Implementation Of
Community-Based Management of Acute Malnutrition (CMAM)
In Kebbi State
Nigeria
May-June 2009
Valid International
Gertrude Nyirenda
Anna Cirera
Anne Walsh
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Implementation of CMAM report Nigeria May 2009
Table of contents
Acknowledgements ………………………………………………………………………..……3
Abbreviations and Acronyms…………………………………………………………………...4
Executive Summary……………………………………………………………………………..5
1. Introduction…………………………………………………………………………………6
1.1. Situation analysis of Kebbi State……………………………………………………...7
1.2. Project background…………………………………………………………...……….7
1.3. Objectives of the mission……………………………………………………………...8
1.4. Methodology…………………………………………………………………………...8
2. Assessment of selected programme sites: OTPs and Stabilisation Care..…..……………11
2.1 Catchment’s area population, distances and number of facilities……….………....…11
2.2 Health facility level and infrastructures…………………………………….…………..14
2.3 Equipment and supplies………………………………………………….……………..15
2.4 Staffing pattern …………………………………………………………….…………….16
3. Set up of OTPs……………………………………………………………….……………...18
3.1 Training for health staff and supervisors:………………………………………………19
- Participants……………………………………………………………………19
- Contents……………………………………………………………………….19
- Methodology……….…………………………………………………………19
- Evaluation…………….……………………………………………………….19
3.2 Mentoring at OTP sites………………………………………………………………...19
- Staff…………………………………………………………………………….20
- OTP admissions and follow up……………………………………………...21
- Evaluation……………………………………………………………………..22
3.3 Stabilisation Care………………………………………………………………………..23
3.3.1 Mentoring at referral hospital……………………………………………………..23
- Staff…………………………………………………………………………….23
- In-patient care……………………………………………………………...…23
- Evaluation………………………………………………………………….....24
3.4. Supplies and equipment……………………………………………...………………...24
4. Way Forward…………………………………………………………………………………25
5. Conclusions and Recommendations……………………………………………………….26
Annexes…………………………………………………………………………………………..28
Annexe 1- RUTF
Annexe 2- OTP sites
Annexe 3- Orientation course
Annexe 4- Handouts
Annexe 5- Admission criteria
Annexe 6- Discharge & Exit criteria
Annexe 7- Routine medicines
Annexe 8- Supplementary drugs
Annexe 9- Revised OTP card
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Implementation of CMAM report Nigeria May 2009
ACKNOWLEDGEMENTS
We wish to express our appreciation to the representatives of the Ministry of Health at State and LGA level for their commitment and contribution to the success of the set up of the OTP/SC sites in Augie and Birnin Kebbi LGAs. In particular, we would like to thank Alh. Aliyu Libata (State Nutrition Officer), Mrs Beatrice Kwere (State assistant nutrition officer) and the community and clinical supervisors. We would also wish to thank Professor Frank Onyezili, Mr San San Dimanche and Mrs Florence Oni from UNICEF for the overall organization and excellent support provided throughout the mission. Last but not least, we are grateful to all volunteers and staff members who actively participated during the training and the field work.
ABBREVIATIONS AND ACRONYMS
ACF Active Case Finding
ADP Area Development Program
CBNC-P Community-Based Nutrition Care Programme
CHEW Community Health Extension Workers
CHO Clinical Health Officer
CMAM Community-based Management of Acute Malnutrition
CORPS Community Resource Persons
CTC Community-based Therapeutic Care
DHS Demographic and Health Survey
EHA Environmental Health Assistant
EHT Environment Health Technician
GAM Global Acute Malnutrition
HBC Home-Based Care giver
JCHEW Junior Community Health Extension Workers
LGA Local Government Area
MDG Millennium Development Goals
MICS3 Multiple Indicator Cluster Survey 3
MUAC Middle Upper Arm Circumference
OTP Outpatient Therapeutic Programme
PHC Primary Health Care
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SC Stabilization Centre
SFP Supplementary Feeding Programme
TFP Therapeutic Feeding Programme
UNICEF United Nations Children Fund
VHW Village Health Worker
VCW Village Community Worker
W/H Weight for Height
WFP World Food Programme
WHO World Health Organisation
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Implementation of CMAM report Nigeria May 2009
EXECUTIVE SUMMARY
After the feasibility assessment for setting up CTC/CMAM programmes conducted in December 2008, UNICEF contracted Valid International to provide technical support during the first phase of implementation in two LGAs and ten outpatient therapeutic programme sites of Kebbi state. The mission lasted from the 9th of May to 9th of June 2009; three Valid consultants participated in the clinical set up and one consultant in the community mobilisation component. Orientation for local authorities and partners and onsite training to all staff implementing the CMAM programme was provided.
Kebbi state did not have any essential nutrition actions in place and not even growth monitoring was being implemented. The management of severely acute malnutrition was upgraded just recently and had been restricted to a hospital-based approach following WHO protocols, limiting coverage and impact.
Before the set up of the Community-based Therapeutic Care (CTC) model, also known as Community Management of Acute Malnutrition(CMAM),l community mobilisation and training of volunteers was undertaken in order to identify and refer children who fulfilled the admission criteria through MUAC and presence of oedema. Although health facilities had reported an average of one to three cases of malnourished children in a month, active case finding lead to discovery of a serious nutrition emergency situation.. A total of 429 children were admitted in the ten Outpatient Therapeutic Progamme (OTP) sites during the two and three weeks of the CMAM set up in Birnin Kebbi and Augie respectively. Among the children enrolled in the programme, 98% of them were admitted due to a MUAC below 11cm, 1.5%due to bilateral oedema and 0.5% due to other reasons.
The level of selected health facilities, number and categories of staff involved in the CTC were higher in Birnin Kebbi and as a result the initial performance was better. However, staff showed an outstanding commitment to the programme, and an eagerness to learn more and develop their skills. A problem of drug supply particularly in Birnin Kebbi LGA, physical examination, clinical management and interpretation of signs and symptoms and nursing skills were some of the main problems identified during mentoring and supervision.
Re-enforcement of the health system, integration, partnership and commitment of the State and LGA level will be crucial for the ongoing success of the programme. In order to assure quality of care, the capacity of the State in terms of human resources, logistics and supplies must be taken into consideration. Therefore, to scale up CTC/CMAM, it will be better to start in another Northern State rather than to increase the number of OTP sites. A sustainable monitoring and supervision system at State level must be institutionalised to ensure continued support and development of this programme.
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Implementation of CMAM report Nigeria May 2009
1. INTRODUCTION
Although in Nigeria the magnitude of childhood malnutrition is not recognised, the nutrition situation in some States, especially in the North West and East, has been proven to be a real silent emergency. According to the Nigeria Demographic and Health Survey (DHS) 2003, and the Multiple Indicator Cluster Survey 2007, the prevalence of severe acute malnutrition (SAM) is above 2%; States like Kano or Niger registered 10.9% and 13.0% of wasting respectively (DHS 2008) and the situation in Zamfara is even worse at 32%(figure 1 shows prevalence of malnutrition in Nigeria by state).
Valid International conducted a feasibility assessment and carried out a plan of action for advocacy/sensitization of stakeholders in December 2008. Following the road map designed with UNICEF for implementation of CTC/CMAM in targeted States and LGAs with high levels of acute malnutrition in Nigeria, during the months of May and June 2009 technical assistance was provided for the set up of OTP sites and inpatient care.
In the first phase, it was decided to start a pilot Community Based Management of Acute Malnutrition programme in one of the States; Kebbi, situated in the North West region of Nigeria, Augie and Birnin Kebbi were the two Local Government Areas (LGAs) identified to place the sites out of the twenty one existing in the State.
Figure 1. Prevalence of moderate and severe wasting in Nigeria
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Implementation of CMAM report Nigeria May 2009
1.1 Situation analysis of Kebbi State
The nutritional status of children in Kebbi State requires special attention as data from different sources reveals a high number of under five children who are suffering from malnutrition. The prevalence of severe acute malnutrition was estimated at 3.8% by the Nigeria DHS 2003, but according to the Multiple Indicator Cluster Survey (MICS3, 2007) it reaches even 7.7%, with approximately almost 50.000 children below -3 SD weight for height (see table 1). The two selected LGAs, Augie and Birnin Kebbi could have SAM rates of 2,8% and 2.5% respectively; however, additional investigations are needed, as data available is not updated or unreliable. In absolute number there are 1,806 and 10,428 acute severely malnourished under-5 children in the 2 LGAs respectively.
Table 1. Nutritional status of children underfive in Kebbi State (MICS3)
Total Population (2006) / Pop Under 5(20%) / Moderate Underweight / Severe Underweight / Moderate
Stunting / Severe Stunting / Moderate Wasting / Severe Wasting
Kebbi / 3,238,628 / 647,726 / 45.1% / 24.8% / 55.6% / 41.3% / 20.3% / 7.7%
Augie LGA / 117,287 / 23,458 / 10,579 / 5,818 / 13,043 / 9,688 / 4,762 / 1,806
Birnin Kebbi / 651,620 / 135,426 / 61,077 / 33,585 / 75,297 / 55,931 / 27,491 / 10,428
In spite of this situation, there are no essential nutrition actions in place at State level. Growth monitoring is not being implemented and it was just recently that hospital health staff has been trained on in-patient treatment of acute malnutrition with water-based therapeutic milk, F-75 and F-100 (WHO protocols). Therefore, the management of SAM has been restricted to a hospital-based approach focused on therapeutic feeding centres (TFC), greatly limiting coverage and impact.
The PHC health system at Birnin Kebbi and especially Augie LGAs is collapsed. There is no equipment and medical supplies, and the existing cost recovery system has lead to a very low utilisation of health services. The few drugs that are available are mainly as a result of donations from politicians but usually health workers buy drugs and charge patients on home visits. Apart from the expanded programme of immunization (EPI) services, which register a very low coverage of children vaccinated indeed, there is very little knowledge and implementation of childhood programmes such as IMCI. There is a coordinator for nutrition interventions at State and LGA level but no existing protocols. The reported case load prior to the of malnutrition at PHC centres or dispensaries prior to this intervention was on average one to three children per month and around five in the stabilisation centres of both LGAs .
1.2 Project Background
UNICEF in its quest to support Nigeria in attaining its MDG 4“ reduction of under five mortality” in Nigeria from 138/1000 and to 63.7/1,000. Moreover, indices shows that more than 50% of these under 5deaths have malnutrition as an underlying cause, UNICEF embarked on supporting the government of Nigeria to manage this silent emergency in particular the Ministry of Health by providing technical support in management of severe acute malnutrition through the CTC/CMAM approach in the country. As a result, in December 2008, UNICEF contracted Valid International to conduct a feasibility assessment of setting up CTC/CMAM programmes. They found that there were indications of strong political will to implement CTC/CMAM and the need for UNICEF to make the initial investments .A major recommendation from the Valid consultancy was a targeted and phased implementation strategy .
It is against this background that UNICEF re-contracted Valid International to assist with the setting up of CTC/CMAM in the state to provide technical support during the first phase of the set-up in two LGAs and ten OTP sites (five OTP sites in each LGA). Kebbi state was selected as a pilot site for the programme due to its high under five mortality rate (166/100, 00 live births) against the national 138/100,000 and a high priority area to reinforce the reduction approach for MDGs. It is important to note that this high rate of SAM warrants an emergency action; however, an average of 1-3 reported cases of malnourished children in a month are reported in the health facilities.
The mission lasted from 9th of May to 9th of June 2009; three Valid consultants participated in the clinical set up and one consultant in the community mobilisation component.
1.3 Objectives of the mission
This first mission aimed to support efforts in Nigeria at developing national capacity to address nutrition issues using innovative community-based approaches to reach and treat children at community level by providing the necessary technical support to ensure an effective set up and implementation of the pilot CTC/CMAM, starting in 2 LGAs (Augie and Bernin Kebbi LGAs) in Kebbi state.
More specifically, this mission undertook the following activities:
· Onsite training provided to all staff implementing the CMAM programme through training workshops
· Orientation for local authorities and partners
· Technical support during the initial implementation phase of the programme.
1.4 Methodology
The CTC model introduced in Nigeria has three main components:
(1)- Community mobilisation stimulating the understanding, engagement and participation of the target population.
(2)- Outpatient therapeutic programme providing RUTF and routine treatment using simple medical protocols for children with severe acute malnutrition without complications.
(3)- Stabilisation centres providing inpatient care for acutely malnourished children with medical complications.
In addition to these three components, there is a supplementary feeding programme which at this stage of CTC implementation has not been included at Kebbi State. It provides dry take-home rations and routine basic treatment for children with moderate acute malnutrition without complications.
Figure2: Stages in CTC set up and implementation (OTP clinical implementation process)
Planning Phase Implementation Phases
Stage 1:
to obtain the ne
The planning process should involve local authorities and/or health service implementers in the assessment of existing capacity to implement components and services within the CTC programme.
a. Assessment of health structures and requirements
The programme aims to integrate CTC within existing health facilities, in order to ensure that effective treatment remains available for as long as acute malnutrition is present in the population. An OTP is implemented through a large number of decentralised points, however, at this first phase a limited number of OTP sites are selected, five in each LGA, in order to assure quality of care and the capacity for follow up. In planning the location, number and schedule of OTP days, the following should be considered:
Ø availability and capacity of existing health facilities.
Ø distance people will need to travel to reach the service; ideally, OTP facilities should be a maximum of three hours’ walk away (a one-day round trip).
Ø The predicted number of target beneficiaries according to nutrition survey findings, whether available.
Ø The opinions of key community figures on appropriate sites.
Ø Areas with the highest malnutrition levels, either according to existing data or local opinion where data is lacking.
Ø How access to sites may be affected by climate or other factors (e.g. rain affecting roads and river crossings).
Ø The timing of market days and general distribution days, and the schedule for health facilities’ outreach activity (i.e. days when health centre/clinic workers are away from their facility).