- The Darfur conflict is considered the worst humanitarian crisis in the world today.
- Although the delivery of humanitarian assistance has improved, continued insecurity has resulted in increased population displacement.
- UNICEF has achieved the majority of its 90 Day Plan targets but coverage remains inadequate, in comparison to the current needs of conflict -affected population.
1. OVERVIEW
The conflict in Darfur continues to be considered the worst humanitarian crisis in the world today. It is characterized by persistent low intensity conflict and widespread displacement. Population estimates from August indicate that there are approximately 1,498,802 conflict affected residents in Darfur. Of this total, approximately 1,227,460 are internally displaced (326,422 in South Darfur, 398,773 in North Darfur and 502,265 in West Darfur) and close to 271,342 are now host communities.
In early 2004, the conditions facing displaced communities were acute. In addition to being victims or witnesses to violent conflict, IDPs lost or left behind property, valued civil infrastructure such as health facilities and schools as well as income generating schemes, livestock and farmland. Families gathered in areas of high concentration for safety and security, becoming dependant upon humanitarian aid. High mortality rates associated with disease and malnutrition indicated inadequate access to food; health services; clean water and sanitation facilities. International intervention was limited, not only by the degree GoS facilitated travel, but by insecurity and a lack of capacity on the part of humanitarian organisations.
In order to provide a more coordinated approach, the UN, INGOs and NGOs developed the 90 Day Humanitarian Action Plan for Darfur. The plan set concrete targets for aid delivery during the period of 1 June to 31 August 2004 in the programmatic sectors of Food, Shelter and Non-Food Items, Health, Nutrition, Water and Sanitation, Education, Agriculture and Protection. UNICEF was appointed Sector Coordinator in the areas of WES, Nutrition and Education and became the focal point for Child Protection and Primary Health Care, within the larger Protection and Health Coordination groups, respectively. Within each sector, UNICEF developed internal service delivery targets for the 90 Day period.
Now, at the close of the 90 Day Plan, following the relaxation of visa, travel and customs restrictions by the GoS, and the arrival of additional implementing partners, significant achievements in the delivery of humanitarian aid have been made. The striking commonality across sectors however is that although UNICEF and partners have achieved most of the 90 Day Plan target goals, the coverage for vulnerable communities remains inadequate in comparison to the actual needs of the affected population.
Continued fighting, banditry and general insecurity have resulted in additional displacements, meaning that the number of conflict affected persons has increased. As progress was made, needs also grew, thus increasing the target population. In some cases, the populations of camps and other sites have fluctuated on a weekly or daily basis, thus complicating the collection of definitive population figures for site specific planning.
In addition, geographic distribution of aid has been unequal. Access to vulnerable communities has been constrained not only by GoS restrictions, but by insecurity and seasonal constraints. In July, 17% of the population was deemed inaccessible by UN Security (14% for North Darfur, 36% for South Darfur and 0% for West Darfur). Expanding coverage into isolated areas remains a pressing priority, but is still, of course, dependant on reliable routes for transport during the rainy season.
Finally, although the number and capacity of implementing partners is improved, there is still insufficient capacity in comparison with the scale of the conflict and the growing needs of the population, in every sector. Humanitarian organisations are no longer constrained by government visa and registration restrictions, but continue to be conservative in their plans as a result of limited funding and the challenges associated with establishing operations in remote regions. 1
2. INTERVENTIONS IN HEALTH
90 DAY TARGETS IN PRIMARY HEALTH CARE
Health Facilities
UNICEF Target: 100 Primary Health Facilities
Progress: 127 established (supported by UNICEF)
Total Beneficiaries: 957,000
Partners: SMoH and SC-UK /US, GOAL, IRC, GHF, HAI, ROUT, MDM, MSF-CH/H/F, MEDAIR, IARA, SUDO, SP/SRC,GOAL, WVI, NCA, UNICEF
Vaccination Campaigns
Measles Target: 2,260,000 Children Vaccinated with Measles: 2,023,000 vaccinated in accessible areas
Polio Target: 1,031,342
Polio Progress: 1,011,463 children in accessible areas (approximately 97% coverage)
Target for SLA-controlled area: 50,000
Preliminary Results: 16,752 children vaccinated in the first geographic sector of the campaign.
Tetnus Toxoid Target: 22,000 pregnant women
Estimate Reached: approximately 18,000
Overview
Access to primary health care facilities for displaced and host communities in Darfur has improved significantly. The UNICEF 90 Day Plan called for the establishment of 100 fixed or mobile health facilities by the end of August. At present there are 145 health centres operating in Darfur. Of this number, 127 primary health care facilities (92 PHC Clinics, 15 mobile teams and 20 OPD Clinics) are supported by UNICEF. Approximately 10 dispensaries are also supported by UNICEF. UNICEF support may be in the form of essential drug kits, medical equipment, technical support and/or allowances and training to mobile teams. At the drafting of the 90 Day Plan in May, the conflict affected population was 1.1 million people and the coverage for primary health care stood at 43%. Now, at the end of the 90 day period, the conflict affected population sits at just under 1.5 million persons and the approximate coverage (to be confirmed) is around 65-70%.
This achievement is significant but a gap of approximately 35% remains and this figure is likely to change if the affected population continues to rise. As of 20 August, some 73 of 127 recognized settlements had access to Primary Health Care. Approximately 15 of these health care facilities were considered inaccessible for UN staff due to security restrictions at some time during the reporting period. Expansion of health facilities into un-reached and isolated regions will be a priority in the coming period.
Building the capacity of health workers and mobile teams is also a priority, as is strengthening and expanding the mechanisms for monitoring of facilities. In West Darfur in August, for example, health monitors made 44 observations at 37 different facilities, out of a total of 59 existing facilities. This number indicates that some health facilities remain un-monitored during a one month period due to insecurity or logistical constraints. A full time UNICEF public health specialist has been assigned to work with three MOH support teams in the states to improve the monitoring system.
From the data collected in August for West Darfur, 90% of observations indicated that facilities were stocked with essential drugs. Some 90% of observations showed that Ante Natal Care was available for mothers. Unfortunately, only 63% of the observations found a functional refrigerator or cold chain system and 59% showed availability of vaccines, thus underlining the need to strengthen routine EPI.
Key UNICEF Achievements during the 90 Day Plan
Access to many communities has been blocked by insecurity and by the need to negotiate for entry into areas of SLM/A and JEM control. Campaigns for polio and measles vaccination have provided an entry point for increasing access to these vulnerable areas. Following successful interagency negotiations (UNICEF, OCHA, WHO, WFP) in Asmara with senior SLM/A-leadership, UNICEF, WHO, and the Ministry of Health targeted an estimated 50,000 children (aged 0-59 months) with polio vaccination in several locations of North Darfur, most controlled by the SLM/A. Training of SLM/A- identified vaccinators and medical assistants commenced on 22 August while pre-positioning of supplies started 25 August. The first phase of the campaign began on 28 August with full support and commitment from community leaders and substantial social mobilization despite great logistical challenges.
Preliminary results indicate that approximately 6101 children were vaccinated in the Muzbat region, 4048 in Dissa, 5721 in Hashaba and 882 in Baashim. Results are still arriving from other teams and they are expected to push the total close to 23,000 children vaccinated. In addition to EPI activities, UNICEF, WHO and WFP are also distributing high protein biscuits, school tents and primary health care kits for major hubs.
The Darfur-wide measles campaign was completed on 27 June with 2,023,000 children vaccinated. This figure represents 89 percent of the target, set at 2,260,000. UNICEF participated in the strategic planning, supervision and monitoring of the campaign as well as procured and transported 3,900,000 doses of vaccines and adequate quantities of cold chain and logistics equipments to sites in Darfur. UNICEF also provided approximately two thirds of the operational costs. As has been previously noted, an estimated 500,000 children were left out of this measles campaign due to inability to enter SLA/M and JEM controlled areas. The recent launch of the polio campaign in SLA/M and JEM controlled areas has provided a platform for the start of a special catch-up campaign for measles vaccination, in the same areas, during the first weeks of September, targeting approximately 150,000 children in the state.
Recent measles surveillance studies show a significant decrease in measles morbidity and mortality, following the June campaign. Reported cases of measles in Darfur dropped from 310 cases reported in May, to 67 in June, 10 in July and 17 in August. There were no reported deaths from measles in July or August. In the coming months it will be ascertained if this drop signifies a definite trend, but these preliminary results are promising. Vitamin A supplementation, administered in conjunction with measles, was given to approximately 540,000 children aged 6-59 months. .
Polio Sub-National Immunization Days were introduced in the three Darfurs, following the reporting of five new cases of Polio in Sudan, (one in West Kordofan, one in West Darfur and three in South Darfur). Final results of the first round of polio campaigns show that 1,011,463 children were reached. UNICEF has also provided the vaccines for this campaign, and has shared the operational costs with WHO. Adding these achievements to the recent totals from the first round of the SLA campaign in North Darfur, we can estimate that over 1,028,215 have been vaccinated for polio in Darfur.
Routine EPI must be strengthened in general, but especially for the administration of Tetnus Toxoid vaccinations. UNICEF continues to provide the routine vaccines for all EPI programs. Unfortunately, as is commonly the case, the special vaccination campaigns have detracted from the success of routine immunization activities. In North Darfur several vaccination sessions have been cancelled due to security constraints, lack of staff capacity and/or social mobilization. In West Darfur, UNICEF and the MoH are dispatching extra vaccination teams to work through mobile clinics to do acceleration drives. At present, updated figures for TT coverage in Darfur are unavailable, but it is estimated that approximately 18,000 pregnant women have been immunized. Between May and 20 August, 14 cases of neonatal tetanus (NNT) were reported in West Darfur, with 6 deaths.
3. INTERVENTIONS IN NUTRITION
90 DAY TARGETS IN THE NUTRITION SECTOR
Sector Target: 24 Therapeutic Feeding Centres (TFC) Progress: 30 TFCs established Sector Target: 24 Supplementary Feeding Centres (SFC) SFC Progress: 30 SFCs established
Partners for SFC/TFCs: ACF, CARE, Concern WW, CRS, GOAL, MoH, MSF-F, MSF-H, MSF-CH, MSF-Spain, MSF-B, NCA, SC-UK, SC-US, TearFund, UNICEF, WVI
Revised target: 35 TFCs/CTCs and 35 SFCs. The original targets expressed in the plan are no longer adequate to cover the nutritional needs of children in Darfur.
Overview and Analysis
The 90 day plan for nutrition interventions aimed at setting up 24 TFC and 24 SFC in Darfur, covering a total population of 4,400 and 31,000 respectively. To date, 30 TFCs and 30 SFC have been established. These centres have since April 2004 admitted 8,094 children in TFCs and CTC and 30,712 children in targeted SFCs. These figures should be interpreted as achievements but not coverage since it is not known how many children have become malnourished following the first surveys on which these estimates of global acute malnutrition (GAM) were based. The GAM may have risen during this period, and thus the target population would also increase, decreasing any current estimation of coverage. Nevertheless, this clearly indicates that the number of children reached has already exceeded the 90 Day target.
Eleven NGOs namely, MSF-F, MSF-H, GOAL, Concern WW, SC-US, ACF, CARE, SC-UK, MSF-CH, MSF-B and MSF-Spain have already implemented nutrition programs in the three states of Darfur. Three additional NGOs namely TearFund, World Vision, and NCA have plans to open selective feeding programs. In the last two month, ACF, SC-UK, MSF-H have expanded and opened additional programs to improve coverage. The Nutrition sector is coordinated by UNICEF. An MOU between WFP and UNICEF however, has given WFP the pivotal responsibility of providing food for targeted and blanket Supplementary feeding. UNICEF in turn, has the responsibility of providing food for TFCs, equipment for SFCs, TFCs and surveys, and specialized treatments and/or micronutrient inputs required for both supplementary and therapeutic feeding. UNICEF also provides technical support, guidance and training to nutrition partners. In late May 2004, all partners received orientation, manuals and reference materials on managing severe acute malnutrition.
Unfortunately, due to increased population displacement, combined with irregular and inadequate food distribution and the prevalence of disease related to sanitation and hygiene, the targets set by the 90 Day Plan in June are no longer adequate to cover the needs of the population. A revised projected need for food and nutrition interventions was calculated at the end of July, based on a population of 1.2 million. Taking an average of 20% children who are expected to be moderately malnourished and 3% severely malnourished, it is believed that the total number of children in need of supplementary feeding could be 42,000, while approximately 7,000 children are in need of TFP. These estimates are approximate however and may change through time due to the planning of additional nutritional surveys and the dynamic situation on the ground.
Based on this rough projection, with double the recommended number of beneficiaries in TFC (200 per centre), a total of 35 TFC are be required to cover the entire population and equally the same number of SFCs. Strategies to increase coverage has been developed and this includes community level screening, and the adoption of the Community Therapeutic Care model, which adopts a public health approach to manage acute malnutrition at community level, and maximize coverage, early detection and treatment.
The Performance of Programs
Standardized reporting systems have been instituted for monitoring trends in admissions, discharges, deaths, defaulters and the general performance of the TFCs and SFCs. Analysis so far has been based on 50% of the centres that have complete and current information. In TFCs, the objective is to have 70% of the children leaving the centre cured from malnutrition, less than 3% death rates and less than 15% defaulter rates. In SFCs, there should ideally be at least 80% cured rates, less than 5% death rates and less than 10 % defaulter rates.
Analysis of the functioning centres and programs has revealed some disturbing indicators. For TFCs, only 50% of the centres have achieved a cure rate of 70% and above. Similarity, the length of stay (the period it takes for a child to fully recover and be discharged) ranged from 17 days to 58 days, which is longer than the recognized average of 3-6 weeks. It appears that less children are fully recovering than normal and they are also taking longer to do it. Mortality rates and defaulter rates in four of the TFCs were also above the norm. These findings must be further investigated and addressed. Very high defaulter rates were indicated in Kass, Kalma, Kabkabiya, Tawila, Abushouk and Nyala. This phenomenon may be linked with inadequate food distribution as mothers abandon feeding programs to line up for general distribution. WFP has been approached about introducing distribution for mothers at the centre.
Challenges of Coordination
UNICEF, as the Nutrition Coordinator, hosts weekly meetings in the field and bi-weekly meeting at the Khartoum level, in order to gather information, plan and coordinate actions. UNICEF also serves as the focal point for the production of the comprehensive sector report which brings together the progress of all implementing partners in management of TFCs and SFCs. Although a standardized reporting system has been instituted for monitoring trends, timely collation of this information needs to be enforced. In addition to the NGO and MOH nutritionists, UNICEF has nutritionists in all field offices to facilitate coordination, as well as a Khartoum level Nutrition Coordinator. WFP also has one Nutrition Coordinator in place and one additional Field Nutritionist to be based in North Darfur. NGOs have representation at both field and Khartoum level.
Coordination is not only required within the nutrition community, but with agencies and sectors focused on Health, Food Distribution, Water, Sanitation and Hygiene. The advent of the rainy season introduced increased incidence of dysentery, acute respiratory infection, acute watery diarrhoea and malaria. The high prevalence of these diseases can contribute to a rise in malnutrition, and subsequently manifest itself in increased SFC/TFC admissions. Inadequate or irregular food distribution also impacts the slide from moderate malnutrition into severe.
Coordination with WFP is essential to monitoring, anticipating and resolving potentially adverse trends. In July, UNICEF and WFP recognized that since general food distribution was initially limited or irregular, there was a need to implement a Blanket Supplementary Feeding Program to prevent moderately malnourished children from sliding into severe malnourishment. WFP is reviewing its pipeline to ascertain if they have adequate inputs to cover the entire population under 5 years old. In the meantime, blanket feeding programs have been implemented by SC-UK, SC-US, ACF and MEDAIR in various locations.
Key Achievements
Of great significance to coordination this period was the finalization and circulation of a draft Guideline for Nutrition Surveys, developed by UNICEF and the MOH. This guideline should facilitate the standardization of all surveys and enable partners to begin independent monitoring activities. In the past few months, priority has been given to rapid assessments followed by life saving activities and very few surveys were conducted. However, the importance of data for advocacy and monitoring can not be understated.
During June-August 2004, a number of assessments and proper nutrition surveys were conducted in El Geneina town, Zalinge, Kabkabiya and Nertiti by MSF-Epicentre, Mesteri, and Arara by TearFund. All the surveys used 30x30 cluster sample methods except in Arara and Mesteri where systematic sampling were used. The rate of Global Acute Malnutrition (GAM) ranged from 10.2% in Arara to 26. 5% in Nertiti, both in West Darfur. In Arara, Mesteri and Zallingi, the prevalence indicates a serious situation although the rates are not as high. Continued support is required to bring the levels down to acceptable level. A high prevalence of disease and inadequate food rations have been cited as the main cause of the high levels of malnutrition.
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