SOUTH SUDAN PROGRAMME PLAN 2013
1. Introduction SOUTH SUDAN PROGRAMME PLAN 2013 Political Situation: South Sudan became independent from the Republic of Sudan (RoS) on 9 th July 2011 following a Comprehensive Peace Agreement (CPA) between the two countries that ended decades of civil war. However, the new state is limited in capacity and resources to effectively deliver the welfare mandate impacting on the expected peace dividends following independence. Government institutions lack critical resources and are heavily reliant on non-governmental organisations (NGO) and other agencies. Conflict (both external & internal) remains the primary concern of the Republic of South Sudan (), which has seriously affected the economy and security of the population. Within there is persistent insecurity particularly along border states and in Jonglei where rebel groups are fighting government forces, Sudan People s Liberation Army (SPLA). Inter-ethnic conflict and disputes over resources especially grazing land are also fuelling instability. As part of the CPA nearly 10,000 ex SPLA combatants in the civil war are being reintegrated by the South Sudan DDR Commission and UNDP. The conflict/tension with RoS has reduced to a certain extent due to recent signing of the cooperation agreement on September 27, 2012 to resolve many of the outstanding issues from the CPA. This agreement included establishing a demilitarised zone along the border, resolved the issue of oil transit fees, ceasing support of rebel groups and freedom for citizens of both countries of work, movement, ownership and residency in each other s country. However Abyei remains an outstanding issue and there have been protests from Northern Bahr el Ghazal over demilitarisation of the border which they say will impact on grazing land access and it being handed to RoS. Economic Situation: s economy is one of the weakest in the world facing poor infrastructure to even provide basic services. The main economic activities are agricultural and a heavy dependency on oil. Oil exports account for up to 98% of government revenues. The suspension of oil production over disagreements of transit fees with Sudan has led to austerity measures in the public sector. Although recent inflation of 42.9% in September compared to the 43.3% registered in August still remains high while the Consumer Price Index (CPI) rose by 0.3% in September 2012. Compounded with fuel crisis due to closure of oil production since January 2012, the cost of commodities has gone up significantly, which has affected both the beneficiaries and programme inputs adversely. Border closures with Sudan over the various disputes have also negatively impacted on the economy. Humanitarian Situation: In 2012, over 126,974 returnees have arrived in since the beginning of the organized returns programme in October 2010 with a total of two millions since the CPA. Northern Bahr el Ghazal (NBeG) has some of the highest number of returnees with 456,860 since CPA. Returnees face significant challenges in restarting their lives, including very few employment opportunities especially for unskilled labour, lack of land and the intensive labour and time required to clear farmland, inadequate basic services, and lack of access to credit, land and agricultural inputs. Serious conflict between the Sudanese armed forces and rebel groups in RoS s Blue Nile and South Kordofan has led to a massive influx of refugees into. Refugee populations are 175,000 in Upper Nile and Unity States. Refugees are arriving in poor health and are severely malnourished. The significant portion has been children with October 2012 seeing them account for 70% of new arrivals. Refugees have been facing continuing health problems including a Hepatitis E outbreak in Upper Nile, limited water and sanitation access and food insecurity 1. Children are also in need of education 1 Humanitarian Bulletin, South Sudan, 1-7 October 12, OCHA.
provision. Internal insecurity specifically in Jonglei has led to massive displacement and the current figures are reaching 170,000. Access by humanitarian agencies is limited due to insecure conditions and most internally displaces persons (IDP) have been surviving in the bush and those able to reach Pibor town have been hosted with relatives and can avail of humanitarian assistance there. The rainy season of 2012 witnessed heavier than normal rains and resulted in severe flooding with the hardest hit states being NBeG, Jonglei, Unity, Upper Nile and Lakes with 260,000 being affected. This has led to displacement and damage to crops and livestock. This will have negative implications for food security and will contribute to high food prices. Needs have been for non-food items (NFI), water, sanitation and hygiene (WASH), shelter and food. Jonglei has suffered the most with 201,000 affected and insecurity has compounded this. Progress and development at government and local levels (against PRSPs/development plans). With a human development index (HDI) of 0.408, Republic of Sudan (inclusive of South Sudan) ranks 169 out of 187 countries included in the latest human development report published by UNDP in 2011. Chronic underdevelopment in the country followed from more than 30 years of civil war has with the weakest economy in the world. Health indicators 2 show a maternal mortality ratio (MMR) 2,054/100,000 live births, infant mortality rate (IMR) of 84/1,000 live births an under five mortality rate of 106 per 1,000 live births and a total immunisation rate of 1.8%. Only 68% of the populations have access to improved sources of drinking water and 15% of the populations have access to improved sanitation 3. There is high prevalence of malaria, diarrhoea and pneumonia among the children at 32%, 34% and 32% respectively. Many of these children do not receive appropriate care due to poor health infrastructure resulting in low coverage and quality of services with only 25% having access to health services 4 and budgetary allocations to health sector is only 6.8% and a significant reliance of 60% from international donors 5. remains food insecure with an unstable economy, poor natural resource use, insecurity, flooding and weak government agricultural services has continued to contribute to this in 2012. These multiple factors have aggravated household level food insecurity with 36% and 14% of the population moderately and severely food insecure respectively 6. The main areas of concern are NBeG, Warrap, Unity, Upper Nile and Jonglei. This is due to flooding, insecurity, high prices and IDP and refugee needs. An inter-agency pre-harvest survey across six states revealed the states to be above the emergency threshold for global acute malnutrition (GAM) 7 ranging between 17.5% and 28.7%. Education in has some of the lowest rates of illiteracy in the world with rates of 49% in urban areas and 76% in rural areas with world s highest female illiteracy rate of 88%. The extent of the prevalence of HIV/AIDS in is not known. According to the 2009 ANC surveillance report by the Ministry of Health, the provisional estimated HIV prevalence was found to be 3.04%. However, this varies between states. NBeG, out of the ten states in, is one of the most underdeveloped and in continuing need of humanitarian aid and longer term development assistance. The situation in NBeG is expected to be worse off due to proximity to the conflict, poor infrastructure and remoteness of the communities. NBeG has some of the worst health indicators in. Maternal mortality rate is 2,182 per 100,000 live births, 129.2 per 1,000 live births infant mortality rate, an under five mortality rate of 165 per 2 Sudan Household Health Survey, 2010 3 Sudan Household Health Survey, 2010 4 Health Sector Development Plan, South Sudan (2011-15) 5 National Budget of South Sudan, 2011 6 WFP. Food Security Monitoring System. July 2012. 7 WHO emergency threshold for GAM is 15%
1,000 live births. Food insecurity in 2012 was high at Crisis (IPC Phase 3) in Aweil West and North Counties and is forecasted to remain at Crisis in Aweil North and Stressed (IPC Phase 2) in Aweil West 8. Crop and animal production have suffered the effects of flooding, poor agronomic practices and minimum livelihoods assets. Therefore, the overall human development outlook for South Sudan and in particular for NBeG is not expected to change significantly in 2013. The economic outlook remains heavily dependent on oil and weak human and physical infrastructure will remain major hurdles for basic services provision by the state. Country Strategic plan Country Strategic Plan Time line 2013-2016 Overall programme plans Programme Goal: Through effective emergency response and long term development programmes reduce vulnerability and achieve long-term improvements in people s lives. During 2012 the first Country Strategic Plan (CSP) for South Sudan has been developed covering the period 2013-2016 and is currently being finalised. The CSP will focus on the programme in South Sudan undergoing a strategic transition moving more towards in line with the country in linking relief, rehabilitation and development (LRRD). This will include consolidation of health and nutrition (H&N) interventions in Aweil West County and Aweil North. The on-going integration of H&N with a systems strengthening approach will help us to align with both the state strategy as well as the evolving funding mechanism such as the Pooled Fund. Food, Income and Markets (FIM) will have three key foci: establishment and promotion of the newly constructed Agriculture Demonstration & Extension Centre (ADEC) at Nyamlel as a joint initiative between the state of NBeG and Concern Worldwide; improving agricultural interventions both with quality extension and diversification; improving quality and targeting of income generation interventions as suggested by the Contextual Analysis. With Preparedness for Effective Emergency Response (PEER) an objective for the CSP there will be a scale-up of visibility and engagement in emergency assessments and responses with increased utilisation of skills and competencies in nutrition and food security. The recently recruited Emergency Coordinator (EC) will lead on assessments and guidance for future engagement in emergencies in South Sudan, while improving our abilities to respond to emergencies both in and outside of current programme locations. Expansion into another state is a strategic shift in the CSP. In 2013 this will be explored and most likely an emergency nutrition intervention will be the entry point. Overall, the programme management and delivery strategy will be realigned to cater to the above mentioned changes. This will be accomplished through recruitment of additional staff; relocation of key staff members; opening up of new bases and regular participation in strategic events and processes that will include CAP and cluster coordination. Programme Closure/opening new locations (if applicable) 8 FEWSNET South Sudan Food Security Outlook Update September 2012
Integrated FIM Health & Nutrition Overall, H&N and FIM would continue to address Nutritional Security of the beneficiaries. This will be in the current locations of Aweil West County of NBeG, where both programme interventions are co-located. New area subject to assessment. Most likely be emergency in nature to start with. Current programme interventions in Aweil West are phased out in March 2013 and continuation of FIM is dependent of funding based on the new Programme Proposal. Locations could be both current county of Aweil West and new county of Aweil North Current H&N interventions are due to phase out in December 2012 and submissions of proposal have been made to donors for continuation. Integrated H&N interventions in Aweil North County to be finalised in consultation with other organisations and government agencies. Expansion to another state with emergency nutrition programme is being explored. 2. Programmes: Health and Nutrition: The programme will be implemented through the Ministry of Health (MoH) facilities in Aweil West County as part of the basic package of health services (BPHS) delivery through a systems approach. Extension of nutrition services in another state will be explored. This expansion will be subject to an assessment and necessary resource generation and approval. The current programme is funded mainly by the Basic Services Fund (BSF), IAPF, Common Humanitarian Fund (CHF), ECHO, General Donations (GD) and with nutrition commodity support from WFP and UNICEF. It is agreed at the national level that DFID led Health Pooled Fund (PF) will cover six out of 10 states in South Sudan in 2013. NBeG is one of those six states. In 2013, it is expected that a bridging fund will be utilised to link the current health sector funding from BSF pot to PF mechanism. We are optimistic that long-term transitional grants will be available from the proposed PF in Health. HIP-2013 of ECHO will be a major funder to complement the bridge fund in health in both the Counties as well as expansion into a new state. Table 1: Beneficiary Numbers for 2013 Health and Nutrition Programme Location Aweil West Aweil West Aweil North Male Total Male Female and Female* Maternal, new-born & Child Health 57,786 59,748 41,218 158,752 (MNCH) interventions through BPHS Children U5 treated for SAM 379 394 616 1,389 Children U5 treated for MAM 2,003 2,081 3,260 8,733 Total 60,168 62,223 45,094 168,874 *gender segregated figures are not available for Aweil North Food, Income and Markets (FIM): In the year 2013, the FIM programme will focus on increasing basic food production through expanded and diversified agricultural interventions. The approach will focus on strengthened linkages with the Agricultural Demonstration and Education Centre (ADEC) for increased demonstration and extension of new varieties, and agronomic practices. The expected outcome will be household level food security through increased staple crop production and area coverage and productivity through better agronomic practices, reduction of post-harvest losses and safe storage. The livestock intervention will focus on small ruminants and improving the quality of the stock through ensured vaccination of birds and small ruminants through the Community Animal Husbandry Workers (CAHW). Income enhancement will be realised through diversification of livelihoods options and development of business skills and working capital support
Food insecurity especially during Hunger Gap period as well as disaster risk reduction (DRR) measures that involve river embankment rehabilitation will be addressed through a better planned Food for Assets (FFA) programmes with commodity support from WFP and in collaboration with local NGOs. The programme will be implemented in Aweil West County of NBeG. However, emergency interventions in other states subject to approval will be based on assessment and staff and systems capacity. Table 2: Beneficiary Numbers for 2013 FIM Programme Male 1,745 Female 7,293 Total 9,038 Emergency Response: A PEER plan was developed in 2012. Both conflict and natural disasters are primary drivers of emergencies in South Sudan. In 2013, emergency interventions will be based on proper assessment and clear plans to be led with plan to recruit an Emergency Coordinator. All emergency responses will be managed through effective coordination with local government authorities, South Sudan Relief and Rehabilitation Commission, UN agencies and NGOs. 3. Monitoring and Evaluation: Programme Contextual Analysis Survey (e.g. baseline/ mid line/ endline) M T Review Internal / External Evaluation Donor (if Applicable) FIM H&N Cross cutting Cultural Anthropological study for informed and aligned programming- Mar 13 in April-May 13 & /Coverage Survey (if not completed in 2012)- Apr 13 2 End-Term Evaluations- Jan-Feb 13 and Mar-Apr 13 OFDA and EU respectively IAPF (Confirmed) To be explored
Results Framework for Health and Nutrition Programme 2013 Programme Results Framework: Improved Health and Nutrition Status Intended Impact 1. Dimension s of Extreme Poverty Health Assets and Return on Assets Outcome( s) Improved maternal and child health and nutrition outcomes among the population of Aweil West and North Counties (MDG 4, 5 and 7). 2. Programme 5. Target Outcome 2013 1 (a). County Health Department provides standard quality BPHNS 9 through health facilities and outreach services (meso) 3. Indicators (to be disaggregat ed by gender and identified extreme poor group, unless disaggregat ed groups are specified ) 1(a).1 of health facilities that provide quality BPHNS defined based on HFA assessment 4. Baseline value and source* 0% Aweil West (AW) 0% Aweil North (AN) (Health Facility Assessme nt (HFA) 10 Table 4) AW: 0 (0%) AN: 0 (0%) 6. Target 2015 2013 valu e and sour ce AW: 1 (3%) AN: 1 (3%) 2014 valu e and sour ce 2015 valu e and sour ce 1(a).2 AW: AW: AW: of health facilities having required # of trained health staff as per BPHNS 10 PHCC 11 : 0% PHCU 12 : 33% AN: PHCC: 0% PHCU: 0% (HFA PHCC: 0 (0%) PHCU: 8 (40%) AN: PHCC: 0 (0%) PHCU: 1 (17%) PHCC: 0 (0%) PHCU: 10 (50%) AN: PHCC: 0 (0%) PHCU: 3 (50%) 9 BPHNS: Basic Package of Health & Nutrition Services 10 Total of 2 PHCCs and 25 PHCUs (with 2 PHCUs with nutrition only and 1 with health only) in Aweil West. Total of 5 PHCCs and 29 PHCUs in Aweil North but 7 health facilities are closed, 23 are temporary structures and 11 are permanent structures. Concern supports 2 PHCCs and 20 PHCUs in Aweil West and 1 PHCC and 6 PHCCs in Aweil North 11 PHCC: Primary Health Care Centre 12 PHCU: Primary Health Care Unit
10,Table5 ) 1(a).3 AW: 0% AW: 50% AW: 60% brought to a health facility with fever, ARI and/or diarrhoea whose clinical care covers all necessary diagnostic tasks. AN: 0% (HFA 13 13 ) AN: 30% AN: 40% 1(a).4 AW: 49% AW: 55% AW: 60% brought to a health facility with fever, ARI and/or diarrhoea who received the correct treatment for their diagnosis. AN: 65% (HFA 2012, table 8, page 14) AN: 65% AN: 68% 1 (b). Improved access and availability of quality maternal and child health & nutritional care services 1(b).1 aged 0-23, with fever during the last 2 weeks who were treated with an 10% (KPC 11) Children 0-23 : 1,274 HMIS) 12% Children 0-23 : 2,653 HMIS, 25% 13 This indicator measures the % of health workers completing diagnostic tasks. In the HFA, it was found the none of the health workers completed all of the tasks necessary for correct diagnosis
effective antimalarial drug within 24 hours after the fever began 1(b).2 of mothers 0-23 who received at least 4 ANC visits during her last pregnancy 42% (KPC 19, Figure 7) Pregnant Women: 4,776 HMIS) 42% 14 Pregnant Women: 5,307 HMIS, 50% 1(b).4 SAM: SAM: SAM: Proportion of discharges U5 from MAM and SAM treatment meeting Sphere Standards: Recovere d: 87.2% Died: 0% Defaulte d: 4.9% MAM: Recovere d: 79.6% Recovered: >75% Died: <10% Defaulted: <15% MAM: Recovered: >75% Recovered: >75% Died: <10% Defaulted: <15% MAM: Recovered: >75% Died: 0% Died: <3% Died: <3% SAM: % children U5 recovered % children U5 died % children defaulted Defaulte d: 0.1% (Monthly Nutrition Cluster Report, Novembe Defaulted: <15% 15 Defaulted: <15% 14 The health system is very weak in South Sudan and it is envisaged that it will take a number of years to build capacity of health personnel and to build the demand for ANC in pregnant women, this is why the targets only increase in 2015. 15 The targets laid out represent Sphere standards. South Sudan has been susceptible to periodic malnutrition spikes and we would expect to see MAM and SAM treatment indicators to vary as these spikes happen. The targets are to maintain Sphere standards, even when these spikes occur.
MAM: r 2012) % children U5 recovered % children U5 died % children defaulted 1(b).5 aged 12-23 who received DPT3 (Diphtheria, tetanus and pertussis third dose) according to the vaccination card or mother s recall by the time of the survey 24% 16 (KPC 21, Table 5) Children 12-23 : 3,716 HMIS, Monthly EPI Reports) 35% Children 12-23 : 6,367 HMIS, Monthly EPI Reports, 60% 1(b).6 aged 6-23 who received Vitamin A in the past 6. 28% (KPC 22) Children 0-23 : 14,860 HMIS, Monthly EPI Reports) 30% Children 0-23 : 21,229 HMIS, Monthly EPI Reports) 37% 16 Aweil West had 75% children receiving DTP3 according to the BSF Final Report, but it is suggested that figures for Aweil North are very low.
Health Inequality Outcome( s) 2(a). Increased ability of women to make decisions regarding the health and welfare of themselves and their children 2(a).1 aged 0-23 whose births were attended by a skilled birth attendant 10% (KPC 24 Table 10) 17 Children 0-23 : 6,369(Sour ce: HMIS) 15% Children 0-23 : 10,615(Sourc e HMIS, 25% 2(a).2 of mothers reporting decision making power specific to the feeding of their youngest child 70% (KPC 24) 7,641 Reports) 72% 7,960 Reports, 75% 2(a).3 of mothers reporting decision making power when their youngest child experience d fever, ARI and/or diarrhoea within the previous two weeks. 76% (KPC 25) 8,278 (Source 78% 8,490 80% 2(b). Women and children have access to free health care (no 2(b).1 Percent of health facilities 0% (Context ual Analysis 2012 pg Health Facilities: 3 Health Facilities: 10 17 There are 2 skilled birth attendants in Aweil West and 1 in Aweil North
registration fee)- (meso) providing free health care (no registration fee) for all at the point of service delivery 30) Monthly Supervisio n Reports, 10% Monthly Supervision Reports, 35% 2(b).2 of carers reporting that they accessed free health care. 0% (Context ual Analysis, 30) Carers: 212 Monthly Supervisio n Reports, Carers: 1,592 Monthly Supervision Reports, 2% 15% Health Risk and Vulnerabil ity Outcome( s) 3. Increased adoption and coverage of key preventative interventions and behaviours(mi cro) 3.1 aged 0-5 who were exclusively breastfed during the last 24 hours. 58% (KPC 31) Children 0-5 : 6,369 Nutrition 60% Children 0-5 : 6,898 Nutrition 65% 3.2 aged 6-23 who were fed an adjusted minimum acceptable diet (omission of milk feeds for non- 3% (KPC 33) Children 6-23 : 531 Nutrition 5% Children 6-23 : 1,061 Nutrition 10%
breastfed children). 3.3 of mothers age 0-23 who consumed iron tablets for 90 days during their last pregnancy 29% (KPC 26) 3,714 HMIS) 35% 4.776 HMIS, 45% 3.4 0-59 who are Underweigh t 18 22.1% Aweil West 24.5% Aweil North (AW: Pre Harvest Survey May 2012) AW: <5,417 children (20%) AN: <5,093 children (20%) (Source Nutrition AW: <4,077 children (15%) AN: <2,292childre n 19 (15%) (Source Nutrition AN: Pre Harvest Survey May 2011) 3.5 of mothers aged 0-23 16% (KPC Survey 27) 1,910 2,127 18 Definition of underweight: low weight-for-age index identifies the condition of being underweight for a specific age. WHO cut-offs and classification of malnutrition: < -1 ro. -2 Z-score: mild <-2 to >-3 Z-score: moderate <-3 Z-score: severe 19 Based on 2.2% annual population growth rate
who live in a household with soap who washed their hands with soap at least 2 of the appropriate times during the day or night 20. 18% 20% 3.6 of mothers aged 0-23 who know at least three effective ways of preventing HIV transmissio n 21 4% Women (KPC Survey 26) 1,061 mothers Endline KPC) 10% 1,582 mothers KPC 15% Baseline Plan Date Baseline (Completed by) December 2012 20 The KPC looked at behaviour rather than knowledge 21 The respondent group for the KPC is mothers or children 0-23. The survey looked at knowledge of ways of preventing HIV transmission