Summary

Important notes & limitations:

Analysis

IDPs and returnees are particularly vulnerable populations from a health perspective. Sudden population movements, whether due to displacement or to population return, may strain local service provision and result in underserved populations. In some cases, local health services have shut down as a result of the conflict, or populations have settled in remote areas that are perceived as safer but that are beyond the reach of the existing healthcare system. IDPs and returnees are also vulnerable to cross cutting issues that may result in higher health needs, including poor nutrition and food security, unhygienic conditions, over-crowding, psycho-social distress and higher risk of GBV and child protection issues.

Despite the relative lull in large-scale hostilities since the signature of the Revitalised Peace Agreement for the Resolution of the Conflict in South Sudan in September 2018 and the formation of the Transitional Government of National Unity in February 2020, sub-national and localised conflict have continued to affect communities and cause new displacement across the country (DTM Event Tracking). In 2020, escalations in violence in Jonglei and Greater Pibor, Central Equatoria, Lakes, Warrap, Unity and Western Bahr El Ghazal (OHCHR) have been a particular cause for concern.

The ongoing humanitarian crisis has been compounded by the devastating effects of two years of exceptionally severe seasonal flooding in 2019 and 2020, affecting over one million people between July and December 2020 (OCHA), and by the economic and health impact of COVID-19 and related border closures. Based on the December 2020 IPC results, 6.35 million South Sudanese – over half of the country’s population – are estimated to be facing severe acute food insecurity, with an IPC global review committee classifying parts of Pibor county as famine likely and identifying populations in IPC phase 5 (Catastrophe) in Akobo, Aweil South, Tonj East, Tonj North and Tonj South.

In this complex and rapidly shifting context, South Sudan has been witnessing a combination of new displacement and return movements. IOM’s Displacement Tracking Matrix (DTM) recorded 261,630 new IDP arrivals during the first nine months of 2020, including both new displacement incidents and individuals moving to a different location of displacement. Yet, during the same period, 174,463 former IDPs and 83,853 former refugees returned to their former areas of habitual residence. Overall, as of September 2020, South Sudan hosted over 1.61 million IDPs and 1.67 million returnees (Mobility Tracking Round 9 Baseline Locations and Baseline Area).

Inadequate access to health services affects an important share of these populations. Based on DTM’s latest multi-sector location assessments, 12.1 per cent of IDPs and 13.4 per cent of returnees in South Sudan live in settlements reporting no access to healthcare, while 26.2 per cent of IDPs and 26.8 per cent of returnees live in settlements reporting no on-site health services and located further than three kilometres away from the closest off-site health service provider. While UNMISS Protection of Civilian (PoC) sites and other large displacement camps benefit from basic service provision from humanitarian actors, needs tend to be higher for IDPs living in smaller camps and camp-like settings, and for IDPs and returnees living in host-community settings which may be harder to reach for humanitarian actors (see Mobility Tracking Round 8, Site Assessment and Village / Neighbourhood Assessment).

Even among settlements with access to a health facility, important differences remain in terms of their functionality and the resulting quality of healthcare provision. IOM DTM and WHO’s Health Service Functionality unit combined their location-level data for September 2020 in order to identify IDP and returnee settlements further than 5km away from the closest functional health facility (a best estimate is used when the actual settlement GPS coordinates are not available; as such, analysis results should be considered indicative rather than exact estimates). The analysis – which is currently at its third iteration – provides a countrywide summary of gaps in access to health services by these two populations of humanitarian concern.

Based on the results of the analysis, 32.8 percent of IDPs (529,470 individuals) and 33.6 percent of returnees (562,019 individuals) live in settlements located more than 5km from a functional health facility, while 4.4 percent of IDPs (70,774 individuals) and 6 percent of returnees (100,367 individuals) live in settlements that are within the 5km range of only facilities with limited functionality. The states with the largest health access gaps in terms of population are Upper Nile (38.9 percent of IDPs and returnees living in settlements more than 5km from the closest functional health facility, or 206,938 individuals), Warrap (50.5 percent of IDPs and returnees, or 169,189 individuals) and Jonglei (35.9 percent of IDPs and returnees, or 163,079 individuals). The following tables and visualizations provide summaries at the state, county, and location levels. An additional 0.4 percent of IDPs (6,846 individuals) and 0.4 percent of returnees (6,029 individuals) live within 5km of a health facility, but the health facility functionality status is unknown. The visualisations below show the results of the analysis at the location and county level.


National & State Summary of IDPs & Returnees Farther than 5km from a Functional Health Facility

Admin Area IDPs & Returnees >5km from Health Facility Total IDPs & Returnees % IDPs & Returnees >5km from Health Facility
National 1,091,489 3,290,433 33.2
Central Equatoria 103,113 402,464 25.6
Eastern Equatoria 43,433 170,726 25.4
Jonglei 163,079 454,126 35.9
Lakes 86,062 259,894 33.1
Northern Bahr el Ghazal 60,837 201,459 30.2
Unity 127,726 386,368 33.1
Upper Nile 206,938 531,841 38.9
Warrap 169,189 334,969 50.5
Western Bahr el Ghazal 70,195 295,678 23.7
Western Equatoria 60,917 252,908 24.1


IDP & Returnee Settlements Located More than 5km from a Functional Health Facility


Counties by Number of IDPs & Returnees Farther than 5km from a Functional Health Facility


Methods & Sources

For any questions on IOM DTM data on IDP and returnee settlements, please contact southsudandtm@iom.int.

For any questions on the analysis or health service availability data, please contact Ryan Burbach (rmburbach@gmail.com), HSF Technical Adviser, or Malick Gai (gaim@who.int), HSF Project Manager.

Analysis Methodology

The joint analysis comprised identification of settlements in IOM’s DTM IDP and returnee data for round 9 which were more than 5 kilometers from any functional facility or facility with an unknown functionality status (i.e. no service availability report is available) in WHO’s Health Service Funcationality data as of 31 December 2020. Facilities with an unknown functionality status were included as this provides the most conservative estimate for health access limitations. To achieve this, the team used QGIS v3.16.2 to draw circles with 5km radii around each functional health facility (n = 1,496) or facility with an unknown functionality status (n = 411). Then, the team conducted points in polygons analysis to identify settlements from the IOM data set which did not fall within any of these 5km-radius circles. The list of these settlements more than 5km from a health facility was extracted from QGIS and analyzed with R v4.0.3 and associated packages.

DTM Mobility Tracking Methodology

DTM enumerators collect data on IDP and returnee populations at the payam and settlement level through consultation with key informants, commonly comprised of local authorities, community leaders, religious leaders, and humanitarian partners. Direct observation at each location in addition to the triangulation and the subsequent verification process (data received through partners and other DTM tools such as biometric registration) at various administrative levels serves to further ensure maximum accuracy of findings. As part of round 9, DTM accessed 2,854 locations (villages/neighbourhoods and displacement sites) a 3.9 per cent increase since round 8. Accessed locations were spread across 509 payams (sub-areas) in every county (78) of all 10 states. Locations are only assessed upon confirmation of presence of targeted populations.

Since Mobility Tracking round six, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) IDP baseline is consolidated with DTM findings. The two agencies continue working together to maintain a unified baseline on IDP populations updated after each round of data collection. Mobility Tracking is implemented on a quarterly basis in order to keep track of South Sudan’s rapidly evolving displacement and return trends.

IDPs
Persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized state border. Both IDPs living in camps and camp-like settings and those living in host-community settings are included in Mobility Tracking.

Time of arrival in assessed area considered for South Sudan: 2014 to September 2020.

Returnees: internal / from abroad
Someone who was displaced from their habitual residence either within South Sudan or abroad, who has since returned to their habitual residence. The returnee category, for the purpose of DTM data collection, is restricted to individuals who returned to the exact location of their habitual residence, or an adjacent area based on a free decision. South Sudanese displaced persons having crossed the border into South Sudan from neighbouring countries without having reached their home are still displaced and as such not counted in the returnee category.

Time of arrival in assessed area considered for South Sudan: 2016 to September 2020.

Health Service Availability Data

Facility data for this bulletin was kindly contributed by the Health Cluster partners, Health Pooled Fund (HPF), the International Committee of the Red Cross (ICRC), Management Sciences International (MSI), UNICEF, and UNHCR. Additional service availability data was extracted from the Ministry of Health DHIS2 platform for facilities without an implementing partner report. Most data was reported as of 31 December 2020, but the report date for each facility is indicated by hovering over a facility marker on the map. Implementing partners self-report on a quarterly basis service availability based predefined, standardized service availability data points and definitions. WHO merges the respective data sets and assigns a functionality level to each facility based on the criteria below.

Health Service Functionality Criteria to Assign Functionality Levels