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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 training 11 .
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 activities 12 .
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
Lucia Zoro, Northern Nigeria, 2011
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.
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
11
ACF 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.
12
For 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.
Figure 1: SAM & GAM prevalence rates in Nigeria,
2008 (by regions)
NORTH WEST
53%
20% NORTH EAST
49%
22%
NORTH CENTRAL
44%
SOUTH WEST 9%
31%
9%
SOUTH
SOUTH
31%
7.5%
Source: NDHS, 2008
SOUTH
EAST
22%
8.6%
% STUNTING
% WASTING
Figure 2: CMAM programme (pilot and scale-up
areas)
No. SAM Children Admitted
12000
10000
8000
6000
4000
2000
0
KATSINA STATE
ABUJA
YOBE
STATE
PILOT LGAs
Figure 3: Pilot programme admissions Katsina & Yobe
states (number of SAM children, September
2010-September 2011)
5461
939
2129
2523
3823
4418
7328
Sept - Dec 10 Jan - Mar 11 Apr - Jun 11 July - Sept 11
Months
Katsina state
Yobe State
A mother at an OTP in
Northern Nigeria
92