By Adewole Kehinde
I will be looking at both Nutrition and malnutrition
across Nigeria but with particular focus on the North East zone due to the
various intervention programs that has been introduced especially by UNICEF and
Community Management of Acute Malnutrition (CMAM) in particular.
Experts agree that nutrition has a significant
impact on child health, growth, and development in the first two years of a
child’s life.
It is on records that scholars have discussed the
effect of a nutrition intervention during early childhood on human capital
(personal attributes such as knowledge, skills, health, and values, that
increase individual productivity) formation and on the economic productivity of
Nigerian adults.
Malnourished children require more health services
and more expensive types of care than other children. Malnourished children
have poorer schooling outcomes and may repeat years more often, thus increasing
education costs. Developing countries are also spending an average of 2 to 7
percent of their health care budgets on direct costs for treatment of obesity and
associated chronic diseases - and the obesity problem is rapidly worsening. All
of these costs fall largely on governments, which provide extensive public
sector financing for health and education for the poor. Returns from programs
for improving nutrition far outweigh their costs Taking into account the
reduced mortality, reduced medical costs, intergenerational benefits (reduced
likelihood of giving birth to a low-birth-weight infant in the next generation),
and increased productivity.
Nutrition and income poverty Under-nutrition and
micronutrient malnutrition are themselves direct indicators of poverty, in the
broader definition of the term that includes human development. But under-nutrition
is also strongly linked to income poverty, although by no means synonymous with
it. The prevalence of malnutrition is often two or three times—and sometimes
many times—higher among the poorest income quintile than among the highest
quintile.
This means that improving nutrition is pro-poor and
increases the income-earning potential of the poor. In countries where girls’
nutrition lags behind, improving the nutrition of young girls adds an extra
equity-enhancing dimension to any such investment. Poverty and malnutrition
reinforce each other through a vicious cycle. Poverty is associated with poor
diets, unhealthy environments, physically demanding labor, and high fertility,
which increase malnutrition.
Malnutrition in turn reduces health, education, and
immediate and future income, thus perpetuating poverty. Even worse, poor malnourished
women are likely to give birth to low-birth-weight babies, thus perpetuating
poverty in the subsequent generation. Addressing malnutrition helps break this
vicious cycle and stop the intergenerational transmission of poverty and
malnutrition.
Direct investment in health and nutrition is needed
to benefit the poor. Often, investments in economic growth outpace improvements
in health.
If under-nutrition can lead to lower human capital,
preventing it could bring about not only health, but also educational and
economic benefits. Programs in health and nutrition aimed at women and young
children could promote better growth and development, which would improve human
capital and by extension increase economic productivity many years later.
The World Bank has positioned nutrition as not only
a matter of human rights, but also as an economic investment and an engine for
economic growth. Investments in health and nutrition should be seen as a
long-term human investment.
Community
Management of Acute Malnutrition (CMAM)
CMAM
is a methodology for treating acute malnutrition in young children using a
case-finding and triage approach. Using the CMAM method, malnourished children
receive treatment suited to their nutritional and medical needs. Most
malnourished children can be rehabilitated at home with only a small number
needing to travel for in-patient care. CMAM is one of World Vision’s core
project models in nutrition.
The
Community-Based Management of Acute Malnutrition (CMAM) approach enables
community volunteers to identify and initiate treatment for children with acute
malnutrition before they become seriously ill. Caregivers provide treatment for
the majority of children with severe acute malnutrition in the home using
Ready-to-Use-Therapeutic Foods (RUTF) and routine medical care. When necessary,
severely malnourished children who have medical complications or lack an
appetite are referred to in-patient facilities for more intensive treatment.
CMAM
programmes also work to integrate treatment with a variety of other longer-term
interventions. These are designed to reduce the incidence of malnutrition and
improve public health and food security in a sustainable manner.
The
CMAM model was developed by Valid International and has been endorsed by WHO
and UNICEF. CMAM was originally designed for the emergency context, as an
alternative to the traditional model of rehabilitating all severely malnourished
children through in-patient care at Therapeutic Feeding Centres. However it is
increasingly being implemented in the context of long-term development
programming, with several Ministries of Health including components of CMAM in
their routine services.
CMAM
has been implemented around the world by many governments and NGOs. World
Vision’s first CMAM project started in Niger in 2006. Since then, World
Vision's CMAM programming has expanded to 15 countries.
CMAM
should be implemented in any area where at least 10% of children under 5 are
moderately malnourished (low weight for height) and there are aggravating
factors present. Aggravating factors include generalized food insecurity,
widespread communicable diseases and high crude death rate. The NCOE's Measuring and
Promoting Child Growth tool explains how to accurately weigh
and measure children.
There
are four key components to the CMAM approach:
Ø
Community
Mobilisation
Build
relationships and foster active participation of the community
Identify
and mobilise community volunteers for CMAM
Volunteers
measure Mid-Upper Arm Circumference (MUAC) of all children under 5 to identify
those with acute malnutrition.
Ø
Supplementary
Feeding Programme (SFP):
Provide
take-home food rations and routine basic treatment for families of children
with moderate malnutrition but no medical complications
Provide
support for other groups with special nutrient requirements, including pregnant
and lactating mothers
Ø
Outpatient
Therapeutic Programme (OTP):
Provide
home-based treatment and rehabilitation using RUTF for children with severe
acute malnutrition but no medical complications (usually 80-85% of children)
Monitor
children’s progress through regular outpatient clinics
Provide
food rations to the whole family of each severely malnourished child
Ø
Stabilisation Centre/Inpatient
Care:
Provide
intensive in-patient medical and nutrition care to acutely malnourished
children with complications such as anorexia, severe medical issues or severe
oedema
Link
with OTP to allow early discharge and continued treatment in the community
CMAM
targets children under 5 years old and their families, but the whole community
is involved. Community leaders, volunteers, health staff and families
participate in the screening, care and follow up of children with acute
malnutrition. Everybody celebrates as the children enrolled in the CMAM
programme gain weight and enjoy better health.
CMAM
is a highly effective approach to rehabilitating malnourished children and
reducing the number of children who die from acute malnutrition. There a few
key secrets to this success:
Community
based – children are cared for and treated in their own communities,
without having to travel away from home for treatment. The whole family is
involved and can also continue their daily activities, rather than one
caregiver needing to leave home for an extended time to accompany a
malnourished child to a treatment centre. This increases access and
participation in the programme, leading to higher coverage and better results.
Active
case finding – community volunteers regularly screen and monitor all young
children so that cases of malnutrition can be identified early and treated
immediately. This leads to high coverage, faster rehabilitation and lower
mortality.
Triage
approach – most children with severe acute malnutrition can be treated at
home which protects them from exposure to infections at the inpatient care
centres. Only those with existing serious medical conditions are referred to
Stabilisation Centres, and they are discharged back to the community for follow
up by the OTP as soon as possible. This reduces mortality and is
cost-effective, as inpatient care is highly resource-intense.
Building
community capacity – CMAM programmes work with communities to identify,
manage and prevent acute malnutrition. This increases community ownership of
malnutrition, which in turn increases participation in treatment and prevention
activities.
In northeast Nigeria, in the three states of
Adamawa, Yobe and Borno that have been affected by the ongoing conflict, one in
every five children is severely malnourished. An estimated 940,000 children
aged 6 to 59 months across these states are acutely malnourished, 440,000 with
Severe Acute Malnutrition and 500,000 with Moderate Acute Malnutrition.
he
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 programmes13.
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 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.
While
nutritional treatment services have become increasingly available in health
centres across Nigeria, the need still remains extremely high. Whilst the
number of SAM children treated – 44,000 in 2010 alone – are more commonly
associated with emergency situations, the only response capable of addressing
needs is through horizontal programmes integrated into health systems and
communities. The question that the ACF and Save the Children pilot programmes
sought to answer is how, in the context of Nigeria, this can be done most
effectively and sustainably.
The
pilots show that part of the answer lies in thinking about the delivery of CMAM
services outside of the traditional NGO model, from rethinking the need for
individual stations at OTP level, to admitting children on a weekly (rather
than daily) basis. For integration truly to occur, CMAM services need to be
tailored to fit health systems at different levels, even if this ultimately
leads to significant variations across different locations. There is not one
approach that will fit all of Nigeria, or even all the LGAs in a state.
Tactical diversity should be encouraged.
Other
aspects of CMAM programming need to be strengthened and enforced. CMAM was
founded on a commitment to reaching a high proportion of the affected
population, and this vision needs to remain at the core of national strategies
for their CMAM integration. The number of geographical areas (e.g. states) or
facilities within them offering the service is a means to this end, not an end
in itself.
Ensuring
that integrated CMAM programmes achieve the highest possible coverage is
closely linked to the degree of community mobilisation carried out. Scarce
resources, overburdened staff, and limited experience have traditionally
hampered the ability of health systems to develop community mobilisation
strategies to accompany the introduction and implementation of CMAM services.
NGOs have a crucial role to play in this regard. Increasing community awareness
and participation in activities is a key feature of what local health systems
will need to do in order to address needs. In high prevalence areas, like
Northern Nigeria, increasing awareness must be accompanied by a simultaneous
strengthening of health systems responsible for managing any rise in demand.
The
roll-out of CMAM services in many high-prevalence contexts, including Nigeria,
has stretched the capacity of government and support agencies to maintain RUTF
supplies. The pilot programmes showed the risks of scaling up without proper
RUTF supplies, a risk that only increases in magnitude and likelihood with the
scale-up of CMAM services on a national scale. Ultimately, the sustainability
and quality of CMAM programmes depends on the degree to which governments (at
federal, state and local level) are willing and able to ensure adequate
procurement and delivery of RUTF. Partners have a vital role in building
capacities at all levels on stock management, including accurate forecasting.
Having more accurate data on needs help to advocate for state governments and
budget allocation.
Delivering
this kind of support ultimately requires a redefinition of the role of NGOs,
from a traditionally implementing role, to one as an enabler. Technical support
proved essential in the implementation of CMAM in Nigeria, at federal, state
and local levels. The decision not to include staff in SDUs was certainly vital
to the sustainability of the project. The NGO role must become one of capacity
strengthening and transfer of skills. Advocacy and the ability to support the development
of national policies to create the right environment for CMAM are vital to the
success of a scale-up framework.
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.
In
Katsina, the programme initially introduced Community Mobilisation mentors to support
volunteers 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.
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 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.
While
nutritional treatment services have become increasingly available in health
centres across Nigeria, the need still remains extremely high. Whilst the
number of SAM children treated – 44,000 in 2010 alone – are more commonly
associated with emergency situations, the only response capable of addressing
needs is through horizontal programmes integrated into health systems and
communities. The question is how, in the context of Nigeria, this can be done
most effectively and sustainably.
The
pilots show that part of the answer lies in thinking about the delivery of CMAM
services outside of the traditional NGO model, from rethinking the need for
individual stations at OTP level, to admitting children on a weekly (rather
than daily) basis. For integration truly to occur, CMAM services need to be
tailored to fit health systems at different levels, even if this ultimately
leads to significant variations across different locations. There is not one
approach that will fit all of Nigeria, or even all the LGAs in a state.
Tactical diversity should be encouraged.
Other
aspects of CMAM programming need to be strengthened and enforced. CMAM was
founded on a commitment to reaching a high proportion of the affected
population, and this vision needs to remain at the core of national strategies
for their CMAM integration. The number of geographical areas (e.g. states) or
facilities within them offering the service is a means to this end, not an end
in itself.
Ensuring
that integrated CMAM programmes achieve the highest possible coverage is
closely linked to the degree of community mobilisation carried out. Scarce
resources, overburdened staff, and limited experience have traditionally
hampered the ability of health systems to develop community mobilisation
strategies to accompany the introduction and implementation of CMAM services.
NGOs have a crucial role to play in this regard. Increasing community awareness
and participation in activities is a key feature of what local health systems
will need to do in order to address needs. In high prevalence areas, like
Northern Nigeria, increasing awareness must be accompanied by a simultaneous
strengthening of health systems responsible for managing any rise in demand.
The
roll-out of CMAM services in many high-prevalence contexts, including Nigeria,
has stretched the capacity of government and support agencies to maintain RUTF
supplies. The pilot programmes showed the risks of scaling up without proper
RUTF supplies, a risk that only increases in magnitude and likelihood with the
scale-up of CMAM services on a national scale. Ultimately, the sustainability
and quality of CMAM programmes depends on the degree to which governments (at
federal, state and local level) are willing and able to ensure adequate
procurement and delivery of RUTF. Partners have a vital role in building
capacities at all levels on stock management, including accurate forecasting.
Having more accurate data on needs help to advocate for state governments and
budget allocation.
Delivering
this kind of support ultimately requires a redefinition of the role of NGOs,
from a traditionally implementing role, to one as an enabler. Technical support
proved essential in the implementation of CMAM in Nigeria, at federal, state
and local levels. The decision not to include staff in SDUs was certainly vital
to the sustainability of the project. The NGO role must become one of capacity
strengthening and transfer of skills. Advocacy and the ability to support the development
of national policies to create the right environment for CMAM are vital to the
success of a scale-up framework.
Improving nutrition contributes to productivity,
economic development, and poverty reduction by improving physical work
capacity, cognitive development, school performance, and health by reducing
disease and mortality. Poor nutrition perpetuates the cycle of poverty and
malnutrition through three main routes - direct losses in productivity from
poor physical status and losses caused by disease linked with malnutrition;
indirect losses from poor cognitive development and losses in schooling; and
losses caused by increased health care costs. The economic costs of malnutrition
are very high - several billion dollars a year in terms of lost gross domestic
product (GDP). Relying on markets and economic growth alone means it will take
more than a generation to solve the problem. But specific investments can
accelerate improvement, especially programs for micronutrient fortification and
supplementation and community-based growth promotion. The economic returns to
investing in such programs are very high.
For many people, the ethical, human rights, and
national security arguments for improving nutrition or the tenets of their
religious faith are reason enough for action. But there are also strong
economic arguments for investing in nutrition:
Ø Improving nutrition
increases productivity and economic growth.
Ø Not addressing malnutrition
has high costs in terms of higher budget outlays as well as lost GDP.
Ø Returns from programs for
improving nutrition far outweigh their costs.
Good nutrition is a basic building block of human
capital and, as such, contributes to economic development. In turn, sustainable
and equitable growth in developing countries will convert these countries to
developed States.
There is much evidence that nutrition and economic
development have a two-way relationship. Improved economic development
contributes to improved nutrition (albeit at a very modest pace), but more
importantly, improved nutrition drives stronger economic growth. Furthermore,
as quantified in the Copenhagen Consensus, productivity losses caused by
malnutrition are linked to three kinds of losses -those due to:
Ø Direct losses in physical
productivity.
Ø Indirect losses from poor
cognitive losses and loss in schooling.
Ø Losses in resources from
increased health care costs.
Therefore, malnutrition hampers both the physical
capacity to perform work as well as earning ability. Malnutrition leads to direct
losses in physical productivity Malnutrition leads to death or disease that in
turn reduces productivity. For example:
Ø According to the World
Health Organization (WHO), underweight is the single largest risk factor
contributing to the global burden of disease in the developing world. It leads
to nearly 15 percent of the total DALY (disability-adjusted life years) losses
in countries with high child mortality. In the developed world, overweight is
the seventh highest risk factor and it contributes 7.4 percent of DALY losses.
Ø Malnutrition is directly or indirectly
associated with nearly 60 percent of all child mortality and even mildly
underweight children have nearly double the risk of death of their
well-nourished counterparts.
Ø Infants with low birth-weight
(less than 2.5 kilograms)—reflecting, in part, malnutrition in the womb—are at
2 to 10 times the risk of death compared with normal-birth-weight infants.
These same low-birth-weight infants are at a higher risk of non-communicable
diseases (NCDs) such as diabetes and cardiovascular disease in adulthood.
Ø Vitamin A deficiency
compromises the immune systems of approximately 40 percent of the developing
world’s children under age five, leading to the deaths of approximately 1 million
young children each year.
Ø Severe iron deficiency
anemia causes the deaths in pregnancy and childbirth of more than 60,000 young
women a year.
Ø Iodine deficiency in pregnancy
causes almost 18 million babies a year to be born mentally impaired; even
mildly or moderately iodine-deficient children have IQs that are 10 to 15
points lower than those not deficient.
Ø Maternal foliate deficiency
leads to a quarter of a million severe birth defects every year.
The strongest and best documented
productivity-nutrition relationships are those related to human capital
development in early life. Height has unequivocally been shown to be related to
productivity and final height is determined in large part by nutrition from
conception to age two. A 1% loss in adult height as a result of childhood
stunting is associated with a 1.4 percent loss in productivity. In addition,
severe vitamin and mineral deficiencies in the womb and in early childhood can
cause blindness, dwarfism, mental retardation, and neural tube defects - all
severe handicaps in any society, but particularly limiting in developing
countries.
Anemia has a direct and immediate effect on
productivity in adults, especially those in physically demanding occupations.
Eliminating anemia results in a 5 to 17 percent increase in adult productivity,
which adds up to 2 percent of GDP in the worst affected countries.
Malnourished adults are also likely to have higher
absenteeism because of illness. In addition to its effect on immune function,
poor nutrition also increases susceptibility to chronic diseases in adulthood.
Diet-related NCDs include cardiovascular disease, high blood cholesterol,
obesity, adultonset diabetes, osteoporosis, high blood pressure, and some
cancers.
About 60 percent of all deaths around the world and
47 percent of the burden of disease can be attributed to diet-related chronic
diseases. About two-thirds of deaths linked to these diseases occur in the
developing world, where the major risk factors are poor diet, physical
inactivity, and obesity.
These diseases are increasing at such a rapid rate,
even in poor countries, that the phenomenon has been dubbed “the nutrition
transition.” Like other types of malnutrition, the strongest for manual labour,
it has also been found in the manufacturing sector and among white collar
workers.
Malnutrition leads to indirect losses in
productivity from poor cognitive development and schooling. Low birth-weight may
reduce a person’s IQ by 5 percentage points, stunting may reduce it by 5 to 11
points, and iodine deficiency by as much as 10 to 15 points.
Iron deficiency anemia consistently reduces
performance on tests of mental abilities (including IQ) by 8 points or 0.5 to
1.5 standard deviations in children.15 Growth failure before the age of two,
anemia during the first two years of life, and iodine deficiency in the womb
can have profound and irreversible effects on a child’s ability to learn.
Height and weight affect the likelihood that
children will be enrolled at the right time in school. Small and sickly
children are often enrolled too late (or never), and they tend to stay in
school for less time.18 Malnutrition also affects the ability to learn. Common
sense tells us that a hungry child cannot learn properly. Although this is true
and short-term hunger does affect cognitive function (particularly attention
span), the effects of immediate hunger pale in comparison with the effects on
school performance of malnutrition in early life, long before the child ever
reaches the classroom.
Children who were malnourished early in life score worse
on tests of cognitive function, psychomotor function, and fine motor skills and
they have reduced attention spans and lower activity levels. These cognitive
skill deficits persist into adulthood and have a direct effect on earnings.
Recent studies have shown that that the positive
correlation between nutritional status and both cognitive development and
educational attainment also applies to children in normal birth-weight and
height ranges. For example, as birth-weight increased by 100 grams among
sibling pairs, the mean IQ at age 7 increased 0.5 point for boys and 0.1 point
for girls.
Educational attainment at age 26 among cohorts with
birth-weights between 3 and 3.5 kilograms was 1.4 times higher compared with
those with birth-weights between 2.5 and 3 kilograms. The odds of having
attained higher education (beyond compulsory schooling) at age 26 were also 2.6
times higher among the tallest cohort compared with the shortest cohort.
It is also worth noting here that the effect of
improved nutrition often extends into the range of what is considered normal - so
that improving birth-weights has a positive effect even for children above the
2,500-gram cutoff for low-birth-weight babies, reducing anemia has similar
benefits beyond those for people afflicted with “severe or moderate” anemia,
and levels of mortality are higher even among mildly underweight children.
Why Invest In
Nutrition:
Not addressing malnutrition has high costs in lost GDP and higher budget
outlays Malnutrition costs low-income countries billions of dollars a year. A
recent study, for example, showed that preventing one child from being born
with a low birth-weight is worth $580.23, 24 At the country level, it has been
estimated that obesity and related NCDs cost China about 2 percent of GDP and
in India productivity losses (manual work only) from stunting, iodine
deficiency, and iron deficiency together are responsible for a loss of 2.95
percent of GDP.25, 26 Preventing micronutrient deficiencies alone in China will
be worth between $2.5 and $5 billion annually in increased GDP, which
represents 0.2 to 0.4 percent of annual GDP in China.
Adewole
Kehinde is a Journalist and Publisher of Swift Reporters based in Abuja,
Nigeria
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