Nutrition Surveillance in Somalia

By Noreen Prendiville

Noreen Prendiville has been involved in health, nutrition and food security programmes in East Africa over the past fifteen years and has a special interest in the subject of maternal health. Currently employed with FAO, she has also worked with UNICEF, WFP and various NGOs.
The support of Brian Thompson and Mark Smulders (FAO Rome) in the preparation of this article is acknowledged and appreciated.

Somalia has been without a central government for the past eleven years and has within its borders a number of areas that are highly vulnerable in terms of food insecurity. Civil insecurity, poor infrastructure and inadequate donor support have led to low levels of humanitarian support in the areas of greatest need. The southern and central regions continue to experience a level of insecurity that hampers long-term development and presents daily challenges to organisations involved in providing humanitarian assistance in the area. This paper focuses on the nutrition surveillance project in Somalia and describes some of the successes and challenges encountered over the past year. It also aims to highlight some of the issues related to working in areas of chronic disaster in the Horn of Africa.

The Food Security Assessment Unit

The Food Security Assessment Unit (FSAU)¹, is currently managed by the UN Food and Agriculture Organisation (FAO) with funding from the European Commission (EC) and USAID. It collects, analyses and disseminates information on the overall food and nutrition security situation in Somalia. Although based in Nairobi, plans for decentralisation and the establishment of bases in four or five areas throughout Somalia are being developed. A team of twenty-two field monitors assemble information on a range of indicators such as livestock health, rainfall and crop conditions as well as on issues like security, population movement and the general economy. Through its partners within the SACB (Somalia Aid Coordination Body) and local government, analysis and interpretation is undertaken and information disseminated through a variety of media. Within the FSAU, interpretation of food security issues has been strengthened through the use of the household food economy approach. This approach aims to describe how households access food and essential items in normal times and to understand the influences of changes in the wider environment on that access.

Nutrition survey in Southern Somalia

Following analysis of this information, the FSAU makes recommendations on the types of interventions most likely to have a positive impact on the availability and access to food. Such recommendations sometimes include food-aid but increasingly look for alternative options.

In an environment where reports on the humanitarian situation are unclear and sometimes conflicting, decision-makers frequently look to nutrition indicators for guidance in making judgements on the overall welfare of the population. In recent years there has been an increased interest in understanding issues related to food security and early warning systems have been developed to try to provide information on this. It is unfortunate however that because descriptions of food insecurity are weighed down with assumptions, conclusions can rarely be described as certain. This contrasts with the reports of high levels of malnutrition and the functional impairment that accompanies it. The rate of malnutrition therefore provides a clearer and less ambiguous assessment of the seriousness of the situation. The response of donors to a crisis is heavily dependent on evidence that the problem has already occurred. Decision-makers increasingly seek the kind of hard evidence produced by good quality nutrition surveillance information to make judgements on the level of impact on the population and on the kinds of action needed to be taken.

The Nutrition Surveillance component of FSAU

Efforts to develop nutrition surveillance activities have been undertaken by FSAU since 1995. In 1997, in collaboration with Action Contre La Faim (ACF), an Alert Site Surveillance Network was established. This system, which was largely based on growth monitoring at clinic level encountered problems related to coordination, support and funding. By 2000, little useful information was being produced. Co-ordination of other nutrition surveillance activities in Somalia was extremely weak and under constant criticism from partners within the Somalia Aid Coordination Body. Poor co-ordination of the agencies conducting surveys, lack of standardisation of approach and poor methodologies employed by agencies² were among the weaknesses identified.

In 2000, FSAU sought funding to strengthen the nutrition component of its work with an emphasis on improving the quality, reliability and coverage of the information collection system along with better interpretation of nutrition related information. With funding from USAID, the current nutrition surveillance component commenced in September 2000 under FAO management. Strong emphasis is given to the generation of good quality information on nutrition and the analysis of this information. As well as developing the capacity to collect this information, the system also aims to better utilise the information related to growth monitoring and supplementary feeding and other sources of anthropometric data generated at health facility level. The response to the project during the first year has been extremely positive and encouraging with both the requests for assistance and the need for support proving greater than originally anticipated.

The major aims of this surveillance project are to establish an efficient and effective nutritional surveillance system for Somalia by ensuring that:

• all nutrition surveys and food security assessments are undertaken according to standard commonly accepted procedures;
• all nutrition data are analysed and interpreted using relevant contextual data;
• nutrition related information is disseminated to potential users in appropriate user-friendly formats.

Nutrition surveys

FSAU has not undertaken independent nutrition surveys believing that surveys should be undertaken by those organisations that already have the capacity to do so and are able to use and respond to the situation realised through that information. However, FSAU provides expertise for the planning, training and analysis of nutrition surveys and has recently acquired additional funding to support partner agencies with inadequate resources. The FSAU has also started to play a lead role in the co-ordination of interagency surveys, with surveys conducted on more rigorous scientific criteria using unbiased and clear transparent objectives. This has led to the wider acceptance of results and to more realistic and broadly supported recommendations. Local government officers, NGOs, UNICEF, CARE and WFP have participated in recent surveys and, together with the communities, have participated in the analysis, discussion and recommendations. This initiative needs strengthening in a number of ways for example, by reaching agreement on the roles and commitments of all partners prior to the survey. In the future, it is hoped that routine surveys in 'normal' times will be implemented and will lead to a better understanding of the underlying problems related to malnutrition and also provide more realistic baselines, from which to better judge any deterioration during times of crisis.

The current role and perceptions of health facility data within the FSAU

Women pounding maize

While recognising the limitations in the use of data generated at health facility level, much time and effort has been invested by the FSAU in recent years in supporting growth monitoring at health centre level and the development of a database for the analysis of that data. The original intended output was the generation of nutritional status trends data from health facilities that would allow monitoring of changes in nutritional status of the population. Data from health facilities collected in this way was not intended for use in isolation but as a stimulus for the questioning of any changes in malnutrition rates - or a (downward) shift in trends.

However, because the changes in malnutrition trends recorded at health facility level can have such a wide variety of causes e.g. population movement, changes in health personnel, absence or availability of supplementary food or other supplies, as well as genuine increases in the number or severity of cases caused by a particular food security or health crisis, the FSAU attaches only limited importance to these data in the overall analysis of the food security situation. Furthermore, in situations where a substantial number of children do not present for routine screening or growth monitoring, the extrapolation of health facility information to the surrounding population should be attempted with caution.

On the positive side, through the process of strengthening health centre based surveillance, health facility personnel are improving their understanding and skills related to the assessment of malnutrition at both individual and population level. Furthermore, because channels of communication have been established through the FSAU, health centre reports of worrying trends are followed-up by FSAU who are in a position to cross-check the reports through Field Monitors and rapid surveys. Feedback to the health facilities of the graphs produced with the information provided by them has now commenced and is proving to be a useful tool in the promotion of more accurate data collection and in the interpretation and analysis of the trends at health facility level.

In addition to more detailed nutritional surveys and health centre data, it was hoped that MUAC screening by FSAU Field Monitors could become a valuable component of nutrition surveillance. In the past, many of the Field Monitors have rejected this idea because of the perceived link between nutrition assessments and food aid input which they felt could compromise their normally low-key presence in their areas of responsibility. This concept may yet be introduced by commencing the activity with Field Monitors in areas of the country that do not have a strong tradition of food relief.

During the past six months information on nutritional status generated as part of the FSAU nutritional surveillance project has been used as:

• A tool in crisis mitigation through enabling the identification of appropriate and timely responses to a variety of threats e.g. in Lower Juba during early 2000³.
• An indicator of the overall health and welfare of populations in the absence of other health information monitoring systems.
• A key information source for decision makers within the humanitarian response body of UN Agencies, NGOs and donors ('informing the aid response')⁴.
• A food security indicator, demonstrating the impact of a variety of climatic, environmental and political influences on the population,
• Part of a system for monitoring the impact of relief interventions⁵.

In addition to the above, the project responds to the needs of other key users of the information:

• The health facility based information providers who receive graphic feedback of the data to assist in the analysis and interpretation of trends in nutrition status in the population in the catchment area of the facility.
• Global nutrition monitoring systems such as the WHO Global Data Base on Child Health and Nutrition who regularly request and use information provided though the FSAU nutrition project
• Regional information systems for analysis and discussion such as the PFEDA (Partners in Food and Emergency Development Aid) website.
• Partners in neighbouring countries. Frequent contacts are made with partners in Kenya and Ethiopia for exchange of information and discussion of common problems.

Regional communication

Exchange of information and discussion of common problems between FSAU and partners in Ethiopia and Kenya has been useful. This relationship has not been formalised and the potential exists for greater development and institutionalisation of the relationships which have up until now depended upon personal contacts. Areas for further development include the standardisation of nutrition survey methodology among countries and identification of specific information needs with the ultimate aim of reaching agreement on common programming approaches.

Communications have been recently established with neighbouring countries including the following exchanges:

• From Ethiopia - for information on micronutrient deficiencies on Ethiopia / Somalia border populations.
• From the FSAU - for information on nutrition survey results from Ethiopia/Somalia border areas in order to understand reported high rates in Ethiopia compared with relatively little malnutrition on the Somalia side.
• From the FSAU - for information from Ethiopia regarding relief activities in Ethiopia that appeared to be influencing population movements in border areas.
• From partners in Kenya - regarding nutrition surveys in border areas due to lack of access to border areas inside Somalia (as in the case of North East Province in Kenya and the neighbouring Lower Juba and South West Gedo region).
• From organisations in Kenya to share information and discuss micronutrient deficiencies in North Eastern Kenya.
• From South Sudan - to share information on the FSAU nutrition surveillance project while in the process of establishing a surveillance system there.

Other positive developments in the nutrition sector in Somalia have been:

• The agreement of all partners in the SACB on the use of standard nutrition survey guidelines. Major donors have supported this initiative by including it as a condition in their funding contracts.
• The 'Nutrition Working Group', which is part of the Health Sectoral Committee of the SACB, is used as a forum for reviewing reports and for the development of recommendations for appropriate action. This public and critical process of peer review has significantly improved the quality and therefore the usefulness of nutrition surveys.

The Role of Nutrition information in Early Warning Systems?

Nutritional status is a result and outcome of a stressful situation and has been shown to respond in a sensitive and timely manner to the intensity and nature of the shock. The fact that a deterioration in nutritional status indicates that a problem already exists has led some observers to conclude that nutritional status is therefore a 'late warning', not an 'early warning' indicator. However, from an operational early warning point of view if surveillance systems are sensitive enough to detect early changes in nutritional status then such changes may occur and be discerned before other types of 'change' are noted, e.g. market prices, unseasonal migration, etc. This has been shown in many countries. Nutritional status is not intrinsically a late indicator in terms of early warning of food crisis as populations change dietary patterns early on in response to food stress (real or anticipated).

Ultimately, it is the sensitivity of the surveillance system which determines whether it is or is not a late indicator. The FSAU is working towards establishing a nutritional surveillance system which can detect early changes in nutritional status at population level.

Cut-off values in surveys: what is 'normal' in a country where there is chronic food insecurity

Migrating in Northern Somalia

According to pre-1996 reports, the people of Southern and Central Somalia experienced malnutrition rates of between 10 and 15%⁶ outside times of crisis. In times of recent crisis (February 2000), this malnutrition rate has risen above 30%. Surveys with high levels of global malnutrition in Bakool Region have also shown high levels of severe⁷ malnutrition (around 6%), representing a high proportion of children under five that are facing a high risk of death. A high incidence of diarrhoeal disease and low immunisation coverage for measles further increases this risk.

Despite the fact that South and Central Somalia have enjoyed relative food security over the past year, the (few) nutrition surveys undertaken seem to hover around total malnutrition rates of around 15% (<-2 Z scores). In the minds of many, numbed by continuously high malnutrition rates, these kinds of rates have increasingly been accepted as 'normal'. A question that then arises is: if we accept a prevalence of wasting of 15% as 'normal', what even more unacceptable and appalling level of death and morbidity should be judged to be appropriate for triggering an intervention.

Trigger levels for action should be determined by two factors; (i) the level of functional incapacity caused by malnutrition in terms of mortality, morbidity, the ability to do work, and to grow and develop and (ii) the level of resources we have available to us; not the level of degradation that is considered to be "historically normal" for any one group. This is tantamount to double standards. We cannot entertain that a certain level of support be given to one population group but not for another group in similar circumstances because they have always had it bad. Recognising that situations require a graded response, with resources being directed preferentially to the worst cases or areas of nutritional deprivation it can be expected that programmers and field staff will have to focus priority attention on those areas that exceed certain "normative" values. It is clear that in order to address these high rates of malnutrition, all three aspects of food security; availability, access and utilisation need to be addressed in the Horn of Africa.

Challenges for the future

In a country like Somalia, which has been in the grip of a chronic disaster for many years, the greatest vulnerability and suffering frequently occurs in areas of greatest physical insecurity and therefore where there is lowest potential for collecting reliable information and making appropriate interventions. A question that arises is whether it is acceptable to lower our standards for quality of information and if so at what cost? The long-term commitment of the FSAU to strengthen the quality of nutrition information coming out of Somalia is borne out of the recognition that nutritional information has a potentially critical role in terms of advocacy, early warning and impact assessment. However, it is also recognised that nutritional information must always be complemented by other contextual information to ensure a comprehensive understanding of what such data are telling us.

¹The FSAU was established in 1994 by the UN World Food Programme and USAID. The third project phase, of three years duration, commenced in May 2000 under FAO implementation, and funded primarily by the EC.

²Shoham.J and Kanyanga.J (1998). Review of the Somalia Food Security Assessment Unit. Report for Oxford Policy Management.

³Interagency nutrition survey was undertaken in Jamame, after which conclusions and recommendations were discussed with and agreed on with the community and the main implementing organisations. Decision to distribute food aid and to support supplementary feeding for a very specific period was agreed.

⁴Information from the nutrition project is frequently used in documents supporting requests for funding.

⁵Levels of malnutrition in and outside times of crisis have provided an input into examinations of the likely impact of interventions.

⁶Moderate malnutrition; below minus two standard deviations from median weight for height of reference population.

⁷Severe malnutrition; below minus three standard deviations from median weight for height of reference population and/or nutritional oedema.