: 14.4 Critical reported to be ill in the 2 weeks prior to the survey Morbidity – 38.9 cases (34.2 – 43.7) Morbidity – 38.3 Vitamin A – 81. Alert Alert Critical (76.4-86.7) Vitamin A – 85.1 Vitamin A: 67 Immunization Status Measles -85.9 Measles -85.7 Measles: 68 Alert Alert Critical (81.9-90.0) Mortality N= 898 N= 1926 N= 324 Crude Mortality Rate per 10,000 per day 0.39 0.58 Acceptable alert 0.52 Alert regional nutrition analysis (retrospective for 90 days) (0.23-0.65) Under five mortality rate per 10,000 per day 0.90 0.40 Acceptable Acceptable 1.33 Alert (retrospective for 90 days) (0.7-1.70) Women Nutrition Status Proportion of malnourished non pregnant women 0.4 Acceptable 0.7 Acceptable 1.7 Acceptable (MUAC≤18.5 cm) (0.0-1.4) Proportion of malnourished pregnant women 31.5 Very critical 24.0 Very critical 23.3 Very critical (MUAC<23.0). (21.7-41.3) Public Health Indicators N=574 N=1789 N=265

Proportion of Women who received Tetanus 78.6 Serious 68.1 Serious 72.2 Serious Immunization Very Critical Households with access to safe water 48.6 (34.2 – 62.9) Critical 66.9 Critical 29.4

Household with access to sanitation facilities 38.9 ( Critical 72.1 Serious 31.7 Very critical Alert Households with access to health facility 76.7 Serious 91.6 60.0 Serious

Proportion of who own mosquito net 9.8 (N=1554) 20.1 (N=1343) 35.3 (N=283) Proportion who use mosquito nets 10.6 (N=1554) 28.5 (N=1343) 26.1 (N=283) Food Security N= N= N= Households with poor dietary diversity (< 4 food 4.5 (1.6-7.5) Alert 9.0 Alert 33.3 Critical groups) Household’s Main Food Source Purchase: 97 91.5 99.6 Own Production 0.3 0.2 0.4 Food aid 1.6 6 0 Food security phase H.E H.E H.E Overall Situation Analysis Very Critical Very Critical Very Critical

FSNAU Technical Series Report No VI. 25 34 Issued September 11, 2009 The current improvement among the Bossaso IDPs is linked to integrated interventions at scale in health, water and sanitation, as well as food aid distributions. Furthermore, there have been no recently reported cholera outbreaks, which had a significant effect on the nutrition situation inDeyr’ 08/09. However, the current HIS data from the Bos- saso IDPs continues to show very high numbers of acutely malnourished children screened at MCHs in the last six months. All IDPs report a very high proportion of stunting (>30%) which provides evidence of the sustained chronic malnutrition among this population.

Findings indicate considerably high morbidity rates, which have a direct effect on the nutrition situation of the children in the IDP settlements. Furthermore, the immunization status of the children assessed in the IDP population was low in Qardho and Garowe, but had shown improvement among the Bossaso and Galkayo IDPs. The proportion of households with access to safe water was low in all the IDP settlements, as was the access to health facilities, with a large proportion of the households in all the IDP towns not having appropriate access to sanitation facilities, which predisposes the population to disease, especially diarrhoea. The worrying nutrition situation is due to a combination of factors, including a high disease burden, reduced access to a diversified diet due to the increasing food prices and sub optimal child care and feeding practices. The results are consistent with historical data on nutrition surveys conducted amongst the IDP population in the northeast region, which highlights their chronic nutritional vulnerabilities.

The key nutrition indicators of these IDP populations that form the basis of the analysis are provided in Table 13.

Table 13: Summary of Key Nutrition Findings in IDPs-Northeast Regions –Qardho IDPs (Exhaustive) N=478

Indicator Results Outcome regional nutrition analysis Child Nutrition Status % Global Acute Malnutrition (WHZ<-2 or oedema) 20.1 Critical Severe Acute Malnutrition (WHZ<-3 or oedema) 5.2 V. Critical

Oedema 0.4 Acceptable

Global Acute Malnutrition (NCHS) 18.4 Critical

Severe Acute Malnutrition (NCHS) 2.7 Alert Acute malnutrition by MUAC (<12.5 cm or oedema in nutrition surveys) 13.6 Critical Stunting (HAZ<-2) 30.8 Serious Underweight (WAZ<-2) 30.3 Critical HIS Nutrition Trends(Aug-Nov’08) <10% Alert Admission trends at TFPs/SFPs - Proportion of malnourished registered in SFs N/A N/A Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity:51.3 Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the Critical Measles: 18.2 survey VitaminA 52.3 Critical Immunization Status Measles: 56.2 Critical Mortality N=376 Crude Mortality Rate per 10,000 per day (retrospective for 90 days) 0.27 Acceptable Under five mortality rate per 10,000 per day (retrospective for 90 days) 0.21 Acceptable Women Nutrition Status Proportion of malnourished non pregnant women (MUAC≤18.5 cm) 0.5 Acceptable Proportion of malnourished pregnant women (MUAC<23.0). 12.0 Critical Public Health Indicators N=307 Proportion of Women who received Tetanus Immunization 42.7 Critical Households with access to safe water 34.5 Very Critical Household with access to sanitation facilities 53.3 Critical Households with access to health facility 96.7 Alert Proportion who own mosquito nets 11.9 (N=311 ) Proportion who use mosquito nets 7.4 (N=311) Food Security N= Households with poor dietary diversity (< 4 FGs 5.7 Alert Household’s Main Food Source Purchase: 98.7 Critical Own Production 0 Food aid 0 Food security phase H.E

FSNAU Technical Series Report No VI. 25 35 Issued September 11, 2009 Poor shelter& sanitation in Galkayo IDPs, FSANU, July ‘09. Rubbish Dump-Galkayo IDPs, FSANU, July ’09.

Sool Plateau and Lower Nugal Livelihood Zones

The Post Gu’09 nutrition analysis has classified the Table 14: Summary of Results Sool plateau and Lower Nugal Livelihood Zones nutrition situation of the Sool Plateau livelihood zone Key Reference Indicator Findings Outcome of Bari and Nugal regions as Serious from Alert in Sool plateau LZ the Deyr’08/09. Data from rapid MUAC assessments Sool plateau: MUAC : <12.5 cm =6.5 , <11 cm=1.0 Serious in 6 sites in the Sool Plateau indicates the proportion (N=512; No. of sites = 6 Oedema 0 of children with MUAC <12.5cm or oedema as 6.5%. Data indicates low (<10%) and sta- The HIS data is indicating low <10% levels of children HIS Nutrition Trend ble trend of acutely malnourished Alert children with acute malnutrition with an increasing trend in Low consumption of fruits and veg- Dietary Diversity Serious some facilities. The dietary diversity is reportedly etables, high prices of cereals, poor with reduced consumption of milk, fruits and Disease Outbreaks None Acceptable Limited Health services in the rural Access to Health Services Critical vegetables. Furthermore, severe water shortages have areas Very Critical also been reported in the area, as most of the berkads Selective feeding Programmes Not exist were not replenished in the Gu’ 09 as result of poor Overall Situation Analysis: Serious rainfall performance in the area. Nugal Valley Livelihood Zones

Nugal:(N=306; No. of sites = 6 ) MUAC: <12.5 cm = 10.7, <11 cm=1.6 Critical In the Lower Nugal Valley livelihood zone, the nutrition situation indicates a Critical situation, with Oedema 0.3 Data indicates a low (<10%) and deterioration from the Serious levels reported in the HIS Nutrition Trend increasing trend of acutely malnour- Alert Post Deyr’08/09 analysis. A rapid MUAC assessment ished children Low consumption of fruits and veg- Dietary Diversity Serious in 6 sites of the Lower Nugal Valley livelihood zone etables, high prices of cereals, Unconfirmed suspected measles indicates a high proportion of children (10.7%) with Disease Outbreaks Critical cases reported MUAC measurements of <12.5cm or oedema, while Limited Health services in the rural Access to Health Services Critical areas regional nutrition analysis (1.6%) with MUAC measurements of <11.5cm. Health Selective Feeding Programmes Very Critical facility data indicates a low proportion of acutely Overall Situation Analysis Critical malnourished children screened in the MCH facilities (<10%) but with an increasing trend in the last three Figure 15 MCHs in Sool Plateau, January 2008 - July 2009 months. Dietary diversity is also poor in this liveli- 8 hood zone with milk consumption being negligible, Waciya 7 compromising their nutrition situation. There has been 6 Rako an increase in reported cases of suspected measles 5 in the lower Nugal Valley livelihood zone. Health 4 services are available in urban towns but limited in Percentages 3 the rural areas. It is imperative to continue to monitor 2 the key food security and nutrition indicators to detect 1 any changes that may occur which may result in a de- 0 terioration of the nutrition situation in the livelihood. jan mar may jul sep nov Jan Mar May

Months

FSNAU Technical Series Report No VI. 25 36 Issued September 11, 2009 Piloting the Trials of Improved Practices (TIPs) in Somalia

As part of a World Bank funded initiative implemented by FAO Somalia, the Trials of Improved Practices (TIPs) methodology is being piloted in two nutritionally vulnerable livelihood zones in Somalia – Gedo Riverine and Hiran Riverine. The TIPs methodology is applied to develop appropriate strategies for behavioural change related to infant and young child feeding (IYCF) using locally accepted inputs. This approach is part of an integrated package to address some of the driving factors to the high burden of acute and chronic malnutrition in South Central Somalia. Vegetable seed distribution targeting improved dietary diversity practices, and nutrition education using the piloted nutrition cluster Information Education Communication (IEC) materials on hygiene, sanitation and care practices will also be implemented alongside the TIPs method to enhance the impact. The TIPS method aims to identify the most acceptable practices in the region in improving infant and young child feeding (IYCF) behaviours.

The objective of the TIPs method is to test mothers’ response to recommendations for improving infant and child feeding practices and to determine which are the most feasible and acceptable solutions to the problems identified in the recent national FSAU Knowledge, Attitudes and Practices (KAP) study on infant and young child feeding. Furthermore it investigates the constraints on mothers’ willingness to change feeding patterns and their motivations for trying and sustaining new practices. The method involves discussion with the mothers and caregivers in moving towards recommended IYCF practices over three household visits.

• The first visit gathers information on the IYCF practices and the reasons they are utilised. • A week later a second visit is undertaken, where mothers/caregivers are given a choice of recommendations to act upon and ques- tioned about their particular choice. Mothers chose 2-3 recommendations which they then test in the following 2 weeks, • The third visit is then conducted to review what has actually happened and whether the recommendation has or has not worked. In this way, the proposed recommendations are tested in a real environment and information is gathered on their acceptability to that community. The reaction of the community, and the acceptability of certain recommendations, can then be used for programme planning and for promoting locally tried, tested and acceptable solutions.

These activities are being undertaken by FAO Somalia, together with three local NGOs – two of which are based in Gedo (SADO and ASEP) and one based in Hiran (Geelo) – targeting 1,000 households in Hiran Riverine and 4,000 in Gedo Riverine. Gedo and Hiran Riverine have been chosen to pilot this approach in Somalia by FAO Somalia following specific IYCF vulnerabilities of the riverine community identified in the national KAP study. Training for the interviewers was held in Mandera, Kenya, in early April, covering basic nutrition information with participa- tory and counselling methods. These interviewers then refined their counselling skills in a local IDP community in Mandera. The first home visits commenced early May, with the three home visits concluded in July. Following on from the completion of the home visits, the acceptable recommended practices were developed into nutrition education sessions, targeting the communities, using feedback from the mother and input into the community on their experiences. The nutrition education sessions are currently on-going, targeting leaders of the community, women and men in three separate education sessions within these communities. An evaluation of the programme will then be conducted and special articles if successful, plans are underway to scale up in other parts of Somalia. More information on the programme is available from FAO Somalia.

Stunting Trends in Somalia: The Case of Bay Region

Chronic malnutrition (or stunting) is a major health problem among young chil- Figure 16: Stunting Prevalence by Regions in dren, accounting for more than 49% of all child deaths worldwide1. The WHO Somalia (2001 - 2008) (1995)2 defines stunting as minus two standard deviations from the median of 40 37.0

the reference population, in terms of height-for-age. Stunting (low height for age) 35 32.8 32.7 is a physical indicator of chronic or long-term malnutrition. In children younger 31.8 30 27.3 than 3 years, stunting reflects an ongoing process of failure to grow, caused by 24.3 25 22.0 frequent bouts of infection and/or dietary deprivation over an extended period 19.2 20 17.6 of time. According to WHO (2007), 33% of children worldwide under the age of 14.9 14.1 15 13.2 12.4 5 are stunted (low height for age), compared to 27% who are underweight (low

Median Stunting (%) 10

weight for age), and 9% who are wasted (low weight for height) in developing 5 countries. Stunting and severe wasting in the first two years of life have been 0 shown to permanently impair an individual’s growth and cognitive development. They are associated with reduced educational achievements, increased risk of 3 chronic disease and diminished economic potential in later life . In Africa, 47 mil- Region lion children are stunted, 35 million are underweight, and 11 million are wasted.4

A meta-analysis of surveys conducted in Somalia provides a median stunting prevalence of 23.2%. This means that almost 300,000 of Somalia’s 1.3 million children under age of 5 are stunted.

Bay region has the highest chronic malnutrition rates (Figure x) estimated at 37.0% (almost 46,000 children), which is Serious according to WHO thresholds. This is an indication of the underlying vulnerability of children in Bay region to chronic and intermittent risk factors of prolonged epi- sodes of drought, civil conflict and frequent bouts of illness. High levels of chronic malnutrition are therefore attributed to elevated disease burden, poor quality and quantity of diet leading to micronutrient deficiencies, and the impacts of civil insecurity restricting access to health services and humanitarian support. Bay region depends on a rain-fed sorghum economy for their means of livelihood and food. The community predominantly consume cereal based diets and given the unstable unfavorable terms of trade, access to other food sources that would provide proteins and micronutrients is severely limited and so even in periods of bumper sorghum harvest, Bay has persistently shown high levels of chronic and acute malnutrition. The typical household diet in Bay is nutrient-poor and less diversified, the bulk of which consists of sorghum-based cereal meal (boiled or milled into flour and prepared as porridge or cake). Poor rainfall often leads to crop failures and outbreaks of acute watery diarrhoea and other communicable diseases which are common in the region. Therefore only sustainable efforts which meet the nutritional requirements of young children and address the chronic disease burden in Bay will have an impact in addressing the existing acute and chronic nutritional crisis.

1 Rosenberg, M. (2007). Global Child Health: Burden of Disease, Achievements, and Future Challenges. Current Problems in Pediatric and Ado- lescent Health Care, 37(9):338-362. 2 WHO (1995). Physical status: the use and interpretation of anthropometry, Report of a WHO Expert Committee. Technical Report Series 854 Geneva. 3 Victora CG, Adair L, Fall C, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008; 371: 340–57. 4 Kleynhans, I.C. (2007). Stunting among young black children and the socio-economic and health status of their mothers/caregivers in poor areas of rural Limpopo and urban Gauteng – the NutriGro Study. SAJCN, 19(4): 163-164.

FSNAU Technical Series Report No VI. 25 37 Issued September 11, 2009 4.8 Northwest Regions

The Northwest regions comprise mainly of pastoral livelihood zones namely West Golis, Guban, East Golis of Sanaag region, the Hawd, Sool Plateau and the Nugal Valley. In addition, there are two agro-pastoral livelihood zones consisting of the Northwest Agro-pastoral of Awdal and Galbeed region and Togdheer Agro-pastoral of Togdheer and Sahil region. The livelihood zones cut across the administrative regions of Awdal, Galbeed, Togdheer, Sool and Sanaag (Map 12).

Historical Overview Post Deyr ‘08/09 Map 12: North West Livelihood Zones The FSNAU Post Deyr ‘08/09 analysis classified the Hawd, Sool Plateau, Nugal Valley, and Togdheer Agro- pastoral livelihood zones as Borderline Food Insecure (BFI), while the West Golis, Guban, East Golis of Sanaag region, Gebbi Valley and Northwest Agro-pastoral livelihood zones deteriorated from BFI and were identified as being in Acute Food and Livelihood Crisis (AFLC). The Post Deyr ‘08/09 integrated nutrition analysis classified the West Golis, Guban and the East Golis of Sanaag region nutritional situation as Very Critical, while the Nugal Valley, Hawd, Gebbi Valley and both the agro- pastoral livelihood zones, were classified asSerious. The Sool Plateau of Sanaag region was the only livelihood zone in the North West region classified as Alert. The nutrition situation among the Hargeisa and Burao IDPs was classified asSerious and Critical respectively. His- torically the nutrition situation in the North West region has been below emergency thresholds (GAM <15%) apart from the IDP populations, that have been reporting high acute malnutrition rates (Figure 17).

Current Situation

Food Security The FSNAU Post Gu ’09 integrated food security analysis Figure 17: Trend in levels of acute malnutrition (WHZ< -2 or has classified the West Golis/Guban inAcute Food and oedema, (WHO 2006 ) in Northwest region 2002- 2009

Livelihood Crisis (AFLC), similar to the Post Deyr 30.00% ‘08/09 phase, nevertheless the food security indicators show a general improvement. In addition, the Northwest agro-pastoral and the East Golis (of Sanaag region) liveli- 15.00% hood zones have also been classified inAFLC , however regional nutrition analysis with an indication of a worsening situation. The Togdheer 0.00% agro-pastoral and the Sool Plateau pastoral livelihood East Golis Burao IDPs Burao IDPs Burao IDPs Burao IDPs Gebbi Valley Gebbi Valley Sahil Region zones have deteriorated from the situation in the Post Sool Plateau Sool Plateau Sool Plateau Sool Plateau Berbera IDPs Berbera IDPs Awdal Region Awdal Hargeisa IDPs Hargeisa IDPs Hargeisa IDPs Huddun District Togdheer Region Togdheer Region Togdheer Deyr ‘08/09, and are classified inAFLC, with 75% of the Golis/Guban West Golis/Guban West Jan May May Aug Jun July Jun Aug Oct Oct Sep Sep Sep July Dec Dec April April April June June June poor identified inHumanitarian Emergency (HE). The 02 02 03 03 04 05 06 06 08 08 07 07 07 08 08 08 09 09 09 09 09 09 populations of the Hawd and the Nugal Valley livelihood zones are also classified inAFLC, with a moderate risk of deterioration. The estimated rural population in AFLC is now 240,000 people, an increase from 45,000 people in Deyr ‘08/09, in addition to the 20,000 people currently identified in HE. The population of the urban poor in AFLC has also increased by 36% to 150,000, however the number in HE remains the same at 30,000 similar to the Post Deyr ‘08/09.

Nutrition The current Post Gu ’09 nutrition situation depicts a varied situation, with three1 of the nine livelihoods in the Northwest regions illustrating an improvement, five demonstrating evident deterioration, and the rest remaining stable compared to the Post Deyr ‘08/09. The West Golis and Guban livelihood zones indicate an improvement from Very Critical to Serious, while the East Golis of Sanaag show slight improvement from Very Critical to Critical. The nutrition situation for the Sool Plateau livelihood zone compared to the Post Deyr ‘08/09, deteriorated from Alert to Serious. The Gebbi Valley livelihood zone nutrition situation also deteriorated from Serious to Critical. Also illustrating deterioration are the populations of the agro-pastoral livelihood of Togdheer and Galbeed regions from Serious to Critical and the Hawd from Serious to Critical, with the Southern Hawd of Togdheer Region being classified asVery Critical. The remaining livelihood zones of Hawd of Hargeisa and Sool regions and the Nugal Valley

1 West and East Golis and Guban livelihood zones

FSNAU Technical Series Report No VI. 25 38 Issued September 11, 2009 remains Serious. However the following livelihood zones: - Hawd of Hargeisa and Togdheer region, Sool Plateau and Nugal Valley indicate a potential to deteriorate. The nutrition situation of the IDPs from Burao is classified as Very Critical, a deterioration from Critical in the Post Deyr ‘08/09, while the Berbera IDP population is classified as Critical. The nutrition situation of the Hargeisa IDPs remained stable at Serious.

Sool Plateau Livelihood Zone of NW The Post Deyr ‘08/09 integrated nutrition analysis clas- Figure 18: Dhahar and Hingalool MCH Nutrition Trends sified Sool Plateau of Sool and Sanaag region as Alert. Jan-Jun 2009

This was attributed to the good September and October 160 2 Total screened No.Mal. ‘08 rain performance that led to increased access to food, 140

water and income in the area. Conversely the Post Gu ’09 120 integrated nutrition situation analysis has classified the 100 livelihood zone as Serious with a risk of deterioration. 80 Analysis of MUAC measurements from 330 children in 3 sites indicates the proportion of children with MUAC 60 of <12.5cm or oedema as 5%. Data from health infor- 40 mation systems (HIS) in the area indicates low numbers 20 but an increasing trend of acutely malnourished children 0 Dhahar Dhahar Dhahar Dhahar Dhahar Dhahar Hingalol Hingalol Hingalol Hingalol Hingalol Hingalol

screened at health facilities (Figure 18). Jan.09 Feb.09 Mar.09 Apri.09 May.09 Jun.09 Jan.09 Feb.09 Mar.09 Apri.09 May.09 Jun.09

An integrated analysis of nutrition, health and food security indicators (Table 15) indicate that the nutrition Table 15: Sool Plateau of Sool and Sanaag Region Livelihood Zone regional nutrition analysis <11.5 cm = 0 <12.5 cm = MUAC (N= 330 Sites = 3) Serious situation in Sool Plateau is Serious. Current analysis fur- 5.0% ther identifies reduced intake of milk and meat products Data indicates low numbers following the Gu ’09 rain failure and the out-migration HIS Nutrition Trend and increasing trend of acutely Serious malnourished children of livestock, as the main factor contributing to the de- Poor; no milk available, high clining nutrition situation in the livelihood zone. The Dietary Diversity food costs and reduced Serious livestock remaining in the area are unproductive and in frequency of meals reported poor body condition. This has led to reduced access to Disease Outbreaks No disease outbreaks reported Alert income, and milk for consumption, and contributed to Immunization Status Low Critical Limited health facilities in the poor household dietary diversity. The ongoing drought Access to Health Services Critical area in the livelihood zone has especially had a negative Selective Feeding Very limited Critical impact on the vulnerable groups (women and children). Programmes According to the FSNAU Post Gu ’09 gender analysis Overall Situation Analysis: Serious report, women and children’s access to food is limited due to significant livestock out migration from the area, which has caused families to split, with women losing access and control of income from livestock products and sales. In addition, the drought has also affected the feeding practices of the household, women are spending longer hours away from the home in search of water, compromising the child care practices in the households, leaving children more susceptible to malnutrition. Additional compounding factors further aggravating the vulnerable nutritional situation in the area include, high food costs, lack of adequate safe water (water availability for domestic and animal consumption in the area is very limited due to the on going drought), high morbidity rates and limited access to sanitation and health facilities.

West Golis/Guban Livelihood Zone The Post Gu ’09 integrated nutrition analysis indicates a noticeable improvement in the nutrition situation of the population in the West Golis/Guban livelihood zone from Very Critical in the Post Deyr ‘08/09 to Seri- ous (Table 16). A nutrition survey conducted in June 2009 reported a global acute malnutrition (WHZ<-2 or oedema) rate of 13.3% (10.4-16.9) and a severe acute malnutrition (WHZ<-3 or oedema) rate of 2.5% (1.5-3.9). The improvement of the nutrition situation in the livelihood is mainly attributed to an improved food security situation as a result of good rains received in the area, compared to the Post Deyr ‘08/09 season. Consequently, water availability, pasture and livestock body conditions improved, resulting in increased meat and milk A woman milking a goat

2 Food Security and Nutrition Brief November 2008

FSNAU Technical Series Report No VI. 25 39 Issued September 11, 2009 consumption and income for the households. Based on the June 2009 nutrition survey findings, the proportion of households consuming a diversified diet (>=4 food groups) has increased from 76.4% in the Post Deyr ‘08/09 to 86.5%. Milk consumption has also improved with 60.4% of the assessed households reporting to have consumed milk, based on 24 hour recall, compared to 33.5% in the Post Deyr ‘08/09. The precarious nutrition situation reported during the Post Deyr ‘08/09 prompted immediate humanitarian interventions and establishment of feeding centres and mobile clinics in the region (by UNICEF, MOHL, WVI and SRCS) and have facilitated the rehabilitation of acutely malnourished children and reduced morbidity. The morbidity rate (16.2%) reported from the recent assessments indicated an improvement, with lower rates of diarrhoea (10.8%) reported. Child Health Days conducted in the region by UNICEF and MOHL have improved the overall immunization status of the children, with Vitamin A supplementation reported at 92.2% and measles vaccination at 84.6%. Although an improvement in the nutritional situation in the area has been observed, the vulnerability of the region, to natural shocks, e.g. drought, necessitates continued close monitoring of the situation.

East Golis and Gebbi Valley Livelihood Zones of Sanaag Region The Post Deyr ‘08/09 integrated nutrition analysis classified the nutrition situation in the East Golis of Sanaag region as Very Critical. Poor household access to milk and meat for consumption, to food and non-food commodities due to high prices, and to clean water and appropriate sanitation and health facilities3 were the main driving factors. The Post Gu ’09 integrated nutrition analysis, classified the nutrition situation in the area as Critical indicating a slight improvement for the previous season (Table 16). The slight improvement is likely attributed to selective feeding and health interventions conducted in Erigavo district. A nutrition survey conducted in June 2009 reported a global acute malnutrition (WHZ <-2 or oedema) rate of 17.9% (14.4-22.0) and a severe acute Young girl herding goats malnutrition (WHZ <-3 or oedema) rate of 3.3% (1.9-5.8). This is the first comprehensive nutrition survey conducted in the livelihood zone and it confirms the distressing nutrition situation identified in the PostDeyr ‘08/09 rapid nutrition assessments. Data from health facilities in the area reported high numbers and an increasing trend of acutely malnourished children. The worrying nutrition situation is mainly attributed to the precarious food security situation and high morbidity rates.

The livelihood zone has received below normal rainfall for four consecutive seasons, including Gu ’09, this has led to abnormal out migration of animals and poor animal body conditions resulting in reduced household income and meat and milk consumption. The population in this livelihood also rely on supplementary income from the sale of regional nutrition analysis gum (frankincense), however due to the poor rains in the region; the gum production has also declined. The morbidity rates reported in the area are high (34.2%), further exacerbating the poor nutrition situation in the area. Poor sanitation, lack of adequate clean water, low immunization coverage and limited health facilities are the chronic underlying factors also affecting the nutritional status of the population. Equally important to note is the mountainous terrain of this livelihood which limits access and humanitarian interventions in the area. Close monitoring of the nutrition situation of this population groups remains crucial, in addition to initializing interventions aimed at rehabilitating malnourished children and improving access to health facilities, especially in the areas outside of Erigavo town.

3 FSNAU Technical Series, Report No V.16, February 20, 2009, Nutrition Situation Post Deyr 2008/09

FSNAU Technical Series Report No VI. 25 40 Issued September 11, 2009 Table 16. Summary of Key Nutrition Findings in West Golis/Guban, East Golis of Sanaag region and Gebbi Valley

West Golis Guban (N=772) East Golis (=603) Gebbi Valley(N=674)

Indicator Results % Outcome Results % Outcome Results % Outcome

Child Nutrition Status

Global Acute Malnutrition (WHZ<-2 or oedema) 13.3 (10.4-16.9) Serious 17.9 (14.4-22.0) Critical 15.0 (11.4-19.5) Critical

Severe Acute Malnutrition (WHZ<-3 or oedema) 2.5 (1.5-3.9) Serious 3.3 (1.9-5.8) Serious 3.3 (1.9-5.7) Serious

Oedema 0 Acceptable 0.5 (0.1-1.6) Serious 0.1 Alert

Global Acute Malnutrition (WHZ<-2 or oedema; NCHS) 13.5 (11.2-16.1) Serious 19.1 (15.6-23.1) Critical 14.8 (11.0-19.8) Serious

Severe Acute Malnutrition (WHZ<-3 or oedema; NCHS) 1.4 (0.8-2.6) Alert 2.0 (1.2-3.2) Alert 1.5 (0.7-3.2) Alert

Acute malnutrition by MUAC (<12.5 cm or oedema in nutrition surveys) 2.5 (1.5-3.9) Acceptable 1.7 (0.8-3.1) Acceptable 4.9 (1.9-7.9) Alert

Stunting (HAZ<-2) 7.1 (5.8-9.7) Acceptable 10.9 (8.6-13.8) Alert 13.9 (10.7-17.9) Alert

Underweight (WAZ<-2) 19.0 (16.4-22.0) Serious 17.1 (14.2-20.4) Serious 17.5 (13.3-22.8) Serious

Low levels and High levels and High levels and HIS Nutrition Trends(Jan-Jun ‘09) Alert Critical Critical stable increasing increasing

Proportion of malnourished children registered in SFs 16.2 Very Critical 21.9 Very Critical 21.9 Very Critical

Child Morbidity & Immunization

Disease trends (seasonally adjusted) Outbreak – None Outbreak -None Outbreak -None

Morbidity refers to the proportion of children reported to be ill in the 2 Morbidity – 16.2 Serious Morbidity– 34.2 Critical Illness – 26.6 Critical

weeks prior to the survey RDT – N/A RDT – N/A RDT- N/A

Vitamin A – 92.2 Alert Vitamin A – 59.9 Critical Vitamin A – 69.7 Critical Immunization Status

Measles – 84.6 Alert Measles- 65.0 Critical Measles- 66.9 Critical regional nutrition analysis

Mortality

0.46 (0.27-0.79) 0.3 (0.10-1.18) 0.23 (0.10-0.56) Crude Mortality Rate per 10,000 per day (retrospective for 90 days) Acceptable Acceptable Acceptable N=754 N=584 N=620

Under five mortality rate per 10,000 per day (retrospective for 90 days) 0.82 (0.34-1.99) Acceptable 1.06 (0.36-3.08) Alert 0.82 (0.28-2.39) Acceptable

Women Nutrition & Immunization Status

Proportion of malnourished non pregnant women (MUAC≤18.5 cm) 4.9 (N=396) Serious 6.5 (N=323) Serious 0.3 (N=338) Alert

Proportion of malnourished pregnant women (MUAC<23.0). 0 (N=87) Acceptable 0 (N=48) Acceptable 22.4 N=13 Very Critical

69.6 (65.2-73.6) 55.8 (50.6-60.9) 58.8 (49.8-67.9) Proportion of Women who received Tetanus Immunization Serious Serious Serious N=483 N=371 N=396

Public Health Indicators N=480 N=369 N=407

Households with access to safe water 41.5 Critical 22.2 Very Critical 14.5 Very Critical

Household with access to sanitation facilities 51.7 Critical 47.4 Critical 13.5 Very Critical

Households with access to health facility 52.7 Critical 20.3 Very Critical 64.4 Serious

Food Security

Households with poor dietary diversity (< 4 food groups) 13.5 Serious 17.1 Critical 14.0 Serious

Household’s Main Food Source 97.1 96.7 95.5 Purchase: 2.7 1.1 0.7 Own Production 0 0 0 Food aid

Food security phase AFLC Critical AFLC Critical AFLC/HE Critical

Overall Situation Analysis Serious Critical Critical

Gebbi Valley Figure 19: Badhan and Hadaftimo MCH Nutrition Trends The Gebbi Valley livelihood zone shows deterioration Jan-Jun 09

from the Serious Post Deyr ‘08/09 nutrition situation 90 Total screened No.Mal. classification to Critical. A nutrition survey conducted 80 in the area in June 2009 reported a global acute malnu- 70 trition (WHZ <-2 or oedema) rate of 15.0% (11.4-19.5) 60 50

and a severe acute malnutrition (WHZ <-3 or oedema) 40

rate of 3.3% (1.9-5.7). Information from the health facili- 30 ties in the area indicates a high and increasing trend of 20 acutely malnourished children (Figure 19) in Badhan and 10 Hadaftimo MCHs). The food security situation in the 0 Badhan Badhan Badhan Badhan Badhan Badhan

livelihood is precarious due to the drought in the region Hadaftimo Hadaftimo Hadaftimo Hadaftimo Hadaftimo Hadaftimo also affecting neighbouring livelihood zones. This has Jan.09 Feb.09 Mar.09 Apri.09 May.09 Jun.09 Jan.09 Feb.09 Mar.09 Apri.09 May.09 Jun.09 led to reduced household income, meat and milk consumption. High morbidity rates have also been reported in the livelihood, with 26.6% of the assessed children reporting to have been ill in the two weeks prior to the assessments. The proportion of children having suffered from diarrhoea was 12.9%. The chronic issues affecting the nutritional situation of the area include inadequate health services, poor sanitation, sub optimal child feeding and care practices

FSNAU Technical Series Report No VI. 25 41 Issued September 11, 2009 and low immunization status. It is therefore vital to expand and commence (in areas that have not began) relevant interventions to rehabilitate malnourished children, alongside long term interventions such as improved child care and feeding practices and provision of adequate health, safe water and sanitation facilities.

The Hawd and Nugal Valley Livelihood Zone According to the Post Gu ’09 integrated nutrition situation analysis, there is deterioration in the Hawd livelihood zone of the northwest region. The Hawd of Hargeisa (Galbeed region) and of Sool Region are classified asSerious , with a risk of deterioration in the Hawd of Hargeisa. The Hawd of Togdheer region is classified asCritical , with potential to deteriorate, whilst the southern part of the Hawd of Togdheer Region is classified asVery Critical. Apart from the Hawd of Hargeisa and Hawd of Sool where the nutrition situation remained stable at Serious compared Table 17: Key Reference Indicator Findings Outcome to the Post Deyr ‘08/09, the Hawd of Togdheer has Hawd of Hargeisa (Galbeed region) Livelihood Zone shown evident deterioration from Serious to Criti- MUAC (N=640 Sites = 6) <11.5 cm = 3.9 <12.5 cm = 8.0 Serious Oedema None cal and Very Critical in southern parts of Togdheer. Data indicates a high and increas- MUAC data recorded from 640 children from 6 HIS Nutrition Trend ing trend of acutely malnourished Critical children sites in the Hawd of Hargeisa indicates that 8.0% Poor, limited household milk consumption, reduced meal frequency of the assessed children have MUAC measurements Dietary Diversity Critical and food access inadequate safe <12.5cm. The proportion of children at risk (MUAC water 12.5-13.4cm) of being acutely malnourished is high No outbreaks reported, however Disease Outbreaks increased cases of diarrhoea re- Serious (12%). Data from the health facilities (Salaleh, Be- ported in the area High due to CHDs1 completed suc- Alert legubaddleh and Adade MCHs) illustrate a high and Immunization Status cessfully in the area increasing trend of acutely malnourished children. Access to Health Services Limited health services in the area Critical Selective Feeding Programmes Very limited in the area Serious Household income and consumption of milk and Overall Situation Analysis: Serious but likely to deteriorate meat is very poor, as animals have out migrated from Hawd of Togdheer Livelihood Zone <11.5 cm = 8.4 (1 oedema) <12.5 Very MUAC (N= 630 Sites = 6) the region (See photo on page 43) due to poor rains cm = 16.3 Critical Data indicates high and increas- in the area resulting in lack of water and pasture. HIS Nutrition Trend ing trend of acutely malnourished Critical Lack of adequate safe water has also led to increased children Poor, very limited household milk incidences of diarrhoea in the area, which unfortu- consumption, food access and Dietary Diversity Critical nately correlates directly with acute malnutrition. reduced meal frequency and inadequate safe water In the Hawd of Sool Region, MUAC data collected Increased cases of diarrhoea Critical from 550 children in 5 sites, indicate the proportion Disease Outbreaks were noted in Ali Farrah, Jeenolaays,Harada Guboto of children with MUAC measurements of <12.5cm High due to CHDs completed suc- Alert Immunization Status as 7.5%, with 16.6% of the children assessed being cessfully in the area Access to Health Services Limited in the area Critical at risk (MUAC 12.5-13.4) of acute malnutrition. Very Selective Feeding Programmes Very Limited Low but increasing trends of acutely malnourished Critical Overall Situation Analysis: Critical and likely to deteriorate, children were reported from Kalabeydh health fa- Very Critical in southern Hawd of Togdheer cility. The MUAC measurements for a total of 630 Hawd of Sool Region regional nutrition analysis MUAC (N= 550 Sites = 5) <11.5 cm = 0.3 <12.5 cm = 7.5 Serious children from 6 sites in the Hawd of Togdheer region Data indicates low and increasing indicated that 16.3% were acutely malnourished HIS Nutrition Trend trend of acutely malnourished Serious children (MUAC <12.5cm or oedema), and 8.4% severely Poor, limited household milk Dietary Diversity Critical malnourished (MUAC<11.5cm or oedema), with one consumption oedema case observed. The proportion of children Disease Outbreaks No disease outbreaks reported Alert High due to CHDs completed Immunization Status Alert at risk (MUAC 12.5-13.4) was also high at 17.3%. successfully in the area Access to Health Services Limited in the area Critical Information from the Hajisalah and Balidhiig MCHs Selective Feeding Programmes Very Limited Critical Overall Situation Analysis: Serious indicated a high and increasing trend of acutely malnourished children. Although there was no disease outbreaks reported in the area, high incidences of diarrhoea were reported from Ali Farrah, Jeenolaays and Harada Guboto villages. Water availability in the area is very limited due to the poor rainfall performance in the area, also resulting in lack of adequate pasture and hence the out migration of livestock and poor animal body conditions. This has limited the household income and milk and meat consumption. Even though the situation in the Hawd of Togdheer is Critical, the villages in the southern section namely Ali Farrah, Jeenolaays, Harada Guboto and Dhoqoshey reported higher rates of acutely malnourished children classifying the situation in this area as Very Critical, mainly attributed to the precarious food security situation and high diarrhoea incidences. This is also illustrated through admission trends in Burao OTP showing high numbers of children from this area. Nevertheless, the northern section of the Hawd of Togdheer classified asCritical also shows a high risk of deterioration and should be closely monitored and measures put in place to avert a worsening situation.

The Post Gu ‘09 integrated nutrition analysis has classified the nutrition situation in the Nugal Valley livelihood zone as Serious, remaining stable from the previous season, but with an indication of possible deterioration if the food security indicators do not improve. Nugal Valley has also been affected by the poor rainfall performance

FSNAU Technical Series Report No VI. 25 42 Issued September 11, 2009 reported in the Northwest region. This has had an effect on water and pasture availability and animal body conditions, subsequently having a direct impact on the meat and milk production, consumption and income of the households. MUAC measurements recorded from a total of 1100 children from 10 sites, indicates a low proportion of children both with MUAC of <11.5cm, 0.5%, and with MUAC of <12.5cm was 5.0%. Nonetheless, it is prudent to note that high proportions (18.7%) of the children were identified at risk (MUAC 12.5-13.4cm) of being acutely malnourished. Additionally, data from the health facilities (Garadag, Ainabo, Huddun and Taleh MCHs) indicates high and increasing numbers of acutely malnourished children. Moreover, although there were no disease outbreaks reported in the area, increased cases Livestock out migrating from the Hawd of Togdheer

of diarrhoea were noted in Ali Hersi and Qaridhere Table 18: Nugal Valley Livelihood Zone villages, mainly associated with consumption of MUAC (N= 1100 Sites = 10) <11.5 cm = 0.5 <12.5 cm = 5.0% Serious unsafe water, owing to the water scarcity in the area. Data indicates high numbers and In addition to the food security and morbidity risk HIS Nutrition Trend increasing trend of acutely malnour- Critical ished children factors, the population remains vulnerable to the Poor; limited milk availability, re- Dietary Diversity duced frequency of meals and food Serious persistent hazards associated with poor child care access and feeding practices, low immunization status, poor No disease outbreaks reported, how- regional nutrition analysis ever increased cases of diarrhoea Disease Outbreaks Serious sanitation and limited health facilities in the area. reported in Ali Hersi and Qaridhere The livelihood zone will need close monitoring of villages High due to CHDs completed suc- Immunization Status Alert the both the food security and nutrition situation. cessfully in the area The initiation of interventions aimed at support- Access to Health Services Limited health facilities in the area Serious Selective Feeding Pro - ing livelihoods and protecting vulnerable groups Limited in the area Serious is crucial, and should be done along side selective grammes feeding programmes targeting acutely malnourished Overall Situation Analysis: Serious but likely to deteriorate children in addition to health programmes aimed at reducing morbidity. Table 19: Summary of Results of Northwest Agro-pastoral LHZs Key Reference Indicator Findings Outcome Agro-pastoral (Awdal region) Livelihood Zone Agro-pastoral Livelihood Zones MUAC (N= 646 Sites = 12) <11.5 cm = 0.5 <12.5 cm = 6.0 Serious Data indicates low numbers and stable trend of The nutrition situation of the population in the agro- HIS Nutrition Trend Alert acutely malnourished children pastoral livelihood zone of Awdal region is classified Poor; due to low crop production and limited milk Poor Dietary Diversity Serious as Serious, indicating no change from the Post Deyr availability and food access Disease Outbreaks None reported Alert ‘08/09. The MUAC measurements collected from High due to CHDs completed successfully in Immunization Status Alert 646 children from 12 sites indicated 6.0% and 0.5% the area of the assessed children recorded a MUAC measure- Access to Health Services Limited Serious Selective Feeding Programmes Limited in the area Serious ment of <12.5cm and <11.5cm, respectively. Health Overall Situation Analysis: Serious facility data (from Boroma Central, Qorgab, Dila, Agro-pastoral (Galbeed region) Livelihood Zone Qulujed and Idhanka MCHs) indicated low numbers MUAC (N= 1179 Sites = 21) <11 cm = 5.0 (1 oedema) <12.5 cm = 11.0 Critical Data indicates a low but increasing trend of and a stable trend of acutely malnourished children. HIS Nutrition Trend Serious acutely malnourished children Poor; due to low crop production and limited milk However due to the low crop production in the area Dietary Diversity Serious availability and food access and decreased household access to food and milk, None reported however increased cases of Disease Outbreaks Serious the area should be closely monitored. The agro- diarrhoea and ARI were reported High due to CHDs completed successfully in Immunization Status Alert pastoral livelihood of Galbeed region deteriorated the area from Serious to Critical according to the Post Gu Access to Health Services Very Limited in the area Critical ’09 integrated nutrition analysis. The proportion of Selective Feeding Programmes Very Limited in the area Critical Overall Situation Analysis: children with MUAC measurements of <12.5cm and Critical <11.5 cm was 11.0% and 5% respectively. Data from Agro-pastoral (Togdheer region) Livelihood Zone <11 cm = 5.0 (2 oedema 1 Marasmus) <12.5 cm MUAC (N= 1269 Sites = 18) Critical health facilities (Gebiely, Togwajale, Allaybadley = 11.4 Data indicates a low but stable trend of acutely and Arabsiyo MCHs) in the livelihood zone indicated HIS Nutrition Trend Serious malnourished children low numbers but with an increasing trend of acutely Poor; due to low crop production and very limited Dietary Diversity Serious malnourished children noted in the last six months. milk availability and food access None reported, however increased cases of diar- Disease Outbreaks Serious Increased cases of diarrhoea and acute respiratory rhoea in Gideys, Himan and Beer villages High due to CHDs completed successfully in infections were noted in the area. The deterioration Immunization Status Critical the area in the nutrition status was mainly attributed to very Access to Health Services Very Limited in the area Critical low crop production in the area due to poor rainfall Selective Feeding Programmes Very Limited in the area Critical performance, thus reducing household income and Overall Situation Analysis: Critical food access. Milk availability and consumption in

FSNAU Technical Series Report No VI. 25 43 Issued September 11, 2009 the area is also limited. The nutrition situation of the agro-pastoral population of the Togdheer region also illustrated a deterioration from Serious in Post Deyr ‘08/09 to Critical according to the Post Gu ’09 integrated nutrition analysis. MUAC measurements from a total of 1269 children from 18 sites were recorded, the proportion of children acutely malnourished (<12.5cm) was 11.4%, while the proportion of children severely malnourished (<11.5cm) was 5%, with 2 oedema cases observed. Data from the health facilities indicated a low and stable trend of acutely malnourished children, although no disease outbreaks have been reported, increased cases of diarrhoea have been noted in the area in Gideys, Himan and Beer villages (the same areas where the oedema and marasmus cases were observed). In addition to morbidity, the precarious nutrition situation is also attributed to the poor food security situation also affecting the agro-pastoral and pastoral livelihoods regions in the area. The agro-pastoralists of Togdheer regions are more of livestock holders than crop cultiva- tors in comparison to the agro-pastoralists of Awdal and Galbeed region, and therefore more vulnerable, as the drought in the region has affected the pastoral populations in the area more severely; this coupled with the low crop production noted in the area increases their vulnerability.

IDPs of the North West: Hargeisa, Burao and Family out migrating from the Hawd of Togdheer Berbera The nutrition situation of Burao IDPs has deteriorated from, Critical to Very Critical, the Hargeisa IDPs nutrition situation is stable at Serious and the Berbera IDPs at Critical according to the Post Gu ’09 integrated nutrition analysis. During the Post Deyr ‘08/09 integrated analysis, there was insufficient data for the Berbera IDPs to con- fidently classify their nutrition situation. In April 2009, comprehensive exhaustive (except Hargeisa, small cluster survey conducted) nutrition surveys were conducted among the IDP population of Burao and Berbera towns (Table 19). A global acute malnutrition (WHZ<-2 or oedema) rate of 10-15% (Pr=0.96 using the CDC Probability Calcula- tor), 20.5% and 18.3% was recorded among the IDP population of Hargeisa, Burao and Berbera respectively. The severe acute malnutrition (WHZ<-3 or oedema) rate among the Burao, Berbera and Hargeisa IDPs was 4.9%, 3.3% and 1-2% respectively. Data from the health facilities in Hargeisa indicated a high and increasing trend of acutely malnourished children, morbidity data collected indicated that the proportion of children that had suffered from one or more illnesses in the two weeks prior to the assessment was high (30.3%). Although the nutrition situation among the Hargeisa IDPs has remained stable, close monitoring is required due to the vulnerability of the population. Low immunization status, poor feeding and child care practices, lack of adequate sanitation facilities are also likely to aggravate the fragile nutrition situation.

The nutrition situation of the Burao IDPs has deteriorated from Critical to Very Critical. The drought currently being experienced in the region has also drawn destitute families from the rural areas hoping to benefit from op- regional nutrition analysis portunities in Burao Town. From April 2009 increased cases of admissions into selective feeding centres in Burao have been recorded.4According to reports from Medair, the implementing agency in the region, majority of the acutely malnourished children admitted in the SFPs are mainly from rural villages of Togdheer region, namely Harada, Ceeg, Dhooqoshey, War Cibraan, Waraabeeye, Dabaqad, Cali Ciise, Cali Saahid, which are located south of Burao; a few cases were also noted from east of Burao from Beer village (data collected from this village also indicated high cases of diarrhoea). Elevated numbers of acutely malnourished children were also reported from villages south of Togdheer such as Adow yurura, Sanyare,Ceel Bilcille, Ceel Xume. The main factors contributing to the Very Critical nutrition situation of the IDP population include high morbidity rates (29.7%), poor child feeding and care practices, poor dietary diversity (36.8% of the households consumed <4 food groups a day) and poor food access due to high food costs, coupled with chronic underlying risk factors such as poor access to safe water and sanitation facilities. It is therefore imperative to continue, expand and initiate (in affected areas that have not began) appropriate interventions to immediately rehabilitate acutely malnourished children, these interventions should also be backed by long term interventions such as improved child care and feeding practices, improved dietary diversity and enhanced access to safe water and sanitation and health facilities.

4 Medair Nutrition Programme report April 2009

FSNAU Technical Series Report No VI. 25 44 Issued September 11, 2009 Table 20: Summary of Key Nutrition Findings of the North West IDPs: Hargeisa, Burao and Berbera

Hargeisa IDPs (N=300)2 Burao IDPs (=431) Berbera IDPs(N=520) Indicator Results % Outcome Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) 10-15(Pr=0.96) Serious 20.5 Very Critical 18.3 Critical 1-2 4.9 3.3 Severe Acute Malnutrition (WHZ<-3 or oedema) Alert Critical Serious (Pr=0.77) Oedema 0.3 0.5 - Alert Serious -

10-15 18.8 17.9 Global Acute Malnutrition (WHZ<-2 or oedema; NCHS) Serious Critical Critical (Pr=0.96) 1-2 3.0 1.7 Severe Acute Malnutrition (WHZ<-3 or oedema; NCHS) Alert Critical Alert (Pr=0.77) (1.2-3.2) Acute malnutrition by MUAC (<12.5 cm or oedema in nutrition 2.5 9.7 Acceptable Serious 13.1 Critical surveys) (1.5-3.9) 30 20.5 36.3 Stunting (HAZ<-2) Critical Critical Critical (25.4-35.0) 21.1 17.1 32.5 Underweight (WAZ<-2) Critical Critical Critical (15.9-27.4) (14.2-20.4) High levels and High levels and High levels and HIS Nutrition Trends(Jan-Jun ‘09) Critical Critical Critical increasing increasing increasing High and increas- Admission trends at TFPs/SFPs ( Jan-Jun’09) High levels and stable Critical Critical High and stable Critical regional nutrition analysis ing Proportion of malnourished registered in SFs 39.1 Very Critical 31.6 Very Critical 16.7 Very Critical Child Morbidity & Immunization Disease trends (seasonally adjusted) Outbreak – None Outbreak -None Outbreak -None

Morbidity refers to the proportion of children reported to be ill Morbidity – 30.3 Critical Morbidity– 29.7 Critical Illness – 42.1 Critical

in the 2 weeks prior to the survey RDT – N/A RDT – N/A RDT- N/A Vitamin A – 67.7 Critical Vitamin A – 59.9 Critical Vitamin A – 83.1 Immunization Status Critical Measles – 69.3 Critical Measles- 73.5 Critical Measles- 48.7 Mortality Crude Mortality Rate per 10,000 per day (retrospective for - 0.29 (0.14-0.59) 0.58 (0.33-1.02) - Acceptable Alert 90 days) N=280 N=316 Under five mortality rate per 10,000 per day (retrospective 0.55 0.99 - - Acceptable Acceptable for 90 days) (0.19-1.60) (0.42-2.29) Women Nutrition & Immunization Status Proportion of malnourished non pregnant women (MUAC≤18.5 1.5 (N=133) Alert 2.1 (N=243) Alert 0.4 (N=229) Alert cm) 14.8 Proportion of malnourished pregnant women (MUAC<23.0). 7.1 Serious 25 Very Critical Critical

Proportion of Women who received Tetanus Immunization 62.7N=161 Serious 57.0N=291 Serious 72.8N=339 Serious Public Health Indicators N=161 N=280 N=316

Households with access to safe water 67.1 Serious 63.6 Serious 96.3 Alert

Household with access to sanitation facilities 91.1 Alert 55.0 Critical 61.7 Alert

Households with access to health facility 90.2 Alert 83.2 Serious 96.5 Alert

Food Security

Households with poor dietary diversity (< 4 food groups) 21.1 Serious 36.8 Critical 40.3 Critical

Household’s Main Food Source

Purchase: 99.4 86.6 83.6

Own Production - 0.4 0.6

Food aid - 9.4 0.9

Food security phase AFLC- Critical AFLC Critical AFLC/HE Critical

Overall Situation Analysis Serious Very Critical Critical

1 UNICEF Child Health Days Report June 2009 2 Small cluster survey (30x10) anthropometric results analyzed using the CDC probability calculator

FSNAU Technical Series Report No VI. 25 45 Issued September 11, 2009 4.9 URBAN NUTRITION ANALYSIS

In June-July 2009, a rapid urban nutrition assessment was conducted in 24 Somali urban centers consisting of Mid Upper Arm Circumference (MUAC) of children aged 6-59 months, household dietary diversity in the preceding 24 hrs to the study, and coping strategies undertaken at the time (July 2008) compared to June 2008.

A total of 8117 children from 841 households were assessed with varied findings, these findings however are not representative therefore should be interpreted with caution, they are merely to highlight vulnerability. The urban centers indicating highest proportion of acutely malnourished children (with MUAC <12.5cm or oedema) comprised of Merka, Afgoye and Qoryoley in the Shabelle regions, Baidoa in Bay region, Burao in Togdheer region and Buale in Middle Juba. In Shabelle and Juba, this was mainly attributed to high disease incidences (acute watery diarrhea and acute respiratory tract infections) while in Erigavo, poor food access was the key driving factor. Worrisome proportions of households reportedly consuming a poorly diversified diet (<4 food groups) were reported in Erigavo (37.5%), Dinsor (32.5%), Luuq (30%) and Bardera (30%). While purchase is the main means by which urban livelihoods access food and is reflected likewise in the assessed centers (Table 21), the situation in Qoryoley highlights food aid as the main source (55%).

The change in proportion of households reportedly employing either of the following coping strategies: Skipping entire days without a meal OR restricting consumption by adults in order for small children to eat, OR borrowing food or relying on help from friends or relative (considered in this analysis as very worrying) in June 2008 and June 2009 were analyzed. Improvements are observed in Juba and Gedo regions, where the proportions have decreased from 95-100% to 19-46% and 40% to 15-20% in June 2008 and June 2009 respectively. In Juba, this is associated with improved food access following

urban analysis positive Gu’09 rains with resultant favorable livestock conditions, and good harvests in the riverine

and agropastoral areas. In other areas, findings A market day in Hargeisa, June 2009 indicate varied situations (Table xx for summary of the findings).

An integrated analysis of the findings based on the Nutrition Situation Framework (Feb’08 Draft) indicates a concerning nutrition situation ranging from Serious to Very Critical, similar to the adjacent rural livelihoods across all regions. The high disease incidence in Juba and Shabelle, unfortunately have negated the gains made through improved access to food, leading to overall Very Critical and Critical situations respectively in these areas.

FSNAU Technical Series Report No VI. 25 46 Issued September 11, 2009 Table 21: Summary of Key Findings, Rapid Urban Nutrition Assessments, June - July 2009

Coping Strategies: Proportion of households either Proportion of 1. Skipping entire days households Overall Nutri- Proportion without a meal, OR reportedly tion Situa- of chil- 2. restricting consumption Urban consuming Main source of tion in urban Gedo No. Assessed dren with by adults in order for Center < 4 food food center MUAC<12.5 small children to eat, OR groups in cm 3. borrowing food or relying preceding on help from friends or 24 hours relatives June 2009 June 2008 Luuq 337 children, 15.7% Gedo 30% Purchase (100%) 40% 15% Very Critical 40 households 210 children Bardera 14.1% 30% Purchase (50%) 40% 20% Very Critical 20 households 210 children Juba Jilib 11.5% 4.8% Own prod(66.7%) 95.2% 19.9% Critical 20 households 210 children 100% Doble 13.8% 0% Purchase (100%) 57.1% Critical 20 households 220 children Own prodn Jamame 17.8% 0% 95.5% 40.9% Very Critical 20 households (59.1%) 220 children Buale 19.1% 0% Own prod (70%) 100% 45.9% Very Critical 20 households 220 children Bay Dinsor 16.2% 32.5% Purchase (87.5%) 63.5% 95% Very Critical 20 households Qansad- 220 children 16 17.5% Purchase (87.5%) 50% 85%

Very Critical urban analysis here 20 households 440 children Baidoa 22.5 6.3% Purchase (97.5%) 98.8% 91.3% Very Critical 40 households 220 children Purchase Bakool Elberde 23.6% 16.7% 100% 94.5% Very Critical 20 households (63.9%) 220 children Huddur 5% 37.5% Purchase (97.5%) 80% 91.3% Serious 20 households Sha- 220 children Jowhar 8.2% 0% Purchase (55%) 53% 23% Serious belle 20 households 220 children Purchase (80%) Afgoye 23.6% 2.5% 78% 100% Very Critical 20 households Food Aid 12.5%) 220 children Food aid (55% Qoryoley 22.3% 17.5% 100% 100% Very Critical 20 households Own prod 7.5% 330 children Purchase Merka 30.9% 3% 100% 100% Very Critical 60 households (63.3%) 1980 children Purchase Benadir Mogadishu 17.1% 0.7% 65% 56% Very Critical 281 household (82.2%) 220 children N. East Galcayo 1.8% 0% Purchase (94.1%) 91.2% 80% Critical 20 households 220 children Garowe 14.5% 0% Purchase (100%) 70% 62.5% Critical 20 households 220 children N. West Burao 19.5% 0% Purchase (75%) 42.5% 70% Very Critical 20 households 440 children Hargeisa 13.4% 1.3% Purchase (97.5%) 33% 48.8% Critical 40 households 220 children Purchase Togwajale 15.0% 5.0% 42.5% 85% Very Critical 20 households (92.5%) 220 children Purchase Erigavo 13.6% 37.5% 82.5% 82.5% Critical 20 households (62.5%) 220 children Boroma 9.0% 2.5% Purchase (95%) 55% 62.5% Critical 20 households 220 children Purchase Lasanod 10.0% 5.0% 72.5% 93.5% Critical 20 households (82.5%)

FSNAU Technical Series Report No VI. 25 47 Issued September 11, 2009 Table 22: Summary of Nutrition Assessments (April - July 2009) GAM based on SAM based on GAM based Date of WHO 2006 SAM based on CMR/ U5MR / Affected Region/ WHO 2006 <-3 Z on NCHS <-2 Nutrition <-2 Z scores or NCHS <-3 Z scores/ 10,000/ 10,000/ Livelihood Participating Agencies Sample Size scores/ Z scores or Survey oedema Oedema (%) day day Oedema (%) oedema (%) (%) Northwest & Northeast

Regions 13.3 2.5 13.5 1.4 0.46 0.82 1. Guban/West Golis June ’09 772 (10.4-16.9) (1.5-3.9) (11.2-16.1) (0.8-2.6) (0.27-0.79) (0.34-1.99) 17.9 3.3 19.1 2.0 0.35 1.06 2.East Golis June ’09 603 (14.4-22.0) (1.9-5.8) (15.6-23.1) (1.2-3.2) (0.10-1.18) (0.36-3.08) FSNAU , UNICEF, MOHL. 15.0 3.3 14.8 1.5 0.23 0.82 3.Gebi/Karkar SRCS, June ’09 674 SDRA.AID ORGANIZATION (11.4-19.5) (1.9-5.7) (11.0-19.8) (0.7-3.2) (0.10-0.56) (0.28-2.39) 4.Hargeisa IDP(Small Sample 10-15 1-2 10-15 1-2 April.’09 300 N/A N/A cluster survey) (Pr=0.96) (Pr=0.77) (Pr=0.96) (Pr=0.77) 5.Burao IDP 20.5 April.’09 431 4.9 18.8 3.0 0.29 0.55 (Exhaustive survey) 6. Berbera IDP April 2009 520 18.3 3.3 17.9 1.7 0.58 0.99 (Exhaustive survey) 7. Qardho IDP 0.21 July.’09 478 20.1 5.2 18.4 2.7 0.27 ( Exhaustive survey) 21.4 4.8 20.7 1.8 0.39 0.90 8. Bossaso IDPs July.’09 924 (18.8-24.1) (3.0-6.5) (17.9-23.6) (0.8-2.8) (0.23-0.65) (0.07-1.70) >16.4 9. Bossasso Urban (Small 15.2 >2.6 >1.0 FSNAU, UNICEF, MOH.SRCS July.’09 199 (Pr=0.90) N/A N/A sample cluster survey) SDRA, AID, (Pr=0.90) (Pr=0.90) (Pr=0.93)

10. Garowe IDPs (Exhaustive July.’09 460 24.5 6.5 23.5 1.7 0.52 1.33 survey) 11. Galkayo IDP July.’09 3114 20.0 4.6 17.8 2.1 0.58 0.40 (Exhaustive survey)

Central Regions 18.0 5.5 16.9 3.7 0.71 0.92 12. Hawd Pastoral May’09 751 (13.8-23.1) (3.7-7.9) (12.5-21.4) (2.0-5.5) (0.40-1.25) (0.48-1.77) 17.3 2.6 15.6 1.7 0.55 1.36 13. Addun Pastoral May’09 831 FSNAU, UNICEF, SRCS MOH (13.8-21.5) (1.6-4.4) (11.7-19.6) (0.5-2.9) (0.31-0.98) (0.67-2.78) 14.9 3.3 14.7 2.2 0.20 0.28 14.Cowpea belt May’09 693 (12.4-18.7) (2.6-5.4) (11.3-20.6) (0.1-6.7) (0.08-0.48) (0.07-1.16)

15. Coastal Deeh (Small sample >12.6 >2.0 >6.6 >0.01 May.’09 202 N/A N/A cluster survey) (Pr=0.90) (Pr=0.91) (Pr=0.90) (Pr=0.91)

18.3 4.9 18.6 2.5 0.66 1.30 16. Mudug May.’09 749 FSNAU UNICEF, SRCS (15.4-21.6) (3.7-6.6) (15.3-21.8) (1.1-3.9) (0.23-1.88) (0.74-2.27) MOH,WFP 14.3 3.3 13.3 2.2 0.39 0.54 17. Galgadud May.’09 916 (10.3-19.3) (1.9-5.3) (9.2-17.5) (0.8-3.5) (0.19-0.79) (0.13-0.93)

Hiran Regions 18. Hiran Pastoral (small sample ≥15 4.5 ≥15 2.5 April’ 09 198 N/A N/A cluster survey) (Pr=0.95) (1.5-7.6) (Pr=0.98) (0.4-4.7) FSNAU, UNICEF, SRCS, 25.5 8.2 24.5 3.7 0.64 1.41 19. Hiran Agro-pastoral April ‘09 518 IMC.SCUK. CONCERN (19.7-31.2) (5.6-10.6) (18.3-30.8) (1.4-5.9) (0.45-0.90) (0.76-2.61) 16.9 4.6 15.9 2.0 0.36 1.61 20. Hiran Riverine WORLWIDE April’09 540 (11.5-22.2) (2.7-6.5) (11.3-20.6) (0.7-3.3) (0.14-0.95) (0.58-4.45) 21.2 6.2 21.0 2.9 0.64 0.97 21. Beletweyne April’09 680 (16.3-26.0) (3.7-8.7) (16.1-25.9) (1.4-4.5) (0.40-1.93) (0.48-1.93) Shabelle Regions assessments time table 19.6 8.2 20.0 3.5 1.02 2.43 22. Shabelle Agro-pastoral May’09 536 (14.6-29.9) (5.7-11.6) (15.1-25.4) (2.4-4.7) (0.71-1.46) (1.48-3.98) FSNAU, UNICEF, COSV, 10.3 2.0 10.3 N/A 23. Shabelle Riverine May’09 203 1.0 N/A MERCY USA, IINTERSOS, (5.4-15.3) (0.1-3.9) (5.8-14.9) SRCS, ZAMZAM, MUSLIM 11.7 3.5 9.2 1.5 0.50 1.00 24. Shabelle IDP (Merka/Afgoye) AID May’09 597 (8.8-14.7) (2.0-5.1) (6.2-12.2) (0.4-2.6) (0.28-0.88) (0.46-2.19) 0.48 16.5 5.1 16.0 2.7 1.09 25. Adale District May.’09 667 (0.30-0.78) (13.5-20.0) (3.5-7.4) (12.7-19.3) (1.2-4.2) (0.57-2.05)

Gedo Region 22.6 5.4 23.0 2.7 0.77 1.34 26. Gedo Pastoral July’09 754 (18.3-27.5) (3.9-7.5) (18.6-28.1) (1.8-3.9) (0.45-1.30) (0.68-2.64) 22.9 5.6 FSNAU GHC, SRCS, WFP 23.4 2.7 0.81 2.90 27. Gedo Riverine July ’09 676 18.7-27.7 (3.9-8.1) AFRICA MUSLIM (19.0-28.4) (1.6-4.5) (0.44-1.51) (1.67-5.00) AID,HIRDA,NCA,COSV 3.82 19.9 4.4 19.3 2.0 1.17 (2.20-6.58) 28.. Gedo Agro-pastoral July ’09 753 (17.3-22.8) (2.9-6.6) (16.5-22.3) (1.2-3.3) (0.75-1.81)

Juba Region 12.5 3.6 11.3 2.8 1.19 2.62 29. Juba Riverine July’09 676 FSNAU , UNICEF AFREC, (10.1-15.4) (2.2-5.9) (8.7-14.6) (1.6-4.8) (0.87-1.63) (1.71-4.00) WVI, MERCY USA, SRCS, 21.7 7.4 19.9 3.2 0.17 0.37 30. Juba Agro-pastoral MERCY USA,SAF, EIRG,APD, July’09 753 (19.0-24.7) (4.8-11.2) (17.3-22.8) (2.2-4.7) (0.06-0.48) (0.08-1.59) JUBA FOUNDATION, WRRS, JCC, MVDO, PCDDO, ICDA, 20.6 6.8 20.2 2.2 0.80 2.19 31. Juba Pastoral July’09 754 AMA-UK (16.1-26.1) (4.2-10.8) (15.5-25.8) (0.9-5.0) (0.45-1.43) (0.99-4.81)

Bay & Bakool Regions

23.9 5.2 22.7 3.4 0.68 1.18 32. Bay Agro-pastoral June’ 09 882 (19.2-29.4) (3.9-6.9) (18.7-27.3) (2.1-5.4) (0.48-0.96) (0.62-2.16) FSNAU,UNICEF, WFP,SRCS, GREENHOPE, 14.9 3.4 14.6 2.3 0.53 0.98 33.Bakool Agro-pastoral June’ 09 617 DEGARES, (12.1-18.3) (2.1-5.4) (11.7-18.1) (1.4-3.6) (0.34-0.82) (0.40-2.37) GAREDO 25.1 1.2 25.2 1.3 0.61 0.77 34.Bakool Pastoral June’09 686 18.6-32.8) (0.5-2.6) (19.0-32.7) (0.6-2.9) (0.37-0.99) (0.31-1.93)

FSNAU Technical Series Report No VI. 25 48 Issued September 11, 2009 5. Guidance for use of the Plausibility checks

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 shoud lie between 0.8 and 1.2 Z score. SD increases as the proportion of erroneous results in the data set increases.

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

Kurtosis of WHZ: This demonstrates the relative peakedeness or flatness compared to a normal distribution. The normal distribution has zero kurtosis and surveys should lie between +1 and -1. Posotive 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 plausibility checks 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.

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 younger age (6-29) children are more likely to be 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 ratio 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 like between 0.8 and 1.2.

Table 18 provides a summary of findings on plausibility checks for nutrition assessments conducted in the Gu ’09

FSNAU Technical Series Report No VI. 25 49 Issued September 11, 2009 Table 23: Plausibility Checks

Missing/Flag Overall sex Overall age Dig Preference Dig Preference Skewness Kurtosis Poisson Location Criteria SD WHZ ged data ratio distribution score-weight score-Height WHZ WHZ Distribution

Missing/Flag Overall sex Overall age Dig Preference Dig Preference Skewness Kurtosis Bay Bakool Regions Date Criteria SD WHZ ged data ratio distribution score-weight score-Height WHZ WHZ Jun-09 Category Good Good Poor Good Poor Good Good Good Good Bay Agropastoral Score 0 0 4 0 4 0 0 0 0 Jun-09 Category Good Poor Poor Acceptable Unacceptable Good Good Good Good Bakool Pastoral Score 0 4 4 2 10 0 0 0 0 Jun-09 Category Good Good Acceptable Good Poor Good Good Good Good Bakool Agropastoral Score 0 0 2 0 4 0 0 0 0 Shabelle Region Category Acceptable Good Poor Good Good Unacceptable Good Good Good Adale May-09 Score 5 0 4 0 0 20 (SD:1.25) 0 0 0 Category Good Good Good Good Acceptable Acceptable Good Good Good Shabelle IDP May-09 Score 0 0 0 0 2 2 0 0 0 Category Good Good Acceptable Acceptable Acceptable Unacceptable Good Good Good Shabelle Agropastoral May-09 Score 0 0 2 2 2 20 (SD1.22) 0 0 0 Category Good Good Poor Poor Acceptable Acceptable Good Good Good Shabelle Riverine May-09 Score 0 0 4 4 2 2 0 0 0 Central and parts of Northeast regions Category Acceptable Good Good Good Acceptable Good Good Good Good Galgadud Region May-09 Score 5 0 0 0 2 0 0 0 0 May-09 Category Acceptable Good Poor Good Acceptable Acceptable Good Good Good Mudug Region Score 5 0 4 0 2 2 0 0 0 Category Good Good Poor Good Acceptable Good Good Good Good Addun LZ May-09 Score 0 0 4 0 2 0 0 0 0 Category Good Good Good Acceptable Acceptable Good Good Good Good Cowpeabelt May-09 Score 0 0 0 2 2 0 0 0 0 Category Acceptable Good Good Good Good Acceptable Good Good Good Hawd LZ May-09 Score 5 0 0 0 0 2 0 0 0 Category Good Good Poor Acceptable Acceptable Poor Good Good Good Coastal deeh May-09 Score 0 0 4 2 2 6 0 0 0 Category Good Good Poor Good Poor Good Good Good Poor Hiran Agropastoral Apr-09 Score 0 0 4 0 4 0 0 0 3 Category Good Good Good Good Acceptable Acceptable Good Good Good Hiran Pastoral Apr-09 Score 0 0 0 0 2 2 0 0 0 Category Good Good Unacceptable Good Acceptable Good Good Good Unacceptable Hiran Riverine Apr-09 Score 0 0 10 0 2 0 0 0 5 Category Good Good Poor Good Acceptable Good Good Good Acceptable Beletweyne district Apr-09 Score 0 0 4 2 2 0 0 0 1 Northwest and Northeast regions Jun-09 Category Good Good Poor Good Acceptable Good Good Good Good West Golis Guban Score 0 0 4 0 2 0 0 0 0 Jun-09 Category Good Poor Poor Good Good Good Good Good Good Gebi/Karkar Score 0 4 4 0 0 0 0 0 0 Category Good Poor Good Good Acceptable Acceptable Good Good Good East Golis Jun-09 Score 0 4 0 0 2 2 0 0 0 Category Good Acceptable Good Good Acceptable Acceptable Good Good Good Burao IDP Apr-09 Score 0 2 0 0 2 2 0 0 0 Category Good Good Good Acceptable Acceptable Acceptable Good Good Good Hargeisa IDP Apr-09 Score 0 0 0 2 2 2 0 0 0 Category Good Poor Poor Acceptable Poor Good Good Good Good Berbera IDP Apr-09 Score 0 4 4 2 4 0 0 0 0 Category Acceptable Good Poor Good Acceptable Good Good Good Good Bossaso IDP Jul-09 Score 5 0 4 0 2 0 0 0 0 Category Acceptable Acceptable Unacceptable Good Acceptable Good Good Good Good Galkayo IDP Jul-09 Score 5 2 10 0 2 0 0 0 0 Category Good Good Good Acceptable Acceptable Poor Good Good Good Garowe IDP Jul-09 plausibility checks Score 0 0 0 2 2 6 0 0 0 Category Good Good Acceptable Good Acceptable Acceptable Good Good Good Qardho IDP Jul-09 Score 0 0 2 0 2 2 0 0 0 Category Good Good Acceptable Good Good Acceptable Good Good Good Bossaso Urban (Small Sample Cluster Survey) Jul-09 Score 0 0 2 0 0 2 0 0 0 Gedo and Juba Regions Category Good Good Unacceptable Acceptable Poor Unacceptable Good Good Good Juba Agro-Pastoral Jul-09 Score 0 0 10 2 4 20 (SD:1.23) 0 0 0 Category Good Good Poor Acceptable Poor Good Good Good Good Juba Riverine Jul-09 Score 0 0 4 0 4 0 0 0 0 Category Good Good Poor Acceptable Poor Acceptable Good Good Good Juba Pastoral Jul-09 Score 0 0 4 2 4 2 0 0 0 Category Good Good Poor Good Acceptable Acceptable Good Good Good Gedo Riverine Jul-09 Score 0 0 4 0 2 2 0 0 0 Category Good Good Unacceptable Good Acceptable Good Good Good Good Gedo-Agro-Pastoral Jul-09 Score 0 0 10 0 2 0 0 0 0 Category Acceptable Good Good Acceptable Acceptable Acceptable Good Good Good Gedo-Pastoral Jul-09 Score 5 0 0 2 2 2 0 0 0

FSNAU Technical Series Report No VI. 25 50 Issued September 11, 2009 Breast Feeding is the Best Feeding Method for Healthy Growth and Development- (World Breastfeeding Week 2009)

The World Breastfeeding Week (WBW) is celebrated annually from 1st to 7th August in more than 120 countries to encourage breastfeeding and improve the health of babies around the world. It commemorates the Innocenti Declaration by the WHO and UNICEF in August 1990 on the need to protect, promote and support breastfeeding.

The WBW 2009 message was “Breastfeeding – a vital emergency response, are you ready?” The theme was based on the rationale that emergencies can happen anywhere in the world, and in such times young children are the most vulnerable, with the possibility of child mortality rising from 2 to 70 times higher than average. Breastfeeding is a life saving intervention in disasters and breast feeding mothers need active support during times of crises. This year’s theme was therefore relevant to the Somalia context, a country which has faced a chronic crisis since the collapse of the central government in 1991, leading to high levels of nutritional vulernability. Nutrition assessments conducted by the FAO-FSNAU and partners in Somalia for the last ten years, including the Knowledge Attitude and Practices (KAP) study conducted in September 2007, indicate very poor infant and child feeding and care practices including delayed initiation of breastfeeding, early introduction of fluids and solid foods before the age of six months and early cessation of special article breastfeeding. These practices are major contributing factors to the high incidences of diseases, especially diarrhea, and acute malnutrition.

Given the public health significance of appropriate infant and young child feeding practices in relation to the nutritional crisis in Somalia, FSNAU, in collaboration with UNICEF, has seized every available opportunity to constantly advocate the importance of appropriate breastfeeding and general care practices and the need to support breastfeeding mothers and their children, socially, environmentally and economically. FSNAU has used the World Breastfeeding Week forum to produce and disseminate flyers and posters with informative key messages aimed at advocating for the protection, promotion and support of breastfeeding. These WBW materials are always translated into Somali language and have been positively received by both partners and mothers and have become an important source of breastfeeding information at MCHs level and mothers often describe them as easy-to-read and understand. The use of verses from the Holy Koran that support breastfeeding, have contributed to their acceptance and adaptation of some of the key messages.

In line with this year’s theme, FSNAU has produced a flyer entitled “Breastfeeding is the Best Method for Infant Feeding for Growth and Development”. The key message emphasized is “Breastfeeding is the best known life saving intervention that offers to the infant and young children the most suitable nourishment and protection from common illnesses at all time.” It underscores the importance of appropriate breastfeeding in times of stability, crisis, illness and recovery.

Other related publications by FSNAU include ‘Breastfeeding for a Health Community’, ‘Breastfeeding for a Healthy Family’, “Somali Knowledge Attitude and Practices towards Childcare and Health Seeking Behaviors, 2007” and ‘Supporting Breastfeeding for a Health Family’ all of which can be downloaded from FSNAU website, www.fsnau.org

FSNAU Technical Series Report No VI. 25 51 Issued September 11, 2009 6. APPENDICES

6.1: Somalia Livelihood Zones SOMALIA: LIVELIHOOD ZONES

Calula

DJIBOUTI Gulf of Aden Qandala

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

Hargeysa Qardho Burco Owdweyne Xudun Caynabo Talex Bandar Beyla TOGDHEER SOOL

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 a Cadaado MUDUG i d Hobyo n Cabudwaaq I

Dhusa Mareeb

GALGADUD Harardheere Ceel Barde Beled Weyne

appendix Ceel Bur BAKOOL Livelihood zones Addun Pastoral: Mixed sheep & goats, camel Rab-Dhuure HIIRAN Xudur Awdal border & coastal towns: Petty trading, fishing, salt mining Ceel Dheere Dolo Central regions Agro-Pastoral: Cowpea, sheep & goats, camel, cattle Bulo Barde Luuq Wajid Tayeglow Coastal Deeh: Sheep Aden Yabal Dawo Pastoral: Shoats, cattle, camel Beled Hawa Jalalaqsi East Golis Pastoral: Frankinncense Garbaharey Baydhaba Cadale Fishing Jowhar M. SHABELLE Gagaab Pastoral: Frankincense Guban Pastoral: Sheep, goats & camel Qansax Dheere Wanle Weyne GEDO BAY Hawd Pastoral: Camel, sheep & goats Hiran Agro-Pastoral Ceel Waq Balcad Bur Hakaba Hiran riverine: Sorghum, maize, cattle & shoats Afgoye Juba pump irrigation: Tobacco, onions, maize Baardheere Dinsor "/ BANADIR MOGADISHU Kakaar-Dharor Pastoral: Sheep, goats, camel

A Qoryoley L. & M. Shabelle Agro-Pastoral Irrigated: Maize/Sorghum & cattle Sakow Y Marka Kurtun Warrey L. & M. Shabelle Agro-Pastoral rain-fed: Maize,cowpeas, sesame & cattle

N M. JUBA Lower Juba Agro-Pastoral: Maize & cattle Sablale

E L. SHABELLE North-West Agro-Pastoral: Sorghum, cattle Bu'aale North-West Valley Agro-Pastoral: Irrigated vegetables, shoats K Hagar Brava Nugal Valley Pastoral: Sheep & camel Potato zone & vegetables Afmadow Jilib Shabelle riverine: Maize, fruits & vegetables Sool-Sanag Plateau Pastoral: Camel, sheep & goats South-East Pastoral: Cattle, sheep & goats Jamaame L. JUBA Southern Agro-Pastoral: Camel, cattle, sorghum Southern Juba riverine: Maize, sesame, fruits & vegetables Kismayo Southern coastal pastoral: Goats, cattle Togdheer Agro-Pastoral: Sheep, goats & vegetables ± Urban Badhadhe 0 20 40 80 120 160 200 West Golis Pastoral: Goats, camel, sheep Bay-Bakool Agro-pastoral Low Potential Kilometers Bakool Agro-pastoral Low Potential Bay Agro-pastoral High Potential Southern Inland Pastoral: Camel, Sheep & Goats Datum: WGS84, Data Source: FSAU, 2009, Admin. layers: UNDP, 1998

Food Security Analysis Unit - Somalia http://www.fsausomali.org P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-3745734 fax:254-20-3740598 FSAU is managed by FAO. 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.

FSNAU Technical Series Report No VI. 25 52 Issued September 11, 2009 6.2 Progression of Estimated Nutrition Situation Deyr ’06/07 - Gu ’09 SOMALIA - ESTIMATEDDeyr NUTRITIO ‘06/07N SITUATION (JANUARY 2007) SOMALIA - ESTIMATEDGu NUTR ‘07ITION SITUATION JULY 2007)

43°0'0"E 46°0'0"E 49°0'0"E 43°0'0"E 46°0'0"E 49°0'0"E N N " " 0 0 ' ' 0 0 ° ° 2 2 12°0'0"N 12°0'0"N

Alula 1 1 DJIBOUTI Gulf of Aden Gulf of Aden Alula DJIBOUTI )" Kandala Zeylac Zeylac Bosaso Kandala Lughaye Lughaye Bosaso Badhan Erigavo Awdal Iskushuban Awdal " Iskushuban Berbera ) Badhan Borama Baki Sanag Berbera Erigavo El Afwein Bari BoramaBaki Sanag Sheikh El Afwein Sheikh Bari Woq. Galbeed Woq. Galbeed Gabiley Hargeisa Gabiley Gardo )" Odweine Bender Beila Hargeisa Odweine Gardo Burco Burco Bender Beila Caynaba Xudun Taleh Caynaba N N

" Xudun "

Togdheer 0 Taleh 0 ' Togdheer '

Sool 0 0

° Sool ° 9°0'0"N 9°0'0"N 9 9

Buhodle Lasanod Garowe Lasanod Buhodle )"Garowe Eyl Nugal Nugal Burtinle Burtinle Eyl

Jariban ETHIOPIA Goldogob ETHIOPIA Jariban Galkayo Go)"ldogob Galkayo )"

Adado Mudug N N Abudwaq " Adado " 0 0

Hobyo ' Mudug ' Abudwaq Hobyo 0 0 ° ° 6°0'0"N 6°0'0"N 6 6

Dusa Mareb Indian Ocean !( Dusa Mareb Indian Ocean Galgadud Belet Weyne Haradhere Galgadud El Barde El Bur Haradhere El Barde Belet Weyne !(El Bur Bakol Rab-Dhuure Bakol Hudur Rab-Dhuure Hiran Hiran El Der H)"udur Dolo Bulo Burti El Der Luuq Wajid Tieglo Dolo Bulo Burti LEGEND Luuq Wajid Tieglo Nutrition Situation Aden Yabal Belet Hawa Jalalaqsi LEGEND Aden Yabal Belet Hawa Jalalaqsi Insufficient Data Garbahare Baidoa Adale Garbahare Baidoa Nutrition Situation N Insufficient Data but likely N " !( M. Shabelle " 0 0

Gedo M. Shabelle ' ' Qansah Dere Jowhar to be critical Jowhar 0 Gedo 0

3°0'0"N Wanle Weyne 3°0'0"N El Waq No Data ° Qansah Dere °

3 Wanle Weyne Adale 3 Bay El Waq Alert Bur Hakaba Balad Bay Alert Bur Hakaba Balad Serious Afgoye Bardera Dinsor Qoryoley Banadir Afgoye A !( Mogadishu Bardera Dinsor Qoryoley Ba!(nadir Critical Serious Y Mogadishu Sakow L. Shabelle Kurtun Warrey Marka N Sakow L. Shabelle Very Critical M!(arka E !( Kurtun Warrey

KENYA Critical M. Juba Sablale K IDP Concentration areas M. Juba Sablale Buale prior to January 2007 Brava Projected Trend (Jan-Jun '07) Very Critical Buale Brava Projected Trend (July-Dec '07) IDP Concentration areas Potential to Improve IDP Concentration Areas after January 2007 Afmadow Jilib Potential to Improve Uncertain Afmadow Jilib The nutrition situation is analysed using a range of Uncertain /" !( nutrition indicators from direct and indirect sources Potential to Deteriorate National Capital Jamame from January to July, nutrition surveys, sentinel sites, " Potential to Deteriorate "

L. Juba 0 Jamame 0 Coastline ' health facility data, rapid MUAC assesments, ' 0 0

0°0'0" 0°0'0" L. Juba

° selective feeding centre data, health reports and oth° ers Kismayo International Boundary 0 0 Coastline ± Regional Boundary Kismayo International Boundary Badhadhe 4020 0 40 80 120 160 District Boundary Badhadhe Regional Boundary Kilometers ±

River 40 20 0 40 80 120 160 District Boundary Datum: WGS84 Data Source: FSAU, 2006 Kilometers River 43°0'0"E 46°0'0"E Admin. layers: UNDP,49°0'0"E 1998 Datum: WGS84 43°0'0"E 46°0'0"E 4D9a°t0a' 0So"Eurce: FSAU, 2006 SOMALIA - ESTIMATED NUTRITION SITUAUpdated:TIO MarchN J, 2007ANUARY 2008 Admin. layers: UNDP, 1998

Food Security Analysis Unit - Somalia http://www.fsausomali.org P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-3745734 fax:254-20-3740598 SOMALIA - EFSoodT SeIcMurityA AnaTlysEis UDnit - SNomUaliaT htRtp://IwTwwI.fOsausNoma lSi.orgITUATION AUGUST 2008 FSAU is managed by FAO, funded by EC, the Government of Norway and USAID. FSAU Partners are FEWS NET, WFP, FAO, UNOCHA, SCF-UK, UNICEF, CARE, UNDP P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-3745734 fax:254-20-3740598 43°0'0"E The boundaries and names on these maps do not imply46° official0'0" endorsementE or acceptance by the United Nations. 49°0'0"E FSAU is managed by FAO, funded by EC, the Government of Norway and USAID. FSAU Partners are FEWS NET, WFP, FAO, UNOCHA, The regional & District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986. SCF-UK, UNICEF, CARE, UNDP N N N N Deyr ‘07/08 " The boundaries and names on these maps do not Guimply official endor sem‘08ent or acceptance by the United Nations. " " "

0 The regional & District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986. 0 ' '

0 0 CALUULA ' ' " 0 43°0'0"E 46°0'0"E 49°0'0"E 0 ° ° 0 0 ° ° 2 2 2 2 1 1 1 Alula 1 Alula QA NDALA " ZEY LAC Gulf of Aden " !( LAASQORAY DJIBOUTI " Kandala Kandala Gulf of Aden Zeylac Bosaso Zeylac Bosaso DJIBOUTI LUGHAYE " Lughaye Lughaye Badhan Awdal BERBE RA Erigavo Badhan Awdal " Iskushuban !( Berbera BAKI Baki ISK USHUBA N Berbera " " Borama Baki Sanag Borama Bari El Afwein Sanag El Afwein Erigavo Bari Iskushuban SHEIKH CEEL AFWE YN Sheikh Woq. Galbeed " Sheikh " GE BILEY Woq. Galbeed "Gabiley Bender Beila Gabiley Harge!(isa QA RDHO BANDARB EYLA " " Hargeisa OWDWEYNE !( Odweine Gardo " Gardo Bender Beila Odweine Burco Taleh XUDUN TALEEX Caynaba N Caynaba " " N N N " "

" Taleh " Togdheer Xudun 0 CAYNABO Xudun 0 ' Togdheer '

0 0 " ' ' Sool 0 0

0 Burco 0 ° ° ° °

9 Sool 9 9 9

Buhodle Garowe Buhodle Lasanod Garowe !( BUUHOODLE Lasanod "

Nugal EYL appendix Nugal " Eyl Eyl Burtinle BURTINLE Burtinle "

JARIIBAN "

GA LDOGOB Jariban Jariban " ETHIOPIA Goldogob Goldogob Galkayo Galkayo ETHIOPIA !(

CABUDWAA Q "

N CADAADO N " " " N N Adado " " Adado 0 0

' Mudug '

0 0 Abudwaq ' Mudug ' Hobyo Abudwaq Hobyo 0 0 ° ° 0 0 ° ° 6 6 6 6

Dusa Mareb HOBYO Dusa Mareb Indian Ocean " Indian Ocean Galgadud Galgadud CEEL BARDE Haradhere " El Bur Haradhere CEEL BUUR El Barde Belet Weyne " XARARDHEERE El Barde Belet Weyne El Bur "

Rab Dhuure Bakol Bakol " LEGEND DOOLOW Rab-Dhuure Hiran Rab-Dhuure Hiran " Hudur Hudur TAY EEGLOW " Nutrition Situation El Der El Der Dolo BULO BURTO CEEL DHEER Dolo WA AJID " " BELET XAAWO LUUQ " ADAN YABAAL Bulo Burti " " Tieglo " Luuq Wajid Tieglo Luuq Wajid Bulo Burti No data Aden Yabal Aden Yabal JALALAQSI Belet Hawa " Insufficient data but likely Belet Hawa Jalalaqsi Jalalaqsi LEGEND Garbahare Baidoa Adale Garbahare Baidoa Adale N to be critical N N N " !( " " " 0 0 ' '

0 Nutrition Situation 0

' ' QA NSAX DHEE RE 0 Gedo M. Shabelle Alert 0 " BUUR HA KABA ° ° 0 Gedo M. Shabelle 0 CEEL WA Q " " CADALE

° ° Qansah Dere Jowhar " Qansah Dere Jowhar No data 3 Wanle Weyne 3 3 Wanle Weyne 3 El Waq WA NLA WEY N El Waq " Serious Bay Balad Bay DIINSOOR " BALCAD BAARDHE ERE Bur Hakaba " Bur Hakaba Balad Alert " Afgoye Critical AFGOOYE Afgoye Bardera !("

A Dinsor !( Bardera Dinsor Qoryoley Banadir Serious Banadir

Y L. Shabelle Very Critical Mogadishu QORYOOLEY Kurtun Warrey "Qoryoley N L. Shabelle Sakow SAAKOW Critical " KURTUNWA AREY !( Sakow " Marka Kurtun Warrey Marka IDP Phase E M. Juba K SABLA ALE Serious M. Juba Sablale " Sablale IDP Phase Buale BARAA WE Buale " Brava Serious Brava Critical Very Critical Critical Jilib Afmadow AFM ADOW Jilib " JILIB The Nutrition Situation is analysed using a range of Afmadow Projected Trend (January - July '08) " Projected Trend (July - December '08) Very Critical nutrition indicators from direct and indirect sources Potential to Improve Potential to Improve from July to Dec '08: nutritional surveys, sentinel sites, " "

" " JAMAAME 0 "Jamame 0 ' health facility data, rapid MUAC assesments, select' ive 0 Jamame The nutrition situation is analysed using a range of 0 ' ' Uncertain 0 L. Juba Uncertain 0 ° ° 0 L. Juba nutrition indicators from direct and indirect sources 0 feeding centre data, health reports and others ° ° 0 0 0 0 Potential to Deteriorate from July to December, nutrition surveys, sentinel sites, Potential to Deteriorate " Kismayo !( District Capital Kismayo health facility data, rapid MUAC assesments, selective feeding centre data, health reports and others Coastline

Coastline Badhadhe International Boundary Badhadhe BADHAADHE " ± International Boundary ± Regional Boundary Regional Boundary District Boundary

40 20 0 40 80 120 160 District Boundary 40 20 0 40 80 120 160 River 43°0'0"E 46°0'0"E 49°0'0"E 43°0'0"E 46°0'0"E 49°0'0"E Kilometers River Kilometers Datum: WGS84, Data Source: FSAU, 2006 Datum: WGS84, Data Source: FSAU, 2006, Admin. layers: UNDP, 1998 Admin. layers: UNDP, 1998 SOMALIA - ESTIMATED NUTRITION SITUATION JANUARY 2009 Food Security Analysis Unit - Somalia http://www.fsausomali.org Food Security Analysis Unit - Somalia http://www.fsausomali.org P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-3745734 fax:254-20-3740598 SOMALIA - ESTIMATtel:E 254-D20-37 45N734 fUax:254T-20-R37405I98TION SITUATION JULY 2009 FSAU is managed by FAO, funded by EC, the Government of Norway and USAID. FSAU Partners are FEWS NET, WFP, FAO, UNOCHA, FSAU is managed by FAO. N SCF-UK, UNICEF, CARE, UNDP N The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. " " 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. 0 0 ' CALUULA ' The regional & District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986. " 0 43°0'0"E 46°0'0"E 49°0'0"E 0 ° Deyr ‘08/09 ° Gu ‘09 CALUULA 2 2 " 1 Alula 1 QA NDALA " ZEY LAC Alula " QANDALA !( " LAASQORAY ZEYLAC " " (! LAASQORAY Kandala Gulf of Aden " Gulf of Aden Bosaso Zeylac Kandala DJIBOUTI LUGHAYE " Zeylac Bosaso Lughaye DJIBOUTI LUGHAYE BERB ERA Erigavo Badhan " Awdal " Iskushuban !( Berbera Lughaye BAKI Baki ISK USHUBA N BERBERA Badhan Borama " " Awdal " Sanag (! Berbera BAKI Baki ISKUSHUBAN El Afwein Bari " " Borama Sanag Iskushuban SHEIKH CEEL AFWE YN " Sheikh " El Afwein Bari Erigavo Woq. Galbeed SHEIKH CEEL AFWEYN GE BILEY " Sheikh " "Gabiley Bender Beila Woq. Galbeed GEBILEY Harge!isa QA RDHO BANDARBEYLA " ! " " Gabiley OWDWEYNE !( ! " ( QARDHO BANDARBEYLA Gardo Hargeisa " " Odweine OWDWEYNE (! Gardo Burco Taleh " XUDUN TALEEX Bender Beila N Caynaba " " N Odweine " " Burco Caynaba 0 CAYNABO Xudun 0 XUDUN TALEEX ' Togdheer ' " " "

0 0 Xudun Taleh ° ° Togdheer CAYNABO "

9 Sool 9 Sool Buhodle !(Garowe ^ BUUHOODLE Lasanod " Buhodle Lasanod (!Garowe BUUHOODLE " EYL Nugal " Eyl EYL Burtinle Nugal " BURTINLE " Eyl " District Capital " District Capital Burtinle BURTINLE " Coastline Major Road JARIIBAN International Boundary " Coastline GA LDOGOB Jariban JARIIBAN " International Boundary " Regional Boundary ETHIOPIA Goldogob GALDOGOB Jariban Galkayo " ETHIOPIA Goldogob District Boundary !( Regional Boundary Galkayo River District Boundary (! River CABUDWAA Q "

N CADAADO N "

" " CABUDWAAQ Adado " CADAADO 0 0 " ' Mudug ' Abudwaq Hobyo Adado 0 0 Mudug ° ° Abudwaq Hobyo 6 6

Dusa Mareb HOBYO " Dusa Mareb HOBYO Indian Ocean " Galgadud Indian Ocean CEEL BARDE " El Bur Haradhere Galgadud CEEL BUUR CEEL BARDE El Barde " XARA RDHEERE " Belet Weyne " El Bur Haradhere El Barde CEEL BUUR XARARDHEERE Belet Weyne " "

Rab Dhuure Bakol " Rab Dhuure Bakol DOOLOW Rab-Dhuure Hiran " " Hudur DOOLOW Rab-Dhuure Hiran TAY EEGLOW " " Hudur El Der TAYEEGLOW Dolo BULO BURTO CEEL DHEER LEGEND " El Der LUUQ WA AJID " " BELET XAA WO " " ADAN YABAAL Dolo " Tieglo " BULO BURTO CEEL DHEER WAAJID " " Luuq Bulo Burti BELET XAAWO LUUQ " ADAN YABAAL Wajid Nutrition Situation " " Tieglo Bulo Burti " Luuq Wajid Aden Yabal JALALAQSI Belet Hawa " Aden Yabal Acceptable JALALAQSI Jalalaqsi Belet Hawa " Garbahare Baidoa Adale N N Jalalaqsi " !( " Garbahare Baidoa Adale 0 0 ' Alert ' (! QA NSAX DHEE RE 0 Gedo M. Shabelle 0 " BUUR HA KABA CEEL WA Q ° ° " " Jowhar CADALE Gedo QANSAX DHEERE M. Shabelle Qansah Dere " " 3 Wanle Weyne 3 BUUR HAKABA CEEL WAQ " CADALE WA NLA WEY N " Qansah Dere Jowhar " El Waq " Insufficient data but likely Wanle Weyne LEGEND WANLA WEYN Bay Balad El Waq " DIINSOOR " Bay BALCAD BAARDHEERE Bur Hakaba to be Alert Balad " " DIINSOOR " BAARDHEERE Bur Hakaba BALCAD Afgoye " " Nutrition Situation AFGOOYE " Serious Afgoye Bardera Dinsor ! !( AFGOOYE Banadir " L. Shabelle Insufficient data but likely Bardera Dinsor Ba(!nadir Acceptable QORYOOLEY "Qoryoley L. Shabelle Kurtun Warrey QORYOOLEY Sakow SAAKOW " " KURTUNWA AREY ! to be Serious Qoryoley " Marka Sakow Kurtun Warrey SAAKOW KURTUNWAAREY " " Marka Alert M. Juba Critical Sablale SABLA ALE " M. Juba SABLAALE Sablale " BARA AWE Insufficient data but likely Buale " Serious Buale BARAAWE Brava to be Critical " Brava Critical Jilib Very Critical Afmadow AFM ADOW JILIB Jilib " " Afmadow AFMADOW Projected Trend (January - July '09) " JILIB Very Critical Insufficient data but likely " Projected Trend (July - December'09) to be Very Critical " Potential to Improve " JAMAAM E 0 "Jamame 0 Potential to Improve ' ' JAMAAME J" amame 0 L. Juba Uncertain IDP Phase 0 ° ° L. Juba Uncertain Hot Spot for Very Critical

0 0 ^ Potential to Deteriorate Serious Kismayo !( (! Potential to Deteriorate IDP Phase Critical Kismayo Serious Badhadhe Very Critical Critical BADHAADHE Badhadhe " BADHAADHE The Nutrition Situation is analysed using a range of nutrition " ± indicators from direct and indirect sources from July to Dec '08: Very Critical nutritional surveys (Oct-Dec '08), health facility data, rapid The Nutrition Situation is analysed using a range of nutrition MUAC assesments, selective feeding centre data, health reports 40 20 0 40 80 120 160 ± indicators from direct and indirect sources from Jan to July '09: and others 43°0'0"E 46°0'0"E 49°0'0"E nutritional surveys (Apr-July'09), health facility data, rapid Kilometers Datum: WGS84, Data Source: FSAU, 2006 40 20 0 40 80 120 160 MUAC assesments, selective feeding centre data, health reports Admin. layers: UNDP, 1998 Kilometers and others

Food Security Analysis Unit - Somalia http://www.fsausomali.org Food Security and Nutrition Analysis Unit - Somalia http://www.fsnau.org P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] tel: 254-20-3745734 fax:254-20-3740598 P.O. Box 1230 Village Market, Nairobi, Kenya Email: [email protected] FSAU is managed by FAO. tel: 254-20-4000000 fax:254-20-5000555 The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. FSNAU is managed by FAO. The regional & District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986. 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. FSNAU Technical Series Report No VI. 25 53 Issued September 11, 2009 6.3 Nutrition Assessment Tools Post Gu ‘09

FSAU POST GU ASSESSMENT 2009 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 conflict and natural disaster (drought, flooding, 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 floods, drought, or where there is insufficient 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 Gu Assessment all Nutrition Field Analysts will the 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 sufficient time and staff and

appendix 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 significant way. However the following steps have been identified 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. • 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 floods

FSNAU Technical Series Report No VI. 25 54 Issued September 11, 2009 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 confirmed 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 measurers - 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 classification can only be reserved for a statistically significant nutrition surveys otherwise the figures 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 significant 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

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 appendix 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

Annex 1 - Tally Sheet for MUAC Screening Children 6 – 59 months. – Please just use one sheet per

FSNAU Technical Series Report No VI. 25 55 Issued September 11, 2009 village and one tick per child. For ease of completion please group the children into ten so the first ten measured the results should be in the first 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 Screen- er:______

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 <11.5cm 11.5- 12.5- >/=13.5 Oedema Clinical signs 12.4cm 13.4cm (65-110) of malnutrition <65cm (oedema or marasmus Child 1 - 10

Child 11 – 20

Child 21 – 30

Child 31 – 40

Child 41 – 50

appendix Child 51 – 60

Child 61 – 70

Child 71 – 80

Child 81 – 90

Child 91 – 100

Child 100-110

TOTAL

FSNAU Technical Series Report No VI. 25 56 Issued September 11, 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 appendix

Any recent incidence of Acute Watery Diarrhoea in Y / N this location?

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

Are the Health services Can communities Top 3 illnesses for Recent Outbreaks? Are there any Health functioning (do they have access the health <5yrs Services Available staff drugs etc) services 1) Y / N Y / N Y / N 2) If N how close is near- Y / N If Y what? est (km) If N why not? 3) WATER Describe the quality of this L i s t t h e m a i n Do families have sufficient What water storage containers water (pls ask to see the water sources of quantities for drinking during are being used by the majority then circle then option most drinking water the day? (circle) please list appropriate) 1) Reasonable 2) Y / N Unclean If N why not? Not sure 3)

SANITATION List the main sanitation facilities used now by the List any concerns the community may have about the sanitation, such community as the impact of the recent floods

FSNAU Technical Series Report No VI. 25 57 Issued September 11, 2009 Nutrition Programmes SFC (Location, Agency, Nos of admis- TFC / CTC (Location, Agency, List the closest nutrition pro- sions) Nos of admissions) grammes available for referral if malnourished cases are identified and the agency that operates 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 6 months to 5years MUAC (cm) Nutritional status N= ( % ) >13.4cm 12.5cm to 13.4cm At risk of Malnutrition 11.5cm to 12.4cm Moderate Malnutrition < 11.5 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 Identified: (summarise the key findings)

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.

Sample - Screening Data / Rapid Assessment Tool - Children 6 months to 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 6 months and above or 65-110cm standing) appendix Clinical signs of Child Group <11.5cm 11.5-12.4cm 12.5-13.4cm >/=13.5 Oedema malnutrition <1yr Child 1 - 10 1 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 100-110 11 11 11 11 11 TOTAL 5 10 18 72 5 0

Summary of Nutrition Status: - Children 6-59 months MUAC (cm) Nutritional status N= 110 (100 % ) >13.5cm 72 (65.5%) 12.5cm to 13.4cm At risk of Malnutrition 18 (16.4%) 11.5cm to 12.4cm Moderate Malnutrition 10 ( 9%) < 11.5 cm Severe Malnutrition 5 ( 4.5%) Oedema Severe Malnutrition 5 (4.5%)

FSNAU Technical Series Report No VI. 25 58 Issued September 11, 2009 HHNO: NUTRITION ASSESSMENT HOUSEHOLD QUESTIONNAIRE, 2009

Household Number ______Date______Team Number ______Cluster Number ______Cluster Name ______District: ______

Q1-8 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 Pre 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= 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=Self-Employment (Bush products/handicraft) 8= Others, specify ______

Q8-15 Feeding and immunization status of children aged 6 – 59 months in the household. appendix Q10 Q12 Q11 (If 6-24 months) How many Q 13 (If 6-12 months Q15 If you stopped times do Has child Age Q8 At what age breastfeeding you feed the been pro- (months) Are you- was child given Q14 Has the before the child child in a vided with breastfeed- water/ foods Has child child ever First was 12 months, day (besides Vitamin A (if child ing1 the other than breast been Vacci- been given Name why did you breast in the last 6 is more child? milk? nated against polio vaccine stop? milk)? months? than 24 (if no, skip to 1= <1 weeks measles? orally? 1= Pregnancy 1= 1 time (show months Q10) 2=1wk – 3 1=Yes 2=Illness 2=2 times sample) old, skip 1=Yes months 2= No 3=Child refused 3 = 3 times to Q13) 2= No 3=4-6 months 1=Yes 4= Other 4=-4 times 1=Yes 4=6 months or 2= No 5= Never breast- 5= 5 or more 2= No more. fed times 1 2 3 4

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

FSNAU Technical Series Report No VI. 25 59 Issued September 11, 2009 Q16-27 Anthropometry and morbidity for children aged 6 – 59 months in the household

Q26 Q27 Q25 Where did you seek healthcare Q21 Q22 Q23 Is the child Q20 Q24 D i d t h e assistance when Diar- Serious Febrile currently child sleep child was sick? (If Q16b rhea2 in ARI (oof illness/ registered Q17 Q18 Q19 MUAC Sus- u n d e r a yes in Q21 – 24) last two wareen/ sus- in any Q16a (cm) pected mosquito Sex weeks wareen- pected feeding Oedema Height (cm) Weight (kg) Measles5 n e t l a s t 1=No assistance to)3 in the Malaria4 centres? First Age To the near- in last night? sought last two in the Name To the near- To the nearest tenth of one 2=Own medica- 1=Male weeks last two 1= SFP 1=yes est tenth of est tenth of a cm month tion 2=Fe- weeks 2= TFC 2= No a cm a kg 3 = T r a d i t i o n a l male 3= OTP/ 1=Yes 1=Yes healer 1= Yes 1=Yes 1=Yes CTC (>6 mo) 2= No 2= No 4=Sheikh/Prayers 2= No 2= No 2= No 4= Other 5=Private clinic/ 5=None Pharmacy 6= Public health facility 1

2 3 4

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

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

FSNAU Technical Series Report No VI. 25 60 Issued September 11, 2009 Q 29 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 1= Own production 6=Borrowed household consume 7=Gathering/ Food group consumed: What foods groups did members of the food from any these 2=Purchases household consume in the past 24 hours (from this time yesterday to food groups in the last wild 8=Others, now)? Include any snacks consumed. 24 hours? 3=Gifts from friends/ relatives 1=Yes specify___ 0= No 4=Food aid 9=N/A 5=Bartered What is the main source of the dominant food item consumed? Type of food (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 fish, lobsters)? 12. Miscellaneous (e.g. spices, chocolates, sweets, beverages, etc)? appendix Q30 In general what is the main source of staple food in the household? (*Use codes in 29 above) ______Q31 Total number of food groups consumed in the household: ______

Q32 How many meals3 has the household had in the last 24 hours (from this time yesterday to now)? 1= One 2=Two 3= Three

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

FSNAU Technical Series Report No VI. 25 61 Issued September 11, 2009 WASH Questionnaire Pretesting

Q30-35 Access to water (quality and quantity) Q30a What is the household’s main source of drinking water? Protected sources: 1 = Household connection 2 = Standpipe (Kiosk) 3 =Protected Shallow well (covered, with hand pump or motorized pump) 4 = Tanker 5 = Protected spring 6 = Bottled water 7 = rooftop rainwater 8 = covered Berkads Unprotected sources 9 = river/stream 10 = dam/pond (Balley) 11 = shallow well/ spring 12 = Others (specify) … Q30b What is the household’s main source of water for other domestic uses? ______(Use codes in Q33a above)

Q31a If household has no access to protected water sources, what is the main reason? 1= Not Available 2= Distance too far 3= Security Concerns 4=Cannot afford 5= Other reasons (specify) … Q31b Do you get a reliable supply of drinking water from this source? 1= Always available 2=Seasonally available Q31c If your water system is mechanized, how frequent did it breakdown last month? 1= Once 2 = 2-3 times 3= more than 3 times

Q32a Is water treated/chlorinated at the: a) source? 1= Yes 2= No 3 = don’t know b) H/H level? 1= Yes 2= No Q32b If treated at H/H, what is the method of treatment (select more than 1 option if applicable)? 1= Boiling 2 = Chlorination 3= straining/filtering 4= Decanting/ letting it stand and settle 5= Others (specify) …… Q32c Are Aqua tabs used for H/H treatment on daily basis? 1= Yes 2= No Q32d If used, how much do Aquatabs cost your family (in Somali shillings) per month? ………………...

Q33a Average time taken per TRIP to and from the nearest water point (including waiting and collecting time)? 1 = <30 min 2=30 – 60 min 3= more than 1 hr Q33b How many trips are usually made by all family members (trip.person) every day? 1 = 1 trip 2 = 2 Trips 3 = Others (specify) …

Q34a Number of water collecting and storage containers of 10-20 liters in the household: 1=1-2 containers 2= 3-4 containers 3=5-6 containers 4= more than 6 Q34b Does the family pay for drinking water? 1= No 2= Yes Q34c If yes, how much per day (amount in Somali Shillings)? ……… appendix Q35a How is water stored in the household? 1= Clean containers with cover 2= open buckets/ pans 3 = Ashuun (with constricted neck/end)

Q35b What is the result of the H2S sampler test for water quality/? 1= Suitable for drinking 2= Contaminated 3= Test not done.

Q36 Access to Health Facility Q36a Do you have access to a health facility? 1 = Yes 2 = No Q36b If yes, do you use it? 1 = Yes 2 = No Q36c If not in Q39a, why not? 1 = Too expensive 2 = Too far 3 = Not enough time 4 = Security concerns 5= other, specify ……

Q37-41 Sanitation and Hygiene (access and quality) Q37a Do you have access to a usable latrine or sanitation facility? 1= Yes 2= No Q37b If yes, Type of toilet used by most members of the household 1= Open pit /open ground 2= latrine discharging to the outside 3= latrine discharging to a pit 4= Flush toilets Q37c If no access to sanitation facility, what is the main reason? 1= Pastoral/ frequent movements 2 = L a c k resources to construct 3= lack of space (in case of camp) 4= doesn’t see the need 5 = don’t know Q38a Distance between latrine and water source (if underground or surface source) 1=less or equal to 30 meters 2=more than 30 meters Q38b How many households share/use the same facility? 1= One 2= 2- 3 3 = 4-9 4= 10 or more Q38c Who cleans the latrine (tick more than one option if applicable)? 1= Adult female 2=Adult male 3 = Girls 4=Boys 5=Nobody Q39 What key times do you maintain hygienic hand washing practices (tick all that are applicable) 1= before eating 2 = before preparing food 3= before feeding the baby 4= after cleaning the baby’s bottom 5= after defecation 6 = before handling water/storage 7= None /Not applicable

FSNAU Technical Series Report No VI. 25 62 Issued September 11, 2009 Q40 What substance do you use for hand washing? 1= Soap/Shampoo 2= Sand 3= Ash 4= Plant extracts 5= None (only with water) 6= Don’t wash hands Q41 Have you been exposed to information on correct personal hygiene and sanitation practices? If yes, then how? 1= No. 2= Yes via mass media 3= Yes via printed media 4= Yes via interpersonal communication 5= yes via group meetings

(Footnotes) 1 Child having received breast milk either directly from the mothers or wet nurse breast within the last 12 hours 2 Diarrhoea is defined for a child having three or more loose or watery stools per day 3 ARI asked as oof wareen or wareento. The three signs asked for are cough, rapid breathing and fever 4 Suspected malaria/acute febrile illness: - the three signs to be looked for are periodic chills/shivering, fever, sweat- ing and sometimes a coma 5 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

FSNAU Technical Series Report No VI. 25 63 Issued September 11, 2009 HHNO:

URBAN ASSESSMENT HOUSEHOLD QUESTIONNAIRE, 2009

Household Size ______Date______E n u m e r a t o r : ______Name of Town ______Section: ______

Q 1 Food Consumption & Dietary Diversity

Did a member of your *Codes: h o u s e h o l d c o n s u m e Food group consumed: What foods groups did members food from any these food 1= Own production 5=Bartered of the household consume from yesterday morning and groups from yesterday including the night)? Include any snacks consumed. 2=Purchases 6=Borrowed morning and including the night? 3=Gifts from friends/ relatives 7=Gathering/wild 1=Yes 2= No 4=Food aid 8= N/A What is the main source of the dominant food item Type of food consumed? (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? A11. Fish and sea foods (e.g. fried/boiled/roasted fish, lobsters)?

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

Q6. Coping and coping strategies During the PAST YEAR, have there been times when you did 2 = No not have enough money to buy food or cover other essential 1 = Yes (skip) expenditures (health, cooking fuel, school etc.)? If yes, how did your household manage to put food on During the PAST Year (June 2008) Now (In June 2009) the table last year? And how has your household man- 2 = No 1 = Yes 1 = Yes 2 = No aged to put food on the table this year? (skip to 2008) 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 Restrict consumption by adults in order for small B5 1 = Yes 2 = No 1 = Yes 2 = No children to eat 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 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, fod- B10 1 = Yes 2 = No 1 = Yes 2 = No der, animal feed, vet. Care…. Sell domestic assets (radio, furniture, fridge, B11 1 = Yes 2 = No 1 = Yes 2 = No TV, carpet…) 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

FSNAU Technical Series Report No VI. 25 64 Issued September 11, 2009 Sell productive assets (farm implements, sew- B12 1 = Yes 2 = No 1 = Yes 2 = No ing machine, 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-migrat- B17 1 = Yes 2 = No 1 = Yes 2 = No ing for work and/or food B18 Increase in the amount of remittances received 1 = Yes 2 = No 1 = Yes 2 = No

Mortality Questionnaire, June 2009

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

2: Sex 3: Age 4: Born since 5: Arrived since 6: Reason for 7: Cause of No. 1: First Name (1=M; 2=F) (yrs) __ / 03/2009 __ / 03/ 2009 leaving death a) How many members are present in this household now? List them. appendix

b) How many members have left this household (out migrants) since March __, 2009? List them

c) Do you have any member of the household who has died since March __, 2009? 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/ 4=Divorce/ Married away 9= Other, specify 4= Malaria physical injuries 5=Visiting 5= STD/ HIV/AIDS 9= Hunger/starvation 10= Other, specify

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

FSNAU Technical Series Report No VI. 25 65 Issued September 11, 2009 Data collection form for Malaria

Date GPS Coordinates North Name of the Village Cluster No East Name of medical person of the team

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

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

FSNAU Technical Series Report No VI. 25 66 Issued September 11, 2009