Monthly Nutrition Update for Somalia Mar 2003

This month, the Nutrition Update once again highlights the continuing high level of vulnerability among the displaced and urban poor in Mogadishu, where continuing insecurity restricts comprehensive monitoring.

In Gedo, with the acute food insecurity crisis declining, humanitarian organisations hope to commence discussions on the longer term interventions required to address the chronic and underlying issues that make Gedo the most vulnerable region in the country.

In the north, similar needs exist in Sanaag, where emergency nutrition interventions can save lives and prevent the longer term effects of malnutrition on individual children but will do little to improve longer term food insecurity.

The nutrition survey results from Hargeisa reflect a generally disappointing lack of improvement in the nutritional status of returnees' despite numerous interventions over the past year.

MOGADISHU - high levels of malnutrition in a vulnerable population

Insecurity continues to have a direct negative effect on the income available to many households in Mogadishu. Despite the relatively good availability of a wide range of food items, a significant proportion of the population in the city is unable to access these because of low income. The rehabilitation and further development of essential infrastructure in Mogadishu has been insufficient to support the large population of displaced households. The largest city in Somalia continues to face challenges in the delivery of basic services to its population and the level of humanitarian assistance is extremely low.

The displaced population, estimated at 230,000 persons, and the poor urban residents of Mogadishu remain in a vulnerable state. A rapid nutrition assessment carried out by FSAU in June 2002 using measurement of Mid Upper Arm Circumference in five 'camps' in Mogadishu showed high levels of malnutrition1. The two Therapeutic Feeding Centres run by ACF in Mogadishu have continued to admit significant numbers of severely malnourished cases. During 2002, ACF admitted 2434 beneficiaries in their TFCs compared to 2250 beneficiaries in 2001. Of the beneficiaries admitted in 2001 and 2002, 83.9% and 88.3% respectively were children aged less than five years.

The data presented on the graph indicates that the total admissions for each month over the years has been persistently high and ranged from 150 to 272. The high increase in admissions for January 2003 was mainly linked to diseases (diarrhoea and malaria) in the city and also in Lower Shabelle. The majority of the TFCs beneficiaries are either residents in Mogadishu or are recorded as displaced but resident in Mogadishu for over twelve months.

Poor sanitation in most parts of the city along with a high incidence of communicable diseases including TB also continue as significant factors in the continuing high levels of malnutrition. Poor basic infrastructure, limited access to the available basic services, assets loss, reduced trade and labour opportunities due to insecurity within Mogadishu and other parts of Somalia has contributed to the high malnutrition levels in the area too.

In an area where malnutrition levels remain persistently high, basic services poor and humanitarian assistance significantly low, the need to foster peace is key to allow for the implementation of relevant interventions.

RAPID ASSESSMENTS IN GEDO - Dolow, Garbaharey and Burdhubo

Despite significant signs of recovery from the recent acute crisis related to food insecurity, Gedo Region continues to remain in the spotlight due to significant chronic food insecurity. Although the Deyr 2002 season was considered good throughout the region, recent food security assessments confirm the continuing vulnerability of numerous groups in the region, particularly in the north. These groups include the poor wealth group among the Dawa pastoralists; both middle and poor wealth groups among the agro pastoralists; lower middle and poor wealth groups in Riverine household economy groups as well as the urban poor and IDP populations.

Harvest has been obtained in Bardera, Burdhubo and the riverine areas of Luuq although this was limited due to higher prices of fuel for irrigation pumps. Now mid way through the long dry season (Jilaal), the livestock body condition is currently considered normal but milk production is experiencing its seasonal decline. Most of the camels are now pregnant thus decreasing milk production further and many animals have moved further from urban populations in search of better pastures. In all three districts, milk prices have increased by around 30% between December 2002 and February 2003. This scarcity and price increase reduces access for poorer households.

During the last four months insecurity has limited access to humanitarian organisations for delivery of interventions as well as for detailed monitoring of nutritional status. Organisations have been constrained in verifying the reports on nutritional status from health facilities and from selective feeding interventions. Insecurity has prevented the undertaking of further nutrition surveys.

From 21 February to 2 March, FSAU in collaboration with Gedo Health Consortium conducted rapid assessments in four districts of Gedo Region using measurement of Mid Upper Arm Circumference (MUAC). A total of 200 children between 6 and 59 months were randomly selected and screened in each of Garbaharey, Burdhubo and Dolow towns.2

The total acute malnutrition (MUAC <12.5 cm) was recorded as 28% in Garbaharey, 32% in Dolow and 28% in Burdhubo as shown in the table below. The somewhat higher rate of malnutrition in Dolow can be partly attributed to the fact that around 25% of poor households in Dolow are returnees (mainly Bantu Garra Mare Clan) from the Ethiopian side of the border and have few assets. This has increased the proportion of poorer households living within Dolow town. According to the registers of the Supplementary Feeding Centre in Dolow, about 20-25% of the beneficiaries also cross over the border from Dolow Addo on the Ethiopian side on a regular basis.

<11.0 cm
Total malnourished <12.5cm
At risk
≥12.5 ≤13.4
≥ 13.5 cm
Total screened
1 (0.5%)
56 (28%)
45 (22.5%)
99 (49.5%)
200 (100%)
3 (1.5%)
68 (34%)
67 (33.5%)
200 (100%)
3 (1.5%)
57 (28%)
57 (28%)
89 (44%)
203 (100%)

In Garbaharey the high rate of malnutrition was attributed to the successive droughts, insecurity, limited assistance from the international community and the relatively high milk prices described above. The last food aid distribution took place in October 2002 when CARE and GHC distributed dry ration and fortified blended food.

Organisation supporting interventions in Gedo are currently contributing to the development of a matrix outlining ongoing activities in the region. It is hoped that this initiative will provide the foundation for further discussion on the development of effective longer term interventions for a chronically vulnerable population. For more information and a copy of the draft matrix contact


Sanaag Region has been repeatedly highlighted as having a substantial proportion of households that are regularly exposed to significant seasonal fluctuations in household food security. One of the main issues causing these seasonal fluctuations is access to water, which, during periods of drought and during the seasonal dry periods has direct effects on the livelihoods of the population. These seasonal fluctuations in access to water influence movement of livestock and population, reduce access to the foodstuffs that constitute an adequate diet and frequently prevent households from maintaining basic standards of health for all members. The burden of high prices for water purchase on households is substantial.

The last nutrition survey in the area, in May 2002 showed a high level of malnutrition (13.7% <-2 Z score and/or oedema) including a severe malnutrition rate of 5% (<-3 Z score and/or oedema) and prompted UNICEF to implement a targeted intervention in the four districts of Dahar, Badhan, Eil Afwein and Erigavo. The intervention included the distribution to malnourished children of fortified blended food and the provision of both preventive and curative health services. Some targeted food distribution was also undertaken by WFP in mid 2002. During March 2003, a team consisting of Ministry of Health and Labour representatives, UNICEF and FSAU reviewed this intervention.

The review indicated that the situation around Erigavo appears to have improved and the proportion of malnourished children detected during screenings (6.7% out of 612 less than 80%W/H) and attending the health facility is low. However, the overall proportion of malnourished children detected during the final screenings in late January/early February in the four districts remains high (18.4% out of 1909 less than 80%W/H including around 2% severely malnourished - <70% W/H).

While the situation in Sanaag is very worrying and the needs of malnourished children remain critical, the underlying issues demand longer term interventions aimed at strengthening and diversifying the livelihoods of these vulnerable households. UNICEF is currently reviewing the lessons learned though the experience and the potential value in continuing the intervention in its current form.


Since 1997 to date, UNHCR in collaboration with the Ministry of Resettlement, Rehabilitation and Reconstruction (MRRR) has supported voluntary repatriation of over 200,000 individuals mainly from the neighbouring camps in Ethiopia. An equally large number of people are also estimated to have resettled in Somaliland without going through the formal repatriation processes. It is estimated that more than 80 000 (Inter-agency assessment June 2002) of the returnees have chosen to settle in Hargeisa town mainly occupying the outskirts of the town. Earlier studies in the settlement areas (UNICEF nutrition survey 2001, IRC led inter-agency assessment 2002) revealed widespread lack of basic services, overcrowding and poverty especially in the informal settlements. For example, the June 2001 nutrition survey revealed a high malnutrition rate (16.3% WT/HT with <-2 z-scores and/or oedema as the cut-off) while the 2002 inter-agency assessment showed unsanitary conditions, inadequate water, high incidences of diseases and poverty to be widespread. This continues despite considerable attempts by both local government and humanitarian agencies in Hargeisa to provide basic infrastructure (water, health services, education facilities etc). It is thought that continued population influx in Hargeisa and limited resources available for effective solutions still pose immense challenges to the agencies and local authorities in Somaliland.

Between 1st and 10th February 2003, UNICEF in collaboration with Ministry of Health and Labour (MOHL) and FSAU conducted a nutrition survey in the eight-returnee/IDP resettlement villages of Hargeisa town aimed at determining the level of malnutrition among under five children. The survey further aimed at understanding the likely causes of malnutrition, analysing and interpreting the results using the relevant contextual information and providing guidance on decision making related to appropriate future interventions. Using a two-stage cluster sampling methodology, a total of 913 children aged 6-59 months were examined. Mortality data was also collected during the survey.

As indicated by the preliminary results, the prevalence of global acute malnutrition defined as W/H<-2 z-scores or oedema was 15.3% (95% CI 12% - 18.6%), acute malnutrition defined as W/H<-2 z-scores 14.4% (95% CI 12.2% - 16.9%), severe acute malnutrition defined as W/H<-3 z-scores was 2.9% (95% CI 1.9% - 4.2%) and oedema was 0.9%. The survey results confirm a persistently poor nutritional status in the resettlement areas. Overall, the malnutrition rate reported was similar to that found during the 2001 survey with the exception of severe malnutrition, which was lower than the 2001 results (severe acute malnutrition 5% as defined by <-2 z-scores or oedema).

Preliminary analysis of mortality data shows a high mortality rate in three months prior to the survey of about 3.7 per 10 000 per day. Further analysis and triangulation of findings is expected to reveal any possible linkage between the relatively lower severe malnutrition (compared to 2001) and the observed high under-five mortality rate.

About 48% of the children had received Vitamin A supplementation in the six months prior to the survey and 62% had been immunised against measles. Vitamin A supplementation was substantially lower than the 2001 survey figures (about 78% coverage according to 2001 survey); an observation partly explained by previously vigorous NID campaigns (Vitamin A supplementation is conducted during the NID exercise to complement the facility based supplementation). More so, the 2001 survey was conducted soon after the NIDs exercise unlike the current survey. About 8.5% of the children came from recent internally displaced and returnee households.

Persistent poor nutritional status of the Returnee/IDP residents in Hargeisa

Limited food accessibility due to income deficits; poor childcare/feeding practices, inadequate sanitary facilities and disease incidences, all contribute to the persistent poor nutritional status of the population in resettlement areas of Hargeisa.

Most households purchase most of their foods while casual work and petty businesses like operating kiosks, roadside selling of "khat", tailoring etc were the dominant income sources. Findings from an urban household economy assessment conducted by FEWS-NET one week after this survey reveal that poor households in Hargeisa have low income levels (less than two dollars a day). Expenditure on foods (meat, milk, vegetables etc) other than cereals was revealed minimal, low remittances amongst the group and vulnerability to seasonal fluctuations in employment at construction sites and fluctuations on exchange rates were also reported. With an average household size of about 7 people (FEWS-NET urban assessment), the poor households depend on less than two dollars a day (just about a third of a dollar per person per day) far below the global comparisons. The inter-agency assessment in 2002 also reported low intake of the relatively expensive proteins, fruits and vegetables. For example almost a half of the residents could only eat meat once or less in a month while about 40% of the families reported never purchasing/consuming milk (inter-agency assessment 2002).

Exclusive breastfeeding was uncommon while separation of the young children from their principal caretakers (mothers) for a great part of the day while mothers worked outside home, was common. Although further statistical investigations are yet to be conducted, there are indications of association between the observed malnutrition and diseases like diarrhoea and acute respiratory infections that could confirm communicable diseases still represent a major problem that calls for continued support for comprehensive health and nutrition intervention programmes. Over 40% of the residents did not have access to toilet facilities while the cost of water was more than triple the prices reported in the more permanent residents of Hargeisa.

For example, while a 20-litre jerican was about SL800 in Ayaha, it was only SL 200 in permanent settlements of Mohamed Mooge.

Further analysis of the survey findings including mortality data and food security information is currently taking place between the collaborating partners with a view of developing plausible recommendations.

Children under five years screened during the survey
Global acute malnutrition - W/H <-2 Z-score or oedema
Severe acute malnutrition - W/H <-3 z-score or oedema
W/H <-2 z-score
W/H <-3 Z-score
% of children with diarrhoea in two weeks prior to the survey
% of children with ARI in two weeks prior to the survey.
% of children that received Vitamin A within last six months
% of children immunised against Measles


Status 17th March 2003
October 2002 South Belet Hawa - Gedo FSAU/GHC/CARE/WHO Report available
December 2002 Puntland Galdogob Town UNICEF/MOSA/FSAU Report available
December 2002 Puntland Jerriban District UNICEF/MOSA/FSAU Report available
January 2003 Somaliland Hargeisa Returnees UNICEF/MOHL/FSAU Prelim. results available
March 2003 Puntland Galcayo Town UNICEF/MOH/FSAU/MSF-H Planned
March/April 2003 Somaliland Sanaag UNICEF/MOHL/FSAU Planned
April 2003 Somaliland Sool FSAU/UNICEF/MOHL/NPA/SRCS Planned
April/May 2003 South Tayeglow - Bakool FSAU/SRCS/UNICEF Planned
May 2003 Puntland Bosasso UNICEF/MOH/FSAU Planned
May - July 2003 South Micronutrients survey all zone UNICEF Planned
May - June 2003 Bakool Elberde/Huddur IMC/FSAU/UNICEF Planned
May-Aug 2003 South Belet Weyne UNICEF/FSAU/IMC/SRCS Planned
June 2003 South Haradheere CISP/FSAU Planned
June 2003 Somaliland Burao IDPs FSAU/MOHL/UNICEF Planned
July 2003 Somaliland Haud of Togdheer FSAU/MOHL/UNICEF Planned
August 2003 South Kismayo UNICEF/FSAU Planned
Sept/Oct 2003 South Dinsor IMC/UNICEF/FSAU Planned
2003 Somaliland Awdal FSAU/UNICEF/MOHL Planned
2003 Somaliland All regions (IDD) UNICEF Planned


As part of its Short Course Series, the African Medical and Research Foundation (AMREF), International Training Programme, Nairobi, Kenya will be offering courses on i) Disaster Management from 7th to 17th April, 2003. ii) Communicable and Non-communicable Diseases from 5th May to 6th June, 2003. iii) Management and Sustainability of NGOs from 5th to 16th May, 2003. For more details, contact AMREF at Email: or Website:

The Regional Centre for Quality of Health Care (RCQHC), Institute of Public Health, Makerere University, Uganda will be offering a course on Improving the quality of Malaria Prevention and Control Services from 19th to 30th May, 2003. For more details, contact Ms. Sheila Magero, Programme Coordinator at Email:


This 'Nutrition Update', along with other relevant materials, is available on:

UN Somalia Website.


  • Food Utilisation Study. September, 2002. Nutrition Surveillance Project. FSAU/FAO

  • Monthly Food Security Report for Somalia, FSAU.

  • Greater Horn of Africa Food Security Bulletin. Issue No. 9. February 28, 2003. FEWS NET/LEWS/RCMRD/USGS

  • Kenya Vulnerability Update. February 21, 2003. FEWS NET and WFP.

  • Kenya Food Security Update. March 15, 2003. FEWS NET and WFP.

  • Ethiopia Network on Food Security. Issue No. 3/03. March 14 2003. FEWS/NET/EU-LFSU

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139% of the children screened were malnourished (MUAC <12.5 cm or oedema) and 7.1% were severely malnourished (MUAC <11.0cm or oedema ) while a further 21% were at risk of malnutrition (MUAC ≥12.5 cm <13.5 cm).

2 In each of the three urban centres, four equal sections were identified and 50 children randomly selected for screening.