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South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY

CHILDREN UNDER 5 YEARS OLD

ALEK SOUTH, ALEK NORTH, ALEK WEST, GOGRIAL AND RIAU PAYAMS, GOGRIAL WEST COUNTY, WARRAP STATE, BAHR EL GHAZAL

17TH JANUARY – 9TH FEBRUARY, 2007

Edward Kutondo- NSP Manager Beatrice Otieno - Nutritionist Imelda V. Awino - Nutritionist

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ACKNOWLEDGMENTS

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

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

The entire survey team for their sedulous attitude and boundless determination through out the survey,

Finally to parents and caretakers, local authorities, and community leaders with whose assistance the

survey objectives were realized.

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TABLE OF CONTENTS

.I. EXECUTIVE SUMMARY.....................................................................................................................................4 .I.1. INTRODUCTION ................................................................................................................................................4 .I.2. OBJECTIVES....................................................................................................................................................4 .I.3. METHODOLOGY ...............................................................................................................................................4 .I.4. SUMMARY OF FINDINGS ...................................................................................................................................5

.II. INTRODUCTION ................................................................................................................................................9 METHODOLOGY ..................................................................................................................................................10

.II.1. TYPE OF SURVEY AND SAMPLE SIZE..............................................................................................................10

.II.2. SAMPLING METHODOLOGY............................................................................................................................10

.II.3. DATA COLLECTION .......................................................................................................................................11

.II.4. INDICATORS, GUIDELINES, AND FORMULA’S USED ..........................................................................................11 .II.4.1. Anthropometry .....................................................................................................................................11 .II.4.2. Mortality ...............................................................................................................................................12

.II.5. FIELD WORK ................................................................................................................................................12

.II.6. DATA ANALYSIS............................................................................................................................................13 .III. RESULTS OF THE QUALITATIVE ASSESSMENT.......................................................................................13

.III.1. SOCIO- DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS .................................................................13

.III.2. FOOD SECURITY..........................................................................................................................................14

.III.3. HEALTH ......................................................................................................................................................18

.III.4. WATER AND SANITATION..............................................................................................................................20

.III.5. MATERNAL AND CHILD CARE PRACTICES.......................................................................................................21

.III.6. EDUCATION.................................................................................................................................................22

.III.7. ACTIONS TAKEN BY NGO’S AND OTHER PARTNERS ......................................................................................22 .IV. RESULTS OF THE ANTHROPOMETRIC SURVEY......................................................................................24

.IV.1. DISTRIBUTION BY AGE AND SEX. ..................................................................................................................24

.IV.2. ANTHROPOMETRICS ANALYSIS.....................................................................................................................25 .IV.2.1. Acute Malnutrition, Children 6-59 months of Age ..............................................................................25 .IV.2.2. Risk of Mortality: Children’s MUAC....................................................................................................26

.IV.3. MEASLES VACCINATION COVERAGE.............................................................................................................27

.IV.4. HOUSEHOLD STATUS ..................................................................................................................................27

.IV.5. COMPOSITION OF THE HOUSEHOLDS............................................................................................................27 .V. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY.....................................................................28 .VI. CONCLUSION ................................................................................................................................................28 .VII. RECOMMENDATIONS..................................................................................................................................30 .VIII. APPENDIX ....................................................................................................................................................31

.VIII.1. SAMPLE SIZE AND CLUSTER DETERMINATION .............................................................................................31

.VIII.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE .............................................................................................33 .VIII.3. HOUSEHOLD ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE

SHEET/HOUSEHOLD) .............................................................................................................................................34 .VIII.4. ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE SHEET/CLUSTER)....35 .VIII.5. CALENDAR OF EVENTS IN GOGRIAL WEST COUNTY.....................................................................................36 .VIII.6. FOOD MARKET PRICES IN ALEK MARKET, GOGRIAL WEST COUNTY, FEBRUARY 2007....................................38 .VIII.7. GOGRIAL WEST COUNTY MAP. ..................................................................................................................39

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.I. EXECUTIVE SUMMARY

.I.1. Introduction

Gogrial West County is situated in Warrap State, Southern Sudan’s Bahr-el-Ghazal region. It borders Unity State, Wau, Twic, Tonj, Aweil East and South Counties to the North East, South West, North, East and West respectively. The county counts 116.8161 inhabitants. The predominant denizens of Gogrial West County are the Dinka ethnic group of the Aguok sub clan whose predominant livelihood activity is agro-pastoralism. Gogrial West County is subdivided into payams, bomas and villages. Administratively, the commissioner is in charge of the county while chiefs and administrators govern villages, bomas and payams respectively. The nine administrative payams in the County are Alek South, Alek North, Alek West, Gogrial, Kuac North, Kuac South, Riau, Akon North and Akon South. The county is under the jurisdiction of the GoSS. The area lies within the Western flood plain zone. It is a flat terrain whose soil structure is mainly sandy with pockets of loam clay soil. A number of seasonal rivers exist in the region (Malualawien and Nyantit rivers are the main ones). They provide fishing grounds to the community during certain times of the year. FEWSNET November 2006 report, indicated good production in the highlands while flooding negatively affected lowland crops in Gogrial County. It also revealed that an unknown number of households were displaced due to inter-ethnic conflicts in early 2006. Reports tentatively estimated that up to 20% of the county's population may have been affected by the insecurity. According to FEWSNET December 2006 - January 2007, the potential arrival of large numbers of returnees from Northern Sudan could strain local capacities, sources of food and labor opportunities. Moreover, the insecurity also interrupted some cultivation activities in the area. At the beginning of the year 2005, ACF-USA undertook an exploratory/rapid assessment that detected critical malnutrition rates necessitating the opening of targeted feeding programs. However, due to the reduced admissions the program was closed after seven months. A survey conducted by ACF-USA between February and March 2006 further revealed GAM and SAM rates of 23.9% [20.0% -28.2%] and 4.2% [2.6% -6.6%] in Z-scores (NCHS reference, at 95% confidence interval) respectively. Such prevalence indicated the need to re-open feeding program, and ACF-USA implemented them from May 2006.

.I.2. Objectives

To evaluate the nutritional status of children aged 6 to 59 months. To estimate the crude mortality rate through a retrospective survey. To estimate the measles immunization coverage of children aged 9 to 59 months. To determine immediate, basic and underlying factors influencing the nutrition situation of the community.

.I.3. Methodology

The SMART methodology was applied for both the anthropometric and retrospective mortality surveys. All the accessible villages in Alek South, Alek North, Alek West, Riau and Gogrial payams were included in the survey design. From the SRRC population figures, the target population2 was calculated after which larger villages were divided evenly into sub villages with a target population size not greater than 250. This data was then entered into Nutrisurvey for SMART software (December 2006 version) from where planning was done. Retrospective mortality data was collected alongside the anthropometric data. 1 Source: Acting SRRC Gogrial West County 2 estimated at 20% of the entire population

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Further, qualitative data was gathered through observation and households interviews through structured questionnaires. The data focused on food security, water and sanitation, child care services as well as accessibility and utilization of health care services.

.I.4. Summary of Findings

The region has been one of the most affected by the two decades of conflict in South Sudan. As a consequence, agricultural production and access to local and external markets had markedly deteriorated. A number of areas around Gogrial town, and between Wau and Gogrial town, are believed to be mined. The county has enjoyed relative peace following the signing of CPA in January, 2005 which has enabled the resumption of economic activities and resettlement of returnees. However, episodes of inter-clan fighting between the Aguok and Apuk sub clans have been reported in August, September, November 2006, several episodes of fighting were reported. The disarmament exercise was successfully carried out in the county between November and December 2006. During the survey period, the security situation was calm with no insecurity incident being reported. General information Both the availability and accessibility to potable water in Gogrial West County is generally below the recommended SPHERE and SOH standards3. Despite the fact that there are numerous hand pumps in the county, most of them are in poor condition. The few functional ones can hardly meet the needs of the entire populace. Because of the long queues and the enormous walking distances to these water points, most people resort to consumption of water from shallow wells and stagnant pools. Through observation and interviews during the survey it was noted that, the water is consumed untreated by most of the populace unmindful of the harm it poses to their health. This predisposes the community to the risk of contracting water borne diseases. Hygiene and sanitation situation in Gogrial West County is deemed to be in a poor state owing to the fact that very few latrines were observed during the assessment period. The latrines that were observed were mainly found in administrative compounds and in Alek and Gogrial town. Consequently, human waste was indiscriminately disposed off, a practice which further precipitates the risk of infection. It was also observed that cooking utensils and water containers were not kept clean while child care practices were also generally below standard as most children were observed eating without first cleaning their hands. Despite the free health services proffered in the county, the health seeking behavior of the community is not up to date since medical attention is sought so late when the disease has progressed to critical stages. Results from interviews conducted with the health personnel on ground confirmed that most people prefer taking their sick ones to the traditional healers locally known as kunjurs, as a first resort and only go to the health facilities should the disease persist. However this situation is slowly changing with the continuous health education especially in the towns where people have began to realize the significance of conventional treatment and timely intervention. According to the NCA Health supervisor; malaria, malnutrition and pneumonia are the leading causes of morbidity and mortality in the surveyed community. Anemia and diarrhea are also common, a situation which can be ascribed to poor sanitation and minimal food intake. During the survey period there was an outbreak of meningitis which is believed to be endemic in the region during the dry season. Regardless of the fact that last season harvest was better compared the previous year, most of those households interviewed reported to have depleted their food stocks or had very little reserves; ascribed to the sale of grains and brewing of beer to acquire income to purchase other items. To cope, most households reduced the number of meals per day with wild fruits and vegetables being important supplements. The agencies intervening in the area are listed below: ACF-USA runs nutrition programs (SFC and TFC-HT) in the county since May 2006.

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

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NCA is involved in the provision of primary health care services and education activities in Gogrial West County. The health services are provided in collaboration with the Ministry of Health, whereby NCA is responsible for provision of medical and drug supplies. They run 1 PHCC situated in Alek South Payam and 11 PHCUs each located in Keet, Atukuel, Mandeng, Malual Ajak, Mankuac, Anguoth, Panliet, Ayuang, Malualawien, Bau, and Pakor villages. The health units provide treatment of common ailments, health education, HIV/AIDS and EPI programs. These services are free save for the registration and admission fee which are 100 and 200 Sudanese Dinnars respectively. The PHCC acts as a referral centre to the PHCUs, and offers MCH and in-patient services with a bed capacity of 30. The organization is in the process of setting up a laboratory and for that matter, a laboratory technician has already been trained. They are also involved in training activities for the health personnel such as CHWs, TBAs, EPI and MCH staff; village health committees for PHCUs and Management committees for PHCCs. The CHWs and MCH were trained for 9 months in 2004 and had a refresher course in 2006. Plans are underway to train more MCH and CHWs in the course of the year. In education, the organization has four main activities namely; support of primary schools, school construction, teacher training and adult literacy. They initially supported 14 primary schools, however only 5 schools are currently supported through provision of scholastic materials such as books and pens among others. The other 9 schools are taken care of by the Government. One school has been targeted for construction in Alek whereas the teacher training program is intended to wind up as soon as the Government opens up a teacher training centre in Kuajok. In addition, a women centre whose aim is to curb the low enrolment and literacy levels among females, offers cookery and dressmaking lessons; this has led to the initiation of a primary school which has so far reached class two. FARM AFRICA, whose aim is to eradicate poverty by improving the livelihoods of farmers and herders in marginalized areas mainly incorporates innovative approaches in development to ensure that people live in sustainable situations using natural resources. Their program in the location includes animal health, agriculture, water, community development, research and policy. Animal health main activities are provision of veterinary inputs, improving productivity and disease surveillance. The agriculture component is concerned with improving farming methods, empowering local blacksmiths and encouraging dry season cropping. They also give farm inputs to vulnerable groups such as returnees and those affected by inter clan fighting. In the sector of water, the agency partners with SUPRAID to drill new boreholes, rehabilitate broken ones through the existing water management teams and also explore alternatives to boreholes such as shallow wells. Research and policy which is the key area in the organization, aims at creating models in agriculture and other sectors that are able to meet the community needs in one package. These models can in future be used for up scaling of projects by the Government and other agencies. At the moment the agency is in the process of gathering information on research and policy at Government level and sensitizing the community on policy issues. They also intend to initiate action oriented research for example that which would reduce the women work load in the community. Finally, the community development aspect tries to capture the other needs of the community which are not met by the agency’s interventions; as such models like village development committees have been initiated. SUPRAID is an indigenous organization whose main activity is drilling of new bore holes in the county. Because of their capacity, they are at times contracted by NGOs to drill boreholes. SC-UK is involved in education, HIV/AIDS and child protection programs in Gogrial West County. Under education, they have a teacher training targeting those aged 12-21 years. They also support primary schools in terms of scholastic materials and construction of physical facilities. They are currently supporting a total of 9 primary schools in the county; one school each in Akon South, Kuac North and South payams and 2 schools each in Akon North, Riau and Gogrial payams. In addition they also conduct work shops with local education authorities who assist in community mobilization. The HIV/AIDS program is mainstreamed and integrated into the education program. WVI in Gogrial West County is operating a number of programs including food security which is currently implemented in Ajiep with the main activities being demonstration farms, ox plough training, and tree planting. The food aid program is carried out in collaboration with WFP, and they have currently moved from general food distribution (except for returnees and the vulnerable) to food for assets while in Health and Nutrition, the agency is at the moment running an SFP and one PHCC in Ajiep.

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RESULTS The anthropometric nutritional survey included a total of 642 children. The data of 4 of them were excluded as they presented incoherencies. The table below relies on the analysis of the data of 638 children.

Table 1: Results of the Anthropometrics Survey

REFERENCE INDICATOR RESULTS4 (n=638)

Global Acute Malnutrition W/H< -2 z and/or edema

19.0% (15.3 - 22.7) Z-scores

Severe Acute Malnutrition W/H < -3 z and/or edema

0.9% (0.1 - 1.8)

Global Acute Malnutrition W/H < 80% and/or edema

7.8% (5.4 - 10.2)

NHCS % Median

Severe Acute Malnutrition W/H < 70% and/or edema

0.2% (0.0 - 0.5)

Global Acute Malnutrition W/H< -2 z and/or edema

19.0% (15.1 - 22.8) Z-scores

Severe Acute Malnutrition W/H < -3 z and/or edema

2.8% (1.3 - 4.4)

Global Acute Malnutrition W/H < 80% and/or edema

4.1% (2.2 - 5.9)

WHO

% Median Severe Acute Malnutrition W/H < 70% and/or edema

0.2% (0.0 – 0.3)

Total crude retrospective mortality (last 3 months) /10,000/day Under five crude retrospective mortality /10,000/day

0.58 [0.28– 0.89] 0.97 [0.28–1.65]

Measles immunization coverage (N= 590, children >=9 months old)

By card According to caretaker5 Not immunized

3.9% 17.1% 79.0%

Discussion WVI and ACF-USA have undertaken numerous nutrition surveys in the region since the year 2004. The latest assessments were conducted in the previous year that revealed GAM and SAM rates 23.9% [95% C.I: 20.0% -28.2%] in Z-score survey done by ACF-USA assessment between February and March 2006. This yeas malnutrition rates are lower as compared to last year results, which could be attributed to impact of ACF-USA nutrition treatment program in the region. However, the current GAM rate of 19.0% [ 95% C.I: 15.3%-22.7%] in z-scores is still above emergency threshold and could be attributed to a number of multifaceted factors such as; decline in food security, disease and poor health seeking patterns, water and deplorable sanitation practices, inappropriate feeding and child care practices and insecurity. These can be summarised as follows: Food Insecurity: The food insecurity situation in the location could be attributed to various shocks such as livestock diseases, lack of appropriate and adequate fishing and farming equipment, lack of labor and human diseases. The main coping strategies adopted by most of the households were: eating fewer meals, consumption of wild fruits and vegetables, kinship support and buying using income from petty trade, sell of firewood, livestock, grass and alcohol. These may decline over time further exacerbating food insecurity and in the long run may result to adverse health and malnutrition. Disease prevalence and poor health seeking patterns: 4 The rates are expressed with a 95% confidence interval. 5 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

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Despite free health services offered by the health agency on ground (NCA), the health seeking behaviour of the community is still wanting. Most of the community sought treatment when the disease had already progressed into serious phases. Belief in traditional healers in this community is rampant as evidenced by the presence of various magical paraphernalia as observed in most of the homes visited. This has contributed to the current rate of malnutrition as some community members seek health services as the last resort, making their bodies compromised by diseases. Deplorable Water and Sanitation situation: To meet their water requirements, some of the community members fetch water for drinking and household consumption from sources such as unprotected well and swamps. Unfortunately, water from these sources is not treated by majority before drinking. This coupled with the poor hygiene and sanitation in the area, predisposes the community to diarrhoeal and water borne ailments, especially during the wet season when the waste and feacal matter is swept back into these water sources and as a results of these diseases that compromise the health status of the community members resulting to malnutrition especially the under fives. Inappropriate child care and feeding practices: Women are engaged in many household activities and thus have very little time for nurturing the children, which apparently poses a risk on the nutritional status of the exclusively breastfed children. Moreover, the weaning foods were predominantly the family meal of kuon made from sorghum while other foods such as milk and meat products were minimally consumed. This consequently leads to poor nutrient intake, and ultimately induces poor nutrition state of the children. Security and safety: The county is still believed to be mined, which limits people’s movement to certain areas. Further, the continuous episodes of inter clan fighting between the Aguok and Apuk sub clans have continuously been reported in the county since 2004 hence predisposing the local community to higher risk of food insecurity. This is because the community is forced to run for their lives thus productive time that could have been spent in tilling and preparing land for cultivation is spent either in fighting or defending the community. However, as could be observed in some of these villages, such as Mankuac and Mangok, the community was gradually coming back and had started settling and it is hoped that with time, the community will be able to bounce back to its normal livelihood activities. Recommendations The above emergency level GAM rate among children aged 6-59 months as depicted by the results signify a life precarious nutrition situation in Gogrial West County. This has been closely attributed to a bleak food security situation (access and availability) and diseases as well as various underlying factors discussed above. This is therefore an indicator that the causal factors responsible for the prevailing state need to be nipped from the bud before anything untoward happens. Timely interventions are thus inevitably necessary to bolster the community from the probable effects of malnutrition. Additionally reconstructive and long term measures also need to be put in place in order to prevent future recurrence of the same, and ultimately ensure that malnutrition is alleviated. The following recommendations have therefore been put forth by ACF-USA: Food Security

To continue the food distribution to the returnees, displaced and other highly vulnerable households. To develop new strategies of food for agriculture and food for assets. Besides action oriented researches, to explore possibilities of empowering the community to initiate

livelihood activities through the village development committees. Health

To carry on with targeted feeding programs for the management of both severely and moderately malnourished children, and increase their coverage.

To maintain the existing health initiatives with special focus on MCH and EPI. Water and Sanitation

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To forge ahead and implement the alternative to boreholes initiative by offering training and technical support to the community on how to dig shallow wells, dams and rain harvesting, all of which will ensure sustainability with a cost advantage.

To partner with other agencies involved in water activities to rehabilitate some of the existing dysfunctional boreholes within the county.

To support latrine construction using locally available materials and furnish the community with the required technical skills while at the same time encouraging community participation to ensure their utilization.

To enhance health and hygiene promotion activities within the county by educating the community on the significance of personal hygiene, human waste disposal and water treatment methods.

Security and safety

To carry on with the de-mining activities especially in Gogrial town and its environs which are believed to be heavily mined.

.II. INTRODUCTION

Gogrial West County which is administered by the GoSS is situated in Warrap State, Southern Sudan’s Bahr-el-Ghazal region. It borders Unity State, Wau, Twic, Tonj, Aweil East and South Counties to the North East, South West, North, East and West respectively. The county which has a populace of 116,8166 is further subdivided into payams, bomas and villages. The nine administrative payams in the County are Alek South, Alek North, Alek West, Gogrial, Kuac North, Kuac South, Riau, Akon North and Akon South. The county is majorly inhabited by people of the Dinka ethnicity, specifically the Dinka Bahr el Ghazal clan belonging to Aguok sub clan. Just like the other populace of Bahr el Ghazal region, the Gogrial West County residents are mainly agro-pastoralists, although fishing and trade are also important sources of livelihood. Gogrial West County has enjoyed relative peace following the signing of CPA in January 2005, which has enabled the resumption of economic activities and resettlement of returnees; however there has been insecurity in some parts of the county since 2005 due to inter-clan conflicts between Gogrial West and Gogrial East counties causing displacement and disruption of livelihoods. Similarly due to the insecurity, crop production was low while some did not cultivate at all in the affected locations7. The most recent incidents were reported in the month of September 2006. The county which is located in the Western flood plain zone is characterized by a flat terrain whose soil structure is mainly sandy with pockets of loam clay soil. A number of seasonal rivers exist in the region with Rivers Malualawien and Nyantit providing fishing grounds to the community to supplement their food demands during certain times of the year. FEWSNET November 2006 reported good production in the highlands while flooding negatively affected lowland crops in Gogrial County. It further confirmed the fact that, an unknown number of households were displaced by inter-ethnic conflicts in early 2006 and the insecurity interrupted cultivation activities of some of the remaining non-displaced households. Reports tentatively estimated that up to 20% of the county's population may have been affected by the insecurity. According to FEWSNET December 2006 - January 2007, the potential arrival of large numbers of returnees from Northern Sudan could strain local capacities, sources of food and labour opportunities. At the beginning of the year 2005, ACF-USA undertook an exploratory/rapid assessment that detected critical malnutrition rates necessitating the opening of targeted feeding programs. However, due to the reduced admissions, the program was closed after seven months. A survey conducted by ACF-USA between February and March 2006 further revealed much higher GAM and SAM rates of 23.9% [20.0% -28.2%] and 4.2% [2.6% -

6 Source: Acting SRRC Gogrial West County, population figure of assessed payams. 7 WFP Sudan Annual Needs Assessment report 2007

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6.6%] in Z-score at 95% confidence interval accordingly. This necessitated the re-opening of the feeding programs in the county in May 2006. Due to the recent and prevailing conditions as well as the need to assess the impact of the nutrition programs that were put in place following the high GAM and SAM rates a nutritional survey was conducted in Gogrial West County between 17th January and 9th February 2007.

METHODOLOGY

.II.1. Type of Survey and Sample Size

The anthropometric survey has been done with the SMART8 methodology. The target population is the 6-59 months old age group. Selection of accessible villages was done using a map of the area (Appendix VIII.9) and the administrative information given by the SRRC.The Gogrial West County population is estimated at 116,8169 , from this figure a target population of 23,32 children10 was calculated. The larger villages were divided evenly into sub villages with a target population size not greater than 250. This data was then entered into Nutrisurvey for SMART software, (December 2006 version) from where planning was done. A total of 34 clusters were assigned in proportion to target population size utilizing a design effect of 2, prevalence 28.2% and precision 4.3%. A retrospective mortality survey was done along with the anthropometric one, utilizing SMART methodology. Besides, both formal and informal interviews, observation and structured questionnaires were used to obtain qualitative information so as to determine the immediate, underlying and basic causes of malnutrition within the location.

.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 Nutrisurvey 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 early last year while the design effect was taken to be 2 in both cases. The anthropometric and the mortality survey sample sizes were divided by 1.511 and 612 respectively to get the number of household to be visited. The anthropometric survey results revealed more households; as such a sample size of 826 was adopted. 34 clusters were then randomly selected by inputting the sub village names and the revised target population sizes into Nutrisurvey software, which automatically assigned clusters (See appendix VIII.3). Each cluster comprised of 16 households.

♦ At the second stage, selection of households within each cluster was done. The team began by dividing

the village into sub villages accordingly with the help of the surveyors. 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. All children aged

8 Standardized Monitoring and Assessment in Relief and Transition 9 Source: Acting SRRC Gogrial West County, population figure of assessed payams. 10 20% of the entire population 11 Average under 5 population per household 12 Average population per household

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6-59 months in each household were included in the nutritional survey. If there was more than one wife in the household13, 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. All children aged 6-59 months were measured and the mortality questionnaire completed; the subsequent households were then chosen by proximity. In villages where the houses were closely packed together, the next house on the right was chosen until a total of 16 households were surveyed. However in cases where the villages were spread-out, the house with the door closest to the last house surveyed was considered. The household was recorded on the nutritional data sheet as having no eligible children. The mortality questionnaire was administered to all selected households, whether they counted eligible children or not.

.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). 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 Formula’s Used

.II.4.1. Anthropometry

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 NCHS14 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. 13 A household refers to a mother and her children 14 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74.

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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 0.4 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 Nutrisurvey for SMART software for Emergency Nutrition Assessment. The formula below is applied: Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where: a = Number of recall days (90) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period The result is expressed per 10,000-people / day. The thresholds are defined as follows15: 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

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

13

46%52%

8%2%

0%

10%

20%

30%

40%

50%

60%

Crop

farm

ing

Agro-

paso

ralism

Petty

trade

Other

translator. ACF-USA staff supervised all the teams in the villages. The survey (including training, planning, data collection and travelling) lasted for a period of 22 days.

.II.6. Data Analysis

Data processing and analysis for both anthropometric and mortality were carried out using Nutrisurvey 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

Gogrial West County was one of the regions worst affected by the two decades of conflict in South Sudan. Agricultural production as well as access to local and external markets had markedly deteriorated as livelihoods were put at a deplorable state. Reportedly, a number of areas around Gogrial town and between Wau and Gogrial area are believed to be mined, reflecting the past hostilities between SPLM and GOS in these areas. Unconfirmed reports indicated that someone was blown off after a land mine exploded in Manalom village, near Gogrial town during the time of the assessment. Episodes of inter clan fighting between the Aguok and Apuk sub clans have continuously been reported in the county since 2004.The latest incidence being in September 2006 when skirmishes broke out between the two clans in Mankuac village, at Gogrial East border, during which five women were seriously injured. Alongside the anthropometric survey, qualitative information was gathered on 50 households using structured questionnaires, observation and interviews. Of all the households, 49 (98%) and 1 (2%) of the respondents were residents and IDPs respectively. Majority 42 (84%) were females with only a minimal 8 (16%) representing the males, who in most cases were left behind when their female counterparts went to collect grass for thatching houses. The absence of males could be ascribed to the fact that the prevailing peace in the region has caused most men to move to town areas to seek involvement in developmental and livelihood activities such as trade, employment by government or agencies, among others. As such it was the females who were mostly left behind to tend to the young ones and perform domestic chores.

Figure 1: Sources of Livelihood The county is predominantly inhabited by the Dinka ethnic group, specifically the Dinka Bahr el Ghazal clan belonging to the Aguok sub clan who are mainly agro-pastoralists with crop farming as an important source of

14

28%

14%

58%

12% 10%

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10%

20%

30%

40%

50%

60%

Livestocksale

Crops sale Petty trade Firewoodcollection

Remittance

livelihood. The survey results confirmed this fact, as more than half 26(52%) of households interviewed were agro pastoralists with 23(46%) being crop farmers as shown in Figure 1 above. However, as at the time of assessment, most of the cattle were at the toic (cattle camp) and thus nutritional benefits derived from livestock were minimal. Even though the qualitative analysis does not reveal any returnees, FEWSNET December 2006 projects that a substantial number of IDPs and returnees are expected back with a large percentage expected to settle in Warrap state. A total of 25,400 IDPs and returnees are expected back during the year16. Most 29(58%) of the households rely on petty trade; majorly sale of alcohol and grass for their income so as to meet other household demands. Figure 2: Sources of Income Other sources of income entailed the sale of livestock, crops, firewood and remittance as shown in figure 2 above. Sale of alcohol by the community is rampant as observed during the assessment. The local brew was made using sorghum which in the long run may have led to depletion of the existent stocks. Additionally, most community members were observed to start taking the brew early in the morning and thus productive time was adversely wasted.

.III.2. Food Security

Gogrial West County in the western flood plain zone is characterized by flat terrain mainly covered with sandy soil amid pockets of loam and black cotton soil. According to FEWSNET December 2006 report, food security gains made in this zone are likely to be lost should large scale population returns occur. These will be compounded by chronic vulnerability of some households, impact of structural food deficits as well as targeting problems between returnees and their hosts. As at the time of assessment, private production 39(78%) was the predominant source of food in most households as the last harvest was carried out towards the end of the year. 22(44%) of the community bought their food from the local markets using income acquired through petty trade, remittance and sale of firewood and grass. Notably, majority of the surveyed population 46(92%) planted crops during the last planting season with a negligible number 4(8%) of households having not planted anything due to lack of labour and social instability. Of the households that had cultivated food crops, most of them 33(71.7%) had cultivated relatively smaller farm sizes of approximately 0.5 feddans17, most likely due to lack of tools and other farm inputs. Comparatively, the

16 Warrap state OCHA ,GOSS AND NGO meeting held at Kuajok on 31st January 2007 17 One feddan is a local measure of land equivalent to 4200.833 sq meters (1.038 acres)

15

28.3%

95.7%

4.3%10.9% 8.7%

37.0%

0%10%20%30%40%50%60%70%80%90%

100%

Maize

Sorgh

umBea

ns

Vege

tables

Millet

Other

last seasons harvest was better 27(58.7%) than that of the previous year (2005). Nevertheless, some 41(89.1%) of the respondents reported harvests that were below their expectations and attributed this to lack of rain 31(75.6%), insects 2(4.9%), diseases and pests infestation 3(7.3%). Other problems that led households not to harvest what they expected accounted for 16(39%), these included lack of manure, lack of labour, destruction of crops by livestock and interclan fighting. This concurs with FEWSNET December reports indicating that the year 2006 crop production in the entire Western Flood Plain zone was better than that of the previous year. The report further indicates that the performance of off -farm production such as wild foods was relatively good and this concurs with observations during the survey period. Sorghum was the predominant crop cultivated by most 44(95.7%) of the households with maize, beans and vegetables grown to a minimal extent. Findings further indicated that there is a bit of crop diversification in the community with some 17(37%) households having planted other crops such as tobacco, pumpkin, groundnuts and simsim as illustrated in the figure 3 below. Figure 3: Types of crops grown FARM Africa, which implements a food security program within the county, cited the presence of strigger weeds which greatly affects sorghum production and the agency is currently working on ways through which this problem can be dealt with. To curb the problem of low sorghum yields as a result of unreliable rain patterns, the agency has initiated strategies such as seed priming whereby sorghum seeds are soaked overnight before planting to ease germination. Sorghum transplanting is another strategy in which sorghum is first planted in seed beds just before the rains begin, and then transplanted immediately the rains begin. The program is also trying to empower local blacksmiths to be able to produce farm tools such as malodas and jembes. Dry season cropping is being encouraged besides the rain-fed farming, which is typical in most parts of South Sudan, with vegetables being planted along the river banks. With all these innovative approaches, it is hoped that the sorghum yields are likely to increase in future. Despite improved harvests, most 22(44%) households reported that the food stocks would last for at most three months while an almost similar proportion 17(34%) had already depleted their food stocks and were relying on wild fruits and vegetables 7(41.2%), kinship 3(17.6%), sale of firewood 5(29.4%) and other means 10(58.8%) such as sale of grass and local brew. Nonetheless, despite this improvement, structural food deficits are still expected by a segment of poor households that is chronically food insecure starting in April 2007. Typically, the structural deficits occur anytime between April and August, commonly known as the hunger gap season18. Figure 4 below shows the various coping mechanisms adopted by the respondents.

18 FEWSNET December 2006

16

17.6% 29.4%

58.8%41.2%

0%20%40%60%80%

Wild foodcollection

Kinship Sale offirewood

Other

100%

10%2%

36%

90%

42%

0%10%20%30%40%50%60%70%80%90%

100%

Sorghum

MilkMeat

FishWild fruits

Wild vegetables

Figure 4: Coping Mechanisms Majority of the households’ meal comprised mainly of sorghum, wild fruits such as chum, tamarind (chue) and wild vegetables such as anyuer and akuor, as these were reportedly consumed daily. Additionally, dried fish; locally known as madeja, was consumed by some 18(36%) of the households whereas milk was consumed by very few 5(10%) of the households and notably, the little milk available was only fed to younger children. This was because most of the cattle were at the cattle camp during this time of the year. This attests to the FEWSNET January 2007 report that vindicate that the households in the Western Flood Plain Livelihood Zones were consuming sorghum supplemented by groundnuts, sesame, fish and wild foods. The report further elaborates that less milk was being consumed as cattle were moved to grazing areas away from homesteads. Figure 5 below illustrates the foods frequently consumed during the survey period.

Figure 5: Foods most frequently consumed The last WFP food distribution in the location which was done through WVI was reported to be August 2006 by the households interviewed with no household having received any food aid in the preceding three months. This affirms the WFP new food distribution strategy for South Sudan of food distribution to the chronically food insecure during April-July hunger season, for resettlement and re-integration activities and food for the local population receiving returnees19.

19 Southern Sudan Food Security Update (FEWSNET) December 2006

17

57.1%

42.9% 40.0%

22.9%

2.9%

57.1%

0%

10%

20%

30%

40%

50%

60%

MilkFood

DowrySale

Symbol of Wealth

Other

The Aguok and Apuk of the Dinka ethnic community own a variety of livestock as depicted in the results in which 35(70%) admitted that they own livestock. 22(62.9%) owned cows or chicken, 20(57.1%) had goats with 4(11.4%) owning sheep. Significantly, the cows, goats and sheep were at the cattle camp “toic” with only the chicken found in the homes as observed. The major benefits derived from the livestock by the community included milk 20(57.1%) especially in the wet season, food on special occasions 15(42.9%), payment of dowry 14(40.0%), sale 8(22.9%) and use of livestock as a symbol of wealth 1(2.9%). Other benefits obtained from the livestock accounted for 20(57.1%) and mainly included manure and eggs as demonstrated in Figure 6 below. Most respondents 46(92%) reported that livestock were sold or bought at the local markets. This could be due to the existence of vibrant markets both within the county and in the neighbouring areas. In the past five years, the number of livestock owned has tremendously declined as reported by 23(65.7%) of the households. This declination could be due to persistent insecurity that has led to cattle raiding, sale of livestock, and payment of dowry not to mention slaughter of animals for food. Livestock diseases and lack of adequate pastures may have also contributed significantly to this scenario. According to FARM Africa, the most common livestock diseases in the county are Anthrax, Haemorrhagic septicaemia, Contagious bovine pleuropneumonia, contagious caprine pleuropneumonia and Mange, hence their disease surveillance program targets prevention of these diseases and management of outbreaks.

Figure 6: Benefits derived from livestock A number of vibrant markets exist in Gogrial West County such as at Alek and Gogrial averagely being approximately less than an hour walk for most 35(70%) of the households. These markets sell food and non food items. Some of the food items found in most markets include sorghum, maize, pulses, milk, oil, vegetable, sugar, wheat, salt, and fish. Cash purchases are increasing within the county as households reported to purchase a variety of commodities from the market. Foodstuffs commonly purchased included sorghum, sugar, fish, maize, rice and other such as salt (see food list and their prices are attached in appendix VIII.8). Worth mentioning is the introduction of a new currency, the pound, in Sudan on January 9, 2007. The new currency was established as a result of the north-south peace agreement signed in January 2005 and replaces the dinnar, which was introduced in 1992. The establishment of a new and common currency is expected to have a positive impact on the collection of market data and monitoring of markets, especially in southern Sudan, which has been problematic in the past due to the use of different currencies in different markets and states. This applies to all market data that was collected starting 1995 to 2006.20   

20 FEWSNET January 2007

18

It is paramount to note that various seasonal rivers are extant in the region with Rivers Malualawien and Nyantit providing fishing grounds to the community to supplement their food demands during certain times of the year especially between March and May as reported by the households. According to the findings, only 14(28 %) of the community had access to fishing grounds. This could be associated with the fact that most rivers are seasonal hence dry up when rain stops as was the case during the survey. Of those who had fishing grounds, only 4(28.6 %) practiced fishing, half of whom said they harvested enough fish. Those who did not practice fishing cited a number of reasons such as lack of adequate and appropriate fishing equipment and lack of labor as reported by 3(30%) and 7(70%) of the respondents correspondingly. Men offer the most significant skill and labour in fishing as in the Dinka community, fishing activity is mainly reserved for males therefore the notable absence of men in the representative households interviewed explains the low fishing practice in those households. Half of the respondents who did fishing said they used nets, while a similar proportion used other fishing tools such as baskets locally known as athoy; only 1(25%) said they used hooks for fishing. The results further indicated that the most common fish preservation methods used amongst this community was drying as revealed by all the respondents. This was evidenced by the availability of dried fish, madeja in most local markets. In a nut shell, the food insecurity in the location could be attributed to various shocks such as livestock diseases, lack of appropriate and adequate fishing and farming equipment, lack of labour and human diseases. The main coping strategies adopted by most of the households were eating fewer meals, consumption of wild fruits and vegetables, kinship support and buying using income from petty trade, sell of firewood, livestock, grass and alcohol. Despite the numerous fall-back strategies in the community, some of them are not sustainable and would make the households poorer as they may deprive people of their livelihoods or result to poor health. This is especially when cattle are sold and sorghum used to brew beer. These may decline over time further exacerbating food insecurity and in the long run may result to adverse health and malnutrition.

.III.3. Health

Disease prevalence is one of the immediate causes of malnutrition, therefore lack of and inaccessibility to health care services are key issues when trying to define the nutritional situation unearthed by the results in Gogrial West County. Provision of health care in the surveyed locations is largely undertaken by NCA in collaboration with the ministry of Health. The agency is responsible for medical and drug supply while the Government remunerates the staff. Initially there used to be 11 PHCUs and one PHCC. However 4 PHCUs have since been closed down due to lack of staff as such, only 9 PHCUs are functional at present. The PHCC is run by a medical assistant and supported by two nurses. Good enough, two more nurses have already been trained and are expected to join in the running of the PHCC in the course of the year. The PHCUs on the other hand are each headed by a Community Health worker. TBAs and EPI staff are also attached to every health unit. Other than timely and general supervision, NCA also provides drugs to the health centres every month. The NCA/Government run health units provide both preventive and curative services; these include treatment of common ailments, health education and EPI services. The PHCC which acts as a referral centre to the PHCUs additionally offers HIV/AIDS program, MCH and inpatient services with a bed capacity of 30. There were no laboratory services during the time of the survey; however the structure had been set up. According to the information gathered from the NCA health supervisor, there was already a trained laboratory technician, thus provision of laboratory services is likely to commence soon. According to the NCA health supervisor, the health facilities are well utilized with monthly attendance rates ranging from 1000 to 2000 patients. She further reported that despite the fact that health services were free; the health seeking patterns of the community is deplorable, as majority seek medical attention when it is too late. Belief in traditional healers in this community is rampant as evidenced by the presence of various magical paraphernalia as observed in most of the homes visited. However she noted that health seeking patterns have greatly improved in the recent past, a situation which she attributed to the persistent health education. Provision of EPI services are done routinely in the PHCC; however the health supervisor reported that despite the vigorous health education given, most mothers in this community still do not recognize the significance of immunization and as such some fail to avail their children for vaccination, while those whose children have been vaccinated do not keep the cards well and end up loosing them. These two factors have proved to be major challenges when trying to verify whether a child has been immunised or not. This could elucidate the low (21%) measles coverage unveiled by the results. To curb the problem of enormous walking distances to get children

19

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100%

Malaria

Diarho

eaFe

ver

RTIsOthe

r

immunized in the PHCC, the agency organizes frequent outreach EPI activities through the PHCUs. These outreach activities are usually organised on monthly basis with the last one being conducted in the month of December. Reportedly, all the health units provide general health talks every morning and to individual patients depending on the prevailing condition. Of importance is the MCH clinic where the pregnant and lactating mothers are advised on appropriate child care practices. Nonetheless, due to limited staff who most of the time are overwhelmed, individualised health education is greatly hampered. Growth monitoring is done in the PHCC and the malnourished children are referred to the ACF-USA feeding program. Additionally, HIV/AIDS health education program is also existent in the PHCC and is conducted every Monday. The program utilizes audio visual equipments which are in both English and Dinka languages. Health care service provision in Gogrial West County is greatly hampered by the challenge of limited staff. Out of the 24 trained Community Health Workers, only 14 are currently working. Similarly, the EPI staffs most of who are demoralised since they have not been paid for some time. Pointedly, it is the lack of staff that prompted the closure of four PHCUs run by NCA as the CHWs in charge of these health units had reportedly gone to Kuajok to look for money. The issue of non payment of salaries has reportedly caused most staff to move out and seek alternative sources of income. This has further been aggravated by the fact that the government payroll has not been revised to include new entrants, but still include names of ghost workers. The government through the Ministry of Health thus need to act swiftly to salvage this important sector. The common diseases, as reported by the NCA health supervisor, were Malaria, Respiratory Tract Infections (RTIs), mostly pneumonia and diarrhoeal diseases. Malnutrition was also said to be common especially among the young children. Reportedly, this was due to the fact that most of the households in the community prepare food late at night and hence children are not fed adequately. Malaria, which apparently is the leading cause of morbidity was said to be common during all seasons. Results of the analysis attest to this fact. This could probably be due to lack of mosquito nets as was discovered through interviews with households and observations. The high prevalence of pneumonia especially among children could be ascribed to the fact that most children were left uncovered or wore very minimal clothing as observed in the households visited. Such was the case regardless of the nippy weather especially during the early morning hours. Most household were also observed to be lacking adequate bedding to guard them against the cold during the night. On the other hand the many cases of diarrhoeal infections are most likely precipitated by consumption of untreated well and swamp water as well as poor sanitation as illuminated by the results. The figure 8 beneath shows some of the common diseases mentioned by the respondents.

Figure 7: Common causes of morbidity

During the survey period, there was a meningitis outbreak reported in the county and its environs and was said to have started on 22nd January. According to the NCA health supervisor there were a total of 7 cases reported in the PHCC, 2 of whom passed on. She however noted that following reports from an inter-agency meeting that was held in Kuajok on 31st January, the situation had been contained and was being monitored. She also revealed that they were planning a mass Meningitis immunization exercise to be held in the whole county as soon as the necessary logistical issues were sorted out. The aim would be to curb the endemic occurrence of meningitis in this region during this time of the year, which in most cases results in many casualties.

20

28%

12%

4%4%2%

50%

10-20litres 21-30litres 31-40litres 41-50litres51-60litres >60litres

From the discussion above, it is eminent that a lot more still needs to be done in a bid to enhance the health status of the community. The existing health facilities in Gogrial West County cannot adequately meet the needs of the entire population and the high numbers of returnees expected in the county in future. Assuming that all the residents in the assessed payams in Gogrial West County, which is currently approximated at 116,81621 people, use the PHCC located in Alek as a referral centre, it translates to a ratio of 1:116816 persons. This falls short of the recommended SPHERE and SOH standards which advocate for one PHCC against 50,000 and 80, 000 respectively.

.III.4. Water and Sanitation

Despite the presence of a number of registered hand pumps in Gogrial West County, the water situation is still plagued as most of the hand pumps are dysfunctional. The few that are in good order can hardly meet the need of the populace. As such, accessibility and availability of potable water is still below SPHERE22 standards, which recommends not more than 15 minutes queuing time and 250 persons per hand pump. Reliable sources indicated that out of 256 registered boreholes in this county only a third are functional. As a result of the long walking distances and queues at the water points, some people prefer getting water from shallow wells and swamps as reported by 26% and 10% respectively. Because of the difficulty in accessing water, most households, at the time of the survey were found to use very little water for household consumption with more than half of the respondents reporting that they consume an average of 30-40 litres per day as shown in figure 9 below. For instance, presuming that each household has an average of 6 persons, this therefore translates to 5-7 litres per person per day, which falls below the initial average recommended 15 litres per person per day. Worse still, more than half 40(80%) of the respondents admitted that they drunk untreated water with only 10(20%) saying that they either filtered or sieved water before drinking. This practice, coupled with poor hygiene and sanitation in the area predisposes the community to diarrhoeal and water borne ailments, especially during the wet season. Children are usually the first culprits of such infections and the worst hit owing to their under developed immunity and eventually succumb to effects of malnutrition. Save the children-UK which used to carry out borehole drilling and repairs in the county have so far handed over to FARM Africa. Driven by the fact that agriculture and livestock requires water, the agency intends to partner with SUPRAID to drill more and repair some of the extant boreholes using the existing water management teams. Since borehole drilling is an expensive venture, they are also exploring the possibility of empowering the community to embark on alternatives to boreholes specifically shallow protected wells, digging dams and rain harvesting. These approaches would not only ensure sustainability but would also prove to be relatively cheap when it comes to maintenance.

Figure 8 : Average daily water consumption 21 Source: Acting SRRC Gogrial West County 22 Sphere(2004) standards on water access and quantity include; Average water used for drinking, cooking and personal hygiene per person per day is 15 liters, Queuing time not more than 15 minutes, one hand pump with a flow rate of 16.6 Litres/minute for a maximum of 500 persons and safe water availability on regular basis.

21

Hygiene and sanitation practices in the representative sample surveyed in Gogrial West County seemed to be quite unsatisfactory. To begin with latrine use was rare; virtually all the households interviewed did not have access to a toilet facility, save for those that were observed in NGOs, administrative offices and in town centres. Saddening, majority of the population therefore admitted that they disposed off human waste haphazardly unmindful of the negative health repercussions it may inflict on their health. This reprehensible practice is further aggravated by the cultural belief that prohibits latrine use among the Dinka community. Similarly the stools of young children were gotten rid off by throwing outside the yard as reported by all the respondents who had children. Nonetheless, the various reactions drawn from the respondents as they tackled this question during the interviews clearly proved that they were aware that this practice was not right, thus signifying that health education has had some impact in trying to change the attitudes of this community. It is pretty good to note that majority 46(92%) acknowledged hand washing before meals with only a negligible proportion saying it was not practiced. With this not withstanding, it was observed that personal hygiene was generally not up to standard as most children presented with unclean faces and were seen eating with frowzy hands. Moreover the wild fruits were largely consumed unwashed by most people. Cooking utensils and water containers were not properly cleaned and were left in the open thus risking contamination by house flies and dogs. Poor hygiene and sanitation is linked to the prevalence of diarrhoeal infections.

.III.5. Maternal and Child care practices

Causes of malnutrition in developing countries are often characterized by complex, multidimensional and interrelated factors. Inappropriate child care practices, being one of the underlying causes of malnutrition need to be overemphasized in trying to capture the possible causes of malnutrition unearthed by the survey results. This is because children less than five years of age, in most instances are not able to perform most tasks by themselves, including eating. Their nutritional status is of particular concern since the early years in life are crucial for optimal growth and development. Expectant and lactating women are also of concern as their physiological state warrants them to consume additional nutrients to cater for the elevated requirements. Moreover, due to the inter relationship between birth weight, breast feeding and malnutrition, additional nutrients are thus essential. In Gogrial West County, just like in most parts of South Sudan this category of individuals with special needs are not exempted from the usual tedious duties; neither did they consume adequate and nutritious foods to meet their accelerated nutrient needs. Instead they were seen indulging in nerve cracking tasks such as cutting and transporting large bundles of grass, pounding sorghum among others. In the long run, they ended up depleting even the meagre nutrient reserves, as they ate only once a day. The survey results have generally vindicated satisfactory early infant feeding practices in Gogrial West community. Commendably, more than half 44(93.6%) of the mothers interviewed initiated breastfeeding immediately after birth, 45(95.7%) of whom breastfed their children on demand. Exclusive breastfeeding was highly regarded in the community as unveiled by the results. More than half 31(64.6%) of the mothers interviewed commenced weaning after six months of age which is the recommended weaning period by WHO. Thereafter, beast milk continued to form an important component of food fed to children between 6-29 months. Even though malnutrition is said not to affect milk production both in terms of the quality and quantity, most lactating mothers engaged in activities outside the home such as fetching water, firewood and grass collection, alcohol brewing hence spent very little time with the children. When they came back, they were either too tired or too busy to appropriately breastfeed their children. Unfortunately, this practice poses a risk on the nutritional status of the young exclusively breastfed children. It is a known fact that breast milk is the perfect food for infants as it contains all the necessary nutrients required for growth and development in the very initial stages of life. However, as a child develops, breast milk needs to be supplemented with other foods to take care of the increased nutrient requirements. The weaning foods apart from being palatable should be balanced so as to provide the child with the necessary growth factors. In the surveyed households the predominant weaning food mainly comprised of food eaten by everyone and was made from sorghum locally known as kuon as reported by 37(75.5%) of the respondents. This could be ascribed to the fact that it was the beginning of the dry season thus most cattle had been driven to the wet lowlands (cattle camps) locally known as toic, as such milk availability was limited as only 18(36.7%) fed their young ones on milk.

22

The frequency of feeding among the young children was greatly hampered by the limited food stocks and the involvement of mothers in other household chores outside the home. This implied that the children were either left hungry or under the care of older children who at times consumed most of the food while the young ones remained hungry or consumed very little. It was also a common practice in most households that food is served in a common bowl where both the younger and older children ate together. This practice may have negative consequences on the nutritional status of the younger children as they are unable to keep pace with the older children who eventually ate the larger portion. Nevertheless majority of the households interviewed 35(71.4%) reported that they fed their young children twice a day. These two servings are not adequate since children have small stomachs thus require small but frequent meals.

.III.6. Education

Education in Gogrial West County is currently receiving support, both from the Government and NGOs. Save the Children-UK has various educational activities within the county. They have a teacher training program whereby they do phase training and in -service teacher training which lasts for four years. Additionally, the agency also has an education management training aspect which mainly targets head teachers and supervisors at the county level whose aim is to impart them with management skills so as to improve the quality of education. There is also the intensive English course which targets the Arabic trained teachers, to enable them learn English, which is the main language of instruction. Further, the organization also runs accelerated learning program, which is a four level course fitting in the curriculum of primary 1 up to 8. The programs utilize the syllabus developed by the Sudan secretariat of Education. No school fee is charged in these learning facilities as the services are absolutely free. The agency also extends support to primary schools in terms of scholastic materials such as text books, pens, rubbers, rulers among others. During the time of the survey the agency was supporting 9 schools in Gogrial West County; one school each in Akon South, Kuac North and Kuac South payams and 2 schools each in Akon, Riau and Gogrial payams. Additionally they also engage in construction of primary schools and so far two permanent structures have been constructed each in Ajiep and Akon payams. Workshops are conducted with local education authorities who do community mobilization. NCA on the other hand supported 14 primary schools initially by giving them scholastic materials. However at the time of the survey they were only supporting 5 schools as the rest were being supported by the Government. According to the education officer, the agency also does construction of schools and is planning to begin construction of one primary school in Alek this year. The teacher training program which is intended to close once the government sets up a teacher training college in Kuajok is currently being conducted in three phases. Similarly there is also an adult literacy program in place with cookery and dress making being some of the courses offered. According to the agency, a primary school has been initiated out of it and has so far reached primary two. Non payment of salaries to some teachers by the government is posing a great challenge to the education system in Gogrial West County as reported by the agencies on ground. This has been occasioned by poor teacher regularization hence there are teachers who exist in the government payroll but do not offer services. This has caused loss of morale among the active teachers leading to poor service provision and late reopening of schools. According to the Ministry of Education calendar for South Sudan, there are supposed to be three terms every year running from April, however due to lack of water and food most schools delay in reopening. It was reported that this year schools are likely to reopen in June as opposed to April. This means that a lot of learning time is lost as the community tries to cope with the devastating effects of the hunger gap period. More over, it was also noted by the two agencies proffering education that the exercise of nationalizing positions by most NGOs has impacted negatively on the education sector. The few skilled personnel who are able to read, speak and write in English are absorbed in other sectors thus putting education sector at a halt.

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

Underneath are the different NGOs and SINGOs and their areas of interventions in Gogrial West County: ACF-USA implements targeted feeding (SFC and TFC-HT) programs in the county. A TFC and a distribution centre for the severely and moderately malnourished children respectively are operational in Alek centre. The programs that started off in May 2006 targeted 250 and 1300 patients in the TFC and SFP accordingly. The

23

program has so far registered a total of 224 and 700 severely and moderately malnourished children. The January 2007 reports indicate that there were a total of 32 and 127 children on Therapeutic and Supplementary Feeding programs correspondingly, all of whom were children below five years of age. NCA is involved in the provision of primary health care services and education activities in Gogrial West County. The health services are provided in collaboration with the Ministry of Health, whereby NCA is responsible for provision of medical and drug supplies while the Government remunerates staff. They run 1 PHCC situated in Alek South Payam and 11 PHCUs each located in Keet, Atukuel, Mandeng, Malual Ajak, Mankuac, Anguoth, Panliet, Ayuang, Malualawien, Bau, and Pakor villages. However, 4 PHCUs have been closed down since early this year due to lack of staff (CHWs). The medical assistant is in charge of the PHCC while the PHCUs are supervised by Community Health Workers (CHWs). Among the curative and preventive services proffered in the health units include, treatment of common ailments, health education, HIV/AIDS and EPI programs. These services are free save for the registration and admission fee which are 100 and 200 Sudanese Dinnars respectively. The PHCC which acts as a referral centre to the PHCUs in addition offers MCH and in-patient services with a bed capacity of 30. The organization is in the process of setting up a laboratory and for that matter, a laboratory technician has already been trained. They are also involved in training activities for the health personnel such as CHWs, TBAs, EPI and MCH staff; village health committees for PHCUs and Management committees for PHCCs. The CHWs and MCH were trained for 9 months in 2004 and had a refresher course in 2006. Plans are underway to train more MCH and CHWs in the course of the year. On education, the organization has four main activities namely; support of primary schools, school construction, teacher training and adult literacy. They initially supported 14 primary schools, however only 5 schools are currently supported through provision of scholastic materials such as books and pens among others. The other 9 schools are taken care of by the Government. The schools use the syllabus developed by Sudan Secretariat of Education (SOE) with English being the main language of instruction. One school has been targeted for construction in Alek whereas the teacher training program is intended to wind up as soon as the Government opens up a teacher training centre in Kuajok. In addition, a women centre whose aim is to curb the low enrolment and literacy levels among females, offers cookery and dressmaking lessons; this has led to the initiation of a primary school which has so far reached class two. FARM AFRICA, whose aim is to eradicate poverty by improving the livelihoods of farmers and herders in marginalized areas mainly incorporates innovative approaches in development to ensure that people live in sustainable situations using natural resources. The main program areas the agency is concerned with include animal health, agriculture, water, community development, research and policy. Animal health main activities are provision of veterinary inputs, improving productivity and disease surveillance. The agriculture component is concerned with improving farming methods, empowering local blacksmiths and encouraging dry season cropping. They also give farm inputs to vulnerable groups such as returnees and those affected by inter clan fighting. In the sector of water, the agency partners with SUPRAID to drill new boreholes, rehabilitate broken ones through the existing water management teams and also explore alternatives to boreholes such as shallow wells. Research and policy which is the key area in the organization, aims at creating models in agriculture and other sectors that are able to meet the community needs in one package. These models can in future be used for up scaling of projects by the Government and other agencies. At the moment the agency is in the process of gathering information on research and policy at Government level and sensitizing the community on policy issues. They also intend to initiate action oriented research for example that which would reduce the women work load in the community. Finally, the community development aspect tries to capture the other needs of the community which are not met by the agency’s interventions; as such models like village development committees have been initiated. SUPRAID is an indigenous organization whose main activity is drilling of new bore holes in the county. Because of their capacity, they are at times contracted by NGOs to drill boreholes. SC-UK is involved in education, HIV/AIDS and child protection programs in Gogrial West County. Under education, they have a teacher training program whose activities include; phase training, in-service teacher training, education management training, intensive English course and accelerated learning, which is a four level course targeting those aged 12-21 years. They also support primary schools in terms of scholastic materials and construction of physical facilities. They are currently supporting a total of 9 primary schools in the

24

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

06-17

18-29

30-41

42-53

54-59

BOYSGIRLSA

ge g

roup

s in

mon

th

county; one school each in Akon South, Kuac North and South payams and 2 schools each in Akon North, Riau and Gogrial payams. In addition they also conduct work shops with local education authorities who assist in community mobilization. The HIV/AIDS program is mainstreamed and integrated into the education program. WVI in Gogrial West County is operating a number of programs including food security which is currently implemented in Ajiep with the main activities being demonstration farms, ox plough training, and tree planting. The food aid program is carried out in collaboration with WFP, and they have currently moved from general food distribution (except for returnees and the vulnerable) to food for assets while in Health and Nutrition, the agency is at the moment running an SFP and one PHCC in Ajiep. UNMAS whose main responsibility is to assess and monitor global land mine threat carries out de-mining activities within the county especially around Gogrial town.

.IV. RESULTS OF THE ANTHROPOMETRIC SURVEY

A total of 642 children were measured, however due to incoherent data in four records, only 638 records were subjected to analysis.

.IV.1. Distribution by Age and Sex.

Table 2: Distribution by Age and Sex

BOYS GIRLS TOTAL Age groups (months) N % N % N %

Sex Ratio

06 – 17 68 43.9 87 56.1 155 24.3 0.8 18 – 29 74 54.0 63 46.0 137 21.5 1.2 30 – 41 47 46.1 55 53.9 102 16.0 0.9 42 – 53 61 47.7 67 52.3 128 20.1 0.9 54 – 59 60 51.7 56 48.3 116 18.2 1.1 Total 310 48.6 328 51.4 638 100.0 0.9

The table above demonstrates that there is only a slight variation between the two sexes in the sample population structure.

Figure 9 : Distribution by Age and Sex

25

There are slight imbalances in age distribution as illuminated by the diagram above, with most conspicuous imbalance appearing in age group 30-41 months where there is slight under representation by about 4.1%. Similarly in the age group 54-59 months there is some over representation of 8% more than the average of 10%. These disparities can be associated with recall bias by some of the caretakers in the two age categories. The ages recorded were approximated by use of a local calendar of events.

.IV.2. Anthropometrics Analysis

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

Distribution of Acute Malnutrition in Z-Scores Table 3: Weight for Height distribution by age in Z-scores and /or oedema (NCHS Reference)

< -3 SD ≥ -3 SD & <- 2 SD ≥ -2 SD Oedema Age group (In months) N

N % N % N % N % 06-17 155 3 1.9 33 21.3 119 76.8 0 0.0 18-29 137 0 0.0 30 21.9 106 77.4 1 0.7 30-41 102 0 0.0 8 7.8 94 92.2 0 0.0 42-53 128 0 0.0 19 14.8 109 85.2 0 0.0 54-59 116 2 1.7 25 21.6 89 76.7 0 0.0

TOTAL 638 5 0.8 115 18.0 517 81.0 1 0.2

Table 4: Weight for height vs. Oedema in z-scores (NCHS Reference)

Weight for height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiorkor 0 0.0%

Kwashiorkor 1 0.2%

Oedema NO Marasmus

120 18.8% No malnutrition 518 81.0%

Only one case (0.2%) of Kwashiorkor was found in the sample, the other cases of acute malnutrition are of the Marasmic type.

Figure 10: Weight-for-Height Z-scores distribution, Gogrial West County-2007

26

The marked dislodgement of the sample curve to the left side of the reference curve, demonstrates a poor nutritional situation of the surveyed population. The mean Z-score is 1.2 and standard deviation of 0.82 which is within the acceptable range of 0.8–1.2. Therefore, the assessed sample can be said to have been representative of the entire population. Table 5: Global and Severe Acute Malnutrition in Z-scores in NCHS and WHO references

NCHS reference WHO reference

Global acute malnutrition 19.0 % (15.3% - 22.7%)

19.0 % (15.1% - 22.8%)

Severe acute malnutrition 0.9 % (0.1% - 1.8%)

2.8 % (1.3% - 4.4%)

Distribution of Malnutrition in Percentage of the Median

Cut-offs for acute malnutrition expressed in percentage of the median are commonly used in determining admission criteria in feeding centres. Table 6: Distribution of Weight/Height by age in percentage of the median and oedema (NCHS Reference)

< 70% ≥ 70% & < 80% ≥ 80% Oedema Age groups (In months)

N N % N % N % N %

06-17 155 0 0.0 23 14.8 132 85.2 0 0.0 18-29 137 0 0.0 10 7.3 126 92.0 1 0.7 30-41 102 0 0.0 1 1.0 101 99.0 0 0.0 42-53 128 0 0.0 6 4.7 122 95.3 0 0.0 54-59 116 0 0.0 9 7.8 107 92.2 0 0.0

TOTAL 638 0 0.0 49 7.7 588 92.2 1 0.2 Table 7: Weight for height vs. Oedema in % of the median

Weight for height < 80% ≥ 80%

YES Marasmus/Kwashiorkor 0 0.0%

Kwashiorkor 1 0.2%

Oedema NO Marasmus

49 7.7% No malnutrition

588 92.2% Table 8: Global and Severe Acute Malnutrition in NCHS and WHO references in % of the median

NCHS reference WHO reference

Global acute malnutrition 7.8 % (5.4% - 10.2%)

4.1 % (2.2% - 5.9%)

Severe acute malnutrition 0.2 % (0.0% - 0.5%)

1.9% (0.0% - 0.3%)

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

All 641 children were included in the MUAC analysis.

27

Table 9: MUAC Distribution

MUAC (mm) < 75 cm height >=75 – < 90 cm height ≥ 90 cm height Total

< 110 3 2.9% 0 0.0% 0 0.0% 3 0.5% 110≥ MUAC<120 12 11.4% 2 0.9% 0 0.0% 14 2.2% 120≥ MUAC<125 9 8.6% 12 5.5% 6 1.9% 27 4.2% 125 ≥ MUAC <135 33 31.4% 59 27.2% 35 11.1% 127 19.9%

MUAC ≥ 135 48 45.7% 144 66.4% 275 87.0% 467 73.2% TOTAL 105 100% 217 100% 316 100% 638 100%

According to the MUAC criteria, 0.5% of children in the sample were severely malnourished and 2.2% moderately malnourished.

.IV.3. Measles Vaccination Coverage

The survey results indicate very low measles immunization coverage as more than half (79.0%) of those children measured had not been vaccinated against measles. Only a negligible number (3.9%) of the children had EPI cards that could be used to confirm vaccination. This attests to information gathered from NCA that most mothers fail to keep their cards safely for future use. Table 10: Measles vaccination coverage

Measles vaccination N % Proved by Card 23 3.9 According to the mother/caretaker 101 17.1 Not immunized 466 79.0 Total 590 100

.IV.4. Household Status

Table 11 below shows the household status of the surveyed population. Table 7: Household status

Status N % Residents 427 93.0 Internally Displaced 4 0.9 Temporary Residents (on transit) 23 5.0 Returnee 5 1.1 Total 459 100

The largest proportion of the surveyed population is resident in the location. The results show minimal population movement during the period of assessment with the majority having settled in the county.

.IV.5. Composition of the Households

A total of 544 households were visited during the survey. Table 8: Household composition

Age group N % Average per Household Under 5 years 698 26.5 1.3

Adults 1940 73.5 3.6 Total 2638 100.0 4.8

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.V. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

The crude mortality rate was calculated from the figures collected from all households surveyed. All the households included in the anthropometric survey were considered for mortality data regardless of whether they had children 6-59 months or not. During the survey, a total of 2638 people were present in the assessed households. Of the total population 698 (26.5%) were children below the age of five years of age. 32 people had joined the various households within the last three months while 108 had left. On the same period, 31 births had taken place while the total deaths were 14, six of whom were for children below five years. Thus the retrospective mortality rates are:

♦ The crude mortality rate is 0.58 [0.28- 0.89] /10,000/day. ♦ The under five mortality is 0.97 [0.28-1.65] /10,000/day.

.VI. CONCLUSION

Findings of the anthropometric analysis revealed GAM and SAM rates of 19.0% [15.3%-22.7%] and 0.9 %( 0.1%-1.8%) respectively in Z- score at 95% confidence interval. Analytically, the GAM rate is above the emergency level of 15% and in turn calls for integrated and inter-agency intervention to curb any further decline whereas the SAM is below the emergency level of 4%. Over the preceding three months to the survey period, the mortality rates are 0.58 [0.28- 0.89] /10,000/day and 0.97 [0.28-1.65] /10,000/day respectively for total population and the under five years old age group. Both of the aforementioned rates are below the alert levels. WVI and ACF-USA have undertaken numerous nutrition surveys in the region since the year 2004. The latest assessments were conducted in the previous year that revealed GAM and SAM rates 23.9% [95% C.I: 20.0% -28.2%] in Z-score survey done by ACF-USA assessment between February and March 2006. This yeas malnutrition rates are lower as compared to last year results, which could be attributed to impact of ACF-USA nutrition treatment program in the region. However, the current GAM rate of 19.0% [ 95% C.I: 15.3%-22.7%] in z-scores is still above emergency threshold and could be attributed to a number of multifaceted factors such as; decline in food security, disease and poor health seeking patterns, water and deplorable sanitation practices, inappropriate feeding and child care practices and insecurity. These can be summarised as follows: Food Insecurity: The food insecurity situation in the location could be attributed to various shocks such as livestock diseases, lack of appropriate and adequate fishing and farming equipment, lack of labour and human diseases. The main coping strategies adopted by most of the households were: eating fewer meals, consumption of wild fruits and vegetables, kinship support and buying using income from petty trade, sell of firewood, livestock, grass and alcohol. These may decline over time further exacerbating food insecurity and in the long run may result to adverse health and malnutrition. Disease prevalence and poor health seeking patterns: Despite free health services offered by the health agency on ground (NCA), the health seeking behaviour of the community is still wanting. Most of the community sought treatment when the disease had already progressed into serious phases. Belief in traditional healers in this community is rampant as evidenced by the presence of various magical paraphernalia as observed in most of the homes visited. This has contributed to the current rate of malnutrition as some community members seek health services as the last resort, making their bodies compromised by diseases.

29

Deplorable Water and Sanitation situation: To meet their water requirements, some of the community members fetch water for drinking and household consumption from sources such as unprotected well and swamps. Unfortunately, water from these sources is not treated by majority before drinking. This coupled with the poor hygiene and sanitation in the area, predisposes the community to diarrhoeal and water borne ailments, especially during the wet season when the waste and feacal matter is swept back into these water sources and as a results of these diseases that compromise the health status of the community members resulting to malnutrition especially the under fives. Inappropriate child care and feeding practices: Women are engaged in many household activities and thus have very little time for nurturing the children, which apparently poses a risk on the nutritional status of the exclusively breastfed children. Moreover, the weaning foods were predominantly the family meal of kuon made from sorghum while other foods such as milk and meat products were minimally consumed. This consequently leads to poor nutrient intake, and ultimately induces poor nutrition state of the children. Security and safety: The county is still believed to be mined, which limits people’s movement to certain areas. Further, the continuous episodes of inter clan fighting between the Aguok and Apuk sub clans have continuously been reported in the county since 2004 hence predisposing the local community to higher risk of food insecurity. This is because the community is forced to run for their lives thus productive time that could have been spent in tilling and preparing land for cultivation is spent either in fighting or defending the community. However, as could be observed in some of these villages, such as Mankuac and Mangok, the community was gradually coming back and had started settling and it is hoped that with time, the community will be able to bounce back to its normal livelihood activities.

30

.VII. RECOMMENDATIONS

The above emergency level GAM rate among children aged 6-59 months as depicted by the results signify a life precarious nutrition situation in Gogrial West County. This has been closely attributed to a bleak food security situation (access and availability) and diseases as well as various underlying factors discussed above. This is therefore an indicator that the causal factors responsible for the prevailing state need to be nipped from the bud before anything untoward happens. Timely interventions are thus inevitably necessary to bolster the community from the probable effects of malnutrition. Additionally reconstructive and long term measures also need to be put in place in order to prevent future recurrence of the same, and ultimately ensure that malnutrition is alleviated. The following recommendations have therefore been put forth by ACF-USA:

Food Security

To continue the food distribution to the returnees, displaced and other highly vulnerable households. To develop new strategies of food for agriculture and food for assets. Besides action oriented researches, to explore possibilities of empowering the community to initiate

livelihood activities through the village development committees. Health

To carry on with targeted feeding programs for the management of both severely and moderately malnourished children, and increase their coverage.

To maintain the existing health initiatives with special focus on MCH and EPI. Water and Sanitation

To forge ahead and implement the alternative to boreholes initiative by offering training and technical support to the community on how to dig shallow wells, dams and rain harvesting, all of which will ensure sustainability with a cost advantage.

To partner with other agencies involved in water activities to rehabilitate some of the existing dysfunctional boreholes within the county.

To support latrine construction using locally available materials and furnish the community with the required technical skills while at the same time encouraging community participation to ensure their utilization.

To enhance health and hygiene promotion activities within the county by educating the community on the significance of personal hygiene, human waste disposal and water treatment methods.

Security and safety

To carry on with the de-mining activities especially in Gogrial town and its environs which are believed to be heavily mined.

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.VIII. APPENDIX

.VIII.1. Sample Size and Cluster Determination

PAYAM BOMA VILLAGE POPULATION WALKING DISTANCES

TARGET POPULATION

REVISED TARGET POPULATION. CLUSTER

A 2HRS 769.2 192 B 192 C 192 1 Gaikou 3846

D 192 A 11/2HRS 600 200 B 200 2 Dhok 3000 C 200 A 21/2HR 540 180 B 180 Atokngar 2700 C 180 3 A 1HR 364.8 182 Areumac 1824 B 182 A 40 MINS 420 210

Ngapathian

Keem 2100 B 210 4 A 3HRS 782.2 195 B 195 C 195 5 Amom 3911

D 195 A 21/2HRS 529 176 B 176 Jongar 2645 C 176 6 A 30 MINS 760.4 190 B 190 C 190 7 Rumkwel 3802

D 190 A 2 HRS 521.4 173 B 173

Atukuel

Lur 2607 C 173 8 A 20 MINS 840 210 B 210 C 210 Marial 4200

D 210 9 A 40MINS 714.8 238 B 238 Kuruec 3574 C 238 10 A 2 HRS 456 228 Bulic 2280 B 228 A 20 MINS 326 163 11 Amoth 1630 B 163 A 5 MINS 820 205 B 205 12 C 205

Alek South

Alek

Alek 4100

D 205 A 3HRS 600 200 B 200 13 Mabiormun 3000 C 200 A 2HRS 480 240 Panachier 2400 B 240 14 A 21/2HRS 460 230 Dheng 2300 B 230 A 25MINS 290 145 15 Marialmajock 1450 B 145 A 1HR 20MINS 500 250

Malekngok

Malek 2500 B 250 16 A 11/2HRS 549 183 B 183 Mayom 2745 C 183 A 41/2HRS 640 213 17 B 213

Alek-North

Mankuac

Mangok 3200 C 213

32

A 6HRS 480 240 18 Mankuac 2400 B 240 A 5HRS 300 150 Achol 1500 B 150 A 4HRS 560 186 19 B 186 Nyokthiang Nyokthiang 2800 C 186 A 6HRS 450.4 225 20 Mayen 2252 B 225 A 41/2HRS 364 182 Ajieng 1820 B 182 A 6HRS 370 185 21

Alek-West

Alueth

Alueth 1850 B 185 A 4HRS 654.8 218 B 218 22 Agok 3274 C 218 A 4HRS 539 179 B 179 Wunriang 2695 C 179 23 A 41/2HRS 756 189 B 189 C 189 24 Mandeng 3780

D 189 A 31/2HRS 486 243 Wuntur 2430 B 243 A 2HRS 422 211 25

Gogrial Mandeng

Manalom 2110 B 211 A 5HRS 838.2 209 B 209 26 C 209 Pancier 4191

D 209 A 51/2HRS 783.4 195 27 B 195 C 195 Manyiel 3917

D 195 A 41/2HRS 922.8 230 28 B 230 C 230 Kunyuk 4614

D 230 29 A 5HRS 653.4 217 B 217

Panliet

Maluil 3267 C 217 30 A 31/2HRS 562.4 187 B 187 Riangalei 2812 C 187 31 A 51/2HRS 596.2 198 B 198 Kueec 2981 C 198 A 31/2HRS 788 197 32 B 197 C 197 Malek 3940

D 197 33 A 4HRS 873.8 218 B 218 C 218 34

Riau

Anguoth

Acibut 4369

D 218 TOTAL POPULATION 116816 23363.2 23332

The clusters were automatically generated by Nutrisurvey December 2006 after inputting the revised target population.

33

.VIII.2. Anthropometric Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No:

N°. Family N°.

Status (1)

Age Mths

Sex M/F

Weight Kg

Height Cm

Sitting Height cm(2)

Oedema Y/N

MUAC

Cm

Measles C/M/N

(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.

34

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

Survey Payam: Village: Cluster number: HH number: Date: Team number:

1 2 3 4 5 6 7

ID HH member

Present now

Present at beginning of recall (include those not present now

and indicate which members were not present at the start of the

recall period )

Sex

Date of birth/or age in years

Born during recall

period?

Died during the

recall period

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

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

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

35

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

Survey Payam: Village: Cluster number: HH number: Date: Team number:

Current HH member

Current HH members who

arrived during recall (exclude births)

Past HH members who left during

recall (exclude deaths)

Deaths during recall N

Total < 5 Total <5 Total < 5

Births during recall

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

.VIII.5. Calendar of events in Gogrial West County.

MONTHS SEASONS 2002 2003 2004 2005 2006 48 36 24 12

JANUARY PANTOK/ NYIETH

Cattle take to Toics (cattle camps)

Cut grass for thatching . James Lual raises New

Sudan flag in Alek

Signing g of CPA Gogrial town open to all

people

59 47 35 23 11 FEBRUARY

PENROW/ KOL

Winnowing sorghum for storage

Clearing farms NCA opens EPI in Gogrial West County

Spear master Mordit dies

Beginning of fight between the Aguok

and Apuk clans. NCA begins construction of

PHCC in Alek

Meningitis out break in Warrap state

58 46 34 22 10

MARCH PEN DIAK/ AKANYDIT

Clearing new farms continue

Construct tukuls Movement to water points

Alek airstrip opens

NCA opens PHCC in Bau- Aweil

Plane crashes in Aweil airstrip

ACF-USA conducts a nutrition survey in the County. SC-UK opens a training institute in

Panliet 57 45 33 21 9

APRIL PEN NGUAN/

AKANYTHI

Hunting Fishing starts

Thatching tukuls.

Cattle raiding by Muralin in Gogrial West

County. GOS fight SPLA in Tharkwen

Returnees brought from Khartoum by government.

ACF -US opens TFC IN Alek NCA opens a PHCC

in Alek 56 44 32 20 8

MAY PEN DHIECH/

ADUONG

Rains begins Cultivation of lands begins Cows brought back home

from toics. SPLA defeats GOS in

Wintur The late Dr Garang

visited Alek

ACF-USA TFC reopens in Alek

55 43 31 19 7JUNE

PEN DETEM/ ALETHBOR

Cultivation continues Weeding crops

Young men go for Ker Begin planting maize and

sorghum. SAF captures Gogrial

Town from SPLA

Relief food truck gets stuck in river Malualawien Death of Deng Kong

54 42 30 18 6JULY PEN DHOROW/

AKOLDIT

Planting maize and sorghum. Continues Weeding sorghum

Hunger gap. Machakos protocol

signed Death of Kuec Mayar-

the Executive chief

Commander Ayiang’s son dies

53 41 29 17 5AUGUST

PEN BET/ BILDIT

Men competition Weeding maize and

groundnuts Eating green maize.

Death of Dr. John Garang Salva Kiir sworn in

52 40 28 16 4SEPTEMBER PEN DHONGUAN/

BIELTHI

Harvesting season Court opens cases in

every payam Eating green sorghum.

GOS recapture Torit from SPLA

51 39 27 15 3 OCTOBER

PEN THIAR/ LAL Harvesting continues Tilling of new farms

Lino (an intellectual) dies in Nairobi and taken to Alek for

burial

50 38 26 14 2NOVEMBER PEN THIARTOK/

HORBEKLAI

Rain stops Mudding tukuls

Spear master Madut

Mell dies in Alek. ACF –USA TFC closes in

Alek

49 37 25 13 1 DECEMBER

PEN THIARKUROU / KON

Christmas time Celebration of good

harvest

38

.VIII.6. Food market prices in Alek market, Gogrial West County, February 2007.

COMMODITY

QUANTITY PRICES IN SUDANESE DINNAR

Sugar 1 Kilogram 600 Maize flour 2 kilogram 540 Beans 1 kilogram Not available Maize 1 kilogram 190 Lentil 1 kilogram 300 Beef 1 kilogram 500 Salt 50g 250 Onions 1 big bulb or 1 small bulb 100/50 Chicken 1 Medium size 600 Fresh fish 1 Medium size 1000 Charcoal Sack of 50 kilogram 1500 Goat 1 medium size 10,000 cow 1 medium size 130, 000

39

.VIII.7. Gogrial West County Map.