Update on the Food, Nutrition and Health Situation in Bay ...



Report on the Food and Nutrition Situation

in

Bay, Bakool and Gedo Regions

Somalia

September 29, 2000

Albertien van der Veen, nutritionist, WHO/ORHC[1]

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 10

4 Conclusions 13

5 Recommendations 15

Annex 1: Summary of Nutrition Surveys

Annex 2: Health and Supplementary Feeding Programmes

References

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 authorities. Drought response interventions have heavily relied on data collected and analysed by the Food Security Unit (FSAU) and the (USAID) Famine early warning system (FEWS), 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. These assessments documented both the diversity and the severity of food insecurity in Bakool. 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. In Gedo Region, a multi-donor mission found high food insecurity among poor agro-pastoralists and urban dwellers (comprising 20 to 30 percent of the population).

Following the gu rains, the situation rapidly improved, despite the fact that food aid deliveries 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 has improved.

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 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 usually[2] 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 SACB[3] 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 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 are higher than normal 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. 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 site 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 at least, supplementary feeding coverage among malnourished children is extremely low. ACF’s nutrition survey in Luuq, for example, showed that SF coverage, both in town and in the IDP camps, was 0%. Also Trocaire in Belet Hawa, reports that coverage remains a modest 18% (as compared to 10% last year), despite efforts to improve coverage by strengthening out-reach activities carried out by a mobile team. UNICEF nutrition surveys unfortunately do not assess the coverage of feeding programmes.

In order to increase impact, UNICEF and WFP have linked supplementary feeding to distribution of family food rations in Baidoa town for the period July-September 2000. Preliminary results indicate a spectacular decrease in malnutrition. However, because the pilot period[4] coincides with a period of overall improvement in the food security situation and water availability, as well as a period of decreased morbidity, it will be difficult to draw unambiguous conclusions. For instance, in three MCH clinics in Gedo and non-pilot districts in Bay, visited by the mission, the number of malnourished children had also declined substantially during the last six weeks.

Supplementary feeding is restricted to children. Pregnant and lactating women, both caretakers and others, receive routine micro-nutrient supplementation in the MCH, but no supplementary food, even if malnourished.

Despite an overall average severe malnutrition rate of more than 4%, which, in the surveyed areas, roughly corresponds to some 4,000 children below five years of age, there are only two therapeutic feeding centres (TFCs) in the three regions combined. ACF opened a TFC in Luuq (Gedoa region) in March 2000, while MSF B has initiated health care services including a therapeutic feeding centre in Hudur (Bakool region) in May of this year. Statistics from ACF indicate that after the initial two months, the number of new admissions has stabilised at around 70 per month, with increasing importance of areas outside Luuq and its IDP camps. Admissions are not restricted to malnourished children, but include older children and adults. Performance indicators suggest that mortality and defaulting rates have declined sharply after the first two months. However, a substantial number of attendants continues to be discharged after 60 days, failing to meet discharge criteria, normally due to underlying illness. For instance in August, nearly 30% of the new admissions consisted of (confirmed) cases of tuberculosis or kala-azar. Information from MSF B, similarly confirms that chronic diseases are a major underlying cause of severe malnutrition.

Where there are no TFCs, severely malnourished receive high energy biscuits (HEB), provided by UNICEF, in addition to blended food. These biscuits[5] are a nutritious, high energy food, easy to transport and requiring little preparation. Because the biscuits are sweet, they are generally very acceptable to children. However, HEB have a number of disadvantages. Their protein content of 14-15% is much too high for severely malnourished children and may, in fact, cause a clinical deterioration in this group. In addition, in order to avoid the risk of the biscuits contributing to dehydration there is a need to ensure safe water. Lastly, there is the risk that, because the biscuits represent a highly valued commodity, they will end up on the market place and/or be shared with other household members rather than being used as intended; this is a particular risk if HEB are distributed in dry selective feeding programmes. In summary, the provision of HEB is not an appropriate strategy to cure severely malnourished.

3. Health

Evidence from nutrition surveys suggests that –as elsewhere– high morbidity, due to in particular diarrhoeal diseases, acute respiratory infections (ARI) and –to a lesser extent– malaria and measles have negatively impacted on the overall nutrition situation[6]. UNICEF surveys indicate that the number of children suffering from a diarrhoeal episode during the two weeks prior to the survey ranged from 17 to 43%. In Baidoa district, however, only 13% of the surveyed children had experienced diarrhoea, as compared to more than 30% in Baidoa town the previous year. This improvement was attributed to an extensive water rehabilitation programme. The number of under fives with ARI two weeks prior to the survey varied from 17 to 56%. ACF also reports, that during screening in El Bon (Gedo) in July 2000, many cases of diarrhoeal diseases and ARI were either seen by the team or reported by parents. Other diseases reportedly were measles, conjunctivitis and splenomegaly, thought by the team to be malaria[7]. Interestingly, in neighbouring Yurkut, where malnutrition was much lower, the only main disease children were reportedly suffering from was malaria.

More systematic information on morbidity as underlying cause of malnutrition is expected to become available shortly from a new health information and surveillance system, devised jointly by UN agencies including WHO, and almost 20 NGOs. The system aims to collect nutrition and health data, including information on morbidity and immunisations, from health facilities by means of a standardised monthly reporting form. In May, an outbreak detection system was also launched. This system is based on 17 sentinel sites, which should be providing weekly information on measles, meningitis, cholera, bloody diarrhoea, and any other outbreaks, to allow early detection and response.

Mortality is not recorded systematically in the region, and very few agencies have included questions on mortality in their nutrition surveys. ACF in April 2000 reported an under five mortality rate of 6,6/10.000/day in the IDP camps in Luuq and 5,8/10.000/day in Luuq town, suggesting an extremely alarming situation. Similar alarming rates of 6,0/10.000/day and 6,7/10.000/day were found in two villages near Luuq. Rapid assessments, carried out in July, indicated that in other towns under five mortality was 5,83/10.000/day and 3,23/10.000/day respectively. Mortality rates among persons over five in these two towns were 0,6/10.000/day and 0,7/10.000/day, strongly suggesting that nearly all excessive deaths were among children under five. Data were collected retrospectively through household interviews. This method is prone to recall bias and may result in an over-estimate of mortality due to a variety of reasons, such as including deaths, which in fact occurred prior to the recall period, or counting people who do not belong to the household as defined by the surveyors. Retrospective mortality figures therefore, that cannot be cross-checked with verifiable information such as clinical records or grave counts, should be treated with extreme caution.

Measles were the primary cause of mortality, in case causes were recorded. Other main causes were malaria, malnutrition and diarrhoea. This is in line with information available from nutrition surveys regarding morbidity and measles vaccination coverage. Although measles mass vaccination campaigns are carried out regularly (UNICEF conducted nine campaigns in these regions during the last year), coverage and frequency seem insufficient to reduce transmission. Data show that coverage between and within districts varied considerably, ranging from less than 10% to more than 60%. In particular among IDPs and in rural areas coverage was low. The number of children who had received a vitamin A supplement[8], however, was in some areas much higher due to the fact that vitamin A is also provided during the polio national immunisation days (NID). The new NID rounds scheduled for September, October and November are expected to further increase vitamin A coverage.

There are presently 12 NGOs active in the health sector. These include eight international NGOs (ACF, AMREF, Cordaid (previously Memisa) IMC, IFRC/SRCS, MSF, Trocaire and WVI) and four Somali NGOs. The latter focus on MCH, usually in clinics handed over by UNICEF. Coverage of health facilities is uneven among the three regions, partly reflecting (past) insecurity. Please refer to annex II for details.

Gedo boosts three functioning hospitals[9] in Belet Hawa (supported by Trocaire), Luuq (supported by AMREF) and Garbaharey (supported by Cordaid) respectively. All three hospitals provide a full range of health services, including treatment of tuberculosis (DOTS). Treatment in Belet Hawa, where defaulting is as little as 2%, includes patients from Kenya in an agreement between MSF Spain in Mandera (Kenya) and Trocaire. The latter in turn, refers severely malnourished to the therapeutic feeding centre operated by MSF.

There is no hospital in Bakool, while the referral hospital in Baidoa functions on a skeleton basis only, due to lack of support. Voluntary staff cares for emergency cases. This includes providing treatment in case of epidemics, notably (each year recurring) cholera. Laboratory facilities supported by WHO are presently set up however, and WVI is scheduled to start TB treatment in October.

Although not typically in response to the drought, but as a result of improved security the number of health care facilities has considerably increased during the last year. In particular in Bay, where WVI and IMC have resumed previous activities in (primary) health care, coverage in the rural areas is rapidly improving, although gaps continue to exist and catchment areas vary considerably in size. A weaker point is also, that many Somali NGOs and some INGOs such as IMC, (no longer) provide regular out-patient services, leaving a gap in the health care for adolescents and adult males. In Bakool, health coverage in general remains poor in every respect.

3. Food Situation

1. Food Security

Almost total failure of the 1999/2000 deyr (secondary) season harvest in most rain-fed sorghum-growing areas of Gedo, Bakol and parts Bay Regions resulted in extreme food insecurity in these regions. Deyr production in Bakol Region was estimated at only 5% of the post-war average. Over the first three months of the year, drought-affected populations in northern Gedo, Bay and Bakool moved in a number of different directions, including into Ethiopia, in search of land for cultivation, opportunities for employment and the sale of bush products, and food distributions. In April, people started returning to their areas of origin however, in expectation of rain and planting.

Current relief efforts continue to be hindered by civil insecurity. CARE almost 2,100 MT of emergency relief food in Bay, Bakol and Gedo Regions, CARE food distributions in Garbahare District (Gedo Re-gion) were disrupted by civil insecurity and even-tually suspended. WFP delivered over 570 MT of food in Bakol Region (Wajid, El Barde and Rab-Dure Districts) at the end of February but noted that civil insecurity makes it virtually impossible to provide intended levels of food aid to target Late rains in 2000, Following the gu rains, the situation in part of Bay improved, but not in Bur Harkaba district.

Food security conditions, reported as deteriorating in preceding months in Bakol Region (FEWS bulletin, February and March 2000), are now considered stable, but continued food shortages and high levels of malnutrition in some areas will require additional international relief assistance, at least through July 2000. In the worst-affected parts of Wajid, Rab-Dure and El Barde districts, the international response over the past couple of months to deteriorating food security conditions—and particularly food aid distributions by WFP and water rehabilitation efforts by UNICEF—seem to have provided relief for many of the most vulnerable people. Serious water shortages are still being reported from El Barde district. Reports of severe water shortages and depleted pasture have also been received from parts of the central and southeastern regions of Somalia, notably from Jariban District of northern Mudug and in parts of Galgadud, Hiran and Gedo Regions. The groundwater level has be-come so low in Garbahare and Belet Hawa that the increase in salinity is further reducing al-ready- scarce supplies of potable water for both livestock and people. Dry conditions and pasture shortages in Ethiopia have resulted in increasing migrations of people and animals into Togdheer Region in the northwest, raising concern over the number of vulnerable people and the possible environmental consequences in affected areas.

In Gedo Region, a multi-donor mission found high food insecurity among poor agro-pastoralists and urban dwellers (comprising 20 to 30 percent of the population). The assessment also noted the likelihood that poor nutritional status and a depletion of livelihood assets, especially livestock, would continue till the next rains.

Prospects for the 2000 gu (main) cropping season, which normally begins around April 1, are poor in some of the key rain fed areas, which remained virtually dry during the first dekad of April (figure 1). Climate experts have forecast an enhanced probability of below-normal rains during the gu season. In addition, despite efforts of the international community to ensure adequate seed availability, serious shortages exist in

Bakol Region, where only 16 percent of the estimated seed requirements have been met, and in Bay Region, where the supply is 35 percent below estimated needs. The absence of rainfall in Ethiopia during March has left the Shabelle and, in particular, the Juba River unseasonably low. In some areas, people can cross these rivers on foot. Gravity irrigation has been possible in only a few locations, raising concern over production prospects in irrigated areas as well. The Dawa River, which passes along the Kenya-Ethiopia-Somalia border, is now completely dry.

Somalia

Food security conditions, reported as deteriorating in preceding months in Bakol Region (FEWS bulletin, February and March 2000), are now considered stable, but continued food shortages and high levels of malnutrition in some areas will require additional international relief assistance, at least through July 2000. In the worst-affected parts of Wajid, Rab-Dure and El Barde districts, the international response over the past couple of months to deteriorating food security conditions—and particularly food aid distributions by WFP and water rehabilitation efforts by UNICEF—seem to have provided relief for many of the most vulnerable people. Serious water shortages are still being reported from El Barde district. Reports of severe water shortages and depleted pasture have also been received from parts of the central and southeastern regions of Somalia, notably from Jariban District of northern Mudug and in parts of Galgadud, Hiran and Gedo Regions. The groundwater level has be-come so low in Garbahare and Belet Hawa that the increase in salinity is further reducing al-ready- scarce supplies of potable water for both livestock and people. Dry conditions and pasture shortages in Ethiopia have resulted in increasing migrations of people and animals into Togdheer Region in the northwest, raising concern over the number of vulnerable people and the possible environmental consequences in affected areas.

Prospects for the 2000 gu (main) cropping season, which normally begins around April 1, are poor in some of the key rainfed areas, which remained virtually dry during the first dekad of April (figure 1). Climate experts have forecast an enhanced probability of below-normal rains during the gu season. In addition, despite efforts of the international community to ensure ade-quate seed availability, serious shortages exist in Bakol Region, where only 16 percent of the esti-mated seed requirements have been met, and in Bay Region, where the supply is 35 percent below estimated needs. The absence of rainfall in Ethiopia during March has left the Shabelle and, in particular, the Juba River unseasonably low. In some areas, people can cross these rivers on foot. Gravity irrigation has been possible in only a few locations, raising concern over production prospects in irri-gated areas as well. The Dawa River, which passes along the Kenya-Ethiopia-Somalia border, is now completely dry.

In addition to information from the FSAU/FEW regarding overall food security, results from nutrition surveys have provided some information on food security at household level. ACF in April 2000, reported that households in villages near Luuq were consuming only one meal a day, consisting of tea, meat, maize and edible wild grasses. The primary source of food at the time was purchase from the market with cash derived from casual farm labour. Only a few families reportedly had benefited from free food distribution by CARE in February (50 kg per family). By contrast, 100% of the households interviewed as part of a rapid assessment carried out in Yurkut in July, had received 50 kg of cereals in May, while almost one third had received a second ration. All households claimed that their last harvest had been in 1997 and only one third owned animals. In El Bon, only 17% of the households owned livestock, while about 60% had profited from general food distribution. Households were employing a variety of coping mechanisms such as the consumption of wild plants, out-migration, sale of firewood, charcoal, daily labour and petty trade. In all villages and towns surveyed, a substantial number of families had a history of displacement.

Although the original intention[10] was to link UNICEF nutrition surveys to food security assessments carried out by the FSAU, this remains to materialise. This is a lost opportunity, because regular data collection by the FSAU is insufficiently dis-aggregated to allow anthropometric data collection by UNICEF (and NGOs) to be placed in a (household) food security context. Neither is it therefore possible to assess to which extent household food insecurity is (or was) a (major) contributing factor of malnutrition.

Conclusions

Results from nutrition surveys indicate persistent high levels of malnutrition. However, in the absence of base-line data –preferably by season– it is difficult to ascertain whether this years’ pre-harvest malnutrition levels are abnormal for Somalia. Interpretation is also complicated by the fact that, in line with international recommendations, malnutrition is presently measured in Z scores, which result in systematically higher rates than weight for height as percentage of the median, used in pre-war Somalia. Results from the only post-harvest nutrition surveys 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 has improved.

Despite a long history of supplementary feeding provided through MCH clinics, little is known about the impact of this intervention. Recent screening by UNICEF suggests a substantial inclusion error. Data about exclusion is virtually non existent.

ANNEX I

NUTRITION SURVEYS 1999 – 2000

|Location |Date of survey |Agency |Sample size |Metho-dology |Nutrition Indicators[11] |

|Bay region |

|Baidoa town |August 1999 |UNICEF |903 |30 clusters |W/H ................
................

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