PARTNER FINAL REPORT

PARTNER FINAL REPORT 1

FINAL REPORT COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION (CMAM) 11 STATES OF NORTHERN NIGERIA Implemented by UNICEF and Partners In collaboration with Federal and State Governments of Nigeria July 2013 September 2015 Funded by: Children s Investment Funds Foundations (CIFF) Covering grants SC130444 and SC140633 October 2015 2

Organization name: Program title: Lead partner contact: UNICEF Community Management of Acute Malnutrition in Nigeria. Arjan De Wagt, Chief of Nutrition, UNICEF Country Office Abuja, Nigeria (Email: adewagt@unicef.org) CIFF Portfolio Manager: Claire Harbron, Portfolio Manager, Children s Investment Fund Foundation Programme year: July 2013 to September 2015 (Agreement signing date 3 rd July 2014) Reporting period: July 2013 to September 2015 (Final report) Date: October, 2015 3

Table of Contents Financial Utilization Report Summary Table... 5 Acronyms... 6 1. Executive Summary... 7 2. Background... 9 3. Progress in the implementation of Programme activities: July 2013 to September 2015... 11 3.1. Expanded availability of CMAM intervention... 11 3.1.1. Admission and performance indicators... 11 3.1.2. Analysis of Key Performance Indicators... 11 3.1.3. Summary of Performance Indicators:... 12 3.1.4. Progress in Achievement on Milestones... 15 3.1.5. Progress in Achieving the Key Performance Indicators (KPIs)... 16 3.1.6. Supply Chain and Logistics Management... 16 3.1.7. Supply chain analysis and improvement plan... 17 3.2. Improved quality and continuum of care from community to OTP care... 19 3.2.1. Continuum of care analysis... 19 3.2.2. Strengthening CMAM programme monitoring and supervision... 22 3.3. Coordination at Federal and States Level... 22 3.4. Increased political commitment and leadership for increased nutrition resource allocation... 22 3.4.1. Leadership and coordination... 22 3.4.2. Advocacy for leveraging resources... 23 3.4.3. Advocacy strategy... 23 3.4.4. Media dialogues... 24 3.4.5. Press Release`... 24 3.4.6. Fundraising to public institutions... 25 3.5. Stakeholders Meeting at States... 25 3.5.1. Coordination and Cooperation with CMAM Partners... 26 3.5.2. Results for Development (R4D) CMAM costing and fiscal space analysis... 26 3.5.3. ACF Coverage (SLEAC and SQUEAC) Surveys and OR Social Marketing... 26 3.6. Gender... 26 3.7. Challenges... 27 3.8. Lessons Learnt... 27 3.9. Future Plans... 28 3.10. Financial Report... 29 4

Financial Utilization Report Summary Table SUPPORTED COUNTRY Nigeria SUPPORTED PROGRAMME Nutrition GRANT NUMBER SC130444 and SC140633 REPORTING PERIOD 1 July 2013 to 30 September 2015 DATE PREPARED October 2015 TOTAL RECEIVED US$ 32,398,399 i SC130444 US$ 14,284,721 SC140633 US$ 18,113,678 PROGRAMMABLE AMOUNT US$ 30,464,013 ii SC130444 US$ 13,375,638 SC140633 US$ 17,088,375 FUNDS UTILISED (Total) US$ 30,457,955 iii (as of 30.09.2015) SC130444 US$ 13,375,638 SC140633 US$17,082,317 FUNDS UTILISED (Reporting) US$ 30,457,955 iv (as of 30.09.2015) BALANCE US$ 6,058 v (as of 30.09.2015) i This report covers the grants received in 2013 (SC130444; US$ 14,284,721) and in July (SC140463; US$ 18,113,678) ii US$ 13,375,638 (SC130444) from July 2013 + US$ 17,088,375 (SC140633) from July 2014 iii US$ 13,375,638 (SC130444) from July 2013 + US$17,082,317 (SC140633) from July 2014 iv US$ 13,375,638 (SC130444) from July 2013 + US$17,082,317 (SC140633) from July 2014 v US$ 6,058 (SC140633) from July 2014 5

Acronyms ACF CHW CIFF CMAM CCPN CoC CSD CV FCT F-FNCC GoN FO IMC ITP LGA MAM MSF NFP NGO OTP PHC R4D SAM S-FNCC SNO SPHDA SMART SQUEAC SUN SWOT Action Contre La Fain (Action against Hunger) Community Health Workers Children Investment Fund Foundation (UK) Community-based Management of Acute Malnutrition Center for Communication Programme Nigeria Continuum of Care Child Survival and Development Community Volunteer Federal Capital Territory Federal level Food and Nutrition Coordination Committee Government of Nigeria Field office International Medical Corps In-patient Therapeutic Programme Local Government Authority Moderate Acute Malnutrition Nutrition Focal Point Non-Government Organization Out-patient Therapeutic Programme Primary Health Care Research for Development Severe Acute Malnutrition State Food and Nutrition Coordination Committee State Nutrition Officer State Primary Health Care Development Agency Standardized Monitoring and Assessment for Relief and Transitions Semi-Quantitative Evaluation of Access and Coverage Scaling Up Nutrition Strength Weakness Opportunity Threat 6

1. Executive Summary This is the final report for CIFF funding (grants number SC130444 and SC140633) provided to the UNICEF programme in Nigeria for the period 1 st July 2013 to 30 th September 2015. More specifically, it supports the Strengthening and Scaling Up the Community Management of Acute Malnutrition Project in Nigeria. The total programmable budget is US$ 30,464,013 and during the reporting period, US$ 30,457,955 has been utilized. The UNICEF Strengthening and Scaling Up Community Management of Acute Malnutrition Project in Nigeria is aimed at support the Federal Government of Nigeria (FGoN) in continuing, reinforcing and scaling up the existing public sector, UNICEF-supported CMAM program in Nigeria. By providing support to both service delivery and leverage activities, the Children Investment Fund Foundation (CIFF) support aims to help mainstream Communitybased Management of Acute Malnutrition (CMAM) as a routine intervention delivered by the public sector health and nutrition services in Nigeria. Overall five years programme framework from 2013 to 2018 has been divided into two phases i.e. phase one covering of initial two years (July 2013 to June 2015 then extended to September 2015) and phase two covering the remaining period of three years (October 2015 to December 2018). This report cover activities supported under grant SC130444 and SC140633; where grant SC130444 is covering the year one (July 2013 to June 2014) and grant SC140633 is for year two (July 2014 to September 2015) of phase I. The year 1 targeting 200,000 and year 2 targeting 222,088 cases. As part of its Basic Cooperation Agreement with the government of Nigeria, UNICEF is implementing the Programme to support Nigerian Government in the Management of Severe Acute Malnutrition (CMAM). The aim of this programme is to contribute (a) to averting up to 95,000 deaths from severe acute malnutrition among children under five years over five years by treating up to 1 million children through CMAM, and b) to mainstreaming CMAM as a routine intervention delivered by the public health sector nutrition services in Nigeria. The phase I project aimed to support the following nutrition program areas: i) Expanded availability of CMAM interventions, ii) Improved quality and continuum of care from household through to OTP care, iii) Increased political commitment and leadership for increased nutrition resource allocation, iv) Coordination with other partners for coverage assessment work (with Action Against Hunger - ACF) and on CMAM costing work (with Research for Development - R4D), v) Preparation for Phase II CMAM Programme in Nigeria. The main activities and results are as follows: a) Expanded availability of CMAM intervention: The treatment of Severe Acute Malnutrition is currently being implemented in 498 facilities in 77 local government authorities (LGAs) in 11 Northern states. A total of 524,670 children suffering from SAM have been treated in phase I (from July 2013 to September 2015) according to the national guidelines for the management of SAM. This resulted in a cure rate of 81.5 per cent, a death rate of 1.3 per cent and a defaulter rate of 15.8 per cent, which exceeded the agreed (CIFF and UNICEF) quality standards: cure rate >65 per cent, defaulter rate of <25 per cent and death rate of <2 per cent. It is estimated that during the reporting period 100,000 lives were saved as a consequence of the CMAM programme. 7

A total of 480,757 cartons of RUTF, 584 F-75, 1,945 F-100, 350 ReSoMal; and 4,378 pack of 50 each MUAC tape, Weighing Scales, height boards and 578 job aids have been procured and distributed to 642 facilities in 11 Northern states A supply chain analysis and improvement plan assessment was conducted in 2014 (July September 2014) to identify key challenges and opportunities to improve supply chain for nutrition supplies especially therapeutic supplies for the treatment of SAM to guide the implementation of phase II. The following were the recommendations from the assessment: 1) Identification of Key Performance Indicators across different segments of the supply chain to monitor the measure the effectiveness and efficiency; 2) Improvement of RUTF pipeline visibility through the use of Smartphone technologies to gather and disseminate Supply Chain data and reports, 3) Enforcement of use of government sanctioned documents and regulatory practices when recording RUTF transactions in storage, handling and movement of supplies at state level. In addition, the introduction of stock movement log sheet ensures that an audit trail in the transactions is maintained, and 4) Introduction of improved data validation practices to enhance accuracy of monthly reports submitted by state. The development of the implementation plan has been delayed due to delays and is scheduled to take place in mid-november 2015. b) Improved quality and continuum of care from household through to OTP care The improved and continuum of care study was conducted in 2014. The results revealed Active case finding and defaulter tracing are not effective, ii)the case of CVs dropping out deserve proper attention from States/LGAs and UNICEF, iii) Limited synergies between OTPs, ITPs and community and iv) weak capacity to utilize data collected from at OTP, ITP by Nutrition Focal Points (NFP) and State levels staff. The development of the implementation plan and validation has been postponed to phase II of the project. c) Increased political commitment and leadership for increased nutrition resource allocation UNICEF signed a project corporation agreement with Center for Communication Programme Nigeria (CCPN) to commence the process of developing strategies that could drive advocacy activities for CMAM in six states of Kano, Katsina, Kebbi, Sokoto, Jigawa and Borno. CCPN team conducted advocacy strategy and materials development workshop in each of the state. During the workshops, state specific advocacy issues informed advocacy efforts for CMAM in each of the states were identified and addressed. Media dialogue resulting in more than 50 articles in newspaper and electronic media as well as television coverage on the situation of nutrition in Nigeria and the need to scaling up the response to reach all 1.7 million children with SAM annuallyunicef in collaboration with the Government of Nigeria, in August 17th, 2015, jointly conducted a press release to share CMAM programme achievements and way forward. The press release also provided updates on new CMAM related data and articles which were developed by CIFF and resulted in engaging the attention of social, print and visual media in Nigeria. The press release also resulted in government Secured commitment of government, a statement released from the government The Government of Nigeria is committed to reaching more children with CMAM, said Linus Awute, Permanent Secretary of the Nigerian Federal Ministry of Health, We cannot accept that Nigerian children continue to die of malnutrition and that our potential future leaders should be diminished by its effects. FMOH Continuous advocacy activities by UNICEF and CIFF resulted in Government commitment to RUTF procurement this and last years in Kebbi, Kaduna 8

2. Background Severe acute malnutrition (SAM) is estimated to affect 500,000-1,000,000 children under the age of 5 per year in Nigeria, and contribute to as many as 100,000 deaths per year. A proven intervention to treat SAM exists, the community-based management of acute malnutrition (CMAM), and has already been started in 11 northern states of Nigeria, but is estimated to cover only 15-25% of the national burden each year. In 2011, CMAM interventions reached 141,000 children at 363 sites. While UNICEF was closely involved in the initiation of all CMAM services in Nigeria, 3 broad approaches of CMAM service delivery: State Government programs with UNICEF technical support and funding: UNICEF directly supported the State public health sector systems to deliver CMAM in 318 of the sites. In these locations, all RUTF is funded by UNICEF but only light technical support is provided, while health staff are all paid for by the GoN. NGO led programs: a further 45 sites also located in government facilities, but managed with more direct involvement of international NGOs (ACF, Save and MSF). NGO costs are funded by their donor base, while RUTF used by these sites remains funded by UNICEF. Mixed State Governments / UNICEF / NGO model: In addition, DFID is funding the introduction of CMAM to 75 sites in 5 states as part of its working to Improve Nutrition in Northern Nigeria (WINNN) program, implemented in partnership with State governments, UNICEF and NGOs. DFID is covering both the costs of RUTF and NGO support at these sites. To ensure harmonization and sustainability of the CMAM services it is important that the services are mainstreamed into GoN primary health care services. However, several challenges exist in achieving this goal of mainstreaming CMAM services, beyond simply supporting an increased in the number of children reached. The key challenges include: - Limited Government commitment to date: There is uncertainty about government commitment to continue interventions that have, to-date, been funded largely by foreign donors. - Lack of long term funding for nutrition: Most funding to date has been emergency in nature, which impedes planning, government resources allocation, and efforts to improve performance over a longer time frame. - Poor default rates and low coverage: There are concerns about default rates and the low proportion of children affected by SAM who are believed to be treated within a given catchment area. - Unreliable supply chain and logistics: Significant constraints exist with the import of RUTF due to long port delays, and with in-country storage and distribution To ensure sufficient funds and uninterrupted treatment of SAM, in 2012, the CIFF Board approved the first phase of a five year programme to treat up to 1 million children for Severe Acute Malnutrition (SAM) in Nigeria and to support the successful mainstreaming of the programme into the Nigerian health system. The first phase of the programme ends in June 2015 and this investment memo lays out our proposed way forward for the next three years - phase 2 - from July 2015 to June 2018. The programme was designed to address the key challenges to the CMAM programme above. The main goal of CIFF support to CMAM programme through UNICEF is to support the successful mainstreaming of Community Management of Acute Malnutrition (CMAM) into the Nigerian health system and demonstrate that it is possible for a country like Nigeria to finance and deliver a high quality CMAM programme at scale. This goal is in-line with UNICEF focus area 1: young child survival and development; focus area 2: organizational target: Increase coverage and quality of services for the management of severe acute malnutrition 6. 6 The UNICEF Strategic Plan, 2014-2017 - Realizing the rights of every child, especially the most disadvantaged 9

The partnership between CIFF, UNICEF and the Government of Nigeria (GoN) on this program over 5 years, divided into 2 phases: Phase 1 2013-14: Funding existing CMAM interventions for 18-24 months while conducting in depth research to identify how to improve performance and secure further Government leadership and funding during phase 2 Phase 2 late 2014/early 2015-17: Steps to improve the performance of existing sites, increase the caseload, transfer leadership of the CMAM program to the federal and state health systems, and achieve an increased public awareness of SAM and its treatment 10

3. Progress in the implementation of Programme activities: July 2013 to September 2015 3.1. Expanded availability of CMAM intervention 3.1.1. Admission and performance indicators The programme performance indicator for CMAM of comprises of admission and performance indicators recovery rate, defaulter rate, death rate and non-recovery rate; covering the period of July 2013 to September 2015. The Key Performance Indicators (KPIs) table also completed based on the CMAM key performance indicators analysis. Coverage of SAM Treatment: Since its inception, the CMAM program continued its expansion to meet the increasing needs and by the end of September 2015, the treatment of SAM was expanded to 495 facilities in 75 LGAs to 642 sites, 97 LGAs of 11 northern States. During the two years of phase I, the programme has been scaled up with an increase of 147 OTP sites in additional 22 LGAs within the same 11 States in north-east and north-west Nigeria. The overall coverage of CMAM services, ACF in coordination with UNICEF conducted a Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage (SLEAC) survey in 11 CMAM States in Northern Nigeria. The result shows an overall CMAM coverage of 36.6 percent (Source: ACF SLEAC Survey result).. 3.1.2. Analysis of Key Performance Indicators Admission: In total 524,670 new cases of under five children with SAM were admitted and treated from July 2013 to September 2015 exceeding the phase I target of 350,000 of new cases admitted. The table below shows the admission per month for the past 15 months: Table 1: CMAM new admissions, July 2013 - September 2015 State Admission Discharged Cured Defaulted Adamawa 1,876 1,278 934 317 Bauchi 22,028 18,166 13,875 3,739 Borno 30,313 23,043 15,838 6,700 Gombe 15,552 14,228 9,719 4,134 Jigawa 87,681 73,151 61,741 9,990 Kano 93,496 57,573 45,443 11,277 Katsina 126,213 113,173 106,055 3,564 Kebbi 29,899 30,004 27,065 2,033 Sokoto 39,973 35,884 32,613 2,332 Yobe 50,500 44,724 35,694 6,507 Zamfara 27,139 23,005 21,155 1,285 Total 524,670 434,229 370,132 51,878 11

Table 1a. Performance indicators in percentage by years Year Admission Death rate Nonrecovery rate Defaulter rate Cure rate 2013 95,862 1.3 1.8 16.6 80.3 2014 246,909 1.2 1.7 12.1 85 2015 181,899 1 1.5 9 88.5 3.1.3. Summary of Performance Indicators: The performance of the CMAM program is assessed using four key indicators; recovery rate, defaulter rate, death rate and non-recovery rate. All the four indicators met the program target. Of the 524,670 children aged 6-59 months discharged from the program; 81.5 per cent recovered, 15.8 per cent defaulted, 1.3 per cent died and 1.5 per cent not-recovered. Though, the defaulter rate is slightly higher than the Sphere standard (less than15 percent) but based on year 1 of phase I UNICEF and CIFF agreed to keep the defaulter rate at < 25 per cent hence 15.8 is within the agreed cut-off. Recovery Rate: The quality of the program is assessed using the data collected monthly routinely against Sphere minimum standards. However, the Sphere standard is designed for emergency response programs and it is usually difficult to meet this standard in development context such as the Nigeria CMAM program. Given this fact and the previous trend in the country, it was agreed with CIFF to achieve a recovery rate of greater than 65 per cent. A minimum recovery rate set by Sphere standard is greater than 75 per cent. Figure 2: Recovery rate by state, July 2013 to December 2015, Nigeria Overall, 81.3 per cent of children age 6-59 months discharged from the program recovered. The average recovery rate was agreed at > 65 per cent, all States achieve the minimum recovery rate of greater than 65 per cent. The highest recovery rate is reported from Katsina, Zamfara, and the lowest Gombe 93.7 and 68.3 per cent respectively. 12

Although Borno and Gombe states achieved the target recovery rates there is a still need to improve the quality of the SAM service in Borno and Gombe states as the recovery rates in these states did not reach the Sphere standards of greater than 75 per cent. Defaulter Rate: The figure 3 below shows the defaulter rates in 11 States. Given the nature of the program, which is operating in a development context as oppose to emergency where the Sphere standard is strictly followed, it was agreed with CIFF to maintain defaulter rate below 25 percent. The Sphere minimum standard is to maintain defaulter rate below 15 percent. Overall, 15.8 per cent of SAM cases discharged from the program reported to have defaulted. This shows that the performance indicator has worsen over time. The defaulter rates for programme is behind in achieving this perform that, we are in line with the target set for the project after the first semester of the project and the programme has improved compared to year 1. However, detailed analysis showed that 2 States; Borno and Gombe, failed to meet the project target (< 25 percent). Given the high defaulter rate in those 2 states, efforts will be made in the next semester to address the problem by implementing the recommendations from the continuum of care study. Figure 3: Defaulter rate by State, July 2013 September 2015, Nigeria Death Rate Overall 1.3 per cent of children discharged from the SAM treatment program were reported to have died. The Sphere minimum standard for death rate is less than 10 percent while the agreed rate with CIFF for year two is less than 2 13

per cent based on the year one achieved performance of 2 per cent. Ten out of 11 States reached the death rate target of 2 per cent, and only one failed to reach the target (Adamawa state). Figure 4: Death rate by State from July 2013 September 2015, Nigeria The observed low death rate is an indication of the quality of the program being provided in the area. However, it is also imperative to continue strengthen the monitoring and supportive supervision. Non-recovery Rate: During the reporting period, 1.5 per cent of children age 6-59 months discharged from the program. The non-recovery rate in all States was reported within the target less than 10 percent, with the highest reported at 4.1 percent in Yobe State and the lowest in Adamawa and Kano States at zero and 0.1 percent respectively. Figure 5: Non-recovery rate by State, July 2013 to December 2015, Nigeria 14

3.1.4. Progress in Achievement on Milestones Below summary reflects the achievements against milestones for year 1 and 2 of phase I, expected outputs were revised due dates for completion. The progress and achievement were discussed between CIFF and UNICEF team, and agreed that there is a need to be realistic in preparing and finalizing work plan, and ensure implementation to achieve all the activities and milestones as per the agreed timelines. Table 2: Progress in achieving milestones Sn Milestones Outputs Due date Progress updates 1 2 Distribution of the procured supplies to the CMAM 11 states Supply chain improvement plan developed September Shipment and delivery 2014 of RUTF and other supplies to 11 states January 2015 April 2015 Supply chain November improvement plan 2014 The procured therapeutic and other nutrition supplies for CMAM were distributed to the 11 states on timely manner. The supply chain improvement plan is scheduled to be developed in the November 2015 3 Training of 50 low performing OTP sites Training report May 2015 completed Training of 50 staff from low performing OTP site has been completed 4 5 6 7 8 9 Continuum of care improvement plan developed Monthly CMAM meetings in 11 CMAM states conducted Improvement plan to January 2015 continuum of care Progress update including details on July 2015 monthly CMAM meetings held Mobilize support (a) at the federal and zonal level for programme management, (b) at the field level for programme Progress updates January 2015 monitoring, and (c) within the state departments for capacity support for government authorities Training of State Consultants, Government Store Keepers, LGA NFPs on supply and logistics management completed Data base for financial tracking of government funding contribution to Data base for financial Oct-14 CMAM programme created and tracking populated Effective support provided for (a) programme management - Federal and Zonal, (b) programme monitoring at field Progress update and (c) capacity building support for State government departments Continuum of care improvement plan will be developed in November 2015. Monthly CMAM meetings to discuss progress and prepare plans conducted in the 11 States Support was mobilized from Federal and zonal level for management, Field Office for programme monitoring and state departments were mobilized to provide capacity support for the government authorities Training report July 2015 The training is scheduled for November 2015 Jun-14 Database for financial tracking has been developed Activities were carried out and continuing at different level using UNICEF s capacities at Federal and local levels. Key achievements: 15

CMAM programme ids implemen5ted in 498 OTP sites in 77 LGAs within 11 States in north eastern and north western Nigeria. The performance indicators including cure rate, defaulter rate and death rate remained within the acceptable international standard and better than the set targets of the project. CMAM sites performance indicators were analyzed on a monthly basis in Abuja and feedback was provided to field teams to discuss at States level monthly review meeting, which helped analyze and set priorities to focus for capacity building training using on-the-job training, monitoring and supportive supervision in low and medium performing CMAM/OTP sites. 3.1.5. Progress in Achieving the Key Performance Indicators (KPIs) The table below shows summary of the achievements against the baselines and targets agreed as key performance indicators for the programme covering the period of July 2013 to September 2015. Table 3: Progress in achieving Key Performance Indicators Sn Key Performance Indicators Baseline Target Achievement Comments 1 Total admission to the CMAM program is maintained 251,314 422,088 524,670 Achievement is higher than baseline and target 2 Proportion of discharge cured 80% > 80% 81.5% In line with the target 3 Proportion of discharge as defaulter 17% <15 % 15.8 % Although the defaulter rate is higher than target and its lower then baseline 4 Proportion of discharge died 1% <2% 1.3% In line with the target 5 Proportion of discharge nonrecovered 2% < 2% 1.5% In line with the target 300 health 6 workers (HW) and 1,104 health Number of targeted health 350 1,250 workers and workers and volunteers trained community 6,140 (CV) In line with the target volunteers (CV) 7 % of sites reporting out of stock of RUTF 27% 15% 20 Did not meet the target 8 % of CMAM sites reporting routine data each month 84% 90% 90% In line with the target 3.1.6. Supply Chain and Logistics Management Procurement and distribution of CMAM supplies (RUTF, ReSoMal, F75 and F100, anthropometric equipment) for 11 States 16

Supply forecasting has been done based on the need of the yearly target of children to be treated. Sales and purchase orders for the procurement of RUTF and other commodities as well as equipment were raised, approved and procurement through UNICEF Copenhagen. Under the phase I, a total of 480,757 cartons of RUTF of which 200,000 in year 1 and 235,270 cartons of RUTF in year 2 and additional 45,487 in years 2; and 584 and 1,945 cartons respectively for F-75 and F-100 therapeutic milk, 350 cartons of ReSoMal, and 4,378 packs (218,900 pieces) of MUAC tapes and other anthropometric equipment have been procured and distributed in phase I. The additional 45,487 cartons of RUTF procured towards the end of year 2 were based on agreement with CIFF to cover the 3 months extension (1 July 30 September 2015). In addition to that total of 578 CMAM Job-Aids were produced and delivered during the first year of phase I. The job aidswere distributed to partners. Due to increase in the number of sites additional Job-Aids were printed in 2015. 3.1.7. Supply chain analysis and improvement plan A supply chain mapping and analysis was conducted from June to September 2014. The study was a crucial contribution to the identification of potential challenges affecting RUTF Supply Chain from importation, clearance at the port of entry, efficient distribution to the states and OTP sites. The main objectives of the study were as follows: 1) Identify areas where the removal of blocks would improve the reliability of supply, and/or alternative means of storage and distribution, 2) Create buffer stock to minimize delays in distributing RUTF to states, 3) Conduct mapping of the flow of RUTF to create a more accurate picture of consumption patterns and improve the forecasting of RUTF requirements by LGA and State authorities, 4) Create a realistic plan for the hand-over of some logistics activities as regard to CMAM supply chain management tentatively by end of 2014. The desk review of relevant documents, analysis and mapping of supply chain process was conducted in Abuja, Sokoto, Katsina and Lagos. Field visits to States, LGAs and OTP sites in Katsina and Sokoto was conducted for the review of the supply chain flow and processes. It was noted that to a large extent compliance of CMAM operational guidelines, government policy and regulations in management of RUTF supplies are in place. The analysis explored end to end supply process, forecasting, procurement, delivery, distribution and monitoring and helped to analyse the current supply chain, identify constrains to inform decision for strengthening the chain and identify the required sources in order to improve it. The figure 6 below shows the processes at each level and key activities for RUFT distribution in Nigeria. The following opportunities were recommended to improve the supply chain: i) Identification of Key Performance Indicators across different segments of the supply chain to monitor the measure the effectiveness and efficiency; ii) Improvement of RUTF pipeline visibility through the use of Smartphone technologies to gather and disseminate Supply Chain data and reports, iii) Enforcement of use of government sanctioned documents and regulatory practices when recording RUTF transactions in storage, handling and movement of supplies at state level. In addition, the introduction of stock movement log sheet ensures that an audit trail in the transactions is maintained, and iv) Introduction of improved data validation practices to enhance accuracy of monthly reports submitted by state. It was also recommended that an area that need further improvement is the strengthening the capacity for documentation and recording system of RUTF receipts, storage and dispatch at State, LGA and OTP levels. As an example, the figure 6 below reflects the recommended recording and documentation flow at LGAs when dispatching and receiving RUTF supplies. Key achievements: 17

- The supply chain improvement assessment was completed and recommendation were made. UNICEF is working with the Federal Ministry of health to validate the report and recommendations, the validation and development of the implementation plan for the recommendations will be develop with set of monitoring indicators is planned for end of October 2015. - A total of 480,757 cartons of RUTF were procured and distributed to the OTP sites Suggested Map of Document Flow and Recording Practice when Receiving and Dispatching RUTF Supplies At LGA Storage Facility Reference: Receive RUTF Supplies (1) Driver arrives at LGA and warehouse storekeeper endorses state goods issue voucher (2) Driver or LGA representative receives the endorsed state goods issue voucher] (3) LGA good receipt voucher is completed by LGA storekeeper (4)Driver or LGA representative receives the endorsed state goods issue voucher (5) Stores ledger and bin card is updated (Goods receipt voucher is filed) Reference: Dispatch RUTF Supplies (6) Driver arrives at state warehouse and supplies are loaded and LGA storekeeper completes goods issue voucher (7) LGA storekeeper gives driver or OTP representative two copies of LGA goods issue voucher (8) Storekeeper updates ledger and bin card and files copy of the LGA goods issue voucher LGA Warehouse Trucks arrives at LGA warehouse And offloads supplies 1 State Goods Issue Voucher Endorse LGA Goods Issue Voucher 2 Endorsed State Goods Issue Voucher 3 Compete LGA Goods Receipt 4 Voucher Signed and Stamped LGA Goods Receipt Voucher UPDATED Ledger 5 File Goods Receipt Voucher Update Stock Ledger Update Bin Card Signed and Stamped LGA Goods Reciept Voucher UPDATED Bin Card Trucks arrive at LGA Warehouse and Supplies are loaded 6 Complete LGA Goods Issue Good Issue Voucher Voucher 7 LGA Goods Issue Voucher Driver or OTP representative Receives LGA Goods Issues Voucher Signed and Stamped Signed and Stamped UPDATED Ledger 8 File Goods Issue Voucher Update Stock Ledger Update Bin Card UPDATED Bin Card Driver or LGA representative Receives Endorsed state Goods Issue Voucher And LGA Goods Receipt Voucher Figure 6: Suggested Supply Chain at LGA level Training to Health Workers and Community Volunteers Recruitment and deployment of staff: To ensure quality of SAM treatment services continuous capacity strengthening of health workers in OTP sites through monitoring and supportive supervision is crucial. UNICEF/Nutrition Section finalized the recruitment of additional staff to continue its support to the Government for the improvement of CMAM programme implementation in 11 states. The National officers category B (NOB) in Bauchi and Borno; and National Officer category C (NOC) in Katsina as well as the international Nutrition Information Officer, L2, Nutrition Specialist Advocacy (P4) and Nutrition Manager CMAM (P4) have been recruited. The International professionals L3 Nutrition Supply and Logistics Specialist is still under recruitment. Recruitment and deployment of state consultants (SSA) The total number of state consultants remaining at state level is ten out of eleven. The State consultants provide support on CMAM programme implementation, monitoring and supportive supervision at all level including State, LGAs and OTP sites. The states currently covered by state consultants are Bauchi, Borno, Jigawa, Gombe, Sokoto, Zamfara, Adamawa, Katsina, Kano and Yobe since August 2014. Recruitment is underway to fill current vacant positions in Kebbi. 18

In order to sustain active CMAM admission in all 11 states, capacity of health care providers need to be strengthened. Trainings for the existing staff with emphasis to the low performance LGA/sites is required as well as increase capacity in quantity by recruiting additional qualified staff and consultants to support technically the implementation of the programme. Trainings: A 3 days training of State Trainers and State Consultants as well as health workers and community volunteers for the low performance OTP was conducted. A total of 1,107 health workers, 4,040 community volunteers and 40 trainers including the recently recruited CMAM consultants. Table 4: Number of health workers and volunteers trained States Number of CHWs Number of CVs Adamawa 30 30 Bauchi 30 30 Gombe 30 30 Jigawa 60 60 Kano 180 750 Katsina 192 800 Kebbi 385 1540 Sokoto 125 500 Zamfara 75 300 Total 1,107 4,040 Key achievement: Monthly analysis of performance indicators helped to identify low and medium performing OTP sites to target for capacity building training and improved supportive supervision to the health workers and community volunteers. With this increased support, it is expected to improve the quality of performance of health workers and community volunteers in delivering quality OTP services. 3.2. Improved quality and continuum of care from community to OTP care In order to improve quality and continuum of care at all levels (from community to OTP care), the following activities were carried out: i) Continuum of care analysis and ii) Strengthening CMAM programme monitoring and supervision, iii) Strengthen joint monitoring and supervision, iv) Strengthen routine CMAM data management and quality monitoring as shown in the sections below. 3.2.1. Continuum of care analysis The CMAM programme continuum consists of; 1) community mobilization and screening for acute malnutrition, 2) Outpatient (OTP) program - treatment of children with Severe Acute Malnutrition in OTP sites, and 3) referral from community and/or OTP sites to inpatient programs (ITP) for management of complications such as diseases for the children with Severe Acute Malnutrition (SAM) and medical complications. Continuum of Care Analysis was conducted from June to September 2014. The objectives of the analysis were to: 19

1) Conduct a comprehensive assessment and analysis of the existing situation of the CMAM services implemented for the treatment of children with Severe Acute Malnutrition (SAM) across the Continuum of Care mainly the linkages between the components of community, OTP and referral/stabilization services at ITP centres. 2) Assess and analyze the factors/challenges causing low level of performance indicators reported from a number of CMAM sites e.g. low admissions and high defaulter rate and low recovery rate in some areas, 3) Analyze the Strengths, Weaknesses, Opportunities and Threats (SWOT) of overall program with specific focus on linkages between the components of the program (community, OTP and ITP); review the current methods/tools for supportive supervision and monitoring/evaluation of the program at different levels; and put forward concrete recommendations for the measures to be taken to improve quality of services with effective functional linkages between community level; CMAM OTP sites and referral/stabilization services at ITP centres. The study was conducted in 4 States (8 LGAs) including 2 states with high performance and 2 with low performance and has used both qualitative and semi-quantitative methods., The finding revealed that across the continuum of care for CMAM services, the major drawback is the lack of incentives for Community volunteers, which leads to high attrition rates and defaulting among volunteers. This contributes to lower performance in terms of admission, defaulter tracing and eventually the quality of services/care provided at OTP sites. The main relationship between the community and OTPs is the cooperation between CVs and OTP staff (CHWs) with CVs identifying children with SAM and referring them to the OTP site where staff initiates treatments. The link between OTP and ITP is rather natural as PHCs usually refer all patients with complications to comprehensive and better-equipped secondary or tertiary health care centres where ITP are located. In many cases, OTP staff use standardized referral slips. In turn, OTP staff is concerned with the lack of feedback from ITP on progress or discharge of transferred cases. Some OTP mentioned they follow up on cases they refer to the ITP. In addition, the following were the key findings of the analysis: Active case finding and defaulter tracing are not effective The case of CVs dropping out deserve proper attention from States/LGAs and UNICEF, Limited synergies between OTPs, ITPs and community Data utilisation at OTP, ITP and NFP and State levels are not common meetings are meant to collect data from different OTP sites and not critical analysis of the data on quality issues and challenges The recommendations of the study include (please also see annex 1 for detailed report): a. States and UNICEF to document the effectiveness and success factors and implications of income generation activities as compared to the effects of cash for volunteers, which is already seen as not sustainable by almost all State authorities. Results should be discussed with States, LGAs and CMAM sponsors for decision-making and adoption. b. UNICEF to pilot a Result-based Financing approach in a few LGAs with admission, defaulting and CV and OTP level performance indicators (e.g., number of CVs on OTP days, number of SAM cases referred, number of re-admitted defaulters, etc.) c. States and UNICEF to consider training both new CMAM and IYCF volunteers on CMAM and IYCF. Expanded CMAM CoC. d. LGAs and States to facilitate information sharing with non-cmam PHC on CMAM protocol by visiting each PHC or by organizing PHC staff to attend OTP sites weekly in order to be familiarised with CMAM. Such orientations create linkages between CMAM and non-cmam PHCs that allow for the delegation of followup activities with those caretakers living closer to a non CMAM PHC as well as early referrals and timely absentee or defaulter tracing. e. Where circumstances permit, an extended CoC should be encouraged. Such extended CMAM CoC should primarily include IYCF volunteers and non-cmam PHCs who should be familiarized with CMAM protocols. Various options are put forward for States, LGAs and UNICEF to consider: Roles of IYCF volunteers: Currently training on IYCF is underway but concerns new volunteers. States should review the scope of work of CMAM and IYCF volunteers and decide on whether to use same 20

volunteers for both CMAM and IYCF. It is expected that training CMAM volunteers on IYCF will increase knowledge and enhance efficiency as well as provide incentives to perform duties. Furthermore training new IYCF on CMAM enables to cover unmet needs for more volunteers (coverage and defaulter tracing). Potential roles of IPD volunteers: UNICEF to liaise with WHO regional offices and assess the feasibility of using IPD volunteers in active case finding based on volunteers current workload. Such a convergence approach may be cost effective as it is easier to increase financial incentives by NGN 100 or 200 to volunteers that already earn NGN 3000 than retaining new volunteers with ad hoc monthly or quarterly NGN 200. Potential roles of non-cmam PHC if introduced to CMAM/IYCF s protocols. Non-CMAM PHCs actually refer SAM cases to OTPs and mostly to ITPs (late referrals) and are willing to participate in CMAM. PHC staff can on a routine basis perform MUAC and weight measurements and referrals of SAM cases, follow-up of discharged SAM cases (actual MAM cases) and follow-up on SAM cases who receive double ration due to distance, and community mobilization Potential roles of caretakers of recovered and recovering SAM cases after they are properly counselled at discharge to identify and refer at least 3 SAM cases in their close environment and refer them to PHC/OTP. Mother-to-mother referral is a reality. After 8 visits to OTP it is assumed that caretakers know about the various presentations of SAM and the potential of RUTF as well as the contents of IYCF-like advice. Eventually, pupils and secondary school students can be taught about SAM and MAM and be given short assignments during school-based health education lessons. It is assumed pupils and students can draw their own MUAC tapes, practice measurements at home and advise their family to bring their sister/brother to OTP/PHC f. States and LGAs should promote the generalization of weekly meetings between OTP staff and Community volunteers as ways of allowing timely data collection and analysis and feedback to volunteers g. States and LGAs to adopt, where feasible, the strategy of creating an in house OTP to bridge the gap for the caretaker between the times of discharge and reaching the nearest OTP. This will also facilitate proper nutritional counselling from OTP staff under less stress than those working at the ITP h. UNICEF expands current work on data collection into a substantial functional area of support for knowledge management to support learning and sharing, capacity building and empowerment of LGA level actors (communities, OTPs, ITPs). This work of knowledge management should cover a number of different aspects: Development of a CMAM Best Practice Collection, to translate more information into practical guidance Exploration of innovative means of dissemination, including a forum of CVs, OTPs and ITPs Facilitation of horizontal learning and skills building to support the use of information, including State and LGA skills building workshops (SNOs, NFPs), and study tours (CVs and OTP/ITP staff) i. Substantial time should be allocated to thematic discussions (admission, defaulting, incentives, best practices, etc.) during CMAM meetings. If this change is made, it would require direct participation in monthly meetings of representatives of each CMAM component member (CVs, OTP and ITP) j. UNICEF, FMoH, the Ministry of LGAs and the NPHCDA to support an advanced multisecoral planning process to advance the CMAM towards an Integrated Management of Acute Malnutrition (IMAM) with formal working and supervisory roles and responsibilities defined for the different components. This will require the creation of opportunities for representatives of the three components (community outreach, OTP and ITP) to reflect together on and take responsibility for their work and to develop a network of integrated planning at LGA and State levels k. Substantial time is allocated to thematic discussions during CMAM meetings. If this change is made, direct participation to monthly meetings of representatives of each CMAM component s members (CVs, OTP staff and ITP staff) should be enabled. 21

3.2.2. Strengthening CMAM programme monitoring and supervision Routine Monitoring and supervision In an effort to improve quality of services, monthly routine monitoring to monitor performance indicators is conducted by SNO and UNICEF staff including the State Nutrition Consultants on quarterly basis in all 498 CIFF supported CMAM sites using a predesigned supervision checklist. The information from the supportive supervision is compiled and entered in a Microsoft Excel based tool mainly for SNOs and FOs for quick quality checks. The results of 3.3. Coordination at Federal and States Level In cooperation with Nutrition Section of FMOH FHD at Federal and SNOs at SMOHs at States, the Nutrition sector coordination and networking, with a main emphasis on CMAM interventions, continued to be held at Federal and State levels. The key fora for CMAM coordination at State level are State Food and Nutrition Coordination Committees (S-FNCC) and monthly CMAM stakeholders meeting for coordination and review of progress and discussed issues at State level. The issues of programme performance, stock level and technical issues are deliberated in these meetings. Similarly, the coordination forum at Federal level are Food and Nutrition Coordination Committee (F-FNCC) CMAM Task Force and Nutrition Stakeholders Meeting which meet on quarterly basis and had recent meetings in March and May 2014 respectively for CMAM/ stakeholders and FNCC. It has been discussed and agreed to have the CMAM Task Force meeting regularly in a quarterly basis in a rotation basis at Abuja and in any of the selected States alternatively. Key Achievement: Routine CMAM data collection and analysis of performance indicators had an impact in improved feedback to the field teams towards making swifter and scientific collection, collation and analysis of CMAM program related data. The introduction of RapidSMS using mobile phones has improved timeliness of information, analysis and provision of feedback to the States for prompt action and strengthening quality of supportive supervision. 3.4. Increased political commitment and leadership for increased nutrition resource allocation 3.4.1. Leadership and coordination Government is improving coordination and leadership for CMAM programme through CMAM Task Force meeting, a quarterly and monthly forum institutionalized respectively at Federal and State levels since 2013. At Federal level, the task force meetings are organized Nutrition Division, Family Health Department with UNICEF support and other partners involved in the implementation of the CMAM programme. The quarterly CMAM task Force meetings organized at Federal levels for all partners under the leadership of Nutrition Division of FMOH, while monthly meetings are conducted at state level. The agenda include the following topics: ng of key progress in the area of CMAM, experience and lesson learnt in order to allow everybody to be updated on CMAM programme implementation and to define way forward to continue improving programme performance. This helps the 22

Government to coordinate all partner s efforts in response to the improvement of the programme achievements. All partners in the area of CMAM attend the CMAM task Force meeting including Donors. 3.4.2. Advocacy for leveraging resources Government of Nigeria, mainly the state and local governments continued making available the primary health facilities for CMAM sites, health workers and staff to provide OTP and related services in the sites, logistics and transport of RUTF from state to sites, management and monitoring supports by the government staff at state and LGA levels. Continuous advocacy effort for State contribution to CMAM programme resulted on yearly contribution of 2,178,834 USD as shown in the table below. Table 5: State Contribution to CMAM programme projected to end of 2014 State Contribution to CMAM programme projected to end of 2014 States Amount in NAIRA Amount in Frequency Comments USD Adamawa 4,000,000 24,540 Monthly for drugs and RUTF transportation since March 2014 Bauchi 6,750,000.00 41,411 Monthly Realized since April Borno 42,300,000 259,509 Yearly 33,000,000 for RUTF procurement and 9.3 million for drugs and transportation of RUTF Gombe 2700000 16,564 Monthly for drugs and RUTF transportation since March 2014 Jigawa 10,000,000.00 61,350 Monthly To be released end of Sept Kano 6,000,000.00 36,810 Monthly To be released end of Sept Katsina 30,000,000 184,049 Yearly Kebbi 177,400,000.00 1,088,344 Yearly for RUTF procurement, drugs and transportation of RUTF as well as monitoring Sokoto 10,000,000.00 61,350 Yearly Released Yobe 30,000,000 184,049 Yearly for drugs, RUTF transportation and monitoring Zamfara 36,000,000.00 220,859 Yearly To be released Total 355,150,000 2,178,834 The information from 2015 will be presented in the next report. 3.4.3. Advocacy strategy UNICEF signed a project corporation agreement with Center for Communication Programme Nigeria (CCPN) to commence the process of developing strategies that could drive advocacy activities for CMAM in six states of Kano, Katsina, Kebbi, Sokoto, Jigawa and Borno. CCPN team conducted advocacy strategy and materials development workshop in each of the state. During the workshops, state specific advocacy issues informed advocacy efforts for CMAM in each of the states were identified and addressed. In each state the stakeholders drawn from the Ministry of Health (MoH), Ministry of Finance and Budget met for a one-week advocacy workshop facilitated by CCPN. Advocacy issues around CMAM were identified and analysed for identified audiences. These became the issues around which creative activities were developed to fill the gap that may be created by the dwindling funds even from the international development organisation. The state specific advocacy strategies will be consolidated to inform the broader national advocacy strategy. The development of the advocacy strategy will also include the development of information education and communication advocacy materials for different segment. 23