South Sudan nutrition: Overcoming the challenges of nutrition information systems
The health sector in South Sudan, the youngest nation in Africa, has been growing from strength to strength amid insecurity and emergencies that have affected the general nutrition situation. The Ministry of Health and partners are implementing various nutrition programmes and coordinating efforts to put in place a sustainable nutrition information system. In an interview with Titus Mung'ou, ENN Regional Knowledge Management Coordinator (SUN), Rebecca Alum William, the Director of Nutrition in South Sudan, and Shishay Tsadik, the Nutrition Technical Advisor seconded to the Ministry of Health by Save the Children International, discuss progress made.
Q: How would you summarise South Sudan’s current nutrition situation?
A: Overall, the nutrition situation in South Sudan is worrying, with global acute malnutrition (GAM) persistently above the emergency threshold in the Greater Upper Nile, Northern Bahr el Ghazal, Warrap states and Eastern Equatoria states (FSNMS, Dec 20161). According to the most recent national data, nearly one third of children under five years old are stunted, 23 per cent wasted, and 28 per cent underweight (SSHHS 2010)2. The prevalence of GAM varies seasonally and substantially across states, with peaks of up to 30 per cent in some locations.
From April to August 2016, a total of 26 county-level assessments were conducted; 81% of these assessments showed GAM rates above the 15% WHO emergency threshold. Based on the analysis, the GAM/Proxy GAM3 was ‘Extreme Critical’ (>=30% prevalence) in Aweil North and Aweil West, which were the only two counties with recent assessments4, and ‘Critical’ (15% to 29.9% prevalence) in Akobo, Twic East, Uror, Abiemnhom, Guit, Mayom, Mayendit, Panyinjar, Rubkona, Bentiu POC, Pariang, Longetchuk, Nasir, Maiwut, Ulang, Wau, Gogrial West and Gogrial East. Counties classified as ‘Serious’ (10% to 14.9% prevalence) were Kapoeta North, Melut, Maban and Tonj North, while Kapoeta South is in ‘Alert’ (5% to 9.9% prevalence).
The deterioration in the nutrition situation is primarily due to physical insecurity (which partly hinders the humanitarian response), the effects of the economic crisis, and depleted stocks from the last harvest. In the Greater Upper Nile, while conflict subsided in most areas, it persists in some pocket areas. Furthermore, the economic crisis (partly due to devaluation of the South Sudanese pound and exponential increase in food prices in 2016), coupled with persistent violence, notably in Wau and some parts of the Greater Equatoria, aggravate the malnutrition situation.5. Major additional contributing factors to malnutrition in the worse-off counties are sub-optimal Infant and Young Children Feeding (IYCF) practices and poor water, sanitation and hygiene (WASH) facilities and practices. Child-feeding practices, such as untimely introduction of complementary foods or poor quality and inadequate quantity of these foods, contribute substantially to the high levels of malnutrition. Additionally, low exclusive breastfeeding practices are a key contributing factor.
In the upcoming season (September to December 2016), the nutrition situation is expected to improve slightly in most counties due to the expected harvest, pasture and availability of milk. Admission trends to nutrition centres are also expected to decrease in most counties in the country during this season. However, taking into consideration the current existing burden of acute malnutrition, market price trends and the existing high level of conflict, the nutrition situation in Northern Bahr el Ghazal and Unity states are not likely to see significant changes and will likely remain in ‘Critical’ phase (GAM prevalence currently 15% and 29.9% respectively).
Q: Since joining the Scaling Up Nutrition (SUN) Movement in June 2013, what important steps have been taken and milestones achieved in South Sudan as a result of joining the Movement?
A: The Republic of South Sudan officially joined the global SUN Movement in 2013 after a letter of commitment was signed by H.E the Vice President. The letter expressed the political commitment from the Government of the Republic of South Sudan to scaling up nutrition in the country.
The SUN Movement was launched in the country with commitment to include nutrition in the Food Security Council so that it became ‘the Food and Nutrition Security Council (FSNC)’ in in 2013, the same year of the launch of SUN Movement. The FNSC is a high-level, multi-sector policy coordination platform chaired by H.E the President. SUN Movement activities have been slow since the launch, with limited progress in establishing the country’s SUN Secretariat and SUN networks, developing the National SUN Work Plan and other activities. This partly reflects the crisis which erupted in 2013, resulting in a refocus on humanitarian activities. However, revitalisation of the SUN Movement started again in April 2016. A six-month detailed work plan for revitalisation of the country’s SUN Movement was developed with a focus on conducting social mobilisation and advocacy, establishment of different SUN Networks, development of work plans for the networks, and development of a national SUN work plan. Factors that contributed to this revitalisation included nutrition being prioritised in Ministry of Agriculture and Health policies, strengthening of the Nutrition Directorate by the Ministry of Health (MoH), and United Nations (UN) agencies supporting a ‘rebooting’ of the SUN Movement in the country.
The South Sudan SUN Movement Steering committee was established in late 2015 with a responsibility to provide technical support to SUN networks and advise the SUN Focal Point, the Under-secretary in the MoH. This position is temporarily located in the MoH with its permanent location still under discussion. The steering committee is composed of UN agencies (UNICEF, WFP, WHO and FAO) and government line ministries chaired by the MOH Nutrition Director. The Steering committee conducts weekly meetings.
Media advocacy has been identified as one of the key strategies for advancing the SUN Movement in South Sudan. Through advocacy, it is hoped to reach out to the many stakeholders that can have an impact on nutrition in South Sudan, as well as inform them about SUN activities.
The establishment of multi-stakeholder networks including UN agencies, Donor, Civil Society, Academia/Research, and Business/Private Sector has begun.
Government SUN Focal Point and SUN representatives from MoH and Ministries of Agriculture and Finance have attended global and regional meetings and workshops for experience-sharing and learning exchange.
Q: In 2013, South Sudan nutrition actors noted challenges of nutrition information during emergencies and the need for a coordinated, validated Nutrition Information System (NIS). Significant and important changes were then made to validation of SMART surveys, OTP/SFP (Outpatient Therapeutic Programme/ Supplementary Feeding Programme) reporting harmonisation, IPC (Integrated Phase Classification) and FSMNS (Food Security and Nutrition Monitoring System). Have these improvements been maintained and what steps are being taken or are needed to strengthen NIS in South Sudan?
A: Yes, improvements have been made and maintained. There are efforts to integrate the NIS into the District Health Information System (DHIS) and Health Management information system (HMIS). Currently, nutrition information reporting formats, registration books and other tools are being developed and finalised in consultation with the Nutrition Information Working Group (NIWG). Nutrition information is then shared with the M&E Department of the MoH.
Together with the nutrition coverage network6 the MoH and Nutrition Cluster facilitated a lesson-learning workshop on how to maintain the capacity of partners and government actors to conduct coverage assessments for the treatment of SAM and MAM and maximise the use of coverage assessment results.
Beyond the traditional SMART assessments, there are initiatives to consider other monitoring mechanisms like the Integrated Food Security and Nutrition Causal Analysis (IFANCA), strengthening the FSNMS and IPC system for South Sudan which helps MoH to make informed decisions.
Q: How is the MoH undertaking its functions as the Secretariat of NIWG? What key lessons and challenges have MoH noted in coordinating activities with NIWG members?
A: In April 2015, the MoH assigned two national technical staff, together with the Nutrition Advisor seconded from Save the Children (SCI) working with the NIWG, to lead the overall coordination of the group. Moreover, there is an initiative to integrate NIWG’s Technical Working Group (TWG) into the MoH’s M&E Department, where all health and nutrition information activities are coordinated, to ensure sustainability of the function of NIWG. However, due to competing priorities, this may take time.
Q: In South Sudan, the NIWG officially reports to the Nutrition Cluster. How has this arrangement improved coordination of nutrition information?
A: The NIWG is still reporting to Nutrition Cluster, which is one of the limitations, since the MoH is unable to access, utilise and review the working group’s performance. However, the move to integrate within the MoH’s M&E Department will address this and provide a comprehensive database of assessment proposals and results.
Q: What is the role of the Government and key actors in sustaining the NIWG? How have SUN Movement actors/networks connected with NIS? Have SUN actors’ activities been influenced by NIS?
A: The Government and partners sustain the NIWG. Once the SUN networks are established, it is hoped that the NIS will help inform their planning and activities.
Q: How has the NIS helped shape policies and programmes in relation to country and global nutrition targets?
A: The available information from SMART surveys, IPC, FSNMS and programme reports significantly helps nutrition stakeholders in resource mobilisation, planning and decision-making. However, most nutrition assessments focus on emergencies and the results don’t influence stakeholders in addressing longer-term nutrition resilience and protection responses.
Q: The need for advocacy by Nutrition Cluster partners to build MoH understanding of the importance of information systems in relation to preparedness and response planning was identified in 2013. Has it been addressed? How?
A: The MoH has started emphasising the critical importance of NIS. There are moves to integrate systems, as outlined earlier; NIS tools and indicators have been identified; and the MoH is looking for resources to train and build the capacity of health and nutrition service providers and personnel involved in data collection, reporting and analysis on how to use these nutrition information tools (mainly the reporting formats, registration books, monitoring and supervision checklists). The integration/harmonisation will critically allow for a central database within government that can be used for planning, decision-making and further research.
Q: How has MoH addressed the challenge of its capacity to lead and implement NIS and engage technically in NIWG? What progress has the MoH made in enhancing its capacity in information management?
A: The developments outlined so far reflect actions and progress made in this regard, such as moves to harmonise NIS within DHIS and HMIS, integrate the NIWG within the MoH’s M&E Department, and transition the Nutrition Cluster NIS to DHIS and HMIS. In terms of enhanced capacity, SCI seconded a Nutrition Technical Advisor to build capacity of the NIWG and NIS and the MoH has assigned two technical staff responsible to the NIWG who are receiving training supported by partners. The MoH has taken a leadership role as chair and co-chair of the NIWG and the MoH Nutrition department is working closely with the Nutrition Cluster team and partners.
Q: Overall, to what extent has strengthening of the NIS (helped by the Nutrition Cluster and largely driven by emergency programming needs) contributed to the aims and objectives of the SUN Movement and how could the existing NIS in South Sudan be strengthened to further enable SUN Movement aims and objectives?
A: The current NIS provides a means to understand the levels of malnutrition in South Sudan, the investments on nutrition, the gaps, priorities and the need for national and local government leadership to tackle the situation. However, in order to strengthen the contribution of NIS to the objectives of the SUN Movement, NIS should move beyond SMART, FSNMS and IPC to include assessments which involve a causal analysis of malnutrition. There is also a need for harmonised and standardised national SMART and coverage survey guidelines, in line with the international guidelines. Furthermore, the most recent national household survey (Demographic Health Survey) was conducted in 2010. This urgently needs updating, as there has been substantial change in the nutrition landscape over the past six years.
1World Food Programme South Sudan, Food Security and Nutrition Monitoring Report (FSNMS) bulletin 18 July 2016.
2South Sudan Household Health Survey 2010 Final Report, published August 2013.
3Proxy GAM is a term used to denote findings from rapid nutrition assessments where conditions often involving insecurity have prevented standard ENA SMART methodologies being used.
4August 2016 Aweil North and Aweil West exhaustive MUCA screening result.
5World Food Programme South Sudan, Food Security and Nutrition Monitoring Report (FSNMS) bulletin 18 July 2016.
6The Coverage Monitoring Network is an inter-agency programme implemented by ACF UK and its partners Concern Worldwide, Helen Keller and International Medical Corps. The project aims to improve nutrition programmes through the promotion of quality coverage assessment tools, capacity-building and information sharing in nine priority countries in Africa and Asia, including South Sudan.
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Reference this page
Titus Mung'ou (2016). South Sudan nutrition: Overcoming the challenges of nutrition information systems. Field Exchange 53, November 2016. p73. www.ennonline.net/fex/53/southsudannutrition