Somali Region Ethiopia

Summary of situation report

Two consultants from UNICEF and WHO carried out an assessment of the emergency response in the Somali region of Ethiopia in August this year¹. The objectives of the assessment were:

1. to provide an overview of the humanitarian response to date, and
2. to outline the major problems hindering an effective response.

The methodology for the assessment consisted first of the collation of various survey reports and assessment reports of non-government organisations (NGOs), the Disaster Preparedness and Prevention Committee (DPPC) and United Nations (UN) agencies. This was followed by interviews with key informants such as agency directors, medical co-ordinators and nutritionists and finally, field visits to Gode zone, Jijiga zone and Shinile zone.

The Somali region in Eastern Ethiopia comprises 9 zones and has a population of approximately 3.76 million, the majority of whom are pastoralists and agro-pastoralists. The area is remote and isolated from the highlands. Three consecutive years of poor rainfall had adversely affected agricultural yields and the condition of pastures. This led to a gradual depletion in food stores, livestock and other household assets and severe deterioration in household food security. As a result, the prevalence of acute wasting in the population under 5 years of age reached critical levels in many parts of the Somali region in early 2000 and remained of serious concern in some areas. There was also evidence that crude and under-5 mortality rates had increased and passed the thresholds used to define an emergency.

Findings of the Assessment

Nutritional Surveillance

There is no formal nutritional surveillance system covering the Somali region. In many other regions of Ethiopia, the early warning department of the DPPC in conjunction with SCF-UK monitor the nutrition and food security situation through the Nutrition Surveillance Programme (NSP). The NSP is a longitudinal monitoring system that utilises a standard set of food security, agricultural and anthropometric indicators to track changes over time. The anthropometric indicator that has been used by the NSP is mean weight for length (MWL) of the population. A cut-off point of 90% MWL has been used by the DPPC to define population nutritional vulnerability and the need for external food aid. Even though the NSP has not been formally operating in the Somali region, the MWL indicator had been used by a number of non-government organisations (NGOs) and by the DPPC itself as an indicator of nutritional vulnerability. Because MWL reflects the population mean and not the proportion of children falling below internationally recognised cut-offs for the definition of wasting, the MWL alone is an inadequate indicator of nutritional vulnerability in an emergency situation.

In addition to the MWL and standard anthropometric indicators such as weight for height Z-score and percentage of the median, other anthropometric indicators used in the region include Mid Upper Arm Circumference (MUAC) and MUAC for height (QUACK stick). The different indicators used made comparison from zone to zone or region to region difficult and international comparisons or longitudinal monitoring over time virtually impossible.

Sampling methods for nutritional surveys had also varied considerably; the minority of surveys had been formal 30 clusters surveys employing the standard EPI methodology. Rapid assessments usually reporting MUAC, results from the screening of beneficiaries of supplementary feeding programmes, or convenience samples of children less than 5 years of age measured at a central village location were frequently employed. Survey methods that do not employ random sampling are prone to selection bias and the interpretation of results is extremely problematic.

The majority of anthropometric information had been collected by NGOs operating in the southern zones of the Somali region.

Few surveys attempted to identify underlying causes of malnutrition. There was however, evidence suggesting that high morbidity due to diarrhoeal disease, exacerbated by unusual population concentrations and poor water and sanitation conditions, had negatively impacted on the overall nutrition situation.

Selective Feeding Programmes

In response to the high prevalence of malnutrition, international and national NGOs commenced selective feeding programmes throughout the Somali region from April to July 2000. The coverage and type of programmes varied widely within and between zones. Disparity in coverage can be partly attributed to security constraints and partly to differences in population size between these zones. However, given that malnutrition prevalence rates in all five zones had been extremely high, it appears that Gode zone and Gode woreda in particular were over-targeted while other zones were relatively under-served.

In the absence of current guidelines from DPPC or the MOH for therapeutic feeding and insufficient institutional support, NGOs used their own criteria and guidelines. Not surprisingly the quality of care provided by less experienced NGOs did not always meet minimum standards; some of the problems observed in TFCs included:

• Admission criteria were variable and often inconsistent (for example, MUAC and weight for height criteria were intermingled, children were admitted who had another illness such as tuberculosis but were not severely malnourished etc.).
• Routine medical treatment was sometimes inadequate and not in line with standard protocols in respect of measles vaccination, micronutrient supplementation, treatment of intestinal parasitosis, systematic treatment of infections with oral antibiotics.
• Feeding protocols varied and types of food provided were frequently not in line with Sphere/WHO recommendations. Of particular concern was the misuse of BP-5 biscuits which have an inappropriately high protein content for the early phases of therapeutic feeding and should not be given as a take-home ration overnight because of the high probability of them being shared or sold.

Supplementary Feeding Programmes (SFPs) were also disproportionately represented in Gode zone, particularly Gode woreda, when compared with other zones. Again in the absence of guidelines and coordination, admission and discharge criteria and target groups varied widely. In addition, although levels of global malnutrition and the inadequate General Food Ration (GFR) would have justified (at least temporarily) blanket distribution of dry supplementary feeding to all children less than five years of age and pregnant and lactating women in many zones. Only two agencies engaged in such programmes. Problems with the supplementary feeding programmes included the following:

• Provision of health care (routine immunisation, ORT, vitamin A supplementation) did not always meet minimum standards.
• In Gode in particular, catchment areas of SFP overlapped and because distributions were not on the same days, an unknown but perhaps substantial number of beneficiaries registered in more than one feeding programme.

Food Security

Many assessments addressing differing facets of food security had been carried out since the first reports of the deteriorating situation in the Somali region. However, because the Somali region is not covered by the NSP there is a lack of base-line food security data that makes this information difficult to interpret.

NGOs included aspects of food security in nutrition surveys but this information could not substitute for a comprehensive food security monitoring system in a region where geographic variability is so pronounced.

General Food Distribution

A variety of constraints resulted in an uneven and sometimes insufficient distribution. Verification was difficult in the absence of accurate statistics on populations (and movements) or on food allocations and distribution. A system of post distribution monitoring at the distribution point and/or household level had not been implemented.

Initially, the zonal DPPC used official population statistics to identify affected numbers and eligible beneficiaries. Although in theory certain groups did not qualify for food distribution, in practice food was distributed to all people counted on the day before a distribution.

New food allocations were based on head-counts from previous distributions. As populations were attracted to areas with a reliable GFR, the amount of food allocated did not always match the eligible number of beneficiaries present during the new round of distribution.

Reliable figures on the amount of food distributed were difficult to obtain. Due to a complicated and fragmented information system with most data only available at the central levels of DPPC and WFP, allocation, dispatch and distribution figures could only be compared months after actual distribution took place. Furthermore, WFP and implementing partner on site monitoring during head-counts and distributions was extremely limited due to security restrictions, insufficient (air) transport and insufficient logistic or human resource capacity. Also, despite attempts to improve information sharing and co-ordination, neither DPPC/B nor WFP managed to incorporate in its distribution figures, food distributed by other organisations.

Summary Problem Analysis

The overall problems with the humanitarian response in the Somali region relate to the lack of a comprehensive surveillance system and the lack of a suitable coordination mechanism and therefore the lack of an integrated response. The DPPC/B whose mandate was to co-ordinate the response lacked sufficient technical and human resource capacity to fulfil this role.

While some therapeutic and supplementary feeding programmes are of excellent quality, many also do not meet minimum standards. The fact that the quality of these programmes remains poor reflects the overall lack of nutrition co-ordination and monitoring.

The lack of a comprehensive nutrition surveillance system has resulted in a failure in targeting of food aid to the most vulnerable geographic areas and adjusting priorities according to needs. It has allowed some areas such as Gode to attract a relative surplus of food items, selective feeding programmes and support in the health sector, while other areas such as Shinile and Jijiga zones have remained with grossly inadequate assistance in these sectors and an ongoing nutritional emergency.

Finally, a major problem in assessing the food situation has been the absence of accurate statistics on populations (including the displaced) and food distributions.

¹Peter Salama, UNICEF/ IEHRB(CDC) , Albertien van der Veen, WHO/ORHC, Report on the Food and Nutrition Situation in Gode, Fik, Korahe, Jijiga and Shinile zones of the,Somali Region, Ethiopia, August 11, 2000