Melut County Nutrition Survey Final Report 0407

South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY

CHILDREN UNDER 5 YEARS OLD

MELUT, PALOCH, GALDORA AND BEMICHUK PAYAMS, MELUT COUNTY, UPPERNILE STATE

12TH FEBRUARY – 14TH MARCH, 2007

Edward Kutondo- NSP Manager Joseph Nganga – Nutritionist Monica Asekon – Nutritionist Deborah Morris- Program Assistant

ACKNOWLEDGMENTS

The UK Department for International Development (DFID) for funding the survey,

Medair for hosting and facilitating movement of the ACF-USA nutrition survey team,

Sudan Relief and Rehabilitation Commission (SRRC) in Melut County, for ensuring smooth progress of the whole exercise,

The local surveyors for their tireless efforts, contribution and determination towards fulfilling the survey objectives,

Final but not least, gratitude goes to caretakers, local authorities, and community leaders without whose cooperation and assistance the survey objectives could not have been realized.

TABLE OF CONTENTS .I. EXECUTIVE SUMMARY...... 4 .I.1. INTRODUCTION ...... 4 .I.2. OBJECTIVES...... 5 .I.3. METHODOLOGY ...... 5 .I.4. SUMMARY OF FINDINGS ...... 6 .I.5. NUTRITION AND MORTALITY SURVEY RESULTS ...... 8 .I.6. RECOMMENDATIONS...... 9 .II. NTRODUCTION ...... 10 METHODOLOGY ...... 11 .II.1. TYPE OF SURVEY AND SAMPLE SIZE...... 11 .II.2. SAMPLING METHODOLOGY...... 11 .II.3. DATA COLLECTION ...... 12 .II.4. INDICATORS, GUIDELINES, AND FORMULAS USED...... 12 .II.4.1. Acute Malnutrition...... 12 .II.4.2. Mortality ...... 13 .II.5. FIELD WORK ...... 14 .II.6. DATA ANALYSIS...... 14 .III. RESULTS OF THE QUALITATIVE ASSESSMENT...... 14 .III.1. SOCIO- DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS ...... 14 .III.2. FOOD SECURITY...... 15 .III.3. HEALTH ...... 19 .III.4. WATER AND SANITATION...... 21 .III.5. MATERNAL AND CHILD CARE PRACTICES...... 22 .III.6. EDUCATION ...... 23 .III.7. ACTIONS TAKEN BY NGO’S AND OTHER PARTNERS ...... 23 .IV. RESULTS OF THE ANTHROPOMETRIC SURVEY...... 25 .IV.1. DISTRIBUTION BY AGE AND SEX ...... 25 .IV.2. ANTHROPOMETRICS ANALYSIS...... 26 .IV.2.1. Acute Malnutrition, Children 6-59 months of Age ...... 26 .IV.2.2. Risk of Mortality: Children’s MUAC...... 28 .IV.3. MEASLES VACCINATION COVERAGE ...... 28 .IV.4. HOUSEHOLD STATUS ...... 28 .IV.5. COMPOSITION OF THE HOUSEHOLDS ...... 29 .V. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY...... 29 .VI. CONCLUSION ...... 30 .VII. RECOMMENDATIONS...... 32 .VIII. APPENDICES ...... 33

.I. EXECUTIVE SUMMARY

.I.1. Introduction

Melut County is located in Upper-Nile state. It is bordered by four counties in the same state: Manyo County in the south west, Maaban County in the east, Baliet County in the south and Renk County in the north. Melut County is situated in the Nile Sobat zone and along East of Nile corridor which it shares with Manyo County in the western bank of the river. The county counts six administrative Payams namely Melut, Paloch, Bemichuk, Galdora, Wunamom and Panamdit. Administratively it falls into the jurisdiction of the central government, under the auspices of Government of South Sudan (GoSS) and Government of Sudan (GoS), which has headquarters in Melut Payam.

It is characterized by flat, low lying and vast plains, with black cotton soils. Savannah grasslands and acacia trees are the typical vegetative cover. The banks of Nile and its small seasonal tributaries such as river Awilwil and Thor Ager criss-crossing the county determine the settlement patterns of the villages. These rivers are the main sources of drinking water, fishing grounds and watering points for the community livestock especially during the dry season. River Nile is also central to long distance migration and transport into and out of Melut and the adjoining counties.

There are different communities coexisting in Melut County. The major ones being Dinka, Shilluk, Burun, Furs, Nubians and Nuer. Other communities are in minority (Murle and Anyuak). The population is estimated at 128, 5711 persons. The predominant livelihoods of the communities in this region are agro-pastoralism, formal and informal employment and small scale trading. Fishing is practiced on a small scale. An important proportion of the population relies heavily on kinship support.

Melut County is located along the migratory path of the Nile River and road network. Therefore it counts many migrants that are mainly settling in the cosmopolitan areas of Melut, Paloch and Galdora areas. Along with this constant path, a movement of people into Melut began in November 2006 as a result of conflict between Sudan Peoples Liberation Army (SPLA) and Sudan Armed Forces (SAF) in Malakal town, which, is not far from Melut town2. 60 in-migrants were reported to be coming to Melut Payam every week.3 This has a constraining effect on food security situation of the hosts, who provided kinship support.

According to a Fewsnet report in January 2007, food security was expected to remain stable for most of the households in this region during the dry season (between January and April 2007), following harvests which started in October 2006. However, the arrival of displaced people in the area could destabilize the food security situation, by causing strain on available food and increased food prices4.

The water and sanitation situation is poor as well: the water reportedly consumed in the region is untreated and there is no proper system of human waste disposal in the vastly populated human settlements, thus predisposing the communities to immediate and underlying causes of malnutrition such as diseases and poor child care practices respectively5.

In the last two years ACF-USA implemented surveys in Payuer, which is located in Melut County. Only Galdora and Panamdit payams were covered.

1 Source: SSRRC Melut 2007 2 Southern Sudan Food Security update (Fewsnet) January 2007 3 Medair Assessment July, 2006. 4 Source: SSRRC Melut 5 Medair Assessment July, 2006.

This year, the good security conditions allowed the survey to cover 4 of the 6 Payams in Melut county. The results of the previous surveys are therefore not comparable to this one’s due to different geographical coverage, but are given are as an indicator (in Z-scores, reference NCHS):

Table 1: Results of the previous nutrition surveys in Melut County April 2005 February 2006* Global Acute 28.1% 20.8% Malnutrition (23.4-33.3) Severe Acute 4.5% 1.7% Malnutrition (2.6-7.4)

.I.2. Objectives

In consideration of the population movement and past malnutrition rates, ACF-USA decided to undertake a nutrition survey to establish the nutritional status of the community in Melut County. The survey which was implemented between 12th February and 14th March 2007 was guided by 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 identify the sex at higher risk to malnutrition. ⌧ To estimate the crude mortality rate through a retrospective survey. ⌧ To determine immediate, basic and underlying factors influencing the nutrition situation of the community. ⌧ To identify priority areas in program implementation

.I.3. Methodology

SMART6 methodology was employed for both nutrition and mortality surveys. The target population is children under five years of age. The list of all the accessible villages were obtained from the SSRRC, however no administrative population figures per village were available for Melut, Paloch, Galdora, and Bemichuk Payams. The population was therefore obtained by estimating the number of households and household size in at least one village in each payam and then through triangulation, with assistance of local residents, to assign other villages weights and relative size. The target population for all accessible villages was evenly sub divided such that each geographical unit had a maximum proportion of 250. The geographical units and their respective population were then inputted into the Nutrisurvey for SMART software (December 2006 version) for calculation of sample size and assignment of clusters. Utilizing malnutrition prevalence of 28.1% based on previous surveys, precision of 4.2% and design effect of 2, a sample size of 828 children was obtained. The sample size was then increased by 5% to cater for missing children during data collection. A total of 36 clusters were calculated, considering that 16 households were suitable for collection of anthropometric and retrospective mortality data per cluster/day.

Epi method was used to randomly select households included in data collection: households were randomly selected by first going to the centre of the clustered village and spinning a pen to determine randomly the direction to be followed by the survey team towards the periphery of the village. Once at the edge of the village, the survey team spun the pen again till it pointed towards the body of the village, this time, to determine the direction the team would follow till the periphery of the village while counting all the houses on the team’s path and assigning them numbers. Thereafter, the starting point was established through balloting so as to further minimize bias and ensure random representation of households in the villages. In the selected household, mortality and anthropometric data of all children aged between 6-59 months were measured. Once the questionnaires filled in the first household, the next household was chosen by proximity, to the next house on the right, until all data was collected in a total of 16 households.

6 Standardized Monitoring and Assessment in Relief and Transition

Retrospective mortality data utilizing a 90 day recall period was collected alongside the anthropometric data and in every household where anthropometric information was collected.

Qualitative data was, also, gathered through interviewing the household and making relevant observations. Household interviews were systematically conducted using structured questionnaires. The qualitative data centered on food availability and accessibility, water and sanitation, child care practices as well as accessibility and utilization of health care services.

.I.4. Summary of Findings

Prior to signing of the CPA agreement in January 2005, the livelihoods of the population were directly and regularly affected by oil prospecting in the area. Major oil wells were drilled on lands that were previously used for cultivation and cattle grazing7. Militia activities and insecurity has mainly been relegated to the east and south of the county since signing of the CPA agreement. Disarmament which was carried out in October 2006 was peaceful and successful, and currently there is presence of SPLA, SAF and GIU military units in the county and the weapons are in their custody. The most recent insecurity incident was reported in the eastern border of Melut to Maaban, when the Militia fought government forces in the beginning of February 2007. However, no casualties were reported and the root cause of fighting was reportedly not known.

There has been constant migration in and out of Melut given that it is placed strategically along the road to Renk, Nasir and Khartoum and also, on the eastern bank of river Nile. The number of returnees reported in the last three months to have settled in Melut, Paloch, Galdora, Bemichuk, Wunamom and Panamdit were 5,300, 3,900, 2,400, 3,500, 4,200 and 5,500 respectively8.

Cultivation in most parts of Melut commenced in May 2006, and the major crop of the season is sorghum and maize to a lesser extent. Other crops are cultivated throughout the year, although on small scale: tomatoes, okra and onions. The cultivation areas’ size averages 2 feddans,9 but some farmers cultivate large tracts of land, usually above 4 feddans and used hired mechanized harrows. In the last cropping season the government, through the director of agriculture, assisted farmers in mass spraying of crops in some areas to minimize pest attacks and also, to easily access fuel used in cultivation. The rains commenced late and intensified in the month of July and August. The timing did coincide with the planting calendar, thus affected crop performance and delayed the harvest time up to the end of February 2007. Birds and rats attacks were also cited as major aggravators of crop performance and contributed to below par output.

Most populace have settled along or near the banks of river Nile and depend on river water for household consumption, drinking and for livestock. Other households are supplied with untreated water for both household consumption and drinking by commercial water vendors and oil company trucks. There are no community boreholes in Melut. This exposes the community to risk of contracting diarrheal diseases and other waterborne diseases and it can be correlated to the outbreak of acute watery diarrhea reported between April and September 2006 in Melut Payam.

The poor hygiene both within the household and in the surrounding environment exposes the community to high risk of contracting diseases. Urban waste especially dirty water drained into the river banks and in effect polluted the water collection points. Most of the households interviewed did not own or use toilets. Enquiry and observation revealed that human waste was disposed off in open fields, food handling and preparation was not adequately safe, while domestic pets regularly licked utensils and consequently increased contamination levels and risk of infection.

Health seeking behavior of the community was found to be satisfactory during the assessment. Members of the households sought health services in public clinics when one of its members fell sick. However, majority of the

7 Melut SSRRC and community leaders. 8 Melut SSRRC 9 Unit of land measurement equivalent to approximately 4200 sq meters

population access these health services through private clinics in the county’s urban areas as opposed to the bigger hospital in Melut or its dispensaries. This was attributed to the fact that private clinics were said to offer better laboratory services than public hospital. The common causes of morbidity were found to be mainly chest infections during the dry season, and malaria and diarrheal diseases during the wet season. Malnutrition was also cited as common cause of mortality.

Despite availability of EPI services in the hospitals and in the dispensaries which have been running health services in the area, measles immunization coverage is yet to reach some parts of the county which did not have immunized children.

The international non governmental organizations and institutions operating in the area include:

NORTHERN-UPPERNILE CONSORTIUM (NUNC): The consortium which has collective objectives comprises of TEARFUND, FAR (Fellowship for African Relief), STROMME Foundation, Mercy corps, and ECS (Episcopal Church of Sudan) with each organization having different programs in Melut County and other Upper-Nile counties of Maaban and Reng. NUNC commenced operations around mid 2006 and its programs in recovery and rehabilitation includes health, education, food security, water and sanitation.

MEDAIR: It provides Primary health care, which focuses on preventive and curative as well as emergency programs in Melut County. The organization started a PHCC in Melut Payam in February 2007 and negotiations with the local authority are underway on other locations for construction of 3 PHCUs in Paloch, Pariak and Galdora Payams. In addition there is one PHCU in Payuer and Thiagrial which are managed by village health committees, while staffs are supervised by the organization. There are 2 CHWS and one female assistant in Payuer, 1CHW and female assistant in Thiagrial. Melut PHCC has 1 medical doctor, 4 nurses (3 of them Midwives), 1 nutritionist, 1 health promotion manager, 2 Medical assistants (MAs) and 1 CHW. The organization offers both inpatient and out patient services with maternal-child health care, vaccination (EPI), Kalazaar and tuberculosis treatment, antenatal services, laboratory services, health promotion activities and nutrition screening and treatment. The organization trains its CHWS, TBAs, EPI and hygiene health promoters. Plans are underway to commence community therapeutic care (CTC) and stabilisation unit for severe cases. The organization’s emergency program had drilled 6 boreholes in Payuer (Panamdit Payam) and plans to do more drilling in Thiagrial (Galdora Payam). There is a water assessment planned for Melut, where the PHCC is located, and water is currently treated within the precincts of the clinic.

OXFAM GB: This is an international NGO which undertakes capacity building through training of the local community on animal care and also distributes veterinary drugs at a minimum cost to farmers. 8 Community Animal Health Workers (AHWs) who are distributed in all the 6 Payams of Melut County implement outreach activities focusing on disease surveillance and treatment. The program also aims at involving the community in ownership and running of the program to promote sustainability. The program also works in coordination with government agencies in supervising slaughtering of animals and assessing the meat from the town abattoir to ensure safety.

UNMIS: it is mandated to closely monitor and observe the peace progress and any potential insecurity incidents within Melut County.

MELUT HOSPITAL: The hospital has been run by the national health insurance since January 2006, and the insurance provides drugs and remunerates staff. Previously, the Ministry of health managed the hospital operations since February 2005 with 1 MA and 20 nurses. Currently there are 2 doctors, 1 MA, 1 pharmacist, 1 laboratory technician and 10 nurses. The doctors graduated from national universities in Sudan, while the other staffs were trained at Malakal teaching hospital. The hospital offers mainly curative services to out patients and inpatient services to clients with national insurance cover. There are 3 wards (1 male ward, 2 female wards) and a theatre which performs minor surgeries. However, it does not have an equipped laboratory for comprehensive diagnosis. The hospital runs two dispensaries in Paloch and Galdora respectively. Galdora has 1 MA, 1 TBA and three nurses all of whom have not received formal training, while Paloch has 1 trained nurse and 3 untrained nurses. The hospital referral centers at the time of the assessment were Reng and Malakal hospital, although the hospital does not have the means of transferring emergency cases. Medical services include antenatal care and deliveries, and EPI program within and outside the hospital. There is an EPI outreach program run by one technician who recruits volunteers paid by MoH when vaccines are available. The last

outreach was conducted in January 2007 for Polio in conjunction with UNICEF. Measles outreach is planned for the month of April and May 2007. There is no child growth monitoring and nutrition screening procedures, although plans are underway to start the programs. Consultancy fees are charged to the clients who are not under the health insurance scheme while clients who are under the scheme pay 25% of all the charges they incur for medical services. Although the hospital receives timely drug supply, it is underutilized with an average of 3 patients per day.

MINISTRY OF AGRICULTURE: The government of South Sudan has a department of farming stationed in Paloch and headed by director of agriculture. There are also 2 extension workers under the director’s office. The objectives of this office are to allocate land for cultivation, offer agricultural extension services with a primary theme of advising farmers on best farming practices and reporting severe crop attacks. The office also assists farmers with quality hybrid seeds and access to fuel at low cost. In case of severe crop attacks, the department intervenes through aerial spraying of crops with pesticides and insecticides.

.I.5. Nutrition and mortality survey results

The anthropometric nutritional survey included a total of 716 children. The data of 3 children were excluded of the analysis. Therefore, the data of 713 children are considered for the following results.

Table 2: Results summary, Melut nutrition survey 2007

10 INDEX INDICATOR RESULTS Global Acute Malnutrition 21.0 % W/H< -2 z and/or oedema [17.2%-24.9%] Z-score Severe Acute Malnutrition 1.7% NCHS W/H < -3 z and/or oedema [0.5%-2.8%] Global Acute Malnutrition 11.8% W/H < 80% and/or oedema [9.2%-14.4%] % Median Severe Acute Malnutrition 0.1% W/H < 70% and/or oedema [0.0%-0.4%] Global Acute Malnutrition 21.3% W/H< -2 z and/or oedema [17.8%-24.9%] Z-score Severe Acute Malnutrition 4.5% W/H < -3 z and/or oedema [2.9%- 6.1%] WHO Global Acute Malnutrition 7.2% W/H < 80% and/or oedema [5.0%-9.3%] % Median Severe Acute Malnutrition 0.0% W/H < 70% and/or oedema [0.0%-0.2%] Total crude retrospective mortality (last 3 months) /10,000/day 0.83 [0.41– 1.25] Under five crude retrospective mortality /10,000/day 0.69 [0.19 – 1.20] Measles immunization By card 22.0% coverage According to caretaker11 30.0% (n=669, age>=9 months) Not immunized 48.0%

10 Results in bracket are confidence intervals at 95% 11 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker.

.I.6. Recommendations

The high GAM rate among children aged 6-59 months as depicted by the results signify a life threatening nutrition situation in Melut county. Multifaceted interventions would be necessary to significantly lower the risks associated with prevalence of the malnutrition. The following recommendations have therefore been put forth by ACF-USA:

Food Security To establish suitable programs such as training, pest control, farming methods and acquisition of tools for the increase of food production

To implement actions to prevent perennial flooding in some low lying areas, to protect crop yield

To support the community in adopting suitable fishing practices to boost this underutilized resource.

Given the planned and spontaneous returnee situation, a strategy should be immediately put in place to address returnee food needs to forestall food shortage in the host community.

Agencies should sustain cattle vaccination services and improve extension services with an aim of increasing productivity.

Health

Health care programs should have mechanism of expanding coverage of EPI services to cover areas where there is limited access.

The health programs should continue to offer targeted feeding program to reduce the malnutrition rates in the county while also building the capacity of local health institutions in detection and treatment of malnutrition.

Promotion of proper child care practices that focus on hygienic food preparation, quality household diets, appropriate breastfeeding practices and mother psychological support through individual and family counselling.

Water, Sanitation and Hygiene

Increase safe water access at household level (through boreholes drilling, water pumps installation, rain water collection, creation of dams, etc).

To initiate viable human faecal disposal methods by supporting construction of durable latrines, establishment of tool banks, community participation and partnership with the government to promote good public health.

.II. NTRODUCTION

Melut County is located in Upper-Nile state, which mainly forms the Eastern side of South Sudan. The county is bordered by four counties in the same state, thus, Manyo County in the south west, Maaban County in the east, Baliet County in the south and Renk County in the north. Melut County which has a population of 128,57112 persons comprises of six administrative Payams namely Melut, Paloch, Bemichuk, Galdora, Wunamom and Panamdit. Administratively the county is controlled by the central government under the auspices of Government of South Sudan (GoSS) and Government of Sudan (GoS) with headquarters in Melut Payam.

Melut County is situated in the Nile Sobat zone and along East of Nile corridor which it shares with Manyo County in the western bank of the river. It is characterized by flat, low lying terrain with black cotton soils. In the vastness of the plains, savannah grasslands and acacia trees are the typical vegetative cover. The banks of Nile river and its small seasonal tributaries such as river Nyal, Awilwil and Thor Ager criss-crossing the county determine the settlement patterns of the villages making up the payams and cattle camps; and are main sources of drinking water, fishing grounds and watering points for the community livestock especially during the dry season. River Nile is also central to long distance migration and transport into and out of Melut and the adjoining counties.

There are numerous communities coexisting in Melut County, the major ones being Dinka, Shilluk, Burun, Furs, Nubians and Nuer. There are also other communities that live in this area like Murle and Anyuak. The predominant livelihoods of the communities in this region are agro-pastoralism, formal and informal employment and small scale trading. Fishing is practiced on a lesser scale and the area has a significant number of dependants on kinship support.

Melut County, being along the migratory path of the Nile river and road network was observed to have many migrants settling mainly in cosmopolitan areas of Melut, Paloch and Galdora areas and 60 in-migrants were reported to be coming to Melut Payam every week.13 This alone had a constraining effect on food security situation of the hosts, who provided kinship support as the arrivals looked forward to reintegration and participation in the census scheduled for November, 2007. Partly, the movement of people into Melut was unprecedented and could have begun as early as November 2006 as a result of conflict in Malakal town, which, is not far from Melut town14.

According to a FEWSNET report in January 2007, food security was expected to remain stable for most of the households in this region in the dry season between January and April 2007, following harvests which started in October 2006. However, there was a possibility the situation could be reversed by increased trickling in of people into the area causing strain on available food and increased food prices that could result from growing demand, thus, reducing food access15. The bulk of water reportedly consumed in the region was untreated and there was no proper system of human waste disposal in the vastly populated human settlements, thus predisposing the communities to immediate and underlying causes of malnutrition such as diseases and poor child care practices respectively16.

In the last two years ACF-USA implemented surveys in Payuer that is located in Melut County. Only Galdora and Panamdit payams were covered. This year, the good security conditions allowed the full county to be covered. The results of the previous surveys are therefore not comparable to this one’s due to difference in the geographical coverage, but are given are as an indicator (in Z-scores, reference NCHS):

12 Source: SSRRC Melut 2007 13 Medair Assessment July, 2006. 14 Southern Sudan Food Security update (Fewsnet) January 2007 15 Source: SSRRC Melut 16 Med air Assessment July, 2006

Table 3: Results of the previous nutrition surveys in Melut County April 2005 February 2006* Global Acute 28.1% 20.8% Malnutrition (23.4-33.3) Severe Acute 4.5% 1.7% Malnutrition (2.6-7.4)

METHODOLOGY

.II.1. Type of Survey and Sample Size

An anthropometric survey was conducted targeting children aged between 6 and 59 months utilizing SMART methodology, which ensures accuracy and precision of data collected.

Selection of accessible villages was done using a map of the area indicating administrative boundaries of the Payams and villages. Information on population figures for the whole County and individual Payams17 was available, however, that of individual villages (which are the units of cluster assignment) were non-existent. The population was therefore obtained by estimating the number of households and household size in at least one village in each payam and then through triangulation, with assistance of local residents, to assign other villages weights and relative size.

The target population (32,954) for all accessible villages (26) was evenly sub divided such that each geographical unit had a maximum proportion of 250. The geographical units and their respective population were then inputted into the Nutrisurvey for SMART software December 2006 for planning. Utilizing malnutrition prevalence of 28.1% based on previous surveys, precision of 4.2% and design effect of 2, a sample size of 828 children was obtained. The sample size was then increased by 5% to cater for missing children during data collection. A total of 36 clusters were calculated, considering that 16 households were suitable for collection of anthropometric and retrospective mortality data per cluster/day.

Retrospective mortality data utilizing a 90 day recall period was collected alongside the anthropometric data and in every household where anthropometric information was collected.

Qualitative data was, also, gathered through interviewing the households and making relevant observations. Household interviews were systematically conducted using structured questionnaires. The qualitative data centered on food availability and accessibility, water and sanitation, child care practices as well as accessibility and utilization of health care services.

.II.2. Sampling Methodology

A two-stage cluster sampling method was used:

♦ At the first stage, the sample size was determined by inputting necessary information into the Nutri- survey software for both anthropometric and mortality surveys. The information included estimated population sizes, estimated prevalence rates of mortality and malnutrition, the desired precision and design effect. The prevalence’s were derived from the nutrition survey conducted in the location in April 2005 while the design effect was taken to be 2 in both cases. Prevalence of 28.1% (GAM C.I. 95%) with a precision of 4.2% and design effect of 2 was employed to obtain an anthropometric sample size of

17 Payams are large administrative geographical units encompassing villages or Bomas as human settlement in South Sudan.

828 children. 5% of the sample size was added to 828 to cater for the number of children who might not be present in the village at all at the time of the assessment. The anthropometric survey sample size was divided by 1.518 to get the number of households to be visited (552). It was estimated that 16 households could be surveyed in a field work day. Therefore the sample would be comprises of 36 clusters. Those were randomly selected by inputting the geographical unit’s names and their respective target population sizes into Nutri-survey software, which automatically assigned clusters (See appendix VIII.3).

♦ At the second stage, selection of households to be visited within each cluster was done. The EPI methodology was used whereby a pen was spun from the centre of the village to randomly choose a direction. The team then walked in the direction indicated, to the edge of the village. At the edge of the village the pen was spun again, until it pointed into the body of the village. The team then walked along this second line counting each house on the way. Using simple balloting, the first house to be visited was selected at random by drawing a number between one and the number of households counted when walking. In the selected household, mortality and anthropometric data of all children aged between 6-59 months were taken after which the teams always moved to the house on the right till all data was collected in a total of 16 households.

.II.3. Data Collection

Four selected surveyors were subjected to a standardization test to ascertain their capability in taking accurate and precise measurements, so as to minimize errors during data collection (see appendix VIII.2).

All children aged 6-59 months in each household were included in the nutritional survey. If there was more than one wife (care taker) in the household19, each wife was considered separately regardless of whether they were cooking together. If there were no children in a household, the house remained a part of the “sample” that contributed zero children to the nutritional part of the survey. The household was recorded on the nutritional data sheet as having no eligible children. The mortality questionnaire was only administered in households that were included in the anthropometric questionnaire and numbered correspondingly. Additionally, qualitative data was collected systematically along side the anthropometric data.

For each selected child, information was collected during the anthropometric survey using an anthropometric questionnaire. The information included (See appendix VIII.4):

• Age: recorded with the help of a local calendar of events (See appendix VIII.7). • Gender: male or female • Weight: children were weighed without clothes, with a SALTER balance of 25kg (precision of 100g). • Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm were measured lying down, while those greater than or equal to 85cm were measured standing up. • Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children (precision of 0.1cm). • Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet. • Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking caretakers. • Household status: for the surveyed children, households were asked if they were permanent residents, temporarily in the area, displaced or returnee.

.II.4. Indicators, Guidelines, and Formulas Used

.II.4.1. Acute Malnutrition

Weight for Height Index

18 Average under 5 population per household 19 A household refers to a mother and her children

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 the NCHS20 and the 2005 WHO references. The indexes are presented in both NCHS and WHO references, but currently, only the NCHS reference is used at field level for identification of malnourished cases. The WHO reference indexes are mentioned for information.

WFH indices are expressed in both Z-score and percentage of the median. The expression in Z-score has true statistical meaning, and allows inter-study comparison. The percentage of the median on the other hand is commonly used to identify eligible children for 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

Children’s Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. MUAC measurements are presented for all children form 6 to 59 months, divided by height groups, as MUAC is a malnutrition indicator in children taller that 65 cm in some protocols, and children taller than 75 cm in others. The guidelines are as follows:

MUAC < 110 mm severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm moderate malnutrition and moderate risk of mortality MUAC ≥ 120 mm and <125 mm high risk of malnutrition MUAC ≥ 125 mm and <135 mm moderate risk of malnutrition MUAC ≥ 135 mm adequate’ nutritional status

.II.4.2. Mortality

Mortality data was collected using Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. A prevalence of 0.24/10000/day and precision of 0.6% were used during planning. The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR is calculated using Nutri-survey 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 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.

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

The thresholds are defined as follows21:

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

.II.5. Field Work

Three teams of three surveyors each executed the fieldwork. All the surveyors participating in the survey underwent a 4-day training, which included standardization exercise and a pilot survey. Qualitative data was collected alternately by the ACF-USA staff with the help of the qualitative data supervisor who acted as a translator. ACF-USA staff supervised all the teams in the villages. The survey (including training, planning, and data collection and travelling) lasted for a period of 33 days.

.II.6. Data Analysis

Data processing and analysis for both anthropometric and mortality were carried out using Nutri-survey for SMART software, December 2006 version. Excel was used to carry out analyses on MUAC, measles immunization coverage, household status and composition. Qualitative data was analyzed using SPSS (Statistical Package for Social Sciences) version 10.0.

.III. RESULTS OF THE QUALITATIVE ASSESSMENT

.III.1. Socio- demographic Characteristics of the Respondents

Melut County is traversed by major roads and river links to the adjacent counties of, Baliet, Reng, Malakal and Maaban. It is characterized by areas in which oils had been drilled with presence of oil factory, trading activities and more importantly there is a government administrative arm stationed in Melut and Paloch towns. It is a major transit point of people migrating into or outside the county due to various commitments ranging from access to health facilities to search of livelihood opportunities. Ideally Melut County is mainly composed of Dinka, Shilluk, Burun, Furs, Nubians and Nuer. There are also other communities that live in this area like Murle and Anyuak. Coexistence of many communities in this county is due to the nature of economic opportunities which attracts job seekers and traders.

Security of the area has been relatively stable; although it was reported that insecurity situation in Malakal caused tensions in the last few months. However, activities within the towns were minimally affected except river transport.

At the time of the assessment returnees were reported to be mainly arriving from Khartoum, while quite a number of people were reported to be trickling in spontaneously from the adjacent counties. The number of returnees reported in the last three months to have settled in Melut, Paloch, Galdora, Bemichuk, Wunamom and Panamdit were 5,300, 3,900, 2,400, 3,500, 4,200 and 5,500 respectively22.

Qualitative information gathered on 60 households using structured questionnaires, observation and interviews revealed that 96.7% (58), and 3.3% (2) were residents and returnees respectively. Majority of the respondents were females 91.7% (55) while males were 8.3% (5). Most of the males were out of the households in engaged in livelihood activities such as employment or trading among others. As such it was the females who were

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

22 Melut SSRRC returnee figures

mostly left behind to tend to the young ones, as much as males worked, some females were also engaged in employment, but eventually went home early to attend to domestic chores. Figure 1: Sources of livelihood

50%

30%

17% 12%

3% 3%

M G G T M E IS N N N S D L I I E LI A A H M M R IS R Y O T R F A O R Y O F L T T T P P S T S A E A O M -P P P R E O C R G A

Survey results in figure 1 above illustrate that the major livelihoods activities were employment in government and private agencies represented by 50 %( 30), crop farming 30 %( 18) and petty trade 17 %( 10). To a lesser extent, agro pastoralism 12 %( 7), fishing and pastoralism each at 3 %( 2) also provided livelihoods. In the case of farming, focus group discussions revealed that there were people who could not cultivate on arrival in the location pending allocation of cultivation area. The authority could not offer estimates of expected arrivals; nevertheless, entry of returnees was expected to increase gradually before the end of the year 200723. Estimated number of returnees into the upper Nile state in general for the year 2007 has been estimated at 49,510 (ANLA, Dec, 2006).

Correspondingly, major sources of income were reported to be from employment and sale of crops among others. Survey results revealed that permanent employment [53.3% (32)] and sale of crops [32% (19)] were major sources of income. Sale of livestock, casual labour and petty trade also contributed significantly as sources of income with 10% (6), 10% (6) and 8.3% (5) of the households engaged in the activities respectively. Employment was offered by the government, private businesses, and Oil Company which had a large presence in the area. Petty trade activities included sale of alcoholic brews, sale of fencing and thatching grass, as well as engagement in selling vegetables and wood in the market. Sale of crops is common as it offers easy source of income to households who would also be able to buy other items from the market. It was particularly noted that, a combination of factors were found to affect the ability of households to secure their livelihoods in both short term and long-term. These included low levels of agricultural productivity due to constraints such as pests and diseases, lack of seeds and tools, lack of adequate veterinary services and location specific climatic factors, low availability of employment opportunities and increased demand on them.

.III.2. Food Security

It is characterized by flat, low lying terrain with black cotton soils. In the vastness of the plains, savannah grasslands and acacia trees are the typical vegetative cover. The banks of Nile river and its small seasonal tributaries such as river Nyal, Awilwil and Thor Ager criss-crossing the county determine the settlement patterns of the villages making up the payams and cattle camps; and are main sources of drinking water, fishing grounds and watering points for the community livestock especially during the dry season. This is an area with diverse livelihoods and as it has been shown by the results that crop farming and agro- pastoralism form part of community's livelihoods at rates of 30% (18) and 11.7% (7) respectively it follows that not all the community in this area cultivated. 55.9% (33) households reported to have grown crops during the last season while 44.1% (27) did not cultivate. The reasons put forth for not cultivating were lack of arable land 65.4% (17) especially for those who had not stayed in area for at least a year, lack of interest 12% (3) as well as

23 Melut SSRRC returnee figures

lack of labour and other commitments which accounted for 24.0% (6). Majority cultivated more than 2 Feddans 54.5% (18) while quite a number 21.2% (7) had land sizes of between 1-2 Feddans. The survey results indicate that food security gains were registered in this area in the last planting season as revealed by 85.7% (24) of respondents who harvested 100kgs of sorghum and above while 32% (9) harvested more than 250 kg of the same crop, nevertheless, quite a number of households had not completed harvesting. This concurs with the FEWSNET report (January 2007) that majority of people in this zone would have ample harvest. However, the food gains are likely to be lost due to unpredictable and spontaneous nature of returnees in the location.

Crop farming activities in year 2007 season, just like in most parts of upper Nile and South Sudan in general are heavily reliant on rainfall patterns. Rains in this area commenced slightly late than expected in the month of June and this also marked the period in which most households had already put their seeds in the ground. Farmers reported to have prepared their lands in time well prior to 2006 year rains. The major grains crops that were cultivated in this region were sorghum and Maize. However, sorghum was grown in much larger scale compared to maize. Survey results reveal that 87.9% (29), 69.7% (23) and 3% (1) of the interviewed households cultivated sorghum, maize and beans in that order. This reflects dire lack of crop diversification, and reliance on particular crops. The common method utilised for cultivation are traditional hoeing, however, a number of farmers who had large cultivation areas used mechanised farming using hired tractors which was arranged individually between a farmer and the office of agriculture director at a cost to the farmer. The office assisted farmers to be accessible to fuel by bringing it closer to them. It is noteworthy that a way of ensuring proper utilization of agriculture productivity is to encourage introduction of animal traction in effort to curtail cost that accrues from use of mechanized farming requiring fuel costs and out of reach of majority of farmers with small cultivation areas. Most farmers reported that compared to the last season (2006) this season harvest was not as good. In particular, farmers did not harvest up to their expectations as evidenced by 90.6% (29) of the respondents. Various factors were cited to have influenced harvests negatively, thus floods, poor timing of planting, insects, pests and birds contributed the diminished harvest output by 23.3% (7), 30% (9), 65% (20) and 65% (20) of the interviewed households respectively. Some areas harvests were reportedly to have been severely affected by floods such as Payuer in Panamdit Payam in the last growing season. The figures 2 below illustrate these causes. Figure 2: Causes of poor harvest

70% 65% 65%

60%

50%

40% 30% 30% 23%

20% 10% 10% 3%

N S S CT ODS AI E ST EM O BIRDS E L F R INS B FL O D P O N CK A A L E

ISEAS OTHER PR D

The low diversification of crop production with majority of the population depending on sorghum may make its failure or inadequacy to have the potential to render the community highly vulnerable to hunger.

Major sources of food in the community are varied as much as the livelihood activities. It was observed that besides reliance on private production for source of food, majority of household depended on buying as their predominant source of food.

Figure 3: Current sources of food

78% 80% 70% 48% 60% 50% 40% 30% 20% 5% 2% 10% 0%

N S DS FT TIO C GI BUYING DU O WILD FOO PR TE A

PRIV

Survey results reveal that 78.3% (47) of the respondents’ households relied mainly on buying as a source of food while 48.3% (29), 5.0% (3), and 1.7% (1) of the households depended on private production, wild foods and gifts as sources of food respectively. The heavy reliance on buying explains the lack of keenness on diversification of crops cultivated. This leaves households vulnerable to food deficits that could be occasioned by price fluctuations that would affect food accessibility at household level. This is compounded by the fact that most of the traders imported food items sold in the market from other areas that are not proximate to Melut meaning that prices of less supplied items were likely to be higher. The most vulnerable group of children under five years of age would be most affected by dearth of some foods in the households. It was observed that households that relied on sale of crops as source of income could be facing negative effect of erosion of market value of produce since the same income would be used to purchase other food items. Survey results reflected various ways in which households adopted coping strategies upon depletion of food stocks. At the time of the survey most households had food stocks, and relied heavily on their incomes to meet their food needs. A few of the households 12 (20%) had food from private production that could last them for more than three months. Coping strategies adopted by households upon depletion of food stocks are illustrated in figure 4 below. Figure 4: Household coping strategies

6.10% 41.20% 21% 29.40%

K IP C H ... TO G INS S K VE D L LIVE L E OTHER MEANS S

FRUITS AN D WIL

The coping strategies include reliance on kinship support, dependence on wild fruits and vegetables, sale of livestock and other activities such as engaging in casual labour if available. A household could adopt multiple

coping strategies in an attempt to acquire adequate food. A large number of people had income from casual labour, although it was not dependable and sustainable. Areas which were not proximate to the cosmopolitan locations such as Chuei, Wunbarkou, Tiep and Duki among others were reportedly relying on wild fruits and vegetables. Typically the structural food deficits occur between the months of April and August and it is expected to last the same period this year (2007). The major foods that form the diets of the community are illustrated in the figure 5 below Figure 5: Foods constituting current diets

FOODS CONSTITUTING CURRENT DIET

10 0 %

10 0 % 82% 82%

90%

80% 62% 60% 70%

60%

50% 30% 40% 27% 23% 30%

20% 10 % 10 % 10 % 0% S S T UM A SH KRA SES MILK FI L OOD GH ME O MAIZE F R PU SO WILD FRUITS OTHER

WILD VEGETABLE

CURRENT FOODS

Sorghum forms the bulk of the diet in the community just like in most parts of South Sudan, showing that all (100%) the respondents consumed it. The diversity of the foods composing of these current diets was a reflection of community’s behaviour in acquisition of food for household consumption. This however, does not reflect the diversity of single meals prepared or regularity consumed. Analysis of frequency ( daily basis) of consumption of the foods show that maize and sorghum, vegetables, fish, milk, fruits and poultry were consumed at rates of 95% (57), 55% (33), 86.7% (52), 80% (48), 63.3%(38) and 8.3% (5) correspondingly. Wild fruits such as Lalop and Lang as well as dessert dates comprised frequently consumed fruits while onions, Kudhura, salsa, Tum, pumpkins and okra comprised common vegetables.

The last WFP food distribution in the location which was reported to have been done on September 2006 by the households interviewed with 16.7% (10) and 3.3% (2) of the respondents having received WFP food aid at least once and twice respectively in the preceding three months. These results agrees with the WFP new food distribution strategy for South Sudan; food distribution to the chronically food insecure during April-July hunger season, mainly dwelling on resettlement and re-integration activities and provision of food for the local population receiving returnees24. This process, however, needs to be hastened by effective registration of incoming returnees.

56.7% (34) of the interviewed household owned livestock mainly cows [17.9% (7)], goats [63.9% (23)], donkeys [16.7% (6), sheep [20.0% (7)], and chicken [66.7% (24)]. Since majority of human settlements are along the Nile River and its tributaries which had not dried up, most cattle could access pasture grounds and watering points while at home (97.1%). The benefits derived from livestock include milk, food, sale and dowry. Thus 65.7% (23), 48.6% (17), 20% (7) and 2.9% (1) of the assessed households reported these as the benefits respectively. The bulk of the milk was consumed by the children although households reported that it was not available in adequate quantities either because of chronic low production or milk selling with an aim of earning income. Majority of the community 65.6% (21), sell livestock in the local market where they can fetch relatively higher

24 Southern Sudan Food Security Update (FEWSNET) December 2006

prices compared to selling livestock among the community. Other benefits accruing from livestock although on a small scale included egg production.

Livestock diseases that have contributed to continuous decline of animal production were cited as trypanosomiasis, Brucellosis, Anthrax, Mastitis, Haemorrhagic septicaemia, contagious bovine Pleuro- pneumonia and contagious caprine Pleuro-pneumonia as reported by AHWs supervisor who works for OXFAM- GB in Melut. The organisation is undertaking capacity building project by training locals on animal care and recruiting them in the outreach programs in the location and also distribution of veterinary drugs to the community at a cost. There are 8 community AHWs in the entire county distributed in the six Payams of the county.

The major vibrant markets existing in Melut County include Melut and Paloch. Melut market serves residents of Melut as well as Tharkuach and Riyardit villages which are furthest and more than five hours walk away. Paloch which serves as the biggest market in Melut is situated at intersection of the roads to Melut, Reng and Khartoum. The other markets are found in Thiagrial, Chuei and Bemichuk. On average 25% (15) of the respondents walk 3-6 hours to access markets in their respective Payams whereas the take less than an hour. All the markets sell food as well as non-food items. Some of the food items available in these markets are sorghum, wheat, variety of vegetables, sugar, fish, oil, maize, rice among others. A complete food list is attached as appendix VIII.8.

According to the survey findings majority of the households [88.1% (52)], had fishing grounds, however, only 12.3% (7) practice fishing. Those households who practice fishing do it mainly in the months of April as a way of supplementing their household diets and this is the time when waters recede and fish availability is satisfactory. Hence, 100% (7) of those who do fishing use traditional fishing nets, 85.7% (6) use hooks while 14.3% (1) use other means. The fish preservation methods used are drying, salting, smoking and freezing as represented by 85.7% (6), 57.1% (4), 14.3% (1) and 14.3% respectively. Most of these preservation methods were evident in the market where fish was sold. Despite availability of fishing grounds those who did not practice fishing cited lack of labour, over flooding and lack of fishing equipment as the major constrains as represented by 74.5% (38), 11.8% (6) and 13.7% (7) respectively.

In summary food security situation in Melut is determined by a myriad of factors that can make sudden changes in availability and accessibility of food at household level. The fragility of the labour market, poor crop diversification, attack of crops by pest and diseases, slow land allocation to the arriving returnees, low livestock production and poor utilization of fish resources are some of the factors that could be directly attributed to the situation. The main coping strategies adopted by most of the households such as eating fewer meals, consumption of wild fruits and vegetables, kinship support and buying using income from petty trade and casual labour, as well as selling livestock impact negatively on the livelihoods and the nutritional status of the community. The cyclical nature of malnutrition is enhanced by poor hygiene practices both at household and public level and as such complicates the scenario where individuals are not consume adequate nutrients necessary for proper physiological and physical function of the human body.

.III.3. Health

Effect of disease(s) is one of the immediate determinants of malnutrition. In Melut county provision of health care in the surveyed locations is largely undertaken by Melut hospital, private practitioners and Med-air.

Health seeking behavior of the community was found to be satisfactory because members of the household sought health services when one of the members fell sick. However, majority of the population access these services through private clinics in the county’s urban areas as opposed to the bigger hospital in Melut or its dispensaries. This was attributed to the fact that the community preferred the private clinics as they could offer laboratory services. This could explain community perception that they are able to get proper services if laboratory diagnosis is comprehensive and also, that there is stark disparity in hospital attendance at Melut hospital and Medair PHCC with the latter attending to relatively large number of people. The situation whereby Melut hospital is under-utilized was alluded to by the resident doctor who cited lack of laboratory services. According to the nutrition survey results 38.3% (23), 11.7% (7), 18.3% (11) and 31.7% (19) of the population spent less than 30 minutes, half hour to 1 hour, 1-2 hours and more than 2 hours to reach the health facilities in that order. The population that lives on the opposite side of both Medair’s PHCC and Melut hospital has to cross

river Nile to access health services. Needless to say, they use local canoes to cross the river which is risky and unreliable. The number of residents in Melut County was approximated at 12857125 which is more than the capacity that the available health facilities based on sphere minimum standards of 1:50,000. However, it is within SOH standards which advocate for 1:80,000. This is done in assumption that the hospital is capable of offering services of PHCC which was contrary to the survey findings. Therefore, accessibility to health services can be deemed wanting and need expansion and improvement in service delivery. Accessibility in terms of time used to reach the clinics is summarized in figure 6 below.

Figure 6: Accessibility to health facility

ACCESSIBILITY TO HEALTH CARE SERVICES

38.30% 31.70%

Percentage 18. 30% 11. 70%

N UR S S MI O UR UR 0 -I H O O 3 IN 2 H 2 H < M 1- > 30 TIME

The common causes of morbidity were found to be acute respiratory infection especially during the dry season while Malaria and diarrhoeal diseases are endemic during the wet season. Besides, causes of morbidity in under-fives, observable malnutrition was also cited as common cause of mortality

Despite availability of EPI services in the hospitals and in the dispensaries which have been running health services in the area, measles immunization outreach is yet to reach some parts of the county. This information is collaborated in the analysis of the data collected during nutrition survey and summarized in the below figure 7

In the year 2006 between the month of April and September there was severe outbreak of acute watery diarrhoea in Melut which was attributed to the poor hygiene practices that enhances spread diseases of this nature. The situation was contained through emergency water chlorination and treatment of reported cases. Health services, have improved compared to the previous periods. Accessibility to health services by some sections of the community is a challenge that needs to be addressed urgently. Of equal importance is to strengthen health education activities with continuous monitoring so as to evaluate most ideal strategies in health promotion which could be designed to have long term efficacy in curbing entrenched unhygienic practices in this area.

25 Source: Melut SRRC secretary

Figure 7: Common diseases in the households

COMMON DISEASES IN THE HOUSEHOLDS

OTHER DISEASES 28.3%

RESPIRATORY INFECTIONS 48.3%

FEVER 85.0%

DIARHOEA 83.3%

MALARIA 95.0%

.III.4. Water and Sanitation

Melut County is highly dependent on river Nile and its tributaries as a source of water for both human and cattle. The major sources of water for household consumption were found to be river [81.7% (49)], unprotected well [5% (3)], swamps 8.3% (5) and other sources 16.7% (10) which included commercial water vendors and water truck commissioned by the oil company in Paloch. Majority [85% (51)] of the populations used less than 30 minutes 10% (6) and 5% (3) spend between 30 minutes and 1 hour and between 1-2 hours to reach and come back from water points respectively. Most households do not treat water it to make sufficient and safe water for consumption. All the households interviewed did nothing to water before drinking it. The figure (8) below shows various sources of drinking water by the community.

Figure 8: Sources of drinking water

SOURCE OF DRINKING WATER

18.3% OTHER

8.3% SWAMP

3.3% UNPROTECTED WELL

91.7% RIVER

Analysis of accurate amounts of water consumed within the household was not plausible as most of the household members undertook household chores such as washing cloths near the river bank where they would access enough water to do so. People also bathed next to the riverbanks and most importantly near the water collection points. Most of individuals consume untreated water, a practice which exposes the them to the to risk of contracting diarrhoeal diseases and other waterborne diseases and this explains the outbreak of acute watery diarrhea reported between April and September 2006 in Melut Payam. Thus, the water consumed in most households in Melut County largely fall short of minimum requirements as embodied in the sphere standards for sufficient, safe, physically accessible and affordable water for personal and domestic uses.

Most of the household interviewed did not own or use toilets, and enquiry and observation revealed that human waste was disposed off in open fields. The cosmopolitan areas did not have a system of human waste disposal and due to concentrated human settlements in these areas; the practice of indiscriminate disposal of human waste would be a recipe for disease outbreaks. Survey results revealed that only 6.7% (4) had traditional pit latrines while the rest used the open fields and the bush. Observations revealed that there was faecal deposition near the river. Urban refuse haphazardly drained into the banks without restraint thus, exposing water collection points to direct contamination leaving possibility of enormous potential for waterborne disease outbreaks. This could be exacerbated by the fact that there is a tendency of populace in the town centre, which also acts as transit points, to consume food prepared in public eating places which use this water for food preparation and drinking.

Indiscriminate disposal of Human waste could be contained if community were supported in construction of toilet as they expressed interest to use them if they are available. It is noteworthy that majority of the households acknowledged hand washing before meals; however, this could not be confirmed on practice.

All these findings not withstanding, it was observed that personal hygiene was generally not up to acceptable standards. Water supply and sanitation program should be urgently introduced to in order to reduce the transmission of faeco-oral diseases and exposure to disease bearing vectors through promotion of good hygiene practices, provision of safe drinking water, and the reduction of environmental health risks. And since provision of sufficient water on its own will not ensure their optimal use or impact on public health, community should be given necessary information, knowledge and understanding to prevent water and sanitation related disease and to mobilize their involvement in the maintenance of safe water.

.III.5. Maternal and Child care practices

Maternal and child care practices have a strong bearing on the nutritional status of the community. Some of the common maternal practices affecting mother’s nutritional status in South Sudan are responsibility to contribute to household livelihood, physiological states of pregnancy and lactation which are not matched with dietary requirements and non-exemption from hard labour during pregnancy. In Melut County, most mothers were involved in livelihood activities such as trading thus they could only be able to take care of their young children especially the under-fives at particular times of the day. Lack of adequate foods to meet increased physiological needs especially during pregnancy predisposed women to poor nutritional status.

Child feeding practices are well learnt and practiced especially on exclusive breastfeeding in most households in South Sudan. During the survey all the mothers initiated breastfeeding immediately after birth. However, only 56.7% (34) breastfed their children on demand as they were mostly engaged in other livelihood activities during which time their children were fed on cows/goats milk and in some instances left under the care of the older children. Results further revealed that children were introduced to other foods other than breast milk mainly after six months, thus 41.7% (25) of the mothers introduced other foods at the age of 4 to 6 months while 56.7% (25) introduced their children to other foods at the 6 months and beyond. Some of the foods introduced to the children and fed between ages of 6 to 29 months include cows/goat milk, pumpkin, fish soup, breast milk and porridge. Children beyond this age group were fed on the common bowl that included cow/goat milk, walwal (which is made from sorghum), traditional vegetables and fish. Worth to note is that, most children were not breastfed during this period. Young children were given meals in most cases twice per day as revealed by the survey that 63.3 % (38) of all the children were fed twice per day while 13.3% (8) were given one meal per day.

Preparation of food for children was done in precarious environments that exposed food to direct access to houseflies and dust. This could be worse when mothers left the care of young ones in the hands of the older children. Domestic pets were observed to constantly lick household food handling utensils, not to mention the potential hazard created. The water used for preparation of households’ food and that of children in particular was not treated and was used directly from the river. Children were also observed to be eating with untidy hands, a poor hygiene habit that puts them at risk of contracting diseases such as diarrhoea. Child feeding practices were found to be wanting and could be adequately addressed through intensive health education as well as improved access to potable water.

.III.6. Education

Education in Melut County is receiving government as well as organizational support at both primary and secondary level. There are several educational institutions in the towns, a fact which also explains the presence of in-migrants who could have come in the location in search of educational opportunities. In Melut there are about 9 educational institutions comprising of primary and secondary schools. Sido Primary school happens to be the biggest institution with 900 students served by about 15 teaching staff. Melut high school has about 300 students with teaching staff of 15. Gakbany and Paloch basic schools are in Paloch Payam and have students numbering 120 and 500 and teaching staff of 8 and 10 respectively. Bemichuk payam has Pariak primary school which has 300 students and 15 teaching staff. Galdora payam has Thiagrial, Galdora and Chuei primary schools which have 300, 420 and 200 students and teaching staff of 8, 6, and 5 correspondingly. Initiation of some schools especially Tharkuach primary school in Melut has been through the support of UNICEF which has provided teaching/learning materials and incentives to teachers. The learning season usually starts in April when students report back from holidays between December and March. The syllabuses used in the schools are varied although New Sudan syllabus is common.

Majority of the educational institutions confirmed that the enrollment rate in both primary and secondary schools had increased since the signing of the CPA agreement in 2005. This could be attributed to relative peace which allows people to focus on education among other activities. There were however, dropout cases among students who sought for livelihood opportunities to support themselves and cater for their educational needs. There is also difficulty in getting trained teachers and some usually opt out of the career to look for competitive fields. Northern Upper Nile consortium (NUNC) has began a program of assisting the community to build schools in Melut County and their plan is to build two schools in Melut County, one in Bemichuk Payam and the other in Panamdit. Enhancing the community livelihood would be a lead factor in enabling them to afford and prioritize education.

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

NORTHERN-UPPERNILE CONSORTIUM (NUNC): The consortium which has collective objectives comprises of TEARFUND, FAR (Fellowship for African Relief), Stromme Foundation, Mercy corps, and ECS (Episcopal Church of Sudan) with each organization having different programs in Melut County and other Upper-Nile counties of Maaban and Reng. NUNC commenced operations around mid 2006 Their objectives are to initiate rehabilitation and recovery programs which are developmental in nature to cover education, health, food security, water and sanitation. These programs have various objectives as outlined below:

HEALTH Rehabilitation of the general health units present and building of new health centers is in the core of this objective. The aim is to support cost of this activity up to 70% while the rest is footed by the community. Currently construction of a health center is in progress in Pariak where the community provides sand, gravel and water.

VETERINARY SERVICES AND TRAINING They are involved in training of Para vets and community AHWs in Melut, Maban and Reng. The last training of community AHWs was in Melut in the same period that the survey was being implemented (February 2007). They also provide drugs and vaccination for animals as well as equipments used in veterinary care. Currently they are in the process of employing ACHWs in the counties that they operate after training them.

FOOD SECURITY

The programs aim at multiplying cattle in the community through multiplier effect initiated by the program and sustained by the community itself. This year (2007) in the month of February the program has acquired and distributed goats in Panamdit, Paloch and Melut Payams. The program also distributes seeds and traditional farming implements in all the three counties of its operation. About 10 projects have been initiated in Reng as income generating in form of vegetable cultivation also aimed at creating a rotating Fund.

EDUCATION The plan is to build two schools in Melut County, one in Bemichuk Payam and the other in Panamdit. The constructions have already started. The community, however, participates by donating sand, gravel, water and labour while the consortium purchases rest of the building material and contracts the builder. The consortium is also rehabilitating other schools in Reng County. Currently, they support adult education in Melut and have offered assistance to initiators of similar program in Reng County.

WATER AND SANITATION The aim is to install water pumps but the program has not yet started. There are plans to undertake water and sanitation project in Reng.

MEDAIR: It is a Christian organization providing Primary health care, which focuses on preventive and curative as well as emergency programs in Melut County. The organization started a PHCC in Melut Payam in February 2007 and negotiations with the local authority are underway on other locations for construction of 3 PHCUs in Paloch, Pariak and Galdora Payams. In addition there is one PHCU in Payuer and Thiagrial which are managed by village health committees, while staffs are supervised by the organization. There are 2 CHWS and one female assistant in Payuer, 1CHW and female assistant in Thiagrial. Melut PHCC has 1 medical doctor, 4 nurses (3 of them Midwives), 1 nutritionist, 1 health promotion manager, 2 Medical assistants (MAs) and 1 CHW. The organization offers both inpatient and out patient services with maternal-child health care, vaccination (EPI), Kalazaar and tuberculosis treatment, antenatal services, laboratory services, health promotion activities and nutrition screening and treatment. The organization trains its CHWS, TBAs, EPI and hygiene health promoters. Plans are underway to commence community therapeutic care (CTC) and stabilization unit for severe cases. The organization’s emergency program had drilled 6 boreholes in Payuer (Panamdit Payam) and plans to do more drilling in Thiagrial (Galdora Payam). There is a water assessment planned for Melut, where the PHCC is located, and water is currently treated within the precincts of the clinic.

UNIMIS: It is mandated to closely monitor and observe peace progress and any potential security events happening within Melut County.

MELUT HOSPITAL: The hospital has been run by the national health insurance since January 2006, and the insurance provides drugs and remunerates staff. Previously, the Ministry of health managed the hospital operations since February 2005 with 1 MA and 20 nurses. Currently there are 2 doctors, 1 MA, 1 pharmacist, 1 laboratory technician and 10 nurses. The doctors graduated from national universities in Sudan, while the other staffs were trained at Malakal teaching hospital. The hospital offers mainly curative services to out patients and inpatient services to clients with national insurance cover. There are 3 wards (1 male ward, 2 female wards) and a theatre which performs minor surgeries. However, it does not have an equipped laboratory for comprehensive diagnosis. The hospital runs two dispensaries in Paloch and Galdora respectively. Galdora has 1 MA, 1 TBA and three nurses all of whom have not received formal training, while Paloch has 1 trained nurse and 3 untrained nurses. The hospital referral centres at the time of the assessment were Reng and Malakal hospital, although the hospital does not have the means of transferring emergency cases. Medical services include antenatal care and deliveries, and EPI program within and outside the hospital. There is an EPI outreach program run by one technician who recruits volunteers paid by MoH when vaccines are available. The last

.IV. RESULTS OF THE ANTHROPOMETRIC SURVEY

The anthropometric nutritional survey included a total of 716 children. The data had 3 incoherent values and, therefore, 713 data sets were included in the final analysis.

.IV.1. Distribution by Age and Sex

Table 4: Distribution by Age and Sex Age groups BOYS GIRLS TOTAL Sex (months) N % N % N % Ratio 6-17 91 50.6 89 49.4 180 25.2 1.0 18-29 91 47.2 102 52.8 193 27.1 0.9 30-41 74 46.0 87 54.0 161 22.6 0.9 42-53 52 48.6 55 51.4 107 15.0 0.9 54-59 30 41.7 42 58.3 72 10.1 0.7 Total 338 47.4 375 52.6 713 100.0 0.9

Figure 9: Distribution by age and sex

54-59

42-53

30-41 BOYS GIRLS

18-29Age in Months

6-17

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

The above chart shows distribution of male to females in various age groups. There are slight imbalances in age distribution as illuminated by the diagram above, with most conspicuous imbalance appearing in age group 42- 53 months where there is slight under-representation by about 5.0%. In the age group 18-29 months there is a small over representation by 2.1%. The imbalances could be attributed to the inability of the caretakers to recall their children’s ages accurately. The ages were estimated using local calendar of events which is prone to recall bias. However, the other age groups are within the right proportions and the entire sample has an acceptable sex ratio.

.IV.2. Anthropometrics Analysis

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

Distribution of Acute Malnutrition in Z-Scores Table 5: Weight for Height distribution by age in Z-scores and /or oedema

≥ -3 SD & <- 2 Age group < -3 SD ≥ -2 SD Oedema N SD (months) N % N % N % N % 6-17 180 5 2.8 40 22.2 135 75.0 0 0.0 18-29 193 3 1.6 43 22.3 147 76.2 0 0.0 30-41 161 2 1.2 20 12.4 139 86.3 0 0.0 42-53 107 0 0.0 19 17.8 88 82.2 0 0.0 54-59 72 2 2.8 16 22.2 54 75.0 0 0.0 Total 713 12 1.7 138 19.4 563 79.0 0 0.0

Table 6: Weight for height vs. Oedema in z-scores

Weight for height < -2 SD ≥ -2 SD

Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 0 0.0% Oedema Marasmus No malnutrition NO 150 21.0% 563 79.0%

151(21.1%) children were mainly Marasmic with no kwashiorkor cases. No oedema was detected in the nutrition survey. Figure 10: Weight for height distribution in Z-scores

Weight for height Z-score distribution curve shows marked displacement to the left of the reference curve indicating a critical nutrition situation. Both the skewness (0.175) and kurtosis (0.101) are within the moment range of +1 and -1 and consequently the degree of asymmetry around the mean and the relative flatness compared with normal distribution are satisfactory. The mean Z-score is -1.33, while the standard deviation is equal to 0.84 and lies within the normal range of 0.8 – 1.2. The assessed sample can be conclusively said to be representative of the surveyed population.

Table 7: Global and Severe Acute Malnutrition in Z-scores in NCHS and WHO references

NCHS reference WHO reference 21.0 % 21.3 % Global acute malnutrition (17.2% - 24.9%) (17.8% - 24.9%) 1.7 % 4.5 % Severe acute malnutrition (0.5% - 2.8%) (2.9% - 6.1%)

Distribution of Malnutrition in Percentage of the Median These are cut-offs for acute malnutrition expressed in percentage of the median that are commonly used in determining admission criteria in feeding centres. Table 8: Distribution of Weight/Height by age in percentage of the median and oedema

Age groups < 70% ≥ 70% & < 80% ≥ 80% Oedema (months) N N % N % N s% N % 6-17 180 1 0.6 29 16.1 150 83.3 0 0.0 18-29 193 0 0.0 27 14.0 166 86.0 0 0.0 30-41 161 0 0.0 8 5.0 153 95.0 0 0.0 42-53 107 0 0.0 9 8.4 98 91.6 0 0.0 54-59 72 0 0.0 10 13.9 62 86.1 0 0.0 Total 713 1 0.1 83 11.6 629 88.2 0 0.0

Table 9: Weight for height vs. Oedema in % of the median

Weight for height < 80% ≥ 80%

Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 0 0.0% Oedema Marasmus No malnutrition NO 84 11.8% 629 88.2%

Table 10: Global and Severe Acute Malnutrition in NCHS and WHO references in % of the median

NCHS reference WHO reference 11.8 % 7.2 % Global acute malnutrition (9.2% - 14.4%) (5.0% - 9.3%) 0.1 % 0.0 % Severe acute malnutrition (0.0% - 0.4%) (0.0% - 0.2%)

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

All 713 children were included in the MUAC analysis. Table 11: MUAC Distribution

>=75 – < 90 cm < 75 cm height ≥ 90 cm height Total MUAC (mm) Height N % N % N % N % < 110 1 0.8% 0 0.0% 0 0.0% 1 0.1% 110≥ MUAC<120 8 6.6% 2 0.7% 0 0.0% 10 1.4% 120≥ MUAC<125 9 7.4% 8 2.7% 3 1.0% 20 2.8% 125 ≥ MUAC <135 32 26.4% 54 18.4% 10 3.3% 96 13.5% MUAC ≥ 135 71 58.7% 229 78.2% 286 95.7% 586 82.2% TOTAL 121 100% 293 100% 299 100% 713 100%

According to the MUAC analysis, there is one case of severe malnutrition, and 10 (1.4%) cases of moderate malnutrition.

.IV.3. Measles Vaccination Coverage

On the 669 children aged 9 months old and more, 22.0% and 30.0% have been immunised against measles according to card and mother respectively. The table 9 below summarises rates of measles vaccination as reported by the households visited in the survey. Table 12: Measles vaccination coverage Measles vaccination N % Proved by Card 147 22.0% According to the mother/caretaker 201 30.0% Not immunized 321 48.0% Total 669 100%

.IV.4. Household Status

The largest proportions of the households in the anthropometric survey were resident in the location; 441(86.5%) while the 2.9% and 10.2% composed of the people who had returned and those who were in transit respectively. Displaced persons accounted for 0.4%. The low returnee rates differ from the figures reported earlier because majority of the persons who had arrived had surpassed the period of 6 months which was used as threshold duration in determining status in the nutrition survey. It is important to note that quite a number of households that could not be captured in this time frame had arrived slightly earlier and had not settled down for more than one year at the time of the survey. It is also worth to note that 86(14.9%) of the mortality households were not included in the anthropometric survey due to lack of eligible target population. Table 11 below shows the household status of the surveyed population. Table 13: Household status Status N % Residents 441 86.6% Internally Displaced 2 0.4% Temporary Residents (on transit) 52 9.9% Returnee 15 3.0% Total 510 100%

.IV.5. Composition of the Households

A total of 576 households were visited during the mortality survey. Among tem, 66 did not have eligible children for the anthropometric questionnaire, but all them were included in the mortality questionnaire. In terms of composition, the results have revealed that the average number of children less than 5 years of age per household is 1.4 whereas the mean number of persons above 5 years of age per household is 4.0. Table 14: Household composition Average Age group N % per household

Under 5 years 829 26.1 1.4 Adults 2342 73.9 4.1 Total 3171 100.0 5.5

.V. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

Calculation of mortality rate was done using the figures collected in all households included in the survey. All the households included in the anthropometric survey were considered for mortality data regardless of whether they had children between 6-59 months or not.

During the survey, a total of 3171 people were present in the assessed households. Among the total population 829(26.1%) were children below the age of five years. 208 persons including under fives had left various households while 96 people had joined within the last three months.

Over the retrospective period estimated at 90 days from the time the nutrition survey was being conducted, 60 births had taken place while the total deaths were 24, 5 of whom were children below five years. Thus the retrospective mortality rates are:

♦ Crude mortality rate is 0.83 [0.41- 1.25] /10,000/day. ♦ Under five mortality is 0.69 [0.19-1.20] /10,000/day.

.VI. CONCLUSION

ACF-USA implemented a nutritional survey in Melut County between 12th February and 14th March 2007. In the last two years ACF-USA implemented surveys in Payuer that is located in Melut County. Only Galdora and Panamdit payams were covered. This year, the good security conditions allowed the survey to cover additional two payams in Melut County.

The results of the previous surveys are therefore not comparable to this one’s, but are given are as an indicator (in Z-scores, reference NCHS): Table 15: Trends of malnutrition in Melut County. 2005 2006* 2007 28.1% 21.0% GAM 20.8% (23.4-33.3) (17.2-24.9) 4.5% 1.7 % SAM 1.7% (2.6-7.4) ( 0.5-2.8) * Exhaustive survey

Over the retrospective period of three months to the survey period, the crude mortality and 0-5 years death rates were of 0.83 [0.41- 1.25] /10,000/day and 0.69 [0.19-1.20] /10,000/day respectively. Both rates are below the alert levels of 1/10,000/day and 2/10,000/day accordingly.

The findings of the nutrition survey which revealed high GAM rates above the emergency threshold and relatively low SAM rates calls for an integrated approach in addressing the underlying rates of malnutrition such as food insecurity at household level, inappropriate maternal and child care practices, and poor public and household hygiene as summarized below;

Inadequate food intake and food Insecurity:

The survey results shows that, food security gains were registered in this area in the last planting season and concurs with the FEWSNET report (January 2007) which indicated that majority of people in the surveyed zone would have ample harvest. The major crops that were cultivated in this region were sorghum and Maize and form the staple food among the community. This situation however, is precarious due to unpredictable and spontaneous nature of returnees who depend on the host community and production that still remains below the annual household cereal requirements. The factors cited to have influenced harvests negatively were; floods, poor timing of planting, insects, pests and birds which led to diminished harvest output by 23.3%(7), 30%(9), 65% (20) and 65%(20) among the interviewed households respectively. Floods are reported to have affected severely crop performance in areas such as Payuer in Panamdit Payam in the last growing season. Low crop diversification that has led to high dependence on sorghum exposes the community to high risk of inadequate food intake and related dietary imbalances incase of poor crop performance. Survey results reveal that 78.3% (47) of the respondents’ households relied mainly on buying as a source of food while 48.3% (29), 5.0% (3), and 1.7% (1) of the households depended on private production, wild foods and food gifts as sources of food respectively. Heavy dependence on buying in a not well established economic system leaves households vulnerable to food deficits that could be occasioned by price fluctuations and imperfect commodity supply, and consequently affect food accessibility at household level.

The potential of fishing is underutilized as findings in the survey revealed. Fishing could not only be a source of food, but can offer income that can help individuals cushion themselves during structural food deficit periods.In summary food security situation in Melut is faced with myriad of factors that can make sudden changes in availability and accessibility of food at household level. The fragility of the available employment, poor crop

diversification, attack of crops by pest and diseases, slow land dispensation to the arriving returnees, low livestock production and poor utilization of fish resources are some of the factors that could be directly attributed to the situation. The main coping strategies adopted by most of the households such as eating inadequate meals and selling livestock can lead to deterioration of livelihoods and the nutritional status of the community.

Disease prevalence:

Effect of disease(s) is one of the immediate determinants of malnutrition. The common causes of morbidity were found to be mainly acute respiratory infection especially during the dry season while Malaria and diarrhoeal diseases are endemic during the wet season. The diseases produce effects such as appetite loss, mal absorption of nutrients, muscle breakdown and eventually malnutrition. Accessibility to health services, timely seeking of treatment and better service delivery require prime attention in order to improve the health needs of the populace.

Deplorable Water and Sanitation Situation:

The major sources of water for household consumption were found to be river [81.7% (49)], unprotected well [5% (3)], swamps 8.3% (5) and other sources 16.7% (10) which included commercial water vendors and water truck commissioned by the oil company in Paloch. Most households did not treat water to make it safe for consumption, a practice that exposes the community to the risk of contracting diarrhoeal diseases and other waterborne diseases. The outbreak of acute watery diarrhea between April and September 2006 in Melut Payam is an example of dangers of consuming untreated water.

Inappropriate Child Care and Feeding Practices:

Preparation of food for children was done in precarious environments that exposed food to direct access to houseflies and dust. This could be worse when mothers left the care of young ones in the hands of the older children. Domestic pets were observed to regularly lick household food handling utensils, not to mention the potential hazard created. The water used for preparation of households’ food and that of children in particular was not treated and was used directly from the river. Children were also observed to be eating with untidy hands, a poor hygiene habit that puts them at risk of contracting diseases such as diarrhoea. Child feeding practices were found to be wanting and could be adequately addressed through intensive health education as well as improved access to potable water.

.VII. RECOMMENDATIONS

Food Security To establish suitable programs such as training, pest control, farming methods and acquisition of tools for the increase of food production

To implement actions to prevent perennial flooding in some low lying areas, to protect crop yield

To support the community in adopting suitable fishing practices to boost this underutilized resource.

Given the planned and spontaneous returnee situation, a strategy should be immediately put in place to address returnee food needs to forestall food shortage in the host community.

Agencies should sustain cattle vaccination services and improve extension services with an aim of increasing productivity.

Health

Health care programs should have mechanism of expanding coverage of EPI services to cover areas where there is limited access.

Water, Sanitation and Hygiene

Increase safe water access at household level (through boreholes drilling, water pumps installation, rain water collection, creation of dams, etc).

32 .VIII. Appendices

Sample Size and Cluster Determination

Mode of Estimated total Estimated target Revised target Assigned Walking Payam Geographical unit transport population Population size Population size cluster distances used Melut HAYA MATAR A 3540 708 236 1 15 to 20 Min Walk HAYA MATAR B 236 2, 3 HAYA MATAR C 236 4 HAYA SORA A 4120 824 206 5 15 to 20 min HAYA SORA B 206 6 HAYA SORA C 206 7, 8 HAYA SORA D 206 9 HAYA CHENJERA A 2000 400 200 10 20-30 min HAYA CHENEJRA B 200 11 HAYA CHATHI 1074 214 214 12 20-30 min HAYA AGOOK A 2888 577 193 13 20-30 min HAYA AGOOK B 193 14 HAYA AGOOK C 191 15 WUNTHON 1270 254 254 16, 17 40 min Walk MAHD/TURPAYUER/RIYARDIT 1200 240 240 18 4 hours Vehicle THARKUACH 600 120 120 19 4hours 30 Vehicle Paloch NYANTUON/ATLABARA 620 124 124 8-10hours Vehicle HAYA WAI 956 191 191 20, 21 8-10 hours Vehicle WUNAYUPDAU 820 164 164 8-10 hours Vehicle HAYA BURRON 1204 240 240 22, 23 8-10 hours Vehicle Galdora GOLDORA CENTRE 924 184 184 24 11-12 hours Vehicle SAPIO/WUNBARKOU/NYAG 1968 393 196 25 13-14hours Vehicle SAPIO/WUNBARKOU/NYAGOOKA/WUNALAU 197 26 13-14hours Vehicle THIANGRIAL A 2850 570 190 27 16 hours Boat THIANGRIAL B 190 28 16hours Boat THIANGRIAL C 190 29 16 hours Boat TIEP 836 167 167 30 3hours Vehicle and DUKI/ GOR 600 120 120 31 3hours 30 Vehicle and CHATONY/ ROORAYIK A 2412 241 32 4 hours Vehicle and CHATONY/ ROORAYIK B 241 33, 34 Vehicle and CHUEI 850 170 170 35 17 hours Boat Bemichuk PARIAK/BAPING/BEMICHUK A 1420 284 142 12 hours Vehicle PARIAK/BAPING/BEMICHUK B 142 36 Vehicle TOTAL 32954

The clusters were automatically generated by Nutri-survey December 2006 after inputting the revised target population.

33 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.

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 Nutri-survey 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

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

36 Calendar of events that happened in Melut County in the last five years.

MONTH SEASONS 2002 2003 2004 2005 2006 2007

JANUARY -Harvesting sorghums 49 37 25 13 1 PAY-TOK -collect gum Elijah elected Peace signing in Naivasha New Sudan flag is commissioner for Melut raised FEBRUARY Population move to River 48 36 24 12 PAY-RUW Bank Ador chief of staff dies

MARCH Built and repair Tukuls 59 47 35 23 11 Pay-deok Fighting between GoS Fighting between Militia Cholera is reported in and SPLA in Maijak and SPLA in Fashoda Melut

APRIL People Rest and celebrate 58 46 34 22 10 Pay-nguan WFP drops food in New school and hospital Senior SPLA army leader Traditional birth Payuer are constructed called Manyang came to Melut. attendant called Nyachan is killed.

MAY Cleaning land for cultivation 57 45 33 21 9 Pay-Dhich Vice-president of GoS comes Road to Malakal is Five officers who betray to Melut officially opened. SPLA are captured and killed.

JUNE Planting Maize 56 44 32 20 8 Pay-Dhatem SPLa came and killed UN peace keeping force comes 3 SPLA soldiers kills a people at Mahd Village. to Melut fisherman

JULY Planting sorghum and 55 43 31 19 7 Pay-Dhorou simsim Chiefs are elected by Dr John Garang dies Mobutu Mahmur comes And it is hunger gap GoS. Sudan Airways to Melut to a big plane crushes in Adar reception. near Paloch August Hunger Gap 54 42 30 18 6 Pay-Bet Inter-clan fighting in A man is burnt to death on Akoka, where one was suspicion that he is a spy. allied to GoS while the other to SPLA

SEPTEMBER Eating green Maize 53 41 29 17 5 Pay-Dhonguan Road between Payuer Fighting erupts in Torit and Melut is officially between SPLA and GoS. opened. OCTOBER Harvest of simsim and 52 40 28 16 4 Pay-Tier peeling of back tree for gum

NOVEMBER Chasing of Birds that attack 51 39 27 15 3 Pay-thierkutok sorghum Fighting between Sudanese refugees and Ethiopians in Ethiopia DECEMBER Celebrate Christmas 50 38 26 14 2 Pay-Thierkuruw

37 Average food market prices in Melut market, Melut County, March 2007.

COMMODITY PRICES IN SUDANESE QUANTITY DINNAR Sugar 1 Kilogram 300

Maize flour 2 kilogram 350

Beans 1 kilogram 600

Maize 1 kilogram 600(Depends on season)

Lentil 1 kilogram 600

Beef 1 kilogram 1200

Salt 500g 300

Onions 1 Kg 1000

Chicken 1 Medium size 1200

Fresh fish 1 Medium size/dried 300

Charcoal Sack of 50 kilogram 1500

Goat 1 medium size 25,000

cow 1 medium size 200,000