From Pilot to Scale-Up: The CMAM Experience in Nigeria
By Maureen Gallagher, Karina Lopez, Stanley Chitekwe, Esther Busquet & Saul Guerrero
Maureen Gallagher is the Technical Coordinator for ACFInternational in Nigeria since July 2010. She has worked for the last 10 years in nutrition, food security and hygiene promotion programming in Niger, East Timor, Uganda, Chad, DRC, Burma, and Sudan.
Karina Lopez is Nutrition Advisor for Save the Children in Nigeria and started the CMAM pilot in Katsina state. She has worked in nutrition and CTC/CMAM programmes for over 7 years in countries like Cambodia, DRC, Mozambique and Swaziland.
Stanley Chitekwe is currently leading the UNICEF Nutrition Team in Nigeria. He has worked with UNICEF for over 12 years. He supported CMAM implementation in Malawi from 2005 to 2009 and has worked in Nigeria since 2010.
Esther Busquet has been a Nutrition Adviser in the Hunger Reduction and Livelihoods Team with Save the Children UK in London since 2010, mainly working on CMAM, a cost of diet tool and supporting country teams. Previously she has worked in nutrition programmes in Africa and Asia for ACF, CAFOD and UNICEF (2002-2009).
Saul Guerrero is the Evaluations, Learning and Accountability (ELA) Advisor at Action Against Hunger (ACF-UK). Prior to joining ACF, he worked for Valid International Ltd. in the research, development and roll-out of CTC/CMAM. He has worked in over 18 countries in Africa and Asia.
The authors would like to thank (in no particular order), Katsina SPHCDA, the Yobe state Primary Health Care Management Board (YSPHCMB), health workers and communities in both states for their support of CMAM activities. Thanks also to Oseni Azeez, Binyam Gebru, Caroline Enye, Susan Grant and Cecile Basquin for their support with the programmes and the development of this article. The authors would like to acknowledge the contribution of the Humanitarian Aid and Civil Protection Department of the European Commission Humanitarian Office (ECHO) for their support of the CMAM programmes in Katsina and Yobe states.
|DHS||Demographic and Health Survey|
|LGA||Local Government Area|
|MCH||Mother & Child Health|
|NHIS||National Health Insurance Scheme|
|OTP||Outpatient Therapeutic Programme (OTP)|
|PATHS2||Partnership for Transforming Health Systems 2|
|PRRINN/MNCH||Partnership for Reviving Routine Immunisation in Northern Nigeria/ Maternal Newborn and Child Health Initiative|
|SHAWN||Sanitation, Hygiene and Water in Nigeria|
|SNO||State Nutrition Officer|
|SPHCDA||State Primary Health Care Development Agency|
|SDU||Service Delivery Units|
|VCT||Voluntary counselling and testing|
|WASH||Water, sanitation and hygiene|
Community Mobiliser during an outreach visit in Yobe State
This article describes the experiences of ACF, Save the Children and UNICEF in supporting government scale up of CMAM programming in Nigeria.
Nigeria has the third highest number of children suffering from severe acute malnutrition (SAM) and stunting1 in the world. According to the 2008 Demographic and Health Survey (DHS), Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) rates were estimated at 13.9% and 7% respectively, with the worst rates detected in the north-western (19.9% GAM, 10.6% SAM) and north-eastern (22.2% GAM, 11.4% SAM) regions of the country (see Figure 1). UNICEF estimates that in Northern Nigeria alone, there are approximately 800,000 children suffering from SAM2.
In 2009, UNICEF, with the support of Valid International, launched a Community-based Management of Acute Malnutrition (CMAM) pilot programme in Kebbi and Gombe states. The pilots demonstrated the appropriateness of the CMAM model in the Nigerian context, and generated sufficient evidence to advocate for the expansion of services to other parts of the country.
In this context, and with support from ECHO3, Save the Children and ACF International launched pilot CMAM programmes in Katsina and Yobe states respectively. Both organisations sought not only to address the needs of the population in Northern Nigeria, but also to explore and evaluate different approaches to integrate CMAM into routine services in a sustainable manner. Along with other nutrition partners in-country (including MSF-F and MSF-H), UNICEF, Save the Children and ACF started to work on the development of CMAM approaches that would complement the type of support provided to State, Local Government Areas (LGAs) and health facilities, the integration of CMAM services into the health system, and quality of the care provided by health staff in pilot states (see Box 1).
|Box 1: Key aspects of the pilot programmes|
|Supporting agency||ACF||Save the Children (UK)|
|Number of LGAs (Number of OTPs)||3 LGAs (21 OTPs)||4 LGAs (40 OTPs)|
|Number of admissions||9,031 (Jan-Sept 2011)||21,750 (Sept 2010 – Sept 2011)|
|Nutrition guidelines||National CMAM Guidelines & WHO inpatient guidelines.||No national guidelines available at the start.
Save the Children developed guidelines used and then transitioned to national guidelines in April 2011.
|HR support||1 Programme Manager.
1 staff seconded to state.
6 staff supporting 21 SDUs in 3 LGAs (3 community, 3 OTP).
1 staff supporting 2 inpatient units.
|1 Programme Manager + 1 deputy
21 staff supporting 40 SDUs in 4 LGAs.
5 staff supporting 6 inpatient units
2 M&E officers & 1 data entry.
|Logistics||Support transport of RUTF from LGA to SDUs.||Storage of supplies at central level Support transport of RUTF to LGAs and then to SDUs.|
|RUTF||ACF supplied once by UNICEF (then shifted to direct supply State-LGA as state was directly supplied by UNICEF).||First phase of the pilot RUTF supplied by Save the Children (through programme budget and CHAI donations), though due to delays, loans were received from several partners. Then transitioned to supply by state from UNICEF.|
|Community volunteers||30-50 per SDU.
Motivation kit/no incentive.
|5 per SDU.
Incentive to those working on OTP days.
|OTP services||Undertaken by health workers with ACF coaching support.
Started once a week and some health facilities chose to extend services to 2 times a week.
|2 staff supporting each of the health facilities with CMAM (1 OTP, 1 Community). Undertaken once a week.
Trainings of other SDUS not providing OTP also done for stronger referral to focal health facilities.
Each organisation implemented CMAM programmes independently but under a common (yet informal) framework of coordination and information sharing. This collaborative approach enabled partners to seize the opportunity provided by additional DFID funding in late 2011 to launch a joint strategy for the scale up of CMAM in selected states (see Figure 2)4. The present article sets out to describe the approaches used by partner agencies in the design, implementation and monitoring of their pilots, and how the (strategic and tactical) lessons learned in this pilot phase will shape the future of CMAM in the country.
Key features of CMAM implementation in Nigeria
Selection of programme areas
The success of CMAM pilots rests partly on selecting adequate locations. From the start, both organisations sought to engage closely with the relevant federal, state, local government and ‘traditional’ authorities to ensure that their support would serve to strengthen, rather than undermine, existing nutrition and health strategies in the country. Each organisation, however, started their pilot under distinct conditions. Save the Children, present in the country since 2001, is a member of the Partnership for Reviving Routine Immunisation in Northern Nigeria/Maternal Newborn and Child Health Initiative (PRRINN/MNCH) operating in the northern part of the country. The selection of Katsina State was designed to maximise the synergy between existing PRRINN/MNCH and CMAM services. ACF, having recently arrived in the country, based the selection of Yobe State on a more general mapping of nutrition partners and availability of technical support in different states.
Once the pilot states had been selected, both organisations liaised with the relevant health authorities (including the State Primary Health Care Development Agency5) to jointly select Local Government Areas (LGAs) in which to implement the programmes6. In both states, the organisations supported all LGAs identified by the authorities, either as part of the first or the second phase of the pilot programme. The final stage of the selection process involved the identification of Service Delivery Units (SDUs) to be included in the first phase of the pilot. The selection of facilities was done in consultation with the LGA’s Primary Health Care (PHC) Coordinators. The selection of SDUs took into account different alternatives within each LGA, including Mother & Child Health Centres (MCH), Dispensaries and Health Posts. As part of the selection process, both organisations carried out joint needs assessment with staff from the LGA PHC departments. A number of issues were considered7 but the decision was ultimately influenced by three factors:
- Geographical coverage: the selection of sites aimed to ensure maximum possible coverage of the selected LGAs. In spite of the requests from Government in some areas (e.g. Katsina) for the introduction of CMAM in nearly all health facilities simultaneously, an approach of gradual introduction was ultimately agreed upon.
- SDU capacity: the analysis looked primarily at staffing. In Yobe, staff motivation played an important role in the selection of facilities for the pilot.
- Availability of routine drugs: facilities under the National Health Insurance Scheme (NHIS) and the Millennium Development Goal (MDG) scheme, which provide free drugs to U5 children, were prioritised.
The gradual introduction of CMAM during the pilot phase has influenced the vision guiding the scale-up process. There is a clear recognition that the work carried out in selected states must be consolidated before CMAM can be expanded to other areas of the country. The scale-up will therefore focus on covering more LGAs within states with existing CMAM services. In choosing these LGAs, the experiences of the pilot have also enabled the partners to develop a specific set of criteria (see Box 2) designed to maximise the potential for success. Political will and commitment and the means by which to deliver and sustain programme quality are essential determinants in this selection process. At a more local level, the selection of SDUs will also benefit from the experiences of the pilots. The criteria developed for the selection of SDUs (see Box 3) reflects the importance of accessibility (coverage), staffing & resources, and commitment highlighted during the pilot.
Box 2: Criteria for selection of local government areas (LGAs)
• Have a demonstrable nutritional problem as evidenced by accessing nutritional interventions in neighbouring LGAs, states or Niger Republic. Where possible, statistics should validate this problem (MNCH week MUAC screening, admission for inpatient treatment, etc).
• Be new with no ongoing CMAM intervention.
• Have an existing primary health structure with functional PHC facilities.
• Have the requisite number of health staff required for the management of a CMAM Out-Patient Therapeutic Feeding Programme (OTP) in the health facilities.
• Be able to dedicate the requisite number of staff for the OTP services.
• Have the political will and express commitment to address the observed nutritional situation in the LGA.
• Have functional community committees that drive the process of community involvement and engagement in each community, including the process of selection and functionality of community volunteers to support programme activities.
• Be able to provide a child-friendly health facility with appropriate infrastructural facilities.
• Be able to provide adequate essential drugs, equipment and basic infrastructure required for the intervention with appropriate plans to ensure replenishment without stock out.
• Be a part of the Partnership for Reviving Routine Immunisation in Northern Nigeria/Maternal Newborn and Child Health Initiative (PRRINN), Partnership for Transforming Health Systems 2 (PATHS2), Sanitation, Hygiene and Water in Nigeria (SHAWN) or other DFID projects
Box 3: Criteria for selection of service delivery units (e.g. health facilities)• The health facility should be made accessible (motorable road conditions, public transport, etc)
• The health facility should be able to provide basic essential PHC services (immunisation, antenatal care, nutrition/growth monitoring and HIV voluntary counselling and testing (VCT)).
• The health facility should provide or be rehabilitated to provide a child-friendly environment. Physical facility in good state, not in danger of collapsing.
• Space for consultation and adequate sitting facilities.
• Water, sanitation and hygiene (WASH) facilities in place and adequate hospital waste management.
• Availability of basic medical equipment and adequate storage space for supplies.
• Officer in charge committed to run the programme.
• Appropriate mix of health staff including community extension workers and nutritionists, where available. Usually a minimum of five health workers.
• Presence of referral mechanism (ambulance, referral tracking etc).
• Community acceptance of the facility.
• At least one health facility per ward.
Addressing human resource limitations
In both pilot areas, inadequate human resources were a primary constraint8. The support organisations developed plans to support and address existing gaps at different levels.
At state level, both organisations developed strategies to support State Nutrition Officers (SNOs) whose work had focused hitherto on school gardens and Vitamin A supplementation schemes9. The aim was to foster greater participation of the SNO in data collection, collation and analysis, supervision and supply management in all LGAs delivering CMAM (with or without the support of ACF and Save the Children10).
At LGA level, both programmes focused on supporting the PHC Coordinator and the Nutrition Focal Person. Both programmes successfully engaged Nutrition Focal Points by providing training and actively involving them in the initial assessment of facilities, the selection of Community Volunteers and their training. Whilst the involvement of Nutrition Focal Points decreased over time in Katsina, the involvement of PHC Coordinators increased, helping to secure drugs and basic equipment for CMAM activities. Other focal points at LGA level included the M&E (Monitoring & Evaluation) Officers, Health Educators and Maternal and Child Health Officers.
It was at SDU level that the approaches of the two agencies varied most. Save the Children, in order to achieve quality care (SPHERE standards) and prevent mortality among the numerous cases of SAM coming from the communities, created a robust support team, comprised of (Outpatient Therapeutic Programme (OTP) Officers and Community Volunteer mentors attached to each SDU, to complement and support SDU staff during OTP days. In addition, a medical doctor was recruited to supervise the Stabilisation Centres (SC) and two M&E Officers to follow-up on overall programme performance. ACF opted not to place any staff at health facility level for fear of jeopardising the sustainability of the programme. Instead, they relied on the process of SDU selection to delineate, from the start, the terms of the support that facilities would (and would not) receive as part of ACF’s involvement. From then on, much of the emphasis was placed on formal and on-the-job training11.
The actual involvement of both organisations was ultimately shaped by the realities of the emerging programmes. In both states, admissions into the programme increased rapidly. Between September 2010 and September 2011, the pilots admitted a combined total of 26,621 SAM cases (see Figure 3). In many cases, health facilities and their staff were overwhelmed by the number of admissions, leading to more active involvement of NGO teams in the running of daily activities. Both of these factors also had an impact on the inpatient component of the programme, as the high caseload affected the motivation of inpatient staff, many of whom were ‘volunteers’ without the qualifications necessary to manage the scale and complexity of the programme. Faced with a growing number of admissions, the health authorities opted to introduce complementary responses. In Katsina, the LGA created an OTP mobile team (10 people per LGA) responsible for supporting health facilities during OTP days. Although allowances were initially offered by the authorities, this never materialised, forcing Save the Children to step in to fill in the gaps and avert total disruption to programme activities12.
Supporting existing logistics systems
In order to maximise the impact of the pilot programmes, robust logistical support was provided to LGAs covered by the pilot.
The issue of RUTF supplies was addressed by each programme from a different perspective. Save the Children, in the initial stages, included Ready-to-Use Therapeutic Food (RUTF) as part of the support package and was therefore involved in its procurement and distribution. Yet, delays in both the arrival of RUTF in country and its release by Customs meant that the programme relied on loans from other organisations using RUTF in-country (e.g. MSF & Catholic Relief Services (CRS)), as well as requests for ad-hoc donations (Clinton Foundation (CHAI)). The high caseload and continuing delays in RUTF deliveries (for Save the Children and other organisations in-country) meant that by the time RUTF finally arrived on-site, it was quickly depleted through use and repayment. In spite of the early challenges, a more robust system was soon put in place. RUTF was provided by UNICEF through the State Primary Health Care Development Agency (SPHCDA), stored in Save the Children’s central stock in Katsina and then delivered to the SDUs across the LGAs, where it fell under the supervision and management of the facilities’ in-charges.
By the time ACF started operations in Nigeria, RUTF supplies into the country were stabilising, enabling them to work directly with UNICEF for the procurement and supply of RUTF for Yobe State. Thus, only a buffer stock was included as part of the support package to enable the programme to respond to unanticipated shortages and stock-outs. Following the lead of UNICEF’s approach in Nigeria, Yobe State authorities collected RUTF from UNICEF’s regional office, LGA authorities collected from the State’s central stock, and ACF supported the LGAs in the final delivery to the SDUs. In both programme areas, further efforts are planned to ensure a more comprehensive handover of responsibility to the local authorities for the procurement and management of RUTF. Save the Children complemented the transport provided by the SPHCDA by renting and buying other vehicles, whilst ACF donated motorcycles to the supported LGAs to support regular supervision.
In terms of essential drugs, both programmes relied on health structures for the supply of most essential drugs associated with the programme. This was recommended by UNICEF as a good mechanism to strengthen LGA ownership of CMAM. Nonetheless, drugs were also purchased to cover gaps as the LGA had challenges in providing the drugs for CMAM activities.
A mother at an OTP in Northern Nigeria
These experiences have had two significant implications on the scale-up of activities. The first is the delegation of all responsibilities for the procurement of RUTF at a national level to UNICEF. They will be responsible for the distribution to their zonal offices, or directly to states to minimise storage costs. From then on, each LGA will be expected to request from the State and make necessary arrangements for its collection. Save the Children and ACF will support this process by working with LGAs in calculating and forecasting needs, and accounting for common delays related to procurement, clearance and transport.
The second is the decision to exclude essential drugs from the support package offered by the partnership. This decision was influenced by a number of factors, including costs (which in a project of this scale would be prohibitively expensive) and monitoring the appropriate use and non-commercialisation of drugs due to the time implications for staff. Ultimately, however, it is the fact that most states have free MNCH that has proven most critical. CMAM is seen as an opportunity to advocate to states that they should honour their commitments, and assume their responsibility to include essential drugs in their annual budget. There are obvious risks associated with this approach, including the introduction of fees for essential drugs, stockouts, and/or longer recovery times. Yet, the decision has meant that political ownership and commitment is not just important but essential to the success of the intervention.
Technical support & capacity building
The pilot programmes recognised the value of each agency’s prior experience with CMAM, and made the most of this opportunity to develop and adapt national protocols, guidelines and training material to build on known best practices whilst acknowledging the particular needs of the Nigerian context.
For outpatient treatment, both programmes used pre-existing CMAM guidelines. When preparations began for the implementation of the Save the Children pilot in Katsina, discussions about CMAM Guidelines for Nigeria were still ongoing. As a result, training materials and job aids had to be developed using documents and experiences from other countries (including FANTA CMAM Training Package, Nigeria’s basic pack developed by the Clinton Health Access Initiative, and material from CMAM programmes around the world). These tools were progressively adapted based on decisions made by the CMAM Taskforce incountry and the finalisation of the National Guidelines. This had practical implications for the pilots. Whilst the pilot in Katsina originally introduced both MUAC and weight-for-height entry criteria, delays in procuring the necessary anthropometric tools and the prioritisation of MUAC at national level meant that MUAC was ultimately adopted as the primary entry criteria into the programme. In the case of Yobe, where activities began later, ACF was able to secure approval from the Federal Ministry of Health to begin using the CMAM guidelines developed by the CMAM Taskforce, facilitated by Valid International, in September 2010. This enabled the programme to begin immediately using national tools and criteria (e.g. MUAC as entry criteria). For inpatient treatment, both organisations relied on WHO manuals and the experience of local trainers previously trained by UNICEF (see Box 4).
|Box 4: CMAM training in pilot states|
|Yobe State||Health Workers||ACF Nutrition Programme Officer & Nutrition Focal Persons||4 day theoretical/practical followed by on-thejob support||Module 8, FANTA Training Package, National CMAM Guidelines & Draft Training module|
|Community Volunteers||ACF Staff & LGA Health Promotion Officer||1 day theoretical/practical, on-the-job follow-up||National CMAM Guidelines & Draft Training module|
|Inpatient Staff||ACF Staff with participation of State Nutrition Officer||4 day theoretical training, 1 day practical training||WHO Guidelines|
|Katsina State||Health workers from all Health Facilities in the LGA||Save the Children staff||3 day mostly theoretical training followed by on-the-job support||FMOH/CHAI training modules, FANTA training modules, integration of IYCF support into CMAM training modules, other countries’ training materials|
|Community Volunteers||Save the Children Staff with LGA Nutrition Focal Persons||1 day theoretical/practical training followed by on-the-job support||Training curriculum developed by Save the Children for the programme|
|Inpatient Staff||Master Trainers with Save the Children staff||5 days standard WHO inpatient training according to manual (adapted to CMAM)||WHO Training course on the management of severe malnutrition|
The scale up partnership will build on the lessons learned from the pilot phase. With the support of UNICEF, the technical framework required for the scale up of CMAM will be created, including the finalisation and dissemination of national training schemes for CMAM. Existing MoH trainers will receive additional technical support, coaching and refresher training, and new trainers will be identified and supported if necessary. Training tools will be in line with the standardised package being developed by the CMAM Taskforce in the country. UNICEF will also play a pivotal role at advocating, at a national level, for improved CMAM investment and policy-making (including the introduction of CMAM into the national health curriculum).
|Box 5: Coverage assessment results (Katsina & Yobe states)|
|Location||Coverage Estimate||Barriers to Access Identified|
|Daura & Zango LGAs
(36.7% - 52.7%, 95% CI.)
(24.4% - 42.7%, 95% CI.)
|Awareness about the programme
Waiting times on-site
At a more local level, Save the Children and ACF will place an advisory team in the field to support health authorities at State and LGA level in order to build capacities of key individuals (responsible for programme delivery) in programme management and planning. The approach aims to strengthen capacities at the management level in order to improve ownership and sustainability. State Nutrition Officers and the PHC Department at the LGA level will be trained and coached until they are able to take over fully the State Nutrition Programme. They will also focus on building the capacity of local health workers and facility staff on issues ranging from CMAM implementation, infant and young child feeding (IYCF) to M&E systems. The experiences of UNICEF and ACF in training health staff at regional, state and LGA level and providing subsequent support and supervision will be replicated.
The pilot programmes introduced mechanisms to foster community participation and involvement in CMAM activities. Both programmes engaged with religious leaders, traditional leaders, administration officials, Traditional Birth Attendants (TBAs), Traditional Health Practitioners (THPs) and other key figures of the community (e.g. hairdressers). In Yobe, ACF carried out a Rapid Socio-Cultural Assessment (RSCA) designed to provide a more complete picture of the context in which the programme operates, and the opportunities and challenges presented by it. In order to strengthen case finding, the project identified and trained between 30 – 50 volunteers per SDU. These were identified jointly with community leaders to ensure that they were from communities within the SDU catchment area. By focusing on training a large group of volunteers per health facility, the project pre-empted the high dropout rate that generally accompanies CMAM programmes13.
In Katsina, the programme initially introduced Community Mobilisation mentors to support volunteers (five per SDU) in the sensitisation, case-finding and follow-up activities. The mentoring approach was soon superceded, however, by a desire to reach more cases and the Community Mobilisation mentors became more directly involved in sensitisation activities at community level. From the outset, community volunteers were involved in supporting OTP days at the SDUs. They learned about treatment and this became particularly useful during strikes or at times of conflict, as volunteers supported by Red Cross and National Orientation Agency volunteers (who had received similar training to the community volunteers) were responsible for maintaining activities and avoiding interruptions to the treatment.
The pilot experiences provided ample evidence of the importance of community mobilisation, but also served to highlight the challenge of linking services at SDU level with communities, and the resource implications of this process. The scale-up approach will therefore explore ways of utilising existing resources such as the Nutrition Focal Person and Health Educator at the LGA PHC to support these activities and the work of the Community Volunteers. Linking CMAM with other health activities (such as MNCH weeks, immunisation, malaria programmes) will also be used to increase community awareness about the problem and the services available. RSCAs will be conducted to support community mobilisation activities in programme areas on best message delivery mechanisms; in the new projects areas, RSCA will be used for the first time to collect information for larger (and more heterogeneous) populations. The aim of the partnership is also to create a more meaningful dialogue with beneficiary communities, by creating mechanisms for improved accountability and capable of delivering beneficiaries views about CMAM and its activities to those responsible for CMAM policy and practice.
Monitoring & Evaluating Performance
In order to monitor and evaluate their performance, the pilot projects relied on the indicators provided by the CMAM National Guidelines. In line with most international standards, these included standards for cured (>75%), defaulters (<15%), mortality (<10%) and coverage (>50%).
Each programme established its own data collection and monitoring system. In Katsina, at the request of the SPHCDA, Save the Children collected (first weekly and then monthly) figures through their OTP support team. In Yobe, ACF support staff also visited SDUs on a weekly basis, using these visits to carry out the necessary data collection to produce weekly reports including statistics and key activities, needs and challenges faced. An additional monitoring system has also been included (mostly in Yobe) to identify “needs for strengthening” for each SDU, with all facilities categorised (red, yellow and green) according to their capacity to carry out treatment of acute malnutrition independently. Both pilot programmes also assessed their coverage using the Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) methodology. These assessments were carried out jointly by both organisations in August – September 2011, and the results of these investigations led to significant changes in each pilot (see Box 5). In Yobe, it resulted in the expansion of CMAM services to new SDUs (to reduce distance) and the strengthening and diversification of sensitisation activities (including drama, radio and visual materials)14. In Katsina, it also resulted in the strengthening of community mobilisation activities, and an increase in the number of volunteers operating within catchment area of CMAM SDUs.
In both programmes, data collection and reporting has been largely the responsibility of the NGOs, who have in turn reported to state authorities. Both programmes actively encouraged the State Nutrition Officer (SNO) and LGA Nutrition Focal Point to participate in these visits with varying degrees of success. To foster greater participation, a national reporting format was presented in July and August 2011 to all State Nutrition Officers from north-eastern and north-western states. This was followed by trainings for LGA Nutrition Focal Persons and M&E Officers, and additional training of SDU staff. Trainings focused on data collection mechanisms as well as on the importance of the data in understanding what is happening at each health facility level and the rationale for its collection and reporting of such data. This helped create a simple yet innovative15 data collection and reporting line stretching from each SDU to policy makers at state level.
During the scale-up phase, monitoring activities will be carried out by M&E officers at LGA PHC departments, with the help of the M&E Advisors based at state level providing support to different LGAs. In choosing the most appropriate M&E framework, the experiences from the pilot have been pivotal. There is consensus that the nationally agreed M&E system (based on national CMAM guidelines) is a suitable starting point. Additionally, the experiences of both Save the Children and ACF in conducting coverage assessments has led to its inclusion as a key feature of the monitoring plans for the scale-up phase.
Conclusions and recommendations
Mothers waiting with their children for appetite test
While nutritional treatment services have become increasingly available in health centres across Nigeria, the need still remains extremely high. Whilst the number of SAM children treated – 44,000 in 2010 alone – are more commonly associated with emergency situations, the only response capable of addressing needs is through horizontal programmes integrated into health systems and communities. The question that the ACF and Save the Children pilot programmes sought to answer is how, in the context of Nigeria, this can be done most effectively and sustainably.
The pilots show that part of the answer lies in thinking about the delivery of CMAM services outside of the traditional NGO model, from rethinking the need for individual stations at OTP level, to admitting children on a weekly (rather than daily) basis. For integration truly to occur, CMAM services need to be tailored to fit health systems at different levels, even if this ultimately leads to significant variations across different locations. There is not one approach that will fit all of Nigeria, or even all the LGAs in a state. Tactical diversity should be encouraged.
Other aspects of CMAM programming need to be strengthened and enforced. CMAM was founded on a commitment to reaching a high proportion of the affected population, and this vision needs to remain at the core of national strategies for their CMAM integration. The number of geographical areas (e.g. states) or facilities within them offering the service is a means to this end, not an end in itself.
Ensuring that integrated CMAM programmes achieve the highest possible coverage is closely linked to the degree of community mobilisation carried out. Scarce resources, overburdened staff, and limited experience have traditionally hampered the ability of health systems to develop community mobilisation strategies to accompany the introduction and implementation of CMAM services. NGOs have a crucial role to play in this regard. Increasing community awareness and participation in activities is a key feature of what local health systems will need to do in order to address needs. In high prevalence areas, like Northern Nigeria, increasing awareness must be accompanied by a simultaneous strengthening of health systems responsible for managing any rise in demand.
The roll-out of CMAM services in many high-prevalence contexts, including Nigeria, has stretched the capacity of government and support agencies to maintain RUTF supplies. The pilot programmes showed the risks of scaling up without proper RUTF supplies, a risk that only increases in magnitude and likelihood with the scale-up of CMAM services on a national scale. Ultimately, the sustainability and quality of CMAM programmes depends on the degree to which governments (at federal, state and local level) are willing and able to ensure adequate procurement and delivery of RUTF. Partners have a vital role in building capacities at all levels on stock management, including accurate forecasting. Having more accurate data on needs help to advocate for state governments and budget allocation.
Delivering this kind of support ultimately requires a redefinition of the role of NGOs, from a traditionally implementing role, to one as an enabler. Technical support proved essential in the implementation of CMAM in Nigeria, at federal, state and local levels. The decision not to include staff in SDUs was certainly vital to the sustainability of the project. The NGO role must become one of capacity strengthening and transfer of skills. Advocacy and the ability to support the development of national policies to create the right environment for CMAM are vital to the success of a scale-up framework.
1ACF Strategic Plan 2010-2015 & UNICEF ‘Tracking Progress on Child and Maternal Nutrition. A survival and Development priority. November 2009. World Bank, Nutrition at a glance, Dec 2010
2As cited in ‘Commission Decision on the financing of humanitarian actions in West Africa from the 10th European Development Fund’. European Commission, 2010
3Humanitarian Aid and Civil Protection Department of the European Commission
4Under this formalised partnership, UNICEF/Save the Children/ACF will continue to focus on the current 11 states supported by UNICEF, but will make a coordinated attempt to consolidate and extend CMAM services in five of those states (Jigawa, Zamfara, Yobe, Katsina and Kebbi) and in the process, help create the right environment for health systems across the country to plan, implement and support CMAM activities.
5State Primary Health Care Agencies (SPHCDA) are the government body in charge of all Primary Health Care (PHC) activities, with state Ministries of Health (SMOH) having a focus on policies.
6In Katsina, Save the Children prioritised LGAs undertaking PRRINN/MNCH activities. In Yobe, the SPHCDA was not yet in place during this period, so ACF liaised with other health authorities, including PHC Directors from the Ministry of LGA & Chieftaincy Affairs and the Ministry of Health.
7Other considerations included willingness to participate, HR capacity (including number of staff and technical expertise), physical structures available, ongoing routine activities, water availability, understanding of malnutrition and estimated caseload (based on previous weeks attendance).
8In the case of Yobe State, the problem was particularly acute due to a ban, in place for over five years, on the recruitment of additional technical staff. As a result, existing staff at facility level are often trained as Community Health Extension Workers (CHEWs) and many of the in-charges possess only an environmental sanitation diploma, leading to a limited number of technical staff.
9CMAM started in Katsina State in July 2010 and in Yobe State in November 2010 with support of UNICEF.
10The state support component implemented by ACF for all of Yobe state (ACF and UNICEF supported LGAs) was jointly planned and designed with UNICEF team in Abuja. A ToR was then agreed with the state and zonal UNICEF offices.
11ACF did not provide any stipend to health staff or Community Volunteer working on CMAM activities, though per diems were provided during formal trainings in line with PRRINN/MCH’s standards in the state.
12For this, Save the Children signed an MOU with the LGA authorities in which it was stated that the first six months of allowances would be provided by the organisation and subsequently the LGA would take over this responsibility, this was done to provide some time for the LGA to allocate budget to this effect.
13During this process, the organisation provided no stipends or incentives, other than the tools required for their work (e.g. laminated photos, MUAC and CMAM volunteer bags).
14A follow-up SQUEAC will also be conducted in 2012 to indicate the possible impact of the programme changes on its coverage.
15CMAM programme data in Yobe State, for example, is collected by the Nutrition Focal Person who in turn shares it with the State Nutrition Officer (SNO) on a weekly basis via SMS. In-charges of health facilities send the SDU data and RUTF consumption at the end of the OTP service day or week to the Nutrition Focal Person who then compiles and sends it to the SNO by SMS. Nutrition Focal Persons often work with support of M&E Officers in the compilation of the data (a desktop, stabiliser & printer were donated by ACF to each LGA for these purposes).
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Reference this page
Maureen Gallagher, Karina Lopez, Stanley Chitekwe, Esther Busquet & Saul Guerrero (2012). From Pilot to Scale-Up: The CMAM Experience in Nigeria. Field Exchange 43: Government experiences of CMAM scale up, July 2012. p89. www.ennonline.net/fex/43/from