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Field article
is to get the field cluster coordination meetings
working more effectively.
Integration and linkages
Integration with MOH
In Somaliland and Puntland, IMAM services
are linked with Maternal and Child Health
(MCH) and health posts. In Somaliland, 34
OTPs and 4 SCs are delivered through government
health facilities, whilst in Puntland 10
OTPs are operating through government structures.
In practice this means the services are
delivered by MOH staff with financial incentives
paid by the humanitarian community. In
SCZ integration with MOH is very limited.
Linkages with Essential Package of Health
Services (EPHS) and Health System
Strengthening (HSS)
The EPHS for Somalia was developed in 2008
and defines the four levels of health service
provision (primary health care unit, health
centre, referral health centre and hospital) and
the six core and four additional health
programmes to be implemented throughout the
country. According to the EPHS, nutrition interventions
are integrated across the ten
programmes. Overall there is a drive to ensure
that nutrition is considered a significant part of
the EPHS. This is being achieved in part
through the review of job descriptions and
training packages of health professionals. There
are however, disparities across the three zones
due to differences in the presence and capacity
of local government, the presence of international
staff and the implementation of the
cluster approach.
Integration of the Basic Nutrition Services
Package 10 (BNSP), IYCF and nutrition education
Integration of BSNP activities into IMAM
programmes is a gradual process. It is included
in UNICEF’s standard proposal format but
many agencies struggle to understand the
concept of BNSP. The level of integration is
limited by supervision, capacity, supplies and
logistics.
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The BNSP for Somalia provides guidance and justification
on what nutrition services should be included at various
levels of the health system and throughout the lifecycle.
The essential components are defined as: management of
acute malnutrition, micronutrient supplementation, immunisations,
deworming, promotion and support for optimal
IYCF, promotion and support for optimal maternal nutrition
and care, prevention and management of common
illnesses, fortification (home based and food vehicles) and
monitoring and surveillance.
Breastfeeding mother at
Bosaso General Hospital
The IYCF and nutrition education activities
are linked to IMAM programmes. Their integration
as components of IMAM programmes
is encouraged at proposal level and is
supported by UNICEF through to implementation
stage. Each IMAM programme has an IYCF
promoter supported through funding from
UNICEF. To date, a total of 100 IYCF counsellors
have been trained and the programme is
ongoing. Furthermore, some IMAM
programmes have set up community support
groups for IYCF within the community to offer
advice to each other. However, with the magnitude
of the problem in Somalia, the cluster
recognises other approaches to improving IYCF
practices also need to be considered to achieve
significant behavioural change.
Nutrition education activities are also delivered
on a routine basis through IMAM
programmes. This may be through group
education sessions with mothers attending
IMAM sites and/or through sessions
conducted within the community. Further
strengthening and exploration of different
approaches is required to improve impact. In
recognition of this, nutrition and WASH clusters
have started to work together on
nutrition/WASH promotional messages and
how best to deliver them. UNICEF has signed a
contract with BBC World Trust for the development
of drama, where promotional messages
are delivered via the radio. Other options to be
explored include the use of mobile phone technology
in sending promotional messages via
text messaging.
Inter-sectoral integration
In such a challenging operating environment,
the use of existing programmes and structures
as a delivery mechanism for integrated activities
across sectors is crucial. Furthermore, the
absence of integrated services can prolong
recovery and increase relapse rates. At proposal
stage, the current format of CAP proposals,
UNICEF Programme Cooperation Agreement
(PCAs) and WFP Flash Appeals requires that
health and water, sanitation and health (WASH)
activities, e.g. immunisation or soap distribution,
are integrated within nutrition
programmes. However, it is recognised that
implementation of an integrated response at
field level needs strengthening, particularly in
SCZ. Capacity may be a limiting factor in this.
Current reporting requirements for nutrition do
L Matunga/UNICEF, Somalia, 2010
not capture the extent of provision of complementary
services systematically e.g. number of
immunisations or soap distributions. Health
Information Systems (HIS) are supposed to
capture this information. Third party monitors
do report on level of integration but a question
remains as to whether this information is
collated in any way.
Inter-cluster linkages
Good coordination and collaboration exists
between WASH, Health, Agriculture and
Livelihoods and Nutrition Clusters at Nairobi
level. Clusters share information on the
strengths and weakness of potential partners
and which organisations are capable of scaling
up a more integrated approach to delivery. In
SCZ, the Agriculture and Livelihoods and
Nutrition Clusters work closely together to
ensure any agriculture and livelihoods
programmes, such as cash for work, include
nutrition beneficiaries.
An inter-cluster strategy was developed in
June 2011 to address the acute food insecurity
and nutrition crisis in SCZ. This defines which
inter-cluster activities are to be delivered at
each target location (e.g. nutrition centres,
health centres, transit points, IDP settlements)
and includes nutrition, health, livelihoods and
WASH cluster activities.
Capacity, training and supervision
Capacity is an important issue for the scale up
of IMAM throughout Somalia. As highlighted
above, the vast majority of nutrition services for
the management of acute malnutrition are
implemented by UNICEF and WFP in partnership
with local NGOs. There is wide variation
in the capacity of these local organisations.
There has been notable improvement and
capacity development amongst organisations
that first started implementing IMAM two
years ago. However, in South and Central
Somalia, many of the most efficient and reliable
partners have been expelled from Al Shabab
controlled areas, resulting in a need to work
with less experienced partners. For many local
partner organisations new to nutrition
programming, commitment is strong but technical
knowledge, experience or understanding
may be more limited. This applies not just for
technical nutrition capacity but also project
cycle management, funding mechanisms,
proposal writing, audits reporting, etc. In the
Somalia context, training and supervision are
often difficult or challenging, given the limited
access of senior (and particularly international)
staff to the centres. Innovative ways of training
and supervising staff need to be developed for
this purpose.
Capacity has been a limiting factor in scale
up but to what extent is not clear. The following
are some examples of impact of capacity limitations
on scale up. A local partner organisation
effectively implementing OTP at five sites may
lack the capacity to scale up to six more sites,
resulting in the need for another partner to be
brought in. Other agencies may agree to scale
up without the capacity to deliver, resulting in
delays or problems with the quality of service.
Others have asked for expansion but have
underestimated the funding implications with
the result that the project is underfunded.
Lack of capacity also limits the extent to
which nutrition services are integrated with
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