NUTRITION SURVEILLANCE IN SOMALIA

Grainne Moloney, Nutrition Project Manager, FSAU

NIPHORN Meeting, Nairobi, 1st to 3rd February, 2007

Nutrition Coordination in Somalia

• Prior to the conflict in 1991, coordination was managed under the Ministry of Health both at national and regional level

• Now all sector coordination is under one governing body – Somalia Support Secretariat (formerly SACB), supported by UNDP.

• Nutrition Working Group/ Nutrition Cluster Coordination co chaired by UNICEF & FSAU with UNICEF chairing the Cluster Coordination

• Monthly meetings with UN, NGO, CBO in Nairobi: Update on Nutrition Information, Emergency Response, Health , Food Security, Logistics, new developments, etc

• Regional meetings in Somalia frequency varies depending on location, access and availability of partners

• Challenges - lack of Gov, often lack of technical staff (in field), too much to cover in short period – lack of time to discuss more proactive issues such as guidelines etc

Nutrition Data Collection & Sources

Nutrition Surveys 1) National LevelMICS, UNICEF. 1999, Sept 2006 – useful for MDG monitoring2) Localised: • National Nutrition Assessment Guidelines have been produced

endorsed and updated on an annual basis by FSAU/ UNICEF in collaboration with the NWG members.

• Nutrition Surveys are conduced by UN agencies, predominantly FSAU with support UNICEF/WFP and NGO (MSFB, MSFH, ACF, IMC, WVI). In many instances surveys are done on an interagency basis as recommended by the NWG

• Nutrition Surveys are done in areas of operation (for NGO) and areas of concern or where there is no data (FSAU) , right now a database exist in FSAU. Ongoing analysis on seasonality to review the trends in malnutrition over the different seasons

Nutrition Data Collection & Sources

Feeding Centre StatisticsUNICEF consolidates the information from NGO statistics into a central excel database then shares with partners.

Sentinel SitesFSAU collect bi monthly data from 102 sentinel sites (villages) in Sth and Central Somalia. 50 kids per sites, WHZ, MUAC, Oedema. Morbidity, dietary diversity – useful for trends - ? Mean WHZ

Rapid AssessmentsDec 06, developed a MUAC rapid assessment tool (adapted from Darfur) used in the Deyr 06 assessment measuring 100 children per site and classifying % <12.5cm.

HIS Data105 HC measure WHZ of all children 6-59months and collect additional info on morbidity, Epi, maternal health monthly, data submitted to key agencies (FSAU - nutrition, UNCIEF- Epi, WHO morbidity) Central database in Nairobi – useful for trends analysis

Nutrition Data Collection & Sources

Dietary DiversityInformation collected from sentinel sites and assessments – ongoing work on use of indicators (FAO) and recall period (WFP) Child care feeding practicesInformation collected predominantly from nutrition assessment – need for further investigation into obstacles - ? KAP survey

OUTPUTSMonthly Nutrition Update – produced by FSAU – inputs from UNICEFQuarterly Food Security and Nutrition BriefBi annual IPC - seasonal analysis – Nutrition Situation MapNutrition assessment reportsTraining Materials – food preservation, hygiene promotion, micronutrientsWebsite – www.fsausomali.com – (updates, assessment reports, training materials plan to continue expanding info available.)

Nutrition Key Indicators and Categorization – Version 1 Jan 07

Nutrition key indicators

Alert Serious Critical Very Critical

GAM (WHZ) from nutrition surveys

5-9.9% usual range and stable

10-14.9% 15-19.9%(or 10-14.9% where there has

been a significant increase from seasonally adjusted previous

surveys)

>20% or (15-19.9% where there has been a significant increase from

seasonally adjusted previous surveys)

SAM (WHZ) from nutrition surveys

<1.5% 1.5-2% 2-3% >3%

CMR/10,000/day from nutrition surveys

0.45-0.99 1-1.99/10,000/day >2/10,000/day >2/10,000/day

MUAC Screening – TBC (% <12.5cm)

<5% 5-9.9% 10-14.9% >15%

Feeding Centre Data – adjusted on length of operation & coverage

Low admissions and stable

Low admissions but increasing in last 2 months (seasonally & coverage adjusted)

Significant increasing admission - (seasonally & coverage adjusted)

Significant increasing admissions – out of season

HIS Nutrition Trends Low numbers ofacutely malnourished for area and stable (seasonally adjusted)

Low numbers of acutely malnourished children from previous months but increasing in >2 rounds (seasonally adjusted)

High levels and stable numbers ofacutely malnourished children’s (seasonally adjusted)

High with significant increasing numbers in >2 rounds of acutely malnourished children from screening

Poor dietary diversity for population (<4 food groups) – assessments &SSS

<5% 5-9.9% 10-25% >25%

Key Indicators and Categorization Contd. – Version 1 Jan 07

Nutrition key indicators

Alert Serious Critical Very Critical

Meal Frequency: At least 5 x day (for <5yrs)

>20% 5-19.9% <5% <20%

Sentinel Site Trend - levels of children identified as acutely malnourished from HC data

low levels and oneround indicating increase seasonally adjusted)

Increasing levels to based on two rounds (seasonally adjusted)

High levels of malnourished

children and stable (seasonally

adjusted) (15-19.9%)

Increasing levels to with

increasing trend

Affected pop with access to formal/informal humanitarian assistance: feeding centres health centres, clean water etc

Access to humanitarian interventions for most vulnerable

Reduced access to humanitarian support for most vulnerable

Limited access to humanitarian support for majority

Negligible or no access

Health: (seasonally adjusted)Frequency of cases of ARI, Suspected malaria, and diarrhoea Measles:Immunisation Coverage: (Measles & Vit A)

Within expected seasonal norms

1 case

<95%

Seasonal increase in Suspected Malaria, ARI and Diarrhoea- contained

1 case

<95%

Seasonal increase – not contained, Epidemic

Epidemic

<95%

Pandemic

Pandemic

<95%

Food Security Situation - current IPC status

Chronically food secure

Acute Food and Livelihoods Crisis

HE Famine/ Humanitarian Catastrophe

Nutrition Situation - MapsNutrition Situation, Jan 07Nutrition Situation, July 06

Link with Food Security Analysis

• FSAU food security project collects information on markets prices livestock, agriculture, security climate (FEWSNET), though a range

• Two main assessments linked to the rains are conducted annually, post Gu (June) post Deyr (December) leading to the production of the IPC – includes nutrition information – IPC is recognised as a valuable tool for linking information to action by partners and donors

• In addition quarterly briefs on risk factors and early warning are produced incorporating nutrition and food security information

• The IPC is now being rolled out in the Horn East and Central Africa Region as a tool for classifying severity across different contexts. – currently Somalia specific

• There is a need to review the nutrition indicators due to the heavy reliance on WHZ and mortality data only available from localised assessments which may not be representative of larger areas and across season.

Key Reference Outcomes Strategic Response Framework Phase Classification

(current or imminent outcomes on lives and livelihoods; based on convergence of evidence)

(mitigate immediate outcomes, support livelihoods, and address underlying/structural causes)

Crude Mortality Rate < 0.5 / 10,000 / day Acute Malnutrition <3 % (w/h <-2 z-scores) Strategic assistance to pockets of food insecure groups

Stunting <20% (w/age <-2 z-scores) Investment in food and economic production systems Food Access/ Availability usually adequate (> 2,100 kcal ppp day), stable Enable development of livelihood systems based on principles

Dietary Diversity consistent quality and quantity of diversity of sustainability, justice, and equity Water Access/Avail. usually adequate (> 15 litres ppp day), stable Prevent emergence of structural hindrances to food security

Hazards moderate to low probability and vulnerability Advocacy Civil Security prevailing and structural peace

1 Generally Food Secure

Livelihood Assets generally sustainable utilization (of 5 capitals) Crude Mortality Rate <0.5/10,000/day; U5MR<1/10,000/day

Acute Malnutrition >3% but <10 % (w/h <-2 z-score), usual range, stable Design & implement strategies to increase stability, resistance Stunting >20% (w/age <-2 z-scores) and resilience of livelihood systems, thus reducing risk

Food Access/ Availability borderline adequate (2,100 kcal ppp day); unstable Provision of ‘safety nets’ to high risk groups Dietary Diversity chronic dietary diversity deficit Interventions for optimal and sustainable use of livelihood assets

Water Access/Avail. borderline adequate (15 litres ppp day); unstable Create contingency plan Hazards recurrent, with high livelihood vulnerability Redress structural hindrances to food security

Civil Security Unstable; disruptive tension Close monitoring of relevant outcome and process indicators Coping ‘insurance strategies’ Advocacy

Livelihood Assets stressed and unsustainable utilization (of 5 capitals)

2 Chronically Food Insecure

Structural Pronounced underlying hindrances to food security Crude Mortality Rate 0.5-1 /10,000/day, U5MR 1-2/10,000/dy Support livelihoods and protect vulnerable groups

Acute Malnutrition 10-15 % (w/h <-2 z-score), > than usual, increasing Strategic and complimentary interventions to immediately ? food Disease epidemic; increasing access/availability AND support livelihoods

Food Access/ Availability lack of entitlement; 2,100 kcal ppp day via asset stripping Selected provision of complimentary sectoral support (e.g., Dietary Diversity acute dietary diversity deficit water, shelter, sanitation, health, etc.)

Water Access/Avail. 7.5-15 litres ppp day, accessed via asset stripping Strategic interventions at community to national levels to create, Destitution/Displacement emerging; diffuse stabilize, rehabilitate, or protect priority livelihood assets

Civil Security limited spread, low intensity conflict Create or implement contingency plan Coping ‘crisis strategies’; CSI > than reference; increasing Close monitoring of relevant outcome and process indicators

Livelihood Assets accelerated and critical depletion or loss of access Use ‘crisis as opportunity’ to redress underlying structural causes

3 Acute Food and Livelihood Crisis

Advocacy

Crude Mortality Rate 1-2 / 10,000 / day, >2x reference rate, increasing; U5MR > 2/10,000/day

Acute Malnutrition >15 % (w/h <-2 z-score), > than usual, increasing Urgent protection of vulnerable groups Disease pandemic Urgently ? food access through complimentary interventions

Food Access/ Availability severe entitlement gap; unable to meet 2,100 kcal ppp day Selected provision of complimentary sectoral support (e.g., Dietary Diversity Regularly 2-3 or fewer main food groups consumed water, shelter, sanitation, health, etc.)

Water Access/Avail. < 7.5 litres ppp day (human usage only) Protection against complete livelihood asset loss and/or Destitution/Displacement concentrated; increasing advocacy for access

Civil Security widespread, high intensity conflict Close monitoring of relevant outcome and process indicators Coping ‘distress strategies’; CSI significantly > than reference Use ‘crisis as opportunity’ to redress underlying structural causes

4 Humanitarian Emergency

Livelihood Assets near complete & irreversible depletion or loss of access Advocacy

Crude Mortality Rate > 2/10,000 /day (example: 6,000 /1,000,000 /30 days) Critically urgent protection of human lives and vulnerable groups Acute Malnutrition > 30 % (w/h <-2 z-score) Comprehensive assistance with basic needs (e.g. food, water,

Disease pandemic shelter, sanitation, health, etc.) Food Access/ Availability extreme entitlement gap; much below 2,100 kcal ppp day Immediate policy/legal revisions where necessary

Water Access/Avail. < 4 litres ppp day (human usage only) Negotiations with varied political-economic interests Destitution/Displacement large scale, concentrated Use ‘crisis as opportunity’ to redress underlying structural causes

Civil Security widespread, high intensity conflict Advocacy

5 Famine /

Humanitarian Catastrophe

Livelihood Assets effectively complete loss; collapse

Integrated Food Security and Humanitarian Phase Classification Reference Table (FAO/FSAU June 2006)

Somalia Food Security Phase Classification –Post Deyr ’06/’07 Projection Jan - June ’07Post Gu ’06 Projection Jul ‘06 - Dec ’06

Specific Issues for Nutrition Surveillance in Somalia

• Challenge of access to conduct good quality large scale assessment• Lack of capacity of Somali based staff• Limited partners – concentrated in certain areas. • Lack of structures of long term integrations of monitoring systems –

HIS exists but needs much support• Reliability of age data – stunting data???• Different ethnic groups (Bantu – riverine, pastoral, agropastoral) • Interpretation of nutrition data only high rates of wasting trigger

appropriate response• Need to further link nutrition assessments to seasonality and

livelihood zones for better trends analysis & interpretation of results over time

• Limited if no data on micronutrients available• Differing needs of IDP’s.

Way Forward• Recommend nutrition surveys for 2007 will be based on seasonality from

previous analysis and will be conducted at livelihood level not administrative (except for IPD) to link with food security analysis

• Use of mapping/ segmentation rather that EPI for 2nd level sampling

• Use of uniscales to reduce measurement error

• Review Sentinel site data, ? Mean whz, interpretation of results

• Move away from estimates of malnutrition when recent surveys are not available to a statement reflecting a range of indicators

• Establishment of Somalia regional based experts in conducting nutrition surveys (UNICEF/ FSAU) when access is an issue

• Continue analysis in using non anthropometric indicators such as dietary diversity, meal frequency - easier to monitor also at community level.

• Review use of MUAC in rapid assessments,

• Discuss the possibility of conducting micronutrient deficiency prevalence assessment with FSAU/UNICEF/ WHO/MI, KAP.

• ? Roll out of new WHO Growth Curves

• ? Integration of Nutrition Information System into Gov/ … future??