Nutrition Analysis Post Gu 12

Transcription

1 Nutrition Analysis Post Gu 12 Technical Series Report No VI. 47 September 26, 2012 Food Security and Nutrition Analysis Unit - Somalia Information for Better Livelihood Technical Partners Funding Agencies Swiss Agency for Development and Cooperation SDC

2 Post Deyr 2011/12 Nutrition Analysis ii

3 Acknowledgements FSNAU would like to thank all our 24 partner agencies for their participation and support in the Deyr 2011 seasonal nutrition assessments and analysis. Post Deyr 2011/12 Acknowledgement Nutrition Analysis From April through July 2012, a total of 46 nutrition surveys were conducted based on standard SMART methodology. Seventeen of the nutrition surveys were conducted in the south. Additionally, nutrition data from about 130 health and nutrition facilities was reviewed. Without the support and expertise of the 8 local NGOs, 3 International NGOs, 3 Local Authorities, 8 line Ministries and 2 UN agencies, this would not have been possible. Special thanks to UNICEF, for financial and/or technical support. A sincere note of appreciation also goes to the FSNAU nutrition team based in Somalia who work under such difficult conditions yet continue to produce such high quality professional work. iii Participating Partners - north central regions only United Nations Children s Fund (UNICEF), World Food Programme (WFP), Ministry of Health (MOH Somaliland), Ministry of Agriculture (Somaliland), Ministry of environment and rural development, and NERAD (Somaliland); Ministry of Health (Puntland), Ministry of Women Development and Family Affairs (MoWDFA), Ministry of Wildlife, Tourism and Environment (Puntland), Puntland State of Water and Energy (PSWEN), Medair, Somalia Red Crescent Society (SRCS), CAFDARO and Elberde primary health care organization (EPHCO). Mahad Sanid

4 Post Deyr 2011/12 Table of Contents Nutrition Analysis iv TABLE OF CONTENTS 1 Executive Summary 1 2 Cases of Acutely Malnourished Children in somalia 10 3 Nutrition Analysis in Somalia REGIONAL NUTRITION ANALYSIS Gedo Region MIDDLE and LOWER Juba Regions Bay and Bakool Regions Middle and Lower Shabelle Regions hiran region Central Somalia: Galgadud and Mudug regions Northeast Regions Northwest Regions 58 5 Urban Summary Findings 67 6 Plausibility checks 69 7 APPENDICES Progression Of Estimated Nutrition Situation Gu Nutrition Assessment Tools Post Gu Nutrition Assessment Household Questionnaire, May 2012 Idp Urban Rapid Assessment Record Form - Gu Mortality Questionnaire, June Field Supervisor Verbal Autopsy Southern Idps And Urban Questionnaire - July Somalia Livelihood Zones Glossary of terms 92 List of Figures Figure 1: Global Acute and Severe Acute Malnutrition, (WHZ < 2 and 3 z Scoresor Oedema) April- July 2012 Somalia 1 Figure 2: Retrospective crude and under 5 death rates per 10,000 per day 2 Figure 3: Median wasting rates, WHOGS (WAZ<-2 and WAZ <-3) April- July Figure 4: Median Stunting rates, WHO GS (HAZ<-2 and HAZ <-3) April- July Figure 5: Propotion of Total Cases of Acutely Malnourished Children (WHZ<-Z or Oedema) by Region, September Figure 6: Trend in Level of Acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Gedo Region, Figure 7: HIS Malnutrition Trends in Gedo Agropastoral MCHs Figure 8: Trend in levels of Acute Malnutrition (WHZ <-2Z scores or oedema, WHO 2006), Juba Regions Figure 9: HIS Malnutrition trends in Juba agro-pastoral MCHs Figure 10: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) Bakool region, Figure 11: Admissions trends into OTP programmes Bakool Figure 12: Trend in levels of Acute malnutrition (WHZ< -2 or oedema, WHO 2006) bay Agropastoral, Figure 13: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) Bay region, Figure 14: HIS Malnutrition trends in Bay Agro-pastoral MCHs, Figure 15: Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Middle and Lower Shabelle Regions ( ) 34 Figure 16: HIS Malnutrition Trends in Shabelle Reverine MCHs Figure 17: HIS Malnutrition Trends in Shabelle Agropastoral MCHs Figure 18: Trend in Levels of acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Hiran Region, Figure 19: HIS Malnutrition trends in Hiran Riverine MCHs Figure 20: Trends in Levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) Central Regions, Figure 21: HIS Malnutrition Trends in Hawd LZ of Central areas( ) Source: MoH; SRCS 42 Figure 22: HIS Malnutrition Trends in Addun L/Z of Central areas ( ) 42 Figure 23: HIS Malnutrition Trends in Cowpebelt L/Z ( ) 43 Figure 24: HIS Malnutrition Trends in Central Coastal Deeh L/Z ( ) 43 Figure 25: Trends in levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) Northeast regions ( ) 49 Figure 26: HIS Malnutrition Trends in Golis/ Karkaar LZ ( ) 49 Figure 27: HIS Malnutrition Trends in Sool Plateau LZ ( ) 50 Figure 28: HIS Malnutrition Trends in Nugal Valley LZ ( ) 50 Figure 29: Trend in Levels of Acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Northeast IDPs ( ) 52 Figure 30 : Trends in levels of Acute Malnutrition (WHZ <-2Z scores or oedema, WHO 2006 in North West regions Figure 31: HIS Malnutrition Trends in Health Facilities in NW West Golis MCHs - January 2011-June Figure 32: HIS Malnutrition Trends in Health Facilities in NW Hawd MCHs - January 2010-June Figure 33: Trend in Levels of acute Malnutrition (WHZ<-2 or oedema, WHO 2007)

5 in Northwest Regions Region, List Of Tables Table 1: Nutrition Surveys Schedule April-July Table 2: Somalia Integrated Food Security Phase Classification, Population Numbers, Aug - Dec Table 3: Estimated Cases of Acute Malnutrition in Somalia, by Region, September Table 4. The Nutrition Situation Classification Framework, Draft 8, January Table 5: Summary of Key Nutrition Findings in Gedo Livelihood Zones, May Table 6: Summary of Key Nutrition Findings in Dowlo IDPs May Table 7: Summary of Key Nutrition Findings in Juba Livelihood Zones, July Table 8: Summary of Key Nutrition Findings in Kismayo IDPs July Table 9: Summary of Key Nutrition Findings in Bakool Pastoral livelihood zone - July Table 10: Summary of Key Nutrition Findings in Bay Regions-July Table 11: Summary of Key Nutrition Findings in Mogadishu Town - April- July Table 12: Summary of Key Nutrition Findings in Mogadishu IDPs - April- July Table 13: Proportion of the malnourished women in Banadir and Hiran Regions 40 Table 14: Summary of Key Nutrition Findings in Hiran region - July Table 15: Summary of Key Nutrition Findings in Hawd, Addun and Dhusamareb IDPs Central regions 44 Table 16: Summary of Key Nutrition Findings in Cowpea Belt Agro-pastoral and Coastal Deeh Pastoral of Central regions - July Table 17: Summary of Key Nutrition Findings in Northeast Regions - July Table 18: Summary of Key Nutrition Findings in Hawd, Addun and Coastal Deeh Northeast Regions 53 Table 19: Summary of Key Nutrition Findings among Northeast IDPs (Bossaso, Qardho, Garowe and Galkayo) May Table 20: Summary of Key Nutrition Findings in West Golis/Guban, Nugal Valley Table 21: and Sool Plateau Livelihood Zones, December Summary of Key Nutrition Findings in Hawd, East Golis and Agro-pastoral Livelihood Zones, July Table 22: Summary of Key Nutrition Findings for Hargeisa, Burao and Berbera IDPs, June Table 23: Summary of Urban Assessment Findings: Northwest and Northeast Regions Post Gu 12 Table 24: Plausibility checks 72 Table 25: Summary of Nutrition Assessments (April - July 2012) 73 Post Deyr 2011/12 Table of Contents Nutrition Analysis v List Of Maps Map 1: Somalia Nutrition Situation, January Map 2 Somalia Nutrition Situation, August Map 3: Estimated Nutrition Situation (September-November) Map 4: Somalia Acute Food Insecurity Overview, Rural, Urban and IDP Populations, July Map 5: Distribution of estimated Cases (%) of Acutely Malnourished Children in Somalia by Region, based on Prevalence, August Map 6: Gedo Region Livelihood Zones 16 Map 7: Juba Regions Livelihood Zones 20 Map 8: Bay and Bakool Regions Livelihood Zones 27 Map 9: Shabelle Livelihood Zones 34 Map 10: Hiran Livelihood Zones 39 Map 11: Northeast Livelihood Zones 48 Map 12: Northwest Livelihood Zones 58 Special Articles Sustained high levels of acute malnutrition across Somalia and Kenya border 24 Case study 1: A family s experience during a hunger period, in Huddur district 29 Case study 2: Increased nutritional vulnerability among the families in the besieged Huddur town, Bakool region 33 Nutrition Survey Results in Mataban and Beletweyne, Hiran Region Indicate an Extremely Worrying Health Situation 38 Food safety and malnutrition in Somalia 47 Strengthening of Infant and Young Child Feeding Programming and Planning for Emergency; The Infant and Young Child Feeding (IYCF) London Workshop (25-29 June 2012) Preparedness and Response. 69

6 Post Deyr 2011/12 Acronyms Nutrition Analysis vi LIST OF ACRONYMS USED AWD Acute Watery Diarrhoea ARI Acute Respiratory Tract Infections CDC Center for Disease Control and Prevention, Atlanta CDR Crude Death Rate CHD Child Health Days CI Confidence Interval COSV Co-operatione Di Svillupo International FAO Food and Agricultural Organization of the United Nations FSNAU Food Security and Nutrition Analysis Unit FEWSNET Famine Early Warning System Network GAM Global Acute Malnutrition HAZ Height for Age Z Scores HIS Health Information System IDP Internally Displaced persons INGO International Nongovernmental Organization LZ Livelihood Zone MCH Maternal and Child Health Center MOH Ministry of Health MT Metric Ton MUAC Mid Upper Arm Circumference NCHS National Center for Health Statistics NGO Non Governmental Organization OTP Out Patient Therapeutic Programme OPD Out Patient Department PWA Post War Average R Reliability Score RR Relative Risk/Risk Ratio SAM Severe Acute Malnutrition SC Stabilization Center SC-Uk Save the Children - UK SRCS Somalia Red Crescent Societies SD Standard Deviation SFP Selective/Supplementary Feeding Program TFC Therapeutic Feeding Center TOT Terms of Trade U5DR Under Five Death Rate UNHCR United Nations High Commission for Refugees UNICEF United Nations Children s Fund WAZ Weight-for-Age Z Scores WHO World Health Organization of the United Nations WFP World Food Program of the United Nations WHZ Weight for Height Z Scores WVI World Vision International

7 Post Deyr 2011/12 Forward Nutrition Analysis vii Forward The FSNAU Post Gu 2012 Technical Series report (September 2012) is the seventh edition of the bi-annual nutrition situation technical series launched by the Food Security and Nutrition Analysis Unit (FSNAU) in February The publication complements the FSNAU bi-annual seasonal technical series reports and provides specific focus on nutrition information for the last 6 months. The FSNAU Post Gu 2012 Technical Series report was released on September xx, 2012, and is accessible at It provides a detailed analysis of the integrated food security situation, by region and by sector.

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9 1. Executive Summary Nutrition Situation Overview With the exception of the coastal strip of West Golis/Guban, the Coastal Deeh of North and Central, Cowpea Belt livelihood zones, Bay and parts of Juba regions where the food security situation is of concern, increased purchasing power and improved livestock productivity, and sustained humanitarian support enhanced household access to food and nutrition through the Gu (April-July) 2012 season, and mitigated the nutrition situation across the country. Humanitarian support in terms of cash, food and non-food items strengthened the communities purchasing power; while health care and nutrition support enabled control and management of endemic diseases, seasonal outbreaks, and malnutrition, thereby saving lives in these areas. Consequently across the country, levels of acute malnutrition have declined to below the Integrated Phase Classification (IPC) famine threshold of 30%, while crude death rates (CDR) are below the UNICEF emergency threshold of 2/10,000/day. From April-July 2012, FSNAU in collaboration with partner agencies conducted 46 representative nutrition surveys in Somalia, assessing rural, urban and internally displaced populations (Table 1). Of these, 16 were done in the south; 4 in central rural livelihood zones; 10 in northwest and northeast rural pastoral and agro-pastoral livelihood zones; 8 in IDPs in the north and central regions; and 8 in the urban livelihood zones in the north. Due to security restrictions, updated nutrition and mortality data was not collected in Shabelle regions and the southern parts of Gedo, Bakool and Hiran regions. However, indirect information on nutrition trends from health centers and feeding programmes was analysed. A calm looking Somali child FSNAU 2011 Based on the Gu 2012 analysis, at national level, an estimated 236,000 (16% of the 1.5 million) Somali children are currently acutely malnourished and in need of specialized nutrition treatment services. Of the 236,000 children, 54,000 (3.5% of the 1.5 million Somali children) are severely malnourished requiring immediate lifesaving interventions. Seventy percent of the malnourished are from the southern regions, where there are concerns about their ability to access vital basic services needed for survival. Nevertheless the figures reflect a reducing trend since August 2011, the peak of famine when an estimated 450,000 (30% of the 1.5 million Somali children) of the children were acutely malnourished with 190,000 (13%) in severe state, and January 2012, when 323,000 (or 22%) were acutely malnourished, with 93,000 (6%) in severe state. Despite the improvements therefore, lifesaving humanitarian assistance remains crucial between now and December 2012 to meet immediate nutrition, health and food needs, protect livelihoods and build resilience. Post Deyr 2011/12 Executive Summary Nutrition Analysis 1 Survey findings (Figures 1 and 2) show significant improvements in the nutrition situation in parts of the southern and northeast regions, and deteriorations in parts of the northwest regions (Maps 1 & 2), since January Nevertheless, across the South, the situation remains except for parts of Juba and Hiran regions in phase. In Central and Northeast regions, the situation is except for the Coastal Deeh and Cowpea Belt in Central regions in phase. In the northwest regions, the situation is in all livelihoods apart from the Hawd in, Nugal Valley in phases due to high morbidity and disease outbreaks, and West Golis/Guban in phase due to deteriorated food security conditions. Southern regions In Bay region and Juba riverine communities, the situation has improved from Extremely phase with GAM rates in excess of 30% in January 2012, to with GAM rates of 20.4% ( ) in Bay, and 21.5% ( ) in Juba riverine. Juba pastoralists have improved from a phase in January 2012 to with the Global Acute Malnutrition (GAM) rate currently at 15.8% ( ). CDR is 0.44/10,000/day and within acceptable range. For Mogadishu IDPs and urban, the situation has Figure 1: Global Acute and Severe Acute Malnutrition, (WHZ < 2 and 3 z Scoresor Oedema) April- July Somalia

10 Post Deyr 2011/12 Executive Summary Nutrition Analysis 2 improved from phase (with GAM of 20-22%) in January 2012 to phase. o Mogadishu IDPs: GAM reate is currently 9.6% ( ) o Mogadishu urban: GAM rate is 10.8% ( ) Findings from other parts of the south assessed during the Gu 2012 indicate a sustained phase with GAM rates between %. The 90 days retrospective crude death rate (CDR) in Bay region, Mogadishu IDPs and urban is in the range of /10,000/day indicating a situation, and highest in the country, but nevertheless below UNICEF s emergency threshold of 2/10,000/day. Across most of the other assessed areas of Southern Somalia, crude death rates are below 0.5/10,000/day and therefore within acceptable levels. For additional findings, refer to Figures 1 & 2, regional information, and the summary table of findings. Northern and Central regions There are improvements to a nutrition situation from in East Golis of northeast along the Red sea, and in the Hawd of central regions. However, in West Golis/Guban, the Hawd in the northwest, and Nugal Valley livelihood zones, the situation has deteriorated to - phases, while global acute malnutrition levels are elevated above seasonal norms of %. West Golis/Guban: The deterioration is attributed to declined milk and food access by women and children left behind following rain failure and the out-migration of livestock with men and boys. GAM rate is 21.7% ( ). The Hawd livelihood zone at the Ethiopian border has deteriorated to from phase mainly due to high morbidity, mainly acute watery diarrhea and measles, in April-July. The GAM rate is 16.7% ( ) Nugal Valley livelihood zone has deteriorated to Very from phase due to high morbidity and measles outbreaks in the Burao and Ainabo districts. The GAM rate is 20.1% ( ). Crude death rates are nevertheless within acceptable levels of <0.5/10,000/day based on UNICEF s classification. For additional findings, refer to Figures 1 & 2, regional information, and the summary table of findings. Urban livelihoods In July 2012, FSNAU and partners undertook 10 nutrition surveys in the urban population of Somalia. Five regional surveys were conducted in northwest regions, two in northeast, two in central regions and one in Mogadishu town. Northwest regions: Gu 2012 survey findings depict or nutrition situation in urban populations and varied trend since January o Woq. Galbeed and Sanaag regions: The nutrition situation remains, with a GAM rates in the 5-9.9% range. o Awdal and Sool regions: The nutrition situation is in sustained phase with GAM rate of %. o Togdher region: The nutrition situation has deteriorated from in January 2012 to with a GAM rate of 14.7% ( ). Northeast regions: The nutrition situation among the urban populations in the northeast regions is either sustained or has deteriorated since January o Bari region: The situation has deteriorated to a phase from. o Nugal region: The situation is in a sustained phase Central regions: The nutrition situation is both in Galgadud and Mudug regions with GAM rate of %. In Mudug, the findings indicate deterioration from phase in December 2011 when GAM and SAM rates of 14.9% ( ) and 4.15 ( ) respectively were recorded. A survey was not conducted in Galgadud in December Mogadishu urban: The nutrition situation is in phase with GAM rate of 10.8% ( ) sustained since April 2012 and an improvement from in January 2012, Due to security reasons, it was not possible to undertake nutrition surveys in the other urban livelihoods zones of the southern regions. Nevertheless the nutrition situation in these regions is likely, and consistent with the rural livelihoods and IDP populations with whom there is codependence. Figure 2: Retrospective crude and under 5 death rates per 10,000 per day

11 Table 1: Nutrition Surveys Schedule April-July 2012 No. Livelihood Zone (LZ)/Population Group PERIOD 1 Agropastoral LZ (Togdheer & Northwest) July West Golis /GubanPastoral LZ July Sool Plateau LZ (Northwest and Northeast) July Hawd Pastoral LZ (Northwest) July East Golis/Gebbi Pastoral LZ (Northwest) July East Golis/Kakaar Pastoral LZ (Northeast) July Nugal Valley Pastoral LZ (Northwest and July 2012 Northeast) 8 Coastal Deeh LZ (Northeast) July Coastal Deeh LZ (Central) July Hawd Pastoral LZ (Central and Northeast) July Addun Pastoral LZ (Central and Northeast July Sool Region Urban LZ July Sanaag Region Urban LZ July Bari Region Urban LZ July Nugal Region Urban LZ July Mudug Region Urban LZ July Awdal Region Uban LZ July Woq Galbeed Region Urban LZ July Togdheer Region Urban LZ July Cowpea Belt (Central) July Galgadud Region Urban LZ 22 Dusamareb IDPs May Hargeisa IDPs May Burao IDPs May Berbera IDPs May Bossaso IDPs May Qardho IDPs May Garowe IDPs May Galkayo/Margaga IDPs May Kismayo IDPs July Dobley IDPs July Dolo IDPs June Mogadishu IDPS April Mogadishu IDPs July Mogadishu Urban April Mogadishu Urban July Juba Pastoral LZ July Juba Agropastoral LZ July Juba Riverine LZ July North Gedo Pastoral LZ June North Gedo Riverine LZ June Bakool Pastoralists June Hiran Region Beletweyne District July Hiran Region Mataban District July Bay Region July Baidoa IDPs July 2012 Southern regions: o The nutrition situation in Mogadishu IDPs has improved to with GAM rate of 9.6% ( ) from phase in January o Baidoa IDPs face a nutrition situation with GAM rate of 15.8%. o Dolow, Kismayo, Dobley IDPs are faced with a Very with GAM rates in the range of %. Median levels of malnutrition Median levels of acute malnutrition have been calculated based on findings from the 46 nutrition surveys conducted across Somalia in Gu They therefore exclude Shabelle and the southern parts of Gedo, Bakool and Hiran regions which could not be accessed due to insecurity. Based on the Gu 2012 survey findings, the median GAM rate for the country is 17.2% which is consistent with 16.2%, the median rate for the country based on 220 surveys conducted in Somalia from The Gu 2012 median rate is 24.3% for IDPs only, and 16.1% for all excluding IDPs, and 21.6% for the south. (Source: FSNAU ). With regard to stunting, the Gu 2012 median rate for Somalia is 15.6%. This is lower than 23% which is the median rate for the country based on 220 nutrition surveys undertaken in The difference is of statistical significance. The median stunting rate for IDPs, 22.0% and southern regions, 19.2% are nevertheless consistent with the 10 year median rate. Additional details are provided in the Figures 3 & 4 below. Figure 3: Median wasting rates, WHOGS (WAZ<-2 and WAZ <-3) April- July 2012 Post Deyr 2011/12 Executive Summary Nutrition Analysis 3 Internally displaced persons (IDPs) Except for Hargeisa and Mogadishu IDPs in phase, findings from nutrition surveys conducted in IDP settlements across Somalia depict a - situation with GAM rates above the WHO emergency threshold of 15%. Northwest regions: The nutrition situation is sustained in phase in Hargeisa IDPs and phase in Berbera IDPs, but has improved to from Very phase in Burao IDPs, since January Northeast and Central regions: The nutrition phase has improved to from phase in Bossaso and Galkayo IDPs; deteriorated to Very from phase in Garowe and Qardho IDPs; and remains in Dusamareb since January Figure 4: Median Stunting rates, WHO GS (HAZ<-2 and HAZ <-3) April- July FSNAU 2012: A Meta-analysis report on nutrition surveys undertaken in Somalia in

12 Post Deyr 2011/12 Executive Summary Nutrition Analysis 4 Gender Statistical analyses for Gu 2012 survey findings show no significant differences between acute malnutrition and sex of the child, or with sex of the household head. Likewise, there are no statistically significant differences between sex of the child with morbidity status (based on recall) nor with child feeding practices. However in Sool plateau, there are statistical differences between stunting rate and sex of the child. Nevertheless, across all the surveyed population groups, a higher proportion of boys than girls tended to be acutely malnourished. This disparity is likely, given the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as acutely malnourished. With the new WHO reference standards, a girl of a certain height has to be much lighter than a boy of the same height to meet the WHZ<-2 threshold for acute malnutrition. A review of data from therapeutic feeding centers (TFC) from 13 African countries found that when children 6-59 months were admitted using UNISEX tables, there was no significant difference in the number of boys and girls admitted and there was no significant difference in the mortality rate 2. The review meeting recommended the use of unisex (boys only) reference tables based on the WHO growth standards for children aged 6-59 months in admissions to selective feeding programs. Discussions are underway to establish the most appropriate way forward with regard to nutrition surveillance and analysis. 2 Golden, M., Grellety, Y., Schwartz, H., & Tchibindat, F. (2010). Report of a Meeting to harmonize the criteria for monitoring and evaluation of the treatment of acute malnutrition in West and Central Africa. 30th November 1st December 2010; Dakar, Senegal. Retrieved February 27, eng.pdf Considerations for the Nutrition Outlook for September-November 2012 The projected nutrition outlook for September-November 2012 has been derived from the analysis of current situation vis-à-vis historical seasonal trends of nutrition, disease outbreak patterns and its impacts on nutrition, anticipated agricultural production, livestock and milk access, civil insecurity which limits access to imports, and humanitarian assistance. Pastoralists and northwest agro-pastoralists: Although the current nutrition situation is -, improvements are observed across all pastoral livelihood zones associated with increased household food access. This is with the exception for West Golis/Guban livelihood zone. The forecasted moderate El-Nino will bring above-average rains in October to December This will lead to continued improvements for pastoralists across the country, including West Golis/Guban, in terms of good pasture/water availability; increased livestock holdings; improved milk availability; increased income following livestock demand at the time of the Hajj festivity. The nutrition situation in pastoral communities, and the northwest agro-pastoralists who are more inclined to pastoralism than farming are therefore likely to improve across the country (Map 3) but unlikely to improve beyond seasonal levels of in the north and central regions, and in the south. Agro-pastoralists in south and central regions: The forecasted moderate El-Nino will bring above-average rains in October to December This is likely to increase cultivation, and with it labor opportunities for the poor. The carryover food stocks and incme access from the Deyr 2011/12 and the below average Gu 2012 harvests are likely to deplete by October. This is likely to contribute to increased cereal prices and further limit household access. Planned reduction of humanitarian assistance with the end of the 2011 famine, and some moderate flooding anticipated in Juba regions are likely to aggravate the nutrition situation. In addition, based on historical trends uncontrolled outbreaks of cholera, malaria or measles are expected in October- November This will further hinder any nutritional gains. The nutrition situation in the southern/central agropastoralists is therefore likely to remain in Very phases. (Map 3). Riverine: The forecasted moderate El-Nino will bring above-average rains in October to December This is likely to lead to river overflow into the underground storage facilities, contamination of water sources and displacements. Considering that seasonal outbreaks of acute watery diarrhea/suspected cholera are also anticipated in October-November, the more likely scenario is sustained phase. (Map 3) IDPs: These remain vulnerable due to their dependence on humanitarian assistance, income from petty trade and casual labor opportunities that are closely linked with rural and urban livelihoods. The outlook of their nutrition situation therefore remains of concern, as in the Gu (Map 3). The current projection assumption will be reviewed in October 2012 based on updated information on climate performance; cereal price dynamics; humanitarian interventions; insecurity.

13 Post Deyr 2011/12 Executive Summary Nutrition Analysis 5 Map 1: Somalia Nutrition Situation, January 2012 Map 2 Somalia Nutrition Situation, August 2012

14 Executive Summary Map 3: Estimated Nutrition Situation (September-November)

15 Food Security Situation Overview The food security and nutrition data indicate continued improvements in food security in Somalia. During 2011, a famine affected over 4 million people, or more than half of the population of Somalia, leading to tens of thousands of deaths. An estimated 2.12 million people are in crisis for the August to December 2012 period, a 16 percent reduction from the beginning of the year. Therefore humanitarian assistance remains necessary between now and December to help food insecure populations meet immediate food needs, protect livelihoods and build resilience. Poor rains and below average harvest Outlook A predicted moderate El Niño between now and December 2012, is expected to have positive impacts on Somalia as this phenomenon is associated with average to above average October to December Deyr rains. However, these rains are not always well distributed and therefore, cropping conditions could vary greatly over the rainfed, agro-pastoral areas. In addition, riverine areas are likely to experience flooding as a result of heavy rainfall and increased river levels. During the moderate El Niño, Deyr rains caused flooding, which disrupted production and markets, especially in the Juba Valley. Executive Summary 7 According to recent assessment findings, the August/ September Gu harvest is significantly below average due to a late start of rains, poor rainfall totals, and pest outbreaks, among other factors. However, food stocks from last season s exceptional Deyr harvest will help to mitigate this shortfall and overall production for the 2012 calendar year will be average. Low cereal prices, high casual labor wage rates, and high livestock prices over the past six months have also contributed to reduced food insecurity by significantly strengthening the purchasing power of poor agropastoral households. In pastoral areas, households have also benefited from record livestock sales prices, robust livestock exports, and increasing livestock holdings, which have resulted in improved milk availability. This improved access to milk, among a variety of other factors, has driven a 27 percent reduction since January in the number of children requiring nutrition treatment. Currently 236,000 children are severely malnourished, of which 70 percent are in the South. International food prices have risen and will likely have an impact on prices in Somalia between now and December, especially for wheat and sugar. Over the past three years, wheat and wheat product imports have averaged 73 percent of Somalia s food imports in grain equivalent terms. Prices for local maize and sorghum, the staple foods consumed by the poor, are likely to rise seasonably over the coming six months, but substantially lower than The epicentre of Somalia s humanitarian crisis remains in the South, largely due to the long-term effects of drought and famine, and the short-term effects of this year s poor Gu rainy season. Efforts to meet immediate needs are essential to prevent further deterioration of food security. Assistance to help food insecure populations meet immediate food needs, protect their livelihoods, build their resilience, and improve food access remain necessary in Somalia between now and the Deyr harvest in January. While conditions have improved considerably since last year, the food security crisis has not ended. In the southern and central agro-pastoral areas, the below average Gu harvest, the continued need for cash to pay down debts, and low livestock holdings are keeping most southern and central agropastoral areas in IPC Phase 3 (Crisis). Other areas of concern include coastal areas and the coastal plains along the Gulf of Aden and the Indian Ocean in the northern and central regions.

16 Executive Summary Map 4: Somalia Acute Food Insecurity Overview, Rural, Urban and IDP Populations, July

17 Table 2: Somalia Integrated Food Security Phase Classification, Population Numbers, Aug - Dec 2012 Region UNDP 2005 Total Population UNDP 2005 Urban Population UNDP 2005 Rural Population Urban in Stressed Rural in Urban in Stressed Crisis Rural in Crisis Urban in Emergency Rural in Emergency Total in Crisis and Emergency as % of Total population Executive Summary North Awdal 305, , ,513 35,000 35, , ,000 8 Woqooyi Galbeed 700, , , ,000 40, , Togdheer 402, , ,893 40,000 65,000 15,000 10, Sanaag 270,367 56, ,288 10,000 25,000 25,000 35,000 5,000 5, Sool 150,277 39, , ,000 15,000 10,000 5, Bari 367, , ,005 20,000 40,000 60,000 15,000 20, Nugaal 145,341 54,749 90, ,000 20,000 5,000 5, Sub-total 2,341,718 1,054,371 1,287, , , , ,000 35,000 10, Central Mudug 350,099 94, , ,000 25,000 20,000 5,000 35, Galgaduud 330,057 58, ,080 10,000 60,000 15,000 35, , Sub-total 680, , ,774 10, ,000 40,000 55,000 5,000 70, South 0 Hiraan 329,811 69, ,698 15,000 20,000 15,000 50, , Shabelle Dhexe (Middle) 514,901 95, , ,000 30,000 25, , Shabelle Hoose (Lower) 850, , , ,000 70, Bakool 310,627 61, ,189 20, ,000 20,000 55,000 5, Bay 620, , ,749 25, ,000 35, , Gedo 328,378 81, ,076 30,000 70,000 15,000 35, Juba Dhexe (Middle) 238,877 54, , ,000 25,000 45, Juba Hoose (Lower) 385, , , ,000 20,000 45,000 20,000 5, Sub-total 3,579, ,632 2,792,965 90, , , ,000 25,000 65, Banadir 901, , ,000-60, Grand Total 7,502,654 2,895,568 4,607, ,000 1,025, , ,000 65, , Assessed and Contingency Population in Crisis and Emergency Number affected Notes: 1 Source: Population Estimates by Region/District, UNDP Somalia, August 1, FSNAU does not round these population estimates as they are the official estimates provided by UNDP 2 Estimated numbers are rounded to the nearest five thousand, based on resident population not considering current or anticipated migration, and are inclusive of population in Stressed, Crisis and Emergency 3 Source UN-OCHA/UNHCR: New IDP updated January rounded to the nearest 5,000. Total IDP estimates are based on Population Movement Tracking data which is not designed to collect long-term cumulative IDP data 4 To avoid double counting, only IDPs in Settlements (Bossasso, Berbera, Galkayo, Hargeisa, Garowe, Kismayo, Afgoye, Burao and Mogadishu are considered in the overall population in Crisis. FSNAU does not conduct IDP specific assessments to classify them either in Crisis or Emergency 5. Percent of total population of Somalia estimated at 7,502,654 (UNDP/WHO 2005) % of Total population Distribution of populations in crisis Assessed Urban population in Crisis and Emergency 530, % Assessed Rural population in Crisis and Emergency 790, % IDP in settlements* (out of UNHCR 1.3million) to avoid double counting 800, % Estimated Rural, Urban and IDP population in crisis 2,120, %

18 2. Cases of Acutely Malnourished Children in somalia Caseloads 10 FSNAU in collaboration with partners conducted a total of 46 representative nutrition surveys throughout Somalia, between April July Seventeen of the surveys were done in the South, and the rest in the northern and central regions. With the exception of Shabelle regions and the southern parts of Gedo, Bakool and Hiran which were inaccessible for security reasons, all population groups were assessed during this period. Table 3 provides the summary of key findings from these surveys. Since 2008, FSNAU in collaboration with nutrition cluster partners have illustrated the distribution of cases of the acutely malnourished children in Somalia rather than just presenting the prevailing nutrition situation. The purpose is to draw the attention of response agencies and donors to the needs in different parts of the countries, rather than just focusing on the prevailing situation. In this way, the impact of the population density in determining response needs is manifested. By extrapolating the prevalence rates of acute malnutrition in each assessed population group to the total under five population during the Gu 2012, cases of acutely malnourished children, based on Weight-for-height Z scores (WHZ) findings, have been estimated. The cumulative total cases at regional level has been obtained by adding the cases from the assessed livelihood and IDP groups. For population groups where representative nutrition survey data for the whole population forms the main reference, reliability of data is high and is ranked as 1 (R=1). For the Shabelle regions and southern parts of Gedo, Bakool and Hiran regions where it was not possible to collect nutrition survey data, the median rates for surveys conducted in the Gu season during the period has been applied. This implies that FSNAU has estimated the current cases of malnourished children on the basis of 100% of the population children aged below 5 years in Somalia. Population figures from the UNDP 2005 settlement survey are used as the standard reference for Somalia. (Table 3). The integrated analysis and overall phase classification of the assessed population is based on the Nutrition Situation Classification Framework. (Table 2). Analysis of the Post Gu 2012 findings indicates an estimated total of 236,000 children as acutely malnourished. This translates to 16% of the 1.5 million under five population, and implies 1 in 7 Somali children acutely malnourished. This reflects a 27% decrease in numbers at the national level, compared to the Deyr 2011/12 when 323,000 children were estimated to be acutely malnourished. Of these, 168,000, or 71% are located in the southern regions. Of the 236,000 children, a total of 54,000 children are severely malnourished. At national level, this translates to 3.5% of all Somali children estimated to be severely malnourished. This reflects a significant decrease at the national level, compared to the Deyr 2011/12 when 93,000 children were estimated to be severely malnourished, and 160,000 in August 2011 at the peak of the famine. Of the 54,000 severely malnourished children, 39, 500 (or 72%) are located in the southern regions. At regional level, these figures are derived by extrapolating the prevalence rate of acute malnutrition to the total under five population. (Table 3). Hence, with regard to cases of acute malnutrition: Shabelle regions (including Mogadishu IDPs and Banadir) are host to 25% while northwest regions host 21% of all the Table 3: Estimated Cases of Acute Malnutrition in Somalia, by Region, September 2012 Total acutely malnourished Total severely malnourished Cases % of total % of total Cases cases cases Bay 25, , Lower Shabelle 23, ,650 9 Banadir (Mogadishu Town) 22, ,100 6 Woq Galbeed 18, ,700 7 Gedo 17, ,050 7 Lower Juba 16, ,950 7 Bakool 13, ,200 8 Middle Shabelle 12, ,200 6 Hiran 11, ,550 5 Togdheer 10, ,150 4 Middle Juba 9, ,450 5 Bari 9, ,600 5 Mudug 8, ,500 3 Awdal 8, ,600 3 Galgadud 7, ,300 2 Mogadishu IDP 7, ,450 3 Sanag 7, ,450 3 Sool 4, Nugal 2, , , acutely malnourished children in Somalia. Bay hosts 11%, Lower and Middle Juba region, 11%, Gedo 7% and Bakool 6%. (Map 5 and Figure 5). Hence, Banadir, Middle and Lower Shabelle, Bay, Juba, Gedo and Bakool regions are host to 60% of all acutely malnourished children in Somalia. For cases of severe acute malnutrition, Shabelle regions, Bay and Lower Juba, Gedo and Bakool regions are host to 63% of the 54,000 children in the country, with Shabelle/Banadir hosting 20%, Bay 16%, and Juba regions 12%. Likewise, the northwest regions are host to 21% the total acutely malnourished and 18% of the severely malnourished. This illustrates the implication of population density on caseloads, as Shabelle/Afgoye/Banadir, together with Woqoyi Galbeed are most densely populated areas of Somalia. In Figure 5, the proportion of cases of acutely malnourished children by region is provided in descending order. In Map 6, illustrations for (i) the Gu 2012 nutrition situation and (ii) the cases for both total and severe acute malnutrition based on the May-July 2012 nutrition surveys data are provided. For more information please contact info@fsnau.org. Figure 5: Propotion of Total Cases of Acutely Malnourished Children (WHZ<-Z or Oedema) by Region, September 2012

19 Map 5: Distribution of estimated Cases (%) of Acutely Malnourished Children in Somalia by Region, based on Prevalence, August 2012 Caseloads 11 Pregnant and lactating women The cumulative total estimate for acutely malnourished pregnant and lactating women based on MUAC measurements < 23cm is 81,000. The severe at risk based on MUAC<21cm is 19, 000. In the Deyr 2011, the cases of acutely malnourished pregnant and lactating women was estimated at 85,000 based on MUAC measurements < 23cm. This indicates a 5% reduction in the cases. In the Gu 2011, the peak of the famine, the cases of acutely malnourished pregnant and lactating women was estimated at 101,000, based on MUAC measurements < 23cm, hence there is significant progress since then.

20 Special Article 12 Nutrition Cluster response in 2012 LINKING NUTRITION SITUATION TO RESPONSE Nutrition treatment services In eight months of service provision, the nutrition cluster response agencies reached 532,615 acutely malnourished children with treatment services (165,129 in stabilization centre/out-patient therapeutic care programme (SC/OTP) and 367,486 in targeted supplementary feeding programme )TSFP). The number reached is above the post dyer caseload of 323,000 acutely malnourished children. The reason for surpassing the estimated caseload maybe due to population figures as well as the incidence rate of 2 which we use. The figure i below shows admission trends for January to August The low admissions figures for July and August are due to low reporting rate and not necessarily a drastic improvement in the nutrition situation.. Figure ii shows admission trends by zone. The Southern zone of Somalia contributes most of the children reached consistent with the caseloads identified through nutrition surveys. Figure i: SC/OTP and TSFP admissions by month The table iii shows the prevalence and the cluster targets for July to December The Cluster aims to reach 142,000 (60%) acute malnourished children ( 109,000 moderate, 33,000 severely malnourished children) from the caseload of 236,000. Maternal Child Health and Nutrition Prgrammes The cluster s response agencies have also reached 1,100,618 targeted beneficiaries of which children 6-23 months (907,071), pregnant and lactating women (193,547) with a preventive food ratio. From these a total of 983,321 are in the south central Somalia. Figure ii: Admissions trends by Zone Transit IDPs WFP and partners reached 87,849 households with a 5 days High energy Biscuits supplementary ration and 19,605 children 6-59months with a supplementary ration of supplementary plumpy in the transit areas of Gedo and Lower Juba. This project will continue to offer relief to populations in transit in the border areas. Basic Nutrition Service Package The cluster partners have embraced the basic nutrition services package (BSNP-) in programming in an effort to address underlying causes of malnutrition. In this regard, the cluster is sensitizing partners on the incorporation into programming of an innovative approach (home fortification), to deliver micronutrients to young children (6-23 months) so as to improve their micronutrient status and decrease morbidity. Coordination mechanisms The cluster membership now stands at 142 partners, an increase by 31 members from last year s 111 members. This resulted to an increase also of service delivery points from 1650 by the end of 2011 to 2454 currently. Regional coordination has greatly improved in the last quarter of the year in the areas where it had been weak due to poor access such as the Shabelles, Bay and Bakool. It is hoped that there will be a continued improvement in the coordination of services in these and other areas for effective response. Table iii: Nutrition cluster target figures July to December 2012 Zone Prevalence Data GAM (60% target) Prevalence Data MAM (60% target) Prevalence Data SAM (60% target) South Somalia 150,850 90, ,700 68,220 37,150 22,290 Central Somalia 18,102 10,861 15,106 9,064 2,996 1,798 Northern Somalia 66,988 40,193 52,499 31,499 14,489 8,693 All Somalia 235, , , ,783 54,635 32,781 Rounded off to 236, , , ,000 55,000 33,000 For details, contact Nutrition cluster coordinator: Leo Matunga Address: lmatunga@unicef.org Nutrition cluster Lead: UNICEF

21 3. Nutrition Analysis in Somalia The April-July 2012 (Gu) Nutrition Situation Analysis Twice per year, in line with the seasonal assessments, post Gu (April July) and post Deyr (October-December), FSNAU in collaboration with partners undertake a nutrition situation analysis by livelihood, region and IDP settlement. During the April-July 2012 (Gu 2012) season, FSNAU in collaboration with partners undertook 46 representative nutrition surveys aimed at estimating the nutrition situation in the various population groups in Somalia. The survey tools used are provided in the appendices. Data management of the nutrition surveys involved the use of the standard two stage cluster sampling based on SMART recommendations, quality assurance during data collection and entry, and validation of data quality by running frequencies and plausibility checks of core statistical inferences. (Table 24). ENA software was used in the analysis of anthropometric and mortality data, and EpiInfo in the cross tabulations and analysis of non-anthropometric data. Analysis has been conducted using EpiInfo ENA, and interpretation of findings on specific indicators are based on internationally recognized thresholds, mainly the UN-WHO, UNICEF, Sphere, and FANTA/UNFAO. UN-WHO thresholds have been used to determine the cut-offs for anthropometry where available, and to interpret findings on acute malnutrition. SPHERE 2011 has been referenced on cut-offs for the mid upper arm circumference for pregnant and lactating women and aided in estimating prevalence and cut off for child imunization status. Nevertheless they are limited in providing thresholds for interpreting the situation. FANTA/UNFAO protocols have been referenced on thresholds for dietary intake, however they are limited in guiding on interpretation of the situation. The mean WHZ, are based on a Review of Nutrition and Mortality Indicators for the Integrated Food Security Phase Classification (IPC) by Young and Jaspars, The UNICEF 2005 classification has been used to interpret death rates. The findings for each of analyzed variables are categorized into six different phases based on the recognized thresholds:,,,, or Extremely. Where internationally recognized interpretation frameworks are not available, for example, MUAC thresholds for the adult non-pregnant women, and the health information system trends, quartile distributions of the meta-data at the FSNAU from 250 nutrition surveys conducted in has been used. The Nutrition Situation Analytical Framework The Nutrition Situation Analytical Framework provides a summary of international thresholds (WHO, UNICEF, Fanta, Unicef) used to interpret findings from the various indicators. Where these are not available, contextually relevant analysis forms the basis. Considering the diversity of indicators collected by FSNAU and partners in Somalia, (acute malnutrition, death rates, proportions at risk based on the mid upper arm circumference, nutrition trends from health facilities and selective feeding programs), the framework forms the basis for integrated analysis of the situation. The January 2012 version of the analysis framework, used in the Gu 2012 analysis, has three sections: A. Core Outcome Indicators (mainly anthropometry related information, and mortality. Those from surveys have more weight) B. Immediate Causes C. Driving/Underlying Factors Where representative nutrition surveys have been conducted, the global acute malnutrition (GAM), is the core outcome reference indicator, denoting the prevalence of acute malnutrition. The outcome of the integrated nutrition situation analysis process, the estimated nutrition situation, is based on convergence of the evidence of the findings from the indicators. A minimum of 2 anthropometric indicators (global and severe acute malnutrition rates, for example have been used to make an analysis and classification of the situation into either of the six different phases. Information from the season in progress only is used. However historical data has been used for overall contextual and seasonal trends analysis. The overall analysis is consolidated into the Estimated Nutrition Situation Map. In the cartographical presentation, reliability of data source is illustrated through solid color (for survey data which is quite reliable, R=1), or through slash marks (when statistically representative data is not available, in which case data reliability is lower and, R=2). Although FSNAU-led, the framework has been developed over the years through a consultation process involving the WHO, UNICEF, WFP, ACF, CONCERN, SCUK, IMC, WV and more recently, Medair, DIAL and the Nutrition Cluster Support team as well as many nutrition partners in the region. The purpose is to have a tool that helps describe the nutrition situation with contextual analysis, rather than focus on prevalence estimates and thresholds which is traditionally the case in nutrition analysis. The January 2012 version accommodates current research developments, the switch from NCHS 1997 to WHO 2006 growth standards and a category for extremely critical or famine level nutrition situation where for example global acute malnutrition rate is 30% and above. The analytical framework remains a working document, updated and refined as new information and guidance becomes available. Nutrition Analysis 13

22 Nutrition Analysis 14 Table 4. The Nutrition Situation Classification Framework, Draft 8, January 2012 A. CORE OUTCOME INDICATORS (Anthropometry & Death Rates) Reference Indicators Extreme Global Acute Malnutrition 1 (IPC Reference) Reliability (R) =1 Mean Weight-for-Height Z (WHZ) scores (R=1) SAM 2 (WHZ and oedema 3 ) (WHO to advice on thresholds) R=1) Crude death rate 4 / 10,000/day (R=1) Under five death rates 5 /10,000/day (R=1) <3% >-0.40 MUAC 6 Children: (% <12.5cm): Ref: FSNAU Estimates 7 (R=2) <2.0% 3 to <10%; Usual range and stable to -0.69; Stable/Usual 10 to<15% or where there is significant increase from usual/ seasonal trends in last >3 yrs to -0.99; >usual/increasing 15 to<20% or where there is significant increase from baseline/ seasonal trends in last >2 yrs <-1.00; >usual/increasing 20 to <30% >30% <-1.5 TBC <2.5% % % % 10% <0.5 < to <1 or doubling of rate in preceding phase. 1 to <2 >2 >2 <1 <1 1 to to 3.9 >4 > % with increase from seasonal trends % %, or where there is significant increase from seasonal trends %, Or where there is significant increase from seasonal trends 20.0%, Or where there is significant increase from seasonal trends MUAC<11.5cm 8 (R=2) <1.0 < Adult MUAC 9 - Pregnant and Lactating(%<23.0cm,Meta Data- < FSNAU Adult MUAC - Non-pregnant & nonlactating <18.5cm, Meta data FSNAU) < Non Pregnant Maternal 10 Undernutrition BMI<18.5 <10% 10.0 to 19.9% 20.0 to 39.9% >40% Non Pregnant Maternal 11 TBC Overnutrition BMI>24.9 TBC TBC TBC Moderate (10 to Low proportion <15%) and stable High (> 15%) and V. low (<5%) (5 to <10%) and or low (5 to <10%) stable proportion High (> 15%) and increasing HIS 12 Trends of Acutely Malnourished proportion in the stable trend in but increasing in the preceding proportion in the preceding Children preceding 3mths the preceding proportion in the 3mths relative 3mths relative to >2yr seasonal (Ref: HIS), (R=3) relative to >2yr 3mths relative preceding 3mths to >2yr seasonal trends seasonal trends to >2yr seasonal relative to >2yr trends trends seasonal trends Sentinel 13 Site Trends: levels of children identified as acutely malnourished(whz), FSNAU 06 SSS Very low (<5%) and stable levels Low levels (5 to <10%)and one round indicating increase, seasonally adjusted Low (5 to < 10%) & increasing or moderate (10 to <15%) levels based on two rounds (seasonally adjusted) High levels (> 15%) of malnourished children and stable (seasonally adjusted) High levels (> 15%) and increasing with increasing trend (seasonally adjusted) OVERAL NUTRITION SITUATION Extreme B. IMMEDIATE CAUSES Reference Indicators Poor HH Dietary Diversity (% consuming<4fdgps) <5% 5 9.9% % % >50% Mean HH dietary diversity Score 13 Disease Outbreaks 14 : (seasonally adjusted). Frequency of reported outbreaks of AWD &, malaria & measles Morbidity Patterns: Proportion of children reported ill in 2wks prior to survey (R=2) Health facility morbidity trends (R=3) /WHO surveillance (R=1) TBC Normal levels, & seasonal trends, Review data in relevant context TBC Very low proportion reportedly sick TBC -AWD 1 case -Measles 1 case -Malaria doubling of cases in 2 weeks in hyper endemic areas using RDT TBC Low & stable proportion of reportedly sick based on seasonal trends TBC TBC TBC Outbreak not contained and/or in non endemic area limited access to treatment: CFR for AWD >2% rural CFR for AWD >1% urban AWD duration exceed >6 wks TBC Low proportion reportedly sick, from previous months but increasing in >2 mnths based on seasonal trends TBC High levels and stable numbers in >2 months based on seasonal trends TBC High with significant Increase in numbers of sick children, based on seasonal trends

23 C. DRIVING FACTORS Reference Indicators Complementary feeding 15 in addition to breastfeeding i. Introduction of complementary food at 6 mths of age: ii. %introduced Meeting minimum recommended feeding frequency 16 Dietary diversity17 score iii. Breastfeeding (BF) Practices 1 8 I. Exclusive BF for 6mths ii).continued BF at 1 yr iii)continued BF at 2yr reference Measles immunization/status Vitamin A Supplementation Coverage 1 9:1 dose in last 6 mths Population have access i). to a sufficient quantity of water for drinking, cooking, personal & domestic hygiene min 15lts pp/ day ii).sanitation facilities Affected pop with access to formal/informal services: health services Selective Feeding 20 Programs Available: Coverage of TFP /SFP & referral systems(sphere04); -Admissions trends (R=3) Food Security Situation- current IPC status Civil Insecurity 3 MONTH NUTRITION SITUATION OUTLOOK 95% 95% 95% >90% >90% >90% >95% >95% 100% 100% Should not be necessary Should not be necessary Generally Food Secure 80-94% 80-94% 80-94% 50-89% 50-89% 50-89% % % TBC TBC Access to humanitarian interventions for most vulnerable Access for most vulnerable Borderline 60-79% 80-94% 80-94% 12-49% 12-49% 12-49% TBC TBC Reduced access to humanitarian support for most vulnerable Acute Food and Livelihood Crisis 0-59% 0-59% 0-59% <80% <80% TBC TBC Limited access to humanitarian support for majority None available Humanitarian Emergency 0-11% 0-11% 0-11% 0-59% 0-59% 0-59% TBC TBC Negligible or no access Famine/Humanitarian Catastrophe Food Secure Unstable Prevailing Limited spread, low Widespread, high disrupted Widespread, high intensity structural peace intensity intensity tension Convergence of evidence on immediate Causes/Driving factors vis-à-vis Projected trend in 3 months time No change: Stable; Uncertain: Potential to deteriorate Potential to improve: Nutrition Analysis 15 Analytical Process: Key Points 1 Global Acute Malnutrition (weight for height <-2 Z score/oedema), IPC Vs 2, Nov Severe Acute Malnutrition (weight for height <-3 Z score/oedema): Thresholds derived from quintile distribution of SAM from 250 SMART survey datasets at FSNAU, January Bilateral oedema is riverine livelihood specific indicator rather than for the whole country 4 Refs: i). Sphere 2004; ii). Emergency Field Handbook (A guide for UNICEF staff, pg 139) July WHO and Integrated Food Security Phase Classification Technical Manual Version 2.0, Final Draft, November Technical consultations 6 Mid Upper Arm Circumference, data source rapid assessments, based on children 6-59 months: Thresholds derived from quintile distribution of SAM from 200 SMART survey datasets at FSNAU, January Follow up with S. Collins study/ Mike Golden/ Mark Myatt and on-going studies 8 Review of Nutrition and Mortality Indicators for the Integrated Food Security Phase Classification, Helen Young and Susanne Jaspars, Sept Thresholds for adult MUAC (pregnant/lactating and non-pregnant women) derived from quintile distribution of MUAC data from 99 SMART survey datasets at FSNAU 10 WHO Expert Committee, WHO Expert Committee, Health Information System, data source health facilities 13 Data source, over 120 sentinel sites in different livelihoods in South Central Somalia 14 Data source, nutrition surveys, dietary studies and sentinel sites 15 Data source, nutrition surveys, Health Information System, Sentinel sites, feeding centers, rapid assessments 16 Data source, nutrition surveys and dietary studies 17 WHO Indicators for assessing infant and young child feeding practices. 2-3 feeds recommended for 6-8 months old, & 3-4 feeds for 9months old and above 18 WHO Indicators for assessing infant and young child feeding practices 19 FANTA Generating indicators of appropriate feeding of children 6 through 23 months from the KPC WHO, Infant and Young child feeding. A tool for assessing national practices, policies and programmes 20 WHO references 21 Data source, 12 Therapeutic Feeding Centers (TFC) and 14 Supplementary Feeding Centers (SFC)

24 Regional Analysis 4. REGIONAL NUTRITION ANALYSIS 4.1 Gedo Region Map 6: Gedo Region Livelihood Systems 16 Gedo region in southwest Somalia administratively comprises of six districts: Luuq, Dolo, Belet Hawa, Garbaharey, El Wak, and Bardera, see Map 6. Gedo region has three main rural livelihood zones namely: pastoral, agropastoral and riverine (Juba riverine pump irrigation). The pastoral livelihood, is further sub-divided into the Southern Inland and Dawa pastoralists. The Dawa pastoral livelihood zone located in northern Gedo is the largest pastoral group in the region rearing mainly cattle, a few sheep, goats and camel. The Southern Inland pastoral population is located in southern Gedo and mainly keep camel besides a few sheep and goats. The agro-pastoral population is divided into Southern agro-pastoral and Bay, Bakool and Gedo agropastoral - the sorghum high potential. Figure 6 indicates the historical trends of acute malnutrition in Gedo since Historical Overview - Post Deyr 11/12 Food Security The FSNAU Post Deyr 11/12 integrated food security analysis classified both rural and urban livelihoods of Gedo region to be either in Crisis or Emergency. In the rural livelihoods, the Crisis phase was identified mainly among the southern agro-pastoral, southern inland pastoral, Juba Pump Irrigated and Dawa pastoralists. An estimated 32,000 people in the urban livelihoods were identified in Crisis, while an estimated 11,000 people of the riverine livelihood (Juba riverine pump irrigation) were identified to be in Emergency. However, the overall food security situation in Gedo region showed an improvement, with the exception of the riverine livelihood which was affected by flash floods and remained in Emergency. The general improvement of the food security situation was due to a number of factors: good cereal and cash crop harvest, in addition to improved terms of trade (ToT) for local goat to cereal, increased access to humanitarian interventions and improved livestock body conditions. Good off-season maize harvests from the riverine areas, together with average camel milk production, increased livestock prices and household income also contributed to the improved food security situation in the region. of acute malnutrition compared to the Gu 11 season. These improvements were mainly linked to the enhanced food security situation and humanitarian response in the region. Nevertheless, the nutrition situation remained of concern and was generally linked to seasonal outbreaks of acute watery diarrhea AWD, cholera, malaria, measles and whooping cough. Current Situation-Post Gu 12 Food Security The FSNAU Post Gu 12 integrated food security analysis classifies both rural and urban livelihoods of Gedo region as either Stressed or in Crisis. In the rural livelihoods, the Crisis phase is mainly identified among the Gedo agropastoral high potential,and Juba Pump Irrigated livelihood zones. However, the overall food security situation in Gedo region shows an improvement from the respective Crisis and Emegency in Deyr 11/12 due to a number of factors: good cereal and cash crop harvest, in addition to improved terms of trade (ToT) for cereal to local goat, increased Figure 6: Trend in Level of Acute Malnutrition (WHZ<- 2 or oedema, WHO 2006) in Gedo Region, Regional Analysis Nutrition The Post Deyr 11/12 integrated nutrition situation analysis of Gedo region using data from health and feeding (SFP/ OTP) facilities, indicated a sustained likely nutrition situation across all the three (agro-pastoral, pastoral and riverine) livelihood populations of Gedo region. However, triangulation of data from health and feeding facilities in Gedo region indicated an improvement in levels

25 access to humanitarian interventions, improved livestock body conditions and the anticipated good off-season maize harvests from riverine areas. Average camel milk production, increased in livestock prices and household income has also contributed to the improved food security situation. Figure 7: HIS Malnutrition Trends in Gedo Agropastoral MCHs Regional Analysis Nutrition No surveys were conducted in Southern Gedo region due to inaccessibility as a result of civil insecurity, therefore the available data (from health and feeding facilities) is insufficient to make an overall nutrition situation estimation. The current Gu 12 integrated nutrition situation analysis of Northern Gedo region depicts a sustained Very nutrition situation among the pastoral and riverine populations. Nutrition assessments conducted in May 12 in Northern Gedo region indicate elevated levels of acute malnutrition with GAM and SAM rates of 28.4% ( ) and 6.2% ( ) respectively in the Dawa pastoral, and GAM and SAM rates of 22.5% ( ) and 6.1% ( ) respectively, reported in the riverine livelihood zone. Data from health facilities from January to July 2012 in the pastoral, agropastoral (Figure 7) and riverine livelihood zones of Northern Gedo region, indicate a high (>20%) and decreasing trend of acutely malnourished children. Analysis of data from feeding facilities in Northern Gedo region indicates a decline in levels of acute malnutrition compared to the Deyr 11/12 season. The analysis indicates a sustained nutrition situation in the two livelihoods in Nothern Gedo region. There was no statistically significant difference in the proportion of boys and girls acutely malnourished in both surveys (p> 0.05). The 90 days retrospective crude death rates is among both the pastoral (0.59/10,000/day) and riverine (0.20/10,000/day) populations according to UNICEF classification. The respective U5 death rates 1.36 ( ) and 1.60 ( ) in pastoral and riverine livelihoods are also in phase (Table 5). The nutrition situation remains concerning, given the area is generally prone to seasonal outbreaks of AWD, cholera, malaria, measles and whooping cough. The situation is further aggravated by chronic underlying factors such as: household food insecurity, poor dietary quality, inadequate social and care environment (sub-optimal child care and feeding practices), and poor public health (limited access to basic human services such as safe water, health and sanitation facilities), which predispose the communities to high morbidity and subsequently high levels of acute malnutrition. It is therefore crucial to initiate or continue interventions targeting the health and nutrition of the population and also address the underlying causes of food insecurity and disease, therefore close monitoring of the situation is crucial. The key reference nutrition indicators used for analysis are provided in Table 5. Dolow IDPs An exhaustive nutrition survey conducted among the Dolow IDPs in July 2012 reports a GAM rate of 25.9% and a SAM rate of 7.5%,which indicates a nutrition situation. The 90 days retrospective crude and under five death rates reported are 0.60 and 0.81 per 10,000/day indicating an situation according to UNICEF 2005 classification. Overall, the nutrition situation among the Dolow IDPs is, and the population remains highly vulnerable due to the direct impact of household food insecurity and the high disease burden in the town, further aggravated by limited access to health services. Results further indicated that a high proportion of the children assessed in the survey had fallen ill two weeks prior to the survey. The overall rate of morbidity reported is 36.7%. The proportion of children reported to have suffered from diarrhoea in the 2 weeks prior to the assessment is 18.4%, while those suffering from suspected pneumonia and measles is lower at 7.8% and 0.5% respectively. The measles immunization and vitamin A supplementation status for the assessed children in the 6 months prior to the assessment is high (89.4% and 90.9% respectively), however still below the recommended Sphere standards of 95%. In addition chronic underlying factors that affect the nutritional status of the population persist such as; poor child care and feeding practices, inadequate sanitation facilities and lack of access to safe drinking water remain as long term challenges to the health and nutrition wellbeing of the population. It is therefore crucial to initiate or continue interventions targeting the health and nutrition of the population and also address the underlying causes of food insecurity and disease. 17

26 Regional Analysis 18 Table 5: Summary of Key Nutrition Findings in Gedo Livelihood Zones, May 2012 Gedo Pastoral (N=694, =339,=335) Gedo Riverine (N=757, =397, =360) Dolow IDPs (N= 974 =470, =504) Indicator Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) Severe Acute Malnutrition (WHZ<-3 or oedema) Mean of Weight for Height Z Scores 28.4 ( ) 31.0 ( ) 25.9 ( ) 6.2 ( ) 6.2 ( ) 6.2 ( ) 22.5 ( ) 26.7 ( ) 17.8 ( ) 6.1 ( ) 7.8 ( ) 4.2 ( ) ± ± ±1.12 Oedema Global Acute Malnutrition 26.3 ( ) 22.9 ( ) 23.9 (NCHS) Severe Acute Malnutrition 2.1 ( ) 3.9 ( ) 5.1 (NCHS) Proportion with MUAC (< ( ) 9.2 ( ) 13.8 cm or oedema) 5.8 ( ) 7.0 ( ) ( ) 11.5 ( ) 13.5 Proportion with MUAC (<11.5 cm or oedema) Stunting (HAZ<-2) 2.1 ( ) 2.3 ( ) 1.9 ( ) 17.6 ( ) 15.4 ( ) 19.6 ( ) 0.9 ( ) 0.5 ( ) 1.4 ( ) 19.0 ( ) 20.6 ( ) 17.1 ( ) Underweight (WAZ<-2) 23.1 ( ) 24.4 ( ) 21.9 ( ) 21.0 ( ) 23.6 ( ) 18.2 ( ) HIS Nutrition Trends ( January July 2012) Child Morbidity & Immunization High (>30%) levels and increasing trends High (>30%) levels and increasing trends High (>30%) levels and increasing trends Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Morbidity-29.2 ( ) 27.6 ;-30.7 Diarrohea ; Pneumonia ; 11.9 Measles ; 0.2 Morbidity-25.9 ( ) -25.0;-26.8 Diarrohea-10.3; Pneumonia ; 8.2 Measles0.3-0;-0.8 Morbidity ;-37.8 Diarroh ; 18.1 Pneumonia ; 8.0 Measles ; -0.7 Very Immunization Vitamin A :-92.7 Measl ;-91.4 ) Vitamin A :-93.1 Measles-88.4: -89.4; Vitamin A ;-90.6 Measles ;-89.2 Death Rates Crude deaths, per 10,000 per day (retrospective for ( ) 0.2 ( ) 0.60 days) Under five deaths, per 10,000 per day (retrospective for ( ) 1.6 ( ) 0.80 days) Pregnant and lactating women (MUAC <23.0 cm) 30( ) 24.9( ) 24.1( ) Pregnant and lactating women (MUAC <21.0 cm) 24.1( ) 4.3( ) 4.8( ) Non pregnant and lactating women (MUAC <18.5 cm) 0 0.6(0.0-16) 4.8( ) Food security phase Stressed Stressed/Crisis Stressed/Crisis Overall Risk to Deterioration Stable Stable Stable Overall Situation Analysis

27 Table 6: Summary of Key Nutrition Findings in Dowlo IDPs May 2012 Dowlo IDPs (N=974, =470, =504) Indicator Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) 153 : Severe Acute Malnutrition (WHZ<-3 or oedema) Mean of Weight for Height Z Scores ±1.12 Oedema 0.80 Global Acute Malnutrition (NCHS) 23.9 Severe Acute Malnutrition (NCHS) 5.1 Global Acute malnutrition by MUAC (<12.5 cm or oedema) Severe Acute malnutrition by MUAC (<11.5 cm or oedema) Stunting (HAZ<-2) Underweight (WAZ<-2) HIS Nutrition Trends (July- December 2011) Child Morbidity & Immunization Morb Regional Analysis 19 Disease trends (seasonally adjusted) Diarrohea Pneum Measle Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) 0.60 Under five deaths, per 10,000 per day (retrospective for 90 days) 0.80 Food security phase Crisis Overall Risk to Deterioration Unstable Overall Situation Analysis Gender and nutrition analysis in Gedo Region Nutrition assessments conducted in two livelihoods zones of Northern Gedo region recorded a higher proportion of acutely malnourished boys than girls in the pastoral (31% vs 25.9%) and riverine (26.7% vs 17.8%) livelihoods. Similarly, a higher proportion of acutely malnourished boys than girls are observed in the Dolow IDPs (31.1% vs 21 %). However, these differences are not statistically significant (Pr<75%). Similar patterns are more or less observed in the other forms of malnutrition where in the pastoral livelihood, 15.4% of boys compared to 19.6% of girls were stunted; and 24.4% of boys as compared to 21.9% of girls were underweight. In the riverine livelihood 20.6% of boys compared to 17.1% of girls were stunted; and 23.6% of boys as compared to 18.2% of girls were underweight. In the Dolow IDPs, 29.3% of boys compared to 30.4% of girls were stunted; and 34.6% of boys as opposed to 28.7% of girls were underweight. A higher proportion of girls than boys were reportedly ill two weeks prior to the assessment in the pastoral, agro-pastoral and riverine populations. However, there is no statistically significant difference between the sexes showing that they were both equally affected (Pr<75%). The gender disaggregated results of the assessed children is summarized on Tables 6 and 7. Maternal nutrition status in Gedo region In the pastoral and riverine livelihoods of Northern Gedo and among the Dolow IDPs, a significantly higher proportion of pregnant and/or lactating women were acutely malnourished (MUAC< 23.0 cm, and 21.0 cm, and/or bilateral oedema) than non-pregnant and non-lactating women (MUAC<18.5). The proportion of acutely malnourished pregnant and/or lactating women ranged between 24.1% () among the Dolow IDPs population to 30% () in the Dawo pastoral livelihood. The maternal malnutrition in Dolow IDPs is among the pregnant and lactating women, with 24% of the assessed women recording MUAC measurements of <23cm. The high levels of acute malnutrition among the pregnant and/or lactating women is linked to increased nutrient needs during these periods which may not be met. Gedo region Pregnant and Lactating Women No. Assessed Non-pregnant and Lactating women Proportion Proportion No. with with Assessed MUAC<23cm(%) MUAC<21cm(%) Proportion with MUAC<18.5cm(%) North 389 Riverine 24.9( ) 4.3( ) (0.0-16) Dawo ( ) 2.3( ) Pastoral Dollow IDPs ( ) 4.8( ) ( )

28 Regional Analysis MIDDLE and LOWER Juba Regions Middle and Lower Juba regions have three main rural livelihood zones namely: the pastoral (the Southern Inland and Southeast Pastoralists), agro-pastoral (Lower Juba and Southern Agro-pastoral) and the Riverine communities who are purely agriculturalists. The Juba regions in southern Somalia have a total of seven districts namely: Sakow, Buale and Jilib in Middle Juba, and Jamame, Afmadow, Kismayo and Badhadhe in Lower Juba see Map 7. Map 7: Juba Regions Livelihood Zones The food security and nutrition situation in the Juba regions has varied over time and has largely been linked to rainfall performance and its resultant impacts on the different livelihood systems. Heavy rainfall in the Juba regions or in the Ethiopian highlands often results in floods that devastate crop cultivation and sanitation facilities in the riverine areas, however, the riverine communities later benefit from recessional cropping from the Desheks and fishing opportunities from the flood waters. The agropastoral communities, who rely on rain-fed agriculture, are totally dependent on rainfall and so are the pastoralists, whose livelihood is greatly influenced by water and pasture conditions. Historical Overview - Post Deyr 11/12 Food Security The FSNAU Post Deyr 11/12 analysis classified the food security situation of rural livelihoods of Juba regions in three phases: Crisis, Emergency and Stressed and the urban populations in either Emergency or Stressed. A total of 169,000 people were in crisis and in need of humanitarian assistance and livelihood support. Out of these, 74,000 people in the two regions were in a state of Crisis (35,000 in M/Juba and 39,000 in L/Juba). While another 95,000 were identified to be in Emergency (50,000 in M/Juba and 45,000 in L/Juba). The population facing food insecurity declined by 43% in the Deyr 11/12 (169,000) when compared with 295,000 in Gu 11. In addition, 20,000 people in both regions were identified to be Stressed (7,000 in M/Juba and 13,000 in L/Juba). In the urban livelihood in both regions, 69,000 people were identified to be in crisis with 26,000 in M/Juba and 43,000 in L/Juba in either Emergency or Crisis. The situation of the riverine population in Middle and Lower Juba regions was critical due to the combined impacts of the previous droughts and severe flooding in Deyr 11/12 season, which resulted in total maize crop failure. Nutrition The nutrition situation of the Middle and Lower Juba pastoral, agro-pastoral, and riverine livelihood populations has been in a sustained phase since Deyr 10/11. However, a significant reduction in the GAM and SAM rates of the three livelihoods was recorded compared to the Gu 11. The poor nutrition situation in Juba regions was mainly linked to food insecurity exacerbated by high morbidity. The consecutive seasons of poor rainfall performance experienced in the regions led to poor crop and livestock production as well as high livestock deaths, especially cattle, sheep and goats, resulting in limited access to milk and diversified foods at household level. The reduced humanitarian interventions (health and nutrition services) and recurrent civil insecurity in the area was a major concern, especially since high morbidity remains a major risk factor to acute malnutrition. Figure 8 indicates the historical trends of acute malnutrition in Middle and Juba Regions since Figure 8: Trend in levels of Acute Malnutrition (WHZ <-2Z scores or oedema, WHO 2006), Juba Regions

29 Current Situation - Post Gu 12 Food Security The food security situation in Juba regions shows some improvements since Deyr 11/12. Currently, a portion of the Lower Juba agro-pastoral population (25% of Poor) is identified in Emergency, while the South-East Pastoral, Southern Agro-pastoral and Juba riverine livelihoods in both Lower and Middle Juba regions are identified to be in Crisis. Significant improvements are visible in the Southern Inland Pastoral (camel herders) population, which are classified as Stressed. The positive changes discerned in the food security situations are largely attributable to the effects of previous Deyr 11/12 season which improved overall rangeland conditions, resulting in improved livestock body conditions and market value. Despite the above improvements in parts of Juba region, substantial food and income gaps still exist in most of the major livelihoods. Civil insecurity and closure of Kismayo port activities have resulted in low trade activities and loss of employments from charcoal exports. Nutrition Situation Three comprehensive nutrition surveys conducted in July 2012 among the pastoral, agro-pastoral and riverine livelihoods of Juba region indicate a sustained nutrition situation in the agro-pastoral and riverine populations but an improvement to a phase among the pastoral. Survey findings recorded a GAM rate of 15.8% ( ), 25.1% ( ) and 21.1% ( ) among the pastoral, agropastoral and riverine populations respectively. The SAM rates reported in the three livelihood zones were 2.1% ( ), 5.8% ( ) and 6.6% ( ) in the pastoral, agro-pastoral and riverine livelihoods respectively. Among the riverine population of Juba, these findings indicate a nutrition situation, an improvement from the Extreme nutrition situation reported in the Deyr 11/12 season. This is a significant improvement (p<0.05) in the GAM and SAM rates observed in the October 11 survey that reported GAM and SAM rates of 34.5% ( ) and 11.8% ( ) respectively. The 90 day retrospective crude and under five death rates are 0.20 ( ) and 1.16 ( ) respectively, indicating and situations (UNICEF 2005). Among the pastoral population, a GAM rate of 15.8% ( ) and a SAM rate of 2.1% ( ) is, and when compared to the October 11 GAM and SAM rates of 27.3% ( ) and 9.5% ( ) respectively, illustrates an improvement from a nutrition situation, with a significant decline in acute malnutrition rates (p<0.05). The crude and under five death rates are 0.44 ( ) and 0.81 ( ) respectively, indicating acceptable and alert situations. (UNICEF 2005). Figure 9: HIS Malnutrition trends in Juba agro-pastoral MCHs Data Source: Muslim AID UK, MSF and SCRCS The agro-pastoral population reported a GAM rate of 25.1% ( ) and SAM rate of 5.8% ( ), indicating a sustained nutrition situation since Deyr 11/12. A comparison with the previous GAM rate of 26.1% ( ) and SAM rate of 9.1% ( ) reported in October 11 indicates no significant change (p>0.05). The 90 day retrospective crude and under five death rates reported in July 2012 are 0.25 ( ) and 0.85 ( ) respectively, indicating acceptable and alert situations (UNICEF 2005) 1. Nutrition data from health facilities in the Juba riverine, pastoral and agro-pastoral livelihoods all indicate high numbers (>30%) and an increasing trend of acutely malnourished children Figure 9 show the malnutrition trend in health facilities in agro-pastoral areas. Close monitoring of the food security and nutrition situation will be crucial in the Juba population. The population still remain highly vulnerable to shocks and the current risk factors are: reduced access to humanitarian services, high morbidity burden- reported AWD and measles outbreaks, poor access to health care services and sanitation, sub-optimal child feeding and care practices which all have a direct impact on the health and nutritional status of children, therefore close monitoring of the situation is crucial. The key reference nutrition indicators used for analysis are provided in Table 7. 1 UNICEF, 2005: The Emergency Field Handbook. A guide for UNICEF staff. (pg 139), July Retrieved March 5, 2012 at Regional Analysis 21

30 Regional Analysis 22 Table 7: Summary of Key Nutrition Findings in Juba Livelihood Zones, July 2012 Juba Pastoral (N=520, =261,=259) Juba Agro-pastoral (N=773, =369, =404) Juba Riverine (N= 817 =381, =436) Indicator Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) Severe Acute Malnutrition (WHZ<-3 or oedema) 15.8 ( ) 17.6 ( ) 13.9 ( ) 2.1 ( ) 2.7 ( ) 1.5 ( ) 25.1 ( ) 30.9 ( ) 19.8 ( ) 5.8 ( ) 6.8 ( ) 5.0 ( ) 21.1 ( ) 27.8 ( ) 15.1 ( ) 6.6 ( ) 8.9 ( ) 4.6 ( ) Mean of Weight for Height Z Scores -0.78± ± ±1.06 Oedema Global Acute Malnutrition (NCHS) 14 ( ) 19.6 ( ) 18.8 ( ) Severe Acute Malnutrition (NCHS) 2.1 ( ) 2.8 ( ) 2.4 ( ) Proportion with MUAC (<12.5 cm or oedema) Proportion with MUAC (<11.5 cm or oedema 18.1 ( ) 17 ( ) 19.2 ( ) 4 ( ) 4.5 ( ) 3.5 ( ) 16.1 ( ) 15.3 ( ) 16.9 ( ) 2 ( ) 11.1 ( ) 2.9 ( ) 14.6 ( ) 15.9 ( ) 13.5 ( ) 3.2 ( ) 3.3 ( ) 3.2 ( ) Stunting (HAZ<-2) 24 ( ) 29.1 ( ) 18.9 ( ) 28.0 ( ) 33.1 ( ) 23.4 ( ) 27.8 ( ) 34.2 ( ) 22.2 ( ) Underweight (WAZ<-2) 19.9 ( ) 23.8 ( ) 16 ( ) 33.4 ( ) 44.4 ( ) 23.4 ( ) 34.5 ( ) 44.1 ( ) 26 ( ) HIS Nutrition Trends ( January- July 2012) High (>30%) levels and increasing trends High (>30%) levels and increasing trends High (>30%) levels and increasing trends Child Morbidity & Immunization Morb-31.1 ( ) 32.6 ;Girl Disease trends (seasonally adjusted) Morbidity refers to the proportion of Diarr-11.9 children reported to be ill in the ;10.3 weeks prior to the survey Pneumonia ; 9.0 Morb-16.7 ( ) 17.5;-16 Diarr ;11.1 Pneumonia ; 0.4 Morb-42.4 ( ) 42.4; 42.4 Diarr ; 9.0 Pneumonia ; 8.5 Measles ; 2.2 Measles ; 1.2 Measles ; 0.6 Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) 0.44 ( ) 0.25 ( ) 0.20 ( ) Under five deaths, per 10,000 per day (retrospective for 90 days) 0.81 ( ) 0.85 ( ) 1.16 ( ) Pregnant and lactating women MUAC <23.0 cm 43.0(32-54) 26.3( ) 26.3( ) Pregnant and lactating women MUAC <21.0 cm 23.3( ) 3.0( ) 3.0( ) Non pregnant and lactating women MUAC <18.5 cm 16.3( ) 4.7( ) 0.7( ) Food security phase Stressed Crisis Crisis Overall Risk to Deterioration Unstable Unstable Unstable Overall Situation Analysis

31 Kismayo and Dhobley IDPs The nutrition situation of the internally displaced population in Kismayo Town is classified as. A comprehensive nutrition survey conducted among the Kismayo IDPs in July 12 reports a GAM rate of 28.0% ( ) and a SAM rate of 8.2% ( ) which indicates a sustained nutrition situation. A survey conducted in October 11 survey reported a GAM rate of 26.7% ( ) and a SAM rate of 9.5% ( ), and thus there is no significant change (p>0.05) in the nutrition situation. The 90 day retrospective crude and under five death rates are 0.27 ( ) and 1.71 ( ) respectively, both indicating and situations according to UNICEF (2005) classification. The worrying nutrition situation is mainly related to chronically poor food access, and high morbidity due to inadequate sanitation facilities and safe water and lack of health services. Regional Analysis 23 Table 8: Summary of Key Nutrition Findings in Kismayo IDPs July 2012 Kismayo IDPs (N=547, =277, =270) Dobley IDPs N=781, =392, =389 Indicator Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) 153 : Severe Acute Malnutrition (WHZ<-3 or oedema) 28( ) 32 ( ) 23.7( ) 8.2 ( ( ) 7.8( ) Mean of Weight for Height Z Scores Oedema ± ±1.19 Global Acute Malnutrition (NCHS) 23.8 ( ) 20.6 Severe Acute Malnutrition (NCHS) 4.2 ( ) 4.1 Global Acute malnutrition by MUAC (<12.5 cm or oedema) Severe Acute malnutrition by MUAC (<11.5 cm or oedema Stunting (HAZ<-2) Underweight (WAZ<-2) HIS Nutrition Trends (January - July 2012) Child Morbidity & Immunization 11.3 ( ) 11.7 ( ) 10.9( ) 4.5 ( ) 3.9 ( ) 5.1 ( ) 35.1 ( ) 38.5 ( ) 31.4( ) 40.4 ( ) 45.6 ( ) 35.1 ( ) Morbidity 18.6 ( ) 19.3 ( ) 17.8 ( ) Morbidity Disease trends (seasonally adjusted) Diarrohea 12 ( ) 11.9 ( ) ) Diarrohea Pneum-2.6 ( 0-6.2) 2.8 ( 0-6.5) 2.5 (0-6.2) Pneum Immunization Status Meas-1.4 ( ) 1 ( 0-2.2) 1.7 ( 0-3.5) Vita A- N/A Measles N/A N/A Measle Vita A Measles Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) 0.27 ( ) 0.32 Under five deaths, per 10,000 per day (retrospective for 90 days) 1.71 ( ) 0.96 Food security phase Crisis Crisis Overall Risk to Deterioration Unstable Unstable Overall Situation Analysis

32 Regional Analysis 24 An exhaustive nutrition survey conducted among the Dhobley IDPs in July, 2012 reports a GAM rate of 22% and a SAM rate of 7.6% which indicates a nutrition situation. The 90 days retrospective crude and under five death rates reported are 0.32 and 0.96 per 10,000/day indicating an situation according to UNICEF (2005) classification. Overall, the nutrition situation among the Dhobley IDPs is, and the population remains highly vulnerable due to the direct impact of household food insecurity and the high disease burden in the town, further aggravated by the limited access to health services. There is need for continued support to the displaced population in terms of targeted food supplementation, income-generating activities, health education, shelter improvement and continued immunization programmes and other development interventions to improve the health and nutrition situation of the vulnerable IDPs in Dobley town. Gender and nutrition analysis in Juba Region The nutrition assessments conducted in the livelihood populations of Juba recorded a higher proportion of acutely malnourished boys than girls in the pastoral (17.6% vs 13.9%) and agro-pastoral (30.9% vs 19.8%) livelihoods. Similarly, a higher proportion of acutely malnourished boys than girls are observed in the riverine livelihoods (27.8% vs 15.1 %). These differences are statistically significant (p<0.05) among the boys and girls in the agro-pastoral and riverine livelihoods. In the pastoral livelihood, 29.1% of boys compared to 18.9% of girls were stunted; and 23.9 of boys as compared to 16% of girls were underweight. In the agro-pastoral livelihood,33.1% of boys compared to 23.4% of girls were stunted; and 33.4% of boys as compared to 44.4% of girls were underweight, these differences are statistically significant (p<0,05). In the riverine livelihood, 34.2% of boys compared to 22.2% of girls were stunted; and 34.5% of boys as opposed to 44.1% of girls were underweight, therefore, these differences are statistically significant (p<0,05%). A higher proportion of boys than girls were reportedly ill two weeks prior to the assessment in the pastoral livelihoods while the proportions of girls and boys were similarly affected in the agro-pastoral and riverine populations. The gender disaggregated results of the assessed children is summarized on Tables 7 and 8. Maternal nutrition status in Juba livelihood In the Juba livelihood, a significantly higher proportion of pregnant and/or lactating women were acutely malnourished (MUAC< 23.0 cm, and 21.0 cm, and/or bilateral oedema) than non-pregnant and non-lactating women (MUAC<18.5) across all the pastoral, agro-pastoral and riverine livelihoods in Juba region. The proportion of acutely malnourished pregnant and/ or lactating women ranged between 9.8% () among the Dhobley IDPs to 46.7% () in agro-pastoral livelihood. The high levels of acute malnutrition among the pregnant and/or lactating women is linked to increased nutrients needs during these periods which may not be met. Juba region Pregnant and Lactating Women No. Assessed Proportion with MUAC<23cm(%) Proportion with MUAC<21cm(%) Non-pregnant and Lactating women No. Assessed Proportion with MUAC<18.5cm(%) Pastoral (32-54) 14.0( ) ( ) Agro-pastoral ( ) 23.3( ) ( ) Riverine ( ) 3.0( ) ( ) Dobley IDP ( ) 8.3( ) 0 0 Kiusmayo IDP ( ) 9.1( ) ( )

33 Sustained high levels of acute malnutrition across Somalia and Kenya border Seasonal rain failure is not unusual in the Horn of Africa negatively affecting the population s livelihood systems in the region. Though all countries in the Horn of Africa are affected, the degree of severity varies depending on the governing structures and response mechanism in each country. Communities at the Somalia-Kenya-Ethiopia borders have experienced recurrent rainfall failure in the past ten years, which has hindered rain fed crop production among agropastoralists, and resulted in massive death of livestock among both agro-pastoralists and pastoralists. This has impacted negatively on the communities resilience over the years. The result includes food crises, alarming levels of acute malnutrition and mortality. Nutrition Survey Map Special Article 25 Nutrition and mortality assessments conducted between January and July 2012 along the Kenya- Somalia border show high levels of acute malnutrition and at the same time reveal a severe humanitarian crisis in Somalia 1. Nutrition situation in Wajir and Mandera - Kenya Between January to July 2012, five representative nutrition surveys were conducted by UNICEF Kenya and other partners in North East Kenya, in the two districts of Wajir and Mandera. The results of a nutrition assessment conducted are as follows: Wajir South: GAM rate of 23.1% (19,5-27.3), and SAM rates of 4.6% (3.5%-6.3%). The retrospective crude and the under five death rates are 0.30 ( ) and 0.54 ( ). Wajir West and North: GAM rates of 14.6% ( ) and SAM rates of 2.2% (1.4%-3.5%). The retrospective crude and the under five death rates are 1.0( ) and 0.49( ). These findings on acute malnutrition depict a situation in Wajir South, and nutrition situation in Wajir West and North. Death rates are within acceptable levels in Wajir South, but slightly elevated to levels in Wajir West and North based on UNICEF 2005 classification. Mandera West: GAM rate of 16.2% ( ), and SAM rates of 3.5% (1.9% - 6.4%). The crude and under five death rates are 0.41 ( ), 0.67 ( ) respectively. Mandera Central: GAM rate of 17.9% ( ) and the SAM rates of 3.4% (2.1%-5.3%). The crude and under five death rates are 0.18 ( ) 0.22 ( ) respectively. Mandera North and East: GAM rate of 15.9% ( ) and the SAM rates of 2.2% (1.4%-3.5%). The crude and under five death rates are 0.23 ( ) and 0.8 ( ) respectively. These results depict indicate a nutrition situation across Mandera. The crude and under five death rates are nevertheless within the - phases respectively, based on UNICEF 2005 classification. Nutrition situation in Gedo and Juba regions - Somalia In July 2012, representative nutrition surveys conducted in Gedo and Juba regions in Somalia by FSNAU and partners are indicate a and nutrition situation among the populations in the two regions. No surveys were conducted in Southern Gedo region due to inaccessibility as a result of civil insecurity, therefore the available data (from health and feeding facilities) is insufficient to make an overall nutrition situation estimation. Nutrition assessments conducted in May 12 in Northern Gedo region indicate elevated levels of acute malnutrition with GAM and SAM rates of 28.4% ( ) and 6.2% ( ) respectively in the Dawa pastoral, and GAM and SAM rates of 22.5% ( ) and 6.1% ( ) respectively, reported in the riverine livelihood zone. The analysis indicates a sustained nutrition situation in the two livelihoods in Nothern Gedo region. 1 FSNAU Nutrition Update, May-June 2012

34 Regional Analysis 26 Map showing nutrition situation in Somalia-Kenya border regions Three other comprehensive nutrition surveys conducted in July 2012 among the pastoral, agro-pastoral and riverine livelihoods of Juba region indicate a sustained nutrition situation in the agro-pastoral and riverine populations but an improvement to a situation among the pastoral. Survey findings recorded a GAM rate of 15.8% ( ), 25.1% ( ) and 21.1% ( ) among the pastoral, agro-pastoral and riverine populations respectively. The SAM rates reported in the three livelihood zones were 2.1% ( ), 5.8% ( ) and 6.6% ( ) in the pastoral, agro-pastoral and riverine livelihoods respectively. Conclusion: These results in the Somalia side as well as the neighboring country in Kenya indicate, and nutrition situation. These findings clearly reflect the severity of nutrition situation in the crossborder communities largely due to poor food availability and household access which is as a result of the consecutive seasons of rain failure that adversely affected the livestock dependent population and insecurity. Lack of pasture and water has led to massive deaths of livestock, the main source of food and income for food and non-food items while the remaining livestock have out-migrated. Access to health, safe water and sanitation facilities in these areas are very limited leaving the population highly vulnerable to diseases, thereby aggravating the nutrition situation. In the two border countries, it would be crucial to increase interventions on health and nutrition as well as food security. Rehabilitation of severely and malnourished children remains a priority in the short term to prevent any further deterioration. For a lasting solutions to the persistent problems of food and nutrition insecurity, longer term interventions in health, food and livelihoods are required.

35 4.3 Bakool AND Bay Regions Bakool and Bay regions are located in southwest Somalia. Both regions have two predominant livelihood systems: the agro-pastoral, found in Bay region and in the southern parts of Bakool, and the pastoral found mainly in Elberde district of Bakool region (referred herein as Bakool pastoralists). Bakool region comprises of five districts namely Huddur (Huddur town is the regional capital), Wajid, Tieglow, Rabdure and Elberde. Bay region comprises of four districts, namely Baidoa, (Baidoa town is the regional capital), Qansahdere, Dinsor and Burhakaba (Map 8). The two regions have a high agricultural potential, with Bay region serving as the sorghum basket for Somalia. Map 8: Bay and Bakool Regions Livelihood Zones Regional Analysis 27 Bakool Region Historical Overview Post Deyr 11/12 Food Security The Post Deyr 11/12 analysis classified the food security of the population in Bakool region as Crisis. The total population in crisis was 140,000 which indicated a significant decrease by 30% from the Gu 11 season. Overall, the food security situation in the rural areas had indicated a significant improvement following above normal rains that had led to an improvement of both livestock and crop production. Cereal production in Bakool region significantly improved compared to previous seasons due to the above normal Deyr 11/12 rainfall performance. Humanitarian assistance and remittances from relatives within Somalia and in the Diaspora also contributed to the significant increase in food access across all livelihoods. Nutrition The Post Deyr 11/12 integrated nutrition analysis based on health and nutrition facilities data classified the nutrition situation in both agro-pastoral and pastoral livelihood zones of Bakool region as likely. Nutrition surveys conducted in both livelihood zones in October 2011 did not meet the required quality standards for publication. The trend of acute malnutrition from is shown on Figure 10. Figure 10: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) Bakool region, Current Situation, Post Gu 12 Food security The current FSNAU Post Gu 12 integrated food security analysis identifies the Bakool Southern Inland Pastoral in Stressed phase, an improvement from Crisis in Deyr 11/12. The improvement in the food security situation in the Southern Inland Pastoral livelihood zone is mainly attributed to the positive impact of the Deyr 11/12 rainfall performance which improved access to income and food from livestock and related products, and to the increased access to humanitarian interventions in the region. The agro-pastoral livelihoods however remains in Crisis due to the effect of below normal rain performance affecting crop production; low terms of trade (labor to sorghum), low agricultural labor opportunities; reduced supply of cereal from neighbouring regions and limited humanitarian interventions due to the high civil insecurity in the region. These factors have affected both availability and access to food. Nutrition Situation The Post Gu 12 integrated nutrition situation analysis using data from nutrition assessments, health and feeding facilities classifies the nutrition situation of the Bakool pastoral population as. A nutrition assessment conducted in June 2012 in the Bakool pastoral livelihood zone reported a GAM rate of 26.2% ( ) and a SAM rate of 5.7% ( ) including four (0.5%) oedema cases. A significantly higher (p<0.05) proportion of boys (31.4%) than girls (21.7%) are acutely malnourished. The results show a nutrition situation but an improvement compared to the July 11 findings when GAM and SAM rates of 55.9% ( ) and 20.4 ( ) with three (7.4 %) oedema cases were reported. OTP admission in Bakool region is and increasing since April 2012 (See figure 11) The mortality rates are within the acceptable UNICEF levels with crude death rates (CDR) of 0.31 ( ), and under five death rate of 0.86 ( ), a significant improvement from the mortality rates reported in July 2011 (CDR and U5DR ).

36 Regional Analysis 28 The main causes of death reported through respondent s recall are measles and malaria for the under fives and TB and malaria for adults. Pockets of high malnutrition rates are noted in the following clusters/villages: Maroodicade, Buur Caliyow, Habaasha Inashurbad, Elbaid, Morabus, Nuhley, Hiirey and Wargarweyne all in Elberde district. The concerned villages are hosting an influx of IDPs from areas with high civil insecurity particularly Huddur and Rabdhure. Figure 12: Trend in levels of Acute malnutrition (WHZ< -2 or oedema, WHO 2006) Bay Agropastoral, No assessment was conducted in the agro-pastoral livelihood of Bakool region, therefore there is insufficient data to estimate the overall nutrition situation. However, data from health facilities indicates a high (>45%), and a stable trend of acutely malnourished children. The information from partners conducting feeding programmes in the area indicates high and fluctuating admission trends in the area. (Figure 12. ) Figure 11: Admissions trends into OTP programmes Bakool 2012 Disease outbreaks continue with measles incidences being reported in Elberde, Huddur and Tieglow (WHO Bulletin, June 2012). Though limited, humanitarian interventions in the form of blanket, targeted and outreach supplementary feeding programs by organizations such as WFP, UNICEF, EPHCO and DADO 1, in parts of the agro-pastoral and pastoral livelihood zone may have assisted to mitigate the poor nutrition situation in Bakool region. The support needs to be continued and expanded to cover more rural villages in both livelihoods. Blanket supplementary feeding program(bsfp) in Bakool,July Dareeyl Awareness and Development organization Table 9: Summary of Key Nutrition Findings in Bakool Pastoral livelihood zone - July 2012 Bakool Pastoral June 2012 (N=732;=341;= 391) Indicator Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) Severe Acute Malnutrition (WHZ<-3 or oedema) 26.2 ( ) 31.4 ( ) 21.7 ( ) 5.7 ( ) 8.8 ( ) 3.1 ( ) Mean of Weight for Height Z Scores -1.35±1.03 Global Acute Malnutrition (NCHS) 24.8 ( ) Severe Acute Malnutrition (NCHS) 3.1 ( ) Proportion with MUAC<12.5 cm or oedema 15.1 ( ) 17.3 ( ) 13.3 ( ) Proportion with MUAC<11.5 cm or oedema Stunting (HAZ<-2) Underweight (WAZ<-2) Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Immunization Status Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) Under five deaths, per 10,000 per day (retrospective for 90 days) 1.9 ( ) 2.3 ( ) 1.5 ( ) 23.9 ( ) 30.1 ( ) 18.6 ( ) 28.1 ( ) 34.8 ( ) 22.3 ( ) Morbidity ; Diarrhoea :-18.6 Pneumonia ; Vitamin A ; Measles Vacc ; Women Nutrition Status N= 595 Proportion of acutely malnourished non pregnant/lactating women 0.6 ( ) (MUAC <18.5 cm) Proportion of acutely malnourished pregnant and lactating women 2.4 ( ) (MUAC<21.0) Proportion of acutely malnourished pregnant and lactating women 22.0 ( ) (MUAC<23.0) Food security phase Stressed Overall Risk to Deterioration Stable Overall Situation Analysis

37 Bakool Region: Pastoral Livelihood The food security situation of the Bakool pastoral population has improved, however, the milk availability remains low currently, but is however projected to improve in the coming months. Although the food security outlook in the region is positive, the nutrition situation in Bakool region is projected to be in the coming months due to the persistent disease outbreaks, high morbidity and poor child care and feeding practices. In addition, the population remains vulnerable to the chronic aggravating factors affecting malnutrition such as food insecurity, limited access to safe water and sanitation facilities as well as limited humanitarian services (health, nutrition, wash and food). The population will require appropriate humanitarian interventions to improve and prevent further deterioration. Table 9 highlights the key findings of the nutrition situation analysis. Gender and nutrition analysis in Bakool Regions Although nutrition surveys conducted in the Bakool pastoral livelihood appeared to indicate a higher proportion of boys than girls as acutely malnourished, this difference is not of statistical significance (p>0.05). Other child data such as illness, and immunization status, also do not show any clear differential proportions by gender. Analysis of the distribution of malnutrition cases assessed by MUAC measurements reflects a slightly higher proportion of girls (17.3%) than boys (13.3% ) as acutely malnourished with MUAC<12.5 cm or oedema. The gender disaggregated data of the assessed children is summarized on Table 9. Regional Analysis 29 Case study 1: A family s experience during a hunger period, in Huddur district Huddur town is the headquarter for Bakool region in southern Somalia and is located 180 km northwest of Baidoa and 90 km from the Ethiopian border. It has two main livelihood zones: the pastoral rearing mainly camel, sheep/goat and cattle and the agro-pastoralist who practice cropping farming alongside keeping different types of livestock. Bakool agro-pastoral livelihood was among areas where famine was declared on July The famine resulted from prolonged drought following very poor Deyr 10/11 and Gu 11 rainfall performances, which led to crop failure, loss of livestock. This situation contributed to poor household access to food, milk and income through sales, amidst very limited humanitarian activity to mitigate the situation. The results were a humanitarian catastrophe with malnutrition levels in excess of 30%, crude death rates above 2 per 10,000 per day, and at the least, 20% of households unable to access food needs. The case study below exemplifies how some households coped with the famine situation. Afifa, 34, is a mother of three children- two boys and one daughter and stays with her husband Adam in Dudmaale village, east of Huddur town. The family has a small farm from which in normal circumstances, they produce enough food for their own consumption and for income. However, the last two seasons of the drought have been very harsh and the family farm did not produce anything from their farm. Prior to the drought, the family had seven goats and one pack camel. During the drought period, cereal prices escalated and so many families employed asset stripping distress coping strategies including sales of livestock at throw away prices, to meet the basic food needs. Afifa s family sold their last goat with her kid in January For several times, the husband had to borrow cereals and cash from a nearby Abak beday village. As the drought intensified, the pack camel became weak and fell sick and could not stand on its own (see photo). For this reason, they were also forced to cheaply dispose off the camel at the local butchery. Unlike other families tha are relatively better off, Afifa s family lacks has no means to fetch water, firewood, and lacked transport to move the family to a new place. The health status of the family members worsened. About seven months prior to the interview, the youngest child was reportedly suffering from an unknown disease, with symptoms of high fever, cough, pallor, and swelling in the abdomen.. Afifa sought medical assistance for her son from a local drug vendor, in Huddur town, and ended up with wrong subscriptions. After several visits, spending borrowed cash buying medicine that did not help her son, she sought help from a new clinic supported by Muslim Aid. The child was diagnosed with Leishmaniasis, also known as kala-azar. He was treated and followed up for three weeks. Travelling from Dudumaale to Huddur everyday was very expensive, and family was forced to split. Adam and Afifa agreed that Adam stays with their son in Huddur and Afifa takes care of the other children in the village. This was at a time, the many roadblocks erected by armed groups restricted trade movements limiting businesses in Huddur town. The lorries, cars, and even donkey carts were not allowed to deliver food to Huddur town. Due to this, many women smuggle in food from the villages in order to make a living. Circumstances forced Afifa to join this group. It s a risky business but the little money she earns is what the family survives on. The case study explains how the population in this district is coping with the drought situation, highlighting resilience from the famine and the extent to which they have exhausted their coping strategies and are in dire need of assistance.

38 Regional Analysis 30 Bay Region Historical Overview - FSNAU Post Deyr 11/12 Food security The FSNAU Post Deyr 11/12 integrated food security analysis classified the agro-pastoral (low and high potential) livelihood zones of Bay region in Crisis phase, indicating an improvement from the respective Famine phase in Gu 11. The improvement in Bay region was mainly attributed to good crop production, improved income from livestock and improved purchasing power resulting from the good Deyr 11 rainfall performance. Additionally, humanitarian assistance (cash and food distribution) and social support mitigated the situation. Cereal production from Deyr 11/12 season was estimated at 6,1390 MT which was 195% of post war average (PWA) compared to 8% in Deyr 10/11. It was the third highest Deyr cereal production in the region since The purchasing power of households had improved as a result of better terms of trade (ToT) of daily labour wage and red sorghum. In addition, ToT between local goats and red sorghum had shown an increase due to the reduced cereal prices and improved livestock prices. Figure 13: Trend in levels of acute malnutrition (WHZ< -2 or oedema, WHO 2006) Bay region, to crickets, in addition to low cereal stock availability for the poor and deterioration of wage rates due to the low agricultural labour. Cereal production in this Gu 12 season is well below average. It s the second lowest Gu cereal production in the region since However, terms of trade between livestock/ cereals has mitigated the situation. Baneedi village hosting IDPs from Bakool Nutrition The Post Gu 12 integrated nutrition situation analysis, using data from nutrition assessments, health and feeding facilities classifies the nutrition situation of the Bay agropastoral livelihood population as, indicating an improvement from the Extreme levels in the Deyr 11/12. The nutrition situation of the IDPs from Baidoa town, assessed for the first time, indicates a nutrition situation. Nutrition The Post Deyr 11/12 integrated analysis of data from nutrition assessments 2 conducted in Bay region in October 11, in addition to data collected from health and feeding facilities indicated a sustained Extremely nutrition situation. However, although the GAM rates remained above 30%, a significant reduction in GAM rates was recorded (Figure 13) compared to July 11 (GAM>50%). Current situation, Post Gu 12 Food security The FSNAU Post Gu 12 integrated food security analysis classifies the agro-pastoral (low and high potential) livelihood zones of Bay region in sustained Crisis, though with increased numbers in crisis. This worsening trend in the Gu 12 season is mainly attributed to poor crop production as a result of below normal rainfall and long dry spell, crop loss 2 The surveys were conducted jointly by FSNAU/UNICEF, Somalia Red Crescent Society (SCRS) A nutrition survey conducted in July 12 in the agro-pastoral livelihood zone of Bay region reported a GAM rate of 20.4% ( ) and a SAM rate of 6.9% ( ) with nine (1.0 %) oedema cases. These rates show a nutrition situation, although an improvement from the Extreme nutrition situation reported in the October 11, when GAM and SAM rates reported were ~30.0% and ~7.0%. A higher proportion of assessed boys (22.2%) are acutely malnourished compared to girls (18.7%), although the difference is not statistically significant. The 90 days retrospective crude (CDR) and under five death rates (U5DR) of 1.40 ( ) and 2.70 ( ) indicate a situation according to UNICEF classification, an improvement from levels reported in October 11 when CDR of <2 was recorded. The health facilities also indicate a high number (>50 %) and stable trend of acutely malnourished children and a stable trend (Figure 14). Morbidity levels reported in the two weeks prior to the assessment were high at 32.8% and immunization status for measles and vitamin A supplementation is extremely low (<20%) compared with the Sphere recommended coverage of 95%. The sustained poor nutrition situation of the Bay agropastoral populations is attributed to chronic food insecurity linked to overall poor crop production, high debt levels from the previous season, reduced wage rates, low agricultural labour coupled with high morbidity and limited humanitarian assistance. Further aggravating factors include chronic

39 problems of poor child feeding and health care practices, and low access to safe water, health and nutrition services, which predispose populations to high morbidity and consequently high levels of acute malnutrition. Figure 14: HIS Malnutrition trends in Bay Agro-pastoral MCHs, Nevertheless, recently improved income and food access resulting from increased ToT (labour to sorghum), social support mainly from the diaspora, control of disease outbreaks as well as some limited humanitarian assistance may have mitigated further deterioration and contributed to the reduction of the GAM and SAM rates. Immediate and routine health, food and livelihood interventions are required to mitigate further deterioration and to address the extreme rates of acute malnutrition. In the medium term, interventions to support and rebuild livelihoods is critical. The key nutrition reference indicators of the analysis on the nutrition phase classification are provided in Table 10. Baidoa Town is host to internally displaced persons (IDPs) fleeing from Banadir, Bay and Bakool regions mainly because of insecurity and prolonged drought. Often, IDPs are faced with numerous problems including lack of food, malnutrition, poor sanitation and shelter due to loss of assets and a disruption of livelihood system. In July 2012, FSNAU conducted a comprehensive nutrition survey among the Baidoa IDPs. The GAM and SAM rates of 15.5% ( ) and 5.1% ( ) indicate a nutrition situation (Table 10). More boys (17.1%) than girls (14.1%) are acutely malnourished but the difference is not statistically significant. The 90 days retrospective CDR and U5DR of 0.42 ( ) and 1.52 ( ) indicate and levels respectively, according to UNICEF levels. Morbidity, a key nutrition aggravating factor remains high (28.3%) in the IDPs. Malnutrition rates for pregnant and lactating women (MUAC <23.0 cm) is 24.1% ( ). This rate is high and slightly above the baseline median rate of 22.0% recorded from nutrition surveys in Somalia conducted between Lack of stable livelihood systems among the IDPs coupled with lack access to basic services continue to expose this population group to risks of malnutrition, ill health and food insecurity. Interventions to improve and stabilize food access and provision of health services are crucial in addressing food insecurity and in tackling the high morbidity levels, thereby mitigating the high levels of acute malnutrition. Gender and nutrition analysis in Bay Regions The analysis of the nutrition data in the assessed rural livelihoods as well as the Baidoa IDP populations shows no statistically significant difference in distribution of the malnutrition cases between boys and girls. A high proportion of boys than girls are acutely malnourished, stunted and underweight across Bay agro-pastoral livelihood and Baidoa IDP populations. For example, in Bay agro-pastoral 22.2% ( ) of boys compared to 18.7% ( ) girls are acutely malnourished 39.9% ( ) boys compared to 35.5% ( ) of girls are stunted and 38.2% ( ) of boys as opposed to 31.3% ( ) of girls are underweight. Nevertheless, the distribution of malnutrition cases assessed by MUAC measurements in Bay agro-pastoral shows slightly more girls (20.3%) than boys (15.7%) identified as acutely malnourished with MUAC<12.5 cm or oedema (see nutrition summary Tables). Regional Analysis 31 Maternal Nutrition Status in Bay and Bakool Water source at Eldhere village in Bakool Baidoa IDPs

40 Regional Analysis 32 Table 10: Summary of Key Nutrition Findings in Bay Regions-July 2012 Bay Agro-Pastoral July 2012 (N=889;=419 Baidoa IDP (July 2012) (N= 858 ;= = 470) 391 = 467) Indicator Results Outcome Results Outcome Child Nutrition Status 20.4 ( ) Global Acute Malnutrition (WHZ<-2 or oedema) 15.5 ( ) ( ) ( ) 18.7 ( ) 14.1 ( ) Severe Acute Malnutrition (WHZ<-3 or oedema) 6.9 ( ) 6.7 ( ) 7.0 ( ) 5.1 ( ) 6.1 ( ) 4.3 ( ) Mean of Weight for Height Z Scores -1.08± ±1.16 Global Acute Malnutrition (NCHS) 21.0 ( ) 15.1 ( ) Severe Acute Malnutrition (NCHS) 3.8 ( ) 4.6 ( ) Proportion with MUAC<12.5 cm or oedema 18.1 ( ) 15.7 ( ) 20.3 ( ) 12.7 ( ) 14.4 ( ) 11.2 ( ) Proportion with MUAC<11.5 cm or oedema Stunting (HAZ<-2) Underweight (WAZ<-2) HIS Nutrition Trends(Jan July 2012) Admission trends at TFPs/SFPs Bay Region (Jan-July 2012) Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Immunization Status Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) Under five deaths, per 10,000 per day (retrospective for 90 days) Women Nutrition Status Proportion of acutely malnourished non pregnant/ lactating women (MUAC <18.5 cm) Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0) Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0) Food security phase 4.0 ( ) 2.8 ( ) 5.0 ( ) 37.6 ( ) 39.9 ( ) 35.5 ( ) 34.6 ( ) 38.2 ( ) 31.3 ( ) High (>50% and a stable trend Low and fluctuating number of admissions Morbidity ; Diarrhoea :-19.2 Pneumonia ;- 8.1 Vitamin A ; Measles Vacc ; ( ) 3.5 ( ) 1.9 ( ) 36.0 ( ) 36.3 ( ) 35.6 ( ) 25.7 ( ) 25.6 ( ) 25.8 ( ) N/A - N/A Morbidity ;-29.1 Diarrhoea :-12.0 Pneumonia ;-7.5 Vitamin A ;-27.2 Measles Vacc ; ( ) 0.42 ( ) 2.70 ( ) 1.52 ( ) N=541 N=579 N= N= ( ) N= ( ) Crisis N= ( ) N= ( ) N= ( ) Crisis Overall Risk to Deterioration Stable Unstable Overall Situation Analysis Maternal Nutrition Status in Bay Regions In Bay Region, a significantly higher proportion of pregnant and/or lactating women are acutely malnourished (MUAC< 23.0 cm) than non-pregnant and non-lactating women (MUAC<18.5 cm) across all livelihoods and among the Baidoa IDPs settlements. Information on maternal nutrition indicates a worrying nutrition situation among women. Acute malnutrition (MUAC <23.0 cm) rates for pregnant and lactating women among the Bay agro-pastoral, Baidoa IDPs and Bakool pastoral livelihoods are 34.3% ( ), 24.1% ( ) and 22.0% respectively. These rates are extremely high and are either similar to or significantly above the baseline median rate of 22.0% recorded from the FSNAU surveys conducted between (see Table 10). The high level of acute malnutrition among the pregnant and/or lactating women is linked to increased nutrient demands during pregnancy needs which are not being met. Bay /Bakool Pregnant and/or Lactating women Surveyed population No. Assessed Proportion with MUAC<23cm Bay Non-pregnant/lactating women Proportion with Proportion with MUAC <21cm No. Assessed MUAC<18.5 cm ( ) 2.3 ( ) agro-pastoral Baidoa IDP ( ) 6.5 ( ) ( ) Bakool pastoral ( ) 2.4 ( ) ( )

41 Case study 2: Increased nutritional vulnerability among the families in the besieged Huddur town, Bakool region. Background Huddur is the urban center for Bakool region in southern Somalia and is located 180 km north west of Baidoa and 90 km from the Ethiopian border. It has two livelihood zones: the pastoral and agro-pastoral low potential. Huddur district and Bakool region which has recently come under the administrative control of the transitional federal government (TFG) had been run by a militia group since February 2012, that restricted and controlled entry of people not only goods and services. This has affected the supply of both locally produced and imported food items in the town as well as delivery of the essential health and nutrition services. The case study below exemplifies how the households are coping with the situation and the impact of the siege on nutrition and health of the population. Regional Analysis 33 Case study Khazida, a 34 years old lactating mother and stays with her husband and their four children together with the paternal grandmother. The household of this family is located in Huddur town. Hassan, Khazida s husband was injured in a mortar shell bomb explosion in Mogadishu Bakara market two years ago, the mortar shell particles damaged the spinal code causing paralysis in his lower limps. Previously, Hassan was an unskilled labourer accessing income through construction work, unfortunately from the impact of his injury he is no longer physically fit to work in the same field. With the incapacitation of the household bread winner, Khazida had no alternative but to become the bread winner of her family which she does through sale of vegetables in Huddur market. A severely malnourished child with MUAC<11.5 cm Unfortunately, the siege of the town has affected her business as she is unable to get vegetable supplies from other areas. This has led to the closure of the business, and also compelled her to switch to severe coping mechanism to meet the basic food needs. Some of the coping strategies she employs include reduction of the meals consumed from three to two and more lately, to only one meal in a day. When the situation persisted she was again forced to send two of her children aged 6 and 7 years to her relative in a pastoral village called Hogir. This is one of the worst decisions I have ever made but the circumstances forced me as I had no alternative and I could not wait to see my children die. she said, in tears. Khazida lives in Huddur where, unfortunately there has not been a functional health facility for over a year, hence, most of her children are not immunized. As fate would have it, in August 2012, prior to this case study, she lost one of her sons to suspected measles. As may be expected for such a poor family with reduced food and income; high morbidity and poor nutrition situation is prevalent. MUAC assessment of the family members indicates that the youngest child in the family has severe acute malnutrition with a MUAC<11.5 cm. Khazida who is lactating has a MUAC of 21cm indicating high risk of malnutrition. In addition, five weeks prior to the interview, the youngest child was reportedly suffering from suspected respiratory infection but with no health services available, no medical assistance was sought for Abdullahi, other than administering concoction made from traditional herbs. Conclusion The case study demonstrates how the population in this town is suffering from lack of supply of basic goods and services including food and health services and the extent to which they have exhausted their coping strategies and are in dire need of assistance. This piece therefore, calls for the immediate interventions to ease the human suffering in Huddur town, provision of essential nutrition and health services to rehabilitate the sick and malnourished children and adults as well as continued monitoring of the situation.

42 Regional Analysis Middle and Lower Shabelle Regions Middle and Lower Shabelle Regions Middle and Lower Shabelle rural livelihoods comprise of riverine (pure farmers) and agro-pastoralists (Map 9). The riverine population, located within 10 km of the Shabelle river cultivates maize, sesame and a variety of vegetables and fruits, and keep limited livestock holdings as a result of tsetse fly infestation. The agro-pastoral zone extends km from the Shabelle River and incorporates both cultivation of crop (maize, cowpeas, sesame and fruit), and livestock rearing. The agricultural potential, as well as the labour and income opportunities in the area makes it a haven for seasonal casual work, and also for vulnerable populations in the event of shocks. The Shabelle regions continue to struggle with the negative impacts of civil insecurity. This has affected the population s well being, through disruption of livelihoods, continued lack of access to humanitarian interventions, and a high number of IDPs in the region. Historical Overview - Post Deyr 11/12 Food Security The food security situation in Shabelle regions (Middle and Lower) showed improvement in the Deyr 11/12 season. The total population facing food insecurity in Middle Shabelle region significantly decreased by 55% from the Gu 11 season. Lower Shabelle region also showed significant improvement with only 2% of the population in Crisis. The main factor contributing to the significant improvement in the food security situation in the two regions was related to the good rainfall performance in the Deyr 11/12 season across most livelihoods in the regions, in addition to the off season harvest in October 2011, this resulted in good cereal and cash crop production and a decrease in local cereal prices. The increased humanitarian assistance during the October to December 2011 period also mitigated the situation. In addition, the availability and access to pasture and water resources improved livestock production and sales, milk availability from goats also considerably improved. The urban population in Crisis remained the same, estimated at 8,000 people. Figure 15: Trends in Levels of Acute Malnutrition (WHZ<-2 or oedema) in Middle and Lower Shabelle Regions ( ) Map 9: Shabelle Livelihood Zones Nutrition In Lower Shabelle region, the Post Deyr 11/12 integrated nutrition analysis indicated a likely nutrition situation among the riverine and agro-pastoral population. Due to the lack of access in the region for security reasons, no surveys were conducted. However, data from health facilities in the areas and information from feeding programmes indicated a declining number of admissions and numbers of acutely malnourished children reported in health facilities and feeding centres. Among the agropastoral population, the data from health facilities indicated a high (>30%) and increasing trend, while in the riverine, data indicated a high (>10%), and a declining trend of the number of acutely malnourished children. Although the nutrition situation remained classified the same () as in the Gu 2011 season, it was probable the nutrition situation had improved with the positive food security outcome indicators reported in the region. Figure 15 show the trends of acute malnutrition Current Situation, Post Gu 12 Food Security The food security and livelihood situations in Middle and Lower Shabelle regions continued to improve through the last Deyr 2011 /12 and Gu 2012 seasons. A significant number of people in Adale and Aden Yabaal districts of Middle Shabelle remain in Crisis, however the number affected has reduced since the Deyr 2011/12. This is attributed to the positive impacts of good rainfall that has led to above average crop production, improved livestock condition and purchasing power. This has resulted in improved availability of milk and milk products in Middle Shabelle region. The rest of the population is in Stressed Phase.

43 Nutrition In the Shabelle regions, there were no nutrition surveys conducted in the Gu 2012 due to lack of access. The last surveys to be conducted in the region were done in July Due to the lack of sufficient data, there is no overall nutrition situation estimate for the Shabelle regions. However data from health facilities in the region shows high (>30%) and stable trends of malnutrition among the Lower Shabelle agro-pastoral population and a high (>10%) and declining trend amongst the riverine population (Figure 16). The nutrition situation in the coming months is expected to improve given the positive food security indicators in Shabelle. However the degree of gains will depend on the population s exposure to risk factors which include seasonal outbreaks of acute watery diarrhoea (AWD) in October- November, reduced access to humanitarian interventions with the recent suspension of key actors and the increasing civil insecurity in the region. Persistent chronic factors - such as very limited access to specifically feeding and health programmes, inappropriate child feeding and care practices, poor access to safe water and sanitation facilities and civil insecurity are additional factors likely to negatively affect the nutrition situation. Figure 16: HIS Malnutrition Trends in Shabelle Reverine MCHs Figure 17: HIS Malnutrition Trends in Shabelle Agropastoral MCHs Table 11: Summary of Key Nutrition Findings in Mogadishu Town - April- July 2012 Mogadishu Town April 2012 (N=959 =497 =462) Mogadishu Town July 2012 (N=676; =304 =372) Indicator Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) Severe Acute Malnutrition (WHO 2006) Mean WHZ (WHO, 2006) 10.3 ( ) 12.5 ( ) 8.0 ( ) 10.8 ( ) 13.5 ( ) 8.6 ( ) 1.7 ( ) 1.5 ( ) 1.8 ( ) 3.0 ( ) 1.5 ( ) 0.3 ( ) -0.57± ±1.16 Oedema Global Acute Malnutrition (NCHS) ( ) ( ) Severe Acute 2.3 Malnutrition (NCHS) ( ) 1.2 ( ) Global Acute Malnutrition by MUAC 6.6 ( ) 5.4 ( ) (<12.5 cm or oedema) 6.9 ( ) 5.8 ( ) 6.4 ( ) 5.0 ( ) Severe Acute malnutrition by MUAC (<11.5 cm or oedema) Morbidity Immunization Status: Measles vaccination Vitamin A Supplementation HIS Nutrition Trends (January July 2012) Admission trends at TFPs/SFPs (January July 2012) Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) Under five deaths, per 10,000 per day (retrospective for ( ) 1.2 ( ) 1.3 ( ) 25.2 ( ) 55.5 ( ) 60.5 ( ) Low (>10%) and decreasing trend Reduced numbers of admissions to feeding programmes 1.22 ( ) Very Very 1.2 ( ) 1.3 ( ) 1.1 ( ) 29.1 ( ) 56.3 ( ) 56.9 ( ) Low (>10%) and stable trend Reduced numbers of admissions to feeding programmes 1.23 ( ) 1.54 ( ) 1.06 ( ) days) Women Nutrition N=570 N= 398 Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm) Proportion of acutely malnourished pregnant and lactating women 0.6 ( ( ) - (MUAC<21.0) Proportion of acutely malnourished 17.3 (12.0- pregnant and 22.7) lactating women (MUAC<23.0) Food Security - Food security phase Overall Situation Analysis 1.4 ( ) 7.5 ( ) - Regional Analysis 35

44 Regional Analysis 36 The nutrition situation of the Middle Shabelle agro-pastoral and riverine population is not classified due to lack of sufficient data. Data from the health facilities in the agropastoral livelihood areas indicates a high (>20%) and decreasing trend of acutely malnourished children (Figure 17), while among the riverine population, data indicates low proportions (<10%) and a declining trend of acutely malnourished children. The positive food security indicators noted in Lower Shabelle agro-pastoral and riverine areas are similar to the those of the riverine population of Middle Shabelle region. The population still remains highly vulnerable to shocks and risk factors namely: reduced access to humanitarian services, reduced rainfall, high morbidity burden- reported AWD and measles outbreaks, poor access to health care services and sanitation, suboptimal child feeding and care practices. Therefore close monitoring of the situation is crucial. Banadir Region (Mogadishu) In April 2012, FSNAU and partners conducted nutrition surveys in Banadir region among the IDP and urban population of Mogadishu town 1. The nutrition survey results indicated a and nutrition situation among the urban and IDP populations respectively, with a GAM rate of 10.3% ( ) among the urban population and 16.1% ( ) among the IDP population. The 90 days retrospective crude and under five deaths reported were 1.22 ( ) and 1.06 ( ) while among the IDPs was 1.42 ( ) and 2.80 ( ). In July 2012, FSNAU and partners conducted a repeat nutrition and food security assessments in Mogadishu Town among the urban and the IDP population, as a way of closely monitoring the nutrition and food security situation in the town. 1 All districts excluding Deynile and Huriwa Table 12: Summary of Key Nutrition Findings in Mogadishu IDPs - April- July 2012 Mogadishu IDP April 2012 (N=929; =456 =473) Mogadishu IDP July 2012 (N=675; =313 =362) Indicator Results % Outcome Results % Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) Severe Acute Malnutrition (WHO 2006) 16.1 ( ) 19.1 ( ) 13.3 ( ) 3.7 ( ) 5.0 ( ) 9.6 ( ) 11.8 ( ) 7.7 ( ) 1.8 ( ) 2.2 ( ) 2.3 ( ) 1.4 ( ) Mean WHZ (WHO, 2006) -0.85± ±1.08 Oedema Global Acute Malnutrition (NCHS) 15.1 ( ) 8.8 ( ) Severe Acute Malnutrition (NCHS) 2.8 ( ) 0.9 ( ) Global Acute Malnutrition by MUAC (<12.5 cm or oedema) Severe Acute malnutrition by MUAC (<11.5 cm or oedema) 10.6 ( ) 8.4 ( ) 12.7 ( ) 1.9 ( ) 1.5 ( ) 2.3 ( ) 8.4 ( ) 6.9 ( ) 9.7 ( ) 2.6 ( ) 1.6 ( ) 3.5 ( ) Morbidity 26.3 ( ) 45.9 ( ) Immunization Status Measles vaccination 61.3 ( ) 67.2 ( ) Vitamin A Supplementation 59.9 ( ) 67.9 ( ) HIS Nutrition Trends Low (>10%) and decreasing trend Reduced numbers of admissions to feeding programmes Low (>10%) and stable trend Reduced numbers of admissions to feeding programmes Admission trends at TFPs/SFPs (July- December 2011) Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) 1.42 ( ) 1.41 ( ) Under five deaths, per 10,000 per day (retrospective for 90 days) 2.80 ( ) 2.81 ( ) Women Nutrition N= 523 Proportion of acutely malnourished non pregnant/ lactating women (MUAC <18.5 cm) 0.6 ( ) 0 Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0) 3.9 ( ) ( ) - Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0) 14.1 ( ) 19.1 ( ) Food Security Food security phase Overall Situation Analysis

45 The survey results of the urban population reported GAM and SAM rates of 10.8% ( ) and 1.5% ( ) respectively. The 90 days retrospective crude and under five death rates remain elevated at 1.23 ( ) and 1.54 ( ) respectively, indicating a situation according to UNICEF classification, although a slight improvement was noted from results in April 2012 (Table 11). HIS data from health facilities in Medina, Waaberi, Hamarweyne and Hamarjajab indicated a low number (>10%) and stable trend of acutely malnourished children for the previous six months period. The results depict a sustained nutrition situation among the Mogadishu urban population. A survey conducted among Mogadishu IDPs in December 11 reported GAM rates of 20.5% ( ) and SAM rates of 5.6% ( ). In April 2012, the nutrition survey conducted among the IDP population showed improvements, with GAM and SAM rates of 16.1 ( ) and 3.7 ( ). The 90 days retrospective crude and under five deaths reported remain unchanged from the April 2012 reported rates of 1.42 ( ) and 2.80 ( ). A nutrition survey conducted among the IDP population in July 2012 reported a GAM and SAM rate of 9.6% ( ) and 1.8% ( ) respectively. The mortality rates remain elevated, with the 90 days retrospective crude and under five death rates of 1.41 ( ) and 2.81 ( ), indicating a situation according to UNICEF classification (Table 12). The nutrition situation of the Mogadishu IDPs is classified, although the GAM and SAM rates are, mainly because of the mortality and MUAC rates that remain elevated. However the results indicate an improvement from survey results of December 2011 and April 2012 that recorded and nutrition phases respectively. The current integrated analysis indicates a situation among the Mogadishu IDPs, although there has been a significant improvement (p=0.002) in acute malnutrition rates, the mortality rates still remain elevated. The improvement is mainly attributed to the large scale multi-sectoral humanitarian interventions such as feeding, health, water sanitation and hygiene (WASH) and shelter programmes in the town. The reduced frequency of disease outbreaks and morbidity also helped to reduce acute malnutrition rates. The population still remains highly vulnerable and heavily reliant on the interventions currently in place. A disruption in the provision of humanitarian interventions may lead to a sudden deterioration in the nutrition situation of the population. Gender: Analysis of findings from the nutrition assessments conducted in Mogadishu Town generally indicate a higher proportion of boys than girls as acutely malnourished (WHZ<-2 or oedema). However, these differences were generally not statistically significant (p>0.05). Other child data such as dietary diversity, illness, feeding practices, and immunization status, do not show any clear differences by gender (Table 11 and 12). See tables X-, indicating the gender disaggregated of the assessed children data by sex. Information on maternal nutrition indicates a worrying nutrition situation among women. Acute malnutrition rates for pregnant and lactating women (MUAC <23.0 cm) is 19.1% ( ). Although this rate is high it is still below the FSNAU median rate of 22.0% recorded from surveys between Continued efforts in humanitarian assistance in activities like wet-feeding, supplementary and therapeutic programmes remain essential. Regional Analysis 37

46 Special Article 38 Nutrition Survey Results in Mataban and Beletweyne, Hiran Region Indicate an Extremely Worrying Health Situation The civil conflict in Hiran region has had a negative impact on the population s means of livelihood and access to basic services, thus affecting their overall food security and nutrition well being. Lack of adequate health facilities and limited access to the few operational facilities is a major problem in the region. Humanitarian agencies face a great challenge in establishing and running health facilities in this highly insecure and volatile environment, where aid workers have in the past been directly targeted. From late 2011, many agencies closed their health programmes in the region as instructed by local authorities, leaving a major gap in the provision of health services to the population. As a result, the infrastructure, supplies and staff required for health facilities to function adequately is limited to only a few locations in Hiran region. In July 2011 at the peak of famine in south Somalia, Trends in reported cholera cases, WHO, April June 2012 the nutrition situation of Hiran region was classified as based on nutrition surveys conducted in all three livelihoods. In the Deyr 11/12 season, no nutrition surveys were conducted due to lack of access. The nutrition situation was classified as likely based on contextual information and data from health and feeding facilities. The Gu 12 nutrition surveys conducted in the accessible districts of Mataban and Beletweyne, indicate improvements in GAM rates from >20% in July 2011() ( GAM) to 16% () (GAM -). The 90 days retrospective crude death rates reported in July 2011 were 1.53, 1.37 and 1.50/ 10,000 per day among the pastoral, riverine and agro-pastoral population respectively. The July 2012 survey findings indicate improvements in crude death rates to 0.80 ( ) and 0.99 ( ) in Beletweyne and Mataban districts respectively. Although the overall global acute malnutrition and crude mortality rates and food security indicators show an improving trend, the recent Beletweyne and Mataban survey results indicate no significant change in the under five death mortality rates, elevated morbidity levels and extremely low immunization coverage. In July 2011, the 90 days retrospective under five deaths reported were 3.67, 4.13 and 4.24 among the pastoral, riverine and agro-pastoral population respectively. The July 2012 survey results report a U5DR of 2.23 ( ) and 4.50 ( ) among the Beletweyne and Mataban district populations respectively. These results are currently the highest in the country. The main reported causes of death were diarrhoea and acute respiratory infections. Also of concern are the elevated morbidity rates reported in the districts. The proportion of children reported to have fallen ill in the two weeks prior to the survey was 63.8% ( ) and 28.2% ( ) in Beletweyne and Mataban districts respectively. Qualitative information collected indicated that not only were operational health facilities limited, but also access to them was extremely difficult especially in Mataban district. According to the figure, a high number of cholera cases have been reported in the region since April 2012 (WHO June 2012), further compromising the health and nutritional well being of the population. Proportion of Children that have received Measles Vaccination and Vitamin A supplementation District Measles Vaccination Vitamin A Supplementation Recommened Sphere Standards Beletweyn 12.7% ( ) 20.4 ( ) Above 95% Mataban 11.0% 5.9% ( ) ( ) Above 95% Another indicator supporting evidence of poor health services in the area is the extremely low immunization coverage. In Mataban district the proportion of children immunized against measles and having received vitamin A supplementation is a only 11.0% ( ) and 5.9% ( ). In Beletweyne district, the proportion of children that have received vitamin A supplementation is slightly higher (20.4%), compared to Mataban district although this rate is still far below the Sphere recommended standards. The measles vaccination status in Beletweyne district was also extremely low 12.7% ( ). High morbidity rates and low immunization coverage, combined with limited access to health facilities increases the children s vulnerability to malnutrition and death, therefore the situation needs to be urgently addressed. Even though the nutrition situation is likely to improve due to increased milk availability and better food access (production, cereal prices etc), unless appropriate health interventions are made accessible to reduce the high disease burden, the situation may not improve, as these high morbidity levels predispose the children to disease and death.

47 4.5 Hiran Region Pastoral, Agro-pastoral & Riverine Livelihoods Hiran region comprises of three main livelihood groups: the Pastoral (Southern Inland and Hawd pastoral) covering Mataban and Mahas districts; and the Agro-pastoral and Riverine livelihood systems, both of which cut across Beletweyne, Buloburti and Jalalaqsi districts. (Map 10). Like many other regions in South Central Somalia, Hiran has not escaped the effects of high intensity civil conflict, which has affected people s means of livelihood. Intermittent localised civil conflict, as well as the targeting of aid workers in the region, has continued to hinder humanitarian access. Map 10: Hiran Livelihood Zones Regional Analysis 39 Historical Overview - Post Deyr 11/12 Food Security The overall food security situation in Hiran region showed an improvement following an average to good Deyr 11/12 rainfall performance in most of the livelihood zones. This resulted in increased own production (crop and milk), with the exception of the agro-pastoral livelihood zone where the below normal rainfall led to poor crop production. The total number of people facing food insecurity was estimated at 71,000 people in both the rural and urban areas, of which 40,000 were in Emergency and 31,000 were in Crisis. The agro-pastoral livelihood was the worst affected with 36,000 people in Crisis. The situation also deteriorated in urban areas, where 28,000 people were identified in Crisis. The food security situation was projected to deteriorate within 4-5 months if humanitarian assistance in the region remained limited. The good Deyr 11/12 season also resulted in improved water availability and pasture, resulting in an increased number of saleable animals. Cereal availability in the market increased, consequently the price of staple foods continued to decline and was expected to drop further as more cereals arrive from other neighbouring regions. The ToT of labour and goat to cereal also increased, in addition, the levels of social support (zakat) also improved. Civil insecurity remained a major risk factor likely to affect the food security situation in the region. Figure 18: Trend in Levels of acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Hiran Region, Nutrition No surveys were conducted in the region during the Deyr 11/12 season due to inaccessibility as a result of insecurity. Therefore to estimate the Post Deyr 11/12 nutrition situation for the region, data from health facilities from July to October was used. Information from health facilities in the agro-pastoral livelihood zone of Hiran region, indicated a high (>20%) and increasing trend of acutely malnourished children. Although there was a marked improvement in the food security situation and control of disease outbreaks, in the Deyr season, the nutrition situation remained likely among both the agro-pastoralists and pastoralists due to a high proportion (>20%) of acutely malnourished children reported in health facilities in each of these zones. likely in the riverine livelihood zone with a high (>15%) number and stable trend of acutely malnourished children reporting at health facilities. Figure 18 shows trend of acute malnutrition in Hiran for Current Situation Post Gu 2012 Food Security The food security situation of Hiran region has shown a mixed trend in the Gu 12 season. Hawd and Southern Inland Pastoral livelihood zones of the region were, previously classified in Crisis and Stressed phases respectively. Hawd remains in Stressed, and Southern Inland Pastoral improved to Stressed phase. The agro-pastoral livelihood is the worst affected and is classified in Crisis phase. In addition, the riverine livelihood population, in rural areas are in Stressed phase. The improvement in the pastoral livelihoods of the region is primarily attributable to average Gu 2012 seasonal rainfall performances that resulted in improved water availability pasture and browse conditions. Subsequently, livestock body condition continued to improve, resulting in increased number of saleable animals at high

48 Regional Analysis 40 prices. In riverine livelihood zones where rainfall performance was similar to agropastoral zones, the poor wealth group was not able to cover high irrigation costs due to poor economical position and are thus faced with poor crop production. However, they have cereal stocks to last for a few months and they benefit from cash crop production employment. Levels of social support such as zakat continued to improve in pastoral zones due to average seasonal performances while it indicated declined trend in agro-pastoral and riverine zones of the region as a result of poor rainfall performances. Nutrition In the Gu 12 season, lack of access to conduct livelihood based nutrition surveys in the region persisted, however in July 2012, FSNAU and partners were able to conduct administrative based nutrition surveys in Beletweyne and Mataban districts of Hiran region which were accessible. Majority of the sampled clusters in Beletweyne district were riverine, while in Mataban district the clusters were predominantly pastoral. No surveys were undertaken in Buloburti and Jalaqsi districts, therefore no overall nutrition situation is reported for these two districts because of lack of adequate sufficient data. The nutrition survey conducted in Beletweyne district, in July 2012 reported GAM and SAM rates of 16.6% ( ) and 3.3% ( ) respectively. Data from health facilities in Riverine show high (>20%) and increasing trend of acutely malnourished children (Figure 22). The 90 days retrospective crude and under five deaths reported are 0.80 ( ) and 2.32 ( ), with the under five death rate remaining elevated. The current integrated nutrition situation analysis indicates a nutrition situation, an improvement from likely in the deyr 11/12 with the under five mortality rates remaining of concern. The overall morbidity was very high with 63.8% of the assessed children falling ill in the two weeks prior to the survey, with 40% ( ) suffering from diarrhoea. High morbidity levels predisposes the children to acute malnutrition. The high morbidity rates coupled with the extremely low immunization status - Measles 12.7% ( ) and vitamin A supplementation of 20.4( ) increase the children s vulnerability to malnutrition and should be addressed urgently. Figure 19: HIS Malnutrition trends in Hiran Riverine MCHs The Mataban district nutrition survey also conducted in July 2012 reported similar GAM and SAM rates of 16.7% ( ) and 4.2% ( ) respectively. The 90 days retrospective crude and under five deaths reported are 0.99 ( ) and 4.50 ( ) respectively. Of great concern are the under five death rates in the district which are the highest reported rate in the country. The main causes of death reported were diarrhoea and fever. The area has extremely limited health facilities and services, with the proportion of children immunized against measles and having received vitamin A supplementation a dismal 11.0% ( ) and 5.9 ( ) respectively. The overall morbidity is high with 28.2% of the assessed children falling ill in the two weeks prior to the survey. The proportion of children reported to have suffered from diarrhoea, pneumonia and fever is 9.1% ( ), 8.8 ( ) and 13.4 ( ) respectively. The integrated nutrition situation analysis indicates a nutrition situation, an improvement from the likely, situation reported among the pastoral population in the preceding season, however the elevated under five mortality rates and extremely low immunization rates are alarming and should be immediately addressed. The poor nutrition situation in Hiran region is mainly attributed to the lack of access to health facilities (high morbidity rates, low immunization coverage and high under five mortality rates), in addition to the impacts of persistent food insecurity (especially among the agro-pastoral population) and civil insecurity in the region. Although the projected outlook of the nutrition situation is likely to improve due to the anticipated increase in milk availability/production and the current positive food security indicators in the region, unless appropriate health interventions are accessible in the region to control the high morbidity levels reported, the situation may not improve (Table 13). Maternal Nutrition Status in beletwyne and Mataban Districts The information on maternal nutrition indicates a worrying nutrition situation among the pregnant and lactating women in Beletweyne and Mataban districts. Acute malnutrition rates for pregnant and lactating women in Beletweyne and Mataban district (MUAC <23.0 cm) is 22.7 ( ) and 37.8 ( ) respectively. The rate is high in Mataban district and above the FSNAU median rate of 22.0% recorded from surveys between Table 13: Proportion of the malnourished women in Banadir and Hiran Regions Surveyed population Pregnant and/or Lactating women Non-pregnant/ lactating women Proportion No. with MUAC Assessed <23cm Mogadishu 7.5 ( Urban 10.9) Mogadishu IDPs ( ) Beletweyne District Mataban District 426 ( ) 37.8 ( ) Proportion with MUAC <21cm 1.4 ( ) No. Assessed Proportion with MUAC <18.5 cm 5.2 ( ) ( ) ( ) ( ) ( )

49 Table 14:Summary of Key Nutrition Findings in Hiran region - July 2012 Beletweyne District July 2012 (N=628; =305 =323) Mataban District July 2012 (N=480; =247 =233) Indicator Results % Outcome Results % Outcome Regional Analysis Child Nutrition Status Global Acute Malnutrition (WHO 2006) 16.6 ( ) 15.4 ( ) 17.6 ( ) 16.7 ( ) 21.1 ( ) 12.0 ( ) 41 Severe Acute Malnutrition (WHO 2006) 3.3 ( ) 3.0 ( ) 3.7 ( ) 4.2 ( ) 5.7 ( ) 2.6 ( ) Mean WHZ (WHO, 2006) ± ± 1.12 Oedema Global Acute Malnutrition (NCHS) 16.5 ( ) 15.7 ( ) Severe Acute Malnutrition (NCHS) 1.7 ( ) 2.2 ( ) Global Acute Malnutrition by MUAC (<12.5 cm or oedema) 20.1 ( ) 18.4 ( ) 21.7 ( ) 19.3 ( ) 18.6 ( ) 20.1 ( ) Severe Acute malnutrition by MUAC (<11.5 cm or oedema) 6.4 ( ) 5.5 ( ) 7.2 ( ) Extreme 2.6 ( ) 1.9 ( ) 1.3 ( ) Morbidity 63.8 ( ) 28.2 ( ) Diarrhoea 40.0 ( ) 9.1 ( ) Pneumonia 9.0 ( ) 8.8 ( ) Fever 26.6 ( ) 13.4 ( ) Immunization Status Measles vaccination Vitamin A Supplementation 19.4 ( ) 20.4 ( ) 11.0 ( ) 5.9 ( ) Infant and Young Child Feeding N = N = 89 Proportion Still Breastfeeding 66.2 ( ) 65.8 ( ) 50.0 ( ) 57.5 ( ) 64.1 ( ) 57.7 ( ) Proportion meeting recommended feeding 79.2 ( ) 79.7 ( ) 78.7 ( ) 61.6 ( ) 76.9 ( ) 50.0 ( ) Death Rates (retrospective for 90 days) Crude deaths, per 10,000 per day 0.80 ( ) 0.99 ( ) Under five deaths, per 10,000 per day 2.32 ( ) 4.50 ( ) Women Nutrition N= 475 N = 426 Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm) Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0) Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0) 0.63 ( ) 0.7 ( ) 5.1 ( ) ( ) ( ) 37.8 ( ) Food security phase Stressed Stressed Overall Situation Analysis

50 Regional Analysis Central Somalia: Galgadud and Mudug regions Central Somalia comprises of two regions, Galgadud and South Mudug. There are four main livelihood zones, namely the purely pastoral Addun and Hawd; the fishing and pastoral Coastal Deeh and the agro-pastoral Cowpea Belt. The Hawd and Addun pastoral livelihoods extend across Galgadud, Mudug and southern Nugal regions, while the Coastal Deeh extends from the coast of Shabelle through Galgadud up to Allula district in Bari region, cutting across the South, Central and Northeast zones (Map 13). This section will discuss the nutrition situation of the Hawd and Addun pastoral livelihood zones together with the other livelihood zones in the Central zone. Historical Overview - Post Deyr 11/12 Food Security: The FSNAU Post Deyr 11/12 analysis classified the Addun pastoral population of Central regions of Somalia in Crisis, indicating a sustained situation since Gu 11. The Hawd pastoral livelihood had however showed improvement from the Crisis in Gu 11 to Stressed phase. The situation also improved in the Cowpea agro-pastoral livelihood from an Emergency in Gu 11 to Crisis phase due to the good Deyr 11/12 rainfall performance that led to improved local cowpea and sorghum production. The Coastal Deeh of central regions however, remained in persistent Emergency due to the significant loss of livestock in the past, caused by successive poor rainfall in previous seasons, in addition to widespread civil insecurity, limited humanitarian access and trade disruptions. The regions in Central and South Somalia continued to experience continuous civil unrest and the effects of droughts that led to internally displaced persons and pastoral destitution. Humanitarian access remained limited, aggravating the fragile food security and nutrition situation in the region further in Haradhere, Eldhere, and Elbur districts. Figure 20: Trends in Levels of acute malnutrition (WHZ<- 2 or oedema, WHO 2006) Central Regions, Data Source: COSV/MSF-S in the Hawd was however, projected to improve to based on the favourable food security outlook. An AWD/ cholera outbreak which was the main aggravating factor in the nutrition situation was under control by WHO and partners. The populations of the Addun pastoral livelihood showed improvement from in Gu 11 to in Deyr 11/12. The improvement in Addun was linked to improved access to milk, and dietary diversity, social support, and humanitarian programmes (health services, supplementary feeding, and WASH) in the region. From the outlook, Addun livelihood was projected to remain in a phase based on seasonal trends (Fig. 19). No assessment was conducted in the cowpea agro-pastoral and Coastal Deeh pastoral livelihoods of Central Somalia. Therefore there was no data to indicate that the nutrition situation changed from the respective and Very levels reported among the cowpea agro-pastoral and Coastal Deeh pastoral livelihoods in Gu 11. The Dhusamareb IDPs were in a sustained nutrition phase since post Gu 11. Figure 21: HIS Malnutrition Trends in Hawd LHz of Central areas( ) Source: MoH; SRCS Current Situation- Post Gu 11/12 Food Security The FSNAU Post Gu 11/12 analysis classifies the Addun pastoral population of Central regions of Somalia as Stressed, indicating an improvement from the previous Crisis phase in the Post Deyr 11/12 analysis. The Hawd pastoral livelihood has sustained in Stressed phase since Deyr 11/12. The situation has been sustained at the Crisis phase in the Cowpea agro-pastoral livelihood. The Gu 12 rains though below normal, has contributed to some improvements in livestock performance, reduced cereal prices and positive goat/cereal ToT, since the Deyr 11/12 was good in the cowpea belt. The Coastal Deeh of central regions however, remains in persistent Emergency due to the significant loss of livestock in the past, caused by the previous successive poor rainfall seasons, in addition to wide spread civil insecurity, limited humanitarian access Figure 22: HIS Malnutrition Trends in Addun L/Z of Central areas ( ) Nutrition: The Post Deyr 11/12 integrated nutrition analysis depicted a mixed picture of worsening, sustained or improved nutrition situation in the livelihood zones of Central Somalia compared to the Gu 11 season. The nutrition situation deteriorated from to among the Hawd pastoral livelihood population. The nutrition situation Data Source: COSV/MSF-S

51 and trade disruptions. Humanitarian access remains limited, aggravating the fragile food security and nutrition situation in the region further in Haradhere, Eldhere, and Elbur districts. Nutrition The current Post Gu 12 integrated nutrition analysis depicts a mixed picture of either sustained or improved nutrition situation in the Central livelihood zones compared to the Post Deyr 11/12. The nutrition situation improved from to among the Hawd pastoral livelihood population. The improvement in nutrition situation in the Hawd is attributed to favourable food security indicators including increased access to milk and improved dietary diversity. Besides, there was no disease outbreak in the area unlike in Deyr 11/12 when AWD/cholera outbreak was the main aggravating factor in the nutrition situation. The populations of the Addun pastoral livelihood have shown a sustained nutrition situation since Deyr 11/12. The stable nutrition situation in Addun is linked to improved access to milk, and dietary diversity, social support, and humanitarian programmes (health services, supplementary feeding, and WASH) in the region. Assessments conducted in the cowpea agro-pastoral and Coastal Deeh pastoral livelihoods of Central Somalia show a likely nutrition situation from the respective and situation reported in the Gu 11. No assessment were carried out in the Deyr 11/12 nutrition analysis in these two livelihoods. The Dhusamareb IDPs are in a sustained Very nutrition phase since post Gu 11. Gender: In the Hawd and Addun nutrition assessments conducted in the Galgadud and Mudug regions of Somalia, a higher proportion of boys than girls were acutely malnourished, however, there was no statistically significant difference (Pr<0.75). Other forms of malnutrition followed the same pattern, except Dusamareb IDPs where boys (26.5%) were significantly (p<0.05) more stunted than girls (8.7%) among the Dusamaerb IDPs. Other child data such as dietary diversity, illness, feeding practices, and immunization status, did not show any clear differences by gender. Analysis of household data by gender of household head did not find any significant difference nor clear trend in the proportion with access to sanitation facilities, access to safe drinking water nor consumption of a diversified diet. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized in Table 14. Hawd and Addun pastoral livelihoods of Central and Northeast regions The detailed results of assessments in all the livelihoods transcending the Central and NE regions including the Hawd and Addun are discussed in the sections that follow. The results of the key findings are summarized in Table 12 below. The integrated analysis of data from nutrition assessments conducted in June 2012 among the populations of Hawd and Addun Livelihood zones of Northeast (Nugal) and Central (Mudug and Galgadud), and the health and feeding facilities information shows a sustained phase in Figure 23: HIS Malnutrition Trends in Cowpebelt L/Z ( ) the Addun and an improvement from to situation in Hawd pastoral livelihood. The Hawd pastoral livelihood assessment reported a GAM rate of 11.2% ( ) and a SAM rate of 1.8% ( ). No oedema was reported in the assessment. (11.4%) and (10.9%) girls were equally affected (Pr<0.75). The results show an improvement compared to the December 11 findings where GAM and SAM rates of 18.6% ( ) and 5.5% ( ) were reported respectively, including five (0.9%) oedema cases. The retrospective crude (CDR) and under-five death (U5DR) rates of 0.38 ( ) and 0.50 ( ) respectively indicate levels according to UNICEF classification and indicates no change from the respective rates (CDR and U5DR) of 0.49 ( ) and 0.86 ( ) in Deyr 11/12. There were no outbreaks of any disease reported. The screening data from health facilities in the Hawd pastoral livelihood zone (Figure 21) show high (>30%) and stable trend of acutely malnourished children. In the June 12 Addun assessment, the GAM rate was 14.5% ( ) and the SAM rate was 2.4% ( ) with two (0.3%) oedema cases reported, indicating a sustained nutrition situation and no change from the respective GAM and SAM rates of 12.1% ( ) and 2.8% ( ) recorded in December 11. There are no significant differences in the level of acute malnutrition by gender, even though a higher proportion of assessed boys (16.2%) compared to girls (12.7%) are acutely malnourished (WHZ<- 2/oedema). The retrospective CDR and U5DR rates are 0.48 ( ) and 0.58 ( ) both indicating levels according to UNICEF classification, and similar to the retrospective CDR and U5DR rates of 0.32 ( ) and 0.87 ( ) reported in the December 11 assessment. Figure 24: HIS Malnutrition Trends in Central Coastal Deeh L/Z ( ) Regional Analysis 43

52 Regional Analysis 44 Table 15: Summary of Key Nutrition Findings in Hawd, Addun and Dhusamareb IDPs Central regions Hawd (N=816: 432 boys; 384 girls) Addun (N=701: (374 boys; 327 girls) Dusamareb IDPs (N=202: 109 boys; 93 girls) Indicator Results (%) Outcome Results (%) Outcome Results (%) Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) 11.2 ( ) 11.4 ( ) 10.9 ( ) 14.5 ( ) 16.2 ( ) 12.7 ( ) 22.0 ( ) 24.8 ( ) 18.7 ( ) Severe Acute Malnutrition (WHO 2006) 1.8 ( ) 1.9 ( ) 1.6 ( ) 2.4 ( ) 2.6 ( ) 2.2 ( ) 5.0 ( ) 6.4 ( ) 3.3 ( ) Mean WHZ (WHO, 2006) -0.71± ± ±1.18 Global Acute Malnutrition (NCHS) 12.0 ( ) 14.8 ( ) 22.3 ( ) Severe Acute Malnutrition (NCHS) 1.5 ( ) 1.7 ( ) 3.0 ( ) Proportion with MUAC (<12.5 cm or oedema) 5.4 ( ) 5.3 ( ) 5.5 ( ) 8.4 ( ) 7.8 ( ) 9.2 ( ) 8.9 ( ) 8.3 ( ) 9.7 ( ) Proportion with MUAC (<11.5 cm or oedema) 0.4 ( ) 1.7 ( ) 2.0 ( ) Stunting (HAZ<-2) 11.1 ( ) 12.6 ( ) 9.5 ( ) 14.1 ( ) 17.9 ( ) 9.7 ( ) 18.0 ( ) 26.5 ( ) 8.7 ( ) Underweight (WAZ<-2) HIS Nutrition Trends(Jan Jun 2012) Proportion of acutely malnourished registered in SFs Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Immunization Status 10.7 ( ) 12.9 ( ) 8.2 ( ) High (>30%) proportion and stable trends Outbreak None Morbidity Diarrhea :10.2 Pneumonia: 8.1 Fever: 21.0 Vitamin A Measles ( ) 14.7 ( ) 10.9 ( ) High (>30%) proportion and stable trends Outbreak None Morbidity Diarrhoea Pneumonia Fever Vitamin A Measles ( ) 29.0 ( ) 16.3 ( ) N/A N/A Infant and Young child feeding N= 297 N=229 N=62 Proportion still breastfeeding Proportion meeting recommended feeding frequencies - - Proportion who reported to have consumed <4 food groups Outbreak -None Morbidity Diarrhoea Pneumonia 16.8 Fever Vitamin A Measles Death Rates Crude deaths per 10,000 per day (retrospective for 90 days) 0.38 ( ) 0.48 ( ) N/A N/A Under five deaths per 10,000 per day (retrospective for days) 0.50 ( ) 0.58 ( ) N/A N/A Women Nutrition & Immunization Status N=416 N=375 N=99 Proportion of acutely malnourished non pregnant/lactating women (MUAC 18.5 cm) 0.8 ( ) Proportion of acutely malnourished non pregnant/lactating women (MUAC 21.0cm) 3.5 ( ) 5.8 ( ) 5.6 ( ) Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0) ( ) 18.6 ( ) 33.3 ( ) Proportion of Women who received Tetanus Immunization No dose One dose Two doses Three doses Public Health Indicators N=477 N=449 N=118 Household with access to sanitation facilities Male headed Female headed Household with access to safe water Male headed Female headed Food Security N=477 N=449 N=118 Proportion who reported to have consumed <4 food groups Male headed Female headed Household s Main Food Source Own production Purchase: Food aid Borrowing Food security phase Stressed Stressed Emergency Overall Situation Analysis

53 Data from health facilities in the Addun pastoral livelihood zone reported a high proportion (>30%) and stable trend of acutely malnourished children (Figure 24). Limited humanitarian interventions in the form of targeted interventions are ongoing in parts of the Hawd and Addun livelihood areas and may have assisted to mitigate the poor nutrition situation in Central regions. The support needs to be continued and expanded to cover more rural villages of Hawd, Addun and Coastal Deeh livelihood. Dhusamareb IDPs In May 12, FSNAU conducted a small sample cluster survey among IDPs in Dhusamareb, including those in Guriel area who have been displaced from South Somalia or are pastoral destitute from the Central pastoral livelihood zones. The GAM and SAM rates of 22.0% ( ) and 5.0% ( ) were reported respectively, indicating a Very nutrition situation. Although the overall nutrition situation remains in the same phase (), these findings are indicating an improvement from the Post Deyr 11/12 results when the GAM and SAM rates were 32.3% ( ) and 3.2% ( ) respectively, likely due to limited humanitarian interventions and social support, and improving food security situation in the host and surrounding communities. This population group and many others cropping up in many other towns in the Central regions, however remain vulnerable to malnutrition, food insecurity and other health challenges, and require continued interventions. The key nutrition evidence indicators of the analysis on the nutrition phase classification are provided in Table15. Central Agro-pastoral (Cow pea belt) and Coastal Deeh pastoral livelihoods of Central Somalia The integrated analysis of data from nutrition assessments conducted in June 2012 among the populations of Cow pea belt and Coastal Deeh of Central (South Mudug and Galgadud) regions, and the health facilities information shows a phase in both livelihoods. These assessments did not meet certain data quality criteria (recording high standard deviations and plausibility scores) for SMART surveys and therefore only point estimates calculated from standard deviation of 1 are provided. The Cow pea (central agro-pastoral) livelihood assessment reported a GAM rate of 16% and a mean weight-for-height Z score of (±1.60). The HIS data from health facilities in the cowpea belt livelihood zone remains high (>20%) and show a stable trend (Figure 23). There was no survey conducted on these populations in Deyr 11/12 and thus no data to compare seasonal change. Integrated nutrition analysis from health facility data and rapid assessment conducted a year earlier in July 2011, had reported acute malnutrition (MUAC<12.5/oedema) and severe acute malnutrition (MUAC<11.5/oedema) rates of 12.5% and 4.9% respectively, classified the nutrition situation as likely. The Coastal Deeh pastoral livelihood assessment reported a GAM rate of 16.2% and a mean weight-for-height Z score of (±1.49). The HIS data from health facilities in the Coastal Deeh of central areas remains high (>20%) and show a stable trend (Figure 24). There were no outbreaks of any disease reported. Even though not directly comparable, rapid assessment conducted a year earlier in July 2011, had reported acute malnutrition (MUAC<12.5/oedema) and severe acute malnutrition (MUAC<11.5/oedema) rates of 16.9% and 5.4% respectively, and Post Gu 11 integrated analysis classified the nutrition situation as likely. The key nutrition evidence indicators of the analysis on the nutrition phase classification for cow pea belt and Coastal Deeh are provided in Table16. Regional Analysis 45

54 Regional Analysis 46 Table 16: Summary of Key Nutrition Findings in Cowpea Belt Agro-pastoral and Coastal Deeh Pastoral of Central regions - July 2012 Cowpea Belt (N=1174: 592 boys; 582 girls) Coastal Deeh (N=491: (244 boys; 247 girls) Indicator Results (%) Outcome Results (%) Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) [Calculated from SD of 1] Severe Acute Malnutrition (WHO 2006) Mean WHZ (WHO, 2006) ± ±1.49 Stunting (HAZ<-2) [Calculated from SD of 1] Underweight (WAZ<-2) [Calculated from SD of 1] HIS Nutrition Trends(Jan Jun 2012) High (>20%) proportion and stable trends High (>20%) proportion and stable trends Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Outbreak None Morbidity 37.1 Diarrhoea :21.5 Pneumonia: 14.6 Fever: 17.2 Outbreak None Morbidity 49.7 Diarrhoea Pneumonia Fever Immunization Status Vitamin A 2.3 Measles 3.3 Vitamin A 0.4 Measles 0.2 Death Rates Crude deaths per 10,000 per day (retrospective for 90 days) 0.76 ( ) 0.56 ( ) Under five deaths per 10,000 per day (retrospective for 90 days) 1.46 ( ) 1.34 ( ) Food Security N=702 N=297 Food security phase Crisis Emergency Overall Situation Analysis Likely Likely

55 Food safety and malnutrition in Somalia Food safety is not only an aspect of food security (access to sufficient amounts of safe and nutritious food), but also affects nutrition status by impacting on consumption and utilization of food in the body. Tens of thousands of people fall ill every year and many die due to consumption of unsafe food including water and basic drinks 1. Given the absence of a stable government, that can legislate and reinforce food safety standards and regulations, food safety is one of the major public health problems in Somalia. According to WHO s Somalia Emergency Health Update bulletins, serious food born diseases, mainly acute watery diarrhea (AWD), Salmonellosis, Hepatitis A and recurrent cholera epidemics are often observed in all regions of Somalia on a monthly, or seasonal basis. Regional Analysis 47 According to the Meta analysis draft report (FSNAU, 2009) 2, Somalia bears a heavy burden of reported child illness with 44.8% of the 105,314 children assessed between having been reported ill in the two weeks prior to the (one month for suspected measles) individual surveys. A regression model (from the metaanalysis report) for the causes of malnutrition in Somalia reported a basal GAM prevalence of 9.6% and identified morbidity and dietary diversity as significant predictive factors, explaining 25.2% of the GAM prevalence, the remaining three quarters of the wasting prevalence thus explained by other causal factors including child feeding, food safety & hygiene, sanitation and food security factors as well as other diseases not covered in the surveys. Food borne diseases, due to consumption of unsafe foods and drinks, whether infectious or toxic, are possibly major contributors to high malnutrition levels and related adverse effects including disability 3 and organ dysfunctions in Somalia. While all population groups are susceptible to food-borne disease, there are groups more susceptible due to their low-levels of immunity, early stages of development or greater exposure, the most vulnerable groups being pregnant women and infants, developing foetus as well as young children 4. Due to poor storage and food handling practices, lack of a food safety policy and strategy, and monitoring system to evaluate the food safety and Contaminated odka (Fried meat) hygiene, there is unreliable data to measure the magnitude and severity of the problem. There is no active inspection for both imported and exported foods, nor a drug safety system. There is therefore some doubt whether all imported foods consumed in Somalia meet the internationally required standards and food safety criteria 5. However, it is generally expected that most food storage systems at the household and commercial level are inappropriate and may contribute to both communicable and non communicable diseases country wide. For instance, there is great concern in sorghum and maize producing regions, because if this cereal is stored before it is fully dried it may facilitate aflatoxin contamination which leads to serious liver damage. Bay region is especially known for persistent elevated malnutrition levels even during bumper harvests, usually a time of sufficient food access 6. The high malnutrition rates are attributed to a poor quality staple sorghum-based diet, and consumption of possibly contaminated sorghum stored underground. Further investigations are needed to determine the state of health of the population in regards to liver disease and oedematized wasting (very common in Juba regions) and the relationship with consumption of aflatoxin-contaminated cereals. In Somalia it is also very common for food, diesel, kerosene, insect killers, fatal poisons, human or vet drugs to be all poorly stored together in one small living room, exposing people to mycotoxin, heavy metal and bacterial contamination. In addition, consumption of under-cooked meat and un-boiled milk contributes to the major zoonotic diseases such as brucellosis and bovine. Food spoilage is not restricted to cereal foods and affects animal source foods as well. The photo above illustrates a delicious Somali high-energy, high-protein ready-to-eat meat product that is common among Somali pastoralists called Muqmad or odkc that has been contaminated due to poor handling. The meat is preserved with ghee and sometimes, especially in urban areas, dates and sugar. The meat can be stored for a long time, but when it is not handled properly, and contaminated by dirty hands or spoons, the meat is easily spoiled. To address this problem, the community (women, commercial groups, youth groups, and local governments) need to be educated on proper food storage and handling practices. Awareness on food safety standards in the community can be done through the local media and periodic workshops. In areas with more stable authorities, there is need to develop, implement, monitor and evaluate policies, strategies and programs that meet high levels of food safety for optimal nutrition. 1 Leon, W., & DeWaal, C.S. (2002). Is our food safe?: a consumer s guide to protecting your health and the environment. Three Rivers Pr 2 FSANU (October 2009). Malnutrition Trends ( ) in Somalia A meta analysis study report. 3 WHO global strategy for food safety: safer food for better health 4 WHO/FAO, International Food safety Authority Network, FAO/WHO-The Codex Alimentarius. 6 FSNAU (August 2009). Nutrition Analysis Post Gu Technical Series Report.

56 Regional Analysis Northeast Regions The Northeast regions are predominately pastoral with seven livelihood zones namely: the Hawd, Addun, Coastal Deeh, East Golis, Karkaar/Dharoor Valley, Nugal Valley and Sool Plateau. The Hawd and Addun cut across the Northeast and Central regions and the East Golis, Sool and Nugal Valley livelihoods cut across the NE and NW regions. (Map 11). Historical Overview Post Deyr 11/12 Food Security The FSNAU Post Deyr 11/12 integrated food security analysis classified the East Golis/ Karkaar/Dharoor valley in Stressed phase, indicating an improvement from Crisis in the previous Gu 11 season, and the Sool plateau and Nugal Valley livelihood zones of Bari and Nugal regions remained in Crisis. The Coastal Deeh livelihood zone was classified in a sustained Emergency since Deyr 10/11. The Hawd and Addun pastoral livelihoods in Nugal and northern Mudug regions that were classified in AFLC (or Crisis) in Gu 11 were classified as Stressed, indicating an improvement. Food security improvements in the Golis, Hawd and Addun livelihood zones were attributed to a combination of factors such as improved income from frankincense sales/export in the East Golis and a boom in livestock trade in the regions during Hajj, strengthened purchasing power resulting from increased goat to rice ToT, and less restricted humanitarian access in the northeast regions. Declined fishing activities (in the coastal areas) due to hot weather and insecurity in main export market (Yemen), limited access to milk and number of saleable animals amongst the poor, high water prices, and high debt levels contributed to the sustained livelihood crisis, especially in the Coastal Deeh and parts of Nugal Valley of Iskushuban and Qandala districts that had received below normal Deyr 11 rains. Nutrition The Post Deyr 11/12 integrated nutrition situation analysis indicated a general improvement in the nutrition situation in most of the livelihood zones compared to the Gu 11 season. The nutrition situation improved in the populations of Sool plateau, Addun, and Coastal Deeh livelihood zones from in Gu 11 to. The nutrition situation was classified as in the Nugal Valley livelihood zone, an improvement from in the Gu 11 season. However, the nutrition situation slightly deteriorated in the East Golis/Karkaar and Hawd pastoral livelihoods from to. These deteriorations were due to the limited access to milk and poor dietary diversity following the effects of previous consecutive poor seasonal performance and disease in these livelihood zones. The WHO/MOH reported AWD and cholera outbreaks in the Hawd areas of Galkayo and Adaado districts that aggravated the situation. However, considering the positive food security indicators, the situation in Hawd was projected to improve. The nutrition situation also improved Garowe IDPs from the phase in Gu 11 to, however a sustained situation was observed among the Bossaso, Qardho and Galkayo IDPs. The results were consistent with historical data on nutrition surveys conducted among the IDPs in the northeast region, which highlights the chronic nutritional vulnerabilities. Map 11: Northeast Livelihood Zones Current Situation Food Security The current FSNAU Post Gu 12 integrated food security analysis has classified the East Golis/ Karkaar/Dharoor valley, the Hawd and Addun livelihood zones of Nugal and northern Mudug regions in sustained Stressed phase. The Sool plateau and Nugal Valley livelihood zones of Bari and Nugal regions are also classified in Stressed phase, indicating an improvement from the Crisis phase in Deyr 11/12. The upper partd (Alluula and Iskushuban) Coastal Deeh livelihood zone of Bari region is classified in a sustained Emergency since Deyr 10/11. However, the lower part of Coastal Deeh (Bandar beyla, Eyl and Jarriban) has improved to Crisis from Emergency in Deyr 11/ 12. Food security improvements in the Sool plateau and Nugal Valley livelihood zones are attributed to a combination of factors such as improved access to milk and strengthened purchasing power resulting from increased goat to rice ToT, and less restricted humanitarian access in the northeast regions. The lower part of Coastal Deeh (Bandar beyla, Eyl and Jarriban) has also shown improvement in goat/rice ToT, and increased milk production. However, limited (below baseline) livestock holding, low fishing activities, poor milk production in most parts of the Coastal Deeh livelihood and presence of pastoral destitutes aggravate the food security situation. The situation is projected to improve in the upper part of the livelihood in the next six months due to anticipated improvements in livestock body condition and sales, following the good rainfall prospects for the area and a reduction in the international antipiracy activities opening up fishing opportunities. However, low kidding/calving and associated milk production is expected for all species due to low conception rates in the current season. Nutrition The Post Gu 12 nutrition situation depicts a mixed picture in the nutrition situation in the livelihood zones compared to the Deyr 11/12 season (Figure 25). The nutrition situation has improved in the populations of East Golis and Hawd livelihoods, from in Deyr 11/12 to. The nutrition situation in Sool, Addun and Coastal Deeh is classified in a sustained phase. However, the nutrition situation deteriorated among the populations of Nugal Valley to from in Deyr 11/12. The situation in Nugal valley follows a seasonal pattern of improvements in Deyr and deteriorations in Gu, having improved from in Deyr 11/12 and deteriorated back to the phase reported in Gu 11. A measles outbreak reported in parts of the western districts of Nugal Valley largely contributed to the worsened situation, despite

57 the positive food security indicators. The improvements in East Golis and Hawd are linked to improved milk access, dietary diversity and humanitarian intervention. The WHO/ MoH had reported AWD and cholera outbreaks in the Hawd areas of Galkayo and Adaado districts that aggravated the situation in Deyr 11/12, however, this was controlled and there was no disease outbreak reported in the livelihood zone this season. Among the IDPs, the nutrition situation has improved in Bossaso and Galkayo from to level, and sustained and levels in Garowe and Qardho respectively. The results are consistent with historical data on nutrition surveys conducted among the IDPs in the northeast region, which highlights the chronic nutritional vulnerabilities. Figure 25: Trends in levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) Northeast regions ( ) (U5DR) of 0.11 ( ) and 0.15 ( ) indicate an situation according to UNICEF classification, similar to the respective CDR and U5DR of 0.26 ( ) and 0.36 ( ) reported in December 12. Besides the chronic poor infrastructure, the area received a second season of near normal rains, though with exception of pocket areas after a long period of four consecutive below normal rainfall in the previous seasons, and so is yet to recover fully from livestock losses and debts. Improved sheep/goat calving has increased access to milk, but is limited due to the previous herd size reduction/ losses. Access to camel milk is poor to average due to low conception and calving in the previous season. Figure 26: HIS Malnutrition Trends in Golis/ Karkaar LZ ( ) Regional Analysis 49 Gender: Analysis of findings from the nutrition assessments conducted in the northeast regions of Somalia generally indicates a higher proportion of boys than girls as acutely malnourished (WHZ<-2 or oedema). Conversely, a higher proportion of girls than boy were acutely malnourished based on MUAC (< 125 mm or oedema). However, these differences were generally not statistically significant (Pr<0.75). Other child data such as dietary diversity, illness, feeding practices, and immunization status, do not show any clear differences by gender. Analysis of household data by gender of household head did not find any significant difference nor a clear trend in the proportion with access to sanitation facilities, access to safe drinking water nor consumption of diversified diet. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized on Tables 17 and 18. The detailed results of the assessments in the Hawd and Addun, cutting across both NE and Central regions are discussed in the section for Central zone. East Golis/ Karkaar/Dharoor Livelihood Zones The current Post Gu 12 integrated nutrition situation analysis classifies the nutrition situation of the population in East Golis/ Karkaar/Dharoor livelihood zone of Bari region as. In July 12, FSNAU and partners conducted a comprehensive nutrition survey in the East Golis/Karkaar/Dharoor livelihood zone of Bari region. The results indicated a GAM rate of 13.9% ( ) and SAM rate of 4.1% ( ) including two (0.3%) oedema cases. These rates show an improvement from the situation reported in the December 12 assessment conducted in the same livelihood and region, when the GAM rate was 15.2% ( ) and SAM rate was 3.8% ( ). Higher proportions of assessed boys (14.1%) were acutely malnourished as compared to girls (13.6%), although the difference was not statistically significant. The 90 days retrospective crude (CDR) and under five death rates Data Source: MoH; SRCS Data from the health facilities namely Ufeyn, Waaciye and Iskushuban indicate high proportions (>10%) of acutely malnourished children, with an increasing trend in three (Apr-Jun 12) months (Figure 26). Considering these HIS trends, low mortality rates, and the continued gradual recovery of food security indicators, it is projected that the nutrition situation among the East Golis livelihood population is likely to remain in the coming six months with expected above normal rainfall forecasts. The population remains vulnerable to natural shocks and requires close monitoring, in addition, there is need to address the chronic issues affecting the nutrition status of the population such as inadequate health and sanitation facilities, poor child feeding and care practices and lack of adequate safe drinking water. In the short term, the rehabilitation of the acutely malnourished children, is required. Sool Plateau Livelihood Zone of Northeast The nutrition situation of the Sool plateau of Bari and Nugal regions has sustained the phase since Deyr 11/12. Results from the nutrition survey conducted in July 12 covering four regions of Bari, Nugal, Sool and Sanaag report a GAM rate of 11.3% ( ) and a SAM rate of 1.7% ( ). No oedema was reported. The rates indicate no significant change from the December 12 GAM and SAM rates of 11.6% ( ) and 3.4% ( ). A higher percentage of boys (13.7%) than girls (9.0%) were acutely malnourished, though not statistically significant. The 90 days retrospective CDR and U5DR of 0.12 ( ) and 0.40 ( ) were reported respectively, both indicating levels according to UNICEF classification. HIS data in the area recorded low (<10%) and stable proportions of acutely malnourished children screened at health facilities (Figure 27).

58 Regional Analysis 50 The nutrition situation in the livelihood is mitigated by increased milk access in the area, following successive good Deyr 11/12 and Gu 12 rains and localized humanitarian interventions such as cash relief, food aid, health and nutrition. Although a sustained improvement is projected with a good Deyr 12/13 forecast, the vulnerability of the region to natural shocks, e.g. drought, rise in prices, and disease outbreaks necessitates continued close monitoring of the situation. Nugal Valley Livelihood Zone The current Post Gu 12 integrated nutrition analysis classifies the nutrition situation of the Nugal Valley as Very, a deterioration from the levels in the Deyr 11/12 (Table 14). The nutrition survey conducted in July 12 by FSNAU and partners covering the Nugal Valley livelihood zone that cuts across NW and NE regions, reported a GAM rate of 20.1% ( ) and a SAM rate of 5.4% ( ). No oedema was reported in the assessment. These results show a deterioration (Pr>75%) from the GAM rate of 16.3% ( ) and a SAM rate of 5.2% ( ) reported in the December 11 assessment. The 90 days retrospective crude (CDR) and under five death rates (U5DR) of 0.04 ( ) and 0.19 ( ) respectively, are and did not show any significant change from the respective CDR and U5DR of 0.19 ( ) and 0.48 ( ) recorded in December 11. Though not statistically significant, a higher proportion of assessed boys (22.2%) than girls (17.9%) were acutely malnourished. Data from the health facilities namely Sinujiif, Gambool and Waaberi, indicates low numbers (<10%) but an increasing trend of acutely malnourished children (Figure 28). The deterioration in the nutrition situation is likely linked to disease outbreaks. A measles outbreak was reported in the western parts of the livelihood. However, improved dietary diversity and increased intake of milk and meat products following the good Gu rainy season, and access to humanitarian support given the relative stability in the area are mitigating factors and the situation is likely to improve in the next season if disease outbreak is controlled. High morbidity rates (23.9%) reported from the survey and from the local health facilities, low vitamin A supplementation status (74.8%) and measles vaccination status (77.2%), poor water and sanitation and limited health facilities in the community are some of the aggravating factors for the Very nutrition situation. More than 40% of the households do not have sanitation facilities and a large majority (>80%) of the assessed population do not have safe drinking water. Therefore, the population groups in this livelihood zone need continued nutrition and livelihood interventions with close monitoring especially in light of the chronic vulnerability in the area. The key findings for East Golis, Sool and Nugal livelihood zones are summarized in Table 17. Coastal Deeh Livelihood Zone of Northeast The nutrition situation of the Coastal Deeh population of Nugal, Bari and North Mudug regions has sustained levels since Deyr 11/12. Except for a few spots that received below normal Deyr rains, the area has experienced improved access to milk and income associated with favorable terms of trade (local goat to rice). A nutrition survey conducted in July 12, reported a GAM rate of 12.8 % ( ) and SAM rate of 3.5% ( ), indicating a nutrition situation and no change from the situation in Deyr 11/12 when a GAM rate of 12.2 Figure 27: HIS Malnutrition Trends in Sool Plateau LZ ( ) Data Source: MoH; SRCS % ( ) and SAM rate of 3.1% ( ) were recorded. A higher proportion of assessed boys (15.0%) were acutely malnourished (WHZ<-2 or oedema) compared to girls (10.0%) but this difference was not statistically significant. The 90-days retrospective crude (CDR) and under five death rates (U5DR) of 0.56 ( ) and 1.34 ( ) respectively were recorded, both indicating levels and a slight deterioration from the levels with respective CDR and U5DR of 0.19 ( ) and 0.77 ( ) recorded in December 11. The reported deaths were suspected to have mainly been caused by diarrhoea. Data from health facilities in the NE coastal areas also indicated a high (>15%) but decreasing proportion of acutely malnourished children. Morbidity, poor access to sanitation and drinking water in the area remain critical, with 20.3% of the assessed children reported to have fallen ill in the two weeks preceding the assessment and only 63.1% and 55.2% of the households having access to sanitation facilities and safe drinking water respectively. Previous consecutive rain failures in the Deyr 10/11 and Gu 11 led to a significant deterioration of livestock body conditions and deaths resulting in reduced household income, and meat and milk consumption. Therefore a second successful season with pockets of poor rains is not sufficient for the households to fully recover their assets and livestock heads. The situation needs close monitoring amidst seasonal changes in labour opportunities from fishing activities due to the presence of sea pirates, strong sea tides, and chronically poor infrastructure and frequent disease outbreaks. The findings for Coastal Deeh pastoral livelihoods are summarized in Table 17. Figure 28: HIS Malnutrition Trends in Nugal Valley LZ ( ) Data Source: MoH; SRCS

59 Table 17: Summary of Key Nutrition Findings in Northeast Regions - July 2012 East Golis (N= 695: = 360; =335) Nugal Valley (N=619: =311; =308) Sool Plateau (N=748: = 365; =383) Indicator Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) Severe Acute Malnutrition (WHO 2006) 13.9 ( ) 14.1 ( ) 13.6 ( ) 4.1 ( ) 4.2 ( ) 4.0 ( ) 20.1 ( ) 22.2 ( ) 17.9 ( ) 5.4 ( ) 6.2 ( ) 4.6( ) 11.3 ( ) 13.7 ( ) 9.0 ( ) 1.7 ( ) 1.4 ( ) 1.9 ( ) Mean WHZ (WHO, 2006) ± ± ±1.08 Oedema 0.3 Very Global Acute Malnutrition (NCHS) 13.0 ( ) 20.0 ( ) 11.9 ( ) Severe Acute Malnutrition (NCHS) 1.9 ( ) 2.4 ( ) 2.0 ( ) Proportion with MUAC <12.5 cm or edema Proportion with MUAC <11.5 cm or edema Stunting (HAZ<-2) Underweight (WAZ<-2) HIS Nutrition Trends(Jan-Jun 2012) Proportion of acutely malnourished registered in SFs Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Immunization Status 5.2 ( ) 4.7 ( ) 5.7 ( ) 1.0 ( ) 1.4 ( ) 0.6 ( ) 11.2 ( ) 11.5 ( ) 10.8 ( ) 14.5 ( ) 15.0 ( ) 13.9 ( ) High (>10%) and increasing Outbreak None Morbidity Diarrhoea Pneumonia Fever= Vitamin A Measles Very 2.8 ( ) 3.2 ( ) 2.3 ( ) 1.5 ( ) 1.5 ( ) 1.6 ( ) 5.2 ( ) 6.1( ) 4.2 ( ) 14.6 ( ) 16.5 ( ) 12.7 ( ) Low (<10% but increasing Measles outbreak in the western parts Morbidity Diarrhoea Pneumonia Vitamin A Measles ( ) 1.9 ( ) 3.4 ( ) 0.5 ( ) 0.5 ( ) 0.5 ( ) 12.0 ( ) 16.2 ( ) 8.0 ( ) 11.6 ( ) 12.6 ( ) 10.7 ( ) Low (<10) and stable Infant and Young child feeding N= 221 N=217 N=249 Proportion still breastfeeding ( months) Proportion meeting recommended feeding frequencies Proportion who reported to have consumed <4 food groups Death Rates Crude death per 10,000 per day (retrospective for 90 days) Under five deaths/10,000 /day (retrospective for 90 days) Women Nutrition & Immunization Status Proportion of acutely malnourished non pregnant/lactating women (MUAC 18.5 cm) Proportion of acutely malnourished non pregnant/lactating women (MUAC 21.0cm) Outbreak None Morbidity Diarrhoea Pneumonia Vitamin A Measles ( ) 0.04 ( ) 0.12 ( ) 0.15 ( ) 0.19 ( ) 0.40 ( ) N=410 N=435 N=496 N= N= ( ) 0.0 N= ( ) N= N=268 N=228 Regional Analysis 51

60 Regional Analysis 52 Summary of Key Nutrition Findings in Northeast Regions - July 2012-Continued Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0). Proportion of Women who received Tetanus Immunization No dose One dose Two doses Three doses N= ( ) N= ( ) Public Health Indicators N= 442 N= 351 N=425 Household with access to sanitation facilities Male headed Female headed Household with access to safe water Male headed Female headed Food Security Proportion who reported to have consumed <4 food groups Male headed- Female headed- Household s Main Food Source Own production Purchase: Borrowing N=228 Food security phase Stressed Stressed Stressed Overall Risk to Deterioration Likely to sustain Uncertain Likely to sustain Overall Situation Analysis IDPs of the Northeast: Bossaso, Qardho, Garowe and Galkayo The nutrition situation of IDPs in the northeast regions has either improved or remains at sustained -Very phases as classified in the Post Deyr 11/12. Based on surveys conducted in May 12, the nutrition situation is currently classified as among Bossaso, Garowe and Galkayo IDPs, and among Qardho IDPs, as the population remains vulnerable to effects of pastoral destitution conflict and unfavourable market forces. Findings from the Bossaso IDPs assessment recorded a GAM rate of 18.7% ( ) and SAM rate of 3.9% ( ), with two (0.2%) oedema cases. Significantly more boys (22.4%) than girls (15.4%) were acutely malnourished (Pr>87.5%), a disparity possibly explained by the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as acutely malnourished. The results indicate a nutrition situation, a significant improvement (Pr>87.5%) from the situation reported in the November 2011 assessment when a GAM rate of 24.1% ( ) and SAM rate of 7.2% ( ) were recorded. The retrospective crude and under five death rates of 0.33 ( ) and 0.61 ( ), both indicate levels among the Bossaso IDPs according to UNICEF classification. The CDR and U5DR show a slight improvement from the levels with respective rates of 0.68 ( ) and 1.51 ( ) reported in the November 2011 assessment. The results also show an improvement from seasonal levels of GAM rates >20% usually observed in the Gu since Data from health facilities in Bossaso indicated a high (>15%) but decreasing trend of acutely malnourished children. The improvement is attributed to interventions by humanitarian organizations and the Puntland authorities in the form of targeted food distributions for the acutely malnourished and other nutrition and health services. Other factors such as unstable access to casual labour at the Bossaso port, out-migration of the better off escaping the high temperatures, and reduced fishing activities because of the high tides and winds at sea, still contribute to the persistent poor nutrition situation. The findings of IDPs assessments among Bossaso, Garowe and Galkayo IDPs are presented in Table 17. Among the Qardho IDPs, a small sample cluster survey conducted in May 2012, reported a GAM rate of 21.7% ( ) and SAM rate of 5.6% ( ), indicating a Very nutrition situation. These findings are consistent with the November 2011 assessment that reported a GAM rate of 20.4% ( ) and SAM of 6.1% ( ), indicating a sustained nutrition levels. Similar proportions of boys (20.2%) and girls (23.2%) were acutely malnourished based on weight-for-height Z scores (<-2) and/or oedema. The displaced populations in Qardho have Figure 29: Trend in Levels of Acute Malnutrition (WHZ<-2 or oedema, WHO 2006) in Northeast IDPs ( )

61 also benefitted from the supplementary and therapeutic nutrition interventions by Puntland authorities, together with local and international organizations, which have mitigated the situation from further deterioration. The results of the Garowe nutrition assessment conducted in May 2012 show a GAM rate of 19.2% ( ) and a SAM rate of 4.7% ( ), including two (0.2%) oedema cases, indicating a sustained nutrition situation. Similar levels were reported in the November 2011 survey with GAM and SAM rates of 17.8 % ( ) and 4.5 % ( ) respectively. (19.3%) and girls (19.2%) were equally acutely malnourished (WHZ<-3/oedema). The CDR and U5DR of 0.43 ( ) and 0.59 ( ), both indicate levels among the Garowe IDPs according to UNICEF 2005 classification. The CDR and U5DR show similar levels to the retrospective rates of 0.30 ( ) and 0.77 ( ) reported in the November 2011 survey. The internally displaced populations in Garowe have historically reported stable - levels since June 2010 (Fig. 31). Continued government, non-governmental organization interventions including active case finding and referral of acutely malnourished children and Diaspora support, have contributed to the stability, and in mitigating possible deterioration in this vulnerable population. However, continued conflict-related displacements from the south-central regions have exerted pressure on the host communities, coupled with limited labour opportunities and high food prices have constrained access to food and economic resources among the IDPs. Results for the Galkayo IDP assessment conducted in May 2012 recorded a GAM rate of 19.2% ( ) and SAM rate of 4.1% ( ) including two (0.5%) cases of oedema, indicating a nutrition situation. The proportion of boys (21.3%) who were acutely malnourished was higher than that of girls (17.3%), but the difference was not statistically significant. Although these findings show improvement from levels of 21.8% ( ) and 5.9% ( ) for GAM and SAM rates respectively reported in November 2011, the change is not statistically significant (Pr<75%). The retrospective crude and under five death rates of 0.22 ( ) and 0.62 ( ) among Galkayo IDPs are both within the levels according to WHO classification and an improvement from the respective rates of 0.80 ( ) and 1.39 ( reported in the November 2011 survey. Regional Analysis 53 Table 18: Summary of Key Nutrition Findings in Hawd, Addun and Coastal Deeh Northeast Regions Hawd (N=816: 432 boys; 384 girls) Addun (N=701: (374 boys; 327 girls) Coastal Deeh (N=385: 209 boys; 176 girls) Indicator Results (%) Outcome Results (%) Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) Severe Acute Malnutrition (WHO 2006) 11.2 ( ) 11.4 ( ) 10.9 ( ) 1.8 ( ) 1.9 ( ) 1.6 ( ) 14.5 ( ) 16.2 ( ) 12.7 ( ) 2.4 ( ) 2.6 ( ) 2.2 ( ) 12.8 ( ) 15.0 ( ) 10.0 ( ) 3.5 ( ) 3.9 ( ) 2.9 ( ) Mean WHZ (WHO, 2006) -0.71± ± ±1.09 Global Acute Malnutrition (NCHS) 12.0 ( ) 14.8 ( ) 13.5 ( ) Severe Acute Malnutrition (NCHS) 1.5 ( ) 1.7 ( ) 1.3 ( ) Proportion with MUAC (<12.5 cm or 5.4 ( ) 8.4 ( ) 2.6 ( ) oedema) 5.3 ( ) 7.8 ( ) 1.9 ( ) 5.5 ( ) 9.2 ( ) 3.4 ( ) Proportion with MUAC (<11.5 cm or oedema) 0.4 ( ) 1.7 ( ) 0.8 ( ) Stunting (HAZ<-2) 11.1 ( ) 12.6 ( ) 14.1 ( ) 17.9 ( ) 12.0 ( ) 12.9 ( ) 9.5 ( ) 9.7 ( ) 11.0 ( ) Underweight (WAZ<-2) 10.7 ( ) 12.9 ( ) 8.2 ( ) 12.9 ( ) 14.7 ( ) 10.9 ( ) 14.2( ) 16.5( ) 11.6 ( ) High proportion (>10%) and stable High (>15%) but decreasing High (>15%) but decreasing HIS Nutrition Trends(Jan June 2011) Proportion of acutely malnourished registered in SFs Child Morbidity & Immunization Outbreak None Outbreak None Outbreak None Morbidity 30.6 Morbidity 36.8 Morbidity 20.3 Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Diarrhea :10.2 Diarrhoea Diarrhoea Pneumonia: 8.1 Pneumonia Pneumonia Fever: 21.0 Fever Fever Vitamin A 70.2 Vitamin A 64.9 Vit A Immunization Status Measles 71.4 Measles 60.8 Measles Infant and Young child feeding N= 297 N=229 N=129 Proportion still breastfeeding ( months)

62 Regional Analysis 54 Summary of Key Nutrition Findings in Hawd, Addun and Coastal Deeh Northeast Regions-Continued Proportion meeting recommended feeding frequencies - - Proportion who reported to have consumed <4 food groups - - Death Rates Crude deaths/ 10,000/ day (retrospective for 90 days) Under five deaths/ 10,000 /day (retrospective for 90 days) Women Nutrition & Immunization Status Proportion of acutely malnourished non pregnant/lactating women (MUAC 18.5 cm) Proportion of acutely malnourished non pregnant/lactating women (MUAC 21.0cm) ( ) 0.48 ( ) 0.56 ( ) 0.50 ( ) 0.58 ( ) 1.34 ( ) N=416 N=375 N= ( ) ( ) 5.8 ( ) 1.0 ( ) Proportion of acutely malnourished pregnant/lactating women (MUAC<23.0) ( ) 18.6 ( ) 14.4 ( ) Proportion of Women who received Tetanus Immunization No dose One dose Two doses Three doses Public Health Indicators N=477 N=449 N=252 Household with access to sanitation facilities Male headed Female headed Household with access to safe water Male headed Female headed Food Security N=477 N=449 N=252 Proportion who reported to have consumed <4 food groups Male headed Female headed Household s Main Food Source Own production Purchase: Food aid Borrowing Food security phase Stressed Stressed Crisis Overall Situation Analysis These findings indicate considerably high morbidity rates (>37%) which have a direct effect on the nutrition status of the children. Suspected measles outbreak reported in Galkayo district during the Gu season was controlled. For all the four IDP populations, vaccination status by recall and Vitamin A supplementation are still sub-optimal (60-80%) and far below the Sphere (2004) threshold (Table 19). Although the IDPs population in the urban settlements often have better dietary diversity and access to safe water and sanitation facilities compared to the rural households, the household s access to food, water and other basic services among this group is dependent on the level of income or purchasing power and social support, which remain a major challenge for most displaced populations when food prices rise. Among the assessed IDP populations, only 5% or fewer households in Bossaso, Qardho, Garowe and Galkayo IDP settlements consumed poorly diversified diets, comprising of three or fewer food groups, mainly obtained through purchase ( %). Furthermore, a high proportion of the assessed households among the IDP settlements have access to sanitation facilities, with the proportion of the assessed households reporting access to some type of sanitation facility ranging from 84% in Bossaso, to 100% in Qardho IDP settlements. Similarly, the proportion of the assessed households reporting access to safe drinking water ranged from 71.1% in Garowe to 99% in Qardho. Overall, the nutrition situation is to among IDPs of Northeast. Bossaso, Garowe and Galkayo IDPs are in levels while Qardho IDPs is in Very nutrition. The reasons for the persistent situation and for the improvements are multiple and are associated with climate, food security, level of social support, population and conflict dynamics in the south as well as health related factors. The reliance of IDPs on insufficient humanitarian assistance and on irregular casual labour for income to buy food and other none food items makes them susceptible to food insecurity and malnutrition. The situation is exacerbated by the high food prices and poor food access resulting from the effects of conflict and past drought in the region and inability of the host communities to provide social support. Interventions to improve and stabilize food access and provision of health services are crucial in addressing limited food and in tackling the high morbidity levels, thereby mitigating the high levels of acute malnutrition. Where substantial support was reported and the food security indicators of the surrounding host communities improved, the nutrition situation also showed some improvement. Continued and concerted efforts are thus needed to rehabilitate acutely malnourished children and prevent further deterioration.

63 Table 19: Summary of Key Nutrition Findings among Northeast IDPs (Bossaso, Qardho, Garowe and Galkayo) May 2012 Bossaso (N=1009; 481boys, 528 girls) Qardho IDPs (N=202; 101 boys, 101 girls) Garowe (N=821; 422 boys, 399 girls) Galkayo (N= 997; 473 boys, 524 girls) Indicator Results Outcome Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHO 2006) Severe Acute Malnutrition (WHO 2006) 18.7 ( ) 22.4 ( ) 15.4 ( ) 3.9 ( ) 4.9 ( ) 3.1 ( ) 21.7 ( ) 19.2 ( ) 20.2 ( ) 19.3 ( ) 23.2 ( ) 19.2 ( ) 5.6 ( ) 6.1 ( ) 5.1 ( ) 4.7 ( ) 4.6 ( ) 4.9 ( ) 19.2 ( ) 21.3 ( ) 17.3 ( ) 4.1 ( ) 5.2 ( ) 3.1 ( ) Mean WHZ (WHO, 2006) ± ± ± ±1.11 Global Acute Malnutrition (NCHS) Severe Acute Malnutrition (NCHS) Proportion with MUAC <12.5 cm or oedema Proportion with MUAC <11.5 cm or oedema Stunting (HAZ<-2) Underweight (WAZ<-2) HIS Nutrition Trends(Jan- Jun 12) Admission trends at TFPs/ SFPs (Jan-July 12) Proportion of acutely malnourished registered in SFs 16.6 ( ) 22.5 ( ) 17.8 ( ) 19.3 ( ) 1.3 ( ) 2.5 ( ) 2.3 ( ) 2.1 ( ) 11.5 ( ) 9.4 ( ) 13.4 ( ) 12.4 ( ) 16.0 ( ) 8.9 ( ) 9.9 ( ) 7.1 ( ) 12.8 ( ) 6.6 ( ) 4.5 ( ) 8.4 ( ) 3.8 ( ) 3.0 ( ) 2.1 ( ) 1.3 ( ) 34.9 ( ) 40.2 ( ) 30.2 ( ) 32.0 ( ) 37.0 ( ) 27.5 ( ) High (>15%) but decreasing High but steadily decreasing in number of OTP admissions ( ) 36.8 ( ) 29.8 ( ) 25.4 ( ) 27.6 ( ) 22.4( ) 25.9 ( ) 25.3 ( ) 26.6 ( ) 36.2 ( ) 37.2 ( ) 35.1 ( ) 17.3 ( ) 19.0 ( ) 15.8 ( ) 22.6 ( ) 26.1 ( ) 19.4 ( ) N/A - N/A - N/A - N/A Low and stable number of SC admissions N/A Regional Analysis 55 Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Immunization Status Infant and Young child feeding Proportion still breastfeeding (6-24 months) Outbreak None Morbidity Diarrhoea Pneumonia Fever-23.6 Vitamin A Measles Outbreak None Morbidity Diarrhoea Pneumonia- 7.4 Fever-36.6 Vitamin A Measles Outbreak -None Morbidity Diarrhoea Pneumonia-6.6 Fever-29.0 Vitamin A Measles N=407 N=76 N=313 N= Suspected measles outbreakcontrolled. Morbidity Diarrhoea Pneumonia-9.9 Fever-29.6 Vitamin A Measles

64 Regional Analysis 56 Summary of Key Nutrition Findings among Northeast IDPs (Bossaso, Qardho, Garowe and Galkayo) May 2012-Continued Proportion meeting recommended feeding frequencies Proportion who reported to 80.1 have consumed <4 food groups Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) 0.33 ( ) N/A ( ) Under five deaths, per 10,000 per day (retrospective for ( ) N/A ( ) days) Women Nutrition & Immunization Status N=597 N=52 N=326 N=544 Proportion of acutely malnourished non pregnant/ N=354 N=19 N=217 - lactating women (MUAC ( ) ( ) cm) Proportion of acutely malnourished non N=225 N=33 N=109 pregnant/lactating women 3.1 ( ) ( ) (MUAC 21.0cm) Proportion of acutely N=225 malnourished pregnant/ 13.3 ( ) lactating women (MUAC<23.0). Proportion of Women who received Tetanus Immunization No dose One dose Two doses Three doses N= N= ( ) ( ) 0.62 ( ) N= ( ) N= ( ) N= ( ) Public Health Indicators N=611 N=100 N=498 N=597 Household with access to sanitation facilities Male headed Female headed Household with access to safe water Male headed Female headed Food Security N=611 N=100 N=498 N=597 Proportion who reported to 2.1 have consumed <4 food groups 1.7 Male headed 4.5 Female headed Household s Main Food Source Purchase: Borrowing Food Aid Food security phase Emergency Emergency Emergency Emergency Overall Situation Analysis Gender and nutrition analysis in Northeast Regions In most of the nutrition assessments conducted in the NE regions of Somalia, a higher proportion of boys than girls were acutely malnourished, even though this was generally not statistically significant (Pr<0.75), except for Bossaso IDPs (22.4% vs. 15.4%) where there was a statistical significance (Pr>75%). However, other child data such as dietary diversity, illness, care and feeding practices, and immunization status, do not show any clear differences by gender and so the disparity is likely due to the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as acutely malnourished. With the new WHO reference standards, a girl of a certain height has to be much lighter than a boy of the same height to meet the WHZ<-2 threshold for acute malnutrition. In the other IDP assessments conducted during Gu 12, more boys than girls were acutely malnourished in Galkayo IDPs (21.3% vs. 17.3%), but the differences was not statistically significant. Similar trends are reported in the livelihood based assessments where higher percentage of the boys tend to be more malnourished than the girls including Nugal Valley (22.2% vs. 17.9%) and Sool plateau (13.7% vs. 9.0%) livelihoods of Bari and Nugal regions, as well as in Addun (16.2% vs. 12.7%) and Coastal Deeh (15.0% vs. 10.0%) pastoral livelihoods of NE regions. Analysis of household data by gender of household head did not find any significant difference nor clear trend in the proportion with access to sanitation facilities, access to safe drinking water nor consumption of diversified diet. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized on Tables

65 MATERNAL NUTRITION STATUS IN NORTHEAST AND CENTRAL SOMALIA The proportion of the global and severely malnourished pregnant and/ or lactating women based on the Sphere MUAC cut-offs of 23.0, and 21.0cm, and/or bilateral oedema in the Northeast and Central regions, vary widely from - in most rural livelihood population groups to situation in some IDP population groups. For the non-pregnant or non-lactating, the situation is within acceptable levels in most surveys based on MUAC cut -off of 18.5cm or presence of bilateral oedema. Pregnant and/or Lactating Women Non Pregnant/Lactating Women Proportion with MUAC Proportion with MUAC Proportion with MUAC No Assessed No Assessed <23cm(%) <21cm(%) <18.5cm(%) Bossaso IDPs ( ) 3.1 ( ) ( ) Qardho IDPs Garowe IDPs ( ) 6.4 ( ) ( ) Galkayo IDPs ( ) 1.7 ( ) ( ) Hawd ( ) 3.5 ( ) ( ) Addun ( ) 5.8 ( ) Coastal Deeh ( ) 1.0 ( ) Nugal Valley ( ) 1.3 ( ) ( Sool Plateau ( ) 5.3 ( ) ( ) East Golis ( ) 8.3 ( ) Regional Analysis 57

66 Regional Analysis Northwest Regions The Northwest regions comprise mainly of pastoral livelihood zones namely: West Golis, Guban, East Golis/ Gebbi Valley of Sanaag region, the Hawd of Hargeisa and Togdheer, Sool Plateau and the Nugal Valley. In addition, there is an agro-pastoral livelihood zone that is sub-divided into two, namely, the Agro-pastoral of Awdal and Woqooyi Galbeed regions and Agro-pastoral of Togdheer region. The livelihood zones cut across the five administrative regions of Awdal, Woqooyi Galbeed, Togdheer, Sool and Sanaag. (Map 12). The East Golis, Nugal Valley and Sool plateau also extend to the Northeast regions of Bari and Nugal respectively. Historical Overview Post Deyr 11/12 Food Security The FSNAU Post Deyr 11/12 integrated food security analysis classified the food security situation of the agropastoral, West Golis/Guban, East Golis and Hawd pastoral livelihoods in the Northwest as Stressed indicating a stable food security situation since the Gu 10 season, but an improvement for East Golis and Hawd of Togdheer livelihoods which were in Crisis in the Gu 11. The population in Nugal Valley and Sool plateau were in Crisis, a sustained phase for Nugal Valley livelihood but an improvement from Emergecy for Sool Plateau since the Deyr 09/10. The general improvement in the food security situation in these livelihoods was mainly attributed to the improved milk availability owing to improved pasture condition and water availability. Other factors that contributed to the improvement included kidding among the small rumminats, increased income from sale of livestock and related products, better purchasing power due to improved livestock prices and reduced household expenses and unrestricted humanitarian access due to relative civil tranquility. Nutrition The Post Deyr 11/12 integrated nutrition situation analysis showed a general improving trend in the nutrition situation in Northwest livelihoods with most livelihoods showing either a significant improvement or stable situation compared to the Gu 11 situation. The nutrition situation for the West Golis and Nugal Valley livelihoods significantly improved from in Gu 11 to and respectively. The situation among the population in the Sool Plateau improved from in Gu 11 to while that of the agro-pastoral and East Golis/Gebbi Valley livelihood zones remained stable at level. The improvement recorded in the respective livelihoods was mainly attributed to improved milk access at the household level and declined morbidity levels. Map 12: Northwest Livelihood Zones However, the nutrition situation among the population in the Hawd livelihood significantly deteriorated from levels in Gu 11 to. This was mainly attributed to reduced milk access following opportunistic livestock out-migration to Ethiopia where water and pasture condition was better compared to the situation in Hawd of Togdheer and Sool regions. The nutrition situation of the IDPs in Hargeisa town was sustained at level since Deyr 10/11, while the nutrition situation among the Burao IDPs deteriorated from in Gu 11 to in Deyr 11/12. The nutrition situation among the Berbera IDPs also deteriorated to levels from in Gu 11. The lack of stable livelihood systems among the IDP populations, coupled with irregular access to basic services continue to expose this population group to risks of malnutrition, morbidity and food insecurity. The chronic risk factors for malnutrition among the populations in the Northwest region include high morbidity rates, a precarious food security situation, poor dietary diversity, poor child feeding and care practices, in addition to inadequate safe drinking water, limited access to health and sanitation facilities, remain a challenge to the population especially among the displaced persons and the rural populations. The historical trend of malnutrition in the respective livelihoods since 2003 is shown in (Figure 30). Current Situation Post Gu 12 Food Security The FSNAU Post Gu 12 integrated food security analysis in the most of Northwest indicates a Stress phase of acute food insecurity situation in the agro-pastoral,, Hawd, Sool Plateau and Nugal Valley pastoral livelihoods which is an improvement from Crisis for Nugal Valley and Sool plateau in Deyr 11/12 but a stable situation for the other livelihoods. The general improvement in the food security situation in these livelihoods is mainly attributed to the positive impact normal of Gu 12 rainfall in most parts of these livelihoods which improved livestock body conditions and production and thus increased milk availability and access owing to

67 Figure 30 : Trends in levels of Acute Malnutrition (WHZ <-2Z scores or oedema), WHO 2006 in North West regions Regional Analysis 59 improved pasture and water availability and kidding among the small rumminats, increased income from sale of livestock and livestock products (milk and ghee). The food security situation among the population in Golis Guban and East Golis livelihood has deteriorated from Stressed in Deyr 11/12 to Crisis. The deterioration in these livelihoods is linked to the effect of failure of the hays rains over last two seasons in most of Golis Guban affecting water availability and rangeland condition thereby resulting in poor livestock body condition, low milk production and limited saleable livestock. These together with the increased level of indebtness has affected food availability and access in these livelihoods. Nutrition The Post Gu 12 integrated nutrition situation analysis shows either stable or deteriorating trend in the nutrition situation in Northwest livelihoods compared to the Deyr 11/12. The nutrition situation for the West Golis and Nugal Valley livelihoods has deteriorated from and respectively in Deyr 11/12 to. The nutrition situation among the population in the Hawd livelihood has significantly deteriorated from the levels in Deyr 11/12 to the current. This deterioration is mainly attributed to reduced food access especially household milk access in Guban 1 where following below normal Gu rainfall performance, livestock have been forced to out-migrate in search of water and pasture while those remaining in the area are weak with low milk production. Out-migration of livestock often leads to family splitting where women and young children are left behind with inadequate or no milk access and without saleable animals to cater for food and non-food items and services. In Nugal Valley and Hawd livelihoods where food security is either stable or improved, high morbidity and especially measles outbreak in Burao and Ainabo districts has significantly contributed to the 1 For nutrition assessment, West Golis and Guban livelihoods are sampled together as one population and therefore there is one GAM rate, however food security assessment and classification treat the two livelihoods separately deterioration. On the other hand, the nutrition situation among the populations in the Sool Plateau, East Golis/Gebbi Valley and Agro-pastoral livelihoods has remained stable at levels since Deyr 11/12. The nutrition situation of the displaced people in Hargeisa and Berbera towns is sustained at and levels respectively since Deyr 11/12, while the situation among the Burao IDPs has improved from to. Household access to food, health and other basic services among the IDP is highly dependent on humanitarian services and availability of casual labour and petty trades in the host urban areas. This irregular access to basic services continue to expose this population group to risks of malnutrition, morbidity and food insecurity. Gender: The analysis of nutrition data among the assessed rural livelihood population as well as the IDPs populations of the northwest regions, shows no statistical differences in the distribution of acute malnutrition, morbidity levels, access to vitamin A supplementation and immunization services between boys and girls. However, across all livelihoods and IDPs, slightly higher proportion of boys than girls are acutely malnourished, stunted and underweight. Additionally, there is no statistically significant difference between the female and male headed households in terms of distribution of acute malnutrition, consumption of diversified diets, and access to safe water and sanitation facilities. Pastoral Livelihood Zones West Golis, Nugal Valley and Sool Plateau Livelihood Zones The current nutrition situation of the populations in both West Golis/Guban and Nugal Valley livelihoods is Very, indicating a deterioration from the and levels respectively in the Deyr 11/12. The results of the nutrition surveys conducted in July 2012 among West Golis population indicate a GAM rate of 21.7% ( )

68 Regional Analysis 60 levels, according to UNICEF classification which is similar to levels recored in Deyr 11/12 assessments. In Deyr 11/12 assessment, the respective crude death rate and under five death rate were 0.54 ( ) and 0.27 ( ) among West Golis; 0.19 ( ) and 0.48 ( ) among Nugal Valley, and 0.48 ( ) and 1.22 ( ) in Sool Plateau livelihood. The key nutrition findings in these livelihoods which form the basis of the analysis and classification outcome are provided in table 20. An enumerator conducting an interview in a Hargeisa IDP camp and a SAM rate of 5.5% ( ) indicating a significant deterioration (p<0.05) when compared with a GAM rate of 13.8% ( ) and a SAM rate of 2.2% ( ) recorded in the December 11 assessment. Similarly, results from an assessment done among the Nugal Valley livelihood population reported a GAM rate of 20.1% ( ) and a SAM rate of 5.4% ( ), showing a deterioration compared with a GAM rate of 16.3% ( ) and a SAM rate of 5.2% ( ), reported in the December The change was however not statistically significant (p>0.05). In Sool plateau, results indicate a sustained nutrition situation since Deyr 11/12 with a GAM rate of 11.3% ( ) and a SAM rate of 1.7% ( ) reported in July 2012 assessments. This is similar to the GAM rate of 11.6% ( ) and a SAM rate of 3.4% ( ) recorded in December 2011 assessment. The nutrition data from health facilities in the West Golis and Nugal Valley livelihood zone indicate a high (>10%) and stable proportion of acutely malnourished children (Figure 31), while in Sool plateau, a low (<10%) and fluctuating trend is recorded. Morbidity, a key nutrition aggravating factor remain high (>22%) in the three livelihoods while child feeding practices in terms of continued breastfeeding, feeding frequency and dietary diversity is persistently below the recommended standards. The measles immunization and vitamin A supplementation status was relatively high but below the recommended Sphere standard of 95%. The CDR and U5DR is 0.24 ( ) and 0.45 ( ) respectively among West Golis; 0.04 ( ) and 0.19 ( ) among Nugal Valley, and 0.12 ( ) and 1.22 ( ) in Sool plateau. These death rates are all within the The deterioration recorded in the two pastoral livelihoods is linked to multiple causes. Severe reduction in household milk access has played a key role in West Golis/Gubban where livestock out migration has left some family member especially women and young children with reduced milk access and without saleable livestock or livestock s products to generate income to buy food and other essential goods and services. In Nugal Valley, outbreak of measles in Burao and Ainabo districs has aggrevated the nutrition situation with almost half of all acute malnutrition cases identified in the livelihood concentrated in the two districts. It is important to point out that for the second successive Gu season, Nugal Valley and West Golis/Guban livelihoods have recorded a nutrition situation indicating seasonal vulnerability that need targeted response to address underlying causes. Appropriate interventions to address both the short term acute needs such as rehabilitation of acutely malnourished children and long term programmes that address chronic food insecurity, nutrition and health are vital to address a conspicuous seasonal hunger gaps in Gu season especially in West Golis/Guban and underlying factors that influencing the health and nutrition situations in the area. Concerted efforts to manage and control recurrent outbreaks of measles in Togdheer region and Sool regions need to be imple bmented as a matter of priority. Figure 31: HIS Malnutrition Trends in Health Facilities in NW West Golis MCHs - January 2011-June 2012

69 Table 20: Summary of Key Nutrition Findings in West Golis/Guban, Nugal Valley and Sool Plateau Livelihood Zones, July 2012 West Golis/Guban (N=588: =312; =276) Nugal Valley (N=619: =311; =308) Sool plateau (N=748: = 365; =383) Indicator Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ< ( ) 21.7 ( ) 11.3 ( ) or oedema) 22.2 ( ) 27.0 ( ) 13.7 ( ) 17.9 ( ) 15.8 ( ) 9.0 ( ) Severe Acute Malnutrition (WHZ<- 3 or oedema) Mean of Weight for Height Z Scores 5.5 ( ) 8.4 ( ) 2.2( ) 5.4 ( ) 6.2 ( ) 4.6 ( ) 1.7 ( ) 1.4 ( ) 1.9 ( ) -1.06± ± ±1.08 Oedema Global Acute Malnutrition (NCHS) 22.1 ( ) 20.0 ( ) 11.9 ( ) Severe Acute Malnutrition (NCHS) 2.6( ) 2.4 ( ) 2.0 ( ) Proportion with MUAC<12.5 cm or oedema) Proportion with MUAC<11.5 cm or oedema Stunting (HAZ<-2) Underweight (WAZ<-2) Malnutrition Trends at Health facilities (January July 2012) Proportion of acutely malnourished children in SFs Child Morbidity & Immunization Disease trends (seasonally adjusted) Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Immunization Status Infant and Young Child Feeding (6-24 Months) Proportion still breastfeeding Proportion meeting recommended feeding frequencies Proportion who reported to have consumed <4 food groups Death Rates Crude deaths, per 10,000 per day (retrospective for 90 days) Under five deaths, per 10,000 per day (retrospective for 90 days) Women Nutrition and Immunization Status Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm) Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0) 6.5 ( ) 5.4 ( ) 7.6 ( ) 1.2 ( ) 1.6 ( ) 0.7 ( ) 9.0 ( ) 12.9 ( ) 4.7 ( ) 16.8 ( ) 23.2( ) 9.5 ( ) High (>20% and stable trend of acutely malnourished children in MCHs Morbidity Diarrhoea Pneumonia Vitamin A Measles ( ) 3.2 ( ) 2.3 ( ) 1.5 ( ) 1.5 ( ) 1.6 ( ) 5.2 ( ) 6.1 ( ) 4.2 ( ) 14.6 ( ) 16.5 ( ) 12.7 ( ) High (>10%) and stable trend of acutely malnourished children in MCHs Measles outbreak in Burao and Ainabo distritcs Morbidity Diarrhoea Pneumonia Vitamin A Measles ( ) 1.9 ( ) 3.4 ( ) 0.5 ( ) 0.5 ( ) 0.5 ( ) 12.0 ( ) 16.2 ( ) 8.0 ( ) 11.6 ( ) 12.6 ( ) 10.7 ( ) Low (<10% and trend Morbidity Diarrhoea Pneumonia Vitamin A Measles N=183 N=217 N= ( ) 0.04 ( ) 0.12 ( ) 0.45 ( ) 0.19 ( ) 0.40 ( ) N= ( ) N= ( ) N=299 0 N= ( ) N=268 0 N=228 0 Regional Analysis 61

70 Regional Analysis 62 Summary of Key Nutrition Findings in West Golis/Guban, Nugal Valley and Sool Plateau Livelihood Zones, July 2012-Continued Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0) Proportion of Women who received Tetanus immunization No dose One dose Two doses Three doses N= ( ) N= ( ) N= Public Health Indicators N= 349 N= 425 N=351 Household with access to sanitation facilities Male Headed Female Headed Household with access to safe water Male Headed Female Headed Food Security Proportion who reported to have consumed <4 food groups Male Headed Female Headed Household s Main Food Source- Purchase Male Headed Female Headed Food security phase Crisis Stressed Stressed Overall Risk to Deterioration Unstable Unstable Stable Overall Situation Analysis East Golis/Gebbi Valley and Hawd Livelihood Zones of NW The integrated nutrition analysis of East Golis/Gebbi Valley livelihood indicates a sustained nutrition situation since the Post Deyr 10/11. A nutrition survey among the population in this livelihood in July 2012 reported a GAM rate of 13.6% ( ) and a SAM rate of 2.6% ( ), showing similar results with those of December 11 assessment when a GAM rate of 10.5% ( ) and a SAM rate of 0.8% ( ), were reported. On the other hand, integrated nutrition analysis among the Hawd pastoral population indicates a nutrition situation, a significant deterioration from the level recorded in Deyr 11/12 season. A nutrition survey conducted in July 12 among the Hawd pastoral population reported a GAM rate of 16.7% ( ) and a SAM rate of 4.2% ( ) which indicates a significant deterioration from rates recorded in a similar assessment in December 2011, when a GAM rate of 10.7% ( ) and a SAM rate of 1.8% ( ) (Pr= 93.4%) was recorded. The deterioration among the Hawd livelihood group is largely linked to high (>20%) morbidity, especially the outbreak of measles in Burao district reported since March Morbidity in Hawd livelihood showed a statistically significant association with acute malnutrition where children who were reportedly sick in two weeks prior to the assessment were almost two times more likely to be malnourished as compared to those who were not sick. (RR=1.62: ) children recorded in these facilities (Figure 32). In East Golis livelihoods, data from health facilities shows a high (>10%) and fluctuating trend of acutely malnourished children which is similar to trends observed in 2011 indicating a stable nutrition situation. Good access to milk at household level in East Golis/Gebbi Valley livelihoods, better access to humanitarian support and income from the sale of frankincense are key mitigating factors to acute malnutrition. The retrospective crude and under five death rates of 0.26 ( ) and 0.47 ( ) respectively in Hawd and of 0.18 ( ) and 0.36 ( ) in East Golis/Gebbi Valley livelihood, are all within the level according to UNICEF classification. These show similar levels as the retrospective crude and under five death rates of 0.78 ( ) and 0.19 ( ) in Hawd and 0.59 ( ) and 0.75 ( ) in East Golis/ Bebbi Valley livelihood respectively reported in Deyr 11/12 assessments. The key nutrition findings in these areas which form the basis of the analysis in the classification outcome, are provided in Table 21. Figure 32: HIS Malnutrition Trends in Health Facilities in NW Hawd MCHs - January 2010-June 12 The analysis of nutrition data from health facilities in Hawd areas of Northwest indicates levels of malnutrition with high (>15%) and stable proportions of acutely malnourished

71 Agro-pastoral Livelihood Zones: Awdal/Galbeed and Togdheer Agropastoral The Northwest agro-pastoral zone comprises the agropastoralists of Togdheer who are more pastoral than agropastoralist and mainly grow grass/hay for livestock and the agro-pastoralist of Awdal and Galbeed Regions who mainly practice crop farming alongside keeping different types of livestock. The integrated nutrition situation analysis of the Northwest agro-pastoral population indicates a sustained nutrition situation since Post Deyr 10/11.The nutrition assessment conducted among these agro-pastoral population in July 2012 reported a GAM rate of 13.5% ( ) and a SAM rate of 1.1% ( ) indicating a sustained nutrition situation, similar to levels recorded in the December 11 assessment when a GAM rate of 10.1% ( ) and a SAM rate of 2.6% ( ) were reported. Morbidity is relatively low (12.2%) as compared to the other livelihoods in Northwest and is within the seasonal trend for the area. The nutrition data from health facilities indicates a high (>10%) and fluctuating proportion of acutely malnourished children reflecting a nutrition situation. The death rates from the current assessments indicate sustained mortality levels with CDR of 0.21 ( ) and U5DR of 0.36 ( ). These rates are similar to those reported in Deyr 11/12 assessment when CDR of 0.05 ( ) and U5DR of 0.28 ( ) was recorded. Across all livelihoods in Northwest region, both pastoral and agro-pastoral population in the rural areas are characterized with persistent sub-optinmal child feeding practices where children are breastfed for short period, are fed infrequently and on poorly diversified diets. In addition, limited access to safe water, sanitation and health facilities is evidenced across rural livelihoods, predisposing children to diarrhoeal disease. Morbidity trends are persistently high in these livelihoods. Provision of safe drinking water, adequate health and sanitation facilities and improvement of child care and feeding practices remain crucial issues that require immediate interventions and sustained efforts. The key nutrition findings in these areas which form the basis of the analysis in the classification outcome are provided in Table 21. Regional Analysis 63

72 Regional Analysis 64 Table 21: Summary of Key Nutrition Findings in Hawd, East Golis and Agro-pastoral Livelihood Zones, July 2012 The Hawd Livelihood Zone (N=410: =215; =195) East Golis/Gebbi Valley (N=504: =232; =272) Agro-pastoral Zone (N=451:=233; =218) Indicator Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) Severe Acute Malnutrition (WHZ<-3 or oedema) 16.7 ( ) 18.8 ( ) 14.4 ( ) 4.2 ( ) 5.8 ( ) 2.6 ( ) 13.6 ( ) 18.0 ( ) 9.8 ( ) 2.6 ( ) 2.2 ( ) 3.0( ) 13.5 ( ) 17.0 ( ) 9.7 ( ) 1.1 ( ) 0.9 ( ) 1.4 ( ) Mean of Weight for Height Z Scores -0.90± ± ±1.16 Oedema Global Acute Malnutrition (NCHS) 17.6 ( ) 14.2 ( ) 12.4 ( ) Severe Acute Malnutrition (NCHS) 2.7 ( ) 2.0 ( ) 0.4 ( ) Proportion with MUAC <12.5 cm or 5.6 ( ) 4.8 ( ) 2.2( ) oedema 5.1 ( ) 5.6 ( ) 2.6 ( ) 6.2 ( ) 4.0 ( ) 1.8 ( ) Proportion with MUAC <11.5 cm or oedema Stunting (HAZ<-2) 1.2 ( ) 1.4 ( ) 1.0 ( ) 1.5 ( ) 0.9 ( ) 2.1 ( ) 0.8 ( ) 0.9 ( ) 0.7 ( ) 3.4 ( ) 4.4 ( ) 2.6 ( ) 0.2 ( ) ( ) 5.1 ( ) 7.3 ( ) 2.8 ( ) Underweight (WAZ<-2) 15.4 ( ) 17.2 ( ) 13.3 ( ) 7.4 ( ) 11.7 ( ) 3.7 ( ) 8.2 ( ) 11.6 ( ) 4.6 ( ) Malnutrition Trends at the health facilities (Janauray- July 2012) High (>15%) and stable trends Low (<10%) and increasing trend High (>10%) and fluctuating trend. Proportion of acutely malnourished children in SFs Child Morbidity & Immunization Measles outbreak in Burao district Morbidity Disease trends (seasonally adjusted) Morbidity refers to the proportion of children Diarrhoea 8.5 reported to be ill in the 2 weeks prior to the survey -9.2 Pneumonia Vitamin A Immunization Status Measles Infant and Young Child Feeding (6-24 Months) Proportion still breastfeeding Proportion meeting recommended feeding frequencies Proportion who reported to have consumed <4 food groups Death Rates Crude deaths, per 10,000 per day retrospective for 90 days) Under five deaths, per 10,000 per day retrospective for 90 days) Morbidity Diarrhoea Pneumonia Vitamin A Measles N=177 N=183 N= Morbidity Diarrhoea Pneumonia Vitamin A Measles ( ) 0.18 ( ) 0.21 ( ) 0.47 ( ) 0.36 ( ) 0.36 ( )

73 Summary of Key Nutrition Findings in Hawd, East Golis and Agro-pastoral Livelihood Zones, July 2012-Continued Women Nutrition and Immunization Status Proportion of acutely malnourished non pregnant/lactating women (MUAC <18.5 cm) Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0 cm) Proportion of acutely malnourished pregnant and lactating women (MUAC<23.0 cm) Proportion of Women who received Tetanus immunization No dose One dose Two doses Three doses N=239 0 N=334 0 N= ( ) 2.4 ( ) 0.8 ( ) N= ( ) N= ( ) N= ( ) Public Health Indicators N= 237 N= 271 N=269 Household with access to sanitation facilities Male Headed Female Headed Household with access to safe water Male Headed Female Headed Food Security Proportion who reported to have consumed <4 food groups Male Headed Female Headed Household s Main Food Source-Purchase Male Headed Female Headed Food security phase Stressed Stressed Stressed Regional Analysis 65 Overall Risk to Deterioration Stable Stable Stable Overall Situation Analysis IDPs of the North West: Hargeisa, Burao and Berbera The integrated nutrition situation analysis of the Northwest IDPs populations indicates a sustained and nutrition sitaution among the Hargeisa and Berbera IDPs respectively, and an improvement in Burao IDPs from Very to. The results of a nutrition assessment conducted among the IDPs in Hargeisa town in June 2012 reported a GAM rate of 12.0% ( ) and a SAM rate of 2.9% ( ), rates which are similar to the a GAM rate of 12.0% ( ) and a SAM rate of 1.3% ( ) reported in November 11 assessment. Among the Berbera IDPs, a GAM rate of 16.3% ( ) and a SAM rate of 3.5% ( ) was recorded in June 2012 assessments indicating a stable nutrition situation. These results are within similar nutrition levels as the findings of an exhaustive nutrition survey in November 11 when a GAM rate of 18% and SAM rate of 3.1% were recorded. However, it is important to note that although the current GAM rate indicates a change in the nutrition situation classfication as it is below 20%, the change is not statistically significant (Pr<75%). It is anticipated that the nutrition situation among these IDPs will continue improving as has been seasonally observed in Deyr seasons when livestock-related export casual labour opportunities increases in Burao town during Haji festivities. Availability of casual labour provide income which is key among the IDPs who rely on food purchase as a major source of food. Figure 33 shows historical trend of acute malnutrition Figure 33: Trend in Levels of acute Malnutrition (WHZ<-2 or oedema, WHO 2007) in Northwest Regions Region, In Burao IDPs assessment, a GAM rate of 18.4% ( ) and a SAM rate of 4.3% ( ) are reported indicating a nutrition situation and a slight improvement from the situation reported in November 11 assessment when a GAM rate of 20.3% ( ) and a SAM rate of 4.5% ( ) was recorded.

74 Regional Analysis 66 Table 22: Summary of Key Nutrition Findings for Hargeisa, Burao and Berbera IDPs, June 2012 Hargeisa IDPs (N=497 =238; =259) Burao IDPs Returnees (N=517: =257; =260) Berbera IDPs Returnees (N=555 =257; =260) Indicator Results Outcome Results Outcome Results Outcome Child Nutrition Status Global Acute Malnutrition (WHZ<-2 or oedema) Severe Acute Malnutrition (WHZ<-3 or oedema) 12.0 ( ) 14.9 ( ) 9.2 ( )) 2.9 ( ) 3.8 ( ) 2.0 ( ) Mean of Weight for Height Z Scores ± ( ) ( ) 13.5 ( ) 4.3 ( ) 5.4 ( ) 3.1 ( ) ± ( ) 19.0 ( ) 13.6 ( ) 3.5 ( ) 4.4 ( ) 2.61 ( ) ±1.06 Oedema Very critical 0 Global Acute Malnutrition (NCHS) 12.3 ( ) 19.1 ( ) 15.1 ( ) Severe Acute Malnutrition (NCHS) 1.2 ( ) 3.8 ( ) 0.7 ( ) Proportion with MUAC <12.5 cm or oedema Proportion with MUAC <11.5 cm or oedema Stunting (HAZ<-2) Underweight (WAZ<-2) HIS Nutrition Trends(January July 2012) 4.1 ( ) 3.8 ( ) 4.4 ( ) 1.4 ( ) 1.3 ( ) 1.6 ( ) 10.7 ( ) 15.7 ( ) 6.0 ( ) 13.3 ( ) 16.1 ( ) 10.8 ( ) Low (<10%) but increasing Proportion of acutely malnourished children - - in SFs Child Morbidity & Immunization 10.3 ( ) 8.3 ( ) 12.2 ( ) 3.0 ( ) 2.7 ( ) 3.3 ( ) 8.4 ( ) 12.1 ( ) 4.9 ( ) 16.8 ( ) 22.0 ( ) 11.7 ( ) Low (<5%) and stable trend 4.4 ( ) 2.8 ( ) 6.1 ( ) 1.4 ( ) 1.3 ( ) 1.6 ( ) 1.4 ( ) 1.8 ( ) 1.1 ( ) 9.6 ( ) 12.3 ( ) 6.8 ( ) High (>10%) and fluctuating Morbidity Disease trends (seasonally adjusted) Diarrhoea 20.3 Morbidity refers to the proportion of children reported to be ill in the 2 weeks prior to the survey Measles Morbidity Diarrhoea Measles Morbidity Diarrhoea Measles Immunization Status Vitamin A Measles Vitamin A Measles Vitamin A Measles Infant and Young Child Feeding (6-24 Months) Proportion still breastfeeding Proportion meeting recommended feeding frequencies Proportion who reported to have consumed <4 food groups Death Rates Crude deaths, per 10,000 per day retrospective for 90 days) 0.14 ( ) 0.50 ( ) 0.49 ( ) Under five deaths, per 10,000 per day retrospective for 90 days) 0.21 ( ) 1.01 ( ) 0.74 ( ) Women Nutrition and Immunization Status Proportion of acutely malnourished non N=140 N=165 N=229 pregnant/lactating women (MUAC < (0-4.6) 0 cm) Proportion of acutely malnourished pregnant and lactating women (MUAC<21.0) ( ) Proportion of acutely malnourished N=127 N=100 N=138 pregnant and lactating women 2.3 ( ) 12.4 ( ) 5.1 ( ) (MUAC<23.0)

75 Summary of Key Nutrition Findings for Hargeisa, Burao and Berbera IDPs, June 2012-Continued Proportion of Women who received Tetanus immunization No dose One dose Two doses Three doses Public Health Indicators Household with access to sanitation facilities Male Headed Female Headed Household with access to safe water Male Headed Female Headed Food Security Proportion who reported to have consumed <4 food groups Male Headed Female Headed Household s Main Food Source-Purchase Male Headed Female Headed 12.1 ( ) 20.7 ( ) 29.3 ( ) 37.9 ( ) ( ) 14.5 ( ) 30.2 ( ) 33.2 ( ) ( ) 5.6 ( ) 33.5 ( ) 55.5 ( ) Regional Analysis 67 Food security phase Stressed Stressed Stressed Overall Risk to Deterioration Stable Stable Stable Overall Situation Analysis The mortality rates are within acceptable UNICEF levels in Hargeisa with crude death rates (CDR) of 0.14 ( ) and under five death rate of 0.21 ( ) and among the Berbera IDPs with recorded CDR of 0.49 ( ) and U5DR of 0.74 ( ). In Burao IDPs assessment an CDR of 0.50 ( ) and a U5DR of 1.01 ( ) was reported. These rates are similar to the respective crude and under five death rates of 0.31 ( ) and 0.14 ( ) recorded among Burao IDP, 0.38 ( ) and 0.44 ( ) among Hargeisa IDPs, and 0.37 ( ) and 1.27 ( ) reported among the Berbera IDPs in November 2011 assessments. Morbidity levels remain high among IDP populations in the three host towns, with the reported morbidity in the two weeks prior to the assessment of 31.8% in Hargeisa, 40.3% in Burao and 20.7% in Berbera. Household dietary diversity remains a concern among the displaced population and especially among the Burao IDPs where nearly a half (43.7%) of the households were consuming poorly diversified diets comprised of three or fewer food groups. Access to basic human services such as access to safe water and sanitation facilities among the IDPs is relatively better than among the rural populations but it is highly dependent on humanitarian support. The key nutrition findings in these areas which form the basis of the analysis are provided in Table 22. Immediate interventions to rehabilitate acutely malnourished children and address food and health needs are required. Income generation activities to boost the economic status of the displaced population are needed, these interventions should also be backed by long term interventions such as improved child care and feeding practices, improved dietary diversity and enhanced access to safe water and sanitation and health facilities. High morbidity rates that persist among the assessed IDPs also need to be addressed through both curative and preventive measures. In the absence of a stable livelihood system among the displaced populations, they are constantly faced with chronic food insecurity and poor nutrition situation. Access to basic services such as safe water, good shelter and sanitation facilities remain limited and whatever is available is dependent on humanitarian assistance. Continued monitoring to assess the constantly changing food security and nutrition situation among the IDPs should be maintained, so as to provide up-to-date information that will guide on appropriate interventions to meet the needs of this vulnerable group. A long term solution such permanent settlement of the protracted IDPs will be required in the long run for the people to have stable livelihood and bring to an end the humanitarian dependence status of the displaced people in Somaliland. Gender and nutrition analysis in North West Regions Analysis of the nutrition data in the assessed rural livelihoods as well as among the internally displaced populations shows no statistically significant differences in the distribution of the acute malnutrition cases between boys and girls. In addition, there was no statistically significant difference in the distribution of stunting and underweight between boys and girls in the assessed rural and IDPs populations. This is with exception of the population in Sool plateau, Hargeisa and Burao IDPs where a significantly higher proportion of boys than girls was stunted and in West Golis where significantly higher boys (12.9% ( ) than girls 4.7% ( ) was underweight (P<0.05). In all other rural livelihoods and IDPs populations, more boys than girls are acutely malnourished, stunted and underweight with exception of Hawd livelihoods where slightly more girls than boys are

76 Regional Analysis 68 stunted but the differences were statistically insignificant (p>0.05). For example, in Nugal valley, 22.2% ( ) of boys compared with 17.9% ( ) of girls were acutely malnourished; 6.1% ( ) of boys as opposed to 4.2% ( ) of girls were stunted; and 16.5% ( ) of boys compared to 12.7% ( ) of girls were underweight. This disparity is likely given the use of the new WHO 2006 sex-differentiated reference standards, which has been observed to discriminatively identify more boys as malnourished than girls. With the new WHO reference standards, a girl of a certain height has to be much lighter than a boy of the same height to meet the WHZ<-2 threshold for acute malnutrition. A review of TFC data from 13 African countries found that when children 6-59 months were admitted using UNISEX tables; there was no significant difference in the number of boys and girls admitted and there was no significant difference in the mortality rate 2[1]. The distribution by sex of morbidity cases, childfeeding practices and access to health services such as measles vaccination and vitamin A supplements showed a mixed pattern where in some surveys a higher proportion of boys 2 [1] Golden, M., Grellety, Y., Schwartz, H., & Tchibindat, F. (2010). Report of a Meeting to harmonize the criteria for monitoring and evaluation of the treatment of acute malnutrition in West and Central Africa. 30th November 1st December 2010; Dakar, Senegal. Retrieved February 27, eng.pdf than girls was ill, better fed or had higher access to health and nutrition services while the opposite was true in other surveys. The differences were however not statistically significant (p>0.05). At the household level, results showed a large majority (~80%) of the households assessed were male headed. Analysis of the differences of household characteristics such as consumption of diversified diets, access to basic services such as safe water and sanitation facilities did not show a clear pattern, whereby in some livelihoods slightly more male headed households had better access to these services and the opposite was true for other livelihoods. These differences were however not statistically significant (p>0.05). It is important to point out that due to the small proportion of the female headed households and unclear definition of a household head in Somalia context, existence/or lack of any difference in access to public health services between male and female headed households may have been obscured. A meta-analysis of a large set of similar studies or a study designed to capture such households characteristics would address this limitation. The gender disaggregated data by sex of the assessed children and sex of the household head per livelihood is summarized on Tables 20,21&22. MATERNAL NUTRITION STATUS IN NORTHWEST In the northwest, a significantly higher proportion of pregnant and/or lactating women were acutely malnourished (MUAC< 23.0 cm) than non-pregnant and non-lactating women (MUAC<18.5 cm) across all livelihoods and among the three IDPs settlements. The proportion of malnourished pregnant and/or lactating women ranged between 2.3% () among the Hargeisa IDPs to 28.1% () among women in West Golis livelihood while most of the assessed non-pregnant and non-lactating women were not identfied as malnourished with exception of 2.2% in Burao IDPs and 0.5% of the West Golis. The high level of malnutrition among the pregnant and/or lactating women is linked to increased nutrients needs which are not being met. Proportion of the malnourished women in Northwest Regions NW/IDPs Surveyed population Pregnant and/or Lactating women Non-pregnant/lactating women No. Assessed Proportion with Proportion with No. Proportion with MUAC<23cm MUAC <21cm Assessed MUAC<18.5 cm Hargeisa IDP ( ) Berbera IDP ( ) 1.5 ( ) Burao IDP ( ) ( ) West Golis ( ) 4.6 ( ) ( ) NW Hawd ( ) 4.7 ( ) NW Agro-pastoral ( ) 0.8 ( ) Nugal Valley ( ) 2.9 ( ) Sool Plateau East Golis ( ) 2.4 ( ) 334 0

77 Strengthening of Infant and Young Child Feeding Programming and Planning for Emergency Preparedness and Response. The Infant and Young Child Feeding (IYCF) London Workshop (25-29 June 2012) Infant and young child feeding (IYCF) is core to child health, growth, development and survival. Unfortunately, poor IYCF practices persist in many countries including Somalia where nutrition assessments across the country continue to report sub-optimal child feeding practices. Improved non-emergency IYCF programming is therefore one of the best ways of ensuring good infant and child feeding in emergency (IYCF-E). In light of this, a workshop on Strengthening of Infant and Young Child Feeding Programming and Planning for Emergency Preparedness and Response was jointly organized and funded by the Inter Agency Standing Committee (IASC), Global Nutrition Cluster, IYCN Unit in UNICEF and Save the Children UK and held in London, UK from 25 th to 29 th June A total of 68 nutritionist/iycf experts, representing 22 countries, participated, including the UNFAO-FSNAU Somalia IYCF focal point (See Photo of the participants below). Regional Analysis 69 The main goal of the workshop was to determine how to improve non-emergency infant and young child feeding in (IYCF) programming and learn how to streamline appropriate infant and young child feeding in emergency (IYCF-E) in programming. The specific objectives of the workshop were to ; i. Increase awareness of the importance of IYCF and IYCF-E; ii. Share experiences, challenges, and lessons-learned in IYCF and IYCF-E programming in different contexts; iii. Orient and disseminate IYCF and IYCF-E Workshop participants policies and capacity development tools; iv. Assist in the development of agency/wider consortium action plans. The workshop used various methods of training including power point presentations, lesson sharing on best practices, discussions, questions and answers session and group work. Among the topics covered included: the current global situation of IYCF and IYCF-E; policies and programming of IYCF and IYCF-E; monitoring and evaluation of IYCF and IYCF-E; IYCF and IYCF-E survey and assessments; funding for IYCF and linking of IYCF and IYCF-E programming. Major highlights and way forward There is evidence 1 showing that optimal IYCF reduces risk of mortality and malnutrition, prevents illness, growth faltering and poor child development and death. However when this is not or is imperfectly achieved in non-emergencies it becomes extra hard in emergencies. It was further observed that globally, there has been very little improvement in rate of exclusive breastfeeding (EBF) since 1990 and it remains below 40%; Quality of complementary feeding (minimum acceptable diet) remains generally very poor and frequently correlates with high stunting rates. Most countries lack national monitoring systems for IYCF interventions 23. In addition, IYCF-E is often missing or is implemented ad hoc in an emergency response: Often, IYCF programme staff do not have the required skills to tackle the specific IYCF-E needs and the response approaches tend not to focus on additional or special needs of infant and child caregivers in emergencies. IYCF and IYCF-E are strongly linked and inter-related whereby the success of the IYCF-E will depend on the status of IYCF in non-emergency situation. The workshop concluded that protecting and promoting appropriate infant and young child feeding is critical to saving lives, and that strengthening IYCF outside of emergencies is essential to reducing the loss of life when disasters strike. For Somalia, there is a need to improve non-emergency and emergency IYCF programming; build capacity for IYCF and IYCF-E staff, document and disseminate results/impact of IYCF intervention through various channels including publication in peer reviewed journals and impact research; and learn from successful programmes such as CMAM on how to accelerate IYCF initiatives; Advocacy on IYCF at various levels including among donors is required. On donor advocacy, the participants drafted a letter to be sent to various donors calling for donors support to ensure that IYCF becomes an essential component of humanitarian action as well as development investments. 1 Lancet Child Survival series 2003 & UNICEF database 2012, from DHS, MICS and national surveys 2 A composite indicator representing the proportion of children who meet the minimum recommended dietary and diversity and feeding frequency 3 UNICEF. IYCF Programming status: Results of assessment of key action for comprehensive IYCF programmes in 65 contries