What are the core issues that Medair is aiming to address?

The Nuba Mountains is an area within South Kordofan State and lies outside, but adjacent to, the formal boundaries of Southern Sudan. Due to its geographical location, the Nuba Mountains were a key battleground during the southern civil war. In January 2002, an internationally monitored ceasefire was signed for this area, in advance of the CPA covering the wider conflict. Despite the signing of the CPA, the population in the Nuba Mountains area of South Kordofan remains extremely vulnerable. The area suffers from acute underdevelopment, with extremely limited access to basic services such as primary health care or clean water. The post-conflict transition in South Kordofan will face numerous challenges, such as the significant number of returnees, the merging of two existing systems of administration, the presence of uncleared landmines in many areas, and possible further crises such as disease outbreaks or a return to conflict.

Medical Services: An assessment by the Federal Ministry of Health (MoH) listed South Kordofan as one of the four most underserved states in northern Sudan. Malaria is a particular problem, especially in the rainy season, and there is a lack of routine immunisation services, especially in the former rebel areas. Reproductive health is also a key concern, with a maternal mortality rate of 552 per 10,000 live births. Data from Medair’s ongoing work in South Kordofan shows a high-level of sexually transmitted infections (especially in the Western Jebels), linked with a low level of knowledge about HIV/AIDS.
These problems are compounded by a lack of basic health knowledge within communities, and a lack of capacity among health staff to adequately diagnose and treat cases.

Water & Sanitation: Water is frequently reported as one of the main humanitarian needs in the area, with 55 percent of the population in government areas and only 20 percent in former rebel areas having access to safe drinking water. Up to 25 percent of the hand-pumps in the state are estimated to be non-functioning (sometimes due to mechanical breakdown, but often due to inadequate groundwater supplies or similar problems), and people report walking up to four hours to collect water during the dry season. Although people may access surface water during the rainy season, it is frequently dirty and polluted. Access to sanitary facilities is even scarcer than access to safe water, which clearly increases the risks of diarrhoea and related diseases. For example, only 18 percent of households surveyed in Allirri Hills have a latrine,  with some villages having no latrines at all.

Emergency Response Preparedness: South Kordofan remains vulnerable to localised humanitarian crises, such as disease outbreaks, large returnee movements (or other population displacements), and conflict. Local capacity to respond to such crises is extremely limited, and emergency preparedness and support by external actors is therefore necessary to mitigate the impacts of such events.

How is Medair addressing the problem?

Medical Services

Primary Health Care Services: Medair supports a total of 21 PHC facilities (five PHCCs and 16 PHCUs) by providing training, supervision, supply of essential drugs, and management of a Health Information System (HIS).

Malaria Control: Medair supports the implementation of the Roll Back Malaria initiative through targeted distribution of insecticide treated nets (ITNs), implementation of the MoH’s malaria treatment protocol, and ensuring correct diagnosis of suspected malaria cases.

EPI Services: Medair supports access to routine immunisations (EPI) in the Western Jebels by supporting static EPI services across the area and also through mobile outreaches.

Reproductive Health: Medair is increasing its focus on reproductive health care through staff training, awareness-raising and education, supply of specific medicines and Safe Delivery Kits for expectant mothers, and implementation of a Safe Delivery Area at a supported health facility.

Health and Hygiene Promotion: Medair encourages preventative health approaches by supporting health and hygiene promotion activities, which are provided with clinic services and also through other appropriate methods such as village volunteers, drama groups, Village Health Committees (VHCs), and village elders. Health education messages will focus on achieving appropriate behaviour change with a key focus on HIV/AIDS, nutrition (feeding habits of children under two years), and family planning.

Training and Capacity Building: Medair seeks to improve the delivery and management of health services through appropriate and targeted training. This may include on-the-job supervision and refresher training in basic skills and implementation of MoH protocols for health workers, along with courses in management for VHCs, and support for individual staff to attend specific external courses.

Emergency Response: Medair maintains an emergency response capacity to provide an initial response to likely disease outbreaks or similar health emergencies. Protocols for the most likely outbreak diseases are maintained, basic supplies are kept in stock, and staff are trained in their use.

Water & Sanitation

The following activities are mainly focused on eight targeted villages:

Access to safe water: Medair will seek to directly improve access to safe drinking water by constructing 10 new boreholes. Medair will also seek to support community maintenance of non-functioning boreholes through provision of hand-pump spare parts and supporting the established spare parts distribution centre in Alliri Hills.

Rainwater Harvesting: Medair will seek to improve access to clean water at four supported health facilities by constructing rainwater harvesting systems, such as roof gutters and storage tanks.

Watershed Management: In order to improve recharge of groundwater aquifers, Medair will support community construction of two terraces and will also survey potential sites for the construction of check dams. These structures should improve surface irrigation for agriculture and also demonstrate the benefits of techniques which were once widely practiced but have since been forgotten.

Household Filtration: In areas where typical water solutions are not viable, the community may be forced to obtain water from non-potable sources. Medair continues to make bio-sand filters available to individual households. Bio-sand filters have proven to be effective in treating the highly turbid water that is found in South Kordofan.

Hygiene Promotion: Medair will identify risk practices with regard to sanitation, and then promote alternative improved behaviour, using the health and hygiene promotion mechanisms outlined above. This promotion is particularly important to ensure a desire for and use of latrines, and to increase actual consumption of water once supply is sufficient.

Latrine Construction: Medair will support communities in the construction of 400 household latrines, through production of latrine slabs and supply of appropriate supervision and support.

Emergencies: Medair has procured  an emergency water treatment system that can be used to treat surface water or groundwater supplies, in order to provide access to safe drinking water for at least 2,500 people in the event of an emergency.

Who is Medair Assisting?

Medair’s key target population is the settled rural poor (a description which applies to the majority of the population in South Kordofan) and returnees. Most of these people are subsistence farmers, although many livelihoods also rely significantly on income received from wage labour on large mechanised farms. The situation in the three locations that Medair works in can be characterised as follows:

North East Kadugli: The population are rural poor, but benefit from their relative proximity to Kadugli, which offers opportunity for both employment and access to goods and services.. There are a growing number of returnees coming into the areas where Medair works. Although largely former government-controlled territory, the area includes nomadic encampments and villages currently controlled by the SPLM. Population in Medair’s target area is 30,000 people, served by seven health facilities.

Allirri Hills: The population are also rural poor, but suffer from being more distant from Kadugli, and hence more isolated, with a high percentage of nomads in some areas. However, as the area was government-held during the conflict, there is at least a minimal level of access to goods and services. The population in Medair’s target area is 50,000, served by six health facilities.

Western Jebels: The population are rural poor, but their isolation during the conflict means they are even poorer and less well educated than their counterparts in government-held locations. While international assistance to the area has brought some improvements, access to goods and services continues to be limited and people are more likely to be genuine subsistence farmers The population in Medair’s target area is 70,000, served by eight health facilities.

What are the core issues that Medair is aiming to address?

Prior to the current conflict, the population in West Darfur numbered around 1.7 million, with only around 10 percent in urban areas. Agricultural production in this region is variable and is closely linked to climatic factors. The region suffers from recurrent droughts and has been subject to frequent inter-tribal tensions between nomadic Arabic groups and settled farmers, even prior to the current conflict.

The Current Situation

The current open conflict in Darfur began in 2003. This conflict, with its associated destruction of villages and livelihoods, led to widespread displacement, significantly exacerbating existing problems caused by a lack of development and minimal access to basic services. It is currently estimated that more than two million people have been displaced, with a total of over four million people in need of assistance.

The current conflict situation in Medair’s project area around El Geneina in West Darfur can be interpreted as having at least four interlinked layers:

• A wide, regional conflict between government, militias, and rebels concerning issues of political marginalisation and underdevelopment;
• Local disputes, often between tribes, concerning issues such as access to water or grazing rights;
• Cross-border conflicts, with political destabilisation in Chad resulting in rebel groups operating across borders, cross-border attacks, and refugees flowing into Sudan;
• General lawlessness and common banditry.

This mix of dynamics has resulted in a progressive deterioration in the security situation over the past year, and has been characterised by: increased banditry and criminality; attacks on humanitarian workers; fragmentation of rebel groups, with a breakdown in command and control; continued harassment and assault of certain ethnic groups and IDPs; continued attacks on villages and IDP camps; and cross-border raids between Sudan and Chad and more recently the Central African Republic (CAR).

The DPA (Darfur Peace Agreement) signed in May 2006  did not have the desired effect of providing a political solution that would lead to peace and stability in Darfur and has remained widely unpopular. Meanwhile, the presence of African Union (AU) peacekeepers in West Darfur has also failed to result in significant improvements in security for much of the civilian population. The AU is generally acknowledged as under-resourced for the task in hand.

In August 2007 the decision was made to deploy a so-called ‘hybrid’ mission (combined AU and UN operation). Although the need for improved peacekeeping in Darfur is widely acknowledged, given the time it would take for deployment. and the argument that any successful peacekeeping mission would also need to be based on a viable peace agreement, it is unlikely that there will be any significant improvement in the impact of peacekeeping operations in Darfur in the foreseeable future.

Specific Needs

Medical Services: Although attack rates for malaria and bloody diarrhoea across Darfur in 2006 have been slightly lower than at equivalent times in 2005, the health situation remains extremely fragile, as evidenced by a number of outbreaks, such as meningitis and measles in West Darfur .

The referral system for secondary health care is under extreme pressure, as insecurity has limited the use of ambulances and puts a high risk on using commercial trucks. Consequently, there is an urgent need to maintain a high level of primary health care in rural areas throughout the state. Reproductive health remains of particular concern. It was noted as a key need prior to the current conflict, and there continue to be reports of Sexual and Gender Based Violence (SGBV). A recent survey indicated that over 50 percent of IDPs have no knowledge of HIV/AIDS.

Water: While the water situation in West Darfur has always been precarious, problems have been exacerbated during the current conflict, and recently compounded by a lack of humanitarian access due to insecurity. The water table has dropped during the dry season, and concerns have been raised that over-drawing from boreholes may have permanently affected some deep aquifers. . There is an urgent need to find solutions that will provide sufficient access to clean water, especially for large population concentrations, without affecting long-term sustainability of water sources. Problems with the groundwater supply means that many people rely on unclean surface water sources, which can be linked to the high occurrence of waterborne diseases. Open water sources such as hand-dug wells need improvement, and some existing hand-pumps and water systems are now in need of repair or rehabilitation.

Sanitation: Although not a feature of traditional life in many rural Darfuri villages, access to latrines along with their proper usage is essential to ensuring the health of populations living in camps or larger settlements. Consequently, there is a need both to construct sufficient latrines, and to promote their correct usage. Hygiene promotion is an essential part of both water and health interventions to aid in disease prevention.

How is Medair addressing the problem?

Medical Services

Support For Primary Health Care: Medair supports at least 20 primary health care facilities by providing supervision, staff training, a reliable drug supply, and a framework for a Health Information System. Medair also maintains the capacity to launch a response to health emergencies such as disease outbreaks, and to provide up to six emergency clinics in the event of displacement or returns. To increase the sustainability of services, Medair is working closely with the Ministry of Health (MoH), and will also seek to train and support Village Health Committees (VHCs) to engage in the management of health facilities.

Reproductive Health: Medair is introducing and maintaining access to the Minimum Initial Service Package (MISP) in all its supported health facilities. This includes ongoing training and supervision of health staff and midwives, including HIV/AIDS awareness, provision of Safe Delivery Packs for expectant mothers, provision of contraception and post-rape treatment, and construction of a further two Safe Delivery Areas.

Public Health Promotion: Medair will continue to present public health promotion messages to patients at clinics and to communities at the household level, supporting the activities of both the health and the water & sanitation sectors. These messages will be provided by a total of around 1,100 promoters (community based volunteers), who will receive regular support and follow-up visits. Refresher training will be provided for around two-thirds of an existing 900 volunteers and 30 coordinators, and initial training will be provided for a further 190 new promoters.

Water & Sanitation

Water Supply: Medair is maintaining water systems supplying 130,000 conflict-affected people. Although Medair is phasing out emergency systems such as water bladders and plastic tanks, the systems that are still in place require continued maintenance. In order to make hand-pump maintenance more sustainable, Medair will train around twenty more pump mechanics. Medair will maintain the capacity to deploy up to six emergency water systems in the event of crises (consisting of two tanks connecting a jetted water point with 30 taps), serving a maximum of 25,000 affected people. Medair will rehabilitate existing and build new hand-dug wells, fitted with hand pumps.

Sanitation: Medair is seeking to improve access to sanitation among displaced or recently returned communities through the direct construction of  2,100 household latrines.  Medair also maintains the capacity to construct up to 900 emergency latrines in the event of sudden crises.

Hygiene Promotion: Recognising the critical importance of effective hygiene promotion in ensuring good sanitation practices, Medair combines the promotion activities of both the health and the water and sanitation sectors. Medair also supports the regular clean-up of El Geneina town, implemented through Community Based Organisations (CBOs) such as youth groups and women’s unions.

Who is Medair Assisting?

Medair assists over 210,000 conflict-affected people, including IDPs, refugees, non-displaced, and potential or actual returnees. This work is in 20 locations across four localities in West Darfur state (El Geneina, Kulbus, Habila, and Zalingei). These locations include four IDP camps, one refugee camp, villages with large IDP concentrations, and non-displaced but conflict-affected villages.

With the humanitarian situation in the IDP camps around El Geneina town now relatively stable, Medair is seeking to focus its support on rural areas, where populations are already more vulnerable and where additional services are needed for emergencies such as outbreaks and new displacements or, possibly, returns.  Although most of the displaced are from “African” tribes (Zaghawa, Massaleit, etc), many nomadic communities are also in need, and Medair will seek to extend assistance to those communities as well.

Country Background

The south of Sudan was devastated by the cumulative effects of Africa’s longest running civil war, recurrent famine, economic sanctions, lack of investment and development, and general poor governance. Approximately two million people died, four million people became Internally Displaced Persons (IDPs), and up to eight million people in the south were without access to basic services such as health care and education.

Other areas of the country, away from the capital, also suffered from chronic neglect, lack of investment, and poor governance. In the western region of Darfur, these grievances led to the onset of a rebellion in late 2002. With attempts at both political and military solutions failing, the conflict rapidly grew, resulting in hundreds of thousands of deaths and millions of people being driven from their homes.

Despite the Comprehensive Peace Agreement (CPA) ending the southern civil war in 2005, insecurity and conflict continued in the west. The Darfur Peace Agreement (DPA) signed 5 May 2006 does not include all parties to the conflict, and did not result in a significant improvement to the situation on the ground.

Presence of Medair in Sudan

Medair first worked in South Sudan in 1992, and has had a continuous presence there since 1995, as a member of OLS (Operation Lifeline Sudan). Medair has endeavoured to develop its operations in South Sudan by targeting areas that no other NGO has been operating in, with an increasing focus on effective emergency response. In order to be able to respond equally to needs in the northern states of Sudan, Medair registered as an NGO with the Government of Sudan in February 2000. Medair commenced operations with a PHC Centre in Omdurman El-Salaam IDP Camp, just outside Khartoum, in June 2000.

Medair has worked in West Darfur since 2001, and currently has a large-scale relief program in response to the present crisis there. Medair’s experience in “pre-conflict” Darfur, supporting a widespread primary health care project in a situation of chronic underdevelopment, is particularly relevant to the emerging situation in South Kordofan, where direct conflict has ceased but there is virtually no development occurring.
Medair has been operational in the Nuba Mountains area of South Kordofan since 2003, with a cross-line project that operates in both GoS and former rebel-controlled areas. Medair’s presence and experience in the area meant it was well-placed to respond effectively to the outbreak of yellow fever that occurred in October and November 2005.