Integrated Management of Acute Malnutrition (IMAM) scale up: Lessons from Somalia operations

By Leo Anesu Matunga and Anne Bush

Leo Matunga is currently the nutrition cluster coordinator for Somalia. He has over 12 years experience working in nutrition in emergencies in Somalia, Zimbabwe, Sudan and Pakistan. He has experience working in government, international NGOs and UN agencies. He holds a Masters in Public Health from University of Western Cape, South Africa, a Masters in Development Studies from Leeds University (UK) and a BSc in Nutrition Studies from the University of Zimbabwe.

Anne Bush is a freelance consultant, engaged by the ENN to support write up of this article for the CMAM Conference. She has over 15 years experience working in the field of international public health nutrition in Kenya, Somalia, Tanzania, Ethiopia, the DR Congo, and Indonesia. She holds a Masters in Public Health from the London School of Hygiene and Tropical Medicine and a BSc in Dietetics.

The authors acknowledges the immense contributions of UNICEF Somalia, WFP Somalia, Ministry of Health officials in the Government of Somaliland, Ministry of Health officials in Government of Puntland, Ministry of Health Officials in The Transitional Federal Government, local and international organisations working in Somalia and the Nutrition Cluster team.

Brief history and background

Somalia has been in a state of armed conflict since 1988, and has been without an effective government since the fall of Siad Barre in 1991, representing the longest case of state collapse in modern times¹. Two decades after the collapse of the unified state, Somalia continues to endure protracted armed conflict and a major humanitarian crisis, currently exacerbated by a severe drought and floods. The recent failure of the deyr 2010/11 seasonal rains and the lighter than normal gu rains has resulted in an estimated 32% of Somalia’s 7.5 million people being in need of humanitarian assistance, including approximately 910,000 internally displaced persons (IDPs).

Somalia is an arid country of 250,000 square miles, consisting of three main zones with varied social, livelihood and economic structures. These are:

• the North-west zone (NWZ), also known as Somaliland, comprising Woq Galbeed, Awdal, Togdheer and Sool/Sanaag regions
• the North-east zone (NEZ) also known as Puntland that includes Bari and Nugal regions
• the South Central zone (SCZ) comprising Mudug, Galgadud, Hiran, Bakool, Bay, Shabelle, Juba and Gedo regions.

Somaliland and Puntland both recognise themselves as independent states and are pushing for international recognition as such. Somaliland and Puntland border each other across the contested regions of Sool and Sanaag and occasional border clashes do occur. The SCZ, by far the biggest zone in the country, has an estimated population of 4,810,837, more than 60% of the whole country population. Continued displacement as a result of the ongoing civil conflict in the SCZ has resulted in IDPs from the epicentre of the conflict in Mogadishu and neighbouring areas dispersing over the country, with many returning to their ancestral clan homeland. Although Somalia is formed of a predominantly single ethnic block, the elaborate clan system holds the checks and balances of the country.

The country’s main livelihoods are pastoral (sheep, goats, camels), agropastoral, riverine, fishing, urban and IDP livelihoods. It is estimated that the country receives roughly in excess of 1 billion dollars in remittances from diaspora annually.

Southern and central Somalia have some of the worst social indicators in the world, with over 43% of the population living on less than $1/day,² as well as some of the worst rates of under-five and maternal mortality. Despite the extensive need, a narrowing of humanitarian space has made it virtually impossible for aid organisations to reach many of the people in need.³ The lack of central government means in effect working with three different health authorities and to an extent, involves three different approaches.

Acronyms:
BSNP	Basic Nutrition Services Package
CAP	Consolidated Appeals Process
CERF	Central Emergency Response Fund
EPHS	Essential Package of Health Services
FSNAU	Food Security and Nutrition Analysis Unit
HIS	Health Information Systems
HSS	Health System Strengthening
IDP	Internally displaced persons
IMAM	Integrated Management of Acute Malnutrition
MCH	Maternal and Child Health
MOH	Ministry of Health
NWZ	North-west zone
NEZ	North-east zone
OTP	Outpatient Therapeutic Programme
PCAs	Programme Cooperation Agreement
SCZ	South Central zone
SC	Stabilisation centre
ToT	Training of Trainers
TSFP	Targeted Supplementary Feeding Programme

 

Socio-political operating environment

Since the collapse of central government in 1991 and the resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991, the NWZ declared the independent state of Somaliland, with its governing administration in the capital Hargesia. The region is autonomous, holding democratic elections in 2010, but is not internationally recognised. The NEZ declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that should occur. In South Central Somalia, political conflict and violence continue to prevail, despite attempts to establish and support a central governing entity.

National nutrition and health situation - some history

Twenty years of war and insecurity have had devastating effects on the nutrition and health status of the people of Somalia. The combination of conflict, insecurity, mass displacement, recurrent droughts and flooding and extreme poverty, coupled with very low basic social service coverage, has seriously affected food security and livelihoods and greatly increased vulnerability to disease and malnutrition. The Millennium Development Goal (MDG) health-related indicators are among the worst in the world. Life expectancy is 45 years. One child in every twelve dies before the age of one year, while one child in seven dies before the age of five.

Pre-1991

The pre-war period (before 1991) in Somalia has little background information on the health and nutrition status among representative populations in Somalia. Studies during this period tended to focus on distressed populations, usually in drought affected areas. Various methods and reporting formats were used and a lot of health and nutrition records were lost during the fighting, making it difficult to trace survey reports so it is difficult to establish any baseline data for this period⁴. From 1980 to 1990, nutrition assessments conducted by different agencies in Somalia indicated varying levels of global acute malnutrition (GAM) based on weight-for-height % of median (WHM). Most surveys found a GAM prevalence of below 15% (WHM < 80% or oedema) although there were fluctuations with regular reports of a worrying nutrition situation.

Post-1991

The collapse of the government in the early nineties and the subsequent conflict marked a severe deterioration in the nutrition situation. The highest ever levels of GAM in Somalia were recorded in numerous surveys conducted in 1991 and thereafter.

With the civil conflict and the famine in 1991/92, coping strategies were severely eroded for the majority of the population. In 1991- 1992, a devastating famine hit southern Somalia and led to mass starvation, resulting in rates of acute malnutrition (WHM) of 55-70% in Bay-Bakool and Gedo regions and 45% in Hiran region. These regions that were most affected by the famine are still the regions where the highest rates of acute and chronic malnutrition continue to be reported.

A note on GAM thresholds

All nutrition surveys conducted in the prewar period estimated prevalence of acute malnutrition based on percent of the reference median. Z scores, which estimates prevalence of acute malnutrition based on standard deviations from the mean, were introduced by WHO globally in 1992. The application of the >15% GAM threshold to classify an emergency nutrition situation is only relevant for nutrition surveys conducted using the Z score reference. However, even though direct comparison between assessments conducted before and after the introduction of the concept of Z scores is not intended, trends of malnutrition between 1993 to 2000 demonstrate a persistent poor nutrition situation with results of >15% GAM, being reported in many parts of the country.

Development of the Food Security and Nutrition Analysis Unit (FSNAU)

Following the collapse of the central government in 1991 and the persistent conflict in Somalia, the country’s institutional capacity has been lost, with little to non-existent field monitoring systems in place. The FSNAU⁵, which is based in Nairobi and has been funded by a variety of donors including UN agencies, was formed in 1994 initially to provide food security situation updates to humanitarian response agencies. From 2000, the nutrition component was incorporated to provide up to date information on the evolving nutrition situation, to guide response within the context of a complex emergency (see Box 1). The FSNAU has adapted to the situation in Somalia over the years by developing an extensive network of trained Somali national enumerators and skilled Somali national field analysts spread throughout the country to reduce the dependence on international staff. FSNAU has also spearheaded adoption and implementation of standard assessment guidelines and an analytical framework by the Nutrition Cluster.

 

The FSNAU analysis can inform the targeting and nature of response, but does not necessarily have the capacity to monitor the effectiveness or impact of that response - these tasks therefore fall under the mandate of response agencies. FSNAU international staff have limited access to parts of Somalia because of UN security regulations and where access is permitted, essential security measures and methods of travel are often costly and time-consuming.

Results from FSNAU meta analysis of data from 2001 to 2009 show that over this period, median rates of GAM have remained at serious (10 to <15%) or critical (15 to <20%) levels (WHO Classification 2000) throughout with a national median rate of 16% (see Figure 1). Furthermore, annual national median rates of stunting were above 20% i.e. at serious level throughout the period 2001 to 2009, according to WHO classification (2000), as shown in Figure 2.

Results of the meta-analysis also highlight how the situation has been consistently worse in SCZ than Puntland or Somaliland. In SCZ, median rates of stunting were found to be 29.7% and wasting 18%. This compares to 20% stunting and 17% wasting for Puntland and 18% stunting and 13% wasting for Somaliland (see Figure 3). This reflects the devastating effect of chronic political conflict and insecurity in SCZ in particular.

Rates of malnutrition also vary according to thelivelihood system. Results of the FSNAU meta-analysis of data 2001-2009 revealed that riverine and agro-pastoralist groups had the highest median rate of wasting, stunting and underweight. This suggests a higher nutritional vulnerability to shocks such as floods, drought, displacement and disease outbreak. Rates of malnutrition among the urban population tended to be lower, reflecting better access to a diversified diet and to public services, including health.

The 2009 National Micronutrient and Anthropometric Nutrition Survey, conducted in all three zones, highlighted that micronutrient malnutrition is a significant public health problem throughout Somalia. The prevalence of both nutritional anaemia and vitamin A deficiency among women and children of all age groups was found to be above WHO thresholds for classifying a severe situation in each of the three zones (see Figure 4).

Emergency situations: frequency and severity

The food security and nutrition situation in Somalia is characterised by chronic and recurring emergency situations resulting from repeated episodes of drought, flooding, conflict and displacement. Communities have little chance to recover between crises. The frequency and severity are exacerbated by the absence of strong government and lack of humanitarian space. The maps in Figure 5 show the progression of the estimated nutrition situation from Deyr 2006/07 to Gu 2011.

Political will and policy environment

Political will and support for nutrition is relatively strong in Somaliland and, to a lesser extent, Puntland. It exists for the Ministry of Health (MOH) SCZ but control is largely limited to Mogadishu (see later).

There is no national nutrition policy but the Somali Nutrition Strategy for 2011 to 2013 has been developed. The strategy identifies key priorities and the need for a shift to a more integrated multi-sectoral approach to addressing malnutrition in Somalia. Integrated management of acute malnutrition (IMAM) is identified as a key approach and as programmes for the management of acute malnutrition are reasonably well funded, it is highlighted as an important delivery platform through which to deliver complementary activities. The strategy defines overall goals for the entire country and has been endorsed by the MOH of all three zones. Zonal action plans for the implementation of the strategy are to be developed and costed and will boost compliance at sub-national level. Funding remains a challenge.

Nutrition outcomes are not yet included in sectoral policies and programmes but the Somali Nutrition Strategy is trying to highlight nutrition issues at policy level.

Somali specific IMAM guidelines were developed through the Nutrition Cluster in 2010 and a Basic Nutrition Services Package (BSNP) has been defined and encouraged, also through the Nutrition Cluster. However, whilst many agencies are adopting the approach and include it within activities outlined at proposal level, many organisations find it difficult to conceptualise or lack the capacity to deliver.

MOH systems and structures - where nutrition fits

After twenty years of conflict, the health care system in Somalia remains underdeveloped, poorly resourced, inequitable and unbalanced. The public health care delivery system operates in a fragmented manner, maintained largely by medical supplies provided by UNICEF and other agencies. In the absence of an efficient and adequate public health system, the private sector has flourished but remains unregulated with poor quality of services and poor access to the rural population. Over half of the estimated health workforce is unskilled and unsupervised and staff are paid a below subsistence wage. Most public facilities operate at a level far below their intended capacity and are poorly organised, with very low utilisation rates (estimated as on average, one contact every eight years⁶).

In Somaliland there is a functioning MOH and political will exists. Nutrition has been identified as a key priority area by the Minister of Health and the nutrition focal person within the ministry is motivated and active. Key staff have been appointed at Hargeisa level, and at regional and district levels. Thus a ‘traditional’ MOH structure is in place but remains financially dependent on support from UNICEF and other agencies. In Somaliland, 34 outpatient therapeutic programmes (OTPs) and four stabilisation centres (SCs) are delivered through government health facilities.

In Puntland, political will and support is present to a lesser extent, with health receiving a greater focus than nutrition, primarily due to the qualifications and background of the nutrition focal person. There is willingness to work with UNICEF support on nutrition and government will respond if funding is available. Ten OTPs operate through government health facilities.

In SCZ, the MOH recognises nutrition and ‘allows’ UNICEF and its partners to implement programmes but the public health structure and functioning is largely confined to Mogadishu. Delivery of IMAM programmes through government health facilities is limited to one SC in Mogadishu where hospital staff support the implementation of an otherwise independent centre.

Where OTP services are operating through government health facilities, the services are delivered by MOH staff but they are given financial incentives by humanitarian players. Where MOH is implementing with little staff support, reporting is provided by MOH alone. Where greater levels of support are provided, reports are provided by the supporting NGO. Whether reporting is conducted by MOH or a humanitarian agency, reports are generally delayed. Efforts are currently underway to train staff to strengthen reporting.

Implementation of IMAM in Somalia

The implementation of all four components (community mobilisation, SCs, OTP and targeted supplementary feeding programme (TSFP)) of programmes for the management of acute malnutrition in an integrated way is not always feasible in Somalia. Existence of and access to SCs is limited, such that the ideal programme set up of OTP with SC services available (either attached to a hospital or stand alone) are usually only seen in towns in Somalia. The more common set up is a network of several OTPs with limited possibility of referring complicated cases to SCs. The lack of SC services may be due to distance to the nearest facility, or due to lack of access for other reasons (e.g. transport, clan issues, inability to leave the family for a full week or insecurity). OTPs may or may not be integrated with SFP. In some areas, SFPs are implemented in the absence of OTPs or SCs. In these cases, the centres may admit all malnourished children regardless of their severity.

During the initial expansion of IMAM, programmes were implemented according to operational guidance developed by Nutrition Cluster partners in 2005. In 2010, new guidelines were developed and endorsed by the Nutrition Cluster. These guidelines, initially promoted by UNICEF and the Somali Nutrition Cluster, have been written in consultation with all organisations, departments and agencies implementing programmes to manage acute malnutrition in Somalia. This was done with the intention of capitalising on best practices and experiences, so that lessons learnt by one can be applied by all partners. The guidelines intend to facilitate the process of training new staff and to help with the opening of new centres. These guidelines try to take specifics of the Somali context into account, whenever possible, and give practical suggestions for often difficult circumstances e.g. lack of SC referral site. Field cards have been developed with the aim of being laminated for use in the field. So far, the application of the 2010 guidelines has been limited due to problems in the process of translation into Somali. Some sections have been translated for training purposes.

Some of the specific challenges that IMAM faces in Somalia are:

• Conflict
• High insecurity
• High mobility of population (including health staff)
• Spread of the population, with long distances and isolation
• Difficult transport and communications
• Population displacement (and the inability of IDPs to access services in some host areas)
• Regular migration among pastoralists
• Difficult social environment related to complex clan structure
• Specific conflicts between clans
• Rigid traditional family structures that rely heavily on women's work
• Lack of health infrastructure
• Lack of training infrastructure and there fore chronic lack of qualified health staff
• In some areas, the need to pay fees to access the health system and consequently, lack of access to services.

These challenges result in many problems including:

• Inadequate number of centres to have good geographical coverage of programmes
• Low coverage, even in areas that are theoretically served by a centre
• Lack of referral of complicated cases to SCs for life-saving treatment
• Frequent and unpredictable break-downs in the supply chain
• Discontinuity of programmes in some areas, with regular closure and re-opening of programmes
• Irregular and often inconsistent community mobilisation
• Overall fragmentation of aid and of other interventions to prevent malnutrition
• Low qualification of staff and difficulty to hire new health staff when needed
• High turn-over of staff
• Difficulty in supervision, on-site monitoring or on-the-job training
• Costs for families attending health and nutrition services regularly
• Fear of mothers to attend due to insecurity and volatility of the situation.

Scale up of IMAM in Somalia

IMAM first began implementation in Somalia in 2005/6 with several international agencies adopting the approach in line with increasing global recognition of the benefits and effectiveness of community based management of acute malnutrition. Since then, an impressive expansion of IMAM services has been achieved, with no particular Somali specific trigger or strategy to the scale up. In 2006, around 30 OTP and TSFP sites were providing IMAM services, increasing to around 250 OTPs in 2010. At the time of writing (Sept 2011) there are currently 25 SCs, 461 OTPs and 662 TSFPs being implemented throughout Sosmalia. There are plans to add nine new SCs, 58 OTPs and 138 TSFPs in the coming month to cover some of the identified gaps. Services are supported primarily by UNICEF and WFP, implemented in partnership with local NGOs and also by international NGOs. The number of sites continues to change with scale up plans in response to the current humanitarian emergency. The current rapid scale up has been able to build on the success of the expansion over the previous three to four years and includes greater emphasis on the use of mobile teams and community health workers.

Figure 6 demonstrates the extent of expansion of UNICEF Nutrition services throughout Somalia since IMAM was first implemented in 2006.

Maps 1 and 2 illustrate the scale up of IMAM services, comparing services provided in September 2007 with those of July 2011, in response to the changing food security and nutrition situation.

There are currently 96 Nutrition Cluster partners providing nutrition services throughout Somalia, 65 are local Somali NGOs and 23 are international NGOs⁷. The remaining partners are UN agencies or MOH centres. In addition to Nutrition Cluster partners, nine OTP sites are being implemented by MSF operations.

Funding

Currently, most funding for IMAM services is short term, although there are some donors now looking at multiple year funding. There is limited development funding for nutrition in Somalia.

Funding mechanisms available are:

• Bilateral donors - ECHO⁸, DFID (UK Department for International Development) and UNICEF fund agencies to run projects directly.
• Common Humanitarian Fund (CHF) emergency reserve - 20% CHF allocation is set aside for unexpected emergencies arising.
• CHF second allocation - funding mechanism for high priority projects within the CAP (Consolidated Appeals Process) that have not received bilateral funding. It is not available to projects not included in the CAP.
• The Central Emergency Response Fund (CERF) -Somalia is one of six countries selected for CERF underfunded emergencies allocation.

Donors are doing all they can to provide funding to UN agencies and NGOs. Little funding goes to the government in SCZ but quite substantial amounts are directed through the governments in Somaliland and Puntland.

The CHF funding pool has been established by donors to provide funding to humanitarian players, especially local NGOs managed through the cluster system. CHF funding is available to high priority projects included within the CAP. Proposals are prioritised by the Nutrition Cluster Review Committee according to a set of criteria. These criteria include region of priority, the presence of complementary preventive activities, inclusion of capacity building activities and cost per beneficiary. The availability of CHF has increased considerably the amount of funding being accessed by local NGOs. Some international NGOs are also accessing bilateral aid directly from donors.

In Somalia, there are risks associated with scale-up. With the current crisis, funding is available and rapid expansion of services is ongoing. However, funding is usually 6 to 12 months maximum with no guarantees of continued funding thereafter. To date, there are no programmes that have been stopped due to this but it remains a concern.

The short term nature of funding for IMAM presents several challenges. First, it can lead to the ‘start-stop’ approach and disruption of services and limits the development of more sustained services for IMAM in Somalia. Short term funding mechanisms limit the possibilities for taking a longer term approach to the management and prevention of acute malnutrition. Malnutrition in Somalia is both an acute and chronic problem with multiple underlying causes that cannot be addressed through short term programmes. Even outside years of crisis, GAM rates remain high suggesting the importance of longer term underlying causes, for example inappropriate infant and young child feeding (IYCF) practices. Capacity is a major issue that requires longer term commitment to address in a more sustainable manner.

Secondly, it affects the way programmes are implemented and results in a tendency for organisations to try to implement as many activities as possible in the shortest time, rather than engage in a more gradual process of establishing a programme and introducing different components as needs and capacities are fully understood and realised. This is not necessarily the best way of achieving maximum impact. Trying to do everything at once may be too much, in particular where local implementing partners lack capacity.

Sources and opportunities for self funding in the future are limited and remain a long way off. In Somaliland and Puntland, the regions where stronger governance structures are in place and self funding could one day be more realistic, the governments are not recognised internationally. Furthermore, the governments’ revenue base is very dependent on taxes to civil service and exports of livestock to the Middle East. With the drought having affected livestock, this revenue base has dwindled significantly, thereby squeezing the already cash strapped governments.

Supplies and logistics

Challenges

The Somalia operation has experienced problems with suppliers of RUTF resulting in the need to switch supplier, causing some pipeline delays. Local production in Somalia is not an option. Furthermore, there are logistical challenges in sending nutrition supplies, especially Corn Soya Blend (CSB), to various parts of the country due to numerous difficulties including active conflict, mines, rains, and multiple and changing authorisation requirements of local authorities. Logistics are further complicated by the control of access to many areas by Al Shabab and the closure of the border between Somalia and neighbouring countries. Figure 7 maps the UNICEF logistics hubs. In the insecure environment, looting of stocks in country means pre-positioning in Somalia is not possible.

For SFPs, the current crisis places demands on implementing agencies facing pressures from the local community, resulting in more CSB being distributed than planned so that stocks run out. Some partners are contractually ready to start activities but are awaiting supplies of CSB to do so.

The suspension of WFP activities in South and Central Somalia has had a serious impact. By 2009, WFP had delivered the logistical support for delivery of food in Somalia while UNICEF delivered only on therapeutic nutrition programmes. In January 2010, WFP suspended operations in South Somalia. As provider of last resort, UNICEF picked up their 400 programmes, signing agreements with partners they had not previously worked with. Delays were inevitable in this context and with the lack of adequate notice, supplies or resources. A problem with drug supplies has also been experienced.

Nutrition Information System

Through considerable focus and effort, the completeness of reporting of nutrition information by partners has improved tremendously. With regular follow up, 95% reporting coverage has been achieved on a monthly basis, however, the quality of reporting needs to be further strengthened (see section on performance indicators below). Problems with the current database mean cross checking of this month’s programme information against the previous months has to be done manually.

One challenge for nutrition information is the discrepancy between caseloads from project reporting and FSNAU estimated caseloads. Numbers of beneficiaries identified through project data are often significantly higher than FSNAU estimates for the same area, resulting in coverage rates of greater than 100%. This may be due to a problem with population denominators arising from the use of out of date population statistics. It may also be due to the incidence rate of acute malnutrition used. In view of the multitude of problems and the severity of the situation in Somalia, an incidence rate of 1.6 may not be appropriate - it could even be as high as 8. (Even in Somaliland, an incidence rate of 4 or 5 may be applicable).

There is a positive move to the increasing use of SQUEAC⁹ surveys to triangulate reporting results. Most organisations have included SQUEAC in their proposals. UNICEF will facilitate this through engaging external consultants to accelerate the process.

Performance indicators

Monthly reporting data are collated for IMAM programmes in Somalia. The data indicate that OTP programmes are performing well and meeting SPHERE standards (see Table 1). However, there is recognition that according to the data, programmes are performing better than might be expected given the challenges and constraints of implementation in many areas of Somalia. Efforts are now underway to follow reporting more closely to check the reliability of the data presented by partners.

Table 1: Monthly performance indicators for OTP throughout Somalia
Month (2011)	Cure rate (>75%)	Default rate (<15%)	Death rate (<10%)	Non cure rate
January	88.8%	8.9%	1%	1.6%
February	90.4%	5.2%	1%	3.2%
March	88.2%	6.1%	1%	4.7%
April	91%	4.7%	1.1%	3%
May	84.7%	8.6%	1%	5.6%
June	85.7%	7.8%	1.4%	5%
July	85%	7.7%	1.7%	5.6%
August	84.8%	8.5%	1.4%	5.4%

 

Table 2: Monthly performance indicators for TSFP throughout Somalia
Month (2011)	Cure rate (>75%)	Default rate (<15%)	Death rate (<3%)	Non cure rate
January	65.5%	33%	0.2%	1.1%
February	93%	4.8%	0.4%	1.8%
March	96.1%	2%	0.1%	1.7%
April	75%	14.7%	2.8%	7.3%
May	90.1%	8.2%	1%	0.5%
June	38%	33.6%	0.7%	27.8%
July	40.2%	19.5%	0.6%	39.6%
August	58.7%	7.8%	0.4%	33%

 

Community mobilisation

In Somalia, where there is limited access to SCs, community mobilisation is a very important component of IMAM. Promotion of the early detection and diagnosis of cases of acute malnutrition can reduce the numbers that deteriorate into a severe condition prior to presentation. In general, the level of community mobilisation has improved. Some challenges remain. For example, in SCZ, CHW are, in effect, salaried through the incentives they are paid. This system encourages CHWs to take on large areas (for which they are paid more) but that they may not be able to cover effectively.

Coordination systems

With the lack of effective central government, the Nutrition Cluster plays a significant role in the coordination of nutrition programmes throughout Somalia. Due to security constraints, the cluster is based in Nairobi. Traditionally, regular monthly Nutrition Cluster coordination meetings have been held with excellent participation. However, with such a large number of nutrition programmes implemented by local NGOs, the resulting number of Nutrition Cluster partners means that it has become increasingly difficult to focus on operational issues at these meetings. To overcome this, the general Nutrition Cluster coordination meeting is now held once a quarter to include partners and members, whilst the monthly coordination meeting is held for implementing partners only. In reality, attendance is still too large to be able to discuss implementation issues in a useful way. So, in addition to a monthly cluster meeting, regional meetings are held at Nairobi level. These fora bring together all partners working in a particular region to meet and discuss operational issues. This has proved very helpful to the improved coordination of activities, who is doing what and where and identifying the gaps. There are also thematic working groups for infant and young child feeding (IYCF), micronutrient supplementation and capacity building for more specific technical discussions. Furthermore, field cluster coordination fora at regional level are gradually being established (see Figure 8). This has proved useful in areas of SCZ, in particular where there is a problem with geographical coordination of activities and possible duplication. Regular field cluster coordination meetings allow organisations to discuss and agree issues such as programme coverage amongst themselves at field level. A key aim for strengthening overall coordination is to get the field cluster coordination meetings working more effectively.

Integration and linkages

Integration with MOH

In Somaliland and Puntland, IMAM services are linked with Maternal and Child Health (MCH) and health posts. In Somaliland, 34 OTPs and 4 SCs are delivered through government health facilities, whilst in Puntland 10 OTPs are operating through government structures. In practice this means the services are delivered by MOH staff with financial incentives paid by the humanitarian community. In SCZ integration with MOH is very limited.

Linkages with Essential Package of Health Services (EPHS) and Health System Strengthening (HSS)

The EPHS for Somalia was developed in 2008 and defines the four levels of health service provision (primary health care unit, health centre, referral health centre and hospital) and the six core and four additional health programmes to be implemented throughout the country. According to the EPHS, nutrition interventions are integrated across the ten programmes. Overall there is a drive to ensure that nutrition is considered a significant part of the EPHS. This is being achieved in part through the review of job descriptions and training packages of health professionals. There are however, disparities across the three zones due to differences in the presence and capacity of local government, the presence of international staff and the implementation of the cluster approach.

Integration of the Basic Nutrition Services Package¹⁰ (BNSP), IYCF and nutrition education

Integration of BSNP activities into IMAM programmes is a gradual process. It is included in UNICEF’s standard proposal format but many agencies struggle to understand the concept of BNSP. The level of integration is limited by supervision, capacity, supplies and logistics.

The IYCF and nutrition education activities are linked to IMAM programmes. Their integration as components of IMAM programmes is encouraged at proposal level and is supported by UNICEF through to implementation stage. Each IMAM programme has an IYCF promoter supported through funding from UNICEF. To date, a total of 100 IYCF counsellors have been trained and the programme is ongoing. Furthermore, some IMAM programmes have set up community support groups for IYCF within the community to offer advice to each other. However, with the magnitude of the problem in Somalia, the cluster recognises other approaches to improving IYCF practices also need to be considered to achieve significant behavioural change.

Nutrition education activities are also delivered on a routine basis through IMAM programmes. This may be through group education sessions with mothers attending IMAM sites and/or through sessions conducted within the community. Further strengthening and exploration of different approaches is required to improve impact. In recognition of this, nutrition and WASH clusters have started to work together on nutrition/WASH promotional messages and how best to deliver them. UNICEF has signed a contract with BBC World Trust for the development of drama, where promotional messages are delivered via the radio. Other options to be explored include the use of mobile phone technology in sending promotional messages via text messaging.

Inter-sectoral integration

In such a challenging operating environment, the use of existing programmes and structures as a delivery mechanism for integrated activities across sectors is crucial. Furthermore, the absence of integrated services can prolong recovery and increase relapse rates. At proposal stage, the current format of CAP proposals, UNICEF Programme Cooperation Agreement (PCAs) and WFP Flash Appeals requires that health and water, sanitation and health (WASH) activities, e.g. immunisation or soap distribution, are integrated within nutrition programmes. However, it is recognised that implementation of an integrated response at field level needs strengthening, particularly in SCZ. Capacity may be a limiting factor in this. Current reporting requirements for nutrition do not capture the extent of provision of complementary services systematically e.g. number of immunisations or soap distributions. Health Information Systems (HIS) are supposed to capture this information. Third party monitors do report on level of integration but a question remains as to whether this information is collated in any way.

Inter-cluster linkages

Good coordination and collaboration exists between WASH, Health, Agriculture and Livelihoods and Nutrition Clusters at Nairobi level. Clusters share information on the strengths and weakness of potential partners and which organisations are capable of scaling up a more integrated approach to delivery. In SCZ, the Agriculture and Livelihoods and Nutrition Clusters work closely together to ensure any agriculture and livelihoods programmes, such as cash for work, include nutrition beneficiaries.

An inter-cluster strategy was developed in June 2011 to address the acute food insecurity and nutrition crisis in SCZ. This defines which inter-cluster activities are to be delivered at each target location (e.g. nutrition centres, health centres, transit points, IDP settlements) and includes nutrition, health, livelihoods and WASH cluster activities.

Capacity, training and supervision

Capacity is an important issue for the scale up of IMAM throughout Somalia. As highlighted above, the vast majority of nutrition services for the management of acute malnutrition are implemented by UNICEF and WFP in partnership with local NGOs. There is wide variation in the capacity of these local organisations. There has been notable improvement and capacity development amongst organisations that first started implementing IMAM two years ago. However, in South and Central Somalia, many of the most efficient and reliable partners have been expelled from Al Shabab controlled areas, resulting in a need to work with less experienced partners. For many local partner organisations new to nutrition programming, commitment is strong but technical knowledge, experience or understanding may be more limited. This applies not just for technical nutrition capacity but also project cycle management, funding mechanisms, proposal writing, audits reporting, etc. In the Somalia context, training and supervision are often difficult or challenging, given the limited access of senior (and particularly international) staff to the centres. Innovative ways of training and supervising staff need to be developed for this purpose.

Capacity has been a limiting factor in scale up but to what extent is not clear. The following are some examples of impact of capacity limitations on scale up. A local partner organisation effectively implementing OTP at five sites may lack the capacity to scale up to six more sites, resulting in the need for another partner to be brought in. Other agencies may agree to scale up without the capacity to deliver, resulting in delays or problems with the quality of service. Others have asked for expansion but have underestimated the funding implications with the result that the project is underfunded.

Lack of capacity also limits the extent to which nutrition services are integrated with other cluster activities. The promotion of an integrated approach is undoubtedly something to be strived for. However, where capacity is still being strengthened, the tendency of local partner organisations to take on activities from other clusters, particularly in the context of short term emergency funding, may overstretch and overload some organisations.

In Somaliland and Puntland, capacity development within evolving local authorities is important for more sustainable effects. Appointments to the civil service are often linked to clan association with the relevant minister, rather than technical know-how. This may mean that international staff members ultimately carry out the monitoring work typically undertaken by national civil servants. This amounts to gap filling rather than skills transfer. High staff turnover is also an issue. There is a shortage of technical NGOs capable of travelling to many areas and training local communities. However, compared with 2-3 years ago, when many NGOs were established and collapsed within a short space of time, increased support from international NGOs, and improvement in partner capacity is evident.

One of the cluster’s primary roles is to give hands-on technical support and supervision to partners throughout the implementation cycle, not merely in terms of capturing final results. Capacity building is one of the objectives of the Cluster Response Plan. From the first round of CHF allocation, USD$500,000 went towards capacity building at agency level. The importance of this aspect to continuing the scale up process is highlighted by the investment in the current capacity mapping exercise. This will provide baseline information through the mapping of capacity at three levels being undertaken: i) Nairobi - general management capacity, ii) field level - technical and management capacity and iii) field level - nurses and CHWs. The aim is to gain a better understanding of the gaps and lead to formulation of a specific capacity development strategy to address priority issues for the way forward.

Lessons learned on capacity development

To date, capacity building has mainly been through Training of Trainers (ToT) at Nairobi or Hargesia level. The focus has been mainly on local NGOs and MOH staff. This approach has proved to be less effective when implemented alone and needs to be coupled with other complementary approaches, including on-thejob mentoring. Additional reasons why the ToTs have not been an effective standalone approach include: the wrong people have attending training held at Nairobi or Mandera level, skills learned at training are not passed down and weak capacity in delivering the ToT.

Increased commitment from international NGOs to train and mentor local partners has proved successful. In 2008, Action Contre la Faim (ACF) acted as a training centre for organisations with lower capacity, which had positive results. Another encouraging example is Oxfam Novib’s partnership agreement with local NGO SAACID, in which Oxfam oversees and mentors the activities of the local NGO.

Innovative ways forward for capacity development

Given the significant constraints, some innovative approaches under consideration include:

On the job training where trainees from a lower capacity organisation spend a block of time with a higher capacity organisation (mentor) at the mentor’s work site. This provides the advantages of having an experienced mentor at hand to address questions and difficulties and reinforces information provided during the didactic course. The challenge to using this approach is the availability of quality sites with a mentor.

Twinning, where a relationship between two organisations is established to provide a platform for sharing of expertise and experience.

Consultation using call centre allows newly trained staff to ask questions of experienced providers through direct phone calls to the centre and provides a support network that builds the confidence of newly trained providers.

Distance learning schemes can be run using different technology depending on the resources available to the trainees. It may be through internet or audio tapes combined with written materials. Distance learning has the advantage of reaching a wide geographically disparate audience and allows trainees to remain at their workplace with training in their local language. There can be a call centre to provide technical back up.

On site mentoring using mobile teams is where experienced professionals are sent to sites of less-experienced providers for a few days to offer on-site mentoring. This allows the trainee to practice skills and raise questions and difficulties specific to the trainee’s work situation and means. The use of mobile teams, with a technically strong team leader and supported by a technically strong NGO, reduces the requirement for large numbers of skilled mentors.

Monitoring

Approaches to monitoring vary across the three zones, reflecting the level of security and access in each.

SCZ

With the current lack of access to international staff in SCZ, the monitoring of programme delivery by partners is a major challenge. Programmes tend to be managed remotely and rely on partners’ implementation reports. Verification in quantitative terms may be possible but verification of programme quality is more of a challenge. When experienced monitors are not available and senior staff cannot themselves reach project sites, there is a serious risk that programmes may fall below a desired standard with no repercussions for the implementing partner or direction for improvement. Furthermore, absolute verification that no aid has been diverted or misused is increasingly more difficult when senior staff cannot visit project sites. A further complication is that even when agency (e.g. UNICEF or WFP) staff are satisfied that monitoring activities are sufficient and suitable, donor organisations may continue to seek further verification and evidence of high quality project implementation.

With the challenging context of SCZ including restricted access, new and innovative operational modalities are constantly considered and a number of monitoring procedures are in place. These include the following:

• Programme support missions by technical staff
  These are carried out whenever there is a window of opportunity for access. Such missions may be rapid but can provide vital opportunities to assess needs and monitor ongoing activities and define necessary follow up activities.
• Joint monitoring with communities/local authorities/partners
  This approach relies on the network of partnerships that have been established over the years and is dependent on the presence and capacity of partners to carry out monitoring activities. The expulsion of international partners has reduced the pool of joint monitoring partners.
• Independent third party monitors
  Third party monitoring is a new approach used by both UNICEF and WFP who each contract a different independent organisation to monitor their nutrition programmes by region. These organisations are local NGOs, in the case of UNICEF a local consulting group called Charity Relief Organisation (CRO). Programmes may be visited either as part of a planned schedule or ‘on spec’. A monitoring visit may be requested in response to reports of problems with a particular programme, e.g. from other organisations. Monitors are provided with a checklist and monitoring tools. This includes a set of questions that are intended to flag any discrepancies in reporting and monitoring. Reports from third party monitors are cross checked with partner reports and local community reporting. Third party monitoring provides independent verification of the programme with the contracted organisation acting on behalf of UNICEF or WFP. The monitors are not perceived to be linked with either UNICEF or WFP, which gives them better protection and access in some locations. As well as monitoring, the visit is taken as an opportunity to provide on the job training as necessary. The possibility of using third party monitoring more regularly/ extensively for training and supervision purposes is being explored. Donors are not always satisfied with the use of third party monitors, however.
• Peer monitoring
  Somali staff members use family and friends in different areas to check up on project activities. There are limitations since friends and families may not possess technical skills to assess the quality of programmes.
• Results monitoring
  Nutrition surveys carried out by FSNAU can provide independent verification of the effectiveness of assistance. A recent example is the positive impact of SFPs for IDPs in the Afogoye Corridor¹¹.
• Triangulation of information
  Information reported by partners, different sources at community level (e.g. community elders, education committees, school clubs) and other key informants including other partners, UN agencies and information from third party monitors.
• Direct beneficiary feedback
  Through the use of mobile phone technology available in Somalia, there is potential to source additional information from beneficiaries, although lack of technical skills to assess quality of programmes means the approach needs careful consideration.

Somaliland

With the exception of some areas of Sool and Sanaag, where conflict persists, access to projects in Somaliland is available. The primary challenge with regard to monitoring is lack of time to visit programme sites throughout the region. Staff tend to be overstretched with a high volume of work and missions are difficult, covering long journeys on rough terrain.

Puntland

Direct monitoring is also feasible in Puntland. Agency staff can safely travel to all regions. Some of the monitoring activities in this zone include third party monitoring, monitoring by the relevant government ministry, quarterly monitoring visits to sites and to implementing partners by staff members, and periodic joint monitoring with government (for example, where UNICEF sponsor officers from the Ministry to join UNICEF officers to monitor projects together). However, administrative work often takes priority over site visits. Furthermore, some staff do not want to travel to remote areas due to fears around personal safety or other reasons. In general, staff manage to undertake once a quarter visits instead of the optimal once a month.

Impact and achievements

The real success of nutrition programming in Somalia is the achievement of such rapid scale up of IMAM services in a very difficult context, primarily through UNICEF and WFP partnerships with local NGOs. The expansion of services over the last 3 to 4 years has provided a vital base for the current response to the humanitarian emergency .

Working through local partners can be a successful model when government structures are weak and access for international agencies is limited. While estimates of population coverage greater than 100% in some areas suggests a problem either with population estimates or with incidence rates, it does indicate very positive results. With follow up, monthly reporting is now 95% although there may be some quality issues. The introduction of SQUEAC coverage surveys will allow the triangulation of results. Even in this difficult environment, cure rates are within the Sphere standards.

More recently, the use of mobile clinics rather than static clinics is being promoted. Local organisations are being encouraged to look at the population being served and whether daily attendance warrants a static clinic or whether a mobile team would be a better use of resources (staff time and infrastructure costs). One mobile team would substitute five static sites, for example. Each mobile team provides a timetable of services to the surrounding community for weekly OTP visits and fortnightly or monthly TSFP. Mobile services are not reflected in the nutrition services map (see earlier).

Ways forward

The extent of the scale up of IMAM services over recent years in the face of all the challenges of the Somalia context is a tremendous achievement. With the current emergency, geographical coverage of services and the number of partners continues to expand. In terms of the way forward from here, the major focus is on improving the quality of services through the following:

• Innovative approaches to capacity building, both for local NGOs and government staff, combining ToTs and instructive training with complementary approaches such as on-thejob training, mentoring of lower capacity NGOs by higher capacity NGOs, distance learning and use of mobile mentoring teams.
• Strengthening project management skills as well as technical capacity of local partners.
• The use of third party monitoring to provide on the job training and supervision.
• A move towards the greater use of mobile teams linked to one static site in order to increase programme coverage.
• Introduction of the use of SQUEAC surveys to triangulate reporting results.
• Strengthening of field coordination systems.

The Scaling Up Nutrition (SUN) initiative provides a framework for action to scale up efforts at country level for addressing undernutrition through encouraging country owned nutrition strategies and programmes and taking a multi-sectoral approach that includes integrating nutrition in related sectors. Without an effective central government, Somalia is not an obvious candidate for SUN in the formal sense. However, a Somali Nutrition Strategy has been developed and endorsed by the authorities in each of the three zones. The strategy encourages the use of current IMAM to maximise opportunities arising for a more integrated response. The BNSP epitomises this. Scale up of a more integrated approach is in progress. The scale up of IMAM can certainly benefit other nutrition interventions. Particularly in a context like Somalia where IMAM program- mes are reasonably well funded, they can provide a platform through which to deliver other nutrition and related interventions. However, it is essential to recognise the critical role of capacity strengthening in the expansion and effective integration of a broader spectrum of activities. Capacity of local partners and longer term funding remain key challenges, whilst the priority in the current context is the continued rapid scale up of life saving interventions to prevent morbidity and mortality.

For more information, contact: Leo Anesu Matunga,
email: lmatunga@unicef.org,
tel: +254 728601202

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¹For a more detailed analysis of the his