Mareang and Paguir Final Report 2006

South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER FIVE YEARS OLD

FINAL REPORT MANKIEN AND TAM PAYAMS, MAYOM COUNTY, UNITY STATE.

17TH OCTOBER- 10TH NOVEMBER, 2006

Onesmus Muinde- Assistant CMN Monica Asekon– Nutritionist Imelda .V. Awino – Nutritionist Deborah Morris – Program Assistant.

ACKNOWLEDGMENTS

ACF - USA acknowledges the vital and invaluable support of the following:

European Commission for Humanitarian Aid (ECHO) for funding the nutrition assessment

Sudan Relief and Rehabilitation Commission (SRRC) in Lokichoggio, Mankien and Tam payams for facilitating the work in the field.

World Relief in Mankien for their unlimited and overwhelming support in terms of accommodation and upkeep.

The local surveyors for their dedication, team spirit and hard work despite the various challenges encountered.

To mothers and caretakers, local authorities, and community leaders for their commitment, co-operation and dedication without which the survey would not have been a success.

TABLE OF CONTENTS .I. EXECUTIVE SUMMARY...... 4 .I.1. INTRODUCTION ...... 4 .I.2. OBJECTIVES OF THE SURVEY ...... 4 .I.3. METHODOLOGY...... 5 .I.4. SUMMARY OF FINDINGS...... 5 .I.5. RESULTS OF THE NUTRITION SURVEY ...... 7 .I.6. RECOMMENDATIONS...... 7 .II. INTRODUCTION ...... 9

.III. METHODOLOGY ...... 10 .III.1. TYPE OF SURVEY AND SAMPLE SIZE ...... 10 .III.2. SAMPLING METHODOLOGY ...... 10 .III.3. DATA COLLECTION ...... 10 .III.4. INDICATORS, GUIDELINES, AND FORMULA’S USED...... 11 .III.4.1. Acute Malnutrition...... 11 .III.4.2. Mortality ...... 11 .III.5. FIELD WORK ...... 12 .III.6. DATA ANALYSIS ...... 12 .IV. RESULTS OF THE QUALITATIVE ASSESSMENT ...... 12 .IV.1. SOCIAL DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS ...... 12 .IV.2. FOOD SECURITY ...... 13 .IV.3. HEALTH...... 16 .IV.4. WATER AND SANITATION ...... 17 .IV.5. MOTHER AND CHILD CARE PRACTICES ...... 18 .IV.6. EDUCATION ...... 19 .IV.7. ACTIONS TAKEN BY NGO’S AND OTHER PARTNERS...... 20 .V. RESULTS OF THE ANTHROPOMETRICS SURVEY...... 21 .V.1. DISTRIBUTION BY AGE AND SEX...... 21 .V.2. ANTHROPOMETRICS ANALYSIS ...... 22 .V.2.1. Acute Malnutrition, Children 6-59 months of Age ...... 22 .V.2.2. Risk of Mortality: Children’s MUAC...... 23 .V.3. MEASLES VACCINATION COVERAGE...... 24 .V.4. HOUSEHOLD STATUS ...... 24 .V.5. COMPOSITION OF THE HOUSEHOLDS...... 24 .VI. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY ...... 25

.VII. CONCLUSION ...... 25

.VIII. RECOMMENDATIONS...... 27

.IX. APPENDIX ...... 28 .IX.1. SAMPLE SIZE AND CLUSTER DETERMINATION...... 28 .IX.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE ...... 29 .IX.3. HOUSEHOLD ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE SHEET/HOUSEHOLD)...... 30 .IX.4. ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE SHEET/CLUSTER)...... 31 .IX.5. CALENDAR OF EVENTS IN MANKIEN AND TAM PAYAMS, MAYOM COUNTY...... 32 .IX.6. FOOD MARKET PRICES: MANKIEN AND TAM PAYAM, MAYOM COUNTY, NOVEMBER 2006...... 33 .IX.7. DISTRIBUTION OF BOREHOLES, SCHOOLS AND HEALTH FACILITIES IN MANKIEN AND TAM PAYAMS ...... 34 .IX.8. MAP OF MANKIEN AND TAM PAYAMS, MAYOM COUNTY ...... 35

.I. EXECUTIVE SUMMARY

.I.1. INTRODUCTION

Mayom County, in Unity State, the largest County in South Sudan1 is composed of 10 Payams namely Pub, Ngop, Bieh, Wurach, Wankai, Tam, Mankien, Ruaznyibol, Kueryiek and Madul Payams with Mankien Payam situated at the center of the County. Mankien payam is bordered by Bieh, Wankai and Madul Payams to the west, east and south respectively whereas Tam payam, approximately one hours drive from Mankien Payam borders it to the south east. The Payams in Mayom County are accessible through all weather roads with an improved transport facility of the vast public service vehicles plighting the routes daily.

Tam, formerly a cattle camp, became a Payam in April 2006 due to large population (34,558) 2 that hindered effective administrative management. Comparatively, Mankien Payam has a relatively smaller population (13,888) 3 and has a PHCC managed by World Relief. Additionally, Mankien Payam is Mayom County’ SRRC headquarter and commissioner’s base .The presence of oil fields in the Payam and an oil company are a plus to the community as this provides employment opportunity. Both Payams have army bases, open air markets stocked with both food and non food items.

Mankien and Tam payams are traversed by seasonal rivers and swamps, with flat terrain of black cotton clay soil. The impermeability nature of this soil predisposes the area to flooding during the wet season, which explains why the permanent buildings are elevated. Major inhabitants of these payams are the Nuer tribe of the Bul clan. They are mainly agro pastoralists and at times fish to supplement their food demands.

During the month of April, the food security situation in Unity state was indicated to have deteriorated: food stocks were depleted and the community was reported to be relying on coping strategies to obtain food and income4. To cope, the young adults moved to the oil fields in search of employment to supplement the household livelihood needs5.The report further indicated that the cattle, their major source of livelihood, were in poor condition, and needed to move to the cattle camps. Those are moreover closer to main rivers, and makes fish more easy to get to supplement their food needs. Additionally, malnutrition levels were reported to be very high in Unity state, especially in the rural areas where medical services are non-existent. Lack of proper knowledge of hygiene and child care practices are some of the main causes of malnutrition, even when food is available. After April, the food security situation in Unity state had continued to deteriorate, as the hunger gap progressed.

Due to the aforementioned reasons, ACF USA decided to implement a nutritional survey in the region in order to detect the actual nutritional situation.

.I.2. OBJECTIVES OF THE SURVEY

An anthropometric nutrition survey was carried out in Mayom County (Mankien and Tam payams) by ACF-USA from 17th October to 10th November 2006, with the following objectives:

To evaluate the nutritional status of children aged 6 to 59 months. To estimate the measles immunization coverage of children aged 9 to 59 months. To estimate the crude mortality rate through a retrospective survey.

1 Source: SRRC counterpart Mankien payam. 2 Source: SRRC counterpart Mankien payam and key community informants. 3 Source: SRRC counterpart Mankien payam. 4 WFP South Sudan Food Security and Livelihood Updates April 2006. 5 WFP SSD Food security and livelihoods update, May 2006

To determine underlying factors influencing the nutrition situation of the community.

.I.3. METHODOLOGY

A two-stage 30 by 30 cluster survey methodology was applied, from the estimated total population figure obtained for both Mankien payam (13,888) 6 and Tam payam (34,558) 7. The clusters were assigned to the accessible villages in both payams. Households in the villages were randomly selected and surveyed whereby; all the children aged between 6 and 59 months of the same family, defined as a woman and her children, were included in the survey.

Additional data was collected during the assessment period in the two payams: - Demographic data for the calculation of retrospective mortality rate, using SMART methodology. - Qualitative data on food security, water and sanitation, accessibility and utilization of health care services, as well as child care practices through observation and the use of standardized questionnaires.

.I.4. SUMMARY OF FINDINGS

Mankien payam, being the largest payam in size is the county’s headquarters for the SRRC, has an army base with a commissioner, an open air market, one PHCC runned by World Relief. Both Mankien and Tam payams are crisscrossed by seasonal rivers and swamps, with the presence an Oil company (China Oil Company) which has offered employment to the local community. There are a total of three schools in both Tam and Mankien payams.

Major residents of these payams are the Nuer tribe of the Bul clan whose main livelihood activities are cattle rearing, farming especially cereals more so maize and fishing mainly as coping mechanism when food stocks have depleted.

A number of international and indigenous NGOs had operations in the two payams at the time of assessment as follows:

World Relief runs four programs in the Mayom County namely health, HIV/Aids awareness, education and capacity building. Under the health program; World Relief operates 6 PHCUs in Mayom County and 1 PHCC at Mankien payam. Similarly, the organization supports education in Mankien payam through the provision of schools with learning materials such as exercise books, text books, chalks and offer acceleration studies (adult learning). Additionally, they offer capacity building to the community in the areas that they have operations for their sustainability through selection of locals who meet certain criteria and thereafter sponsoring their training.

Mercy Corps is implementing the Localizing Institutional Capacity in South Sudan (LINCS) in collaboration with International Rescue Committee with the aim of strengthening the institutional capacity of civil society organizations (CSO) that support marginalized groups. . MSF Holland operates an outreach clinic in Tam payam managed by trained CHWs. During the month October; they carried out mass measles immunization in Mankien and Tam payams in response to measles outbreak in the area.

Save the Children -UK supports orphans and children separated from their parents by providing non food items such as blankets, clothes and cooking utensils.

VSF Suisse have a satellite base in Tam payam and the organization runs a livestock program with the aim of disease control through disease surveillance, training the local community and vaccination of

6 Source: SRRC counterpart Mankien payam. 7 Source: SRRC counterpart Mankien payam and key community informants.

livestock .According to the organization Veterinary Field Supervisor for South Sudan, Malignant Catarrhal Fever (MCF), a viral disease that has no treatment nor vaccine, is the major cause of livestock mortality in Mayom County.

South Sudan Operation Mercy (SSOM) an indigenous NGO partnering with FHI (Food for Hunger Initiative) and CMA (Christian Mission Aid) operates in Tam payam. Its major operations are through outreach where they offer non food items such as blankets, sheets and tarpaulins and run a project on trachoma though treatment of eye diseases such as trachoma.

During the assessment period, the security was calm with eminent presence of unarmed soldiers both in Mankien and Tam payams. The last insecurity incident occurred between June and July 2006 as a result of cattle rustling between the Nuer and the Dinka tribes at their borders. Cattle rustling between the two tribes are rampant8 and this ascribes why most of the cattle camps are to the north of both payams, away from the Dinka community borders. The Mankien SRRC counterpart reported that an initial peaceful disarmament exercise was undertaken in Mayom County between August and September 2005 with a second exercise in July 2006 to ascertain that all arms had been collected; those currently in possession of arms had authorization and the arms are used to scare away wild animals hovering around and destroying farm produce.

The major causes of morbidity and mortality amongst the adults are RTIs, STIs and malaria while malaria is a major cause of morbidity and mortality amongst the under-fives. During the months of August, September and October, a total of 13 children under five years of age died due to malaria(5), neonatal tetanus(1) , acute diarrhoea(1) , anaemia (2), RTIs (1) , pneumonia (2) and one due to other illnesses.9

It is worth also noting that there was an outbreak of measles in the location in the month of August 200610. World Relief and MSF-H responded to the outbreak. MSF-H in a bid to curb the situation responded through mass measles immunization at Mankien between 2nd to 6th and 9th to 14th October 2006 at Tam payam respectively. Actual number of immunized children could not be established as at the time of assessment.

From observation, waste disposal in the community is wanting as litter could be spotted, with human waste disposed by the road sides and nearby bushes. Given that the locations have flat terrain and tendency to flood after heavy down pour; this predisposes the community to water borne diseases.

Further, most households had cultivated crop of maize that could be seen stacked in the farms to enhance drying; millet and groundnuts were cultivated in minimal households. In comparison to the last season’s harvest, the community reported a decline in harvest and livestock quantity with current food stocks depleting. A significant number of spontaneous and organized returnees were reported11who rely on kinship and food distribution with the last WFP food drop being in August and September 2006.Exact returnee figures could not be obtained from UNOCHA as at the time of assessment as they are based in Rubkona County, Unity State.

There are a total of 6 and 5 functional boreholes in Mankien and Tam payams. However, boreholes distribution is uneven and in areas without boreholes, the community relied on swamps, seasonal rivers and rain as their source of water for household consumption and drinking.

8 Key community informants and surveyors 9 World Relief Mankien PHCC Epidemiological Report (August, September, and October 2006). 10 Source: World Relief Mankien 11 Source: SRRC counterpart and key informants - November 2006

.I.5. RESULTS OF THE NUTRITION SURVEY

A total of 930 children were measured during assessment. However, only 925 children were used during analysis due to anomalous data. Anthropometric survey results as shown in the table below indicate Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) of 15.0 % [11.9 %-18.7%] and 1.9 % [0.9 %- 3.8 %] respectively. The GAM is precisely at the acceptable emergency threshold rate of 15% whereas the SAM is below the emergency threshold level of 4%. Table 1: Results of the Nutrition Survey

AGE GROUP INDICATOR RESULTS Global Acute Malnutrition 15.6 % W/H< -2 z and/or oedema [12.4%-19.3%]12 Z-score Severe Acute Malnutrition 2.4% 6-59 months W/H < -3 z and/or oedema [1.2%-4.4%] (n =925 ) Global Acute Malnutrition 9.5% W/H < 80% and/or oedema [7.0%-12.7%] % Median Severe Acute Malnutrition 1.2% W/H < 70% and/or oedema [0.4%-2.8%] Total crude retrospective mortality (last 3 months) /10,000/day 0.73 [0.33 – 1.13 ] Under five crude retrospective mortality /10,000/day 0.80 [0.19 - 1.41 ] Percentage of children under five amongst deaths recorded 33.3 % Measles immunization coverage By card 7.0 % on children >=9 months old According to caretaker13 45.4 % (n=872) Not immunized 47.6 %

.I.6. RECOMMENDATIONS

In South Sudan where malnutrition is most often caused by lack of food, the nutrition status is expected to improve significantly in October and deteriorate towards the end or after April and steadily improve after August when the early crop of maize matures and is available for consumption, soon followed by sorghum14. However, the GAM rate in Mankien and Tam payams was critical even after the October harvest. This could be due to the inter-relationship between malnutrition and various factors such as outbreak of diseases, food insecurity, poor hygiene and sanitation and not just the mere absence of food.

This calls for integrated and intensified interventions by various organizations to curb and mitigate the effects of the various factors of malnutrition and ACF-USA therefore recommends the following:

HEALTH To maintain the existing health interventions and consider increasing accessibility of health care services in the area so as to meet the Sphere standards of 1 facility to serve 5000 people. To incorporate specialised treatment and management of the malnourished persons into the existing health structure. To continue consistent and regular EPI services with special emphasis on measles coverage, and ensure provision of cards for proof of vaccination, while at the same time educating the mothers on the importance of the same. To empower the community on early health care seeking behaviour.

FOOD SECURITY

12 The bracketed data are the Confidence Interval at 95%. 13 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker. 14 FEWS NET: 10/29/2002

To maintain existing interventions such as the children gardens and issue of she goats to the marginalized groups. To initiate food security programs while strengthening community participation in the implementation of program activities for sustainable development. Strengthen veterinary services in the location so as to enhance livestock productivity and regeneration. To continue monitoring the food security situation in the locations and provide appropriate assistance in case of lack of suitable coping mechanisms by the households To provide the community with the appropriate farming and fishing tools so as to ensure timeliness in planting and fishing to supplement their food demands. To empower the community on income generating activities to enable them have a purchasing power in times of food shortage. Improve roads and market links to improve access to food all year round.

WATER AND SANITATION

To promote good hygiene and sanitation practices by educating the community on household hygiene, human waste disposal, latrine construction and utilization, treatment and consumption of safe water. To continue constructing water facilities to meet the sphere standard. To empower local authorities and the community with the authority, resources, and professional capacity required to manage water supply and sanitation service delivery.

.II. INTRODUCTION

Unity state in Western Upper Nile, bordered by Warap, Lakes and Jonglei states to the west, south and east respectively, has an area of approximately 35,956 km² and an estimated population of 175,000 (2000). The state is the location of some rich oil fields15 with Bentiu being its capital. Administratively, the state consists of seven counties namely Koch, Leer, Panyijar, Mayom, Ruweng, Rubkoana and Guit that are further divided into 14 payams16. The Nile and other rivers pass through the region, providing an important source of food and income, as well as transport routes to southern Sudan.

Mayom County, Unity state has a total of 10 Payams namely Pub, Ngop, Bieh, Wurach, Wankai, Tam, Mankien, Ruaznyibol, Kueryiek and Madul payams with Mankien payam, one of the largest Payam in South Sudan17 situated at the center of the County. Mankien payam is bordered by Bieh, Wankai and Madul payams to the west, east and south respectively whereas Tam payam, approximately one hours drive from Mankien payam borders it to the south east.

Tam, formerly a cattle camp became a payam in April 2006 due to large population that hindered effective administrative management and has a populace of (34,558) 18.Comparatively, Mankien payam has a relatively smaller population (13,888) 19 with a PHCC runnby World Relief. Additionally, Mankien payam is Mayom County’s SRRC headquarter and commissioner’s base .The presence of oil fields and an oil company in the payam are a plus to the community as this provides optimism for employment. Both payams have army bases and open air markets. The markets are stocked with a variety of products ranging from food and non food items to local and imported goods. Major traders in the market are the Arabs who operate from as early as 7.30 am to around 7.30 p.m.

Mankien and Tam payams are traversed by seasonal rivers and swamps, with flat terrain of black cotton clay soil. The impermeability nature of this soil predisposes the area to flooding during the wet season and this affirms why the permanent buildings were elevated. Major inhabitants of these payams are the Nuer tribe of the Bul clan who are mainly agro pastoralists. Fishing is done by the Nuer-Bul to supplement their food demands.

The SRRC counterpart reported that there were a large number of spontaneous and organized groups of returnees. However, the exact figures could not be obtained as at the time of the survey from UNOCHA who are based at Rubkona County, Unity state, away from Mayom County.

In comparison to the month of April, the food security situation in Unity state had continued to deteriorate. At the households, food stocks had continued to deplete as the hunger gap progressed. To cope, young adults moved to the oil fields in search of employment to supplement the household livelihood needs.20 Similarly in June, the food security situation had drastically declined due to severe shortage of cereals ascribed to below average local production and bad road conditions reducing access to markets.

ACF-USA undertook an anthropometric survey in Mankien and Tam payam as from 17th October- 10th November, 2006 to determine the actual nutrition situation.

15 http://en.wikipedia.org/wiki/Unity_%28state%29: Last modified on 9th November 2006. 16 Sudan Annual Needs Assessment 2006 17 Source: SRRC counterpart Mankien payam. 18 Source: SRRC counterpart Mankien payam and key community informants. 19 Source: SRRC counterpart Mankien payam. 20 WFP SSD Food security and livelihoods update, May 2006

.III. METHODOLOGY

.III.1. Type of Survey and Sample Size

A nutrition survey was undertaken in Mankien and Tam payam during which anthropometric, qualitative and mortality data were simultaneously collected through the use of standardized structured questionnaires and observation.

A two stage cluster 30 by 30 sampling methodology was applied, according the population figures, to get prevalence with 95% of confidence.

A retrospective21 mortality survey was undertaken, using the SMART22 methodology.

Additionally, qualitative data was collected using systematic sampling through observation and use of standardized questionnaires. A total of 50 households were surveyed. Key issues covered were food security, water and sanitation, accessibility and utilization of health care services as well as child care practices.

.III.2. Sampling Methodology

At the initial stage, 30 clusters are randomly selected. Using a random draw, villages were chosen from a list of all accessible villages, and the clusters assigned accordingly. (See appendix.IX.1. Sample Size and Cluster Determination). The probability of selection was proportional to the village population size. Each cluster included a minimum of 30 children.

Secondly, the standard EPI methodology was used to select households within each cluster: a pen was spun while being at the central point of the selected cluster, defining a random direction. All the children 6-59, months of age belonging to the households encountered in that direction were measured.

.III.3. Data Collection

Various information was collected and recorded for each child aged 6 – 59 months after randomly selecting the households using the two-stage cluster sampling methodology as follows: (See appendix .IX.2:Anthropometric Survey Questionnaire)

• Age: This was recorded with the help of a local calendar of events. (See appendix .IX.5: Calendar of events). • Gender: Male or Female • Weight: Children’s weights were taken without clothes using a SALTER balance of 25kg (precision of 100g). • Height: Children’s measurements were taken on a measuring board (precision of 0.1cm). While children less than 85cm were measured lying down, those greater than or equal to 85cm were measured standing. • Mid-Upper Arm Circumference: MUAC measurements were taken at mid-point of the left upper arm for targeted children (precision of 0.1cm). • Bilateral oedema: Normal thumb pressure was applied to both feet for at least 3 seconds to assess. • Measles vaccination: This was assessed by checking for measles vaccination on EPI cards and inquiring from the caretakers. • Household status: For the surveyed children, households were asked if they were permanent residents, displaced, returnees or temporarily in the area.

21 Over the past three months. 22 SMART - Standardized Monitoring and Assessment of Relief and Transitions.

.III.4. Indicators, Guidelines, and Formula’s Used

.III.4.1. Acute Malnutrition

¾ Weight for Height Index For the children, acute malnutrition rates were estimated from the weight for height (WFH) index values combined with the presence of oedema. The WFH indices are compared with NCHS (23) references.

WFH indices were expressed in both Z-score and percentage of the median. The expression in Z-score has true statistical meaning, and allows inter-study comparison. Percentage of the median on the other hand is commonly used to identify eligible children for feeding programs (therapeutic or supplementary feeding programs).

Guidelines for the results expressed in Z-score: • Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the child. • Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema. • Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema.

Guidelines for the results expressed in percentage of median: • Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs • Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema. • Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema

¾ Children’s Mid-Upper Arm Circumference (MUAC)

To quantify wasting of a population in emergency situations where acute forms of malnutrition are the predominant pattern, weight for height index is the most appropriate. This is because it is a good indicator for severe past and current malnutrition. However, mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. MUAC guidelines are as follows: Table 2: MUAC guidelines MUAC Interpretation < 110 mm Severe Malnutrition And High Risk Of Mortality ≥ 110 mm and <120 mm Moderate Malnutrition And Moderate Risk Of Mortality ≥ 120 mm and <125 mm High Risk Of Malnutrition ≥ 125 mm and <135 mm Moderate Risk Of Malnutrition ≥ 135 mm Adequate’ Nutritional Status

.III.4.2. Mortality

Mortality data was collected using Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. The crude mortality rate (CMR) was determined for the entire population surveyed for a given period and calculated using Nutrisurvey for SMART software for Emergency Nutrition Assessment.

The formula below is applied:

Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where: a = Number of recall days (90) b = Number of current household residents c = Number of people who joined household

23 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics.165, 11-74.

d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period

The result is expressed per 10,000 people / day. The thresholds are defined as follows24:

Total CMR: Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day

Under five CMR: Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day

.III.5. Field Work

Collection of data during the assessment period was executed by three teams formed upon critical and careful evaluation of surveyors’ abilities and class participation. Two of the three teams comprised of three persons while the other team comprised of four persons; the fourth persons collecting qualitative data. Each of the three teams was supervised by one of the ACF-USA staff.

All the surveyors underwent an intensive 3-day training, which included a pilot survey to ensure accuracy in data collection.

.III.6. Data Analysis

Data was edited at the field by the ACF-USA staff on daily basis to eliminate mistakes and ensure its’ accuracy.

Using EPI-INFO 5.0 software, EPINUT 2.2 program, Nutrisurvey for SMART software and Statistical Package for Social Sciences (SPSS) data entry and analysis were carried out.

.IV. RESULTS OF THE QUALITATIVE ASSESSMENT

Other than the absence of adequate food to meet an individuals’ nutritional demand; malnutrition could be due to a combination of factors such as poor hygiene, outbreak of diseases both in the dry and rainy seasons and food insecurity. Thence, during the implementation of the anthropometric nutrition survey by ACF-USA in Mayom County, qualitative data was collected from a sum of 50 households using standardized and structured questionnaires and observation. Findings revealed as follows:

.IV.1. Social Demographic Characteristics of the Respondents

Tam and Mankien payams have a populace of 34,558 25 and 13,888 26 respectively. During the assessment, a total of 50 households were interviewed. Findings unveiled that most, 46(90.2%) of the respondents were females; as they were the ones engaged in households chores such as cleaning the homestead (luak), drying cow dung, cooking and tending to the homes thus spent a major part of the day at home; while their male counterparts engaged in other activities that kept them away from their homes a better part of the day.

The Nuer tribes of the Bul clan are the major inhabitants of the payam. They are predominantly agro pastoralists; with fishing mainly as coping mechanism to supplement their food demands when food stocks

24 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95.

25 Source: SRRC counterpart Mankien payam and key community informants. 26 Source: SRRC counterpart Mankien payam.

deplete. Though a number of spontaneous and organized groups of returnees were reported by the SRRC counterpart, the exact numbers could not be ascertained at that time. However, findings indicate that 14.0% of the populations at that time were returnees with majority, 86.0% being residents (see figure 1 below).

The Nuer Bul clan major sources of income are petty trade (44%), sale of livestock (38%), crops (28%), firewood (24%), casual labor (4%) and sale of personal assets (2%) as illustrated in the figure below. Sale of food items such as crops and livestock in the markets in itself places a lot of stress on the minimal stocks as the community had reported depleted harvests and a decline in the quantity of livestock.

Figure 1: Sources of Income

SOURCE OF INCOME

44%

38%

28%

24%

4% 2%

SALE OF SALE OF CASUAL SALE OF CROPS PETTY TRADE FIREWOOD PERSONAL LIVESTOCK LABOUR ASSETS PERCENTAGE 38% 28% 44% 4% 24% 2%

According to Sudan ANA 2006, livelihoods in this region have traditionally been based on agro-pastoralism and fishing, but the opening of the oil fields in the location has opened up a broader range of income opportunities. Notably, since the signing of the CPA, Unity State has experienced a significant improvement in security, which is anticipated to help facilitate recovery from recurrent food insecurity caused by the disruption of livelihoods.

In the months of October and November 2006, the main livelihood activity cited by the majority of the households interviewed in Mankien and Tam payams was agro pastoralism 44(88.0%) with sorghum and maize being the most predominant crops grown by most people as reported by 6(12.0%) households; while the least livelihood activity was pastoralism 4 (8%).Fishing was done by 30.4% of the households.

.IV.2. Food Security

Food security, the availability of safe and nutritious foods in the household to meet all the nutritional requirements of all household members at all times; is a crucial aspect in determining the nutritional status of an individual and their community.

Food security situation of a community is affected by and not limited to various factors such as the availability of arable land, accessibility to markets, knowledge on agriculture, health status of the community and even presence of appropriate equipment. Other aspects include appropriate and safe food preparation, preservation and storage methods to eliminate the germination of harmful microbial organisms detrimental to health.

According to WFP SSD Food security and livelihoods update, May 2006; the food security situation in Unity state had continued to deteriorate in comparison to the month of April. Further, food stocks had continued to deplete in the households as the hunger gap progressed and the young adults opted to move to the oil fields in search of employment to supplement the household’s livelihood needs and demands.

During assessment, the community mainly sourced for food through buying 23 (46%), while a relatively larger percentage 21(42%) privately produced their foods with all households producing maize, 31.7% sorghum, 39% beans and only a few 12.2% producing vegetables.

In Mankien and Tam Payams, most 27(55.1%) of the inhabitants had cultivated 1-2 feddans of land in the previous planting season between April and June 2005.Comparatively, the previous planting season, April – June 2005 was better 33(64.7%) as compared to the current harvest. The decline in harvests were attributed to lack of rains 39(76.5%), diseases and pests (25.6%) and insects infestation 5(12.8%) of plants. For example, in August 2006, harvests of groundnuts and vegetables from 60 children gardens in Tam payam were destroyed by locusts27. On the other hand, some households 10(20%), did not plant any crops during the last harvesting season due to lack of seeds 55.6%, agricultural knowledge 11.1%, farming equipment 44.4% and lack of adequate rainfall thus exerting stress on the existent food stocks. This concurs with the WFP SSD livelihood reports June 2006 stating that the food security situation had drastically declined due to severe shortage of cereals which was ascribed to below average local production and bad road conditions reducing access to markets.

Food stocks in most (50%) households are expected to last for utmost three months (see figure 3 below), long before the hunger gap period between April and June. Additionally, FEWSNET October 2006 report indicates that the harvests in Unity state are expected to mitigate food insecurity in the short term as the grains are likely to be sustained until January or February 2007.However, qualitative analysis findings unveil that some households had exhausted food stocks, forecasting a bleak food security situation. To meet their food demands, households reported to cope through mechanisms such as kinship support (50%), food aid from WFP and NCA especially to the returnees (54.2%), wild foods (41.7%) and slaughtering of the already depleting quantity of livestock due to diseases such as MCF (Malignant Catarrhal Fever) and livestock sale for income. Kinship support, strengthened through marriages, additionally puts stress on the already existent minimal and depleting harvests, thence, attribute to the relatively high malnutrition state.

Figure 2: Food stock availability.

FOOD STOCKS AVAILABILITY IN MAYOM COUNTY, MANKIEN AND TAM PAYAMS;OCT -NOV 2006

50.00%

20.80% 20.80%

4.20% 4.20%

COMPLETED I MONTH 3 MONTHS 6 MONTHS 12 MONTHS DURATION

27 SC-UK South Sudan Child Protection Manager.

The last WFP food drop in the location was between August and September 2006. In the preceding three months, majority, 98% of the population reported to have received the food rations at least twice.

The Nuer of the Bul clan; the major inhabitants of Mankien and Tam payams and agro pastoralists, rare a variety of livestock such as cattle (86.7%), goats (64.4%), chicken (42.2 %), sheep (15.6%) and donkeys (4.4%) The major benefits derived from the livestock by the community include milk (88.2%), dowry (80.0%), wealth (33.3%), sale (26.7%) and food (8.9%). Most (97.8%) of the livestock were sold at the market with the minority (11.1%) sold amongst the community members. Additionally, at the time of assessment, most (86.7%) of the livestock were at home while a smaller percentage (13.3%) were still at the cattle camps situated to the north of the payams, away from the Nuer-Dinka borders. Notably, in the past five years, the quantity of the livestock has continued to tremendously decline. Sudan ANA28 2006 attributes this to perennial raids, inter-factional fighting, livestock diseases, degraded pastures due to inappropriate management practises like uncontrolled fires and lack of adequate water for livestock use in the dry season leading to seasonal migration in search of water.

According to key informants, observation and analysis of qualitative data, decline in livestock herds could be attributed to various factors such as sale of livestock for income, payment of dowry and livestock diseases such as liver fluke, contagious bovine pleural-pneumonia (CBPP) for cows, contagious caprine pleural-pneumonia (CPP) for goats, skin disease, tuberculosis and MCF (Malignant Catarrhal Fever).Worth mentioning is the MCF, a viral cattle disease mainly transmitted through mixing of livestock in the homestead. This disease is affecting the cattle and has drastically increased the cattle mortality. Unfortunately, the disease is incurable and the animals commence by deteriorating in health and gradually die; 29 a bottleneck to food security.

The causes of livestock diseases range from bacterial, viral and parasitic infections to other underlying causes like floods, hunger, drought and poor sanitation and management. Concisely, livestock provide the fundamental basis for wealth, status, an important part of dowry and a critical source of milk and meat.

Fishing, an activity majorly carried out in March, is done to supplement the food demand of the community as the community approaches the hunger gap between April and June. Even though 56.0% of the community has access to fishing grounds, only 30.4% of them engage in fishing with majority, 90.0%, not harvesting enough fish due of lack of adequate and appropriate fishing equipment, lack of adequate fish at the fishing grounds and lack of labor. After harvesting, the fish is mainly preserved through drying (96.6%), with a minor number salting (37.9%) or smoking (6.9%).

During assessment, the meals consumed by the community comprised of milk (80%), maize (88%), okra (44%), meat (18%), fish (18%) and pulses (18%) accordingly. Milk and maize were the predominant meals consumed daily. This can further be ascertained from observation where most household were found treating themselves to their staple dish of walwal made from milk and maize. Though most households reported to consume milk daily, the quantity consumed was uncertain as the average milk production per day was very low. Most households (45.1%) reported an average of 1 liter per day, with 13.7% and only 5.9% of the households producing 2 liters and 3 liters of milk per day respectively.

Presence of vibrant open air markets in the location that sold both food and non food items (see appendix IX.6: Food Market prices), local and imported goods, was noted with Arabs being the major traders. Traders stock these markets from the larger external markets and towns such as Malakal and Bentiu. Reportedly, cash purchases are gradually increasing with the main currency being the Sudanese dinar. From observation and analysis of the qualitative data, wide variety of products were sold in the market ranging from both food such as oil, milk , sugar amongst many others to non food items such as clothing, drugs, utensils and jewelry. Households reported to purchase a variety of commodities from the market. Foodstuffs commonly purchased included oil, sugar, fish, maize, milk, pulses, and rice amongst many others such as salt which as observed, was non- iodized. The market environment was begrimed with food products such meat and offal being sold in the open, a delicacy to the flies; and litter aimlessly disposed. At the time of assessment, it’s worth noting that prices of commodities in the market were reported to have increased due to increased circulation of money in the community. This was because the soldiers had just received their first salary in bulk after 23 years of service.

28 ANA- Annual Needs Assessment 29 SOURCE: VSF SUISSE South Sudan Field Veterinary Supervisor.

For example, a piece of dried fish that initially used to go for 400 Sudanese dinnar went for a whooping 800 Sudanese dinar.

In summary, the food insecurity in the location could be attributed to various shocks such as livestock diseases, lack of appropriate and adequate fishing and farming equipment, human diseases and floods. The main coping strategies adopted by most of the households were eating fewer meals, sale of livestock and crops, fishing, food aid and kinship support; thence, the emergency GAM rates.

.IV.3. Health

WR, an international Christian NGO, offers health services in Mayom County. Other than the Aids awareness program, the organisation currently operates 6 PHCUs in the county at Kerial, Wanam, Kuernyang, Kurenge and Bieh and one PHCC at Mankien centre, Mankien payam. At the PHCUs, WR offers medicines supplied on monthly basis and have trained personnel; a CHW and a TBA to ensure quality of services offered at the PHCU. The CHW manages the daily operations of the health unit while the TBA conducts deliveries. All the serious cases are referred to the Mankien PHCC after basic preliminary management. Additionally, MSF-Holland, manages an outreach post in Tam Payam, Tam centre.

The Mankien PHCC operates on 24 hour basis offering both inpatient and out patient services. Generally, the services offered range from both preventive to curative services. The preventive services offered are such as EPI services, health education (every morning prior to medical treatment), malaria program through which they not only provide prophylaxis for malaria but nets too to the pregnant, lactating and children less than five years of age. The health centre is managed by trained medical expatriates and trained CHWs who act as auxiliary nurses. There are two trained TBAs at the PHCC who conduct deliveries and incase of any complicated cases, the medical experts step in. All complications that cannot be managed at the PHCC due to lack of necessary equipment or seriousness of the condition are referred to Bentiu for further management. Commendably, the PHCC has an excellent supply of drugs with adequate buffer stock in their store. The drugs are supplied on weekly and monthly basis depending on demand. Additionally, laboratory services, carried out by trained personnel are offered at the PHCC. For sustainability, the PHCC is maintained through a user fee of 50 Sudanese dinnar paid by each person on the first visit to get the medical book for prognosis.

WR staff reported that the facility is over utilised with patients from various parts of the County and this can be attested by the fact that 94% of the community first seek medical attention at the public clinics which averagely takes about 30minutes to 1 hours walk. Even though the average distance to the health facilities is 30 minutes to 1 hours walk, some households had to walk for a very long time and distance as could be proven during assessment where the teams could walk for more than three hours and see no health providing service as they are far apart. (See appendix IX.7: Distribution of Schools, Boreholes and Health facilities in Mankien and Tam payams).Further, the ratio of health facilities to the population is 1:24,223 which is much higher than the SPHERE recommended ratio of 5000 people per PHCU facility .This in the long run hinders timely and suitable intervention incase of illness. Additionally, even though majority of the community first sought medical attention from the public centre and units; the care was sought late.

According to the WR epidemiological records, in the months of August, September and October 2006; malaria, RTI, STDs, diarrhoea were the most common causes of morbidity with totals of 1,352, 1613, 574 and 391 cases respectively reported. This is supported by the results of the qualitative household analysis where most common illnesses affecting most households were malaria (98%), diarrhoea (90.2%), fever (82.0%) and Respiratory tract infections RTIs (62%).

In the months of August, September and October 2006, 15 deaths were reported. Of the 15, a total of 13 children under five years of age died due to malaria(5), neonatal tetanus(1) , acute diarrhoea(1) , anaemia (2), RTIs (1) , pneumonia (2) and one due to other illnesses.30 The medical personnel further reported that the cases of malnutrition were on the rise, even though the exact numbers of malnourished cases could not be established as only major illness are tallied on the morbidity forms. However, all the cases of measles, diarrhoea and malaria of children under five years of age presented some degree of malnutrition and this totals to 596 cases. Unfortunately, no specialized care is given to the malnourished patients at the health centres. An increasing

30 World Relief Mankien PHCC Epidemiological Report (August, September, and October 2006).

number of HIV/Aids related complications were reported; for example STI cases reported in the months of August, September and October were 159, 40 and 375 respectively. 31 However, no HIV/Aids tests are carried out at the PHCC. From observation, majority of the assessed children had skin lesions and bleeding wounds.

A measles outbreak was reported and verified in Mankien and Tam payams in August 2006 and WR and MSF- H responded in a bid to curb the situation. The actual number of children immunized could not be established as at the time of assessment, however, those at risk of infection were also immunized by MSF-H and WR through outreach and WR routine EPI services. Thus children below the age of 9 months were immunized against measles while those presenting measles complications were treated. The interrelationship between measles complications and nutrition result to malnutrition hence the measles outbreak could be linked to the current nutrition status.

During the month of November, between 6th and 11th, 2006, mass polio immunisation and vitamin A supplementation was carried out in Mayom County by W.H.O targeting all children less than five years of age. However, the exact number of children immunised could not be established as the data was still being compiled.

From observation and data analysed, the common causes of morbidity such as malaria and diarrhoea could be attributed to a number of factors. Malaria, caused by the female anopheles mosquitoes, is common in the location and this could be attributed to environmental sanitation such as long grass, pools of stagnant water, and litter aimlessly disposed that provides favourable environment for mosquito breeding. Nonetheless, most households visited had mosquito nets and had devised coping mechanism to keep mosquitoes at bay where dried cow dung was burnt in the homesteads ’luaks’ as a mosquito repellent. Diarrhoeal incidences could be attested to poor sanitation in the area as most households (84.0%), did not treat their water before drinking. Secondly, almost all (98.0%) households did not have access to toilet facilities and practised open defecation in the nearby bushes (54.0%) or open field (74.0%).This could flow back to the water sources especially during the rainy season predisposing the households to water borne infections. Further, as observed ,cooked food was left in the open and flies could be seen enjoying themselves to the delicacy, utensils were lying dirty on the ground and in some households the cooking pots were used for laundry; young children were fed on raw cows milk, directly from the cow immediately after milking and the market environment was begrimed.

.IV.4. Water and Sanitation

Safe drinking water and basic sanitation is of crucial importance to the preservation of human health, especially among children. Water-related diseases are the most common cause of illness and death among the poor of developing countries. According to the World Health Organization, 1.6 million deaths of children per year can be attributed to unsafe water, poor sanitation, and lack of hygiene—the vast majority among children under 5. More than one billion people lack access to an improved water source32.

In Mankien and Tam payams, water for household consumption is obtained from various sources namely; borehole 25(50.0 %%), river 15(30.0 %%), surface run offs 13(26.0%), rain water 8 (16.0%), swamps 2 (4.0%), and seasonal springs 8 (16.0%). There are a total of 11 boreholes; 6 and 5 boreholes in Mankien and Tam payams respectively. These boreholes were constructed by various parties such as the community, local NGOs such as LCDA and international NGOs. (See appendix IX.7: Distribution of Boreholes, Schools and Health facilities in Mankien and Tam payams).

The general population obtain their drinking water from boreholes 25(50.0%) and rivers 12 (30.0%), with the minority 9(18.0%), 8(16.0%), 2 (4.0%) and 2 (4.0%) obtaining their water from surface run off, rain water, swamps and unprotected wells respectively approximately an hour 42(84.0%) to and from their households. More time is spent at the water sources especially at the boreholes due to long queues. Unfortunately, a larger percentage 42(82.0%) neither boil nor use chemicals to purify their drinking water and this predisposes the community to water borne infections such as typhoid and guinea worm infestation.

31 World Relief Mankien PHCC Epidemiological Report (August, September, and October 2006). 32 http://www.who.int/household_water/en/index.html

Figure 3: Source of drinking water in Mankien and Tam Payams, October – November 2006.

SOURCE OF DRINKING WATER 50%

18% 16% 15%

4% 4%

RIVER BOREHOLE UNPROTECTED SURFACE RUN SWAMPS RAIN WELL OFF WATER SOURCE

On average, each household of approximately 5- 20 persons consumes approximately 40 litres of water daily. This equates to approximately 2-8 litres of water per person per day falling short of Sphere standards33, contributing to the poor hygiene and sanitation in the community. However, this figure does not take into account the amount utilised by individuals for bathing, drinking and washing at the source point. Notably, distribution of safe water points (boreholes) in the area is uneven as noted during assessment and a lot of time was spent on the queues. (See appendix IX.7: Distribution of Boreholes, schools and health facilities in Mankien and Tam payam.)

Only 2% of the household had access to toilet facilities and hence open defecation was practised (bushes (54.0%) and (74.0%) open fields).Just by the mere fact that only a minimal percentage of the population have access to toilet facilities bespeaks volumes of susceptibility to infection. Further, faecal matter of children aged 0- 3 years is either left on the ground, thrown or buried in the yard. The few toilet facilities observed in the location were mainly found in the local authority, NGO and the health centre compounds; setting a good example to the community.

Further long grass, pools of stagnant water with litter aimlessly disposed was observed. Cooked food was left in the open, utensils were lying dirty on the ground, the young children were fed on raw cow’s milk, and in some households the cooking pots were used for laundry. In addition, the market environment was wanting; human waste and litter was disposed in the open, food such as offal were sold in the open under unhygienic and unsatisfactory standards, their were lots of flies in the food kiosks and water for cooking as could be observed was not clean.

According to a member of LCDA, the observed prevailing poor sanitation in the community could be attributed to the people’s wrong attitude associated with cultural beliefs. The local NGO, through role plays; is gradually sensitizing the community on appropriate health and sanitation. Notably, the community is very responsive and their major gainsay is lack of funding to sustain their programs.

.IV.5. Mother and Child care practices

Appropriate and optimal child care practices are fundamental for adequate nutritional status especially amongst infants and children less than five years of age since the early years are crux for optimal growth and development. Additionally, under nutrition increases susceptibility to, and the severity of, infection.

33 Sphere standards on water access and quantity include; Average water use for drinking, cooking and personal hygiene per person per day is 15 liters, Queuing time not more than 15 minutes and safe water is available on regular basis.

During the course of the survey in Mankien and Tam payams, a number of child care practices were observed that were beneficial and others that were deemed detrimental to the well being of the child. Encouragingly, all households reported to initiate breastfeeding immediately after birth with breastfeeding on demand. This is among the many positive practices so as to ensure adequate stimulation of the let down reflex thence adequate milk production for the child.

In all households, all children aged 6- 29 months were continued to be fed on breast milk, complimenting their diet with cows/goats milk 48 (96%), porridge 34(68%), and 7 (14%) on other foods. Vegetables are rich in vitamins that protect the body against infections and enhance healing of wounds. Saddening, no child was fed on vegetables and this could explain the skin lesions and bleeding wounds observed in most of the assessed children. In addition, of the children aged 30 months and above ; few 19 (38%) of then were breastfed, majority ( 98%) fed on cows and goats milk, relatively large number (76%) on porridge, only (2%) fed on vegetables and 48 % fed on other foods such as a the staple food walwal( a mixture of milk and maize). Encouragingly, most 49 (98.0%) households reported to wash hands before eating with water gotten from the borehole (50.0%), river (30.0%), surface run off (26.0%), rain water (16.0%) and swamp (4.0%). However the applicability of this practise is still questionable as most household were observed to marvel when the cows urinated and would call the other household members and rush to wash their hands with the urine.

Even though the diet of the children under five years of age was majorly complimented with cows’ or goats’ milk, the milk was not boiled to kill the germs as most households were seen to milk the cows and feed the children directly. Further, food preparation was done in the open under unhygienic conditions and water was not treated (84.0%) before drinking. These ultimately predispose the children and adults to water borne diseases such as guinea worm infestations, diarrhoea, brucellosis and typhoid just to mention but a few.

To meet the increased nutrient demand of children aged 6- 59 months, they should responsively be fed on small, thick, energy dense balanced diets frequently as per their recommended dietary allowance. However, despite the fact that the children foods were being complimented by other foods such as cows milk; with a relatively large (56.0%) number initiating complimentary feeds at 6 months; the diet lacked diversity ( only cereals (maize) and milk) and ideal quantity as they were fed at most (78%) twice a day.

Mothers and caretakers of the children were observed to be doing tedious jobs such as cleaning the luak, milking the livestock, pounding and grounding of cereals, fetching water and firewood and cutting grass with no provision of specialized meals (compromising the quality of care given to the children less than five years). This is deduced from the data indicating that the current food consumed constitutes maize 44 (88%), milk 40 (80%), okra 8 (44 %), fish 9 (18%), meat 9 (18%), and pulses 9 (18%) and the most consumed being cereals and maize that were consumed daily as reported by 92% of the household. This in itself indicates an imbalanced diet; a diet lacking most of the nutrients in the right proportions and quality. The imbalance and lack of diversity predisposes the mothers, breast feeding infants and children less than five years of age to risk of malnutrition as an appropriate balance is needed between nutritional requirements and food intake.

Conclusively, early marriages, more births to replace those who had passed away during the two decade conflict alongside heavy workload and strenuous exercise, lack of adequate and diversified meals, poor sanitation and hygiene exacerbates the risks to maternal and child health attesting to the emergency GAM rates.

.IV.6. Education

Mankien payam has 2 primary schools located at Mankien centre and Kuernyang village, while Tam payam has 1 school at Tam centre (See appendix IX.7: Distribution of Boreholes, schools and Health facilities in Mankien and Tam payams). The schools are managed by trained teachers from various parts of East Africa such as Kenya and Uganda and local teachers who use the New Sudan curriculum (from P1-P4) and Kenyan syllabus (from P5 - P8) both of which are approved by the Ministry of Education South Sudan. The schools were constructed by the government and community and are managed by the government through support from various organizations such World Relief and UNICEF.

World Relief (WR) offers support to the two schools at Mankien payam through supplying materials such as chalks, exercise books and text books for the pupils and provision of school bags to the teachers as a

20 motivation. Additionally, the organization offers acceleration studies through which the WR education supervisor instills the teachers with additional skills and knowledge to implement this program. According to key informants and the survey team, at the beginning of the year many children enroll in the schools but this number tends to decline towards the end of the year. Exact reasons for decline could not be established though some community members attribute this to early marriages and a negative attitude towards education.

Currently, plans are underway by the government to train more teachers so as improve the teacher pupil ratio in a bid to improve their quality of education.

.IV.7. Actions Taken by NGO’s and Other Partners

Various organisations and NGOs, both indigenous and international had operations in the area. The different NGOs and areas of interventions/assistance are as follows:

World Relief runs four programs in the Mayom County namely health, HIV/Aids awareness, education and capacity building. Under the health program; World Relief operates 6 PHCUs in Mayom County and 1 PHCC at Mankien payam. Similarly, the organization supports education in Mankien payam through the provision of schools with learning materials such as exercise books, text books, chalks and offer acceleration studies (adult learning).Additionally, they offer capacity building to the community in the areas that they have operations for their sustainability through selection of locals who meet certain criteria and sponsoring their training.

Mercy Corps is implementing the Localizing Institutional Capacity in South Sudan (LINCS) project in collaboration with International Rescue Committee. The projects aim is to strengthen the institutional capacity of civil society organizations (CSO) that support marginalized groups such as the youth, IDPs and the disabled persons. The selection of this area for implementation of the project was based on the population density and the presence of existing and potential CSOs. . MSF Holland operates an outreach clinic in Tam payam runned by trained CHWs. During the month October; they carried out mass measles immunization in Mankien and Tam payams in response to measles outbreak in the area.

Save the Children -UK operates a child protection project in Tam payam which eventually is expected to spill over to Mayom County. The organization supports orphans and children separated from their parents by providing non food item such as blankets, clothes and cooking utensils. Currently, the project is focusing on sustainable and empowering projects by supporting women headed households, orphans and children separated from their parents through farming and livestock distribution. In August 2006, a total of 60 she-goats were given to 30 women headed households after the goats were vaccinated and the households trained on livestock management. Additionally, 60 children gardens were planted with groundnuts and vegetables. Unfortunately, all the farm produce were destroyed by locusts. Despite this challenge, the SC-UK South Sudan Child Protection Manager affirms that the children’s garden initiative will not cease; rather the organization will focus on appropriate ways to mitigate the problem such as planting a variety of seeds and early amongst many others. Currently, plans are underway to offer tailoring classes for the women to impart them with the skills for self sustainability and reliance.

VSF Suisse has a satellite base in Tam payam. The organization runs a livestock program with the aim of disease control through disease surveillance, training the local community on livestock management and vaccination of livestock .According to the organization Veterinary Field Supervisor for South Sudan, Malignant Catarrhal Fever (MCF), a viral disease that has neither treatment nor vaccine, is the major cause of livestock mortality in Mayom County.

South Sudan Operation Mercy (SSOM), an indigenous NGO partnering with FHI (Food for Hunger Initiative) and CMA (Christian Mission Aid) operates in Tam payam. Its major operations are through outreach where they offer non food items such as blankets, sheets and tarpaulins. The organization also runs a project on trachoma though treatment of eye diseases such as trachoma.

Liech Community Development Association (LCDA), an indigenous NGO operating in Mayom and Abiemnam County funded by Pact currently runs a water and sanitation project. Its major activities include training the community on hygiene and sanitation through role plays and have so far built 10 boreholes in Mayom county, 6 of which are situated in Mankien payam as follows: Mankien centre (3), Liengiera village (1), Ruazkey village (1) and Tharchiengbol villages (1).Other objectives of the organization include health, education, promotion of peace and capacity building of the community on income generating activities. However, these objectives have not been actualized due to lack of adequate funds.

.V. RESULTS OF THE ANTHROPOMETRICS SURVEY

After undertaking an anthropometric nutrition survey in Mankien and Tam payams between 17th October and 10th November 2006, anthropometric data of the 930 children measured aged between 6-59 months was analyzed. However, only 925 children were included in the final analysis due to 5 aberrant data.

.V.1. Distribution by Age and Sex

Table 3: Distribution by Age and Sex Age Groups Boys Girls TOTAL Sex (months) N % N % N % Ratio 06 – 17 116 48.7 % 122 51.3 % 238 25.7 % 0.95 18 – 29 97 48.5 % 103 51.5 % 200 21.6 % 0.94 30 – 41 72 48.3 % 74 50.7 % 146 15.8 % 0.97 42 – 53 99 53.5 % 86 46.5 % 185 20.0 % 1.15 54 – 59 84 53.8 % 72 46.2 % 156 16.9 % 1.17 Total 468 50.6 % 457 49.2 % 925 100.0 % 1.02

The distribution by sex does not show a significant imbalance as the results disclose a sex ratio of 1.02. Figure 4: Distribution by Age and Sex

Mayom and Tan Distribution by Age and Sex

54-59

42-53

e 30-41 Boys Ag Girls

18-29

6-17'

-60% -40% -20% 0% 20% 40% 60% Percentage

The typical demographic pattern in developing countries is as follows: 20-25% for the age groups 6-17, 18-29, 30-41 and 42-53 months respectively and; 10% for age groups 54-59 months. The age distribution represented in the chart above shows a significant imbalance: the age groups 30-41 and 42-53 months respectively were slightly under represented while children aged 54-59 months were over represented. This could be attributed to recall bias associated with use of a local calendar of events to estimate the ages of most of the children in households where the mothers and caretakers did not know the actual ages of the children.

.V.2. Anthropometrics Analysis

.V.2.1. Acute Malnutrition, Children 6-59 months of Age

¾ Distribution of Acute Malnutrition in Z-Scores

Table 4: Weight for Height distribution by age in Z-score

Age group < -3 SD ≥ -3 SD & <- 2 SD ≥ -2 SD Oedema N (In months) N % N % N % N % 06-17 238 9 3.8% 46 19.3 % 181 76.1 % 2 0.8 % 18-29 200 3 1.5 % 17 8.5 % 179 89.5 % 1 0.5 % 30-41 146 0 0.0 % 5 3.4 % 141 96.6 % 0 0.0 % 42-53 185 2 1.1 % 18 9.7 % 165 89.2 % 0 0.0 % 54-59 156 4 2.6 % 36 23.1 % 115 73.7 % 1 0.6 % TOTAL 925 18 1.9 % 122 13.2 % 781 84.4 % 4 0.4 %

Table 6: Weight for height vs. Oedema

Weight for height < -2 SD ≥ -2 SD

Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 4 0.4 % Oedema Marasmus No malnutrition NO 140 15.1% 781 84.4 %

Both types of malnutrition, marasmus and kwashiorkor, were found. Marasmus is the most prevalent type.

Figure 5 : Z-scores distribution Weight-for-Height, Mankien and Tam payams, Mayom County

The displacement of the sample curve to the left side of the reference curve shows that, the nutrition situation in the surveyed population is critical. The mean Z-Score of the sample which is – 1.07 (SD: 0.93, which lies within the range of 0.80-1.2034 hence indicating a randomly selected sample).

34 Normal sex ratio range for all age groups

Table 7: Global and Severe Acute Malnutrition by age group in Z-score

6-59 months (n = 925) 6-29 months (n = 438) 15.6% 17.8 % Global acute malnutrition [12.4 % - 19.3%]35 [13.0% - 23.8%] 2.4 % 3.4 % Severe acute malnutrition [1.2 % - 4.4%] [1.5 % - 7.1 %]

Statistical analysis results reveal that there is no significant difference in the malnutrition rates between the age groups age 6-29 months and 30-59 months (uncorrected chi- square value is 3.18, p>0.05).

¾ Distribution of Malnutrition in Percentage of the Median

Acute malnutrition expressed as a percentage of the median is normally used as an admission criteria in feeding centres. Results of the anthropometric analysis reveal the following:

Table 5: Distribution of Weight/Height by age in percentage of the median

Age groups < 70% ≥ 70% & < 80% ≥ 80% Oedema (months) N N % N % N % N % 06-17 238 5 2.1 % 32 13.4 % 199 83.6 % 2 0.8 % 18-29 200 1 0.5 % 10 5.0 % 188 94.0 % 1 0.5 % 30-41 146 0 0.0 % 3 2.1 % 143 97.9 % 0 0.0 % 42-53 185 0 0.0 % 10 5.4 % 175 94.6 % 0 0.0 % 54-59 156 1 0.6 % 22 14.1 % 132 84.6 % 1 0.6 % TOTAL 925 7 0.8 % 77 8.3 % 847 90.5 % 4 0.4 %

Table 6: Weight for height vs. oedema

Weight for height < -2 SD ≥ -2 SD

Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 4 0.4 % Oedema Marasmus No malnutrition NO 84 9.1 % 837 90.5 %

Table 7: Global and Severe Acute Malnutrition by age group in percentage of the median

6-59 months (n = 925) 6-29 months (n = 438) 9.5 % 11.6 % Global acute malnutrition (7.0 % - 12.7 %) (7.8%-16.9 %) 1.2 % 2.1 % Severe acute malnutrition (0.4 % - 2.8 %) (0.7 % - 5.3 %)

.V.2.2. Risk of Mortality: Children’s MUAC

35 The data into brackets are the Confidence Interval at 95%.

Table 8: MUAC Distribution >=75 – < 90 cm MUAC (mm) < 75 cm Height ≥ 90 cm height Total Height < 110 4 2.7 % 0 0.0 % 0 0.0 % 4 0.4 % 110≥ MUAC<120 16 11.0 % 7 2.3 % 0 0.0 % 23 2.5 % 120≥ MUAC<125 19 13.0 % 9 3.0 % 2 0.4 % 30 3.2 % 125 ≥ MUAC <135 42 28.8 % 67 22.0 % 42 8.9 % 151 16.3 % MUAC ≥ 135 65 44.5 % 222 72.8 % 430 90.7 % 717 77.5 % TOTAL 146 15.8 % 305 33.0 % 474 51.2 % 925 100 %

MUAC a significant indicator of mortality amongst children aged 12 months and above (≥ 75cm). During the assessment, MUAC measurements were undertaken and analysed. As tabulated above, MUAC analysis reveals that; amongst children whose height was equal to or greater than 75cm; none of the children were neither severely malnourished nor at high risk of mortality, 7 (0.9 %) were moderately malnourished with moderate risk of mortality, 120 (15.4%) being at risk of malnutrition while 652(83.7%) were well nourished.

.V.3. Measles Vaccination Coverage

Measles, an acute viral illness can be prevented through immunization. Under normal circumstances, the Measles vaccine is often administered to children of age 9 months and above. The data of the 872 children of age 9-59 months assessed were analyzed. Table 9: Measles Vaccination Coverage Measles vaccination N % Proved by Card 61 7.0 % According to the mother/caretaker 396 45.4 % Not immunized 415 47.6 % Total 872 100.0 %

.V.4. Household Status

Table 13: Household Status Status N % Residents 592 95.5 Internally Displaced 7 1.1 Temporary Residents 18 2.9 Returnee 3 0.5 Total 620 100.0

As per the tabulated data above, of the 620 households surveyed 95.5% were residents, 1.1% and 2.9% being internally displaced and temporary residents in that order; while 0.5% were returnees.

.V.5. Composition of the Households

Table 104: Household Composition Age group N % Under 5 years 973 30.7 Above 5 years 2201 69.3 Total 3174 100.0

While undertaking the mortality survey, a total of 620 households were assessed. The average number of children under 5 years of age per household was 1.6 while that of persons equal to or above 5 years of age was 3.5.

.VI. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

As at the time of the survey, a total of 3174 persons were presents in the households surveyed, among which 973 were children less than 5 years.

Various demographic changes were observed over the three months preceding the survey: 43 births were reported. 49 persons had arrived in the location, 3 of them being children under five 116 people had left the location in the same period, 37 of them being children under five 21 deaths were reported within the last 3 months; 7 deaths being amongst children less than 5 years.

The total and under-five retrospective mortality rates are respectively 0.73 /10,000/ day [0.33 - 1.13] and 0.80 /10,000/ day [0.19 – 1.41]. They both are below the alert levels of 1/10,000 and 2/10,000 per day respectively.

.VII. CONCLUSION

The Z- score analysis of the anthropometrics data revealed GAM rate of 15.6% [95% CI: 12.4%-19.3%] and a SAM 2.4% [95% CI: 1.2%- 4.4%]. The GAM rate is at the emergency level. Analysis of malnutrition by age group and sex deduced that there was no significant relationship in the risk of malnutrition. All age groups and sexes were at equal risk of malnutrition (p>0.05).

Additionally, crude and under five mortality rates are both below the alert levels. The nutrition situation detected could be attributed to a number of factors as discussed below.

Food insecurity:

According to WFP SSD Food security and livelihoods update, the food security situation in Unity state had deteriorate in the past months. Food stocks at the household levels had continued to deplete as the hunger gap progressed and the community was already relying on other coping mechanisms to obtain food and income. Young adults had moved to the oil fields in search of employment to supplement the household livelihoods needs. Similarly in June, the food security situation had drastically declined due to severe shortage of cereals which was ascribed to below average local production and bad road conditions reducing access to markets.

The current food security situation is still wanting as a result of lack adequate tools and seeds for cultivation which resulted to small farms cultivation that cannot support the foods needs for the community. The current food harvest is expected to last for three months. The presence of vibrant open air markets in the location that sell both food and non food items is an indicator of an active community with circulation of money. The market is expected to cushion the community against food shortages as most food stuffs are available in the market but only for the middle class and rich household the rest will be at risk of food insecurity increasing the chances of raising the malnutrition rates.

Poor hygiene and sanitation

The hygiene and sanitation practices of the community in Mankien and Tam payams are wanting.. Saddening, only 2% of the households had access to toilet facilities. Faecal matter and litter were observed in the market environment; open air butchery, food kiosks were sullied, water used in food preparation unsatisfactory. Long grass, stagnant pools, and natural features such as the areas flat terrain of black cotton soil (The impermeability nature of the soil predisposes the area to flooding especially in the wet season), aggravates the community’s vulnerability to infections such as malaria and diarrhea. Despite the fact that the community has access to water points; the daily consumption was below Sphere standards consequently compromising sanitation and hygienic standards. In addition, most (84%) of the households did not treat their water before drinking, utensils were left dirty lying on the ground and in some instances used for laundry as observed.

Children aged 6-59 months are a vulnerable group since they are no longer protected by exclusive breast feeding hence susceptible to diseases and infections. The susceptibility to infections such brucellosis, typhoid and diarrhoea was further aggravated as they were fed on raw cows’ milk using unclean utensils.

Inadequate food intake and poor feeding practices:

To meet the daily recommended dietary requirements, an individual needs to take food in the right quantity and quality. Children, pregnant and lactating mothers have additional nutrient demands owing to their physiological status and for healthy growth and development hence are most vulnerable to malnutrition. However in the surveyed locations, the results revealed that most people, including mothers and children, largely consumed inadequate food and undiversified diets. The most commonly consumed food was walwal, a dish made mainly from maize, with milk as an accompaniment. Milk and maize were consumed daily. Even though milk was consumed daily, the quantity and quality of the milk is still questionable as children were fed on raw milk as most (45.1%) households reported to receive an average of 1 liter per day.

Fishing was done by the community to supplement their food demands; however, not all households had access to fish due to lack of appropriate and adequate fishing equipments, lack of fish in the fish points and in some households, lack of fishing grounds. Most (78%) of the households interviewed reported that they fed their young children only twice a day due to lack of food and increased workload. These poor feeding practices are detrimental to the nutritional status of these growing children who have increased nutrient demands.

Poor maternal and child care practises

Despite their being EPI36 and MCH37 services offered in the location; early marriages, more births to replace those who had passed away during the two decade conflict alongside heavy workload and strenuous exercise, lack of adequate and diversified meals, poor sanitation and hygiene continue to exacerbate the risks to maternal and child health.

Disease:

WFP Food security and livelihoods update June 2006 reported that malnutrition levels are very high in Unity State, especially in the rural areas where medical services are non-existent.

Even though most of the community members first seek medical attention at the public clinics which averagely takes about 30minutes to 1 hours walk, the medical personnel at the PHCC reported that this was done very late when the disease had progressed to severe stages. In addition, the distribution of the health facilities is uneven with some households having to walk long distances worsened by the numerous swamps and rivers that traverse the payams hence hindering prompt intervention incase of illness. Further, the ratio of health facilities to the population is 1:24,223 which is much higher than the SPHERE recommended ratio of 5000 people per PHCU facility. According to the WR epidemiological records and the households, malaria, RTI, STDs, diarrhoea were the most common causes of morbidity with malaria being the major cause of mortality. Additionally, the

36 EPI - Expanded programme On Immunization 37 MCH- Maternal Child Health

cases of malnutrition were reported to be on the rise; with no specialized care given to the malnourished patients at the health centre and unit.

Further, the presence of an outbreak of measles in the location during the month of August 2006 could also have attributed to the relatively high amongst the children aged 6- 59 months.

.VIII. RECOMMENDATIONS

In South Sudan where malnutrition is most often caused by lack of food, the nutrition status is expected to improve significantly in October and deteriorate towards the end or after April and steadily improve after August when the early crop of maize matures and is available for consumption, soon followed by sorghum38. However, the GAM rate in Mankien and Tam payams was critical even after the October harvest. This could be due to the inter-relationship between malnutrition and various factors such as outbreak of diseases, food insecurity, poor hygiene and sanitation and not just the mere absence of food.

FOOD SECURITY

WATER AND SANITATION

38 FEWS NET: 10/29/2002

.IX. APPENDIX

.IX.1. Sample Size and Cluster Determination

TOTAL TARGET CUMULATIVE NUMBER NO. OF PAYAM VILLAGE TIME CLUSTERS POPULATION POPULATION POPULATION ASSIGNED CLUSTERS MANKIEN CENTER 5 MIN 4388 877 877 1- 877 1, 2, 3 3 THARLIEL 1 HOUR 300 60 937 878-937 DHULEK 30 MIN 900 180 1117 938-1117 THARCHIENGBOL 45 MIN 500 100 1217 1118-1217 4 1 KAI NHIAL 1 HOUR 150 30 1247 1218-1247 RUAZ KEI 30 MIN 500 100 1347 1248-1347 MANKIEN NYATUEL 40 MIN 500 100 1447 1348-1447 WICHTHEP 2 HOURS 400 80 1527 1448-1527 5 1 PULBUOY 1 HR 30 MIN 350 70 1597 1528-1597 JOK RUOP 2 HOURS 1300 260 1857 1598-1857 6 1 KERNYANG 3 HR 30 MIN 3500 700 2557 1858-2557 7, 8 2 JOHRIAL 30 MIN 1100 220 2777 2558-2777 9 1 TAM CENTER 5 MIN 7000 1400 4177 2778-4177 10, 11 ,12 , 13 4 NGUAN MITH 30 MIN 900 180 4357 4178-4357 RUP DENI 40 MIN 500 100 4457 4358-4457 14 1 PAM RIAK 1 HOUR 450 90 4547 4458-4547 THOK YIER KONGA 50 MIN 4900 980 5527 4548-5527 15, 16, 17 3 TAM GUIY RIAK 5 HOURS 4680 936 6463 5528-6463 18, 19, 20 3 LIENGIERA 3 HR 30 MIN 4680 936 7399 6464-7399 21, 22, 23 3 WANGBIETH 4 HOURS 4700 940 8339 7400-8339 24, 25, 26 3 MATAR 30 MIN 598 119 8458 8340-8458 NYAPEUW 1 HOUR 6000 1200 9658 8459-9658 27, 28, 29, 30 4 PAKUR 1 HOUR 150 30 9688 9659-9688 TOTAL 48,446 9688 30

The sampling interval is equal to total target population divided by number of clusters i.e. 9688/30 =322. The villages included in the clusters are shown in the table above. The random number drawn was 201 and lies between 01 and 322.

A total of 930 children were included in the survey.

.IX.2. Anthropometric Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No: Sitting Measles Family Status Age Sex Weight Height Oedema N°. Height MUAC C/M/N N°. (1) Mths M/F Kg Cm Y/N cm(2) Cm (3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family…), 4= Returnee. (2) Sitting Height is optional. To apply for ACF-USA survey. This data is for research. (3) Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles.

.IX.3. Household enumeration data collection form for a death rate calculation survey (one sheet/household)

Survey Payam: Village: Cluster number:

HH number: Date: Team number:

1 2 3 4 5 6 7 Present at beginning of recall Date of Born Died (include those not present now HH Present birth/or during during the ID and indicate which members were Sex member now age in recall recall not present at the start of the years period? period recall period ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Tally (these data are entered into Nutrisurvey for each household):

Current HH members – total Current HH members - < 5 Current HH members who arrived during recall (exclude births) Current HH members who arrived during recall - <5 Past HH members who left during recall (exclude deaths) Past HH members who left during recall - < 5 Births during recall Total deaths Deaths < 5

.IX.4. Enumeration data collection form for a death rate calculation survey (one sheet/cluster)

Survey Payam: Village: Cluster number:

HH number: Date: Team number:

Current HH Past HH members Current HH members who who left during Births Deaths during recall N member arrived during recall recall during (exclude births) (exclude deaths) recall Total < 5 Total <5 Total < 5 Total < 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

.IX.5. Calendar of events in Mankien and Tam payams, Mayom County.

MONTHS SEASONS 2001 2002 2003 2004 2005 2006 Store harvest 57 45 33 21 9 New commissioner JANUARY Take cattle to cattle Riak Machar comes to Signing of comprehensive Paykel camps Tam peace agreement (CPA) 56 44 32 20 8 Increased famine and FEBRUARY Build tukuls drought in Mayom Payrew Nhialdiu captured by county Arabs WFP food drop 55 43 31 19 7 Increased famine and MARCH Build tukuls drought in Mayom Drought Paydiok county Many cattle died. WFP food drop Their was no water 54 42 30 18 6 Prepare land for Increased famine and APRIL planting drought in Mayom Paynguan Rain begins county WFP food drop Drought continues 53 41 29 17 5 Increased famine and Meningitis campaign. Planting of maize and MAY drought in Mayom sorghum Pay dhiech county WFP food drop Drought continues Planting beans 52 40 28 16 4 groundnuts, pumpkin Increased famine and JUNE and simsim drought in Mayom Pay bakel Return cattle from cattle GOS fought SPLA in county camp Mankien. WFP food drop Drought ends 51 39 27 15 3 GOS capture State Governor comes Dr. John Garang becomes JULY Weeding crops Mankien from SPLA to Tam. Vice president of Sudan. Pay barrow .SPLA flee to Dinka Rain begins after a long James Liyli became People celebrated in area. famine. the new commissioner Khartoum Eating green maize and 50 38 26 14 2 other fresh foods from AUGUST the farm Paybadak Death of Dr. John Garang, SLPA return to fight Brigadier Bolkong former Vice president of the Arabs. comes to Tam Sudan SEPTEMBER 49 37 25 13 1 Lots of pumpkin to eat Paybanguan The fight continues. Lots of mosquitoes OCTOBER Harvesting sorghum 48 36 24 12

Paywal and maize The fight continues. NOVEMBER 59 47 35 23 11 Drying of harvest Peter Gatdet deflects Paywalkel from SPLA to GOS 58 46 34 22 10 Christmas season DECEMBER Gatdet come with Very cold month. Paywalrew GOS to fight SPLA. .

.IX.6. Food market prices: Mankien and Tam payam, Mayom County, November 2006.

COMMODITY QUANTITY PRICES IN DINNAR Sugar 1 Kilogram 280 Wheat flour 1 kilogram 160 Lentil 1 kilogram 200 Salt 250g ( Non iodised) 50 Onions 1 kilogram 300 Chicken 1 Medium size Fresh fish 1 large 1000 Smoked fish 1 medium 1000 Charcoal Sack of 50 kilogram 2500 Goat 1 medium size 8000 Cow 1 medium size 40,000 Sheep 1 medium size 10,000 Oil 500 ml 200 Meat 1 kilogram 600 Honey 60 g 100 Dates 1 kilogram 400 Soda 500ml 250 Rice 1 kilogram 100 Water melon 1 medium size 300

Exchange rates.

300 dinnar = 100 Kenya shillings 250 Sudanese dinnar = US dollar.

.IX.7. Distribution of Boreholes, Schools and health Facilities in Mankien and Tam Payams

BOREHOLES SCHOOLS TOTAL TARGET PAYAM VILLAGE TIME AND HEALTH POPULATION POPULATION FACILITY MANKIEN CENTER 5 MIN 4388 877 3 1 SCHOOL THARLIEL 1 HOUR 300 60 0 I PH0C C DHULEK 30 MIN 900 180 1 0 THARCHIENGBOL 45 MIN 500 100 1 0 KAI NHIAL 1 HOUR 150 30 0 0 RUAZ KEI 30 MIN 500 100 1 0 MANKIEN NYATUEL 40 MIN 500 100 0 0 WICHTHEP 2 HOURS 400 80 0 0 PULBUOY 1 HR 30 MIN 350 70 0 0 JOK RUOP 2 HOURS 1300 260 0 0 39 KERNYANG 3 HR 30 MIN 3500 700 0 I PHCU JOHRIAL 30 MIN 1100 220 0 I SCHOO0 L TAM CENTER 5 MIN 7000 1400 2 MSF CLINIC NGUAN MITH 30 MIN 900 180 0 I SCHOO0 L RUP DENI 40 MIN 500 100 0 0 PAM RIAK 1 HOUR 450 90 0 0 THOK YIER KONGA 50 MIN 4900 980 1 0 TAM GUIY RIAK 5 HOURS 4680 936 0 0 LIENGIERA 3 HR 30 MIN 4680 936 1 0 WANGBIETH 4 HOURS 4700 940 0 0 MATAR 30 MIN 598 119 1 0 NYAPEUW 1 HOUR 6000 1200 0 0 PAKUR 1 HOUR 150 30 0 0 TOTAL 48,446 9688 11 0

39 The PHCC AND PHCU are operated by World Relief.

.IX.8. Map of Mankien and Tam payams, Mayom County40

MAP OF MANKIEN PAYAM

40 Source: Mankien SRRC counterpart, survey team and payam administrator.

MAP OF TAM PAYAM