A review of the humanitarian nutrition response in North-East Nigeria

This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored by Alison Donnelly, Joanne Chui and Arja Huestis.

Alison Donnelly is an independent consultant with more than 10 years of experience working in humanitarian nutrition in Asia and sub-Saharan Africa.

Joanne Chui is an independent consultant with experience in nutrition programming in sub-Saharan Africa.

Arja Karin Huestis is a Monitoring and Evaluation Associate with the Maximising Quality of Scaling Up Nutrition Plus (MQSUN⁺) project at PATH.

Background

Since 2009, Boko Haram insurgencies in North East (NE) Nigeria have caused mass population displacement resulting in food insecurity and high rates of undernutrition. To support nutrition services, UNICEF engaged a consultancy firm to fill gaps in government staffing and to scale up priority nutrition services in a very insecure context where more traditional non-governmental organisation (NGO) partners were unable to operate.

Through the Maximising the Quality of Scaling Up Nutrition Plus programme, the Nigeria UNICEF offices and the UK’s Foreign, Commonwealth & Development Office¹ commissioned a review of the emergency nutrition response and the effectiveness of this approach between December 2018 and March 2019. It included a desk review of key strategies, tools and policies, analysis of available datasets, observation visits to nutrition sites and key informant interviews with Nutrition Sector partners. Key findings and lessons learned are highlighted in this article.  

Findings

Nutrition Sector coordination

Nutrition Sector coordination was felt to be successful owing to strong government leadership, UNICEF support and engagement by key stakeholders.

The Nutrition Sector was able to increase the number and quality of inpatient care facilities in the worst-afflicted state of Borno. The establishment of a Centre of Excellence in the University of Maiduguri Teaching Hospital in 2017 helped to increase the number of functional stabilisation clinics from 19 in 2018 to 26 by early 2019.

Hiring staff through a consulting company enabled the rapid scale-up of outpatient nutrition services in challenging circumstances. Consultant staff quickly filled gaps in government services, likely averting a major crisis.

Despite strong government leadership of the sector, partners did not always coordinate well amongst themselves. Partner-managed ‘outreach’ outpatient clinics were often set up close to health facilities with existing treatment programmes resulting in duplication and some beneficiaries accessed multiple sites and duplicate rations.

A lack of oversight on bilateral funding agreements by the Nutrition Sector caused coordination problems. The Nigeria Humanitarian Fund was new and not widely used. As bilateral agreements were often made between partners and donors without Nutrition Sector prior knowledge, the Nutrition Sector had limited influence on funding allocations.

Package of services included in the response

The need to support infant and young child feeding in emergencies (IYCF-E) was recognised early on and surge deployments were made from the Technical Rapid Response Team and the UNICEF Rapid Response Team and training provided by Save the Children to support Nutrition Sector IYCF-E programming. This support enabled the development of a draft IYCF-E response plan with minimum indicators and an advocacy brief on preventing untargeted breastmilk substitutes.   

However, despite this, the implementation of IYCF-E was not fully realised. The draft IYCF-E plan was not endorsed or disseminated and the Nutrition Sector was unable to identify an in-country focal person to take forward recommendations following the departure of surge deployments.   

Furthermore, insufficient attention was given to infants under six months of age. National community management of acute malnutrition (CMAM) guidelines did not until recently include guidance on inpatient management of severe acute malnutrition in infants under six months and services to manage uncomplicated cases of wasting in this age group in the community were not included in the response. These infants also lacked representation in population-based surveys.

Health systems strengthening

Capacity-building and sustainability

While the external support addressed urgent needs during the response, it risked further weakening the health system by creating a parallel system and not planning for long-term sustainability and government ownership. Furthermore, agencies often recruited government staff which further depleted the government workforce. Most partners installed supervisory staff and structures at district level to provide training and supervision support to frontline health workers. However, technical support and capacity-building beyond health centre staff was limited. Supervision was typically managed by someone recruited by UNICEF, the management company or NGO partners rather than driven by government counterparts.

Meetings of nutrition technical working groups were reactive instead of proactive with meetings often focused on addressing immediate issues rather than long-term priorities.

CMAM data management and reporting

Significant progress was made in ensuring the correct completion of patient records at facility level but discrepancies remained. An assessment of Nigeria’s CMAM information system revealed problems identifying programme absentees and admissions that were never discharged, large discrepancies between partner-reported data and site-level information and underreporting of defaulters (or possibly even deaths).  

Ready-to-use therapeutic food (RUTF) supply chain

UNICEF supported the government to forecast, procure, import and transport RUTF. Based on requests, UNICEF transported supplies to government-managed warehouses where management was ‘handed over’ to agencies or government.² In this way, RUTF supplies could be rapidly scaled up to meet needs.

However, forecasting and ordering were often not based on the most relevant data. Supply requests were based on numbers of children in programmes while forecasting was based on population-level survey results creating the risk of underestimated supply needs. In addition, there was a risk of underestimating supply needs due to changes in mid-upper-arm circumference (MUAC) discharge criteria and overestimation due to failure to accurately record discharges and defaulting.

There were multiple risks of bottlenecks throughout the RUTF supply chain. The steps involved in forecasting, purchasing, ordering, delivering and supplying RUTF to end-users were often poorly linked. As site-level gaps in supply were inconsistently tracked across partners, it was difficult to identify where and why breaks occurred and who was responsible.

Furthermore, partner supply usage was not optimally tracked against forecasts. Partners based their forecasts on previous admissions for existing sites and a standard caseload calculation for new sites. As RUTF orders were placed once funding was received, the buffer supply may have been insufficient when contracts were delayed. Furthermore, forecasting for RUTF supplies was based on weight-for-height prevalence but admission to treatment programmes was based on MUAC measurements which created a discrepancy between forecast and actual RUTF usage. There were also differences in the average amount of RUTF used per child by different partners.

Discussion and conclusions 

This review highlights the importance of early coordination to prevent duplication of services, the facilitation of government ownership, enhanced data quality and the management of and improvement in the tracking and forecasting of supplies. Some of these problems are common across many emergency contexts. Emergency responses often establish parallel structures that are unsustainable and guidance is needed on how to truly support government-led services. Assessing health facility capacity to manage increased caseloads could be beneficial for planning short-term surges as well as assessing medium and long term support needs. Donors should also provide longer term flexible funding to support service integration. Since handover to government may take several more years, steps toward full government delivery and indicators to track progress on this should be identified.  

The simplification of the CMAM approach could be explored to reduce the supervision required and to streamline data reporting. While UNICEF is leading efforts around new, simplified protocols, this will take time and thus renewed efforts to simplify and improve approaches in the existing CMAM model could enhance service delivery and support scale-up.  

The recommendations from this review have been incorporated into the three-year Nutrition Sector strategy developed in 2020 and recommendations to improve the NE Nigeria response have also been accepted by the Nutrition Sector.

For more information, please contact Alison Donnelly at alisonjdonnelly@gmail.com and Carrie Hemminger at chemminger@path.org