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Nutrition programming in conflict settings: Lessons from South Sudan

By Mercy Laker and Joy Toose

Mercy Laker worked as the Health and Nutrition Technical Lead for World Vision South Sudan from October 2014 to April 2016. She is currently the Health and Nutrition coordinator for Care South Sudan.

Joy Toose is an Emergency Communications Specialist with World Vision International.

Location: South Sudan

What we know: Violent conflict typically contributes to increased malnutrition levels and challenges humanitarian response.

What this article adds: Challenges to CMAM implementation encountered by World Vision in conflict-affected South Sudan included stretched government capacity, underfunding, supply chain interruptions, destruction of health facilities, limited staff capacity and compromised access. Adaptations made include investment in cluster coordination, development of alternative CMAM sites, training community volunteers, and pre-positioning therapeutic food. A multi-sector rapid response mechanism (RRM) was piloted to access hard-to-reach locations. Experiences show that flexibility and responsiveness are crucial in conflict settings; close coordination between sectors, including logistics, is essential; and predictable and long-term funding is necessary to sustain life-saving programming.

This article is based on a detailed case study by the authors available at:

Protracted hostilities in South Sudan have caused widespread displacement; high rates of death, disease and injury resulting in disrupted livelihoods; severe food insecurity and a major malnutrition crisis.1 Even before the current conflict began, the nutrition situation was chronic. Of 21 counties assessed during the 2013 lean season, 17 had global acute malnutrition (GAM) rates above the emergency threshold of 15%.

Between December 2013 and February 2015, the number of children suffering from severe acute malnutrition (SAM) doubled to more than 229,000.2 In the worst-hit areas Greater Upper Nile, Warrup and Northern Bahr el Ghazal in 2015, nearly one in three children under five were malnourished. The malnutrition situation was classified as critical (GAM between 15 and 29 per cent) or very critical (GAM above 30 per cent) in more than half the country. Since the beginning of the conflict in December 2013, more than 1.5 million people have been displaced internally, including more than 800,000 children.3 People fleeing their homes are forced to abandon their fields and livestock. Many have sought refuge on UN peacekeeping bases or other informal settlements and can no longer grow crops or tend livestock.

The majority of South Sudanese families rely on emergency food assistance to survive. Those not displaced by fighting have faced difficulties in sowing crops due to interruptions in trade and supply corridors for seeds and supplies. Deteriorating food security is compounded by lack of access to clean water, sanitation and basic healthcare, increased prevalence of disease, and negative impact on feeding practices.

Partnering with United Nations (UN) agencies and other non-governmental organisations (NGOs), World Vision’s response to the malnutrition crisis in South Sudan is multi-sectoral. The community-based management of acute malnutrition (CMAM) model is used to treat severe and moderate acute malnutrition (SAM/MAM), complemented by food assistance, agricultural initiatives to increase food production and improved access to safe water, sanitation and basic healthcare to children under five years of age and pregnant women.  This article documents how World Vision’s nutrition team worked with the nutrition cluster through 2014 and 2015 to adapt its CMAM programme to overcome the challenges faced in South Sudan.

Contextual challenges and programme adaptations

A combination of vast geographical area, poor infrastructure and an unpredictable security situation makes South Sudan one of the most challenging and costly operating environments.4Contextual challenges for conventional CMAM programming, and adaptations made by World Vision to respond to them, include the following:

Gaps in coordination

In February 2014, a Level 3 Humanitarian System-Wide Emergency Response was declared in response to the crisis. This reflected the scale, complexity and urgency of the crisis and the inability to implement effective response without system-wide mobilisation. Due to the fragility and stretched capacity of the South Sudan Government and Ministry of Health (MoH), the bulk of leadership and service delivery was taken on by the UN and partner NGOs.5 Where CMAM programming would usually seek to align with and complement an existing MoH strategy and operations, in South Sudan much of the strategic planning and day-to-day coordination relies on support from UNOCHA (United Nations Office for the Coordination of Humanitarian Affairs) through the humanitarian country team and the sector cluster groups.

Gaps in multi-sector resources

The response in South Sudan has been consistently underfunded. In 2015, only 41 per cent of the required US$1.6 billion had been committed.6 Stretched resources left gaps in the system-wide response.

Adaptation: In the context of these capacity and resource challenges, it is more important than ever for humanitarian agencies to actively participate in the cluster system. This demands agency commitment to attend the bi-weekly cluster meetings and ad hoc sessions addressing specific operational issues, improve focus on HRP targets, and leverage limited resources. World Vision’s nutrition team also prioritised cluster reporting that ensures better coordination of programmes and helps identify and address gaps or target areas.

Breakdown in ready-to-use-therapeutic food (RUTF) supply chain

Supplies for targeted supplementary feeding programmes (TSFP) were provided by WFP, and supplies for outpatient therapeutic programmes (OTP) and stabilisation centres (SCs) were procured through UNICEF. Stretched resources, poor road access and on occasion insecurity often resulted in breakdown of the supply.

Adaptation: World Vision secured alternative supplies from Canadian and US offices as gifts-in-kind, creating a successful buffer to protect programming.

Poor local health infrastructure

The impact of the current conflict on health infrastructure in South Sudan surpasses that of the two-decade civil war that ended in Sudan’s independence. Where fighting has spread, health facilities have been destroyed. Before the crisis, there were more than 300 outpatient treatment centres across the country; by mid-2014, the number had dropped to 183. Access to other programmes addressing acute malnutrition has also declined drastically. Where health facilities still operate, they face significant challenges, including lack of resources for training, low and irregularly paid wages, a lack of supervision at all levels, and high staff turnover.

As a result, humanitarian agencies often struggle to find an appropriate base for CMAM operations and access to referred services for children or pregnant women who require additional medical support. Referred children and pregnant women often have difficulty accessing services or medication due to distance or cost.

Adaptation: In areas without a functioning health facility, World Vision invested in a network of community nutrition volunteers and secured alternative sites such as places of worship for CMAM activities, often transporting equipment and RUTF supplies in and out on an ongoing basis; a challenge that is exacerbated by humanitarian access issues (see below.)

This situation also interferes with capacity-building of local health staff, essential for the sustainability of the programme, which should ultimately transition to local health services.

Adaptation: With capacity-building of local health services out of reach in many areas of operation, the focus is on building community capacity through volunteers who actively participate in case-finding, referrals and follow-up.

However, this community capacity-building does not allow for transition of CMAM responsibilities to government. World Vision acknowledges the need and has continued to resource and respond with CMAM interventions in some of the most hard-to-reach locations in South Sudan.

Access and population movement

Humanitarian access to populations is hindered by lack of infrastructure in South Sudan and by ongoing conflict as fighting prevents staff from travelling to affected communities. Poor road access and flooding during the rainy season, combined with the lack of secure storage for RUTF, can mean that supplies must travel long distances by boat and by foot – increasing the time, cost and risk of programming. This can result in programme activities being delayed or suspended. In addition, the nomadic lifestyle of South Sudanese means high mobility even in the relatively stable locations, while the onset of conflict resulted in recurrent massive population displacements. The fluidity can make it difficult to achieve the eight weeks of contact required for CMAM treatment.

Adaptation: The CMAM project model offers some measures which mitigate these impacts:

  • Increasing the ration of RUTF to malnourished children – providing two or more rations, rather than one week’s supply, when fighting is predicted.
  • Training community volunteers to monitor the children receiving treatment and help ensure that children receive additional rations if access is impossible.
  • Where health facilities are being used, positioning supplies during the dry season before roads become flooded and inaccessible.

Rapid response mechanism (RRM)

In partnership with other humanitarian actors in South Sudan and with funding from the Common Humanitarian Fund (CHF), World Vision trialled a multi-sector RRM to meet the critical needs of displaced populations in hard to-reach areas of the most affected states. RRM missions deploy mobile teams of nutrition water, sanitation and hygiene (WASH); health; child protection; and education technical specialists. (see Figure 1).

Figure 1: Objectives of the multi-sector rapid response team


Through RRM, between July 2014 and March 2015 World Vision established 14 OTP sites across Unity and Upper Nile States (exceeding the projected 13). It screened 25,729 children for malnutrition, treated 825 children for MAM (through supplementary feeding programmes), and 301 children for SAM through OTPs. It trained 142 community nutrition volunteers in CMAM and infant and young child feeding in emergencies; 36 health workers in CMAM; and 180 mother-to-mother support group leaders.

What we learned

In some locations, RRM provided beneficial complementarity surge capacity for existing CMAM programmes. In Bol and Otego districts in Fashoda, for instance, the RRM greatly increased the coverage of existing CMAM programmes through mass MUAC (mid-upper arm circumference) screening and referral of identified children to the existing OTPs for follow-up.

The RRM was quick to fill gaps when a partner was phasing out; for instance, when Médecins Sans Frontières pulled out of Fashoda, the RRM took over the OTP sites in Lul and Kodok. In Koch, the RRM made an impact on the hard-to-reach districts of Nobor and Gany, where the existing partner could not reach. In addition, World Vision’s mobile RRM team took part in inter-agency needs assessments, including Kaldak and Canal, and pre-positioned non-food items (NFI) and food items in Rumbek to support activities in Canal and Khorfulus.

In locations where the RRM team trained community nutrition volunteers and mother-to-mother support groups, the number of children screened and enrolled tended to be higher and there was better follow-up of children even after provision of the RUTF. In Melut and Manyo, for instance, volunteers and health workers continued to monitor and provide food to registered children, even after the project phase-out.

In remote RRM sites where the caseload was very high with limited partner capacity, World Vision sought additional funding from other donors to establish a longer-term presence, such as the mission in Koch, Unity State, which was later funded by Irish Aid for one year before being transitioned back to World Relief after the caseload was contained and capacity built.

Flexibility and sensitivity to a changing operational context were key to achieving some targets, such as establishment of 14 temporary OTP sites using tents rather than semi-permanent structures as stipulated in the proposal. Complementarity with other existing programmes was critical in achieving project objectives.


Although the RRM was meant to support existing nutrition programmes, it was sometimes misunderstood as replacing, rather than complementing, static programmes. In some instances, this resulted in territorial tendencies, with partners on the ground claiming universal coverage even when communities and the County Health Department (CHD) reported otherwise. This affected operations.

The project design underestimated logistical challenges around accessing hard-to-reach locations. Some proposed locations were completely inaccessible in the rainy season, and the logistics cluster was sometimes overstretched with numerous priority locations and limited air equipment. Consequently, several planned activities were not executed.

During design, it was difficult to make accurate caseload projections due to ongoing displacements, hence lack of accurate population numbers, while lack of prevalence and incidence data resulted in overestimations. For instance, although the project exceeded its target number of children screened, the proportion admitted to OTPs was significantly lower than expected.

Low RRM coverage in some locations was due to changing contexts, with unanticipated drops in the incidence and prevalence of acute malnutrition in targeted areas. It is also possible that some malnourished children were not reached due to insecurity and population movements. For instance, operations in Canal County were suspended due to recurrent insecurity.

Some proposed interventions were not appropriate for the RRM model. For example, constructing semi-permanent OTP sites was not possible due to difficulties finding skilled contractors and transporting materials to the hard-to-reach locations and insecurity.

Inability to access commodities sometimes prevented the implementation of certain components of CMAM; better early integration with the mobile food aid team could have mitigated this.


Development of terms of reference (ToR) for the RRM prior to implementation and popularising it among partners would have resulted in more success; the RRM technical working group later developed a ToR. More flexibility would enable partners to implement the RRM, allowing it to happen where there are no field-level agreements or partnership corporate agreements in place. Further integration of food-aid mobile teams and nutrition RRM teams would enable partners to implement the full continuum of CMAM, including interventions to prevent malnutrition. The logistics cluster must prioritise its support; hard-to-reach locations present major logistical bottlenecks which partners cannot always overcome alone. Outsourcing services during peak seasons can result in more effective responses in future. Inter-cluster collaboration is needed to jointly develop an RRM roster to regulate activities. This will enable better coordination among the partners’ various rapid response teams. Mapping of capacity gaps among partners prior to RRM design would help identify specific areas of intervention, avoiding conflict and duplication of activities. Finalising the ToR for the RRM and ensuring it is widely disseminated to all partners will enable common understanding of the mutual benefit the model brings.

CMAM for child survival amid conflict: Results

In 2014, World Vision successfully treated 8,964 children; 3,537 for SAM and 5,437 for MAM through CMAM. World Vision operated three SCs and 33 OTPs in Warrap and Upper Nile states. Food security interventions and WASH projects reached 190,152 people during the same period. This response continued in 2015. Despite disruption of services due to eruptions of violence, World Vison managed to reach more than 235,000 people with food assistance; 97,000 people with WASH interventions; and 26,000 children and pregnant or lactating mothers with treatment for malnutrition. In the 2015 calendar year, humanitarian actors have reached 757,435 people with nutrition interventions. Without interventions across these key areas, the current level of food security and nutrition in South Sudan would be far worse.

Lessons learned

Three higher-level themes emerged in South Sudan that may be relevant to nutrition programming in other conflict-affected contexts:

  • Flexibility and responsiveness is crucial in the context of protracted conflict, with teams empowered to respond to rapidly changing conditions. On-the-ground nutrition teams must also have support to design and test new initiatives to overcome challenges. They should also be accountable for capturing and sharing the results and learnings of these initiatives.
  • Close coordination within and between NGOs, the UN and humanitarian clusters is essential given weakened national infrastructure. Ongoing insecurity and humanitarian access issues mean significant support from UNOCHA and the logistics cluster is required to assist with access negotiations and to deliver nutrition programmes.
  • In the absence of transitioning capacity to local actors, predictable and long-term funding is essential to sustain critical programme delivery and expert staff retention.

World Vision’s experience in South Sudan shows that CMAM remains a critical tool for addressing emergency levels of GAM in a conflict-affected context. Direct treatment of malnutrition is crucial to protect children from death and give them (and ultimately their country) the best chance of a secure future.7

For more information, contact: Joy Toose, email:



1 UNOCHA; South Sudan Humanitarian Response Plan 2015.


2 UNICEF; South Sudan on the edge of nutrition catastrophe if hostilities don’t end now. UNICEF Press Release 4 February 2015.


3 UNICEF; South Sudan Humanitarian Situation Report 23 April 2015.


4 GHA; South Sudan: Donor response to the crisis, (2014) 4.


5 WHO; WHO responds to health crises facing war-wracked South Sudan, (September 2014); Ministry of Health, Health sector development plan 2011–2015, Government of South Sudan, (2011).


6 GHA; South Sudan: Donor response to the crisis, (2014) 4.


7UNOCHA; South Sudan: Humanitarian dashboard, 15 June 2015).


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Mercy Laker and Joy Toose (). Nutrition programming in conflict settings: Lessons from South Sudan. Field Exchange 53, November 2016. p2.



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