MSF has been forced to reduce activities and withdraw its international staff due to rising insecurity. One of MSF's clinics in Mogadishu was forced to close recently, due to increased fighting in the surrounding area leading to an unacceptable risk to patients and staff.

Elsewhere in Mogadishu MSF continues to provide essential healthcare and continues to seek new ways to deliver much needed medical aid, in spite of the rising insecurity.

In this interview, Javier gives an overview of the current situation of MSF's projects in the country.

What are the main problems affecting the Somali population?

"Right now, one of our main concerns is the increasing number of people suffering from malnutrition. This is a regional problem affecting several countries and not one that only affects Somalia. However, here the conflict makes it worse as people find it more and more difficult to obtain food, thus the rates of malnutrition rise.

"Another serious problem the Somali population face is a lack of healthcare, exacerbated by the conflict – the number of hospitals and health centres has decreased and even the ones that are still working are increasingly difficult for the people to get into. This is because prices are very high (most follow the cost recovery system or are private) and because the conflict makes physical access difficult."

How has this malnutrition situation occurred?

"Malnutrition is rife because the war has disrupted an already precarious economy. Nobody regulates anything and chaos rules. Inflation is extremely high and the local currency has depreciated considerably. Prices have soared as the fighting has made land cultivation dangerous for farmers. Also, there are fewer people willing to work in the fields as it is an investment, and thus a risk. This lack of local production is compounded by unfavourable climatic conditions such as droughts and floods.

"As people have fled their homes, often staying with friends and relatives in different areas, things have become even harder. A salary that previously had to feed five people, now has to go as far as to feed some 15."

Are there still many IDPs?

"Many people have fled Mogadishu since January 2007. Since then, some have returned and others left, some have travelled north heading for Bossaso where they attempt to cross over to Yemen and many have been confined to Mogadishu since the war broke out. There are patterns in people's movements, but displacements are difficult to quantify in Somalia. We can see that in many places, displaced people have just arrived and are thus much more vulnerable."

Can you tell us how the project in Jowhar is going?

"In the four clinics we have in the area of Middle Shabelle, we conducted 59,025 consultations during the first half of 2008 in addition to 7,250 dressings and 10,910 antenatal care clinics. Almost 2,000 malnourished children have been admitted to the nutrition programme, both as outpatients and inpatients at the IDP unit opened last year. At present, there are 700 children in the programme. At the maternity unit opened in February 2007, about 1,000 women were admitted between January and June this year and 743 babies were born.

"Numbers of women attending the maternity unit had unfortunately decreased since the expatriates left and no national surgeon was available - a very important position in a society where female genital mutilation is highly prevalent and c-sections necessary. However, we were able to reopen the operating theatre a month ago when a national surgeon was recruited, so now we hope numbers will increase. Nonetheless, we have reached the target set when we opened in terms deliveries."

And what about Mogadishu?

"In northern Mogadishu we have four clinics and a 50-bed hospital for children under 12 offering preventative and curative services, including mother and child healthcare and vaccinations. Between January and June 2008, 84,905 consultations were conducted at the four clinics, including 1,329 admissions at the clinic in Lido, 10,698 dressings and 698 consultations due to war wounds. Over 5,000 women have received antenatal care and 927 postnatal care. In order to address the high malnutrition levels, in July this year we extended our nutritional program to all three urban clinics in Mogadishu. Currently there are about 600 children in the programme. This month the MSF staff also started offering post surgical care to war wounded people."

What are the challenges for MSF in Somalia today?

"There are three main challenges. Firstly, from a medical perspective, the challenge is to provide quality health services on a shared management basis with international staff based in Nairobi. Secondly, finding representatives to promote acceptance of MSF's projects to local groups and authorities is hard. In a context like Somalia, which is already complex in itself, further complications arise as the groups involved become more and more fragmented: the different parties dividing into groups and subgroups. Finally, it is vital that we provide the best possible security for Somali staff."

Can you explain what this way of working consists of?

"Since the end of January, when we were forced to remove international staff from the project we have not been able to send them back on a permanent basis for security reasons. Our work has continued thanks to the dedication of national staff. They implement the projects on the ground with support from the international coordination team based in Nairobi. Here, we are also increasing the numbers of Somali staff and with their support, MSF is able to visit the country and supervise the projects. The level of operational and technical feedback with the local staff is much higher than before and of great importance."