MIESSO, SOMALI, 15 January 2017 – “When the borehole was broken for a year and a half, I used to go to the nearby river for water, which is 12 km away from here. I have five children but I only managed to get one or two jerry cans of water for my family. I was not able to clean or bathe my children regularly at that time. That was difficult,” says Fathiya Ali Aadan, a 32-year-old mother of five living in Miesso town.
Miesso is a small, remote town in the same-named woreda (district) located about 150 km west of the administrative city, Dire Dawa. Out of five non-functional water supply systems in Miesso woreda, one borehole was rehabilitated in the town by the Regional Water Bureau (RWB) in December 2016 with assistance from UNICEF, from the generous support of the Office of U.S. Foreign Disaster Assistance (OFDA). The emergency water, sanitation and hygiene (WASH) intervention benefits 3,500 households in the town as well as the school and health centre.
The Miesso woreda administration office reports that there are currently 86 non-functional boreholes in the woreda, a key intervention necessary to improve the water situation, which is only one part of the challenges facing families in the region. Since most of the region is prone to drought and pastoralist livelihoods critically depend on water, non-functionality of water schemes requires immediate response to save lives of people and their livestock. It also affects children’s opportunity to learn.
At Mulli School, which includes grades one through twelve, a 14-year-old, grade eight student Ibrahim Mohamed explains, “Before, we had to return back home to get water when there was no water at school. It was a big interruption of class.” The impact of water scarcity also causes some schools to close, such as last year after the failure of deyr rains (October-December). Additionally, pastoralist families may move in search of water, thus taking children and even teachers away from school.
“Now we can drink water, keep our clothes clean, wash our hands after using the bathroom and most importantly for me, there is no longer need to go back home to get water during class. Girls need water for menstrual hygiene at school as well,” says Hayat Yusuf Adan, a 13-year-old, grade eight student.
Thanks to the rehabilitated borehole, Hayat’s school managed to remain open. While water supply at school tends to be neglected during emergency, it is clear that water availability contributes to retaining children in school. UNICEF is committed to support the Government of Ethiopia and implementing partners to improve the WASH situation for schools and families across Somali region to protect the futures of children and the livelihoods of their families.
Southern Nations, Nationalities and People’s Region, Ethiopia, 23 February 2016 –Tesfatsion Alemayehu wants to be an engineer someday, but the 14-year-old girl has trouble concentrating in school. She is often dizzy and light headed and complains of a stomach ache.
Tesfatsion likely has worms.
Intestinal worms and bilharzia are rampant in Ethiopia and children suffering from these afflictions are often too sick or tired to go to school or concentrate. In the long term, the result is malnutrition, anaemia, stunting and even impaired cognitive development, all of which result in poor educational achievement.
So one day in February, Tesfatsion is standing in line at her Gurmu Koisha school where she will receive a de-worming tablet from the local health extension workers.
The tablet will take care of Tesfatsion’s worms which could be schistosomes that cause bilharzia and are carried by snails that live in fresh water. Once the worms are gone, she will be able to concentrate in school again.
Integrating Nutrition, Water and Sanitation Behaviour Change Interventions
The programme, which is funded by EU-SHARE and implemented by local authorities and UNICEF, is much more than just giving pills, however. In the shade next to where the students are lining up, trained nutrition club members are conducting games that impart key nutrition and hygiene lessons.
These activities, known as behaviour change interventions, help the students understand the benefits of the tablets and teaches helpful nutrition and hygiene practices that can minimize future parasitic infections.
For her part, Tesfatsion particularly likes the “Who am I?” game in which students learn about six common iron-rich food groups. Learning about which foods contain iron is especially valuable for young girls like Tesfatsion as they start menstruating.
Schools as gateways to behaviour change
Samson Alemayehu, the head of the health bureau at Boloso Woreda, where Tesfatsion lives, said his department is working with the schools to provide these services.
“We believe that Behaviour Change Communication interventions that take place in the schools by health and nutrition clubs play a big role in increasing awareness in the community, particularly on basic hygiene sanitation and optimal feeding,” he said.
The Health Bureau implements the program through the Health Development Army, which is present in every community and the 1-5 network, in which one person is responsible for five others.
The programme supports the integration of water and sanitation as well as nutrition education into the large scale de-worming campaign in 436 woredas across the country.
It also supports the de-worming specifically of adolescents in high schools in 86 woredas in Amhara, Oromia and SNNP regions free of charge.
“I need to attend all the classes and study hard to make my dream a reality,” said Tesfatsion.
GASHAMO, SOMALI, 15 February 2017 – Under the shade of a tree and settled on plastic mats, the mobile health and nutrition team (MHNT) is in full operation. An array of bright coloured fabric represents the crowd of mothers and children gathered around them, all in varying stages of screening, vaccinations, treatment or referral. In the rural Somali region, Gashamo woreda (district), 63 km off the paved road, the MHNT has been operating as a static clinic for the past two months as part of the response to the Horn of Africa drought caused by the negative Indian Ocean Dipole (IOD).
Facing food and grazing shortages and in need of water, drought-affected pastoralist families and their livestock began traveling long distances in search of water. As one of the most vulnerable communities across the country, unique interventions are required to provide them a safety net in times of emergency.
The Government of Ethiopia (GoE) has provided a swift response by setting up five temporary sites in Gashamo woreda, which offer health and nutrition services as well as food and water. This arrangement is crucial and specific to pastoralist communities, where families are scattered across hundreds of kilometres of harsh semi-arid desert.
28-year-old Mohammed, a senior clinical nurse by training, works alongside two nurses who treat and manage cases, in addition to two health extension workers (HEWs) who screen patients and conduct community health education. Mohammed and his team were assigned to this hotspot priority one site by the Somali Regional Health Bureau (RHB), following a recent updating of hotspot woredas, which are most affected by malnutrition according to the latest meher seasonal assessment.
“My family is 200 km away and I am not sure when I will visit them. Probably when the drought is over,” says Mohammed. “But our work here is very important, there are thousands of people who otherwise would not have access to any health services. Especially during a severe drought, our services save lives.” He explains further that while the Ethiopian health system is highly developed, utilizing catchment areas for a tiered health facility structure is not feasible in pastoralist communities.
“Pastoralists are always on the move in order to provide grazing and water for their livestock, so expanding health facilities in these remote areas does not add value. Right now, there are over two thousand families in this location, so why not set up a permanent health post to serve them? Because perhaps in one or three months, there will be 20 families here, or none. Across the region, there are remote areas where people come and go, so the normal health system does not serve its purpose [in this context].”
This is the reason MHNTs were created and why they have helped improve the health and nutrition situation of pastoralist families for the past decade. From regular risk assessments and categorization of vulnerable woredas by the Ministry of Health and partners, including UNICEF, MHNTs are deployed for a minimum of three months, depending on the emergency situation and needs. With the onset of a sudden disease outbreaks or other emergencies, the MHNT will temporary relocate to the affected area to provide initial rapid response and then return to their assigned woreda.
The MHNTs work six days per week, traveling from location to location and setting up mobile clinics along the way. They make contacts with social mobilisers, volunteers from the community, to ensure everyone knows the day and place where the MHNT will be. The social mobilisers know their community well, even those families that are spread out across a vast terrain, and they guarantee everyone receives the information. Every time, a crowd of mostly women and children are gathered, anticipating the needed treatment and care.
The MHNTs conduct screening for malnutrition, provide routine immunizations and basic healthcare treatment, ante-natal care and emergency delivery services, common illness management, health education and promotion, as well as refer patients to higher levels of care as and distributing household water purification supplies as necessary. When the latter happens, they often utilize their vehicles to bring patients to the nearest health facility, as it would be near impossible for timely care otherwise.
UNICEF supports the GoE’s MHNT programme with the generous effort from donors, through vehicle provision, transportation allowances, emergency supplies and technical guidance. There are 49 MHNTs currently operating in Somali and Afar regions, moving around their respective regions according to the identified need.
Our visit is cut short as the team has just identified two children who are not responding to malnutrition treatment – as per the protocol, severe acute malnutrition (SAM) cases should return to the MHNT on a weekly basis to record progress or be referred to higher levels of care. These cases have been escalated to SAM with medical complications and the mothers are encouraged to gather their belongings and take the MHNT car to the nearest stabilisation centre about 30 km away. “Working in a static clinic may be nice,” says Mohammed, who has been working on the MHNT for nearly seven years, “and over time, as Somali region becomes more developed, the health system may be able to cover all areas. But until then, I know there is a great need and I am proud to be working on this team.”
SHEBEDINO WOREDA, SOUTHERN NATIONS, NATIONALITIES AND PEOPLE’S REGION (SNNPR), November 2016 – Looking drowsy and barely active for a two-and-a-half –year-old, Maritu Sultan is sitting on a hospital bed next to her father, Sultan Lentata. Two days ago she was admitted to the Shebedino Hospital Stabilization Centre (SC) due to oedema caused by severe acute malnutrition (SAM). Sultan rushed his daughter to the health post in his kebele (sub-district) when her feet and facial swelling and vomiting became worse. The health extension workers (HEWs) at the health post referred his daughter to the hospital as she needed immediate attention. Maritu had received treatment for SAM in the Outpatient Therapeutic Feeding Programme (OTP) at the health post in the past and recovered well, however she relapsed after a few months. Sultan admits he knows the reason for it,
“The HEWs instructed us on how to feed her after she was discharged but we did not have the means to give her what she needed,” he says. Referring to himself as a poor farmer, he says the recent drought brought calamity on his household. “To begin with, I do not have much land and the corn I planted was destroyed by the flood and hail that came after the drought. So there was not much to eat at home,” he elaborates.
The SNNPR is among the six regions in Ethiopia that have been particularly affected by the recent El Niño-caused drought and flooding, with 71 out of 137 woredas (districts) in the region classified as priority one woredas, requiring urgent humanitarian response. Consequently, UNICEF Ethiopia has continued its support to the Government of Ethiopia for the strengthening of Community-Based Management of Acute Malnutrition (CMAM), a programme that offers a package of services to tackle malnutrition.
Through the provision of ready-to-use therapeutic food (RUTF) at health posts and therapeutic milks and essential drugs at the SCs, a high number of SAM cases are being treated in the region.
Shebedino hospital, where Maritu is being treated, is among the 286 health centres and hospitals that have SCs for in-patient care in the region. According to Zerihun Asres, a stabilization nurse in the hospital, the number of SAM cases referred to them is declining, as the majority of cases are treated as outpatient at health centres and health posts.
Though it has only been a couple of days, Sultan is pleased with the progress his daughter is showing. “She can now take the milk they give her without throwing up,” he says. “I do not want any of my children to go through this again. Once she is discharged from here, I have to do my best to provide for her so that she can grow healthy.”
Tigist Angata is another parent grateful for the SAM treatment her firstborn son, Wondimu Wotei received. “I had almost given up because he was very small and I did not have enough milk to nurse him,” she recounts. At six months old, the HEWs in Telemo Kentise health post found in her kebele referred him to the SC in Shebedino hospital. He was only 3.5 kg at the time, approximately the size of a healthy newborn. Upon his return from the SC, he ate RUTF for a month and was discharged when he reached 4.4 kg. “He ate so well, which made me realize how much my son was deprived of food,” says Tigist. She adds that she is trying her best to prepare food for him at home, based on the lesson she received from the HEWs. However, eight-month-old Wondimu has not gained any weight since he was discharged from OTP. Her family’s livelihood is based on what her husband earns working on other farms. Due to the drought, he has not been able to work much since last year, which has caused a serious food shortage in their home.
Though poverty seems to have a firm hold in her home, Tigist feels like the situation is better than what it used to be when her son was sick. “I was very distressed at the time because I was sick and he did not seem like he had much hope. But the therapeutic milk and food have brought him back to life and I am very happy and thankful for that,” she says. Her hope is for Wondimu to grow strong, become educated and find a better life than her and her husband’s.
Through the contribution of many donors, including the European Commission’s humanitarian aid department (ECHO), UNICEF supported the Government in treating 272,165 SAM cases across the country from January to October 2016. Of those treated, 21,671 children were admitted for treatment in SCs while 250,494 received SAM treatment in the OTP. In SNNPR alone, CMAM services are available in all 106 woredas.
ADDIS ABABA, September 2016 – Ethiopia has experienced repeated droughts, particularly in the past few years, which have eroded rural livelihoods, causing increased food insecurity and malnutrition among vulnerable communities. The 2015/2016 ElNiño-driven drought, for instance, left 9.7 million people in need of emergency food assistance.
In response to recurrent food insecurity, UNICEF has partnered with the European Union (EU) to contribute to building resilience of the most vulnerable groups, which includes children under five, as well as pregnant and lactating women. Resilience, or the ability of a community to withstand, adapt and quickly recover from shocks such as drought, is a cornerstone of the EU’s humanitarian and development assistance.
To this effect, the EU has provided €10 million to UNICEF-assisted programmes as part of its Supporting the Horn of Africa’s Resilience (SHARE) initiative through a project entitled Multi-Sectoral Interventions to Improve Nutrition Security & Resilience. The project is implemented in collaboration with the Food and Agriculture Organization of the United Nations (FAO) in the drought-affected woredas (districts) of Amhara, Oromia Southern Nations, Nationalities and People’s Region (SNNP) regions, benefiting 285,665 households.
How does SHARE work?
The project aims for communities to have access to quality nutrition services in their vicinity and a better understanding of the importance of proper infant and young child feeding (IYCF) practices.
It covers a wide range of interventions including the promotion of exclusive breast feeding and adequate complementary feeding, vitamin A supplementation and deworming of children, as well as the promotion of hygiene and sanitation.
This is complemented by a series of nutrition-sensitive agriculture interventions led by FAO in partnership with the Ministry of Agriculture. This component helps build the capacity of women to improve the variation of their diet through livestock and poultry rearing, as well as backyard gardening. It also brings opportunities for women to collaborate as peer support groups to produce nutritionally valuable complementary foods such as cereal mixtures for sale. This stimulates the local economy by creating jobs and empowering women to ensure the healthy growth of their children.
An evidence-based approach
One achievement of the project was an initiative to analyze and document the nutrition situation in the country from 2000 to 2015. The report was launched in March 2016 and highlights critical gaps in terms of existing policies and programmes which need to be addressed urgently to accelerate nutrition results for women and children. Key findings of the situation analysis report include poor water supply and sanitation as high risk factors for child stunting, educating mothers as a key factor for improving nutrition, as well as the need to improve production diversity, nutrition knowledge and women’s empowerment to ensure that diverse and nutritious foods are available and accessible at all times.
The SHARE project also serves as a platform for multiple non-governmental organizations where they can exchange expertise and best practices to improve implementation and follow a harmonized approach in their respective intervention sites. This way, efforts are combined and the impact on the nutrition status of children and women will be maximized.
UNICEF would like to express its gratitude to the EU for the generous financial contribution to UNICEF-assisted programmes and looks forward to strengthening successful collaboration for children and women in Ethiopia. Thanks to EU support, over 225,000 children under five and over 50,000 mothers will have better access to improved nutrition services. This is in line with the efforts of the Government of Ethiopia to realize the Seqota Declaration to make undernutrition, in particular child undernutrition, history in Ethiopia.
HARSHIM, SOMALI, 19 January 2017 – “For three months, the borehole was not functional and people suffered a lot. There was little rain, so most of the birkas became empty. Additionally, water from birkas is usually contaminated so we suffered from diarrhoea,” Muse Hassan Ali, 45-years-old recalls the time that he and his neighbours did not have access to safe and sustainable water in his town. Birkas are underground water storage systems intended to collect rain water during the rainy season and store for use during the dry season. Birkas can also be used to store water transported by trucks during emergencies.
According to the Harshim woreda (district) administrator, Sied Abraham, this borehole in Harshim town is the only sustainable water source that survived the 2015 El-Niño drought. It was drilled by the Somali Regional Water Bureau (RWB) following a UNICEF groundwater mapping in 2009 to identify potential drilling sites. The depth of the borehole is 535 meters, one of the deepest in the Somali region. After this borehole became non-functional due to electromechanical failure last year, UNICEF, with generous financial contribution from European Commission’s humanitarian aid department (ECHO), supported the RWB to rehabilitate the borehole by replacing a submersible pump, generator and an electric cable.
An immediate rehabilitation of the only sustainable water source in the woreda was crucial not only for Harshim town, but a large part of the region. It typically benefits over 9,000 people in Harshim and neighbouring woredas as well as people who cross the border from Somalia. At the end of 2016, it also served people in far-reaching woredas when drought conditions worsened once again due to the negative Indian Ocean Dipole (IOD). The RWB and partners began providing emergency water trucking, using this borehole as their source. Thus, its well-functioning affects a high number of direct and indirect beneficiaries across the region.
Roda Ahmed, 35 years old, is with her five children collecting water. “This is a source of life. Now I can cook and feed my children,” she says. Another woman from Harshim town also with five children, Rahma Ahmed, explains, “Since this borehole has been working, we stopped drinking water from birkas.”
In addition to people collecting water near the borehole, the on-site trough draws in many pastoralists and their livestock. It takes more than a day for Farah Aden, 60 years old, to walk to the Harshim borehole with his 10 camels. “We are grateful for this borehole. Water is always a great cost for livestock. The functionality of this borehole has impacted our life a lot.” Indeed, during drought periods such as this one, entire herds may be wiped out, as evidenced by dozens of dead carcasses along the roads across the region.
As he contemplates this grave issue in his region, Muse pauses before emphasizing, “Still, this is not enough. There is a great pressure on this borehole. The generator is working 22 hours every day.”
UNICEF and partners will continue efforts to support the Government of Ethiopia to increase water coverage and functional water schemes in the Somali region to save the lives of children, their families and their livestock and contribute to a better future for all.
GASHAMO, SOMALI, 15 February 2017 – Mutas does not look at his mother. He is not looking anywhere, rather he lays still, his unfocused pupils covered occasionally by heavy eyelids. While we talk, his mother, Bedra Dek, keeps her eyes entirely on him. Her one-year-old son is suffering from severe acute malnutrition (SAM) and despite the food and water shortage and her two other children, she explains that all her thoughts are focused on him improving.
“When your child is well, spiritually you feel happy. This is what I am waiting and hoping for. Nothing else is in my mind except this,” Bedra speaks softly, her eyes never wavering from her son.
About six months ago, Mutas became sick with a cold. Since then, he has fought that illness and intermittent diarrhoea while they lived in remote rural areas. Living in remote areas means even farther than where we are now, which is over 300 km from the regional capital and 63 km off the paved road through desert sand – no roads. Bedra walked yet another 15 km to the settlement just outside Al-Bahi kebele (sub-district) after hearing that there was a mobile health and nutrition team (MHNT) providing lifesaving services. She knew Mutas was not improving, and indeed, shortly after her arrival, he had become lethargic and largely unresponsive.
At 21-years-old, Bedra has 7- and 4-year-old daughters in addition to Mutas. They are a pastoralist family, living in a rural village and often traveling vast kilometres in search of water and grazing land for their livestock.
While the semi-arid Somali region is often dry, the drought brought on by the negative Indian Ocean Dipole (IOD) in the past few months is beyond anything Bedra has experienced. Her family’s herd of over 200 goats and sheep is now down to four, and their physical appearance is too poor to sell in the market.
Upon arriving in Al Bahi, she went to the MHNT, which has temporarily set up as a static clinic in the site to service the hundreds of families in the area. MHNTs were initially set up over a decade ago in this region as a unique and necessary component of the emergency health service delivery system to reach nomadic families such as Bedra’s. They respond to disease outbreaks, provide routine immunizations and basic healthcare including treatment of common illnesses, conduct screening and manage uncomplicated cases of malnutrition as well as refer to higher levels of care as necessary. Here, the team has encountered high levels of malnutrition and the majority of children have low immunization status. The team is both responding to emergency care needs as well as conducting mass immunization and other preventative measures to ensure that a temporary settlement like this does not create further disease and suffering.
Once a child is diagnosed with SAM, they are provided with ready-to-use-therapeutic-food (RUTF) and medications which should help them to quickly improve. To ensure progress, mothers are instructed to come weekly to have their children checked. We meet Bedra, as she waits with Mutas for his weekly check.
UNICEF continues to support the GoE’s MHNTs through vehicle provision, transportation allowances, emergency supplies and technical guidance. UNICEF emergency health and monitoring consultant, Kassim Hussein, was present when Mutas was referred. When asked about his role, he explained how he roves around the region providing technical support. “During emergencies, things may be done in a haste, there may be staffing or technical knowledge gaps, or the situation may reach extreme levels and the team is too busy to report. I make rounds to all the teams, providing technical support and ensuring standards of care and supplies are available at adequate levels. I then report back to UNICEF and the regional health bureau,” explains Kassim.
Now Mutas is being seen by Mohammed Miyir, the team leader of the MHNT in Al-Bahi temporary settlement. Originally, he diagnosed Mutas with SAM; now his condition has developed medical complications, making him unable to receive fluids or medicine. This development signals the need for him to be sent to a stabilization centre (SC) at the Gashamo woreda (district) health centre, where he will receive in-patient advanced care until he reaches a minimal level of improvement in his responsiveness and weight.
Bedra is perplexed. Just minutes before they told her this news, she had said she wanted anything for him to improve. Now that it may happen, a new reality hit her. Her two daughters will need to be left behind – there is no room in the MHNT car. This is often an issue mothers out here face. With husbands caring for the grazing livestock, if they need to go to a SC for further treatment, who will take care of their other children? Some find neighbours to watch their kids, other mothers choose to stay and hope for the best, concerned about finding their children again as people are so mobile.
For Bedra, she has another 10 minutes to decide until the car will be ready for her.