Refugees collecting water at the MSF water collection point in Jamam refugee camp Refugees collecting water at the MSF water collection point in Jamam refugee camp Photo credit: Robin Meldrum / MSF
Have we lost the ability to respond to refugee crises? The Maban response
by Sandrine Tiller and Sean Healy May 2013

In November 2011, fighting in Blue Nile State in Sudan led to the flight of some 25,000 refugees to Maban County, in Upper Nile State in South Sudan, where they were settled in two refugee camps, first at Doro and then, from December, at Jamam. More continued to arrive over the subsequent months. Six months later, in May 2012, a second wave of 35,000 refugees arrived, in very bad condition with some dying of dehydration from their journey. After an initial period in transit camps en route, most of this second wave was moved to Jamam camp; new camps were established at Batil (in May) and Gendrassa (in July) for the new arrivals and to reduce the Jamam population.

Death rates were very high from the time of the second wave: data gathered by Médecins Sans Frontières (MSF) in Jamam camp in mid-June showed crude mortality rates at 1.8/10,000/day and under-five mortality rates at 2.8/10,000/day. In Batil camp in July the crude mortality rate was 1.75 and the under-five rate 4.2/10,000/day. Their poor condition on arrival, the difficulty of supplying water to all the refugees and rains, flooding and later a Hepatitis E outbreak all contributed to death and suffering among the refugee population. In Jamam, mortality only started to fall to acceptable levels after ten weeks, while in Batil it reached that point after 6–8 weeks.

In many ways the refugee emergency in Maban County was a ‘classic’ crisis – a sudden influx of a large number of refugees into distinct camps in a rural setting with a small host population. This article assesses the humanitarian response to the emergency. It is based on a review done by MSF, including key informant interviews with 14 organisations.

A difficult setting


The environment in Maban presented particular challenges to the emergency response. It is one of the most remote parts of South Sudan, and is very sparsely inhabited, with an estimated population of 36,000. For a large part of the year the area floods and roads are impassable. Logistics costs were very high as almost all materials had to be flown in, and it was difficult to find local staff. For MSF even frontline positions such as nurses had to be filled by international staff, drastically increasing costs. The refugees, who by June 2012 numbered over 100,000, had very few resources of their own, and were entirely dependent on external humanitarian assistance.

MSF’s response

MSF first responded in November 2011, soon after the first wave of refugees arrived in Maban County. The agency initially set up a hospital with in- and out-patient services in Doro camp, followed by outreach clinics offering outpatient consultations, while a clinic in Bunj town run by the Ministry of Health and another partner organisation covered the needs of the host population and surgical cases. One of MSF’s key interventions in Doro has been the provision of drinking water; more than a year after the start of the intervention, MSF is still supplying water for some 45,000 refugees.

MSF set up a hospital in Jamam in March, providing inpatient and out-patient services to 35,000 refugees. Initially MSF was providing more than 50% of the water in the camp. Nutrition support was set up through an intensive (ITFC) and an ambulatory (ATFC) therapeutic feeding centre, and vaccination campaigns were carried out in all of the camps. MSF also set up a field hospital in Gendrassa camp, which provides in-patient services, while International Medical Corps (IMC) provides outpatient consultations.

Batil camp, which was initially intended for refugees relocated from Jamam, was expanded to host the May influx of 35,000 refugees. MSF set up a clinic providing in- and out-patient care, nutrition and maternity and mental health services, supported by over 60 expatriates. MSF rented aircraft to supply these operations, with the Logistics cluster providing for some expatriate travel.

Refugees, not IDPs

A key feature of the emergency was that, with a new border between Sudan and South Sudan, these were refugees, not IDPs. This changed how the response was organised, as it was under the responsibility of the UN High Commissioner for Refugees (UNHCR) as lead agency and fell outside of the existing cluster system. UNCHR coordinated the response, and selected and funded partner agencies to lead in certain sectors. The principal responsibility for successes or failings must therefore lie with UNHCR. Apart from the World Food Programme (WFP), no other major UN humanitarian agencies were present, and the Humanitarian Coordinator only visited well after the emergency had begun. Not using the existing cluster system meant that a duplicate coordination structure was set up, and there was confusion with regard to standards and reporting lines.

For many NGOs, UNHCR’s status as both donor and coordinator inhibited critical discussion; it was difficult to admit to mistakes, and there was pressure to share only good news. Some NGOs admitted to having taken on more commitments than they could handle. According to interviewees, even internally within NGOs there was little reporting of problems up the line to Juba, and there was little incentive to be open about gaps and failings or to address them in a collaborative manner. In general, there was a culture of blame and competition within the humanitarian system. Once it became clear that some partners could not deliver, UNHCR asked other NGOs to step in and provide additional services, effectively ‘doubling up’ the number of agencies in each sector. This created a ‘patchwork’ of service delivery.

Water supply problems

The major issue plaguing the Maban emergency response was provision of water. In the area around Jamam there were serious problems in finding water sources and extracting and distributing adequate amounts of water. This was known by water and sanitation actors and communicated clearly by them as early as December 2011, but adequate water provision (to SPHERE standards) was only achieved by September 2012. The Hepatitis E outbreak in the camps was, in the view of MSF medical teams, mainly due to the lack of adequate water and sanitation facilities.

A key constraint for getting adequate water supplies to the camps was logistical: only three drills were on-site, one shallow and two deep, and they were in constant demand. Carrying out good-quality hydrogeological surveys to assess the sustainability of aquifers was particularly difficult. There also appeared to be a lack of senior technical staff with experience of responding in this kind of context. Agencies seem to have struggled to change gear from a development to an emergency approach, and suffered from a lack of urgency. Experienced staff were deployed late or not at all, and not in sufficient numbers. Development approaches, which prioritised long-term activities in resident communities and emphasised the use of local staff and contractors, were inappropriate in an emergency setting. This led to delays in the response. As the coordinator of the response, UNHCR took too long to assert leadership in the watsan sector. MSF initially counted on other agencies with the responsibility and expertise to respond to water needs. When capacity and supply constraints became clear, however, MSF began emergency water supply and distribution interventions in Doro, Batil and Jamam camps. Faced with alarming mortality statistics in Batil camp in July, MSF began advocating at senior levels with other humanitarian actors to intervene in water and sanitation. This ‘wait and see’ approach was criticised within MSF, with some saying that it delayed the agency’s own response.

Lack of contingency planning and leadership in key sectors

Poor contingency planning slowed the response to the second wave of refugees in mid-May. While information from Blue Nile State, on the other side of the border, was certainly limited, this should not have prevented agencies from drawing up response plans. Humanitarian actors were caught out by the scale of the influx.

This was also the case with regard to water provision in the camps, especially in Jamam. It became clear as early as March that Jamam would not be able to cope even with existing numbers once the rains arrived. And yet it was only months later and after the second wave began that a third site, Batil, was made available. Precious time was lost in deciding where the refugees would finally be located. Once the decision was made in June, actual site identification and the moving of refugees went quickly – making the delay even more difficult to understand.

Intensive lobbying by MSF

Frustrated by what it saw as a slow and inadequate response, in February MSF began to lobby hard for others to deliver on their responsibilities. MSF became increasingly critical and vocal towards actors that it felt had not responded adequately to the challenges posed by Maban. MSF met UNHCR, WFP and OCHA to push for an improved overall response, particularly in water and sanitation, and shared its concerns with the Emergency Relief Coordinator, Valerie Amos. In August, MSF met ICRC in Geneva and Juba, presenting the results of its mortality surveys. In response, ICRC sent out an assessment team, which eventually resulted in a short-term but large-scale intervention in Jamam, where the ICRC built a 15-kilometre water distribution pipeline, and in Batil, where it installed piping, storage tanks, tap stands and pumps.

MSF was attacked by some for the bluntness of its criticisms, and it appears that some relationships were strained. There was also the question of whether it should even be the role of an international NGO to push other agencies to fulfil their commitments. An ‘insider/outsider’ stance made it difficult for some other actors to anticipate MSF’s response. Nevertheless, MSF’s decision to publicly highlight these problems and demand improvements did have some positive impact in prompting greater urgency and effort and in bringing in new actors with greater capacity.


At the time of writing, the situation in the camps appears to have stabilised, at least in comparison to the desperate, muddy mess of June and July. This is in very large part due to the massive effort of many humanitarian actors. That said, the Maban crisis raises some uncomfortable questions about the humanitarian system’s emergency response capacity. Given humanitarian capacities and the vast body of knowledge and practice, how can it be possible for a refugee camp to lack even the most minimum standards for survival? Why were agencies caught unprepared by eminently predictable events and problems? Why, even now, is this still a risk? Why did it prove so difficult for humanitarian agencies to reach acceptable levels of service delivery? Given that the emergency occurred in an area where large-scale operations had been conducted during Operation Lifeline Sudan, and many of the responding agencies have been present in the country for decades, has the humanitarian system lost some of its former capacity to respond quickly and effectively to this kind of ‘classic’ refugee emergency?

Sandrine Tiller and Sean Healy are humanitarian advisers working for MSF. The authors would like to thank the reviewers and field teams for their contributions to this article.

Humanitarian response in Yida refugee camp, Unity State, South Sudan, 2012

By Pauline Busson, Audrey Landmann, Klaudia Porten and Vincent Brown

In July 2011, fleeing fighting and bombing in the Nuba Mountains, South Kordofan, a first wave of refugees crossed the border and settled in Yida, a small Dinka village in South Sudan. From April 2012, following increased violence and food shortages in the Nuba Mountains and the approach of the rainy season, the rate of new arrivals grew dramatically (up to 1,000 per day). By July Yida’s population had quadrupled, reaching 64,000. While enough food was available, water and sanitation conditions were poor, leading to increased diarrhoeal diseases, which in turn contributed to severe acute malnutrition among children. This combination of factors in densely populated Yida led to global excess mortality; under-five mortality peaked at four deaths/10,000 per day in June and July, twice the emergency threshold. Admissions at MSF’s field hospital doubled, and with many severe cases arriving late, hospital mortality jumped, exceeding 20% for three consecutive weeks in July, before falling back to 3% in August.

To tackle the complex emergency, humanitarian agencies on the ground scaled up their response, although with some delay. It took three months, from May to July, for the WASH situation to reach acceptable standards. The delayed humanitarian response can be explained by several factors. Yida’s location – 12km south of the Sudanese border, a potentially dangerous spot – has limited longer-term investment; UNHCR has repeatedly tried to relocate refugees, and some donors have refused to fund assistance inside the camp. No mortality surveillance system was in place before June, and limited understanding of the situation in the Nuba Mountains meant that humanitarian actors were not prepared for such a large influx of refugees. Roads were inaccessible during the rainy season, further slowing the response. At the time of writing the humanitarian situation has stabilised, but remains precarious and new influxes of refugees are expected. Lessons learned during this emergency should help to ensure better responses in the future.

Pauline Busson is a consultant in the Evaluation Unit, MSF Operational Center Paris (OCP). Audrey Landmann is emergency coordinator at MSF-OCP and Klaudia Porten works in Epicentre (MSF Satellite). Vincent Brown is head manager of the Evaluation Unit at MSF-OCP. The authors would like to thank Patricia Kahn (MSF-USA) for her careful proof-reading.