South Sudan:WHO IS WHERE, WHEN, DOING WHAT (4WS) IN MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT 2018

South Sudan

WHO IS WHERE, WHEN, DOING WHAT (4WS) IN MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT2018

MHPSS Network South Sudan

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Coordination Koen Sevenants (IOM)Report written by Koen Sevenants (with inclusion of existing analysis from IOM and IMC)Reviewers Olivia Headon, Esubalew Wondimu (IMC), Jospeh Mogga (WHO), Ismahan Ferhat (UNICEF)Photos Olivia Headon, Ashley McLaughlin (IOM)Design Megan Kirby (IOM)

For further information, please contact Koen Sevenants, chair of the MHPSS Technical Working Group South Sudan: ksevenants@iom.int

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South Sudan

WHO IS WHERE, WHEN, DOING WHAT (4WS) IN MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT2018

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This report was prepared by the MHPSS Technical Working Group of South Sudan. The objective of this report is to facilitate the exchange of information among MHPSS actors in South Sudan and to provide orientation to external stakeholders.

We would like to express our gratefulness to several people in South Sudan who played a key role in information gathering and processing. These include the coordinators and information management officers of the protection cluster, the child protection sub-cluster, the GBV sub-cluster, the education cluster and the health cluster. We also send our appreciations to the information management unit and the program support unit of IOM, who always where there for advice and hands-on assistance. Also, without the advice and guidance of the team of MHPSS.net and the people of the global MHPSS reference group this report would not have been materialized. Our sincerest gratitude. Finally, we would like to thank the following donors who realize the importance of MHPSS in this humanitarian crisis: USAID and UKaid.

acknowledgements

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Acknowledgements 4

List of Abbreviations 6

Executive Summary 7

Introduction 10MHPSS Coordination in South Sudan 10Contextual Information and MHPSS Background in South Sudan 12Map of South Sudan 12South Sudan Country Statistics 12Socio-political context 12South Sudan Mental Health System 14Prevalence of Mental Health Disorder 15Migrants, Refugees and people on the move 16Earlier MHPSS Assessments and Mapping Activities 17The 4Ws MHPSS Mapping Exercise 18Methods and the 4Ws Mapping Process 18

Findings 21Concentration of services by activity type 22Concentration of activities on the IASC MHPSS intervention pyramid (nationwide) 24Concentration of activities on the IASC MHPSS intervention pyramid by state 25Reported Activities per Category 26Availability of MHPSS Services by County 27

Challenges & Recommendations 29

References 31

Annexes 33A: Detailed MHPSS activities in South Sudan 34B: Data collection Excel form 35C: Total MHPSS providers per state 36D1: Services by MHPSS Activity 37D2: Organizations by IASC Layer 40E: Actors currently active in MHPSS in South Sudan 42F: 2018 MHPSS 4W Overview Report 43G: Summary 2017 MHPSS exercise 44

table of contents

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IASC Inter-Agency Standing CommitteeIMC International Medical CorpsINGO International Non-Governmental OrganizationIOM International Organization for MigrationMH Mental HealthMHPSS Mental Health and Psychosocial SupportMHPSS WG Mental Health and Psychosocial Support Working GroupMoH Ministry of HealthNGO Non-Governmental OrganizationNNGO National Non-Governmental OrganizationOCHA United Nations Office for the Coordination of HumanitarianPHC Primary Health CarePSS Psychosocial servicesPTSD Post-Traumatic Stress DisorderUN United NationsOFDA Office of Foreign Disaster Assistance PS Psychosocial SupportWHO World Health Organization

aBBREVIATIONS

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EXECUTIVE SUMMARY

This report was prepared by the MHPSS Technical Working Group of South Sudan. The objective of this report is to facilitate the exchange of information among MHPSS actors in South Sudan and to provide orientation with external MHPSS stakeholders.

This mapping is based on the Inter Agency Standing Committee (IASC) MHPSS 4Ws (IASC, 2012) tool.1

More than six years since independence, South Sudan remains one of the world’s most insecure and fragile countries.2 Forced migration due to conflict and other crises results in a high number of internally displaced people (IDPs) seeking protection in United Naitons Mission in South Sudan (UNMISS) PoCs and collective centres or creating informal settlements. Displacement trends across geographic regions remain dynamic, and in 2017 are affecting groups across the Equatorias, WBeG, and the Greater Upper Nile region. The number of individuals displaced by the conflict has reached record levels; with around 4 million people uprooted by the end of October 2017 including more than 1.9 million internally displaced persons (IDPs) within South Sudan and more than 2.1 million people who had fled the country as refugees.3 More than 300,000 IDPs are seeking refuge at existing PoCs and other displacement sites across the country.4

Whilst the health system as a whole in South Sudan is in a deeply worrying state, mental health services offered by the Government remain practically non-existent. There is a strong shortage of trained mental health professionals. While mental health data from South Sudan is limited, one post-conflict study from Juba found that 36 per cent of the sampled population (n=1242) met criteria for post-traumatic stress disorder (PTSD) and 50 per cent for depression.5 The main causes of psychological issues that have been identified are loss of loved ones, conflict and violence and protection issues (kidnapping of children, orphaned children due to violence, early marriage), health, Gender-Based Violence (GBV) and environmental issues, including food insecurity.

The data that was collected came from 3 sources: a 4W workshop, data reported to the clusters and sub-clusters and outreach to partners which carry out relevant MHPSS work but do not report to clusters. In this procedure two main challenges were encountered: (1) Some INGO do not report to clusters and also were not responsive to repeated requests for information; (2) There are more organizations or institutions that are relevant for understanding MHPSS in South Sudan that do not report to clusters.

Eighty nine organizations have been identified as deliverers of MHPSS programmes. The 89 organizations submitted 1068 entries. The states with the highest amount of agencies active in MHPSS are Upper Nile and Jonglei, while Western Bahr el Ghazal and Abyei have the lowest amount. The activities that are mostly delivered fall under the catergory “strengthening community and family support”. 6.7 per cent of activities that were reported in the mapping exercise fell in the IASC pyramid in the layer “social consideration in basic security”. Community and family support counted for 70.4 per cent. Focused, non-specialized services covered 13.9 per cent and the remaining 9% are specialized services.

The 2018 4Ws mapping has— among others— the following shortcomings:

• Psychological First Aid is used by many NNGOs as an important strategy in providing psychosocial support. However, the PFA activities of actors are not mapped since different clusters held different interpretations in which level PFA belonged in the MHPSS pyramid.

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• The database systems, the activities and their codes are different from (sub-)cluster to (sub-) cluster. The teams have spend considerable effort in creating the linkages between the systems, but still these are not perfect.

The MHPSS TWG would like to make the following recommendations:

• For clusters coordinators and clusters we reccomend establishing a common set of MHPSS-related activities and indicators against which partners report.

• Overall, in recent years there have been very little systematic MHPSS assessment done in South Sudan. There is very little secondary data available. To direct more targeted MHPSS services, we recommend to all actors to engage in assessments share data. The MHPSS TWG is very willing to provide assistance in this matter.

1 IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings. (2012). Who is Where, When, doing What (4Ws) in Mental Health and Psychosocial Support: Manual with Activity Codes (field test-version). Geneva.

2 OECD States of Fragility, 20153 OCHA South Sudan: Humanitarian Bulletin, October, 20174 IOM South Sudan, Displacement Tracking Matrix Biometric Registration, October 2017.5 Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-conflict mental health needs: a cross-sectional survey of trauma, depression and

associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009; 9: 7.

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IntroductionThis mapping is based on the Inter Agency Standing Committee (IASC) MHPSS 4Ws (IASC, 2012) tool6. This 4Ws tool for MHPSS is useful for the following:

• Providing a big picture of the size and nature of the MHPSS response• Identifying gaps in the MHPSS response to enable coordinated action• Enabling referral by making information available about who is where, when, doing what• Informing appeal processes• Improving transparency and legitimacy of MHPSS through structured documentation• Improving possibilities for reviewing patterns of practice and for drawing lessons for future response.

MHPSS Coordination in South SudanIn June 2016, a Mental Health and Psychosocial Support (MHPSS) Coordination Group was formed in South Sudan following a mission by the IASC Global MHPSS Reference Group. The purpose of the MHPSS coordination group was to bring together in one forum all the stakeholders working in the area of MHPSS with the view to enhancing the response to MHPSS needs of affected persons in the Republic of South Sudan, and thus improving their access to quality services and support.

In the beginning of 2018, a second mission of the IASC took place. The functioning and structure of the MHPSS working group was rebooted. After intense consultation with all stakeholders, an agreement was reached to work in a structure with two platforms: (1) An MHPSS Technical Working Group and (2) an MHPSS Network.

Mental Health and Psychosocial Support Technical Working GroupThe purpose of the Mental Health and Psychosocial Support Technical Working Group (MHPSS TWG) is to provide technical support to a network of actors in South Sudan and raise the quality and coverage of MHPSS services for the population affected by the conflict in South Sudan. This will be done by convening service providers to exchange, learn and benefit from technical guidance in delivering within their respective mandate areas. The network will prove support to a broad range of members including through existing cluster based mechanisms at a technical level7.

The objectives of the MHPSS TWG in South Sudan are:• Improve the design and delivery of MHPSS interventions in South Sudan as part of humanitarian

response • Promote safe and effective MHPPS service approaches, consistent with global standards • Convening partners to learn and exchange on how they are adapting and implementing according to

global standards • Consolidating information on the situation of Mental Health and Psychosocial Wellbeing as well as

service delivery across south Sudan, to support gap analysis, coordinated response, and advocacy for resource allocation to MHPSS actors

• Linking actors with the global resource groups including Global MHPSS reference group and Child Protection Area of Responsibility (CP AoR)/ MHPSS reference group deployable and remote support

INTRODUCTION

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The technical working group is comprised of one UN agency, one INGO and two national partners from Gender Based Violence AoR, Child Protection AoR, General Protection Cluster, Health Cluster and Education Cluster. Each group selected four members through respective coordination processes with a total of 20 members overall. Where possible, one of the national partners for health be from the relevant department of the ministry.

MHPSS NetworkMembership of the MHPSS network is intentionally open, to ensure the greatest reach to promote standards and safe practice, and also in recognition of the critical and sustainable role national actors play in service delivery. As such, the MHPSS network tentatively consists of all actors active in MHPSS service delivery in South Sudan.

6 IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings. (2012). Who is Where, When, doing What (4Ws) in Mental Health and Psychosocial Support: Manual with Activity Codes (field test-version). Geneva.

7 Terms of Reference of the MHPSS TWG, 2018.

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Population 13,026,000 (2017 est.)Capital JubaUrban population 19,3% (2017 est.)

Socio-political contextMore than six years since independence, South Sudan remains one of the world’s most insecure and fragile countries10. South Sudan is politically unstable and has been subject to ongoing conflict since late December 2013, following the onset of civil war between forces loyal to president, Salva Kiir, the Sudan People’s Liberation Army (SPLA), and those supportive of former first vice president Riek Machar, the Sudan People’s Liberation Movement in Opposition (SPLM-IO)11.

In August 2015, the government of Salva Kiir and forces loyal to Machar entered into a binding peace agreement the “Agreement on the Resolution of the Conflict in the Republic of South Sudan” (ARCSS). Machar returned to Juba as First Vice President of South Sudan in April 2016, launching the official formation of the Transitional Government of National Unity (TGoNU). However, significant conflict broke out in the capital,

MoroboKajo-Keji

LainyaYei

Juba

Terekeka

MagwiIkotos

KapoetaSouth

BudiTorit

KapoetaNorth

LafonKapoeta

East

Awerial

Yirol

WestWulu

RumbekEast

Cueibet

RumbekNorth

RumbekCentre Yirol

East

AweilSouth

AweilCentre

AweilWest

AweilNorth

AweilEast

Panyijiar

Mayendit

Leer

Koch

Mayom GuitRubkona

Abiemnhom

Pariang

Tonj

South

Tonj

East

Tonj

North

GogrialEast

GogrialWest

Twic

Wau JurRiver

Raga

Maridi

MundriWest Mundri

EastIbba

Yambio

NzaraMvolo

Ezo

Tambura

Nagero

BorSouth Pibor

TwicEast

Pochalla

Duk Uror Akobo

Ayod

Nyirol

CanalFangak

Ulang

MaiwutNasir

Longochuk

Panyikang

Malakal

Baliet

Fashoda

Melut

Manyo

Renk

Maban

SUDAN

CENTRALAFRICAN

REPUBLIC

DEMOCRATICREPUBLIC O FTHE CONGO

ETHIOPIA

KENYA

Abyei

UGANDA

Refugees 296,748 IDPs 1.76 million8

Official Religion None, Christianity widespread9

Contextual Information and MHPSS Background in SOUTH SUDAN

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Juba, between SPLM-IO and SPLA forces in July 2016. The violence, which left over 270 people killed, served to underscore the fragility of the ARCSS and highlighted ongoing tensions between belligerents. In March 2017, the Human Rights Commission and the Special Adviser on the Prevention of Genocide warned that the indicators for genocide were in place.12

In April 2017 a National Dialogue process commenced, aiming to promote peace, unity, reconciliation and national identity, in order to build consensus and implement reforms called for by the ARCSS. The following month, Salva Kiir declared a unilateral ceasefire across the country in preparation for the proposed reconciliation initiative. In June 2017, the Intergovernmental Authority on Development (IGAD) endorsed the creation of a High Level Revitalization Forum (HLRF) aimed at reviving and implementing the stalled 2015 ARCSS through a restoration of the permanent ceasefire, full implementation of the original peace agreement, and an implementation of the original timetable to allow for elections in 201813.

Despite this dividends from these processes have yet to be realized and conflict has continued across the country. Throughout 2016 and 2017 there have been large-scale Government offensives in Jonglei and Upper Nile, and in previously stable areas such as the Equatorias and Western Bahr el Ghazal (WBeG). There have been attacks on civilians and civilian property by armed actors, forced conscription of male youth (including from within PoC sites), appalling rates of sexual and gender-based violence (SGBV), and neglect of those with identified vulnerabilities14. In Greater Upper Nile, continual political manoeuvrings and attacks on civilians have occurred particularly along the Nile River, including in Wau Shilluk and close to the Malakal PoC, while clashes and resulting population displacements continued throughout the year outside of Bentiu in Unity, around Yuai and Waat in northern Jonglei, and in Maban and Maiwut in Upper Nile15. In the Greater Bahr al Gazals, intercommunal conflict spiked in Warrup and Lakes while deeply-rooted communal tensions and continued clashes around Wau led to largescale displacements into protection sites within Wau town, and displacement and access denials led to a humanitarian crisis in the areas without. In the Greater Equatorias, major incidents of violence and displacement occurred around Mundri, Torit, Lopa Lafon, Ikotos and Magwi and Kajo-Keji town.

The political conflict exacerbates existing ethnic and intercommunal conflict as preferences of state structures toward a single community turned a localized dispute into a component of the national conflict. Particularly in Lakes, Jonglei, Warrap and Western Bahr el Gazal. Groups involved in clashes are often given clandestine support from rival political and military elements.

South Sudan’s abundant natural resources remain largely untapped. According to the World Bank, South Sudan is the most oil-dependent country in the world, accounting for around 60 per cent of gross domestic product and 98 per cent of exports16. Livelihoods are concentrated in low productive, unpaid agriculture and pastoralists work, with 85 per cent of the working population engaged in non-wage work. Youth comprise 70 per cent of the population17 and more than half of them are unemployed18.

The impact of the conflict continues to have deep economic and social consequences for a country where human development is already among the worst in the world19. Oil production disruptions, suppressed domestic production of goods and services, discouraged foreign investment, hyperinflation and below-average agriculture production have put the country on course for an economic collapse. The extreme poverty rate has increased to 66 per cent. On 20 February 2017 localized famine was declared in Leer and Mayendit counties in Unity. However, it is expected that by early 2018, 5.1 million people—48 per cent of the total

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population—will be severely food insecure across South Sudan20.

National and state economic, legislative and judicial structures remain fragile and undeveloped. South Sudan has one of the world’s highest levels of corruption21. There has been minimal Government investment in community services and development and the country is experiencing a collapse of basic services provided to communities, particularly in remote areas. Only 43 per cent of health facilities remain functional and there is a chronic lack of essential medicines and qualified staff22.

Rates of malaria, cholera and measles have increased each year of the conflict, including a long-running cholera outbreak since 2016. It is estimated only 41 per cent of the population have access to safe water, and access to natural resources has contributed to inter-communal violence in certain areas.

Humanitarian service delivery is increasingly hampered and disrupted by active conflict in areas of greatest need, bureaucratic and physical access impediments, threats to safety and security of humanitarian actors, and logistical constraints. There were 729 humanitarian access issues reported between January – August 2017, and insecurity or direct threats cause frequent relocation24. Humanitarian activities continue to be dependent on UNMISS security movements and planning, while UNMISS are also under threat in some locations. NGO partners are at high risk and some have been affected during implementation of the NGO Act of 201625. There are cases of PoC-specific access impediments, such as intimidation and harassment of organizations26. The underdeveloped or maintained transport network means 60 per cent of the country is inaccessible by road during the long rainy season. River ports remain in poor condition, and barge movements are risky.

SOUTH SUDAN’s MENTAL HEALTH SYSTEM

South Sudan’s health care structure consists of different levels of health facilities that correspond with the way the country is divided into different authorities. At the national level there is one teaching hospital, located in Juba.

South Sudan’s territory is divided into ten states. The states are further divided into 79 different local government authorities, referred to as ‘counties’.26 The County Health Departments (CHDs) are responsible for primary health care services In total there are 7 state hospitals and 27 county hospitals.

The counties are further divided into payams, which consist of a number of bomas. Bomas are the lowest administrative authority and consists of a number of villages. The County Health Departments (CHDs) are responsible for the management of primary health care services for the payams, bomas and villages. On the level of the boma there are primary health care units (PHCUs) which deliver basic primary care.27 However, Few communities in South Sudan live in reach of the even most basic health care services.28

Whilst the health system as a whole in South Sudan is in a deeply worrying state, mental health services remain practically non-existent. The Juba Teaching Hospital is the only public medical facility that provides psychiatric care. The availability of psychotropic drugs is inconsistent and limited. Even when the drugs are available, families can rarely afford them, particularly for long-term use. While some patients travel from across the country to access treatment in Juba, the cost of travel and the low awareness of services available make this an unrealistic option for the vast majority of those in need of care. Individuals with mental health conditions are often health in prisons.

Also, there is a strong shortage of trained mental health professionals. There are only two practicing psychiatrists in the country, both of whom are in Juba and neither of whom see patients on a full-time basis. The inadequate number of mental health professionals in South Sudan is due in part to the limited

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opportunities for training in mental health in the country. There is no specialized training available in psychiatry, or counselling.

In its 2006-2011 Health Policy, the Government of Southern Sudan indicated that it saw mental health as an essential component of public health. Mental health is also included in South Sudan’s Basic Package of Health Services, which provides service norms and standards to primary health care service managers and providers at the Village, Boma, Payam, County and State levels. Until now, Mental health care services have not been integrated into the primary health care system. Consequently, the service delivery of MHPSS services is until today almost completely in hands of UN agencies, INGOs and NNGOs.

Prevalence of Mental Health DisorderS

The World Health Organization estimates that in humanitarian emergencies, the percentage of people with common mental disorders such as depression or anxiety disorders can double from a baseline of 10 per cent.to about 20%, while severe mental disorders such as psychotic disorders, which are more rare, can increase by 1 per cent over the baseline of 2–3 per cent.29 In addition, persons who are marginalized and with various disabilities (people with hearing, visual and movement disabilities, with intellectual impairment and with epilepsy) are often neglected or have no caregivers, and/or lack access to services.30

The Health Cluster Bulletin (December 2014) while identifying the need for mental health services states that 30 per cent to 50 per cent of total outpatient consultations in the Malakal PoC and Mingkaman IDP camp consist of people with mental health problems. There are also concerns that there may be under-reporting of people with mental illness either due to lack of identification by health facility staff or failure to seek help by patients/families.31 This is illustrated in the following observation made by one of the international NGO staff in Awerial; “Mental health is the Hippopotamus in the water” - what is seen is only a small part of what is really there. For e.g. one woman committed suicide and only after that did people say she had a mental problem. People do not recognize that such people need medical attention. While mental health data from South Sudan is limited, one post-conflict study from Juba found that 36 per cent of the sampled population (n=1242) met criteria for post-traumatic stress disorder (PTSD) and 50 per cent for depression.32

A study, conducted in northern Uganda and South Sudan, found the prevalence of PTSD was 46 per cent among South Sudanese refugees and 48 per cent among South Sudanese who stayed in the country.33 Another study that combined data from rural and urban settings and used diagnostic interviews (rather than only symptom rating scales) PTSD only was found in 331 (28%) and depression only in 75 (6.4%) of the study population. One hundred and twelve (9.5%) of the participants had PTSD-depression comorbid diagnosis. Exposure to traumatic events and socioeconomic disadvantage were significantly associated with having PTSD or PTSD-depression comorbidity but not with depression. Participants with a comorbid condition were more likely to be socioeconomic disadvantaged, have experienced more traumatic events, and showed higher level of psychological distress (PD) than participants with PTSD or depression alone.34 The estimated rates of generalized anxiety disorder (GAD) only and PD-only (without comorbidity with PTSD) were 5.5 per cent and 3.1 per cent, respectively. Exposure to traumatic events and socio-economic disadvantage were significantly associated with having one or more anxiety diagnoses. After controlling for age, sex, rural/urban settings, and socio-economic disadvantage, exposure to trauma was independently associated with anxiety diagnosis. There were gender differences in the pattern of risk factors for having PTSD, GAD or PD.35 Anxiety, substance abuse, and substance abuse-related complications such as alcohol withdrawal are also frequently seen in post-conflict settings.36 Alcohol and drug abuse is a growing concern in South Sudan as increasing social freedom and access to alcohol and drugs bring increased risk for excessive use and harmful consequences.37 These studies indicate a high prevalence of mental illness in South Sudan as well as the potential for an increase in psychiatric disease as more refugees and internally displaced persons return home.38

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psychchological issues

On collation of information that was reported in the International Medical Corps rapid assessments (Maban, 2013, Awerial and Malakal 2014) and collected during the field visit (February 2015; interviews with 13 PHC staff in Juba, Maban, Malakal, Awerial; 1 FGD with 13 community health workers in Malakal), the following stressful circumstances were cited as most common and can increase the risk of developing mental health problems:• Loss of loved ones: Having family members killed as a result of the violence or death of family members

due to physical illness• Conflict and violence: domestic violence, cattle raiding, tribal conflict, past experience of violence or

armed conflict, killing or torture of children • Protection issues: kidnapping of children, orphaned children due to violence, early marriage • Health/GBV issues: spread of STDs • Environmental issues: Overcrowding, food insecurity, risk of floods

Toxic stress has led to a very high prevalence of moderate to severe depression. Emotional resilience is getting increasingly eroded. Normalization of violence has taken place on a very large scale. Loss of loved ones without proper opportunities to mourn and not knowing the whereabouts of loved ones is leaving deep emotional scars. Very frequent critical incidents are feeding trauma and PTSD. The lack of control that people have over their lives – especially in the PoCs- has led to a high degree of learned helplessness: whatever they do, it does not matter. The whole society is suffering, but some groups are particularly vulnerable: apart from the emotional problems mentioned above, children cannot complete certain developmental tasks, they are often deprived of their rights such as going to school or simply to play. An estimated one million children are suffering from severe emotional distress. Harmful practices, such as child marriage and child labor also commonly affect them. This humanitarian crisis will have an impact for the rest of their lives. Also, the specific psycho-emotional needs of people with a disability are hardly taken into account. The remarkably high amount of people with epilepsy do not receive appropriate assistance. The WHO estimates that not less than 4 per cent of the population –or 20,4000– people suffer from grave mental health disorders, including psychosis, severe depression and disabling forms of anxiety disorders). All of this is leading to levels of suffering, anger and frustration that are not conducive for peace building in society and for prevention of gender based violence (GBV).

MIGRANTS, REFUGEES AND PEOPLE ON THE MOVE

South Sudan has 6,000 km of international borders, neighbouring Central African Republic (CAR), Democratic Republic of the Congo (DRC), Uganda, Kenya, Ethiopia and Sudan. There are 20 identified, official border crossings with Ethiopia, Kenya, Uganda and the DRC. The final sovereignty status of the Abyei Administrative Area is still pending negotiations. Mobility is a common phenomenon in South Sudan and used for community building, for kinship and intertribal marriages, as well as to pursue livelihoods and in response to a range of expected or unexpected threats. People, particularly youth, continue to move internally and across borders to pursue education and employment opportunities. Increasingly, people move to re-join families who have already migrated. Large annual migrations by semi-nomadic pastoralists such as the Misseriya, and Rizeigat between South Sudan and Sudan have been a driver of conflict in northern parts of the country. Weather conditions trigger seasonal human and livestock migration in the search for adequate water sources. 39

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Forced migration due to conflict and other crises results in a high number of internally displaced people (IDPs) seeking protection in UNMISS PoCs and collective centres or creating informal settlements. Displacement trends across geographic regions remain dynamic, and in 2017 are affecting groups across the Equatorias, WBeG, and the Greater Upper Nile region. The number of individuals displaced by the conflict has reached record levels; with around 4 million people uprooted by the end of October 2017 including more than 1.9 million internally displaced persons (IDPs) within South Sudan and more than 2.1 million people had fled the country as refugees.40 More than 300,000 IDPs are seeking refuge at existing Protection of Civilian Sites (PoC) and other displacement sites across the country. 41

Most IDPs live outside of Camp Coodination and Camp Management (CCCM) assessed sites, including with host communities in remote areas.42 The complex crisis has pushed people into areas that are not traditionally part of broader kinship or community ties, and these differences can impact social integration. Host communities in South Sudan continue to share resources and space but the scale of displacement affects the already limited availability of community services, and natural resources including water. Government-assisted relocations have occurred across Greater Upper Nile particularly in parts of Melut, Malakal and Baliet counties. The protracted and multiple crises means that the needs of IDPs and host communities continues to grow more complex. The motivations, intentions and experiences of people are different and mobility into and out of PoCs and other displacement sites remains fluid, according to the seasons and location and intensity of the conflict, and as people try to maintain connections to land and property. However, the overwhelming majority of IDPs seeking protection in these locations continue to cite insecurity as the reason for their displacement.43

International migration to seek refuge in regional countries is increasingly seen as a safer option than internal displacement, particularly in areas with minimal UNMISS presence and where cross border networks exist. An increasing number of informal settlements have been established in border areas as people seek to remain close to their properties but within proximity to safety if conflict escalates. Insecurity in neighbouring countries particularly DRC, CAR and Sudan affects and sometimes prevents populations seeking international protection. South Sudan experiences high levels of informal migration through porous borders, particularly as community and ethnic groups often transcend officially demarcated borders. The conflict continues to affect data collection regarding mixed migration flows consisting of refugees, asylum-seekers, economic migrants and smuggled persons from, to or transiting South Sudan. Large inward cross-border flows of migrants seeking economic employment and investment opportunities are mostly from Ethiopia, Eritrea, Somalia and Uganda although the conflict has affected this. Refugee populations in South Sudan are mainly of Sudanese origin, living in camps in Upper Nile, Unity and Central and Western Equatoria. South Sudan is an origin and destination for men, women, and children subjected to forced labour and trafficking, and is rated as Trafficking in Persons (TIP) Tier 3. 44

Earlier MHPSS Assessments and Mapping ActivitiesIn 2017, an MHPSS 4Ws exercise was carried out in which 32 organizations participated. The data was collected through direct contact between the MHPSS working group coordinator and the organizations. The MHPSS TWG of 2018 did not endorse the 2017 exercise for publication since the limited number of organizations could not represent the whole MHPSS landscape. Notwithstanding, the exercise of 2017 does provide some valuable information for interpretation of the outcomes of the 2018 exercise. These will be discussed in the next chapters. A summary of the report of the 2017 exercise can be found in annex G.

6 At the time of writing, this report is bein renegovciated. Numbers of refugees and IDPs extracted from UNHCR.org.9 South Sudanese religion information extracted from Encyclopedia Brittanica, 2017.10 OECD States of Fragility, 2015.11 The analysis fo the sociopolitical context was provided by IOM Migration Crisis Operational Framework 2018-201912 Report of the Commission on Human Rights in South Sudan, 34th Session, 27 Feb. to 24 Mar, 2017. A/HRD/34/63.13 United States Institutes of Peace, South Sudan High Level Revitilization Forum, 2017.

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Methodology of the 4Ws Mapping ProcessThe following steps were taking in the MHPSS 4W mapping process in South Sudan:1. Agreeing with the MHPSS TWG on the scope and process of 4W, taking into account lessons learned from

the previous mapping exercise (2017).2. Exploring the possibility of using the mhpss.net online tool and conversation with key people in the MHPSS

RG to select the right methodology. The mhpss.net tool was deemed not feasible because internet access is limited in South Sudan. In this regard, the South Sudan MHPSS TWG recommends to mhpss.net to make the tool also available in an offline version: organization fill in the information off line and upload it to the system.

3. A four-day workshop was organized in Juba. On day one, all members organizations of the health cluster, protection cluster, education clusters, child protection sub-cluster and GBV sub-cluster were invited to receive a refresher training on MHPSS basic principles and on the MHPSS 4W mapping tools and processes. On the following days, each cluster came with their members for half a day to input their MHPSS 4W data in the excel sheet. IOM made 18 computers available for those who did not have a laptop. Five people who received in-depth training on 4W were present to assist the participants in the process, as well as two computer technicians.

4. In the meantime, we worked with the information Management Officers (IMOs) of the respective clusters to incorporate the MHPSS data that their member organization reported to the (sub-) cluster. For that, we needed to somehow marry the database and coding used in the clusters with the MHPSS classification and coding. When for each cluster the marrying mechanism were clear, the IMOs submitted all the member’s data to the MHPSS TWG. For those organizations for which we had data available from the workshop and from the IMOs from te clusters, we prioritized the data from the workshop.

5. The MHPSS TWG reached out to a number of member who were known to have a vital position in the MHPSS landscape in South Sudan but were not members any cluster, e.g. Juba University, Juba teaching hospital, etc.

6. The MHPSS TWG reached out to those partners whose information was unclear or doubtful.7. IOM compiled and processed all data. A total of 1,068 Excel lines/entries were collected. A first draft of

outcomes of was present to the MHPSS TWG. Based on their inputs revision took place.8. A one pager with MHPSS essential information was presented by the MHPSS TWG members in their

respective clusters together with recommendations. The MHPSS TWG coordinator also presented the outcomes to the ICWG for advocacy purposes to increase the presence of MHPSS aspect in the Humanitarian Needs Overview (HNO) 2019.

9. Based on questions received during the presentations, the current full report was compiled.

The 2018 4Ws mapping has following shortcomings:• Psychological First Aid is used by many NNGOs as an important strategy in providing psychosocial

support. However, the PFA activities of actors are not mapped since different clusters held different interpretations in which level PFA belonged in the MHPSS pyramid.

• The database systems, the activities and their codes are different from (sub-) cluster to (sub-) cluster. The

The 4Ws MHPSS Mapping Exercise

19

teams have spend considerable effort in creating the linkages between the systems, but still these are not perfect.

• Preparations have started for the MHPSS mapping exercise of 2019. In 2019, all information will be collected through the clusters, with some outreach to partners that do no report to clusters. The process of streamlining activity classifications and codes is taking place and PFA will be integrated. There will be no workshop in which organizations can input their data.

14 South Sudan Protection Cluster, Protection Trends, february 2017; UNMISS Human Rights Report on Violations and Abuses of International Human Rights Law and Violations of International Humanitarian Law in the Context of the Fighting in Juba, South Sudan, January 2017.

15 REACH, Situation Overview: Deisplacement in Upper Nile State, South Sudan, January-February 2017; REACH, Upper Nile, Assessment of hard to reach areas in South Sudan, February 2017; IOM Conflict Analysis, 2016-2017.

16 World Bank, 201617 South Sudan’s HDI value for 2015 is .418, positioning at 181 out of 188 countries and territories18 World Bank 2014c19 World Bank 201620 Integrated Food Security Phase Classification. IPC Global Alert: South Sudan. November 2017.21 The Transparency International Corruption Perceptions Index (CPI) for 2016 gave South Sudan a score of 11 and a ranking of 175 out of 176

countries and territories assessed. The CPI rates countries by the perceived levels of corruption in the public sector on a scale of 0 (highly corrupt) to 100 (least corrupt).

22 Many Health Pooled Fund (HPF) supported facilities closed in 2016 due to funding challenges.23 OCHA HRP, 2017; p. 23a24 OCHA South Sudan: Humanitarian Access Snapshot, August 201725 The NGO Act of 2016 requires all NGOs operating in South Sudan to register with the Registrar of the Relief and Rehabilitation Commission

(RRC).26 OCHA, BAI June 2017, p. 3327 Integrating mental health services into primary health care in South Sudan: a case study, HNTPO, Dec. 201528 Analysis below this point is derived from “Our hearts have gone dark, the mental health impact of South Sudan’s conflict. Amnesty

International, 201629 World Health Organization & United Nations High Commissioner for Refugees (2012). Assessing Mental Health and Psychosocial Needs and

Resources: Toolkit for Major Humanitarian Settings. Geneva: WHO, 201230 The analysis presented in this chapter is taken from: ” International Medical Corps South Sudan Baseline Mental Health Situational Analysis

March 2015.31 South Sudan cluster Bulletin #34, December 21, 2014.32 Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-conflict mental health needs: a cross-sectional survey of trauma, depression and

associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009; 9: 7. 33 Karunakara UK, Neuner F, Schauer M, Singh K, Hill K, Elbert T, et al. Traumatic events and symptoms of post-traumatic stress disorder

amongst Sudanese nationals, refugees and Ugandans in the West Nile, Afr Health Sci. 2004; 4(2): 83-93. 34 Ayazi et al. What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? a cross-

sectional community study in South Sudan BMC Psychiatry 2012, 12:17535 Ayazi et al. Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community

study in South Sudan BMC Psychiatry 2014, 14:636 de Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003; 361(9375): 2128-3037 King. Alcohol a Growing Problem in South Sudan. Voice of America. 200638 Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders. Maithri Ameresekere, MD, MSca and David C.

Henderson, Mda. This document was originally published in two parts the South Sudan Medical Journal in volume 5 number 1 and number 2.39 The analysis of “Migrants, Refugees and people on the move “was provided by IOM Migration Crises Operational Framework 2018-201940 OCHA South Sudan: Humanitarian Bulletin, October, 201741 IOM South Sudan, Displacement Tracking Matrix Biometric Registration, October 2017.42 IOM Conflict Analysis 2016 – 2017. REACH, Greater Equatoria Assessment of Hard-to-Reach Areas in South Sudan, Jan 2017.43 IOM Displacement Tracking Matrix, Site Profiles (Bentiu, Malakal, Wau PoCs), Flow Monitoring Analysis (Bentiu, Wau PoCs); Intention and

Multi-Sectoral Needs Analysis, various 2017.44 The U.S Department of State defines Tier 3 countries as: Countries whose governments do not fully meet the minimum standards and are not

making significant efforts to do so.

20

21

findings

number and type of organizations

In the mapping exercise 89 organizations have been identified as deliverers of MHPSS programs. The 89 organizations submitted 1068 entries. A cross check in submissions through the different cluster and sub-clusters shows that all organizations involved in MHPSS are also in other sectors (general health, GBV, child protection, education, etc.) No agency is exclusive dedicated to MHPSS. Also, most national NGOs have a very divers project portfolio and are active in many clusters and sub-clusters.

concentration of MHPSS activities per state

CentralEquatoria

EasternEquatoria

Jonglei Lakes Northern Bahr el Ghazal

Unity Upper Nile Warrap Western Bahr el Ghazal

WesternEquatoria

Abyei Not Indicated

National Organizations

International Organizations

52

85

21

70 85 40 120 8811

17 63

413

23

0

106

6

49

147

38

47

22

concentration of services by activity type

Disseminating information to the community at large

Facilitating community mobilization

Strengthenting community/ family support

Safe spaces

Psychosocial support in education

Enhancement of social/ psychosocial support

Person-focused psychosocial work

Psychological intervention

Clinical management of mental disorders

Professional management of mental disorders

General MHPSS-related activities

63

30

290

179

127

42

80

91

38

35

93

Raising awareness on mental health and psychosocial support (e.g., messages on positive coping or on available mental health services and psychosocial support)

Information on the current situation, relief efforts or available services in general

Dissemenating information to the community at large

Other

56%

6%

38%

Facilitating conditions for community mobilization, organization and ownership; community control over emetgency relief in general

Support for communal spaces/ meetings to discuss, problem-solve and plan action by commnuity members to respond to the emergency

Support for emergency relief that is initiated by the community

Strengthening parental/ family support systems

Support for social activities that are initiated by the community

Strengthening community and family support

Structured recreational or creative activities (does not include child-friendly spaces)

Facilitation of community supports to vulnerable populations

Strengthening parenting/ family supports

Structured social activities (e.g., group activities)

Early childhood development (ECD) activities

Facilitation of indegenous, traditional, spiritual or religious support, including communal healing practices

The graphs below show the subcategories of these 11 activities:

87%

13%

31%37%

10%

8%7% 5%

1%

1%

23

Other

Child-friendly spaces

Safe spaces Psychosocial support in education

Psychosocial support to classes/ groups of children/ learning spaces

Psychosocial support to teachers/ other school personnel

Other

Orientation of or advocacy with aid workers/ agencies on including psychosocial considerations in programming

Other

Supporting including social/ psychosocial consideration in protection, health services, nutrition, food aid, shelter, site planning, water and sanitaion

Linking vulnerable individuals/ families to resources (e.g., health services, livelihood assistance, community resources) with follow-up

Psychological First Aid (PFA)

Person-focused psychosocial work

Other

Basic counselling for individuals

Basic counseling for groups or families

Psychological intervention

Individual or group psychological debriefing

Interventions for alcohol/ substance abuse problems

Psychotherapy

Other

14%

33%

35%10%

7%

26%

44%

30%

73%

27%

54%30%

16%

19%

81%

1%

24

Clinical management of mental disorders by non-specialized mental healthcare providers (e.g., PHC, post-surgery wards)

Action by community workers to identify and refer people with mental health disorders, including follow-up

Pharmacological management of mental disorders by nonspecialized healthcare providers

Individual or group psychological debriefing

Other

Clinical management of mental disorders by-specialized mental healthcare providers (psychiatrists, psychiatric nurses, psychologists)

Non-pharmacological management of mental disorders by specialized mental healthcare providers

Pharmacological management of mental health disorders by non-specialists

Other

Inpatient mental healthcare

Concentration of activities on the IASC MHPSS intervention pyramid

Most organizations carry out a range of MHPSS activities. 6.7% of activities that were reported in the mapping exercise felt in the layer “social consideration in basic security”. Community and family support counted for 70,4%. Focused, non-specialized services covered 13.9% and the remaining 9% are specialized services.

Since CCCM and WASH actors were not included in the mapping exercise, it is very likely that the layer “social consideration in basic security” is underrepresented in this graph.

Focused, non-specialized supports

7.5%

Community and family supports

70.4%

Specialized services

6.7%

Basic services and security

13.9%

37%

40%

17%

6%

45%

26%

26%

3%

of activities

of activities

of activities

of activities

25

concentrations of MHPSS activities by state

Specialized Services

Focused, Non-Specialized Supports

Community and Family Supports

Basic Services and Security

Central Equatoria

Western Equatoria Eastern Equatoria

Jonglei Warrap Unity

Northern Bahr el Ghazal Western Bahr el Ghazal

Lakes Upper Nile

59.1%

24.8%

8.8%

7.3%

4.4%

4.4%

86.8%

4.4%

0.9%

67.3%

24.5%

7.3%

100%

8.4%

79.6%

6.8%

5.2%

36.4%

54.5%

9.1%

7.1%

4.7%

75.1%

13%

50.9%

27.3%

14.5%

7.3%

91.3%

6.5%

2.2%

62.2%

3%

11.9%

22.6%

Abyei Special Administrative Area

100%

26

reported activities per category

Strengthening Community and Family Support

Safe Spaces

Psychosocial Support in Education

General Activities to Support MHPSS

Psychological Intervention

Person-Focused Psychosocial Work

Supporting Social/ Psychosocial Considerations in Protection, Health Services, Nutrition, Food Aid, Shelter, Site Planning, Water or Sanitation

Facilitating Conditions for Community Mobilization, Ownership or Control over Emergency Relief in General

16.8%

11.9%8.7%

7.5%

5.9%

3.9%

27.2%

3.6%3.3%

2.8%

8.5%

Dissemenating Information to the Community At-Large

Clinical Management of Mental Disorders by Non-Specialized Mental Healthcare Providers (e.g., PHC, Post-Surgery Wards)

Clinical Management of Mental Disorders by Specialized Mental Healthcare Providers (e.g., Psychiatrists, Psychiatric Nurses, Psychologists)

27

MHPSS Services available

MHPSS Services unavailable

availability of mhpss services by county

28

29

challenges & recommendations

Overall, the procedure that the MHPSS TWG selected to gather data for the 4W data collection did not present major obstacles. Notwithstanding, there are some issues that might have caused minor flows in the picture presented in this report. There is in general an over usage of the term “counseling” which might have led to over reporting of activities in the IASC pyramid level 3 and 4. Where possible this has been corrected. Also, in the method that was selected to PFA was not properly registered. This is due to the fact that clusters do not report this activity, and as such we could not integrate it in our database.

In the database, we only included activities that are currently being implemented. Past activities have not been taken into account, which at moments led to irritation of partners who recently ran out of funding. The data that was collected came from three sources: a 4W workshop, data reported to the clusters and sub-clusters and outreach to partners from which we know that they do relevant MHPSS work but do not report to clusters. In this procedure two main challenges were encountered: (1) Some INGO do not report to clusters and also were not responsive to repeated requests for information. (2) There are more organizations or institutions that are relevant for understanding MHPSS in South Sudan that do not report to clusters nor did we reach out to them. These include the numerous churches of various denominations. Various studies have shown that the church is an important institution that help them cope with stress and emotional difficulties. Yet, their counseling work is not mapped in this 4W.

recommendations

It has been our intention to work towards a 2019 mapping exercise in which a workshop for data gathering would not be necessary. It is for this purpose that in 2018 the MHPSS TWG started a series of trainings in various locations across South Sudan to ensure a common understanding of all MHPSS terms across all MHPSS actors. At the same time, the MHPSS TWG like to make the following recommendations:

• For clusters coordinators and clusters IMOs: set out a common set of MHPSS-related activities and indicators against which partners report.

• For MHPSS.net: consider installing a function that would make the 4W reporting tool available off line, and in which data can be uploaded when partners have completed the filling in of their 4W data. This would make the tool suitable for countries where there are locations with instable internet.

• Overall, in recent years there have been very little systematic MHPSS assessment done in South Sudan. There is very little secondary data available. To direct more targeted MHPSS services, we recommend to all actors to engage in assessments share data. The MHPSS TWG is very willing to provide assistance in this matter.

Humanitarian work is a joint effort that involved many partners with different capacities and specializations. To maximize the positive impact of our work, coordination among all partners is necessary. We hereby would like to call to those organizations that did not share information in 2018 to clusters or the MHPSS TWG for cooperation in 2019.

30

31

references

Ayazi et al. Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan BMC Psychiatry 2014, 14:6

Ayazi et al. What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? a cross-sectional community study in South Sudan BMC Psychiatry 2012, 12:175 de Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003; 361(9375): 212830.

Encyclopedia Brittanica. (2017). Retrieved from https://www.britannica.com/place/South_Sudan http://www.hrw.org/news/2012/06/21/south‐sudan‐arbitrarydetentions‐dire‐prison‐conditions International Medical Corps MH Situational Analysis May 2013

Rapid Mental Health Situational Analysis, Maban Refugee Camps, South Sudan, International Medical Corps. April 2013

IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings. (2012). Who is Where, When, doing What (4Ws) in Mental Health and Psychosocial Support: Manual with Activity Codes (field test-version). Geneva. Retrieved from https://app.mhpss.net/resource/ who-is-where-when-doing-what-4ws-in-mentalhealth-and-psychosocial-support/

Inter-Agency Standing Committee (IASC). (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. Retrieved from https://app.mhpss. net/resource/iasc-mhpss-guidelines-in-english/

Karunakara UK, Neuner F, Schauer M, Singh K, Hill K, Elbert T, et al. Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. Afr Health Sci. 2004; 4(2): 83-93

nternational Medical Corps MH Situational Analysis May 2013 Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders. Maithri Ameresekere, MD, MSca and David C. Henderson, Mda. (This document was originally published in two parts the South Sudan Medical Journal in volume 5 number 1 and number 2).

Rapid Mental health Assessment: Akobo and Juba, International Medical Corps, August 2014

Rapid Mental health Assessment: Akobo and Juba, International Medical Corps, August 2014

Rapid Mental Health Situational Analysis: Awerial and Malakal, Feb 2014

Rapid Mental Health Situational Analysis, Maban Refugee Camps, South Sudan, International Medical Corps. April 2013

Rapid Mental Health Siutuational Analysis: Awerial and Malakal, Feb 2014

Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-conflict mental health needs: a cross-sectional survey of

32

trauma, depression and associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009; 9: 7.

Solomon Ehiemua. Mental Disorder: Mental Health remains an invisible problem in Africa. European Journal of Research and Reflection in Educational Sciences Vol. 2 No. 4, 2014

South Sudan Cluster Bulletin #34. 21st December 2014

World Health Organization & United Nations High Commissioner for Refugees (2012). Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Major Humanitarian Settings. Geneva: WHO, 2012. World Health Organization. (2014). Mental health atlas 2014. Geneva: World Health Organization. Retrieved from http://apps.who.int/iris/ bitstream/10665/178879/1/9789241565011_eng. pdf?ua=1&ua=1

annex a: detailed MHPSS activities in south sudan

Disseminating information to the community at large 27

Facilitating conditions for community mobilization, community organization, community ownership or community control over emergency relief in general 18

Strengthening community and family support 29

Safe spaces 26

Psychosocial support in education 29

Supporting including social/psychosocial consideration in protection, health services, nutrition, food aid, shelter, site planning or water and sanitation 22

(Person-focused) psychosocial work 23

Psychological intervention 20

Clinical management of mental disorders by non-specialized mental health care providers (e.g. PHC, post-surgery wards) 11

Clinical management of mental disorders by specialized mental health care providers (e.g. psychiatrists, psychiatric nurses and psychologists working at PHC/general health facilities/mental health facilities)

6

Specific MHPSS Activities Number of Implementing Agencies

General activities to support MHPSS 23

34

annex b: Data collection excel form

WHO?Organization Name Acronym Type Implementing Partner

• NNGO

• INGO

• UN Agency

WHAT?

MHPSS Activity Sub-Code Status• Disseminating information to the community at large• Facilitating conditions for community mobilization, community

organization, community ownership or community control over emergency relief in general

• Strengthening community and family support• Safe spaces• Psychosocial support in education• Supporting including social/psychosocial consideration in protection,

health services, nutrition, food aid, shelter, site planning or water and sanitation

• (Person-focused) psychosocial work• Psychological intervention• Clinical management of mental disorders by non-specialized mental

health care providers (e.g. PHC, post-surgery wards)• Clinical management of mental disorders by specialized mental health

care providers (e.g. psychiatrists, psychiatric nurses and psychologists working at PHC/general health facilities/mental health facilities)

• General activities to support MHPSS

• Planned• In Progress

WHERE?State County Location (Payam/ Village)

• Central Equatoria

• Western Equatoria

• Eastern Equatoria

• Jonglei

• Warrap

• Unity

• Northern Bahr el Ghazal

• Western Bahe el Ghazal

• Lakes

• Upper Nile

• Abyei Special Admin. Areaa

35

FOR WHOM?Beneficiary Type # Direct # Indirect Boys Girls

• IDPS (PoC Site)

• IDPs (Collective Site)

• Host Community

REPORTING DETAILSDate Focal Point

36

annex c: total MHPSS providers per state

Abyei Special Administrative Area 1

Central Equatoria 25

Eastern Equatoria 12

Jonglei 16

Lakes 6

Northern Bahr el Ghazal 2

Unity 21

Upper Nile 17

Warrap 1

Western Bahr el Ghazal 6

Western Equatoria 11

37

annex d, part i: services by mhpss activity

Strengthening Community and Family Support

Safe Spaces

Psychosocial Support in Education

General Activities to Support MHPSS

Psychological Intervention

Person-Focused Psychosocial Work

Supporting Social/ Psychosocial Considerations in Protection, Health Services, Nutrition, Food Aid, Shelter, Site Planning, Water or Sanitation

Facilitating Conditions for Community Mobilization, Ownership or Control over Emergency Relief in General

Dissemenating Information to the Community At-Large

Clinical Management of Mental Disorders by Non-Specialized Mental Healthcare Providers (e.g., PHC, Post-Surgery Wards)

Clinical Management of Mental Disorders by Specialized Mental Healthcare Providers (e.g., Psychiatrists, Psychiatric Nurses, Psychologists)

1 2 3 4 5 6 7 8 9 10 11Abyei Development Association ● ● ● ● ●Action for Conflict Resolution ● ● ● ● ● ● ●Africa Development Aid ● ●American Refugee Committee ● ●Assistance Mission for Africa ● ● ● ● ● ● ●Association of Volunteers in International Service ● ● ●

Child Advocacy and Women Development ● ●

Child Destiny and Development Organization ●

Child Hope Organization ● ●Children Help Foundation ● ● ● ● ● ●Children Humanitarian Aid Organization ● ●

Community Action Organization ● ● ● ● ● ● ●Community Aid Humanitarian Organization ● ● ● ● ● ● ● ● ●

Community Health and Development Organization ● ● ● ● ● ●

Community Initaitive for Development Organization ●

Confident Children Out of Conflict ● ● ● ● ● ● ● ●Danish Refugee Council ●

1

2

3

4

5

6

7

8

9

10

11

38

1 2 3 4 5 6 7 8 9 10 11Diar for Rehabilitation and Development ● ● ● ● ●

Equatoria Rehabilitation and Development Association ● ● ●

Finn Church Aid ●Global Relief and Development Organization ● ● ●

Great Commission Operation Mercy ●Hala-Nil Organization for Persons with Disability ● ● ● ●

Handicap International ● ● ● ● ● ● ●Health Care Africa ● ● ●Hope Restoration South Sudan ● ● ● ●Impact Actions ● ● ● ● ●Impact Relief and Development ● ● ●Initative for Community Prosperity ●Initiative for Peace Communication Association ● ●

International Medical Corps ● ● ● ● ● ● ● ● ● ●International Organization for Migration ● ● ● ● ● ● ● ● ●

International Rescue Committee ●Intersos ● ● ● ● ● ● ●Irish Aid ●IsraAID ● ●Jesuit Refugee Service ● ● ●Llolia Community Development Nuer Organization ● ●

Maternal Child Health Care ● ● ● ● ● ●Mobile Humanitarian Agency ●MSF Spain ● ● ● ● ●Mundri Active Youth Association ● ● ● ●New Page for Peace and Development ● ● ● ● ●NORAD ●Oxfam GB ● ● ● ● ● ●Peace in Action and Social Service ● ● ●Rescue the Nation ●Rural Development Action Aid ● ● ● ●

39

1 2 3 4 5 6 7 8 9 10 11South Sudan Development Agency ● ● ●South Sudan Older Peoples Organization ● ● ● ●

South Sudan Red Cross ● ●Sudan Evangelical Mission ● ● ● ●The Organization for Children’s Harmony ● ● ● ● ● ● ● ●

The Rescue Initative South Sudan ● ●Titi Foundation ● ● ●Touch Africa Development Organization ●

UNHCR ● ● ● ●UNICEF ● ● ●Universal Intervention and Development Organization ●

Universal Network for Child Defence Rights ●

Voice of the Peace ●Watchlist on Children and Armed Conflict ● ●

Women Humanitarian Aid ● ●World Relief ● ●World Vision International ● ● ● ● ● ● ●

40

annex d, part 2: Organizations by iasc layer

Layer 1

Assistance Mission for Africa; Child Hope Organization; Children Help Foundation; Children Humanitarian Aid Organization; Community Action Organization; Community Aid For Humanitarian Organisation; Community Health and Development Organization; Confident Children out of Conflict; Diar for Rehabilitation and Development; Global Relief and Development Organization; Hala-Nil Organization for Persons with Disability; Handicap International; Health Care Africa; Hope Restoration South Sudan; Impact Actions; Impact Relief and Development; International Medical Corps; International Organization for Migration; Intersos; Llolia Community Development Nuer Organization; Maternal Child Health Care; Mobile Humanitarian Agency; Oxfam GB; Rescue The Nation; Rural Development Action Aid; South Sudan Older Peoples Organization; South Sudan Red Cross; The Organisation for Childrens Harmony; Women Humanitarian Aid; World Relief; World Vision International

Layer 2

Abyei Development Association; Action for Conflict Resolution; Africa Development Aid; American Refugee Committee; Assistance Mission for Africa; Association of Volunteers in International Service; Child Advocacy and Women Development; Child Destiny and Development Organization; Child Hope Organization; Children Help Foundation; Children Humanitarian Aid Organisation; Children Humanitarian Aid Organization; Community Action Organization; Community Aid For Humanitarian Organisation; Community; Health and Development Organization; Confident Children out of Conflict; Danish Refugee Council; Diar for Rehabilitation and Development; Equatoria Rehabilitation and Development Association; Finn Church Aid; Global Relief and Development Organization; Great Commission Operation Mercy; Rural Development Action Aid; Rural Vision South Sudan; South Sudan Development Agency; South Sudan Older Peoples Organization; South Sudan Red Cross; Sudan Evalengical Mission; The Organisation for Childrens Harmony; Titi Foundation; Touch Africa Development Organization; UNHCR; UNICEF; Universal Intervention and Development Organization; Universal Network for Child Defence Rights; Voice Of the Peace; Watchlist on Children and Armed Conflict; Women Humanitarian Aid; World Relief; World Vision International

41

Layer 3

Assistance Mission for Africa; Children Help Foundation; Children Humanitarian Aid Organisation; Community Action Organization; Community Aid For Humanitarian Organisation; Community Health and Development Organization; Community Initiative For Development Organization; Confident Children out of Conflict; Handicap International; Health Care Africa; Impact Actions; Initiative for Peace Communication Association; International Medical Corps; International Organization for Migration; Jesuit Refugee Service; Maternal Child Health Care; MSF Spain; Mundri Active Youth Association; New Page for Peace and Development; Oxfam GB; Peace In Action and Social Service; South Sudan Development Agency; South Sudan Older Peoples Organization; Sudan Evalengical Mission; The Organisation for Childrens Harmony; The Rescue Initiative-South Sudan; Titi Foundation; UNHCR; World Vision International

Layer 4 Confident Children out of Conflict; Handicap International; International Medical Corps; International Organization for Migration; MSF Spain

42

annex e: actors currently active in mhpss in south sudan

Abyei Development AssociationAction for Conflict ResolutionAfrica Development AidAfrican Humanitarian OrganizationAmerican Refugee CommitteeAssistance Mission for AfricaAssociation of Volunteers in International ServiceCaritas Torit/Catholic Diocese of ToritCatholic Medical Mission Board Child Advocacy and Women DevelopmentChild Destiny and Development OrganizationChild Hope OrganizationChildren Charity OrganizationChildren Help FoundationChildren Humanitarian Aid OrganisationChildren Humanitarian Aid OrganizationChristian Mission for DevelopmentCommunity Action OrganizationCommunity Aid For Humanitarian OrganisationCommunity Health and Development OrganizationCommunity in Need AidConfident Children out of ConflictDanish Refugee CouncilDiar for Rehabilitation and DevelopmentFinn Church AidGlobal Relief and Development OrganizationGreat Commission Operation MercyGreater Upper Nile OrganizationHala-Nil Organization for Persons with DisabilityHandicap InternationalHealth Care AfricaHold the Child OrganizationHope Restoration South SudanHumane Develoment CouncilImpact ActionsImpact Relief and DevelopmentInitiative for Community ProsperityInitiative for Peace Communication AssociationInternational Medical CorpsInternational Organization for MigrationInternational Rescue CommitteeIntersosIsraAIDJesuit Refugee ServiceLlolia Community Development Nuer Organization

Maternal Child Health CareMercy CorpsMinistry of Gender and Child Social WelfareMobile Humanitarian AgencyMobile Theatre TeamMSF SpainMundri Active Youth AssociationNew Page for Peace and DevelopmentNile HopeNorwegian Refugee CouncilOSPDIOxfam GBPeace In Action and Social ServicePlan InternationalRescue The NationReverend Simon Christian Orphan FoundationRural Development Action AidRural Vision South SudanSave the Children InternationalSouth Sudan Development AgencySouth Sudan Health AssociationSouth Sudan Older Peoples OrganizationSouth Sudan Red CrossStreet Children AidSudan Evalengical MissionTerre des HommesThe Organisation for Childrens HarmonyThe Rescue Initiative-South SudanTiti FoundationTouch Africa Development OrganisationTouch Africa Development OrganizationUnited and Save the NationUniversal Intervention and Development OrganizationUniversal Network for Child Defence RightsVFCVFPVoice Of the PeaceWar Child HollandWatchlist on Children and Armed ConflictWidows and Orphans Charitable OrganizationWomen Humanitarian AidWomen VisionWorld Health OrganizationWorld ReliefWorld Vision International

43

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annex f: 2018 MHPSS 4ws Overview

44

MHPSS actors were requested to accomplished a 4Ws template outlining the different MHPSS activities they’re implementing. The template was based on the IASC MHPSS Guidelines for 4Ws reporting. Thirty-one partners from different clusters and sub-clusters returned the accomplished forms.

After the initial submissions were encoded, a validation exercise was carried with random sampling. Seven partners were requested to validate the data they have submitted. Six out of seven partners validated the accuracy and consistency of the data input in the draft 4Ws matrix.

methodology

main findings

MHPSS interventions in South Sudan in this report were mapped based on the IASC MHPSS pyramid in MHPSS interventions and eleven MHPSS categories set out in the 4Ws tool by the IASC Reference Group.

MHPSS interventions in South Sudan according to the IASC MHPSS Pyramid The graph below shows the MHPSS actors and the services provided in South Sudan according to the IASC Pyramid of intervention.

The biggest number of MHPSS actors, 26 out of 31, work on level two, contributing to strengthening community and family support in the communities and IPD displacement sites.

Focused, non-specialized supports7.5%

Community and family supports70.4%

Specialized services6.7%

Basic services and security13.9%

annex g: summary of 2017 exercises

45

Eighteen out of thirty-one organizations mainstream MHPSS in provision of basic services. Focused non-specialized services are also offered by eighteen organizations. Six organizations: Handicap International, International Medical Corps, Lozoh Women Development Organization, Medecins sans Frontiers, South Sudan Red Cross and Women Empowerment Alliance. These organizations work and have capacities to operate on level four, namely specialized mental health services in the country.

MHPSS interventions as per eleven MHPSS activities of 4Ws

CODE MHPSS ACTIVES

1 Disseminating information to the community at large2 Facilitating conditions for community mobilization, community organization, community

ownership or community control over emergency relief in general3 Strengthening community and family support4 Safe spaces 5 Psychosocial support in education6 Supporting including social/psychosocial consideration in protection, health services,

nutrition, food aid, shelter, site planning or water and sanitation7 (Person-focused) psychosocial work8 Psychological intervention9 Clinical management of mental disorders by non-specialized mental health care providers

(e.g. PHC, post-surgery wards)10 Clinical management of mental disorders by specialized mental health care providers

(e.g. psychia-trists, psychiatric nurses and psychologists working at PHC/general health facilities/mental health facilities)

11 General activities to support MHPSS

18

18 26

6 Community and Family Support

Basic Services and Security

Focused, Non-Specialized Support

Specialized Services

number of Mhpss organizations per service area

46

MHPSS activities by number of organizations

General activities to support MHPSS 26

Clinical management of mental disorders by specialized

mental healthcare professionals (psychiatrists, psychologists, etc)

3

Clinical management of mental disorders by nonspecialized mental

healthcare providers (PHC, psot-surgery wards, etc)

Psychological intervention

Person-focused psychosocial work

6

13

14

The graph shows that the most common MHPSS activity in South Sudan was 11. General Activities to support MHPSS. Twenty-six of out thirty-six reported delivery of trainings and orientation in MHPSS to different target groups between records 11. The second most implemented activity was 4. Safe spaces (19 organizations). Most of the organizations worked towards creation and maintenance of child friendly spaces. The third most common activity was 1. Disseminating information to the community at large, reported by 18 actors, followed by Activity 5 – Psychosocial support in education, implemented by 15 actors.

Only three organizations provided clinical management of mental health disorders by specialized mental health care providers (Activity 10). Six actors provided clinical management as nonspecialized health care providers (Activity 9).

whereJuba was the most congested area in terms of the number of humanitarian actors providing a range of MHPSS interventions. Rubkhona and Paninyjar counties in the former Unity State, Bor South in Jonglei, and Malakal in Upper Nile follow.

target groups

The graph below shows that the most common target group for MHPSS interventions in South Sudan were children. Sixty five per cent (20 actors out of 31) of the organizations participating in this 4Ws exercise indicated that they target children in their activities. General population/communities, which includes host communities and general population in conflict affected areas were targeted by sixteen percent of the organizations (18 actors) followed by twelve percent of organizations (14 actors) working with IDPs directly in the POCs and other displacement sites in the country.

MHPSS Activities by Number of Organizations

47

The groups that were targeted by only one organization have been combined into “Others” group which includes elderly persons, refugees, men, law enforcers and local authorities. Eight per cent of the participating organizations (9 actors) provided MHPSS services specifically designed for women and girls, while four per cent (5 actors) aimed at supporting and providing services for GBV survivors specifically.

MHPSS mainstreaming into activities of other humanitarian actors’, such as of CCCM, WASH, Health, NFI/Shelter etc., was prioritized by five per cent (6 actors) of the participants, while ten per cent (12 actors) supported and build capacity of local educators, health and social workers.

Only two percent of the MHPSS actors in South Sudan, specially IMC, MSF and HI, work with people with moderate to severe mental health problems reflecting the limited availability of focused specialized services and the urgent need for expanding and increasing the access to them45.

Children

General Population/ Communities

IDPs

Caregivers (parents, guardians)

Women & Girls

Education/ Health/ Social Workers

Youth

GBV Survivors

First Responders (humanitarian workers)

Others (elderly, law enforcement, local authorities, refugees, men)

Persons with Physical Disabilities/ Persons Living with HIV (PLHIV)

PMHP

MHPSS Services Target Groups 2017

45 The specialized services of state hospitals are not included in this report.

20

18

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2

MHPSS Network South Sudan