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Community management of acute malnutrition in Nigeria

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Nigeria has one of the highest rates of child malnutrition globally. Supported by the Children’s investment Fund Foundation (CIFF), UNICEF has supported the Nigerian government in its implementation of community management of acute malnutrition (CMAM) services in 12 states of northern Nigeria (2012-2018). CIFF contracted OPM to support the UNICEF programme through research and lesson learning (2017-19). Our learning project had three workstreams, as outlined below.

Mainstreaming and sustainability

Our advocacy in this area focused on:

  • government financial and institutional commitment and resourcing for CMAM;
  • the factors and strategies that promote government commitment, including the influence of the CIFF matched funding mechanism; and
  • CMAM management and oversight by senior leadership.

Longer-term outcomes for children

We looked oat outcomes for children after they have been discharged from the CMAM programme. These focused on:

  • relapse and re-admission;
  • severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) at follow-up;
  • morbidity/mortality; and
  • socio-economic predicators.

Performance assessment of CMAM data systems

This involved an assessment of:

  • the quality of the data produced by the CMAM monitoring system (completeness, timeliness, accuracy, reliability, integrity, confidentiality, relevance, and accessibility;
  • a comparison of the new SMS system with the existing paper-based system; and
  • an assessment of government readiness to manage the system and make effective use of the data.

Challenges

The UNICEF programme had the objectives to set up and strengthen the implementation of CMAM services through the Nigerian primary healthcare system, and to strengthen the institutionalisation of CMAM within Nigeria’s primary healthcare service, through policy, planning, and coordination, and promoting public financing.

The overarching aim of our research has been to support the Government of Nigeria and UNICEF learning about the progress and outcomes of the CMAM programme in northern Nigeria, and to share the learning with the global CMAM community.

Our approach

Government commitment and resourcing for CMAM: This study took a sample of three states (Gombe, Kano, and Sokoto) and federal government. It used a qualitative comparative case study approach combined with political economy analysis. The research was undertaken at six-month intervals over 18 months. This supported understanding of factors that affect progress and challenges. The analysis was based on key informant interviews with government stakeholders, civil society actors, UNICEF, and other development partners.

Assessment of the CMAM information system: This study used a combination of methods. The fieldwork included observation of data collection and recording at health facility level, analysis of data transmission, recounting of data for admissions, exit, and drug utilisation, and interviews with health workers and government officials. We also reviewed the data forms and training materials. The fieldwork focused on nine health facilities in one state (Sokoto). Additional analysis of CMAM facility data was undertaken in four states (Bauchi, Gombe, Kaduna, and Kano).

Longer term outcomes of the CMAM programme: This is a prospective cohort study of children admitted to the CMAM service in one focal state (Sokoto). We are collecting data on nutrition status, morbidity, socio-economic status, and quality of CMAM service data to enable us to determine the predictors of long-term child survival. The study follows two groups of children every two-weeks for six months post-discharge. One group is 700 children who were admitted to CMAM, while the other is a control group of 700 apparently healthy (non-wasted) children who have never been treated for SAM.

Outcomes 

Our analysis of government commitment and resourcing for CMAM helped to strengthen UNICEF’s strategy and engagement in several states. For example, our identification of bottlenecks and mapping of the fund release process strengthened UNICEF’s advocacy strategy. Our analysis of the fund release process has been shared with wider advocacy stakeholders in Nigeria. We also identified specific influencers and CSOs that could be engaged in advocacy, which contributed to the release of funds for CMAM. Our research contributed to CIFF’s decision to support a separate civil society nutrition advocacy project in Nigeria, which we also support.

Our assessment of the CMAM information system has been shared with government stakeholders, and used by UNICEF to plan additional support in Nigeria. Our analysis has also been shared with the wider international nutrition community.