Mobile Health and Nutrition Teams Save Lives in Remote Drought-affected Areas

By Rebecca Beauregard

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).

MHNT in Somali drought 2017
The MHNT in full operation with MHNT team leader Mohammed Miyir at its centre in white. ©UNICEF/2017/Tesfaye

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].”

MHNT in Somali drought 2017
Mohammed, 28-years-old, explains the unique pastoralist context at Al Bahi temporary site where over 2,000 households have gathered. ©UNICEF/2017/Tesfaye

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.”

Mobile Health and Nutrition Teams Providing Crucial Services for Pastoralist Mothers As They Cope with Drought

By Rebecca Beauregard

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.

MHNT in Somali drought 2017
Bedra Dek, 21-years-old, looks at her one-year-old Mutas Abdulahi, who is ill from malnourishment. ©UNICEF/2017/Tesfaye

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.

MHNT in Somali drought 2017
The homes of pastoralists gathered at the temporary Al Bahi site starting from December 2016, in Gashamo woreda, Somali region. ©UNICEF/2017/Tesfaye

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.

KfW provides vehicles to support Mobile Health and Nutrition Teams in Somali region

By Somali Region Mass Media Agency

mhnt1
Mr. Hassan Ismail, Head of Ethiopian Somali Regional Health Bureau ©2016/Mukhtar Mohamed

JIGJIGA, SOMALI REGION, 13 December 2016– In partnership with UNICEF, the KfW Development Bank, which administers Germany’s financial cooperation in developing countries, provided 15 vehicles to support the Mobile Health and Nutrition Teams (MHNT) across the Somali region.

Regional officials and UNICEF staff attended the handover ceremony in Jigjiga, the capital town of the Somali region. Hassan Ismail, Head of the Ethiopian Somali Regional Health Bureau, emphasizing the benefits of the15 vehicles for MHNT services, said, “The vehicles will contribute for the success of MHNTs to reach vulnerable women and children with basic health and nutrition services in drought-affected pastoralist areas.”

The mobile teams conduct outreach services and targeted campaigns, such as the Enhanced Outreach Strategy (EOS) that provides children vitamin A supplementation, treatment for intestinal worms, and screening for acute malnutrition in far-reaching pastoralist areas.

Fartun Mahdi Abdi, Head of the Water Bureau and representing the Vice President of the Somali region at the ceremony, also reiterated the contribution these vehicles will have to reducing maternal and child mortality as well as strengthening the quality of health services.

 Fartun Mahdi Abdi, left, Head of the Water Bureau, receives keys to the 15 vehicles from Dr. Marisa Ricardo of UNICEF Ethiopia.  ©2016/Mukhtar Mohamed
Fartun Mahdi Abdi, left, Head of the Water Bureau, receives keys to the 15 vehicles from Dr. Marisa Ricardo of UNICEF Ethiopia. ©2016/Mohamed

With the support of donors such as KfW, UNICEF Ethiopia provides the Government of Ethiopia with medicine and other supplies for MHNT operations. As a result, 362,815 medical consultations took place between January and October 2016 across Somali and Afar regions. Forty seven per cent of these are children.

UNICEF Ethiopia, through the generous support of KfW, provided an additional five vehicles to MHNTs in Afar for the same purpose.

Prolonged drought and intermittent flooding has gravely affected these areas in recent years, first caused by the effects of El Niño weather in 2015, and currently from effects of the Indian Ocean Dipole, another climatic phenomena.

UNICEF and WFP Regional Directors visit El Niño driven drought response in Ethiopia

Afar Region – Ethiopia Ms Leila Pakkala and Ms Valerie Guarnieri, UNICEF and WFP Regional Directors for Eastern and Central Africa, have visited the ongoing government-led drought response where UNICEF-WFP are closely collaborating. The drought is affecting six regions in Ethiopia, and 9.7 million people are in need of urgent food relief assistance including approximately 5.7 million children who are at risk from hunger, disease and lack of water as a result of the current El Niño driven drought.

In Afar Region, where an estimated 1.7 million people are affected by the drought, including 234,000 under-five children, the Regional Directors visited UNICEF/WFP/Government of Ethiopia supported programmes. These included the targeted supplementary feeding programme (TSFP) and an outreach site where one of Afar’s 20 Mobile Health and Nutrition Teams (MHNTs) provides preventive and curative health, nutrition and WASH services to a hard-to-reach community in Lubakda kebele.

Ms Leila Pakkala and Ms Valerie Guarnieri, UNICEF and WFP Regional Directors for Eastern and Central Africa in Ethiopia visit

The Mobile Health and Nutrition Team provides Outpatient Therapeutic Programme (OTP) and targeted supplementary feeding programme (TSFP) services to remote communities. The TSFP is integrated with MHNT services that address under five children and pregnant and lactating women with moderate acute malnutrition, and link them to TSFP when they are discharged from OTP. This solves the challenge in addressing the SAM–MAM continuum of care and preventing moderate acute malnourished children deteriorating into severe acute malnutrition.

The Directors also visited a multi-village water scheme for Afar pastoralist communities in Musle Kebele, Kore Woreda (district) which suffers from chronic water insecurity.

“Valerie and I are hugely impressed by the work of the WFP and UNICEF teams in Afar,” said UNICEF’s Pakkala.  “The quality of the work being done in such difficult circumstances – from the mobile health and nutrition teams, to WASH, protection, education and advocacy – is remarkable. We were also immensely impressed with the national level partnership between UNICEF and WFP, and our credibility with government and donors. The relationship and collaboration is a model for other countries to learn from and emulate.”

“Ethiopia is showing us that drought does not have to equal disaster,” said Valerie Guarnieri of WFP.  “We can clearly see the evidence here that a robust, government-led humanitarian response – supported by the international community – can and does save lives in a time of crisis.”

UNICEF and WFP continue to support the Government in responding to the current drought with a focus on the most vulnerable and hard to reach communities by using proven context specific solutions and approaches.

Mobile Health and Nutrition Teams Key to Behavioural Change in Somali Region

By Matt Sarson

DHANDAMANE, SOMALI REGION, ETHIOPIA, 23rd October 2013 – As we drive through the Valley of Marvels between JigJiga, the Somali Regional capital, and Babille, which straddles the neighbouring Oromia Region, the emerald glow of vibrant plant life sits in stark contrast to the florescent copper shimmer of the soil below. The road is smooth tarmac and carves a winding path through the sparse moonscape.

This western tip of what is classified as one of Ethiopia’s four developing regional states is currently blessed with more precipitation than its eastern extremities, but drought, regular disease outbreaks, flooding and limited access to healthcare have blighted the majority of the region for a number of years.

Adawe Warsame is a Health & Nutrition Officer with UNICEF.Adawe Warsame is a Health & Nutrition Officer with UNICEF. Having grown up in the nearby city of Dire Dawa and a Somali himself, he is well aware of the historic complications of the region.

“The issues the people face in the Somali Region are multi-layered,” he explains. “In one part of the region there is a flood, which is followed by a disease outbreak; in another, severe drought. This has a huge impact on both the health and nutrition of the people here, as well as the ability of the government to provide adequate services.

“Most regions are underdeveloped in terms of health facilities, human resources and education. It is difficult to provide even the most basic of services in many areas.”

Accessing Hard to Reach Areas

The next morning we continue along the same road through Babille towards Dire Dawa, entering the Oromia Region, before leaving the asphalt and turning back on ourselves towards the Koro kebele – a more direct access road does not currently exist.

Our driver first has to remove branches from the road, which have been placed there by the neighbouring Oromia village. After a brief exchange, in which they question why the support is being provided solely to the Somali people, they help to clear the path for us. With regional governmental offices only responsible for their own kebeles, this is a common occurrence. By working closely with the Ethiopian government, UNICEF are able to mitigate such issues and access areas that others cannot.

“UNICEF is a little privileged in terms of movement compared to other NGOs,” Adawe assures us. ” As we work closely with the Regional Health Bureau, the vehicles have special plate numbers and the staff are also from the government side.”

The MHNT helps to train Health Extension Workers (HEWs) through a 16 package programme, which includes disease prevention and control, family health services, hygiene and environmental sanitation, health education and Harmful Traditional Practices (HTPs). They also provide immunisations, deliver medicine and supplies, support Traditional Birthing Assistants (TBAs) and treat severe malnutrition. UNICEF currently supports 24 MHNTs in the Somali region. There used to be others operated by different NGOs, but due to financing restrictions these have now ceased to be operational.

As we arrive in the village, we are met by Mohamed Almur Musu, the kebele leader, who informs us that he is responsible for protecting both the people and the animals in his community. Adawe briefly explains the purpose of our visit before we begin to make our way through the village.

“We are on the border between the Somali and Oromia regions, and so have been a little neglected,” Mohamed explains at the entrance to one of the village houses. “Nowadays, we have better support and a new health facility, which makes us feel more secure. The problems we face here are many, but slowly things are improving.”

The Plight of Harmful Traditional Practices

Mohamed Almur Musu, Babile,Koro kebele lider father of 8
Mohamed Almur Musu, Babile, Koro kebele leader father of 8. ©UNICEF Ethiopia/2014/Tsegaye

One of the biggest and often most sensitive issues in the region is HTPs, such as early childhood marriage and female genital mutilation (FGM). According to the 2011 Welfare Monitoring Survey (WMS) report, the region has the third highest rate of FGM (in 0-14 year olds) in Ethiopia (31%), after Afar (60%) and Amhara (47%).

“Prior to the government intervention, religious leaders were advising us not to practice these things,” Mohamed informs us, a nervous smile directed at those around him indicating that the issue is still one he is not altogether comfortable with. “The change wasn’t really monitored though and people were still doing it.”

Beyond the obvious initial pain of the procedure, the long term physiological, sexual and psychological effects of FGM are well documented. The consequences can even include death as a result of shock, haemorrhage or septicaemia. Long-term complications include loss of libido, genital malformation, delayed menarche, chronic pelvic complications and recurrent urinary retention and infection. Girls who have undergone FGM or also prone to various complications during birth and are more at risk of contracting HIV.

“We now have a very strong community stance against it. I can confidently say that it is no longer a part of our lives here,” Mohamed exclaims proudly.

At the first Girl Summit – held on July 22, 2014, in London, and joint hosted by UNICEF – Ethiopia’s deputy Prime Minister (DPM) Demeke Mekonnen announced a package to eradicate both FGM and early childhood marriage by 2025. This is the most recent step in a decade’s long struggle, but statistics are now starting to indicate that real progress is being made and this new target is a realistic one.

Women at the Centre of the Progress

Marayma Abdiwahab,Womens group coordinator in Koro Kebele, mother of one 12-year old daughter.
Marayma Abdiwahab, Womens group coordinator in Koro Kebele, mother of one 12-year old daughter ©UNICEF Ethiopia/2014/Tsegaye

The house we are borrowing shade from is that of Marayama Abdiwahad, a confidant woman who plays a central role in the kebele’s women’s group. She has a 13-year-old daughter, Bisharo, and is clearly driven by a desire to improve the quality of life for all children in her community.

“Progress began with just a few simple steps,” she says, directing us to look around at the village as she talks. “The mobile team have taught us how to collect rubbish, to gather it somewhere and to burn it. Before, we didn’t wash our children, and our dishes and utensils were not clean, now we are also doing this.”

Although, this seems straightforward, the impact it has had on the community has been huge,

“Our children always used to get diarrhoea,” she continues. “Now, they are healthy and energetic. If anyone does get sick, we also now have the necessary facilities here to treat them.”

In addition to the hygiene aspect of the 16 package programme provided to the community, Marayama also discusses the role the women’s group has played in eradicating FGM.

“We used to perform FGM, but after receiving the 16 package we have committed ourselves to not performing it,” she says proudly. “We have discussed together the health problems it brings and have vowed to eradicate it from our community.”

When questioned about her own daughter, Marayama is defiant.

Health Extension worker, Abdulallh Abiib, 22, discuss hygine prctices with a women's group in Koro kebele.
Health Extension worker, Abdulallh Abiib, 22, discuss hygine prctices with a women’s group in Koro kebele. ©UNICEF Ethiopia/2014/Tsegaye

“If you yourselves are not ashamed, I will happily show you my daughter,” she insists, with a knowing smile. “I will never allow anyone to perform FGM on her.”

Abdullah Abiid, 22, is the kebele’s only HEW. He has been working in his role for a year now. When we meet him, he is discussing HTPs with the kebele’s women’s group.

“FGM no longer happens here,” he informs us proudly. “There is still early marriage, but now the girls are going to school and learning about this too.” At times, the progress has not been easy, but Abdullah is committed to achieving his objectives and improving life for all in his community.

“Some listen and accept what I am saying straight away, others laugh at me,” he says. “When they laugh, I don’t stop what I am doing because I know they will see what the other women are doing and follow their lead.

“They used to be ashamed to use a latrine even. When I explained that their own hygiene and the cleanliness of the home are important for maintaining the health of their children, they started to make the change.”

Part of a Bigger Picture

The progress in the level of hygiene and the eradication of HTPs is part of a bigger picture, whereby both the health and quality of life of all those in the community is improving – especially for girls.

The training and provision of clean delivery kits to TBAs has had a profound impact on the quality of birthing services, and this has been supported further by Tetanus Toxoid injections, which massively reduces the neo-natal tetanus mortality rate. The presence of the Health Post (HP) and MHNT for emergency situations also enables pregnant women to have more confidence should complications occur.

In the neighbouring Helobiyo Kebele, Ruman Ibrahim Osman, 28, is a prime example of the impact this has had. We are invited into her home where she is sat holding her 1-week old baby girl, Farhiyo. She had previously lost two children during complicated deliveries.

Ruman Ibrahim Osman with her one-week old Farhio Ahemed. Babile, Halobiye kebele“During the delivery of my previous child, the baby was in a difficult position and then got stuck,” she bravely informs us. “I was suffering for around 24 hours. The community tried to help, but finally, after a prolonged issue, the baby died.”

She had also lost another child in similar circumstances just 12 months earlier. With Farhiyo, however, the delivery was much more straight forward and she received support throughout her pregnancy.

“Initially, I met with the MHNT when they came to our village,” she recalls. “They told the pregnant mothers to come and gave us advice, vaccinations and linked us to the birth assistant. Then I got support from the birth assistant and gave birth with her help here at home.”

She is also now receiving continued support from the TBA and HEW.

” I have been told to breastfeed within the first few hours and I don’t give any additional food or water,” she says confidently. ” The mobile team are vaccinating us and our children, and treating diseases like malaria. The situation here is now much better.”

Although there is still some way to go to completely eradicate HTPs from the Somali region and to improve the health and nutrition of all, positive progress is clearly being made. For those working with UNICEF in the region, this is something that they are proud to be a part of.

“As someone with an educational background in public health, it brings me great pleasure to see these poorer communities now learning such important lessons,” Adawe exclaims gleefully back at UNICEF’s Somali regional office in JigJiga. “The people here do not deliberately want to hurt or damage their children.

“Driven by the services of our mobile teams, we are empowering them to protect both themselves and their future.”