This summary highlights findings and recommendations from operation research on a Community-Based Management of Acute Malnutrition (CMAM) programme in northern Nigeria.  The study analysed the perceived benefits of CMAM; reasons for beneficiaries not defaulting from the programme; challenges of accessing CMAM services; the workloads and motivation of health workers and community volunteers; and what is required to integrate CMAM into the primary health system.UK Ai

Adeyemi, Olutayo

Afolabi, Wasiu A.

Akinyele, Isaac

Ferguson, Elaine

Hoyt, Jenna

Lawal, Hussiani

Okunola, Rasheed A.

Webster, Jayne

Yohanna-Dzingina, Cynthia

English

IDS OpenDocs

 ORIE Research Summary
The treatment and prevention of severe acute 
malnutrition via the CMAM programme is 
one of four outputs of the UK Department for 
International Development funded Working 
to Improve Nutrition in Northern Nigeria 
(WINNN) programme. This output aims to 
deliver effective treatment for severe acute 
malnutrition through local health systems in 
collaboration with communities. 
WINNN is implemented by UNICEF, Action 
Against Hunger (ACF) and Save the Children 
International (SCI), in partnership with the 
Federal Government of Nigeria and the state 
governments of Jigawa, Katsina, Kebbi, 
Yobe and Zamfara. SCI is responsible for 
its implementation in Zamfara, Kebbi and 
Katsina states, and ACF is responsible for its 
implementation in Jigawa and Yobe states.
Each of the five WINNN states implements the 
CMAM programme in three Local Government 
Areas (LGAs). The CMAM services are currently 
provided in 79 Outpatient Therapeutic (OPT) 
centres and 15 Inpatient Therapeutic (IPT) 
centres, across the five states. As of April 2014, 
the WINNN CMAM programme had admitted 
58,515 children aged 6-59 months, which 
exceeded their cumulative target levels by 46%. 
Despite the high level of acceptance of 
CMAM services within communities, WINNN 
has identified several key challenges for 
the sustainability and effective delivery of 
the CMAM programme. There are currently 
relatively high programme default rates. 
Additionally, there are implementation 
challenges at the community, LGA and state 
levels that might impact on the long-term 
sustainability of the CMAM programme and its 
integration into the primary health care system. 
Research objectives
Operations research was carried out to: 
• determine opinions and perceived benefits 
of the WINNN CMAM programme amongst 
mothers and fathers of CMAM beneficiaries 
and programme staff; Nu
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 ORIE RESEARCH SUMMARY 09 | October 2015 | How to strengthen a Community-Based Management of Acute Malnutrition programme in northern Nigeria 1
 Nutrition Research in Northern Nigeria
 How to strengthen a Community-Based 
 Management of Acute Malnutrition 
 programme in northern Nigeria
This summary highlights findings and recommendations from operation research on a 
Community-Based Management of Acute Malnutrition (CMAM) programme in northern Nigeria.
«There are 
implementation 
challenges that 
might impact on 
the long-term 
sustainability 
of the CMAM 
programme and 
its integration 
into the primary 
health care 
system.»
Issue 09 • October 2015
The WINNN CMAM service includes:
1. Community outreach, for the early 
identification and referral of severe 
acute malnutrition (SAM) and later 
follow-up; 
2. Outpatient care for children with SAM 
without medical complications at health 
facilities and at home (Outpatient 
Therapeutic, OPT); 
3. Inpatient care for children with SAM, 
and medical complications or no 
appetite (Inpatient Therapeutic, IPT);
4. Treatment of SAM with ready-to-use-
therapeutic-food (RUTF).
 ORIE RESEARCH SUMMARY 09 | October 2015 | How to strengthen a Community-Based Management of Acute Malnutrition programme in northern Nigeria 2
 ORIE Research Summary
• identify the common reasons for beneficiaries 
defaulting from the programme, and the 
challenges they face in accessing CMAM 
services;
• understand what is required to ensure 
workloads of Health Workers (HW) 
and Community Volunteers (CVs) are 
manageable and their motivation and 
long-term commitment to the CMAM 
programme remains high; 
• understand what is required to successfully 
integrate CMAM into the primary health 
system. 
Research approach
The CMAM operations research was 
conducted in two LGAs in two of the five 
WINNN states: Jigawa and Zamfara. Data 
were collected through 24 focus group 
discussions (FGDs) and 44 in-depth 
interviews. FGDs were conducted with 
mothers of CMAM beneficiaries – both 
those who had and had not defaulted from 
the CMAM programme. FGDs were also 
conducted with CMAM community volunteers 
(male and female). In-depth interviews were 
facilitated with State and LGA level officials, 
health workers (management and front line 
positions in the CMAM programme), and 
fathers of CMAM beneficiaries (defaulters 
and non-defaulters). The community level 
FGDs and interviews were facilitated with four 
interviewee strata: (1) urban high/moderate 
defaulter areas; (2) rural high/moderate 
defaulter areas; (3) urban low defaulter areas; 
and (4) rural low defaulter areas. 
Perceptions of the programme
Overall, beneficiary opinions of the CMAM 
programme were highly positive across all 
interview strata and across both states, for 
which the Government was given credit. It 
was felt to contribute to community progress 
and to save children’s lives.
Other perceived benefits of the CMAM 
programme at the community and health 
systems levels were that it brought people into 
the health care system; reduced care-seeking 
from herbalists and traditional healers; 
increased the status of health care workers 
and community volunteers in the community; 
and mothers of CMAM beneficiaries were 
educated on general health issues and the 
causes of malnutrition. 
There was a perception that CMAM is well 
integrated with other programmes in the 
health care system, and particularly with 
childhood immunisation. Respondents were 
positive about this integration because other 
interventions are delivered on CMAM days 
along with the ready-to-use-therapeutic-food 
(RUTF) and treatment drugs. This includes 
health education and advice on specific 
preventive behaviours such as antenatal 
advice for mothers, hygiene education, 
infant and young child feeding (IYCF), 
family planning and HIV counselling. These 
interventions were perceived to contribute to 
an overall improvement in maternal and child 
health status in the communities through the 
prevention, detection and treatment of other 
illnesses as well as SAM.
Barriers to attendance and 
causes of defaulting
The key barriers to attendance identified 
by all interview strata were distance to a 
CMAM facility, drug or RUTF stock-outs, 
lack of transport, and a lack of support from 
husbands (some of whom forbid their wives 
from attending or did not/could not provide 
transport money). Women often had to travel 
long distances to attend CMAM clinics, in 
some cases incurring transportation costs 
they could not afford. These barriers, when 
compounded by long waiting times at the 
health facility, made women disinclined to 
make a return visit. They were especially 
disinclined to make a return visit if they 
had experienced, or had heard rumours of, 
stock-outs of RUTFs or medicines, or their 
child’s health had improved. 
Reasons specific for defaulting included the 
perception that a child is healthy after few 
weeks of treatment and no longer needed 
RUTF, distance from the health facilities or 
lack of transportation, and the death of a 
registered CMAM beneficiary (child) or poor 
maternal health, maternal death or the birth 
of another child. 
Amongst some mothers, there was a mistrust 
of the safety of RUTF or its true purpose (for 
example, some believed that it might reduce 
«The key 
barriers to 
attendance  
were distance 
to a CMAM 
facility, drug 
or RUTF stock-
outs, lack of 
transport, and 
a lack of 
support from 
husbands.»
 ORIE RESEARCH SUMMARY 09 | October 2015 | How to strengthen a Community-Based Management of Acute Malnutrition programme in northern Nigeria 3
 ORIE Research Summary
fertility in the child receiving it). Competing 
demands for the woman’s time, such as other 
household chores, ceremonies and travels, 
were also cited as reasons for defaulting. 
Some mothers who had defaulted from 
the programme also stated they did not 
know that it was important to complete the 
treatment regime.
Implementation challenges
Community volunteers
Community volunteers (CVs) were perceived 
by all interview strata to be vital for the 
success of the CMAM programme. The CVs 
however face constraints in undertaking 
their role. As volunteers, they do not receive 
remuneration for their work, and many had 
to leave their income generating activities to 
carry out CMAM duties, while at the same 
time incurring transportation costs. CVs, 
especially male CVs in both states, wanted 
to be given more responsibility in the CMAM 
programme than their current role allowed. 
Some CVs also felt that some of the tasks 
they had been asked to do were culturally 
inappropriate, such as a man measuring 
the mid-arm circumference of a child – of a 
woman he did not know. 
Although the CVs in Zamfara appreciated 
efforts made to motivate them, including 
occasional monetary tokens, many CVs felt 
that more could be done.
Concerns were raised by some CVs and 
community leaders that the de-motivating 
factors may create a reluctance to take 
on the role of CV by other community 
members; because a reputation is growing 
that it involves hard work without monetary 
rewards. CVs who continued to faithfully 
carry out their responsibilities did so because 
of their religious convictions, a desire to 
contribute to community development, and 
to save the lives of children.
Health workers
Government officials and health workers in 
both study states were concerned about the 
insufficient number of trained health workers 
in CMAM health facilities. To meet the high 
demand for CMAM, it is often necessary to 
recruit health workers from other facilities on 
CMAM days to manage the heavy workload. 
However, health workers from other facilities 
did not always turn up as assigned, or were 
not always trained in CMAM activities. 
Frequent health worker redeployment also 
puts additional pressure on the CMAM 
programme, especially when CMAM trained 
health workers are replaced by those who 
are untrained. At the time of the research, 
the focus of training was primarily on health 
workers in health facilities currently delivering 
CMAM services.
Sustainability and integration
At the time of the research, Zamfara was 
the only WINNN state in which LGAs had 
committed monthly counterpart funds for 
CMAM. In late 2014, the WINNN focal 
LGAs in Jigawa and Katsina made similar 
commitments for LGA counterpart funding 
for CMAM. These earmarked funds are to 
secure adequate resources and establish 
mechanisms for financial sustainability in the 
absence of partners.  
A child is checked for 
signs of malnutrition 
in Katsina State, 
Nigeria, March 2011
Ja
ne
 M
ill
er
/D
FI
D
In Zamfara, government respondents also reported some additional 
factors that may have contributed to sustainability. This includes 
funds donated by some members of the community; a meeting 
convened in Abuja by UNICEF for LGA and state level government 
officials; the awareness raised with both the LGA Chairmen and 
Emir; the visible impact of CMAM on children with SAM; and a 
desire at the state level to own and sustain the programme.
As mentioned above CMAM was perceived as well integrated into 
the primary health care system, because other programmes are 
delivered along with CMAM. There were few mentions, however, 
of wider health systems integration beyond this service delivery. 
CMAM was perceived to be a programme not required by everyone 
and therefore the current model of having dedicated CMAM days, 
as with antenatal care days, was seen as appropriate.
Recommendations for WINNN
1. Improve access to the CMAM programme by encouraging 
communities to identify ways of providing transport for children 
needing CMAM treatment; and increase coverage of CVs in rural 
areas for early identification of SAM cases. 
2. Develop and implement plans for capacity and systems 
strengthening, especially at the LGA level, to ensure a constant 
supply of RUTF and essential drugs through effective forecasting, 
timely delivery of sufficient supplies and safe storage.
3. Design and test strategies of material and non-material incentives 
for CVs, including providing means of transportation for them 
to reach remote areas or facilitating indirect mechanisms that 
would serve to improve livelihoods or reduce their losses. 
4. Review strategies for health worker training.  This may include 
more frequent CMAM-specific trainings, or integration of CMAM 
training into a standard health worker training syllabus and/or 
other trainings.
5. Consider the feasibility of supporting or advocating for the 
establishment of mechanisms that would ensure financial 
sustainability of CMAM across the WINNN states.
 ORIE RESEARCH SUMMARY 09 | October 2015 | How to strengthen a Community-Based Management of Acute Malnutrition programme in northern Nigeria 4
 ORIE Research Summary
ORIE and WINNN
ORIE is an independent 
component of the UK 
Government’s Department for 
International Development 
(DFID) funded Working to 
Improve Nutrition in Northern 
Nigeria (WINNN) programme. 
WINNN is working to improve 
the nutritional status of 
6.2 million children under 
five years of age in five states 
of northern Nigeria. ORIE is 
carrying out research to 
determine the impact of 
WINNN and generate 
important research on key 
evidence gaps regarding 
solutions to undernutrition in 
northern Nigeria.
Credits
This ORIE Research Summary 
is based on the CMAM 
operations research report by 
Olutayo Adeyemi, Wasiu A. 
Afolabi, Isaac Akinyele (late), 
Elaine Ferguson, Jenna Hoyt, 
Hussiani Lawal, Rasheed A. 
Okunola, Jayne Webster, and 
Cynthia Yohanna-Dzingina. 
Readers are encouraged to 
quote and reproduce material 
from ORIE Research Summaries 
in their own publication. In 
return, ORIE requests due 
acknowledgement and quotes 
to be referenced as above.  
ORIE cannot be held 
responsible for errors or any 
consequences arising from 
the use of information 
contained in this publication. 
Any views and opinions 
expressed do not necessarily 
reflect those of DFID.
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ORIE is run by a consortium of UK and Nigerian organisations. In the UK: Oxford Policy Management, Institute of Development Studies, London School of Hygiene 
and Tropical Medicine, Save the Children UK; in Nigeria: Food Basket Foundation International, University of Ibadan. ORIE works in partnership with the Federal 
Government of Nigeria.
For any further information about ORIE please email orienigeria@orie-ng.org or see the website heart-resources.org/tag/orie
«Develop and 
implement 
plans for 
capacity and 
systems 
strengthening, 
especially at 
the LGA level, 
to ensure a 
constant 
supply of RUTF 
and essential 
drugs through 
effective 
forecasting, 
timely delivery 
of sufficient 
supplies and 
safe storage.»


How to strengthen a Community-Based Management of Acute Malnutrition programme in northern Nigeria

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How to strengthen a Community-Based Management of Acute Malnutrition programme in northern Nigeria

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