New York — Intense frustration is building across the aid community that despite its best efforts it has been unable to dent the catastrophic levels of suffering in South Sudan, worsened by war and a political class that doesn't seem to care.
"Every year we gather and we hold this meeting on South Sudan," International Organization for Migration chief William Swing said at UN headquarters last week. "The conclusion is always the same: It cannot get any worse. And each year we come back - in fact it has gotten worse."
The stock taking, part of a high-level meeting on South Sudan's crisis held on the sidelines of the UN's General Assembly gathering, was so awful that some aid officials are exploring alternative ways to alleviate the misery.
"I think we all feel that we are making far greater efforts to support, feed, look after the people of South Sudan than their government and their own leaders," said one Western diplomat. "I think the frustration played out throughout the entire week."
The metrics of suffering in South Sudan are shocking. Around 7.5 million people, or 60 percent of the entire country, are in urgent need of aid - 1.4 million more than a year ago.
The number of people displaced by the conflict between President Salva Kiir and his former vice-president Riek Machar has surpassed four million, including two million who have fled the country.
Mark Lowcock, the newly-installed chief of OCHA, the UN's office for emergency aid coordination, said famine has been narrowly averted in northern Unity State, but "the conflict has caused the number of people, just one step away from famine, to increase from one million to at least 1.7 million since February."
And then there is a cholera outbreak - South Sudan's worst ever, which particularly impacts the displaced.
"There is a recognition that something must change, and we can't find ourselves in a year from now in the same place," Abby Maxman, president of Oxfam USA, told IRIN.
As the civil war splinters the country into armed militia fiefdoms, it makes the task of humanitarian delivery far more complicated and dangerous.
Aid convoys travelling from Juba to Yambio in the southwest of the country have to negotiate with "12 different groups" along the road, said David Shearer, chief of the UN peacekeeping mission in South Sudan, known as UNMISS.
UNMISS is overstretched and has proved unwilling to challenge government or rebel soldiers blocking humanitarian access. On several occasions it has also failed to effectively protect civilians sheltering in UN camps.
Fewer than 700 of what was meant to be a more robust 4,000-strong Regional Protection Force, authorised by the UN Security Council a year ago, have arrived.
They are sorely needed. One of the most disturbing figures is the number of humanitarian workers who have been killed. Eighteen have so far lost their lives this year, bringing the total since the outbreak of the civil war in December 2013 to at least 85, said Lowcock.
South Sudan's First Vice President Taban Deng Gai suggested at the UN last week that aid organisations were putting themselves at risk by not asking the government for protection.
However, diplomats are sceptical.
"All armed actors must stop violent attacks on aid workers," said Norwegian Foreign Minister Borge Brende. "It is just terrible that people that really come to South Sudan... and really try to support people in dire need [are] killed."
But in his next breath, Brende added: "the international community has to continue its humanitarian support."
Therein lies the dilemma: how to continue assisting the millions of South Sudanese in need, while having only limited leverage over the warlords pursuing the war.
There is a long history of aid and donor money being pilfered and skimmed by the country's elite. In May, the government increased NGO registration fees six-fold to $3,500.
"Arbitrary and exorbitant taxes, burdensome regulations, and outright egregious rent-seeking behavior towards NGOs slows the effectiveness and efficiency of humanitarians in South Sudan," said Rob Jenkins, acting assistant administrator at USAID.
South Sudan was ushered into existence in 2011 with a large push from Washington. The United States remains the top humanitarian donor, spending over $700 million this year. Efforts to reform the aid system would therefore need Washington's support.
There seems to be willingness to at least explore options. In early September, USAID Administrator Mark Green told Kiir the US would be "undertaking a complete review of our policy towards South Sudan," according to an interview with the Washington Post.
"It's not a binary choice. There are some pretty significant downsides - politically and in terms of delivery itself - with the current approach to humanitarian assistance," said Payton Knopf, coordinator of the South Sudan Senior Working Group at the US Institute of Peace, and former head of the UN Panel of Experts on South Sudan.
"That does not mean, however, that the answer is to stop humanitarian operations. There are alternatives," he told IRIN.
Knopf recognised that "by far and away the preponderance of violence in the country, and the preponderance of obstruction, is being committed by the government."
So, "there needs to be far more reflection on conditionality and taking a much stronger, more unified line towards the government," he said.
But is the political will really there to, for example, divert assistance through a friendlier third country?
Some aid officials in New York cited the example of Operation Lifeline Sudan, a massive relief operation into southern Sudan run through Kenya, Ethiopia, and Uganda in the 1990s, as a potential alternative model of aid delivery.
A similar approach now would mean bypassing Juba in the flow of aid and money to the needy.
But OLS had a logistical imperative and was founded on a negotiated agreement between Khartoum, the then-rebel SPLA, and the aid community. Circumstances are different now.
The government in South Sudan jealously guards its sovereignty, and already accuses the UN system of siding with the rebels.
"I don't see any real appetite for cutting or shifting humanitarian aid," said a regional analyst who asked not to be named due to their work with a Western donor.
The fear is that there could be retaliation by the government if conditionalities over access were introduced.
"The difficulty with conditionality is that it's got to work on the basis that the people on the other side of the table care," said the Western diplomat.
"The South Sudanese authorities seem to feel immune to conditionality because they seem to think if you don't feed our people that's fine."