Nutrition Cluster, South Sudan

Nutrition Cluster, South Sudan Nutrition Cluster Response Strategy, February June 2014 (draft 2, 4 March 2014) Situation Analysis Violence broke out in Juba on 15 December 2013, and quickly spread to other locations. During the first six weeks of the crisis, Central Equatoria, Jonglei, Unity and Upper Nile states saw heavy fighting between Government and opposition forces. Other states have been indirectly affected as displaced people have sought safety there. An agreement to cease hostilities was signed on 23 January 2014. Despite the signed Cessation of Hostilities, fighting has continued in a number of areas throughout South Sudan, further compounding humanitarian access and increasing the displacement of populations. It is anticipated that fighting will continue particularly in key strategic oil field locations (Jonglei, Upper Nile and Unity States) with an increase between now and the rainy season. As of 24 February 2014, OCHA estimates that the number of displaced population is more than 710,000 people with Central Equatoria, Jonglei, Lakes, Unity, Upper Nile and parts of Warrap states are particularly affected and have the highest number of displaced population. Critical forms of under-nutrition have been prevalent among boys and girls under-five and pregnant and lactating women in South Sudan for many years. According to the results of SMART surveys conducted in 23 counties of seven states during the pre-harvest season of 2013, the pre-crisis levels of global acute malnutrition (GAM) ranged from 5.4 per cent in Wulu of the Lakes State to 35.6 per cent in Gogrial East County of Warrap State. The prevalence of severe acute malnutrition (SAM) ranged from 1.3 per cent in Rumbek to 13.4 per cent in Gogrial East. This suggests that serious and critical levels of malnutrition existed in South Sudan even before the current crisis. 1 Sub-optimal feeding practices of infants and young children were also prevalent with rates of exclusive breastfeeding being as low as 45 per cent before the crisis 2. Aggravating factors such as the likely rise in water-borne illnesses and other infections, limited access to safe water and excreta disposal, increased food insecurity, increased time away from young children, psychological stress related to displacement and violence, limited access to health care (60% of health facilities closed) and difficulty to adequately promote, protect and support optimal Infant and Young Child Feeding (IYCF) practices will significantly deteriorate the nutritional status of young children and mothers. Additionally, the breakdown of traditional livelihoods by pastoralis communities considerably decreased access of young children to complimentary food (milk) with estimated 10 million livestock displaced 3. The nutritional status of population is likely to be seriously affected by deterioration of food security situation. The Food Security and Livelihoods cluster estimates that the current large scale displacement is exacerbating the pre-crisis nutrition situation with most of the IDPs facing crisis levels of food insecurity (IPC Phase 3, January 2014). The IPC analysis estimates that about 6 million people are in stress, crisis and emergency phases, a three-time increase from pre-crisis levels. Of this, a total of 3.2 million are in emergency of crisis phases in addition to 740,000 IDPs within South Sudan. Up-to-date, Food Security and Livelihoods cluster partners reached 290,743 people with food assistance since the start of the crisis about 40 per cent of those in need, including about 71,300 in Jonglei; 84,300 in Lakes; 17,600 in Eastern Equatoria; 43,000 in Central Equatoria; 34,100 in Upper Nile; 22,100 in Unity; 16,200 in Warrap; 2,100 in Western Bar el Ghazal; and, 100 in Western Equatoria 4. Compounded with pre-existing high levels of acute malnutrition, this would have a 1 Reference levels for classification of severity of malnutrition in the community (WHO, 1992): Wasting (GAM): Acceptable (0-5%) / Poor (5%-9%) / Serious (10%-14%) / Critical ( 15%); 2 South Sudan Household Health Survey, August 2013. 3 Risk and Vulnerability in South Sudan, FAO, February 2014. 4 OCHA South Sudan Crisis Situation Report 23, 27 February 2014 1

negative impact on nutritional status of household members, specifically on children, pregnant and lactating women and elderly increasing the prevalence of acute malnutrition in the short term. Nutritional status is compromised where people are exposed to high levels of infection due to unsafe and insufficient water supply and inadequate sanitation. The pre-crisis information from the 2010 Sudan Household Health Survey suggested that less that 23 per cent of South Sudan s population had access to safe water with coverage rates of adequate sanitation at just 12.7 per cent with the implications for water-borne diseases morbidity rates. The crisis and large-scale displacement has greatly increased the vulnerability of people displaced, including potential cholera outbreaks making infant and young boys and girls more vulnerable to malnutrition and exacerbating the risks of morbidity and mortality among infants and contributing to the increased levels of acute malnutrition. Moreover, vulnerable population in the affected areas who are already experiencing protein-energy malnutrition before the crisis and is currently dependent on food aid will be more susceptible to, and less able to recover from, infectious diseases. Strategic Nutrition in Emergencies Interventions The Nutrition Cluster aims to provide life-saving nutrition in emergencies interventions to prevent death in vulnerable groups. Based on the analysis of available secondary information and recent screening data received from cluster partners, the Nutrition Cluster will focus on the implementation of priority nutrition in emergencies (NiE) interventions to save lives of young boys and girls and pregnant and lactating women affected by the current crisis. These interventions in priority counties of six severely affected states will include: 1) Effective coordination of nutrition in emergencies interventions. 2) Support and promotion of IYCF in emergencies (IYCF-E), 3) Prevention and management of acute malnutrition, including nutrition screening/assessments, The Nutrition Cluster coordinates the response plans with the Government, particularly the Dept of Nutrition of the Ministry of Health (MoH). Cluster partners prioritise activities which complement or help to fill gaps identified by the partners or the government or priority areas that the cluster partners have identified to meet the needs of target populations. They also ensure, where possible, alignment with and support to existing government policies and delivery systems. Cluster partners will ensure involvement of caregivers in planning and implementation of activities. Similarly, a feedback will be sought from those who were assisted to improve service delivery. Response Delivery Mechanism The current situation in South Sudan is fast changing and operational context is very complex. Humanitarian access remains limited affecting the way cluster partners deliver life-saving nutrition interventions to the affected population. Considerable number of people is on the move and difficult to track. It is estimated that only about 10 per cent of affected population are based in the protection of civilians (POC) areas based at UNMISS (camp-like settings) and in camps outside UNMISS premises, while the rest of people are either hosted by local communities or seek refuge in the bushes. Some partners capacity on the ground is also limited both in terms of staff and resources, while others have enough capacity but are limited by access constraints. Currently, Nutrition cluster supports a number of international NGOs which run nutrition in emergencies services in SCs and OTPs. NGOs use both Government PHC facilities (at the state level) and/or establish centres in POCs/camps and in host communities In addition, four national NGOS that have the potential to fill gaps in implementation of NiE interventions and are partnering with experienced INGOs. 2

Cluster partners regularly contribute to the development of 3W (who is doing what and where) to enable the cluster to identify gaps in programme delivery. Based on previous experiences and lessons learned from the current context and expected widespread insecurity, nutrition cluster partners have agreed on the need for preparedness and contingency plans to better respond to most likely scenario where capacity on the ground may not cope or in cases where there will be no partner. One approach is to work through national NGOs that are already in priority locations. The cluster employs two-prone strategy in delivering its response: one to provide life-saving nutrition in emergencies interventions to population in protection of civilians (POC) areas and IDPs, and the second one to respond to the needs of IDPs hosted by local communities. For IPDs based in POCs and camps, cluster partners provide focused response through blanket supplementary feeding programme, targeted prevention and treatment of acute malnutrition through OTPs and SCs, including regular screening and targeted IYCF-E interventions. As affected population hesitates to receive services in the Government-run facilities, partners set up OTPs sites and SC within the camps/poc areas. For IDPs hosted in the communities, cluster partners provide interventions on community management of acute malnutrition. Cluster partners will continue to closely monitor the situation and make necessary changes to their response strategies. For details, please see annex 1. Capacity gaps in programme delivery There is substantial geographical coverage of Nutrition partners in the six most affected states of the country. However, this does not translate to delivery of services to all in need. One of the main gaps that have been highlighted is lack of local staff making most INGOs/NNGOs depend on expatriate staff. This has a bearing on the cost of nutrition programme activities. Where specialized skills are required, expatriate technical staffs are used and due to the cost/funding-related reasons, not all partners have all the required personnel. While cluster partners continue to update the cluster capacity mapping, it is obvious that capacity in CMAM and IYCF-E is lagging behind the need. Estimation and Prioritisation of Needs Nutrition Cluster partners acknowledge that there is a lack of up-to-date detailed nutrition information of population affected by the current crisis. Partners plan to undertake surveys using SMART methodology in over 20 counties across ten states to make sure that age and gender disaggregated data on nutrition and mortality is available to inform future decisions and guide cluster partners. However, the January 2014 data received from partners through nutrition screening (MUAC) from 29 counties across six priority states suggest that at least 8.6 per cent of boys and girls aged 6-59 months are at risk of dying from severe acute malnutrition (MUAC <115 mm 5 ) and up to 12.6 per cent have moderate acute malnutrition and likely to deteriorate to severe malnutrition (MUAC between 115 mm and 125 mm). Another recent assessment conducted by IMC in one of the priority counties Malakal suggested that up to 9.71 per cent of children 6 59 months were found to be severely malnourished. This proportion is likely to rise given an equally high proportion of moderate cases at 10.39 per cent in addition to a variety of aggravating factors. The assessment also revealed a significant proportion of children who are at risk of developing acute malnutrition (23.95%). In the same report, mothers also reported difficulty in practicing proper infant and young child feeding practices due to inadequate spaces as well as limited access to appropriate food, safe water, and poor sanitation & hygiene conditions. 6 The Nutrition cluster partners based geographic prioritisation of target groups on the pre-crisis prevalence of acute malnutrition, information available from recent nutrition screening provided by cluster partners, on access to safer water and sanitation and food security status based on IPC, 5 WHO/UNICEF, 2009 6 Rapid nutrition assessment of children under five years, pregnant and lactating women in POC sites Malakal County, February 2014. 3

Phase 3. According to the recent report of FAO/WFP, in two of the most conflict affected states, Unity and Jonglei, pre-crisis food insecurity levels (severe and moderate) had increased compared to last year. 7 The recent conflict had also added a different dimension to the prioritisation of needs. Many displaced people are in the camps, livelihood activities have been shuttered and access to health and other basic services has been hampered. All these contribute to increased vulnerability to malnutrition to the population especially those in camps locations that are perennially endemic to high malnutrition across six most affected states: in Jonglei (Bor, Pibor, Akobo, Pocahlla and Ayod), in Upper Nile (Malakal, Fangak, Malut, Wau Shiluk, Pariang and Lankien), in Lakes (Awerial and Yirol), in Unity (Bentiu, Leer and Guit), in Central Equatoria (POC areas) and in Warrap (Abyei served from Warrap and Twic). Capacity of Government partners, local and international non-governmental organisations and community groups to respond has also been taken into account. The cluster partners estimate that around 1.619 million people will be in need of nutrition in emergencies interventions in six priority states until June 2014. More than 38,600 boys and girls aged 6-59 months in six priority states will suffer from severe acute malnutrition and more than 123,383 boys and girls 6-59 months will be moderately malnourished. More than 78,000 pregnant and lactating women will suffer from acute malnutrition and more than 128,400 will be in need of blanket supplementary feeding up until June 2014. More than 400,000 people, including 200,000 boys and girls aged 0-24 months and 200,000 pregnant and lactating women will be in need of IYCF- E interventions to ensure their survival as well as prevention from acute malnutrition. Based on the partners capacities and humanitarian access, cluster partners plan to deliver lifesaving NiE interventions to about 812,000 people in priority states over the period of January-June 2014. In the current response, the cluster will target up to 80 per cent of those boys and girls aged 6-59 months in need of prevention and treatment of severe acute malnutrition and up to 50 per cent of those boys and girls who are in need of prevention and management of moderate acute malnutrition. Up to 50 per cent of boys and girls aged 6-59 months and pregnant and lactating women will also be targeted with blanket supplementary feeding programmes. Cluster partners aim to provide all families with children 6-59 months of age who receive GFD in POC/camps with a ration of Supercereal Plus for a period of five months. Those who are not in camps and have children 6-35 months will receive a ration of Supercereal Plus together with GFD. Up to half of pregnant and lactating women who will suffer from acute moderate malnutrition will be covered by targeted supplementary feeding programmes. Up to 80 per cent of boys and girls aged 0-24 months and pregnant and lactating women will benefit from IYCF-E interventions. The cluster partners are aware that the planning and target figures for each of NiE interventions are subject to change based on fast evolving situation and anticipated results of detailed nutrition assessments. The figures will be adjusted and agreed by the cluster partners as more information will be made available to take an informed decision. Cluster coordination capacity The South Sudan Nutrition Cluster was activated in September 2010 and is led by the Ministry of Health and UNICEF. Currently cluster has 47 partners, including UN agencies such as WHO, UNICEF and WFP, international NGOs, donors and local NGOs who are on the ground implementing nutrition in emergencies interventions. The cluster partners meet on a bi-weekly basis. The cluster established four thematic working groups: on surveys, on information management (IM), IYCF-E and MAM. The coordination function is supported by a full-time nutrition cluster coordinator (UNICEF), deputy cluster coordinator (ACF-USA) and information manager (UNICEF). To ensure effective cluster coordination in the states, the cluster is supported by two Global Nutrition Cluster (GNC) Rapid 7 FAO/WFP Crop and Food Security Assessment Mission to South Sudan, February 2014. 4

Response Team (RRT) members and an additional information manager at national level who is also a member of GNC RRT. The nutrition cluster recognizes the need to have strong coordination at the state level and is working on this through organisations that work closely with MoH to support coordination in most states as follows: In Jonglei by Save the Children, in Unity by CARE, in Lakes by BRAC and CCM, in Upper Nile by GOAL and UNICEF (in Malakal), in Warrap by World Vision and in Central Equatoria by Concern. State clusters coordination mechanism is also supported by the MoH nutrition staff. However, different SMoHs have varying capacity in implementing NiE interventions. The Nutrition Cluster will deploy roving state cluster coordinators who will coordinate activities at the state level depending on the access and scope of NiE interventions. Supply pipeline To nutrition cluster will work closely with WFP and UNICEF to ensure emergency response is well supported by efficiently managed essential supplies pipeline. This element of the nutrition strategy includes advance procurement and strategic prepositioning of commodities for therapeutic and supplementary programmes. While the current response plan to the crisis spans over a period of six months (January to June), the procurement of supplies is planned to cover a period of 12 months. This is critical in making timely prepositioning possible and avoiding any supply gaps in the course of the year. Please see Annex 2 for details of the pipeline. Inter-cluster linkages The nutrition cluster recognises to complementary role of other clusters in addressing undernutrition in South Sudan. Given the strategic nature of WASH, Health, Food Security and Livelihoods the Nutrition cluster undertakes to participate in inter-cluster initiatives for joint assessments, planning and integration of interventions as much as possible. Food security data and population vulnerability was considered in the estimated caseload of nutrition interventions and therefore the Nutrition cluster will work closely with the food security cluster to monitor changes in food security and its possible outcome on the nutrition situation in the country. Close linkages with health partners, especially on immunization and supplementation will be forged. Nutrition cluster partners will develop a matrix where clear links with other clusters will be made for joint assessments, programme implementation, cluster coordination and information management. The matrix will be updated regularly as more information and actors will be available. Funding The South Sudan Crisis Response Plan (SSCRP) estimates that $83.3 million is needed to implement the package of NiE interventions in six priority states over the period of January to June 2014. Up to date, $12,263,314 (16% of required funding) has been secured. This still leaves a funding gap of $71,004,521. 5

ANNEX 1: NUTRTITION CLUSTER RESPONSE TO THE CRISIS IN SOUTH SUDAN, 2014 Technical interventions NUTRITION Children with severe acute malnutrition (n=30,891) Management of severe acute malnutrition a) SAM with complications Supply of nutrition commodities, F75, F100, Plumpy Nut Vitamin A Supplementation Deworming Rehydration solutions (Resomal) Promotion of continued breastfeeding Active case finding and screening at all IDP sites referral to Stabilization Centers. Training volunteers for MUAC screening. Establishment and Operationalizing stabilization centers at PoC areas b) SAM without complications Setting up of OTP centers in IDP settlements. Operating mobile outreach centers in areas with limited access. Linking with State ministry of health to increase coverage of OTP services by re-establishing services in PHCC & PHCU. Deployment surge capacity partners in areas with High caseloads (i.e Minkaman) to support and build the capacity of existing partners. C) linkage with other sectors/clusters Linking with WASH and NFI clusters for beneficiaries in the OTP s to be targeted for NFI distribution, health education and hygiene kits to complement their treatment. Children with moderate malnutrition (n=61,692) Targeted supplementary feeding program (TSFP) a) Management of moderate acute malnutrition Liaise with WFP & UNICEF to ensure supplies are available Supplementary plumpy (Plumpy Sup). Promotion of exclusive breastfeeding < 6 mo Vitamin A supplementation Iron+ folic acid supplementation Deworming Promotion of continued breastfeeding Promotion of adequate child feeding practices. Active case finding to increase coverage beyond the POC areas. Increasing awareness on service availability Linking with State Ministry of Health to increase coverage of TSFP services by re-establishing services in PHCC & PHCU. Link with faith based organizations, local youth and women groups and National NGO s in areas with limited access. Advocate for GFD to avoid systematic sharing of Plumpy Sup. b) linkage with other sectors/clusters Link with other cluster for the protection of underfives who are unaccompanied. Linking with WASH and NFI clusters for beneficiaries in the OTP s to be targeted for NFI distribution, health education and hygiene kits to complement their treatment. Children 6-59 months (n=625,178) a) Reduction of malnutrition vulnerability Working with UNICEF, WFP and partners to ensure Routine vit A supplementation Promotion of exclusive breastfeeding < 6 mo Promotion of continued breastfeeding Promotion of adequate child feeding practices Deworming Immunization Handwashing and hygiene promotion b) Blanket supplementary feeding Registration and roll out of blanket supplementary feeding in affected areas. Raising awareness on proper utilization of the BSFP ration at home Linking beneficiaries with general food distribution. C) linkage with other sectors/clusters Linking beneficiaries with food security sectors to ensure in the assessable areas household food security is ensured by engaging in farming activities. Women of reproductive age, Pregnant women and Lactating mothers (n=103,317) a) Reduction of malnutrition vulnerability Iodine supplementation (pregnant women) Vitamin A supplementation (lactating mothers < 2 mo) Multiple micronutrient supplements (pregnant women and lactating mothers) Health and nutrition education sessions. Monitoring the use of breast milk substitutes Establishment of breast feeding support groups. Ensure breastfeeding tents are available in the IDP and POC areas. b) Targeted supplementary feeding and BSFP Screening mothers and providing CSB++ to those with MAM. Active case finding to increase coverage Linking beneficiaries with general food distribution. Raising awareness on proper utilization of the CSB++ at home C) linkage with other sectors/clusters Working with health cluster to ensure deliveries are overseen by health professionals Linking with Food security cluster for the reestablishment of livelihoods activities. 6

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