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Field Article
Box 4: CMAM training in pilot states
Location Participants Facilitator Method Tools
Yobe State Health Workers ACF Nutrition
Programme Officer &
Nutrition Focal
Persons
Katsina State
Community
Volunteers
Inpatient Staff
Health workers
from all Health
Facilities in the
LGA
Community
Volunteers
Inpatient Staff
ACF Staff & LGA
Health Promotion
Officer
ACF Staff with
participation of State
Nutrition Officer
Save the Children
staff
Save the Children
Staff with LGA
Nutrition Focal
Persons
Master Trainers with
Save the Children
staff
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
Box 5: Coverage assessment results (Katsina & Yobe
states)
Location
Daura &
Zango LGAs
(Katsina
State)
Fune LGA
(Yobe State)
Coverage
Estimate
44.6 %
(36.7% - 52.7%,
95% CI.)
33.0%
(24.4% - 42.7%,
95% CI.)
Barriers to Access
Identified
Distance
Stigma
Rejection
Seasonal Migration
RUTF stock-outs
Awareness about the
programme
Waiting times on-site
Rejection
Distance
4 day
theoretical/practical
followed by on-thejob
support
1 day
theoretical/practical,
on-the-job follow-up
4 day theoretical
training, 1 day
practical training
3 day mostly theoretical
training followed
by on-the-job support
1 day
theoretical/practical
training followed by
on-the-job support
5 days standard WHO
inpatient training
according to manual
(adapted to CMAM)
Module 8, FANTA Training Package,
National CMAM Guidelines & Draft
Training module
National CMAM Guidelines & Draft
Training module
WHO Guidelines
FMOH/CHAI training modules,
FANTA training modules, integration
of IYCF support into CMAM training
modules, other countries’ training
materials
Training curriculum developed by
Save the Children for the
programme
WHO Training course on the
management of severe malnutrition
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).
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).
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.
Mobilising communities
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 programmes 13 .
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
13
During 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).
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