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Field article
Nutrition outcomes are not yet included in
sectoral policies and programmes but the
Somali Nutrition Strategy is trying to highlight
nutrition issues at policy level.
Somali specific IMAM guidelines were
developed through the Nutrition Cluster in
2010 and a Basic Nutrition Services Package
(BSNP) has been defined and encouraged, also
through the Nutrition Cluster. However,
whilst many agencies are adopting the
approach and include it within activities
outlined at proposal level, many organisations
find it difficult to conceptualise or lack the
capacity to deliver.
MOH systems and structures – where
nutrition fits
After twenty years of conflict, the health care
system in Somalia remains underdeveloped,
poorly resourced, inequitable and unbalanced.
The public health care delivery system operates
in a fragmented manner, maintained
largely by medical supplies provided by
UNICEF and other agencies. In the absence of
an efficient and adequate public health
system, the private sector has flourished but
remains unregulated with poor quality of
services and poor access to the rural population.
Over half of the estimated health
workforce is unskilled and unsupervised and
staff are paid a below subsistence wage. Most
public facilities operate at a level far below
their intended capacity and are poorly organised,
with very low utilisation rates (estimated
as on average, one contact every eight years 6 ).
In Somaliland there is a functioning MOH
and political will exists. Nutrition has been
identified as a key priority area by the
Minister of Health and the nutrition focal
person within the ministry is motivated and
active. Key staff have been appointed at
Hargeisa level, and at regional and district
levels. Thus a ‘traditional’ MOH structure is in
place but remains financially dependent on
support from UNICEF and other agencies. In
Somaliland, 34 outpatient therapeutic
programmes (OTPs) and four stabilisation
centres (SCs) are delivered through government
health facilities.
In Puntland, political will and support is
present to a lesser extent, with health receiving
a greater focus than nutrition, primarily due to
the qualifications and background of the nutrition
focal person. There is willingness to work
with UNICEF support on nutrition and government
will respond if funding is available. Ten
OTPs operate through government health
facilities.
In SCZ, the MOH recognises nutrition and
‘allows’ UNICEF and its partners to implement
programmes but the public health
structure and functioning is largely confined
to Mogadishu. Delivery of IMAM
programmes through government health facilities
is limited to one SC in Mogadishu where
hospital staff support the implementation of
an otherwise independent centre.
Where OTP services are operating through
government health facilities, the services are
delivered by MOH staff but they are given
financial incentives by humanitarian players.
Where MOH is implementing with little staff
support, reporting is provided by MOH alone.
Where greater levels of support are provided,
reports are provided by the supporting NGO.
Whether reporting is conducted by MOH or a
humanitarian agency, reports are generally
delayed. Efforts are currently underway to
train staff to strengthen reporting.
Implementation of IMAM in Somalia
The implementation of all four components
(community mobilisation, SCs, OTP and
targeted supplementary feeding programme
(TSFP)) of programmes for the management
of acute malnutrition in an integrated way is
not always feasible in Somalia. Existence of
and access to SCs is limited, such that the ideal
programme set up of OTP with SC services
available (either attached to a hospital or
stand alone) are usually only seen in towns in
Somalia. The more common set up is a
network of several OTPs with limited possibility
of referring complicated cases to SCs.
The lack of SC services may be due to distance
to the nearest facility, or due to lack of access
for other reasons (e.g. transport, clan issues,
inability to leave the family for a full week or
insecurity). OTPs may or may not be integrated
with SFP. In some areas, SFPs are implemented
in the absence of OTPs or SCs. In these cases,
the centres may admit all malnourished children
regardless of their severity.
During the initial expansion of IMAM,
programmes were implemented according to
operational guidance developed by Nutrition
Cluster partners in 2005. In 2010, new guidelines
were developed and endorsed by the
Nutrition Cluster. These guidelines, initially
promoted by UNICEF and the Somali
Nutrition Cluster, have been written in
consultation with all organisations, departments
and agencies implementing
programmes to manage acute malnutrition in
Somalia. This was done with the intention of
capitalising on best practices and experiences,
so that lessons learnt by one can be applied by
all partners. The guidelines intend to facilitate
the process of training new staff and to help
with the opening of new centres. These guidelines
try to take specifics of the Somali context
into account, whenever possible, and give
practical suggestions for often difficult
circumstances e.g. lack of SC referral site.
Field cards have been developed with the aim
of being laminated for use in the field. So far,
the application of the 2010 guidelines has been
limited due to problems in the process of translation
into Somali. Some sections have been
translated for training purposes.
Some of the specific challenges that IMAM
faces in Somalia are:
• Conflict
• High insecurity
• High mobility of population (including
health staff)
• Spread of the population, with long
distances and isolation
• Difficult transport and communications
• Population displacement (and the inability
of IDPs to access services in some host
areas)
• Regular migration among pastoralists
• Difficult social environment related to
complex clan structure
• Specific conflicts between clans
6
Rossi and Davies, 2008. Rossi L and Davies A. Exploring
Primary Health Care in Somalia: MCH Data 2007. UNICEF
Somalia Support Centre Report 8.
L Matunga/UNICEF, Somalia, 2012
A child who has been rehabilitated in the programme
Figure 6: Scale up of UNICEF support to nutrition
services, 2006 - 2011.
450
400
350
300
250
200
150
100
50
0
2006 2007 2008 2009 2010 2011
SC OTP SFP
Map 1: Nutrition services, September 2007
Map 2: Nutrition services, July 2011
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