• Gain a sound understanding of the causes of acute malnutrition among the children 6-59 months old and the pregnant and lactating women in Renk County. Specifically, the study will result in the production of a causal pathway model through exploring the immediate and, more importantly, underlying risks factors and causes of acute malnutrition and trends.
• Highlight what food and non-food related causes should be taken into consideration in future acute malnutrition reduction programme planning and humanitarian interventions

Supervision

Gabriele Rossi, Nutrition Advisor
Laura Biaruhanga, Deputy Nutrition Advisor

Level
Senior Level – International

Location
South Sudan based (mainly Renk based) and home based.

Application

Interested applicants are requested to submit the aforementioned documents by October, 30 2019 through e-mail to nutadvisor-sds@southsudan.medair.org.

Methodology
The main methodology expected to be utilized is the Link NCA which includes the following:

• Desk study of secondary data (SMART Surveys 2017-2019, KPC Surveys 2017-2019, Exhaustive mass MUAC Screening—previous and October 2019 will be available).
• Assess risk factors’ magnitude and severity, through quantitative study: the Risk Factor Survey is intended to measure the magnitude and severity of a range of under-nutrition risk factors. The tool developed should also capture information on potential economic/financial causality and affordability issues contributing to the persistent high level of acute malnutrition
• Qualitative data collection including: focus group discussions, key informant interview, gathering more information on case histories of acutely malnourished and well-nourished children, information on dietary habits: i) Develop a local definition and understanding of under-nutrition; ii) Characterise food security, health, and care in the community; iii) Explore respondent perceptions of the causes and consequences of poor food security, health, and care in relation to under-nutrition; iv) Understand the practices of caregivers of positive deviant children (i.e., well-nourished and healthy children of parents who seemingly face the same challenges and barriers as parents of under-nourished children); v) Identify seasonal and historical trends in under-nutrition and risk factors; vi) Understand how the community prioritizes these factors.

Duration & Start Date
4 months, November 2019.

Background/Rationale for the Assignment

Renk County is located in Upper Nile State, and is situated on the border with Sudan with an estimated population of 62,663, including 5,926 IDPs, according to Medair estimates1. However, population figures are fluid and difficult to determine due to its transitory nature linked to conflict and food insecurity. Renk has experienced multiple bouts of conflict and displacement since the December 2013 conflict. Despite general stability in the area, the security situation remains fragile and there have been ongoing population movements. The population movement includes also the new wave of returnees from different areas (Sudan, Malakal PoC, Bentiu PoC, etc), which intensified after the signature of the peace agreement in August 2018. It is more appropriate to recognize the conflict-affected nature of the whole Renk population, rather than to distinguish between host communities and IDPs, as many host communities have also experienced displacement.
There have been emergency levels of malnutrition in Renk County since 2015. The May 2019 SMART Survey showed high levels of malnutrition, with a global acute malnutrition (GAM) level of 32.1% among the host population and 24.4% among IDPs, the highest among the SMART surveys conducted in 2019 in South Sudan2. The most recent exhaustive mass MUAC screening (September 2018) and continuous surveillance through systematic screening done by Medair highlighted the need for more decentralized coverage of nutrition services, as the coverage rate ranges between 40% and 60% for both cases of severe and moderate acute malnutrition.
Renk’s County Health Department (CHD) and Rural Water Department remain under capacity, without the presence of a consistent secondary level healthcare service provider, and unable to address the WASH needs of the host community or IDPs.
World Vision is the nominated Health Strengthening System partner for the World Bank Project in Renk and runs 10 PHCC/PHCU health facilities in the County, while Medair’s primary health care clinics in Abayok and Wunthou serve the populations of these IDP locations and the surrounding area. An Integrated Community Case Management (iCCM) network is currently shifting towards the Boma Heath Initiative (BHI) platform and targets vulnerable populations across the county who lack adequate access to healthcare which provides flexibility within the changeable context of the limited health provision in this area.

Purpose / Tasks and expected results

The implementation of a root causal analysis of acute malnutrition in Renk County is informed by the persistent level of acute malnutrition recorded through yearly SMART surveys in the period 2015-2019, despite the presence of a robust nutrition intervention and the relatively low value, IPC2 (outside the lean season) – IPC3 (in lean season), consistently assigned to Renk County by the IPC classification for acute food insecurity throughout the above mentioned period.
While the classic framework for acute malnutrition sets out the multi-causal nature of under-nutrition and represents a useful guide for building hypotheses around causes of malnutrition and food insecurity for different contexts/livelihood, it does not guide the prescription of context-specific interventions.
Despite the many SMART surveys and FSNMS exercises conducted on malnutrition and food insecurity in Renk County, the specific determinants of persistent under nutrition in the County have been only partially investigated.
Previous research covered mostly key health, nutrition and WASH sectoral indicators in both the Host and the Camp population and was not disaggregated by livelihoods – a very important level of stratification that provides more meaningful inference of causal factors.
The causal analysis will aim at establishing the role and adequacy of ongoing interventions, including the importance of nonfood interventions.
Finally, the integrated analysis will provide a more holistic approach to addressing food and nutrition insecurity and vulnerability, highlighting the need for multi-pronged initiatives and informing prioritization decisions on appropriate responses and preventive measures.

Tasks
Under supervision of Medair’s Nutrition Advisor, in close collaboration with the Nutrition Project Manager of Medair Renk project, the Consultant will accomplish the following tasks in the following phases:
Phase 1. Study inception:

• Partner consultation to include bilateral meetings with key operational stakeholders and technical experts from (MoH, UNICEF, WFP, World Vision, NIWG, NAWG, Nutrition Cluster, FSL Cluster, Health Cluster, WASH Cluster).
• Review multi-sectoral secondary data.
• Conduct review and discussions with different staff involved in programming.
• Develop a comprehensive root causal analysis protocol.
• Preparation of the necessary data collection tools.

Phase 2. Community level data collection and management:

• Collection of data at the community level including a qualitative enquiry depending on the availability of existing secondary data in order to:
  o Understand how communities in Renk perceive under-nutrition
  o Explore respondent perceptions of the causes and consequences of poor food security, health, and care in relation to under-nutrition
  o Understand the practices of caregivers of positive deviant children;
  o Identify seasonal and historical trends in under-nutrition and risk factors and
  o Understand how the communities in Renk prioritises these factors
•  Collection and consolidation of qualitative and quantitative data while ensuring compliance with the data quality standards; validity, reliability, precision, integrity, completeness and confidentiality as applicable.
• Data analysis in conformity to the data analysis plan.

Phase 3. Reporting and validation

• Once data collection is complete, the NCA Analyst will synthesize the data to produce a range of outputs, and will use this evidence to rate risk factors based on their relative contribution to under-nutrition and to qualitatively describe the dynamic interrelationships among risk factors and under-nutrition outcomes. The Analyst’s rating triangulates all sources of evidence gathered during the study. During a final workshop, the Analyst will present these results and will lead a sequential, participatory process to build consensus around the plausible causes of under-nutrition. and conduct meeting with operational stakeholders/partners to share the preliminary report;
• Compile the NCA outputs in the form of a report with the following layout outline in line with Link NCA Methodology:
  o Executive summary;
  o Background;
  o Justification;
  o Methods and approaches;
  o Results;
  o Conclusions;
  o Recommendations: in particular, specific and detailed, evidence-based and multi-sectoral recommendations geared towards improving the current humanitarian programming in Renk County
•  Plan and conduct a briefing meeting with key stakeholders including donors, MoH, NIWG representatives to share the preliminary report;

Phase 4. Finalization

• Finalize the study report as per internal and external actionable recommendations

Expected results

• The main objective of the study is to assess the factors associated with persistent high levels of under-nutrition in former Renk County to provide information needed to strengthen the holistic approach to address the situation.

Key questions
The study will aim to answer the following questions.

1. What is the prevalence and severity of under-nutrition and food insecurity?
2. What are the underlying factors that result in the persistence of these rates and what are the risk factors among known vulnerable groups?
3. Does the prevalence and severity of under-nutrition and food insecurity vary geographically or by characteristics such as livelihood or other socio-demographic factors?
4.  How have the different groups perceived the risks and vulnerabilities and managed/coped with them?
5. How have GAM and food insecurity levels changed over time? Is such change related to historical trends, seasonality, cyclical trends or recent shocks?
6.  What are the linkages between morbidity and acute malnutrition/food insecurity?
7.  What are the linkages between food insecurity and acute malnutrition specific to the study area?
8.  Why are different food security indicators telling different stories about the food security situation?
9.  What role does humanitarian response play in the food security and nutrition situation?
10. What are the knowledge, attitudes and practices (KAP) in relation to WASH-sanitation, childcare, health seeking and feeding practices that influence acute malnutrition in the study area.
11. Are mothers and child caregivers inclined to seek treatment for health problems? How strongly embedded are concepts of preventative practices with regard to diarrhea and other health, hygiene and sanitation practices? Is it possible for women to follow better practices given their limited access to resources, time constraints and insecurity?
12. What role do primary healthcare services and access play in food security and nutrition?
13. What role does the socio-political (border with Sudan) and cultural environment play in food and nutrition security?
14. Based on the causal analysis findings, what recommendations can be made for improving food and nutrition security programming for response and preventive measures?
15. Based on the causal analysis findings, what preventative measures need to be addressed to achieve better child nutrition?
16. What contribution has the changing economic situation and inflation made to the level of acute malnutrition?

Qualifications and Competencies

Advanced university degree in food security, public health, nutrition, social sciences, or related fields. Significant knowledge of nutrition interventions and proven extensive experience in conducting qualitative and quantitative causal analysis of acute malnutrition and food insecurity.

Experience

• At least 4 year expertise and experience in root causal analysis of acute malnutrition/food insecurity
• A proven track record of high quality work/ product previously done in understanding causes of acute malnutrition in Sub-Saharan African countries (preferably in South Sudan)
• Strong capacity for meeting deadlines, an ability to prioritize tasks within his/her work program and strategies for working both collectively with others in a team and independently to deliver high quality products.
•  Excellent facilitation skills, ability to bring together stakeholders from different sectors and backgrounds.
•  Strong leadership and team work abilities.
•  Strong information-gathering and analytical skills, coupled with excellent written and oral communication skills.
•  An understanding or knowledge of and experience in CMAM programming in humanitarian contexts.

Estimated duration of the contract
The contract will run from 1st November 2019 to 28th of February 2020.

Duty Station and Official Travel
The consultancy will be based in Juba and (mainly) Renk for phase 1 and phase 2. Phase 3 and Phase 4 will be mainly home based, with the exception – during Phase 3 – to be available in Juba, South Sudan, for sharing preliminary results with key stakeholders (other actors, UN agencies, Donors, MoH).

Consultant Responsibilities

• All travel arrangements to and from the airport of departure in country of above (reasonable travel costs to and from the airport will be reimbursable by Medair; reasonable means public transport, second-class travel and taxis only if no other options or if late at night).
•  To arrange the required visas for travel to Juba (visa cost reimbursed by Medair). Kenyan citizens Visas can be done upon arrival in South Sudan.
• Fulfil the above outputs as listed within the timeframe stated.
• Provide their own medical insurance and obtain the necessary vaccinations before the start of the consultancy (not reimbursable by Medair).
• The consultant/s shall be responsible for his/her income tax and/or insurance during the assignment. However consultancy fees are taxable in South Sudan. Medair will therefore withhold 10% income tax on the consultancy fees.
•  Comply with South Sudan security plan and recommendations on dress and behavior, as given to expat staff.
•  Provide laptop, software, or any other relevant equipment for personal use and report writing (not chargeable to or reimbursable by Medair).

Medair Responsibilities

•  Arrangement of flights to and from Juba, to and from the different sites in Leer County, and booking of accommodation while the consultants is in transit if required
•  Provide transport within South Sudan
•  Arrange and cover the costs of in-country work permits and authorizations
•  Provide food and accommodation in South Sudan
•  Provide translators for consultants as needed
•  Provide staff for data-collection
•  Provide working facilities which will be as secure as is practical in the circumstances. Working facilities in the field will be very basic.
•  Reimburse reasonable expenses with valid receipts

Consultancy Fee and Terms of Payment

• The consultancy fee payable will be a negotiated lump sum based on experience and credentials. This will be calculated on the basis of the days of work as indicated in the workplan.
• The total consultancy fee is taxable in South Sudan and Medair will withhold 10%.
• After withholding tax, 50% of the consultancy fee will be paid into a bank account designated by the consultant(s) at the completion of field work.
• The remaining amount will be paid upon final completion of the report after Medair’s approval.
•  Any visa costs, cost of travel in country of abode, and meals while in transit (up to 3 meals per day, maximum 20 USD per meal, no alcohol, no snacks/drinks between meals) will be reimbursed into the designated bank account against receipt.

Application Details

•  Technical Proposal: A technical proposal (maximum 5 pages) highlighting previous experience in conducting Link NCA and a detailed description of the stipulated survey data collection methodology as per this ToR
•  Curriculum Vitae: Detailed CV(s) clearly highlighting experience and capacity with 3 professional references.
•  Similar piece of work in the form of report(s): This will be used as proof of successful execution of a similar piece of work.
•  Financial Proposal: The financial proposal should provide cost estimates for services rendered including daily consultancy fees.
•  Interested applicants are requested to submit the aforementioned documents by October, 30 2019 through e-mail to nutadvisor-sds@southsudan.medair.org. Only shortlisted candidates will be contacted.