Somalia

Monthly Nutrition Update for Somalia Sep 2003


OVERVIEW
FSAU and partners have highlighted the deterioration in welfare of the populations in the Sool plateau related to food insecurity since early 2003. Short term interventions have been undertaken in the area but the malnutrition rates are still on the increase. During October, an Interagency assessment is scheduled to take place in the affected area with the aim of determining short term and long term priorities with the communities and ultimately defining viable interventions.

A poor nutritional status persists in Hiran region amidst a generally poor 2003 Gu crop harvest. Recent trends in malnutrition during screening at active health facilities are presented this month. Meanwhile, the malnutrition levels in Galgadud region remain relatively low despite the sporadic incidents of insecurity.

Throughout Somalia, Internally Displaced Persons remain a population of great concern. Extreme poverty and limited access to basic amenities predisposes displaced household members to poor nutritional status. A nutrition survey undertaken in Bossaso IDP camps highlights their plight and preliminary results of the survey are presented here.

A baseline nutrition survey among the Hawd of Togdheer population undertaken in August show levels of malnutrition generally consistent with those seen in this area in the past.

SOOL PLATEAU

Inter-agency needs assessment planned amidst reports of rains in some received in parts of the plateau

Since April 2003, FSAU has continued to highlight the livelihood deterioration of the population in Sool plateau. A significant rise in malnutrition levels has been recorded in the area since April 2003 (June & August 2003 Nutrition updates). The food security situation worsened significantly characterised by acute water shortage and massive animal deaths while people have employed unsustainable coping strategies (widespread charcoal burning and the accompanied environmental degradation) as a means of survival. Consequently, FSAU had recommended both short-term and long-term humanitarian and development interventions. Since August 2003, there have been short-term responses by the international community mainly through UNICEF (SFP interventions) and WFP's food rations, albeit to a small proportion of the overall population in need.

In recent weeks, discussions on both emergency humanitarian responses and possible long-term interventions have acquired a renewed vigour amongst both international and local actors in the area. Consequently, plans are currently underway to conduct a needs assessment in the region with the aims of determining both short-term needs and long-term sustainable interventions to the people in the plateau. The inter-agency assessment is scheduled for 5th to 15th October 2003 and will involve UN organisations as well as other INGos working in the area.

Since mid September, there have been reports of rains in some parts of the plateau although it remains premature to determine the impact of such rains. However, what is clear is that it may take several months or even years of good seasons before full recovery of the pastoralists is realised.

HIRAN & GALGADUD REGION

Poor nutritional status persists in Hiran region

In July 2003, a nutrition survey in Belet Weyne District1 documented persistent poor nutrition status of the under five children in the population largely as a consequence of consumption of contaminated water, high disease load and repeated episodes of food insecurity especially amongst the poor wealth groups in the district.

Health facility data shows similar patterns of malnutrition. As shown on the graph, malnutrition rates (as measured by weight for height <-2 z-scores or oedema) has ranged from 14% to 25% of approximately 100 children measured each month in the health facilities. The graph notes steadily high levels of malnutrition in Howlwadaag MCH in Belet Weyne district between May and August 2003. Similar findings were noted during the recent Gu crop harvest assessment in which both qualitative data and MUAC assessments were conducted amongst more than 180 under-five children randomly screened from four villages visited during the assessment mission, at least one from each of three districts in Hiran Region noted malnutrition rates ranging from 13% to 21% (MUAC <12.5 cms).




Although there was an initial improvement in food security indicators following the good Deyr harvest of 2002/2003, once again current food security situation seems to be deteriorating following the below normal Gu 2003 crop harvest. The 2003 Gu crop harvest was generally poor, with crops having been destroyed by heavy insect infestation and significant moisture stress in the region. There was also inadequate pasture growth and cattle have begun to move towards Ethiopia leading to poor milk accessibility for a significant proportion of the poor wealth groups. The poorer households who normally depend on agricultural employment could not get enough opportunities to sustain them. Cereal prices are relatively high in Hiran (this is happening immediately after the harvest) and could increase further should there be below normal 2003 Deyr rains.

As the effects of the poor Gu crop harvest continues to manifest it will be essential to monitor the riverine and the agro-pastoral households who have in the recent past been highlighted as vulnerable due to their reduced food access and minimal household food stocks.

Relatively stable nutrition situation in Galgadud

In the neighbouring Galgadud Region, the malnutrition levels reported in health facilities are less than 9% among the screened children in most districts of the Region. Livestock condition and production have been generally stable with most families having adequate consumption of milk and other livestock products. The assessment findings support available nutrition data from the limited health facilities in the region. Ceel Dheer, Adaado and Waneweyn health facilities have consistently indicated low proportions of malnourished children screened between January and August 2003 i.e. malnutrition levels less than 10% of the more than 200 children screened each month in any of these facilities.

Although the malnutrition levels are stable, sporadic insecurity incidences remain a major concern in the region. There are also inadequate functional health facilities in the region with CISP supporting two health facilities located in the coastal area of the region while SRCS/ICRC supports four health facilities located in the other parts of the region. The huge distances between these facilities makes them generally inaccessible to a significant proportion of the population. Common illnesses reported in these facilities include diarrhoea, ARI, malaria, and intestinal parasites.

BAKOOL REGION

In the past, Bakool Region has been characterised by high malnutrition rates particularly in marginal crop producing areas of Huddur, Rabdure and Elberde. Past nutrition surveys undertaken in the region between 2001 and 2002, all indicated a global acute malnutrition rate of greater than 14% (Weight for Height <-2 z-scores or oedema). Rapid nutrition assessments in the area also reported high levels of malnutrition. Among other factors, establishment of nutrition interventions in the region e.g. the SFP/family ration programme in the area has had a positive contribution in the nutritional status of children. In the April 2003 issue of the monthly Nutrition Update, SFP data from Rabdure MCH indicated a notable decrease in the numbers of total beneficiaries and admissions in 2003 which was attributed to improved food security and better management of the SFP/family ration programmes.




As shown in the figure, 2003 data from Bodan SFP in Rabdure District further shows a decline of both total beneficiaries and admissions attended between May and June. A MUAC assessment in August 2003 conducted by FSAU concurrently with the GU crop harvest assessment in Abal village (one of the main villages in Huddur District) reported a relatively low level of malnutrition. Using an exhaustive methodology, a total of 85 children present at the time of the assessment were screened. A global acute malnutrition (MUAC <12.5cm) of 12.5% was observed. The assessment team observed considerable consumption of cowpea during the assessment. However in view of the poor crop harvest in most parts of Bakool region attributed to poor rainfall, moisture stress, diseases and pest infestation food availability in most households may be inadequate. Furthermore, if the 2003 Deyr rains fail, there is a likelihood that some of the interventions (agricultural activities by FAO) may not yield much leading to an even lower food availability and lowered food intake at household level.

BOSSASO IDPS NUTRITION SURVEY- PRELIMINARY RESULTS

Bossasso Town is located in Bossasso District in Bari Region, Puntland with Kandala, Ishkushuban and Gardo as the neighbouring districts. The coastal town plays host to a significant number of Internally Displaced Persons (IDPs) from different parts of Somalia (mainly southern Somalia) as well as some from Ethiopia. The number of IDPs in Bossasso town has been gradually increasing since 1999. The town also serves as the main seaport that facilitates trade between parts of Somalia and even parts of Ethiopia to the Gulf States.

UNICEF in collaboration with MOH and FSAU undertook a nutrition survey in June 2002 among the Bossaso IDPs population which showed unacceptably high levels of malnutrition. The global acute malnutrition rate was 18.7% (Weight for Height <-2 z-scores or oedema) while the severe acute malnutrition rate was 7.5% (Weight for Height <-3 z-scores or oedema). Following the survey, interventions put in place were short-term supplementary feeding/family ration program supported by UNICEF and WFP which was implemented between October and December 2002. During this programme, immunization services, treatment of diseases, health and nutrition education were provided. However, Bosasso MCH continued to screen malnourished children from the IDP camps.




In July 2003, a repeat nutrition survey by way of a two stage cluster sampling methodology was undertaken among the Bossaso IDPs by UNICEF, MOH and FSAU aimed at determining the nutritional status of children aged 6 - 59 months or 65 - 110 cm in height. The survey further sought to determine the factors influencing the children's nutritional status, measles, NIDs and vitamin A supplementation coverage.

Preliminary survey results indicate a persistently high malnutrition rate of 16.2% (Weight for Height <-2 z-scores or oedema) for global acute malnutrition and 3.2% (Weight for Height <-3 z-scores or oedema) for severe acute malnutrition. The table below presents a summary of the two survey reports.

As shown on the table the prevalence of the ARI and measles was lower than that reported in the 2002 survey while that of malaria and diarrhoea was higher. Vitamin A supplementation among the children for the last six months prior to the survey was significantly high (92.5%) while the proportion of children immunized against measles was 67.9%.

Variable
2002
2003
Proportion
Proportion
Children under five years screened during the survey
100
100
Global acute malnutrition - W/H <-2 Z-score or oedema
18.7 (CI: 15.7%-22.1%)
16.2 (CI: 14%-18.5%)
Severe acute malnutrition - W/H <-3 z-score or oedema
7.5 (CI: 5.6%-10%)
3.2 (CI: 2.2%-4.4%)
Oedema
1.8
0.3
% of children with diarrhoea in two weeks prior to the survey
21.1
22.2
% of children with ARI in two weeks prior to the survey.
27.1
24
% of children with malaria in 2 weeks prior to the survey
8.9
12.9
% of children with measles last one month prior to the survey
10.7
3.4
% of children that received Vitamin A within last six months
72.1
92.5
% of children immunised against Measles
70.5
67.9

About half of the IDPs reported to have originated from South and Central Somalia and 45.1% from Ethiopia. Casual work was the main source of income for 90.4% of the households while purchases was the main source of food for almost all (99%) of the households. Remittances and gifts which form a key source of income among other populations in Somalia was reported as a key source of income by only 0.3% of the population. Borrowing was the main coping strategy reported by 86.5% households followed by splitting of families. The main source of drinking water was through purchases from tanker/truck vendors. Utilisation of sanitation facilities was quite minimal with 75.4% of the population relieving themselves in open grounds or bushes. Additionally, for the minority (24.6%) that used a sanitation facility, about 43% of these facilities were observed to used and dirty.

The malnutrition rates reported in the survey are still high. Diarrhoea, ARI, child age, child sex and use of pit latrines were among the factors with a significant association with the children's nutritional status. Boys were more likely to be malnourished than girls. This is an unusual observation that requires further investigation. Children with diarrhoea or ARI were more likely to be malnourished and so were children whose families utilized pit latrines. Although the use of a sanitation facility is a good sanitation practice, use of these in an unhygienic manner or having unclean facilities can predispose populations to diseases like diarrhoea and worm infestation among others. It is notable that 43% of the used sanitary facilities observed during the survey were dirty. A cholera outbreak in the camps, two weeks prior to the survey further gives an indication of unsanitary practices. Majority of the IDP population live under makeshift shelters which predisposes them to respiratory infections. These shelters are prone to fires which essentially renders these families homeless e.g. during the nutrition survey, a fire broke out in the camps burning down at least 100 shelters.

Children aged 6 - 23 months were more likely to be malnourished than their older counterparts. Child care practices in the IDP camps is wanting. Majority (71%) of the children were weaned before the age of six months. Breastfeeding practices are poor too with half of the children having stopped breastfeeding before one year of age. While about half of the children were fed more than four times in a day, the quality and quantity of food given especially among the poor IDPs is limiting. A concurrent food security assessment with the nutrition survey revealed that protein and vitamins rich foods (cowpeas, powdered milk, meat and vegetables) formed a relatively low proportion of the food sources for poor households. Considering that purchases was the main source of food for the households, income availability remains one of the main factors in determining food availability to this IDP population. The poor IDP population, comprising about two third of the total IDPs are particularly vulnerable to food insecurity particularly in the hot Hagaa season when opportunities are less due to reduced port activity.

Proposed interventions aimed at reducing the malnutrition rates in the IDP camps include modelling of a community based nutrition activity designed to address child care issues; continuation of EPI activities and in a collaborative way, design interventions aimed at addressing sanitation and hygiene problems in the camps. In the long term, it will be useful to design programmes aimed at improving income availability to this population.

HAUD OF TOGDHEER NUTRITION SURVEY - PRELIMINARY RESULTS

The Hawd of Togdheer covers four districts of the Togdheer Region namely: Duruqsi, Odweine, Ballidling and Buhoodle. The area is mainly a pastoralist eco-zone whose inhabitants keep mainly camels and goats with exception of the plains of Tunyo, Arori and Qool- Adey where sheep dominate. Within the last decade there has been high migration especially among the youth from the Hawd to look for job opportunities in the neighbouring Burao town. The migration has been attributed to high poverty levels occasioned by recurrent livestock trade ban, returnees from refugee camps and persistent droughts in the area.



Limited nutrition data is available on the nutritional status of the Hawd of Togdheer population. Thus between 17th and 24th August 2003 a baseline nutrition and mortality survey was undertaken by FSAU in collaboration with MOHL and SRCS. The aim of the survey was to determine the nutrition status of children between 6-59 months or 65-110 cm using weight for height index. The survey also sought to establish factors influencing the nutrition status and to provide recommendations for interventions based on the findings.

The preliminary results indicate a global acute malnutrition rate of 10% using weight/Height < - 2 Z score or Oedema while severe acute malnutrition was 1.3% using weight/height <-3 Z score or Oedema. The table below shows the summary of findings.

As indicated in the table, incidences of diarrhoea, ARI and malaria in the two weeks prior to the survey were all above 15%. The incidence of measles was significant and stood at about 7%. Immunisation coverage for measles (19.5%) and Vitamin A supplementation (27.4%) was significantly low. Majority of the families (57%) sought medication from private health services and pharmacies when unwell while only one-fifth of the population visited public health facilities.

Indicator
No.
%
Under five children screened during the survey.
904
100
Global acute malnutrition- Weight for Height < -2 Z score or presence of oedema
90
10
Severe acute malnutrition - Weight for Height , -3 Z score or presence of oedema
12
1.3
Global acute malnutrition - Weight for Height < 80% of median or presence of oedema
51
5.7
Severe acute malnutrition - Weight for Height < 70 % of Median or presence of oedema
6
7
Oedema
0.6
Proportion of children with diarrhoea in last two weeks prior to the survey.
150
16.3
Proportion of children with ARI in last two weeks prior to the survey.
154
17.1
Proportion of children with Malaria in last two weeks prior to the survey.
154
17.1
Proportion of children with Measles in last one month prior to the survey.
63
7.1
Proportion of children supplemented with Vitamin A in last six months prior to the survey.
240
27.4
Proportion of children immunised against Measles
144
19.5

The survey also noted sub-optimal feeding practices with over 80% of the surveyed children having been introduced to foods other than breast milk before six months of their life. About 67% of the children were fed at least more than three-times a day, a fairly good frequency if the quantity and quality is adequate. About 75% of households were purchasing their food requirements (mainly rice, and sugar). Collectively, small business and sale of animal/animal products accounted for a higher proportion (58%) of the households' source of income.

The 2003 Gu rainfall 2003 was normal except in the agro-pastoral areas where the production was below normal. At the time of the survey livestock body condition was good and livestock production (milk, ghee and meat) remained normal. Most families surveyed noted adequate intake of animal products (milk and meat), with Ghee exchanged for cash. Overall the food security situation in the Hawd is normal due to improved livestock body condition and milk production. The terms of trade were reasonable for the pastoral households with one local goat exchanged for 50 kg of rice. The majority (about 70%) of the families got water for both livestock and domestic consumption from Berkads. However some sections of the Hawd were already experiencing water problem as it was the end of the dry season when most of these Berkads dry up.

The current high incidences of diseases among children, suboptimal sanitation and hygiene practices, use of contaminated water, poor care practices, low levels of measles immunisation and vitamin A supplementation could put children under five at increased nutritional risk. These factors could aggravate the current levels of malnutrition.

A detailed analysis of the survey findings is on-going with a view of coming up with feasible recommendations. However, following an initial presentation of the survey results to both local and international agencies in Hargeisa on 15th September 2003, the following were suggested as possible interventions:

- Intensify the minimum package for health and nutrition care for children and women through

  • Accelerating EPI and vitamin A supplementation coverage
  • Improving access to primary health care services
  • Exploring possibilities of providing cold chain where MCHs exist
  • Increasing access to antenatal and postnatal services
  • Increasing health services e.g. interventions on sanitation and hygiene, Malarial control

- Promote nutrition education focusing on breastfeeding and complementary feeding.

- Environmental agencies should undertake environmental studies in order to initiate water programmes that have minimal negative impact in area.

GEDO

Northern Gedo has been one of the most vulnerable parts in Somalia. Following a good 2002 Deyr season, the region has generally experienced an improved food security situation and continues to show signs of recovery from successive years of drought. CARE has also continued to distribute female-targeted food aid in the area thus contributing positively to the food security status. However insecurity still remains high in the region and this greatly interferes with the recovery process.

Previously, the southern part of the region has been characterised by a relatively stable food security status. However, the agro pastoral areas in Bardera and Burdubo are presently areas of concern following poor 2003 GU rains, extreme wind and Quelea Quelea bird attacks on sorghum crops that caused damage on the expected production.

In the month of August 2003, FSAU carried out a GU harvest assessment in the region during which rapid nutrition assessments were undertaken in Burdubo town and Tubako town in Bardera District. Children aged 6 - 59 months were assessed. The figures below show a summary of the findings. A total of 67 children were screened in Tubako, revealing a global acute malnutrition rate (MUAC <12.5 cm) of 13.4% while 43.2% of the children were either malnourished or at risk of malnutrition. In Burdhubo town 50 children were screened and 4% were malnourished, 30% of the children were either malnourished or at risk of malnutrition.

The global acute malnutrition rates observed in the two locations are significantly lower than those observed in Northern Gedo (see March 2003 Nutrition Update). FSAU will continue to monitor the situation.

SOMALI PUBLICATION

In response to the needs of partners and the Somali speaking audience, FSAU has recently produced an initial publication of a Somali Nutrition Update. The issue covering an overview of nutrition issues in Somalia has been widely circulated in Somalia and well received. Hard or soft copies are available from the FSAU office in Nairobi or any member of the nutrition team.

NUTRITION SURVEYS IN 2003

Dates
Area
Organisations
Status 26rd Sept 2003
February 2003
Somaliland
Hargeisa Returnees UNICEF/MOHL/FSAU
Report available
March/April 2003
Puntland
Galcayo Town UNICEF/MOH/FSAU/MSF-H
Report available
May 2003
South
Kismayo UNICEF/FSAU
Report available
May 2003
Somaliland
Sool Plateau FSAU / UNICEF / MOHL / NPA / SRCS
Report available
July 2003
Puntland
Bosasso UNICEF/MOH/FSAU
Preliminary results
July 2003
South
Belet Weyne UNICEF/FSAU/IMC/SRCS
Preliminary results
August 2003
Somaliland
Hawd of Togdheer FSAU/MOHL/UNICEF
Preliminary results
September 2003
South
Huddur IMC/UNICEF/FSAU
Data Analysis
September 2003
Bakool
Dinsor IMC/FSAU/UNICEF
Data Analysis
September 2003
Puntland
Kandala, Iskushuban, Gardo UNICEF/MOH/FSAU
Underway
Sept/October 2003
South
Tayeglow - Bakool FSAU/SRCS/UNICEF
Planned
Nov/December 2003
South
Haradheere FSAU/CISP/UNICEF
Planned
October 2003
Somaliland
Burao IDPs FSAU/MOHL/UNICEF
Planned
Oct - Dec 2003
South
Micronutrients survey all zones UNICEF
Planned
Nov/Dec 2003
Puntland
Jeriban & Galgodob UNICEF/MOH/FSAU
Planned
2003
Somaliland
Awdal FSAU/UNICEF/MOHL
Planned
2003
Somaliland
All regions (IDD) UNICEF
Planned
2003
Somaliland
Sanaag UNICEF/MOHL/FSAU
Planned

TRAINING COURSES & ANNOUNCEMENTS

As part of its Short Course Series, the African Medical and Research Foundation (AMREF), International Training Programme, Nairobi, Kenya will be offering a course in Advocacy Skills Training from 13th to 17th October, 2003. For more details, contact AMREF at Email: amreftraining@amrefhq.org or Website: http://www.amref.org.

The Centre for African Family Studies (CAFS) in collaboration with WHO Secretariat, Women's Health Project of the University of Witwatersrand and the Harvard School of Public Health will be offering a course on Managing Reproductive Health programmes 20th October - 14th November 2003 targeting managers of reproductive health programmes. For more details contact CAFS at Email: courses@cafs.org.

The Regional Centre for Quality of Health Care, Makerere University, will be offering a Post Graduate Diploma in Quality of Health Care, in Uganda from October 2003 to February 2004 and in home workplace between March and June 2004. The course will be focussing on six quality improvement processes namely quality assurance, management of logistics, facilitative supervision, development and communication of guidelines and standards, cost and quality, and innovative training. For more details contact the Course Coordinator at Email: mail@rcqhc.org or smagero@rcqhc.org

WEBSITES

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

UN Somalia Website. http://www.unsomalia.net/FSAU/nutrition_updates.htm

ReliefWeb. http://www.reliefweb.int/w/Rwb.nsf/vLCE/Somalia?OpenDocument&StartKey=Somalia&Expandview

SACB Website: http://www.sacb.info/commitees/health/Working%20Groups/Nutrition/Nutrition%20Update%20January%2003.pdf

RECENT REPORTS

  • Monthly Food Security Report for Somalia, FSAU.
  • Greater Horn of Africa Food Security Bulletin. Issue No. 15. August 31, 2003. FEWS NET/LEWS/RCMRD/USGS
  • Kenya Food Security Update. September 9, 2003. FEWS NET/MALD/WFP
  • Kenya Vulnerability Update. September 18, 2003. FEWS NET and WFP and UNICEF
  • Ethiopia Network on Food Security. Issue No. 9/03. September 11 2003. FEWS/NET/EU-LFSU
  • Regional Agricultural Trade Intelligence Network, Food Bulletin for East Africa. Issue No. 4. September 11, 2003. FEWS NET


Physical address:

Peponi Plaza, (Block C), Peponi Road, Westlands, Nairobi.
Postal address: PO Box 1230, Village Market, Nairobi
Telephone: +254-2-3741299, 3745734, 3748297. Fax: 3740598
General email: fsauinfo@fsau.or.ke
Comments and information related to nutrition: Noreen.Prendiville@fsau.or.ke

Footnote

1 Global Acute Malnutrition (<-2 z score or oedema) of 17% recorded in July 2003 nutrition survey report.