South Sudan Nutrition cluster 2017: famine lessons learnt
By Isaack Biseko Manyama
Isaack Manyama is the Nutrition Cluster Coordinator for South Sudan. He has 24 years’ experience in the nutrition sector. Previous roles have included Team Leader of the Emergency Coordination Unit (ENCU) in the Early Warning and Response Directorate of the Ministry of Agriculture in Ethiopia, Primary Health Care Officer for UNICEF Tanzania and Senior Nutritionist at the Tanzania Food and Nutrition Centre.
This article was prepared by the Nutrition Cluster Coordinator with input from the Food Security and Livelihoods Cluster Coordinator on the Impact of Rome call for Action, and UNICEF and WFP nutrition sections that reviewed and enriched the article.
The findings, interpretations and conclusions in this article are those of the authors. They do not necessarily represent the views of UNICEF, its executive directors, or the countries that they represent and should not be attributed to them.
Location: South Sudan
What we know: South Sudan is affected by a chronic complex emergency characterised by ongoing conflict, widespread acute malnutrition and food insecurity, disease outbreak and limited access to those affected.
What this article adds: Famine was declared in February 2017 in two counties in South Sudan, which sparked a strong humanitarian response, including nutrition. A minimum life-saving nutrition response package was agreed with nutrition cluster partners, linked with health; food security; and water, sanitation and hygiene (WASH), and using existing and new strategies including mobile response, inter-cluster and integrated rapid response mechanisms, and blanket supplementary feeding programmes (BSFP) in the targeted SFP sites. Famine was averted within four months in two counties and prevented in two others. Critical success factors included strong inter-cluster coordination at national and sub-national level, active information management and gap analysis/filling, good triangulation of food security and nutrition information and two-way communication with partners on the ground. The April 2017 Rome call for action on integration reinforced and heightened pre-existing inter-sector collaboration and partnership, catalysed development of an early warning tool to prompt preventive action, and increased funding availability. Challenges to achieving ambitious country actions on integration included sector-specific shortfalls in funding, short time frames to implement, and workload. To prevent famine, separate thresholds to guide decision makers, donors and technical humanitarian community to initiate early actions/responses are needed.
Since 2013 until now, the Republic of South Sudan has experienced a complex emergency characterised by ongoing and spreading conflict; widespread acute malnutrition at county-level (most of which is at critical levels); increased food insecurity reaching up to 50% of the population by May 2017; prevalence of morbidities and disease outbreaks; and limited access and insecurity for humanitarian services. This has resulted in increased humanitarian needs in all sectors. The food and nutrition situation deteriorated further in 2017 in some parts of the country leading to a declaration of famine in February 2017 in two counties (Leer and Mayendit) with two other counties (Kouch and Panyijar) at famine tipping point (Integrated Phase Classification (IPC) 4).
Following the declaration, humanitarian responses including nutrition activities were initiated with concerted efforts by all partners, including generous funding from donors, which resulted in famine being averted within four months. In April 2017, the Rome call for integrated action to prevent famine in South Sudan reinforced pre-existing collaboration and partnership. Lessons learned from the overall famine prevention/response regarding coordination, information analysis and triangulation, and response are shared in this article.
Following the declaration of famine in February 2017, a dedicated coordination forum chaired by the Nutrition Cluster Coordinator (NCC) was formed. The forum was based in Juba as it was not possible to bring all the partners together in Bentiu town due to security and access concerns. Any partner intending to contribute to or participate in the nutrition response had to go through the cluster coordination team, which was observed by partners in all but a few cases. This prevented duplication and ensured a coordinated nutrition response. Overall, UNICEF, as cluster lead agency (CLA) ensured the presence of a strong coordination team at Juba level and at sub-state level in Bentiu (comprised of operational partners located nearby) that rallied all partners to work together guided by the principles of partnership - equality, mutual accountability, transparency, responsibility and results-orientation, with each partner successfully fulfilling their respective roles.
A minimum life-saving nutrition response package was agreed with Nutrition Cluster partners that included community-based management of acute malnutrition (CMAM); maternal, infant and young child nutrition (MIYCN); deworming; and vitamin supplementation in areas that had not been reached, through campaigns or during Integrated Rapid Response Mechanisms (IRRMs) (see article in this issue of Field Exchange that elaborates on this and other response mechanisms in South Sudan). This was complemented by malaria treatment in outpatient therapeutic programmes (OTPs) and health facilities for children with severe acute malnutrition (SAM). Multiple response strategies included static services; mobile/outreach services; IRRMs implemented by UNICEF and the World Food Programme (WFP); inter-cluster response mechanism (ICRM) coordinated by the United Nations Office for the Coordination of Humanitarian Affairs (OCHA); and the Multi-sectoral Emergency Team (MET) and Emergency Response Team (ERT) implemented by Action Against Hunger (AAH) and Medair respectively. In addition, integrated community case management (ICCM) was implemented by Medair in Leer and the International Rescue Committee (IRC) in Panyijar. Mass screening and treatment of SAM and moderate acute malnutrition (MAM) in selective feeding programmes (Outpatient Therapeutic Programme (OTP) and Targeted Supplementary feeding Programme (TSFP)) of children under five years with acute malnutrition and pregnant and lactating women (PLW) prevented further deterioration. The use of a combination of response strategies enabled reach to affected populations both in accessible and difficult to reach/inaccessible/under-served areas. For example, IRRM/ICRM missions were implemented in 17 locations (14 by IRRM and three by ICRM) that were not easily accessible reaching a total of 28,9841 with lifesaving interventions (Vitamin A supplementation, deworming, infant and young child feeding in emergencies (IYCF-E) key messages) of which 2,9072 were treated for SAM and MAM.
Situation monitoring, analysis and triangulation
A combination of nutrition situation monitoring mechanisms were used, ranging from weekly admission trends analyses in OTP and TSFP sites, and SMART surveys implemented by partners under the coordination of the cluster coordination team through the Nutrition Information Working Group (NIWG). The weekly monitoring and analysis of OTP and TSFP new admission trends during the famine period provided timely understanding of how the nutrition situation was evolving and enabled effective decision making. Sharing and publication of weekly admission trends in a dedicated famine bulletin in April 2017 by the Nutrition Cluster enhanced trust, transparency and confidence on the information provided to stakeholders.
In addition, the Nutrition Cluster, through the NIWG, coordinated implementation of SMART nutrition surveys in Leer, Panyijar and Kouch. The survey results in Panyijar and Southern Leer counties in March and April 2017 respectively, indicated lower prevalence of acute malnutrition that was consistent with decreasing admission trends in OTP and TSFP selective feeding programmes.
Information sharing and communication
One limitation of the coordination process was the lack of field/ground-level information and experience sharing between partners due to insecurity and lack of access. Coordination between partners would be greatly improved by the recruitment of a focal point person who could visit partners in their operational sites. The experience also revealed the importance of consultation with all stakeholders before major decision-making takes place, with respect to introducing or starting a new response strategy or initiative. This should be a two-way process, so that strategic decisions made at lower levels are brought to the attention of senior management of respective cluster lead agencies to achieve common understanding and buy-in. Two-way information sharing and communication should also be strengthened between national and state or sub-state levels and should be cross-checked using different communication channels.
Improvements in situation monitoring, analysis and triangulation
The use of mechanisms to facilitate situation monitoring was effective. It is important to ensure that the description of the nutrition situation is consistent across different sources of nutrition information. For example, admission trends were consistent with SMART survey findings in Leer and Panvijar. This avoids confusion, enhances trust and confidence in the information and the coordination team. In the future, where it is not possible to conduct regular monitoring and supervision, joint monitoring would be very useful. In this scenario, a group of partners would together visit another implementing partner’s site once per month to identify issues, agree on corrective action together, and put things right following the recommended protocols. While this was not implemented during the recent response, the cluster is encouraging all state level focal points to initiate this approach in collaboration with respective cluster partners.
Rapid integrated response to avert famine
A key lesson learned from the response is that famine can be averted within a short time period. In this case, within four months an integrated response (involving food security; nutrition; health; WASH) was implemented at scale with good coverage of beneficiaries using multiple responses strategies. For example, the number of OTP and TSFP sites increased by 62% from 37 in February 2017 to 60 in May 2017 while TSFP sites increased by about 54% from 41 to 63 during the famine period. The increase in nutrition sites enabled selective feeding programme enrolment of 8,859 children with SAM and MAM in the four counties, while blanket supplementary feeding programming (BSFP) reached 362,921 under-fives and 33,896 PLW in Unity State during the same period. Meanwhile, a total of 4373 PLW were also enrolled in TSFP.
“Thinking outside the box” by introducing new response strategies also worked. For example, WFP in collaboration with partners implemented a blanket supplementary feeding programme in the targeted supplementary feeding programme (TSFP) sites in three counties (Leer, Mayendit and Panyijar). This strategy ensured that under-five children and PLWs accessed BSFP supplies (CSB++) in-between general food distribution rounds. The Nutrition Cluster partners believe this key intervention prevented children from becoming moderately acutely malnourished and accelerated improvement in the nutrition situation in the famine affected counties.
Another important lesson learned is that the declaration of famine should not wait for coordination meetings to occur and higher level decisions to be made, but should be guided by early warning information before famine tipping points or thresholds are reached.
Another important lesson learnt is that famine can be prevented if multi-sectoral, multi-year, flexible and timely funding is provided to humanitarian and respective authorities that can build and restore resilience of the affected communities. This calls for unrestricted access, ensuring security and protection for humanitarian actors, especially in famine linked with conflict dynamics.
Effective use of coordination mechanisms
Gap analysis and filling was a regular point on the agenda during weekly cluster famine coordination meetings. In this way, the NCC tracked gaps and commitment of partners to fill them, holding them accountable to agreed time frames. This made partners more accountable to themselves, to the cluster coordination team and to the affected population.
The ICRM provided an opportunity to partners that were not operational in the famine affected counties to participate in the famine response. This alleviated pressure on the cluster coordination team and avoided competition between partners for implementation of response in the affected counties. Collaboration between new and existing partners was also encouraged through the cluster coordination team, one such example being the collaboration that was established in Leer county between Save the Children International (SCI) and Nile Hope. Since Nile Hope was already implementing OTP in the county, SCI through the cluster, agreed to establish a Stabilisation Centre (SC) in Nile Hope operational areas, trained Nile Hope staff and provided infrastructure construction materials and other SC supplies.
Pre-existing capacity and coordination
The presence of partners and on-going nutrition response programmes prior to the famine enabled a timely response. The existing response was accelerated/scaled up through amendment of project cooperation agreements (PCAs)/field-level agreements (FLAs), rather than starting from scratch (e.g. recruitment of staff, establishing an office base, communication arrangements). There was also pre-existing collaboration and partnership between cluster coordinators for WASH, health and nutrition, which had initiated an integrated response plan even before the famine was declared.
Availability of adequate supplies
UNICEF and WFP, the core pipeline partners, ensured that adequate supplies were made available to support the response. In some situations, supplies were relocated from non-famine areas to optimise availability of supplies in the famine affected counties. Prioritised transportation of surge staff by the United Nations Humanitarian Air Service (UNHAS) and delivery of supplies by the Logistics Cluster also ensured timely availability of supplies at site level. This enabled most malnourished children to complete their treatment regimen without or with minimal supply interruption. Use of expanded criteria3 enabled the Cooperating Partners (CP) to manage the cases of acute malnutrition when one of the nutrition commodities was not available. The expanded criteria have been applied both for regular nutrition responses and during IRRM missions. For example, they have been used in Leer county (Padeah, Thonyor), in Mayendit (Mayendit centre, Dablual, Rubkuay, Thaker) and in Koch (Ding ding) where Ready to Use Supplementary Food (RUSF) from WFP was used to treat both SAM and MAM for at least one month.
Thresholds for declaring famine and initiating response
Robust analysis and triangulation of food security and nutrition information is key in declaring famine. For confidence, trust and transparency, the thresholds for declaring famine should be reached. However, it can be challenging in a conflict context, characterised by insecurity and access constraints, to have reliable and accurate information to conclude beyond doubt that famine thresholds for the three indicators (food security, acute malnutrition and mortality) have been met. In such situations, use of plausible proxies should be recommended after vetting by respective experts.
There is a need for a composite index to guide early response based on early warning information. Prevention of famine implies early analysis of warning information and implementation of preventive actions. Relying on current famine thresholds may imply that the humanitarian community is waiting for thresholds to be reached before scaling up responses. New famine prevention thresholds are needed that use a composite index of famine-like conditions that will trigger early actions, such as increased funding from donors and advocacy with the media. Any stakeholder that does not fulfill its responsibility in this regard should be made to account for failing/ignoring the need to prevent famine.
Impact of the Rome call for action
The Rome call for action on promoting an integrated famine prevention package had a noticeable added value to the coordination and implementation of integrated responses in South Sudan. First, the need for working together was reinforced and was part of regular agenda in the ICWG meetings and through IRRM and ICRM responses mechanisms. Second, it increased the understanding of the importance of partnership, building relationships among the clusters and organisations, bringing synergies and complementarity among all the humanitarian responses and actors to a level that had not been previously achieved. Third, the call highlighting the need for timely response, initiated the discussions for developing a composite indicator to guide early response based on early warning information. Fourth, while donors immediately provided increased funding to respond to the famine before the Rome call for action, some partners received additional funding and surge capacity following the Rome call.
Many actions were discussed and initiated following the Rome call for action. An important activity was initiation of the buy-in process at country level that involved holding meetings with cluster lead agencies (FAO/WFP and UNICEF), cluster partners (FSL and Nutrition), and circulation of the 16 points of the call for action to all cluster partners. One key action outcome was the development of integrated action plan and commitment from stakeholders and clusters (Health, Nutrition, FSL and WASH) on prevention of famine that did not previously exist.
FSL and Food Security and Nutrition Monitoring Report (FSNMS) methodology was revised to collect information at county level rather than just at state level as was previously the case. Nutrition SMART surveys were also conducted at county level in selected counties as part of the FSNMS assessments. Capacity building was conducted with both partners and government on FSNMS assessments across the country. The Rome call also reinforced the implementation of targeted General Food Distribution (GFD) as opposed to a blanket approach. For example, enrolment of families of children discharged from selective feeding programme into targeted GFD.
Other important actions included development of an early warning tool by REACH that provides an analysis framework for preparing a localised severity index that in turn guides the IPC and ICWG in prioritising response actions.
A couple of challenges were noted in the process of implementing the Rome call for action. It was viewed by country stakeholders as a ‘top down’ initiative driven by headquarters, as there was limited involvement of humanitarian partners in South Sudan in the development of the call for action. The implementation of the developed action plan included meetings that increased workload, adding to already planned activities in the HRP and other initiatives. The implementation plan was overly ambitious; in practice, many actions were planned for implementation within a short period that proved unrealistic. Limited funding for some of the clusters was one of the major challenges and impaired the call for integrated responses. For example, as of October 2017, the Nutrition and FSL clusters were funded at 62% and 73% respectively; WASH and Health clusters were still trailing at below 30 percent.
Thus while the call for action implied increased need for resources, existing funding requirements were not even being met. It is even more challenging funding long term development activities with short term/emergency funding resources designed for reactive responses.
Key lessons learnt from the 2017 famine response in South Sudan can be emulated in similar or different famine contexts. The need for a strong cluster coordination team and early initiation of coordination mechanisms that engages all stakeholders in major decisions and that has two-way communication cannot be overstated. Timely multiple nutrition response and strategies integrated with other sectors that are implemented at scale can avert famine in a relatively short period. However, this calls for all sectors/clusters to be adequately and timely funded; one sector alone will achieve very little. Perfection should not be the enemy of the good. Good analysis and triangulation is critical in declaring famine to win confidence of all stakeholders and key decision makers, and to ensure transparency. Separate thresholds to guide decision makers, donors and technical humanitarian community to initiate early actions/responses for preventing famine are needed.
The Rome call for action re-revigorated the need for strengthened partnership resulting in development of an integrated action plan focusing on food security and nutrition with input from WASH and Health clusters. The need for engaging all key stakeholders in the development of such initiatives is key for buy-in at county level, ownership and continuity of the proposed actions.
For more information, contact: Isaack Manyama
1UNICEF/WFP Integrated mission reached 25,714 children and the remaining 3,270 were reached by ICRM
2UNICEF/WFP treated 2,474 SAM and MAM cases and the remaining 433 were treated by ICRM
3Expanded criteria are used when one of the nutrition supplies, either Ready to use Therapeutic Food (RUTF) or RUSF, is used to treat both children with either SAM or MAM for a short period jointly agreed by UNICEF/WFP/operational partner and the cluster coordination team. This decision is reached only when either RUTF or RUSF is unavailable/or there is shortage for a short period, e.g. for one month.
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Reference this page
Isaack Biseko Manyama (2018). South Sudan Nutrition cluster 2017: famine lessons learnt. Field Exchange 56, December 2017. p59. www.ennonline.net/fex/56/southsudanfaminelessonslearnt