Report on the Food and Nutrition Situation

in

Bay, Bakool and Gedo Regions

Somalia

October 19, 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 9

4 Conclusions 11

5 Recommendations 12

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 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 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 usually[3] 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[4] 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 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 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[5] 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 (Gode 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 diseases account for a significant number of cases 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[6] 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.

2.3  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[7]. 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[8]. 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 5,8/10.000/day and 3,2/10.000/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 inclusion of 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 crosschecked with verifiable information such as clinical records or grave counts, should be treated with extreme caution.