Report on the Food and Nutrition Situation in Bay, Bakool and Gedo Regions Somalia October 19, 2000 Albertien van der Veen, nutritionist, WHO/ORHC1 Index page 1. Background 2 2 Nutrition situation 3 2.1 Nutrition Surveillance 3 2.2 Selective Feeding Programmes 4 2.3 Health 6 3 Food Situation 8 3.1 Food security 8 3.2 General Food Distribution 9 4 Conclusions 11 5 Recommendations 12 Annex 1: Summary of Nutrition Surveys Annex 2: Health and Supplementary Feeding Programmes References 1 Office of the Humanitarian Co-ordinator for the Drought in the Horn of Africa 1. Background The objective of this report is to provide an overview of the food, nutrition and health situation in Bakool, Gedo and Bay Regions of Somalia, the humanitarian response thus far, to outline existing problems and to provide recommendations for action. The methodology for this assessment consisted of a study of various survey and assessment reports of non-governmental organisations (NGOs), the Food Security Assessment Unit, and United Nations (UN) agencies. This was followed by field visits to Gedo and Bay. Information was gathered from UN agencies and NGOs active in these areas. The humanitarian response in Somalia is co-ordinated by the Somalia Aid Co- ordination Body (SACB), in which UN agencies and NGOs work together. At field level, SACB participants in some areas also work with local government authorities. Drought response interventions have heavily relied on data collected and analysed by the Food Security Unit (FSAU) and the Famine early warning system (FEWS)2 published monthly. To further improve programme planning, early detection and response, a health information system, which incorporates the already existing system of nutrition surveillance, and an outbreak detection system were launched earlier this year. Bakool, Bay and Gedo regions are located in the north western part of southern Somalia. The total population is an approximate 1,1 million, but estimates vary. All regions were severely affected by drought in 1999, following floods in 1997/1998. The drought, compounded by conflict, displacement and lack of public services, left a substantial part of the population highly food insecure. By the end of 1999, approximately 400,000 people in the three regions combined were considered in need of relief food assistance. A famine alert was issued for Bakool in January 2000. A number of rapid assessments were conducted in February 2000. An assessment in Bakool documented both the diversity and the severity of food insecurity. An UNICEF nutritional assessment in Rabdure town found a global malnutrition rate of 30 percent, including 6 percent severe malnutrition. Another UNICEF nutrition survey in Wajid town showed a 21 percent global malnutrition rate, and a severe rate of 3 percent, despite major WFP food distributions in both districts. Also in Gedo Region, an inter- agency mission in February found high food insecurity among poor agro-pastoralists who, as a result, were reducing their consumption levels to below minimum requirements. Nutrition surveys conducted during the period December 1999-April 2000 revealed levels of malnutrition varying from 14% to 24%. Following the gu rains, the situation rapidly improved, despite the fact that food aid deliveries till June were well below planning figures. Results from the only post- harvest nutrition survey thus far carried out are expected soon. In view of a reasonable to good harvest, improved (safe) water availability and decreasing morbidity, the general expectation is that the nutrition situation is improving. 2 FSAU is funded by the EC and FAO; FEWS is funded by USAID. 2 2 Nutrition Situation 2.1 Nutrition Surveillance There is no comprehensive nutrition surveillance system in Somalia, but the FSAU attempts to monitor trends in nutrition by collecting anthropometric data from some 30 to 35 nutrition surveillance sites. Virtually all data are collected in mother and child health (MCH) clinics, mainly in those supported by INGOs and the International Federation of the Red Cross (IFRC). Staff has been trained in the past in proper measuring and recording, but problems continue with the quality and usefulness of these data. A major constraint is uneven coverage among and within districts, biased heavily towards more urban areas, where most MCH clinics are located. In addition, data are usually3 only collected of children attending MCH clinics, resulting in an over- representation of sick children. With a view to increase the quality of data gathering, FSAU has recently secured funding to strengthen the nutrition surveillance system. Representative data are available from nutrition surveys carried out regularly by UNICEF. Since July 1999 UNICEF, sometimes in conjunction with NGOs, has conducted some 10 surveys in the regions worst affected by the drought. In addition, ACF and MSF B have collected anthropometric information. With the exception of rapid assessments, surveys have been random cluster surveys. In accordance with good practice, most surveys also collected data on underlying causes of malnutrition, in particular morbidity and, to a lesser extent, food insecurity (refer to sections 2.3 and 3.1). A Nutrition Working Group, based in Nairobi, analyses survey results (including the methodology used) and provides recommendations on further data collection. Results from UNICEF surveys indicate persistent high levels of malnutrition, ranging from 17% to 30%. In the period May-July 2000 findings showed malnutrition rates of 21,5% in Belet Hawa District (Gedo), 17,2% in Baidoa District and 22,4% in Bur Hakaba District (both in Bay region). Severe malnutrition was 3.5%, 3% and 4,1% respectively. These rates are somewhat lower than last years’, but not significantly so (please refer to Annex I for an overview of nutrition surveys). Also, because surveys carried out in 1999 only covered towns, comparison is not straightforward. Results from the only post-harvest nutrition survey, thus far carried out in 2000, are expected soon. A nutrition survey carried out by ACF, in April 2000, in Luuq (Gedo region) revealed a malnutrition rate of 14,9% among residents of Luuq town and 20,0% among IDPs residing in camps. ACF also conducted several rapid nutrition surveys using MUAC in three areas with potential nutritional problems. Global acute malnutrition rates as defined by MSF and SACB4 were 44,3%, 15,6%, 10,3% and 5,7%. Also using MUAC, rapid assessments carried out by MSF B in the Bakool region in May revealed malnutrition rates of 23% in Rabdure, 20% in El Berde, 19% in Wajid to 16% in Tieglow. Due to the sampling methodology and the small sample sizes, results of these 3 In some areas, also mobile teams collect anthropometric data. 4 MUAC cut-off points vary among organisations. 3 rapid assessments are not representative. Neither can results be compared to results from UNICEF surveys, because MUAC was used instead of weight for height. In the absence of base-line data –preferably by season– it is difficult to ascertain to what extent malnutrition levels found by ACF and UNICEF differ from levels normally found at the peak of the hunger season in Somalia. Interpretation is further complicated by the fact that, in line with international recommendations, malnutrition is presently measured in Z scores, which result in systematically higher rates (30%-60% depending on the sample characteristics) than weight for height as percentage of the median used in pre-war Somalia. 2.2 Selective Feeding Programmes With a few exceptions, supplementary feeding (SF) in Somalia is provided through MCH clinics. In the past, UNICEF operated many MCH clinics, but at present its role is largely in support of NGOs. While many MCH clinics are assisted by INGOs, some have also been handed over to (new) national NGOs. UNICEF continues to provide blended food (and other inputs). As of August 2000, supplementary food was provided in some 22 MCH clinics, that is in approximately 40% of all clinics supported by UNICEF in the south and central zone of Somalia. Of these, seven are in Bay, three in Bakool and five in Gedo (see annex II for an overview). ACF provides supplementary feeding in Luuq, presently in one location, but with plans to extent to at least two more sites, possibly five. Trocaire, in addition to malnourished screened in MCH clinics, also provides supplementary food to malnourished displaced children in the outskirts of Belet Hawa and children screened by its mobile teams in the rural areas. All rations consist of 10 kg of blended food per beneficiary per month. Recommended medical treatment consisting of EPI (or at least measles vaccination), micro-nutrient supplementation, treatment of intestinal parasitosis, and systematic treatment of infections with oral antibiotics is undertaken throughout, facilitated by the fact that most supplementary feeding is linked to MCH. Overall numbers of malnourished children receiving supplementary feeding in MCH clinics have shown little variation during the last year(s), ranging from less than 100 to more than 1000 per MCH. Re-admissions frequently account for over half of the new admissions, suggesting limited impact. In addition, there is some doubt whether the official policy of using internationally accepted criteria for admission and discharge is adhered to. A recent re-screening by UNICEF in Baidoa town, for instance, revealed that out of more than 3,000 children registered as supplementary feeding beneficiaries, only 1,320 (44%) actually qualified. In addition, UNICEF, Trocaire and others report that there is duplication in areas where catchment areas of supplementary feeding programmes overlap. Findings from nutrition surveys also suggest that the number of children receiving supplementary feeding is often much higher than would be expected on the basis of malnutrition rates. At the same time there is evidence that, in some areas, supplementary feeding coverage among malnourished children is extremely low. In Belet Hawa, coverage, according to Trocaire, remains a modest 18% (as compared to 10% last year), despite efforts to improve coverage by strengthening out-reach 4 activities carried out by a mobile team.