Management of acute malnutrition in Niger: a countrywide programme

By Dr Guero H Doudou Maimouna, Dr Yami Chegou and Prof Ategbo Eric-Alain

Dr Guero H Doudou Maimouna is a Paediatrician and holds a PhD in Public Health. She has over 15 years experience in health and nutrition programme management in Niger. She currently holds the position of National Nutrition Director of the Ministry of Health, Niger and is a Lecturer in the Department of Public Health of the Faculty of Medicine of University Abdou Moumouni.

Dr Yami Chegou is Director General of Public Health at the Ministry of Public Health, Niamey, Niger.

Professor Ategbo Eric-Alain is Nutrition Manager at UNICEF, Niamey, Niger.

The authors acknowledge the contributions of the MOH staff, UN agencies and national and international NGO implementing partners in Niger.

Background

National nutrition and health situation

Niger is a land-locked Sahelian country with a population of over 15 million people, of which approximately 50 per cent are children under 15 years of age. Niger ranks 173rd out of 177 countries according to the 2010 UNDP¹ Human Development Index. Millenium Development Goal (MDG) indicators, such as child mortality and maternal mortality rate, are among the worst in the world. The maternal mortality rate has stalled over the past ten years and in 2010, was still 554 per 100,000 live births. Moreover, one child out of five still dies before the age of five in Niger.² Malaria, respiratory infections, and diarrhoea are the main direct causes of under-five mortality. Acute malnutrition is directly or indirectly responsible for 50 to 60 per cent of under-five deaths.

For years, Niger has been confronted with chronic food insecurity and high levels of maternal and child malnutrition, common to the Sahel region. National nutrition surveys carried out over the past five years all point to the conclusion that the nutritional status of young children in Niger remains a matter of great concern. Even in good harvest years, child malnutrition remains high. Since 2005, the prevalence of acute malnutrition among children in Niger has always been above the alert level of 10 per cent, with a few regions exceeding the emergency level threshold (15 per cent) (see Figure 1). The latest national nutrition survey (June 2011) revealed a national average of global acute malnutrition (GAM) of 12.3% with a prevalence of severe acute malnutrition (SAM) of 1.9%. The situation is of great concern among children aged 6-23 months. The prevalence of GAM in this age group is 20.2% according to the latest national nutrition survey.

A child enrolled in the programme eating RUTF

A high prevalence of chronic malnutrition is also a major problem of public health importance as every other child aged 6 - 59 months is stunted, and there is very little variation over the years (see Figure 2).

In Niger, only 46 per cent of the population has access to safe water. The regions of Zinder, Maradi, Tahoua and Agadez, in particular, face limited access to drinking water, low sanitation coverage, and poor hygiene practices, especially among the poor. In a context of high food and nutrition insecurity, the lack of appropriate hygiene, drinking water and proper sanitation increases the incidence of water-related diseases, including diarrhoea, which is a major underlying cause of malnutrition. The health system in Niger is well structured and quite decentralised. However, it is confronted with a serious issue of staffing.

An emergency-prone country

Niger is regularly confronted with episodes of food insecurity, resulting either from dry spells and/or from locust infestations. In 2005, the country was confronted with major food insecurity that translated into a serious nutrition crisis. This happened at a time when the health system of the country was not ready to handle large caseloads of acute malnutrition. In 2010, Niger was again confronted with food insecurity following a poor 2009 rainy season. This also resulted in a major nutrition crisis affecting mostly vulnerable groups, such as young children and pregnant and lactating women. In February 2010, the Nutrition Cluster estimated that 378,000 children aged 6 to 59 months would suffer from SAM that year. In June 2010, the Nutrition Cluster re-evaluated this number to 384,000. An additional 1.2 million children of the same age group were expected to suffer from moderate acute malnutrition (MAM).

In 2010, grain shortage was about half a million tons and the animal fodder deficit was as high as 16 million metric tons. In April 2010, a food security survey revealed that 7.1 million Nigeriens, almost half of the population, were in a situation of food vulnerability, including 3.3 million who were in a situation of severe vulnerability³. For the first time, this survey was also conducted in urban areas and showed that 26 per cent of urban populations were also affected by severe food insecurity.

The magnitude of the nutrition crisis was revealed by the National Nutrition Survey of June 2010, which indicated that the prevalence of GAM among children aged 6-59 months was as high as 16.7 per cent, exceeding the emergency threshold of 15 per cent⁴. This included 3.2 per cent of children affected by SAM. The situation was dire for children aged 6-23 months with one in four children affected by GAM. The prevalence of SAM among this age group was as high as 7 per cent. Another survey in October 2010 confirmed the same picture.

Political will

Political support for nutrition has improved over time. From a politically sensitive issue, nutrition became a national concern. The political commitment to treat nutrition as a national priority was publicly expressed through the organisation of the International Symposium on Food and Nutrition Security (SISAN) held in Niamey from 28th to 31st March, 2011. The purpose of the Symposium was to address structural causes of food and nutrition insecurity in order to reduce incidence of all forms of malnutrition among vulnerable groups. This led to development of a 5 year strategic document for nutrition and agreement to a dedicated budget line for nutrition within the health budget. Niger joined the SUN and REACH international movements and linkages were improved between other public health programmes (vaccination, Integrated Management of Childhood Illnesses (IMCI) and HIV/AIDS).

Where does nutrition fit in government?

As a cross cutting issue, nutrition is handled by several sectors including agriculture, education and health. Emergency Nutrition Response is under the leadership of the Prime Minister’s Office. Responsibility for the management of acute malnutrition rests with the Ministry of Health (MOH). Within the MOH, there is the Nutrition Directorate in charge of designing nutrition policies, plans and strategies, and coordinating and overseeing implementation of nutrition interventions. In each of the eight regions and in each of the 42 districts, there is a nutrition focal point, which represents the extended arms of the Nutrition Directorate. Recently, the newly elected President launched an initiative to strengthen food security in the country. This initiative was named 3N: Nigeriens Nourish Nigeriens. A High Commission, linked to the President’s Office, is managing the 3N and will probably deal to some extent with nutrition-related issues.

CMAM roll out/scale up

The aim of CMAM provision in Niger is to provide adequate care for all children affected by acute malnutrition and thus to contribute to the reduction of morbidity and mortality due to acute malnutrition among children in Niger.

Scaling up CMAM in Niger has been gradual, but not according to a particular plan. Community Management of Acute Malnutrition (CMAM) was partially introduced for the first time as part of the emergency response to the 2005 food and nutrition crisis. Actions taken were establishment of a core group for coordination, a quick survey of the nutritional situation and identification of vulnerable areas, development of a national protocol for management of acute malnutrition, and support from humanitarian organisations in supplies, training and monitoring and evaluation (M&E). Since then, the CMAM approach has been institutionalised and streamlined. It was first implemented by selected non-governmental organisations (NGOs), while government-run facilities still operated following the traditional approach whereby all cases were treated as inpatients. CMAM was adopted progressively by more partners and reflected in the national protocol for management of acute malnutrition. The expansion of CMAM to all stakeholders became effective with the integration directive issued in 2008. This made it compulsory for all partners involved in the management of SAM to integrate their activities into the existing government-run health system.

At the operational level, management of acute malnutrition is undertaken in Niger by health staff, with surge capacity provided by either NGOs or United Nations (UN) agencies during periods when the caseload is high. Community health workers or NGOs undertake screening and case finding at community level and identified cases are referred to a health centre for treatment according to the national protocol. Community-level case finding is done using Mid Upper Arm Circumference (MUAC) and the diagnosis is confirmed at the health centre using weight-for-height z-score. During periods of high food insecurity, MUAC is used as an independent criterion of admission for treatment for SAM. Frequent training of service providers and on-the-job supervision are carried out to ensure quality of treatment, with technical and financial support from UNICEF, WFP, WHO and international NGOs.

Partners provide the required therapeutic supplies (Ready to Use Therapeutic Food (RUTF), therapeutic milks, and essential medicines) and other supplies, including long-lasting insecticide treated bed nets, blankets and soap. More specifically, UNICEF provides all supplies required for the treatment of SAM (RUTF, F-75, F-100, medicines, bed nets, blankets, soap, etc) and WFP provide about 80% of supplementary food required for management of cases of MAM.

The organisation of care is shown in Figure 3. As of July 2011, there is capacity for the treatment of acute malnutrition in virtually all health centres (see geographic coverage).

The Nutrition Directorate and its decentralised personnel in the regions and at district level supervise the management of acute malnutrition. Resources are provided by government, UNICEF, WFP and international NGOs.

There is a system for reporting the number of new cases admitted for treatment on a weekly basis and a weekly monitoring system of performance indicators. These systems were initially set up and managed by UNICEF as a parallel system but are now fully integrated into the national system, the management of which is being progressively transferred to the Nutrition Directorate.

Several issues related to sustainability, quality of services, completeness and timeliness of reporting remain challenges to be addressed in the near future.

To date, the management of cases of acute malnutrition in Niger is fully integrated into the existing health system and the service is provided by government staff, with support from NGOs when need arises (surge capacity).

Geographic coverage of CMAM

In each district, regional or national hospital, there is a unit for inpatient management of SAM with medical complications. A total of 50 such units are available throughout the country. Affected children are treated as inpatients in these facilities, known in Niger as Centre de Rehabilitation Nutritionnelle Intensive (CRENI). Of the 850 Integrated Health Centres available, 772 are in a position to treat cases of SAM without medical conditions. These are centres where children are treated in ambulatory care (CRENAS). Finally the Integrated Health Centres and some Health Posts offer treatment for MAM. In the country, there are more than 850 sites for the treatment of MAM (CRENAM). See Figure 4.

Main partners

The management of acute malnutrition in Niger is carried out by multiple partners, all operating under the leadership of the MOH, through the Nutrition Directorate. Approximately 20 NGOs, most of whom are international, are involved in management of acute malnutrition.

MOH leadership is critical to ensure integration of the management of acute malnutrition into the existing health system and to avoid a vertical approach, as often happens in emergency settings. Donors play an important role to ensure adequate management of acute malnutrition by providing sufficient resources to procure therapeutic and supplementary foods, drugs and other supplies required for the treatment of acute malnutrition.

NGOs support this programme at the operational level to ensure quality of care. Their contribution is mainly in terms of surge capacity, capacity building, and quality assurance. Management of acute malnutrition in Niger is happening at a very large scale. This still, by and large, depends on external funding. Sustaining the gains is a challenge that still needs to be addressed.

Community-based approach

Beneficiaries could play a greater role in CMAM in Niger. To date, management of MAM is decentralised to health post level with a significant involvement of community members, especially those in charge of managing health services in collaboration with the community health worker. In addition to direct management of MAM, community members are involved, via NGOs, with case identification and referral.

Community members, through community volunteers, are in some cases involved with sensitisation on adequate infant and young child feeding practices along with other key family practices. This is a component of the CMAM programme that still needs some strengthening.

Results

Before the 2005 nutrition crisis in Niger, there was only one therapeutic feeding centre in the whole of the country. The programme has grown over time and is now a national programme with more than 820 treatment centres for SAM and a further 1000 centres for the treatment of MAM.

Thanks to the combination of two decisions made by the government to improve access to health care for the population, more and more children now have access to treatment for acute malnutrition. These political decisions were to waive user fees for healthcare for children under five years and to integrate management of acute malnutrition into the existing health system. In addition to the increasing political commitment for nutrition in Niger, additional factors contributing to success in CMAM scale up have been the strong leadership from the Ministry of Public Health for coordination, technical support and assistance from UN and NGO partners, and development of longer term strategies to address malnutrition.

There is substantial capacity for the management of acute malnutrition in Niger. In 2009, about 127,000 children aged 6-59 months were treated for SAM in the country. In 2010, when Niger was confronted with a major nutrition crisis, 330,000 children aged 6-59 months were treated for SAM and 257,000 new cases of MAM were treated. As of the 2nd October 2011, more than 230,000 cases of SAM and just over 309,000 cases of MAM had been treated in Niger. For SAM cases, 26,101 (11%) were managed in CRENI and 205,806 (89%) managed in CRENAS.

The quality of services is monitored using weekly admission data by region and monthly monitoring of performance indicators. Admission data for 2010/11 for SAM and MAM are shown in Figures 5, 6 and 7.

The programme performance indicators are shown in Table 1. As of August 2011, the mortality rate was only 1.5% while the recovery and defaulter rates were 84% and 5.2% respectively. These national averages mask regional variations. A pattern that clearly emerged from available statistics is that where there is an NGO providing technical support, quality of care, as demonstrated by performance indicators, is good. Where government staff are the sole providers, quality remains sub-optimal. The case of Niamey, with the lowest recovery rate, high mortality and defaulter rates, is illustrated in the graphs in Figures 8, 9 and 10.

Challenges

Niger is faced with major challenges as far as CMAM is concerned. First, how to ensure and maintain quality care in all treatment centres, irrespective of the presence of NGOs providing technical support and second, how to sustain adequate provision of therapeutic supplies. To address these two issues, it is essential for the government to strengthen the health system. This will require the recruitment of adequate personnel to staff health facilities. It also requires setting up and implementing an inclusive quality assurance system as well as providing efficient supervision, which will lead to quality of care. A third challenge is how to scale up MAM programmes across the country. Taking charge of malnutrition is an integral part of the axis of nutrition in the food and nutritional security policy document of the government. Addressing MAM will require insertion of a dedicated budget line for purchase of therapeutic inputs and development of social safety nets (with a social safety net ‘cell’ attached to the Prime Minister’s office).

Niger depends on UNICEF and WFP for procurement of therapeutic supplies. This is a fragile situation which needs to be changed. The government could significantly reduce its dependence on UN agencies where therapeutic supplies is concerned, by allocating a budget line for procurement of therapeutic supplies to the Ministry of Health Budget and including procurement of therapeutic supplies in the social safety net package that is expanding very quickly in the country.

Key lessons

There are a number of key lessons from the scale up of CMAM in Niger. CMAM success relies on strong government vision and commitment for strategy, coordination and resource mobilisation. Strong government coordination is vital, especially when many partners are involved. Standardisation of treatment is key to ensure equity in treatment and comparable data. Operational partners prefer to focus on treatment not prevention - there is a need for more preventative programming.

Ways forward

CMAM is well established in Niger and is being carried out on a very large scale. In addition, quality of care is overall in line with Sphere standards. It is now urgent to maintain the existing capacity for the management of acute malnutrition in the country and to improve quality of care where services are still sub-optimal. In general, the community component of CMAM in Niger is rather weak and work needs to be done at this level to ensure effective involvement of communities. Next steps planned include adoption of the national nutrition plan and development of a national preventative nutrition strategy based on ‘best practices’.

In terms of scaling up nutrition more broadly and given the scale of CMAM in Niger, the programme can serve as an entry point for many interventions, including other nutrition programmes, especially those designed with the aim of reducing incidence of all forms of malnutrition in the country.

For more information, contact: Dr Guero H Doudou Maimouna, email: dnutniger@gmail.com or mhalidou2002@yahoo.fr

¹United Nations Development Programme

²Multiple Indicator Cluster Survey on Population and Health in Niger (EDSN - MICS), 2006

³Food Security of Nigerien Households, SAP/INS/FAO/UNICEF/EU/FEWS-NET/PNUD/WFP, April 2010

⁴National Nutrition Survey, National Institute of Statistics, June 2010