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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). 93
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 (
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July 2012 Issue 43 ISSN 1743-5080 (
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