No mother ever wants to face the tough choices many mothers in conflict zones, like Borno have to face on a daily basis. The struggle for survival, keeping a severely malnourished child alive, while at the same time struggling for their own survival, knowing that the treatment that will keep their child alive will also help keep them alive. This is a difficult choice to imagine. In some parts of Northern Nigeria, where health services are still struggling to return to normal following insurgency attacks, this is a daily reality for many families have to face.
Dr. Sulaiman Meleh, The Executive Secretary of the Borno State Primary Healthcare Development Agency (BSPHCDA), in an interview with Nigeria Health Watch in August, stated that primary healthcare was one of the worst-hit sectors at the peak of the insurgency. The local infrastructure was destroyed and human resources grossly depleted. This had far-reaching consequences for the state, including severe malnutrition in children below the age of five. In addition, access to life-saving health care services like family planning, immunisation, maternal and child health services was reduced.
The crisis in Borno has affected the health sector in one of the worst ways - Dr. Sule Meleh, Executive Director, Borno State Primary Healthcare Development Agency.#NHWInBorno @NphcdaNG @UNICEF_Nigeria @SWNInitiative @SUN_Movement pic.twitter.com/bIYHnbKIN8 - Nigeria Health Watch (@nighealthwatch) August 16, 2018
One of the interventions by partners in the midst of the humanitarian crises is the provision of Ready-To-Use Therapeutic Food (RUTF) to treat children with severe acute malnutrition (SAM). These foods are usually given to mothers or caregivers at the Community Management of Acute Malnutrition (CMAM) centres. The Mallah Kachalah Primary Health Centre in Maiduguri, one of the few local medical facilities in locations where UNICEF runs a triage-like setup to manage the inflow of patients in Borno state. The facility offers the local community a range of services such as immunisation and it also doubles as a CMAM centre.
At the centre, Barma Adam Umar, an elderly nurse and nutrition service provider carefully attends to 16-month-old Mohammed Ali and his mother Gana Mohammed. Umar, who said he relocated from the General Hospital in Ngala, Borno, when the insurgents took over the town, mentioned that Ali's condition had significantly improved, compared to the first time he visited the CMAM centre in July, 2018. Ali, who was visiting the treatment centre for the fourth time under the CMAM program, was to be discharged if the improvements in his condition were consistent, Umar said.
"If his Mid-Upper Arm Circumference (MUAC) is above 12.5cm for three consecutive visits and his weight is between 7.9kg - 8kg for two consecutive visits, he will be discharged, and his mother will be advised on how to keep him nourished using local diets," he said.
The nurse also checked the respiratory rate and other vital statistics of 9-month old Sadaja Usman who visited the health facility for the first time in August, 2018. Sadaja still looks underweight but Umar said she was taken into the Centre's Infant and Young Child Feeding (IYCF) program because she didn't have any medical complications. Sadaja and Ali are growing up in a state with a worrying number of malnourished children, 36.5% of the children are stunted and 11.5% are wasted. Both these indices are above the country's averages of 26.5% and17.2%, respectively and the resultant effect is children like Sadaja and Ali with weakened immune systems and impaired brain development.
The IYCF program is part of UNICEF's nutrition intervention and malnourished children like Sadaja and Ali are treated under the CMAM programme, once identified as suffering from severe acute malnutrition. If they do not have any other complications, they are treated in the Out-Patient Therapeutic Program (OTP). Umar mentioned that children with medical complications like intractable vomiting, high fever, and superficial infections are referred to other facilities that deal with children suffering from severe acute malnutrition and they are treated as in-patients. Children are then referred to the IYCF programme once they complete the 8-week RUTF treatment as the focus is now on educating the mothers and caregivers about complementary feeding practices and breastfeeding until the child reaches the age of 2.
While on the CMAM program, caregivers like Sadaja's mother would feed their child with the sachets of RUTF which they give only to the child suffering from severe acute malnutrition for the 8-week program. Umar, the nurse at the nearby primary healthcare centre said that one of the challenges he and his colleagues at the centre faced, was the realisation that some mothers were not administering the treatments meant to treat for their severely malnourished children. Some were selling the RUTF, while others were giving it to their men because they believed it was an aphrodisiac.
"One of the challenges we have is mothers who don't give the RUTF to their malnourished children," Umar said, adding that, "I know it's unbelievable but some of them believe that if the child dies, the husband is there to give them another one".
An independent systematic review was commissioned by the Humanitarian Evidence Programme to access recovery, relapse and episodes of default in the management of acute malnutrition in children in humanitarian emergencies. The review team cited a UNICEF programme evaluation report of an integrated management of acute malnutrition (IMAM) programme in Kenya. The report suggested the lack of a follow-up system to track children treated for severe acute malnutrition (SAM) or moderate acute malnutrition (MAM), together with a lack of encouragement to return for outpatient treatment may have contributed to relapses, as well as the sharing of RUTF among siblings and other non-admitted children.
Some of the reasons for default cited by other papers reviewed by the team include distance to travel to sites, poor community sensitization and household follow-up. Evidence from these findings may have informed some of the interventions by UNICEF in Northern Nigeria as the push for the use of evidence in healthcare planning has continued to gain prominence.
Community Nutrition Mobilisers as demand-side generators
The CMAM program works with Community Nutrition Mobilisers (CNMs) to ensure mothers are responsible in the use of RUTF. The CNMs are like the Volunteer Community Mobilisers who work mostly to improve immunisation coverage in communities.
"These community nutrition mobilisers are very smart. They help ensure the women don't sell the RUTF meant for their children. They follow up and investigate if there is an improvement on the child receiving the RUTF," Umar said. Another tactic they devised was to ask the women to keep the RUTF sachets and bring them back to the centre before they can receive more RUTF.
Beyond asking for the RUTF sachets, the program runs an integrated service delivery strategy where the mothers can access other services within the primary health centre free of charge. "The women access services like immunisation, antimalarial tests and medications. They also receive micronutrient supplements for pregnant and lactating women," Umar said.
The CNMs work with traditional rulers to access the communities, sensitise them on available services at the health centre and use the opportunity to assess the condition of children receiving treatment. Umar said it is important to have a physical assessment of the child, because the retuned sachets is not enough evidence that the child is receiving treatment. Further investigations are initiated if the child's improvement is not in proportion to the amount of RUTF distributed.
He stated that the CNMs have helped increase the number of mothers coming to seek care for their malnourished children. "We used to have monthly visits of about 10 children with 27 in the program. Now, we have over 200 monthly visits and 80 are in the program," he said.
28-year-old Zainab Ibrahim is stationed at the Gubio Road IDP camp, where a clinic supported by UNICEF serves over twenty thousand residents. Zainab was trained as a Community Nutrition Mobiliser by UNICEF and helps to sensitise women in nearby communities that are covered by the camp clinic. She said her team engages with the women and teaches them the benefits of breastfeeding and good hygienic practices before screening the children for malnutrition using the MUAC test and checking for Oedema. They make use of images to help the mothers understand the difference between malnourished and healthy children.
"When we talk to them, not everyone understands," she said, adding, "We have to put the message the way they will understand. We show them the posters that we have and tell them to look at the child that is looking good and another that is not looking good. We ask if they like their children to look bad. We tell them to choose the one they like so if they don't like their child to look bad, they have to follow up by going to the clinic".
The Nutrition in Emergency, Northeast, Nigeria intervention in 2017 received a total funding of US $103.9 million and surpassed the proposed target of 2.7million people by reaching over 3.4 million people comprising young children (male and female) under the age of five, pregnant and lactating mothers. However, the intervention's performance indicator for its out-patient therapeutic program (OTP) had a 10% default rate, which means that 30,707 people dropped out of the program.
The work of community nutrition mobilizers is meant to cut down on the default rate for out-patient programs, and in the case of UNICEF's nutrition intervention in Maiduguri, they have shown moderate success in ensuring that children like Ali and Sadaja not only begin treatment, but are able to successfully complete their CMAM treatment to become healthy, well-nourished children.
The running of IYCF programs, CMAM centres and the provision of RUTFs has been dependent on funding from development partners. Nutrition intervention cannot be seen as a stop-gap exercise. Long-term sustained funding is critical to ensure that on a state-wide basis, nutrition is included in state budgets. Raising generations of children with impaired brain development limits our ability to break out of the vicious cycle of intergenerational poverty and as a country, we are losing the human capital that would lift families out of poverty. Borno state and other similar conflict zones are faced with an added challenge, however other states that do not face the same challenge need to ensure that nutrition is budget for, funds released and existing nutrition policies implemented.