ESSENTIAL NUTRITION ACTIONS IN NIGERIA:

THE BASICS II EXPERIENCE

September 2004

Abstract: The magnitude of malnutrition in Nigeria prompted national authorities and the United States Agency for International Development (USAID) to make nutrition a central piece of the Nigerian child survival program. The focus is on delivering a group of evidence-based micronutrient and infant feeding interventions known as Essential Nutrition Actions (ENA). The implementation of ENAs six priority interventions has proven to be effective in a range of different settings, and can reduce infant and child mortality as well as improve physical and mental growth and development. This document presents information on Nigerias experience in implementing the Essential Nutrition Actions (ENA) from 1999 to 2004. The intention of this document is to provide information to appropriate stakeholdersthe Federal Ministry of Health (FMOH), the Nutrition Partners Group (NPG), the State Ministries of Health (SMOH), and all development partners in Nigeria on ENA approaches, processes, and achievements and on the success factors, lessons learned, and recommendations for strengthening and scaling up ENA interventions in the country.

Recommended Citation: BASICS II. 2004. Essential Nutrition Actions in Nigeria: The BASICS II Experience. Arlington, Va.: BASICS II for the United States Agency for International Development.

BASICS II is a global child survival project funded by the Office of Health and Nutrition of the Bureau for Global Health of the U.S. Agency for International Development (USAID). BASICS II is conducted by the Partnership for Child Health Care, Inc., under contract no. HRN-C-00-99-00007-00. Partners are the Academy for Educational Development, John Snow, Inc., and Management Sciences for Health. Subcontractors include Emory University, The Johns Hopkins University, The Manoff Group, Inc., the Program for Appropriate Technology in Health, Save the Children Federation, Inc., and TSL.

This document does not necessarily represent the views or opinion of USAID. It may be reproduced if credit is properly given.

U.S. Agency for International Development Bureau for Global Health Office of Health and Nutrition Washington, DC Website: www.usaid.gov/pop_health/

Basic Support for Institutionalizing Child Survival Project Partnership for Child Health Care (PCHC), Inc. 1600 Wilson Blvd., Suite 300 Arlington, VA 22209 Tel: (703) 312-6800 / Fax: (703) 312-6900 Website: www.basics.org

TABLE OF CONTENTS

Acronyms .................................................................................................................................................. iii Acknowledgments ....................................................................................................................................... v 1. Introduction ............................................................................................................................................. 1 1.1 Purpose.......................................................................................................................................... 1 1.2 Methodology ................................................................................................................................. 1 1.3 Presentation of Qualitative Study Findings .................................................................................. 5 2. Background ............................................................................................................................................ 6 3. Program Context and Evolution........................................................................................................... 8 3.1 Nutrition Activities before ENA ................................................................................................... 8 3.2 ENA Operational Framework ....................................................................................................... 9 3.3 ENA at the National Level .......................................................................................................... 11 3.4 ENA in the States and LGAs ...................................................................................................... 13 3.5 ENA at PHC, Community, and Household Levels ..................................................................... 14 3.6 Communication for Behavior Change ........................................................................................ 17 3.7 ENA Adaptation among States ................................................................................................... 17 3.8 PTMTCT/Infant Feeding Options in Kano and Lagos States ..................................................... 18 4. Program Achievements ....................................................................................................................... 19 4.1 Achievements at the National Level ........................................................................................... 20 4.2 Achievements at the State level .................................................................................................. 22 5. Key Success Factors ............................................................................................................................. 38 6. Lessons Learned ................................................................................................................................... 40 6.1 Policy Environment .................................................................................................................... 40 6.2 ENA Program Implementation Approach................................................................................... 40 6.3 The Leadership Role and Ownership of the SMOHs.................................................................. 41 6.4 System Strengthening ................................................................................................................. 41 6.5 Flexibility in Implementing ENA ............................................................................................... 42 6.6 Multi-Sectoral Collaboration ...................................................................................................... 42 6.7 The Community-Based Approach (CAPA) ................................................................................ 43 6.8 Communication for Behavior Change ........................................................................................ 43 6.9 Scaling Up ................................................................................................................................... 44 6.10 Sustainability.......................................................................................................................... 44 7. The Way Forward for ENA in Nigeria .............................................................................................. 45 7.1 Next Steps for ENA at the National Level .................................................................................. 45 7.2 Next Steps for ENA in the States ................................................................................................ 46

Tables Table 1: Interventions for Documentation at the National and State Levels ........................................ 2 Table 2: Program Partners and Beneficiaries that Participated in the Qualitative Study ..................... 2 Table 3: Selected Catchment Areas for Qualitative Study ................................................................... 3 Table 4: Stakeholders Interviewed in Each State and Topics Discussed ............................................. 4 Table 5: Nigerias ENA Operational Framework............................................................................... 10 Table 6: Nutrition Activities in Maternal and Child Health Services ................................................ 14 Table 7: ENA Materials and Tools Adapted in Each State ................................................................ 18 Table 8: ICHCS Results ..................................................................................................................... 19 Table 9: Contribution to Advancing Vitamin A Supplementation at the National Level .................. 20 Table 10: PROFILES Activities, Outputs, and Outcomes ................................................................... 21 Table 11: ENA Implementation at the State Level............................................................................... 23 Table 12: Changes in the Knowledge and Rate of EBF, ACF, and Vitamin A Supplementation in BASICS II Focus LGAs in Lagos State as of November 2003............................................ 24 Table 13: ENA Program in Lagos State ............................................................................................... 26 Table 14: Changes in the Knowledge and Rate of EBF, ACF, and Vitamin A Supplementation in BASICS II Focus LGAs in Kano State as of November 2003 ............................................. 28 Table 15: Changes in the Knowledge and Rate of EBF, ACF, and Vitamin A Supplementation in BASICS II Focus LGAs in Abia State as of November 2003.............................................. 34

ii

ACRONYMS

ACF ANG BASICS CA CAPA CAPAC CBC CBO CHP CHW DHS EBF ENA FMINO FMOH HIV/AIDS HOD ICHCS ICHS IDD IEC IMCI MOH NADAC NCFN NGO NID NPHCDA NPG OIC PD TBA USAID VAD VCT

Appropriate Complementary Feeding Agriculture, Nutrition, and Gender Basic Support for Institutionalizing Child Survival Catchment Area Catchment Area Planning and Action Catchment Area Planning and Action Committee Communication for Behavior Change Community-Based Organization Community Health Promoter Community Health Worker Demographic and Health Survey Exclusive Breastfeeding Essential Nutrition Actions Federal Ministry of Information and National Orientation Federal Ministry of Health Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Head of Department Integrated Child Health Cluster Survey Integrated Child Health Survey Iodine Deficiency Disorder Information-Education-Communication Integrated Management of Childhood Illness Ministry of Health National Agency for Drug and Administration National Committee for Food and Nutrition Non-Governmental Organization National Immunization Day National Primary Health Care Development Agency Nutrition Partners Group Officer-in-Charge Positive Deviance Traditional Birth Attendant United States Agency for International Development Vitamin A Deficiency Voluntary Counseling and Testing

iii

iv

ACKNOWLEDGMENTS BASICS II acknowledges the following individuals for their contributions to this document: Design and documentation of ENA experience: Dr. Eleonore Fosso-Seumo Nutrition Technical Officer backstopping Nigeria Program, BASICS II, Arlington Dr. Serigne Diene Nutrition Team Leader, BASICS II, Arlington Facilitators of the stakeholders meetings in Abia, Kano, and Lagos states and Abuja Professor I. O. Akinyele, Lecturer, University of Ibadan Professor B. Oguntona Lecturer, University of Agriculture, Abeokuta Researchers of the qualitative study in Abia, Kano, and Lagos states and Abuja Dr. Abosede Olayinka, Lecturer, University of Lagos Prince W. A. O. Afolabi, Lecturer, University of Agriculture, Abeokuta

BASICS II/Nigeria Team members: Dr. Wumni Ashiru Child Survival Program Manager Dr. Francis Aminu Senior Nutrition Program Officer, National Office, Lagos Grace Essien Nutrition Officer, Lagos Field Office Salamatu Baku Nutrition Officer, Kano Field Office Uche Eze Nutrition and Malaria Officer, Abia Field Office, Aba South

vi

EXECUTIVE SUMMARY

Nigeria ranks second in the world for child mortality with 834,000 deaths annually (The Lancet, June and July 2003). Malnutrition, which contributes to an estimated 60% of deaths among children under five years of age in Nigeria, also increases childrens risk of death from diseases such as malaria, measles, diarrhea, and pneumonia. Almost two in five Nigerian children are stunted (short for their age), and half of these children are severely affected. Stunting is associated with recurring or chronic illnesses and results when children fail to receive adequate nutrition over an extended period of time. The prevalence of vitamin A deficiency (VAD) is 23.2% (marginal) and 3.6% (clinical). This amounts to one out of every five individuals (NFCNS 2001). VAD has been implicated in restricted growth, impaired immune response, and increased susceptibility to infections. The magnitude of malnutrition in Nigeria prompted national authorities and the United States Agency for International Development (USAID) to make nutrition a central piece of the Nigerian child survival program. The focus is on delivering a group of evidence-based micronutrient and infant feeding interventions known as Essential Nutrition Actions (ENA). The implementation of ENAs six priority interventionsexclusive breastfeeding for the first six months, appropriate complementary feeding from 6 to 24 months (with continued breastfeeding), adequate nutritional care of sick and malnourished children, adequate vitamin A status, adequate iodine status, and adequate iron statushas proven to be effective in a range of different settings, and can reduce infant and child mortality as well as improve physical and mental growth and development. ENA constitutes one of the three technical focus areas of the BASICS II child survival program in Nigeria, the two other focus areas being immunization and malaria. ENA was launched in 1999 and built on the achievements of BASICS Is Community Health Partnership. ENA uses a three-pronged approach to engage policy and decision-makers, health program managers at the national, state, and Local Government Area (LGA) level, and community members to improve child nutrition. Consistent and significant improvements in exclusive breastfeeding and appropriate complementary feeding practices have been recorded. These achievements have been attributed to the program success in influencing policy formulation and to the intensive implementation of the community strategy known as Catchment Area Planning and Action (CAPA), coupled with widespread dissemination of ENA messages. At the national level, the program has advanced vitamin A supplementation through the development of vitamin A supplementation guidelines, integration of vitamin A into National Immunization Days (NIDs), and piloting a successful potential vitamin A supplementation strategy called Child Health Week. BASICS II/Nigeria collaborated with partners to develop the advocacy tool PROFILES for policy analysis and built the capacity of a group of national experts in conducting nutrition policy analysis. This strategy has led to increased recognition of the importance of nutrition at national and state levels, and to coalition building and alliances of all key stakeholders in nutrition at the national level. The programs contribution has also enhanced the quality of HIV (human immunodeficiency virus) and infant feeding guidelines. Continuous advocacy and communication with the Nutrition Partners Group (NPG) at the national level about ENA activities in the states has led to the recognition at the highest levels of ENA as an appropriate strategy to improve children nutrition in Nigeria. At the state level, the program has used a participatory, community-based approach to improving child infant feeding practices through a process developed by BASICS II and known as Catchment Area Planning and Action (CAPA). Primary Health Care (PHC) Centers serve as the operational unit of CAPA activities. Under the CAPA strategy, health workers and community members come together to improve child health through capacity building and community mobilization to strengthen ENA service delivery. Almost 500 health workers have been trained in ENA and have been counseling mothers on improving infant feeding practices. Over 4,000 CAPA members and community health promoters (CHPs) have been trained on how to counsel mothers on the ENA. vii

From the beginning, the program carried out Integrated Child Health Cluster Surveys (ICHCS) and Knowledge, Attitude, and Practices (KAP) studies to gather information to help design the program. The program repeated the ICHCS study annually to measure the program achievements toward the targeted objectives. The 2003 ICHCS has shown significant improvements in caregivers knowledge and practices regarding exclusive breastfeeding, appropriate complementary feeding, and the importance of vitamin A supplementation for children. All program partners have acknowledged the community-based approach for ENA as a successful program that is sustainable.

viii

1. INTRODUCTION

1.1

Purpose

The purpose of this document is to compile information on Nigerias experience in implementing the Essential Nutrition Actions (ENA) from 1999 to 2004. The intention of this document is to provide information to the Federal Ministry of Health (FMOH) and the Nutrition Partners Group (NPG), the State Ministries of Health (SMOH), and the development partners in Nigeria on the achievements, processes, and approaches related to ENA and the success factors, lessons learned, and recommendations. It is the intention that this information will help strengthen and scale up ENA interventions in the country. The magnitude of malnutrition in Nigeria prompted national authorities and the United States Agency for International Development (USAID) to make nutrition a central piece of the Nigerian child survival program. The focus is on delivering a group of evidence-based micronutrient and infant feeding interventions known as Essential Nutrition Actions (ENA). The implementation of ENAs six priority interventionsexclusive breastfeeding (EBF) for the first six months, appropriate complementary feeding (ACF) from 6 to 24 months (with continued breastfeeding), adequate nutritional care of sick and malnourished children, adequate vitamin A status, adequate iodine status, and adequate iron statushas proven to be effective in a range of different settings, and can reduce infant and child mortality as well as improve physical and mental growth and development.

1.2

Methodology

The documentation of the ENA experience in Nigeria was carried out by a team comprising professionals who have not been heavily involved in the implementation of the program. The team included the Nutrition Technical Officer in Arlington, two lecturers in the University in Nigeria, and two researchers from the University in Nigeria. The approach was participatory, demanding intense involvement on the part of all levels of program staff as well as program partners and beneficiaries and the documentation team. The reasons for using a participatory process and for involving stakeholders at all levels in documenting ENA experience in Nigeria was to help the stakeholders reflect on the achievements and lessons learned and design the next steps for implementation. This promoted stakeholders ownership of the outputs and the commitments made. The documentation was carried out in a four-step process.

1.2.1

Collect Information Related to the ENA Experience

The collection of information related to the ENA experience was achieved through the review of the program documents and a qualitative study with the program partners and beneficiaries on their perceptions on the program. a) Review program documents Using a logical framework on the inputs, outputs, and outcomes, BASICS II/Nigerias ENA documents for Abia, Kano, and Lagos states and the national level were collected and reviewed for the state and the national levels. The interventions that were reviewed in each state are summarized in Table 1.
1

Table 1: Interventions for Documentation at the National and State Levels Federal Vitamin A supplementation Abia State Exclusive breastfeeding Appropriate complementary feeding Vitamin A supplementation through Child Health Week* Kano State Exclusive breastfeeding PMTCT** Appropriate complementary feeding Vitamin A supplementation through Child Health Week Nutritional care for sick and malnourished children (PD/Hearth) Lagos State Exclusive breastfeeding PMTCT Appropriate complementary feeding Vitamin A supplementation through Child Health * Week

HIV and nutrition

Nutrition policy analysis & advocacy Participation in various forums at the national level, i.e. Agriculture, Nutrition, and Gender (ANG) linkage, and NPG.

*Child Health Week was piloted in 2003 in Lagos State and was scaled up to Abia and Kano in 2004. ** PMTCT = Prevention of Mother to Child Transmission (of HIV)

b) Collect Project Partners and Beneficiaries Perspectives on Factors in the Program Achievements The documentation team conducted a qualitative study to gather the program partners and the beneficiaries perceptions on the program, the key factors that have played a role in the programs achievements, the lessons learned, and the next steps. In-depth interviews were conducted with the program partners and focus group discussions were held with caregivers (beneficiaries). The program partners and beneficiaries that participated in the qualitative study are listed in Table 2.
Table 2: Program Partners and Beneficiaries that Participated in the Qualitative Study Federal
1 2

Abia State SMOH LGAs 6 OICs Partners: UNICEF CAPA members CHPs Caregivers
3

Kano State SMOH LGAs OICs Partners: UNICEF CAPA members CHPs Caregivers

Lagos State SMOH: LGAs OICs Partners: UNICEF CAPA members CHPs Caregivers

Nutrition Partners 4 ANG Working Group 5 NCFN members 7 NPI

1 2

Some key/active members of the NCFN/Nutrition Partners Group located in Abuja UNICEF, WHO, USIPs (Policy Project, JHU/HCP), CDTI Partners (HKI, MITOSATH, SSI, all in Jos), NCFN members (FMOH/Nutrition Division, FMA&RD, FMI&NO, FME, NPHCDA, NAFDAC,), NCFN/NPC, NSN (Ibadan), IITA (Ibadan). 3 Members of the State Committee of Food and Nutrition 4 All are members of the Nutrition Partners Group 5 The National Committee on Food and Nutrition includes nutrition-related line ministries and parastatals, and universities. Some active members are part of the Nutrition Partners Group (NPG). 6 OICs = Officers-in-Charge 7 For perspectives on vitamin A supplementation through NIDs/sub-NIDs

1.2.2

Select Catchment Areas for the Qualitative Study

The main criterion for selecting locations for the qualitative study in each state was the geography (rural and urban). One catchment area (CA) in one rural and one urban LGA in each state were selected for the in-depth interview with LGA partners, OICs, CAPA members, and CHPs and for the focus group discussions with mothers, fathers, and other caregivers. The catchment areas where the qualitative study was conducted are listed in Table 3.
Table 3: Selected Catchment Areas for Qualitative Study States Rural catchment area Urban catchment area Abia State * Osusu I Kano State Warawa Maramara Lagos State Lekki Mushin

*The two LGAs covered by the program are located in urban areas.

1.2.3

Conduct In-depth Interviews

In-depth interviews were carried out with the program partners at the national, state, LGA, PHC, and community levels. At the national level, two members of NPG, the ANG working group, and the NCFN who have collaborated with the program were interviewed. The topics covered during the interviews included: Nutrition priority interventions in Nigeria; Knowledge of ENA interventions being implemented in Nigeria, involvement in ENA, and knowledge of the programs contribution at the national and state levels; Child Health Week: achievements, lessons learned and the way forward; ENA success factors and constraints; and FMOHs plan to sustain and scale up ENA.

At the state level, in-depth interviews were held with the PHC director, the SMOH nutrition officer, two state facilitators, partners from other sectors, OICs, CAPA Committee members, and CHPs. The topics explored with each group of staff are listed in the Table 4.

Table 4: Stakeholders Interviewed in Each State and Topics Discussed PHC Director, SMOH Nutrition Officer, and Partners Knowledge of ENA interventions implemented in the state Involvement and perceptions on the achievements, successes, constraints, lessons learned, and the way forward SMOHs plan to integrate ENA into health services and in others sectors activities Multi sectoral collaboration: roles of other partners in the implementation of ENA Child Health Week: achievements, lessons learned, and the way forward SMOH and LGA Facilitators* OICs, CAPA Committee Members, and CHPs

Knowledge of the program activities in the state and level of involvement in the activities Training follow up: skills acquired and used Support supervision: how often and outputs Tools and CBC** materials received, preferred, and used Sustainability of ENA interventions Child Health Week: achievements, lessons learned, and the way forward Knowledge of the ENA approach

OICs ENA interventions being carried out in the CA and level of involvement ENA training received and the use of the knowledge and skills acquired Most useful ENA tools ENA interventions carried out in the PHC and community CBC materials received and used by health workers ENA messages being practiced at household level Support to CAPA and CHPs CAPA/CHPs support to the PHC CAPA/CHPs Nutrition activities carried out Training received in nutrition and the use of the knowledge and skills acquired Knowledge of ENA messages CBC materials received and used ENA messages being implemented at household level ENA messages that are not being implemented and why Child Health Weeks: involvement and achievements ENA successes and constraints in the community How to sustain and scale up nutrition activities in the CA

*Multi-sectoral facilitators ** Communication for behavior change

1.2.4

Conduct Focus Group Discussions

Focus group discussions were held with mothers and caregivers of children 024 months of age. The objectives of the focus group discussions were to: Assess mothers and caregivers1 knowledge of major health problems in the area and those linked with nutrition; Assess mothers and caregivers knowledge of ENA key messages, and perceptions of the messages that are being practiced (motivations and barriers); Assess mothers and caregivers knowledge and effectiveness of CAPA/CHPs/PMD (patent medicine dealers) activities; and Gather mothers and caregivers suggestions on how to get more mothers to practice ENA behaviors.

1.3

Presentation of Qualitative Study Findings

In each state, the information collected from the in-depth interviews and focus groups discussions was analyzed and the main findings with each group were summarized. The findings of the qualitative study were presented and discussed at stakeholders meetings.

1.3.1

State-Level Stakeholders Meeting

Since the main purpose of documenting the states ENA experience was to gather information to help improve, sustain, and scale up ENA interventions in the state, the documentation team held a stakeholders meeting with the program partners and beneficiaries in each state to reflect on ENA achievements and design the way forward. The participants in the state-level meeting were from the SMOH, LGAs, PHC, and communities. The objectives of the stakeholders meeting were to: 1.3.2 Present the programs achievements; Gather the participants perceptions on the program; Present the key findings of the qualitative study; and Draw the lessons learned and identify the next steps for the state. National-Level Stakeholders Meeting

The documentation team also held a stakeholders meeting in Abuja with program partners at the national level. The meeting reviewed at the ENA program as a whole. The objectives of the meeting were to: Review the program achievements at the national level; Present the ENA lessons learned and next steps for Abia, Kano, and Lagos states; and Identify the lessons and design the next steps for the national level.

Nigerian professionals conducted the qualitative studies and stakeholders meeting at the state and national levels. By so doing, the program was encouraging ownership of local experts to adopt ENA and to ensure sustainability.
1

Caregivers include parents, in-laws, and grandmothers.

2. BACKGROUND In 1992, USAID supported the MOH to improve the quality of and access to immunization services within 15 LGAs in Lagos metropolis. Between 1994 and 1999, USAID funded BASICS I, an urban, community-based initiative known as the Community Partnership for Health (CPH). An assessment conducted in 1999 provided the following findings: At the start of the program, major geographic disparities in the nutrition situation were identified. The nature and severity of underlying and basic causes of malnutrition are distinctly different in the north, suggesting the importance of a locally relevant strategy for addressing malnutrition in the northern areas of Nigeria. No national nutrition policy or strategy was identified, although one was reportedly nearing completion. Based on scant attention paid to decisions such as the adaptation of nutrition components of Integrated Management of Childhood Illness (IMCI), NIDslinked vitamin A distribution, and other feedback, it appeared that the importance of nutrition in child health was not fully understood in Nigeria. Priority needed to be given to improving infant feeding practices and preventing illness, as well as to addressing prenatal and neonatal health and nutrition in order to address the early decline in nutritional status. Specific deficiencies of micronutrients particularly vitamin A, iron, and iodine were estimated to be serious public health problems in Nigeria (UNICEF 1994 Situation Analysis). WHO/UNICEF/IVACG (1995) classify Nigeria with countries having the most severe category of vitamin A deficiency. However, BASICS/Nigeria could not identify an explicit national vitamin A policy or strategy, although efforts were being made to begin the process with an express interest in reviewing the potential for food fortification as an essential component of such a strategy. Actions to improve access and use of iodized salt were considered among the more successful nutrition programs in Nigeria, though data were not found on iodine levels in salt samples or trends in urinary iodine levels. Iron and folic acid supplements were reportedly among the routine components of prenatal care, though national protocols and policies could not be located. Infant feeding practicesparticularly the very low levels of exclusive breastfeedingin Nigeria were striking and among the lowest in sub-Saharan Africa. In 1990, less than 2% of infants under two months of age were exclusively breastfed. However, there was a national breastfeeding policy that recommended exclusive breastfeeding for six months, continuation of breastfeeding with appropriate complementary feeding to two years, and support for implementing the Breastmilk Substitutes Marketing Code. Complementary foods are introduced late in about half of all infants nationally (Demographic and Health Survey (DHS), 1990), and smaller studies indicate that the quality of complementary feeding needs attention.

In 1999, USAID funded BASICS II, a project implementing a community-based approach for child survival. BASICS IIs focus areas in Nigeria included routine immunization, promotion of
6

breastfeeding, appropriate complementary feeding, and vitamin A supplementation, and use of ITN to prevent malaria and early recognition and treatment of fever. The program instituted a strategy called Catchment Area Planning and Action (CAPA), which is a community-based approach to strengthen planning and action through a series of steps involving the participation of all stakeholders in child health, including health providers at the state and LGA levels, nongovernmental organizations (NGOs), and community members. The program also worked with the national level for policy formulation to provide an enabling environment for the implementation of ENA interventions. In nutrition, the focus was on delivering a group of evidence-based micronutrient and infant feeding interventions known as essential nutrition actions (ENA). The implementation of ENAs six priority interventionsexclusive breastfeeding for the first six months, adequate complementary feeding from 6 to 24 months (with continued breastfeeding), adequate nutritional care of sick and malnourished children, adequate vitamin A status, adequate iron status, and adequate iodine status has proven to be effective in a range of different settings, and can reduce infant and child mortality and improve physical and mental growth and development. The ENA interventions selected by Nigeria program were based on their potential for reducing child deaths in Nigeria. They include: Breastfeedingincluding early initiation of breastfeeding (within one hour of delivery), exclusive breastfeeding during the first six months of life, and continued breastfeeding until two years of age. Appropriate complementary feedingthe introduction of solid foods and other fluids from six months of age. Vitamin A supplementationproviding children 659 months of age with 100,000 UI 200,000 UI of vitamin A every six months. Care of severely malnourished or sick childContinued feeding during illness and increased frequency and amount of foods after illness.

The ENA program used a three-pronged approach to improve infant and child feeding practices in the program area: Raise awareness through advocacy on the effects of malnutrition on infant mortality and provide technical assistance for policy formulation to create the enabling environment for implementing ENA interventions; Support state and LGAs in developing and implementing the health and nutrition programs by strengthening systems; and Building on the CAPA process, support a community-based approach for increased use of proven child health interventions in the households, community, and health facilities through caregiver counseling and CBC activities.

3. PROGRAM CONTEXT AND EVOLUTION

3.1

Nutrition Activities before ENA

For several years, nutrition was not considered as a priority agenda for the Nigerian government, due to a lack of proper understanding among political and policy decision makers on the importance of nutrition in national development. After a national conference in 1979, the development of a national food and nutrition policy was launched and evolved over a number of years, with successive rounds of consultations and discussions among various government agencies, academics, private sector, NGOs, and international development partners. In 1989, following another national conference, the National Committee on Food and Nutrition (NCFN) was established as the focal point for the food and nutrition policy program and its planning and coordination in the country. The NCFN was an inter-ministerial committee composed of representatives from six line ministries, academia, and international donor agencies. 3.1.1 International Commitments Related to Improving Nutritional Status

Nigeria has been a signatory to many commitments that have been devised in international conferences to solve the problems of poverty, hunger, and malnutrition in the world. Among the commitments Nigeria has signed are those made at the: 1990World Summit for Children, based on the 1989 convention on the rights of the child 1992International Conference on Nutrition that declared that the nutritional well-being of all people is a pre-condition for the development of societies and is a key objective of progress in sustainable human development 1994International Conference on Population and Development 1995World Summit for Social Development 1995International Conference on Women 1996World Summit and the Millennium Development Goals set by the United Nations for achieving the well-being of people in all nations

After the 1990 World Summit for Children and the 1992 International Conference on Nutrition, the conceptual framework on nutrition for the country evolved and focused mainly on promoting household food security through increased food production and processing. Later on, another approach emerged laying emphasis on to improving infant and young child feeding practices, and reducing micronutrient deficiencies.

3.1.2

National Nutrition Policy

The next step was the drafting of a national policy on food and nutrition, which was finalized in 1995, officially approved in 1998, and launched in November 2002. The policy stresses poverty, inadequate investment in the social sector, inadequate dietary intake, and diseases as the major causes of malnutrition in Nigeria and identifies micronutrient deficiencies as major consequences of this situation. The overall goal of the policy is to improve the nutritional status of all Nigerians, with particular emphasis on the most vulnerable groupschildren, women, and the elderly. The following nutrition actions, which are supported by ENA, are identified in the policy:
8

Protect, promote, and support optimal child feeding practices in the first two years of life; Ensure that iodine requirements of the population are met; Ensure that iron and folate requirements of the population are met; Ensure that vitamin A requirements of the population are met; Ensure that the nutritional support of adolescent girls, pregnant women, and lactating mothers; and Ensure adequate nutritional care and support for people living with HIV/AIDS.

In 1990, the Federal Government took a concrete step toward the reduction/elimination of iodine deficiency disorder and established a legal framework making iodization of all salt produced in Nigeria mandatory and banning non-iodized salt. The Director General of the National Agency for Drug and Administration (NAFDAC) stated at the International Meeting for the Sustained Elimination of IDD (Iodine Deficiency Disorder) I Beijing, China in 2003 that Nigeria achieved 100% USI at distribution and factory levels and 98% USI at retail and household levels. In 1998, the Government of Nigeria approved a breastfeeding policy, and reviewed and amended the code on marketing breastmilk substitutes, with the objective of increasing the rate of exclusive breastfeeding. The NADAC collaboration with the FMOH and the National Planning Committee are developing guidelines for monitoring the marketing of breastmilk substitute. However, the risk of mother to child transmission of HIV through breastmilk poses new challenges that need to be addressed.

3.2

ENA Operational Framework

The programs first step was to develop an operational framework to help communicate with partners about the ENA approach, and to guide the implementation of ENA at national and state levels. As summarized on Table 5, Nigerias ENA operational framework highlights the different levels of implementation of ENA and the activities for each level.

Table 5: Nigerias ENA Operational Framework Activities / Strategies Level/ Components Technical Leadership on Advocacy NATIONAL (Advocacy / Communication) Developing vitamin A national guidelines Training on integrating vitamin A into NIDs Training on PROFILES Technical Orientation Training on ENA Communication for policy reforms and coalition building CAPA Process for Nutrition Communication for the adoption of materials / methods and scaling up of process Training of LGA CAPA facilitators Community Health Promoters (CHPs) Communication for adoption of materials / methods and scaling up of process Training of state trainers of CHPs

STATE (Health System)

Training on integrating vitamin A into NIDs Adaptation and presentation of PROFILES Training of vaccinators on vitamin A during NIDs

Training of the State Technical Team (health staff)

LGA (Health System)

Training of LGA staff: 1. HODs* of Agriculture, Community Dev., Education, Information, Health 2. OICs & service providers (public and private) of health facilities. Monitoring of quality of service and coverage

Training of LGA CAPA facilitators

Training of LGA trainers of CHPs

COMMUNITY

Pre-CAPA Mtg CAPA Process Workshop Post-CAPA Meeting Monthly mtg & monitoring of CAPA activities

Training of CHPs Follow-up Activities to CHP Training (e.g. CHP assessment)

*Head of Department

The program was implemented at national, state, LGA, and community levels. The program staff roles for each level were to: Provide technical assistance for policy formulation at the national level; Support state and LGAs in developing and implementing nutrition interventions at health facility levels; and Support the increased use of proven child health interventions in the households and communities.

10

3.3

ENA at the National Level

ENA activities were launched at the national level in 2001. The milestones for ENA implementation at the federal level are listed in the box below. The program initiated contact with the FMOH for nutrition activities when NIDs were just starting, and consideration was given to integrate vitamin A supplementation into NIDs. Despite the high levels of malnutrition in children under two years of age, nutrition was not a priority. This was due to the limited understanding among political and policy decision makers of the importance of nutrition for the economy and the country as a whole. One of the programs key contributions at the national level was to help put nutrition among the top priority areas for the country.

MILESTONES FOR ENA IMPLEMENTATION AT THE NATIONAL LEVEL

Integration of Vitamin A Supplementation into NIDs August 2001: First NID and vitamin A supplementation experimented November 2001: Session on vitamin A supplementation integrated in the NIDs training module Training of health providers on how to integrate vitamin A into NIDs at national and state levels Development of Policy Analysis and Advocacy Tools (PROFILES) August 2001: Development and adaptation of PROFLES Work with ANG to adapt PROFILES Training nutrition experts and nutrition officers on the process of adapting PROFILES to the Nigeria context Presentation of PROFILES to decision makers Participation in Vitamin A Supplementation Committee July 2003 Contribution of the Program by designing and piloting Child Health Week in Lagos state as a possible post-NIDs vitamin A supplementation strategy June 2004 Contribution of the program by piloting Child Health Week in Abia, Kano, and Lagos states HIV and Infant Feeding 2003 HIV and infant feeding guidelines reviewed by the program Recognition of ENA by the Federal Level 2004 Integration of ENA into the National Plan of Action for Food and Nutrition Participation in the Development of Micronutrient Guidelines 2004 Development of micronutrient guidelines in Nigeria.

The implementation of ENA at the national level started through three main activities: capacity building to integrate vitamin A into NIDs, providing technical assistance for policy formulation, and communicating/informing the partners on ENA activities with the states.

11

3.3.1

Advancing Vitamin A Supplementation

In 2001, the program spearheaded the integration of vitamin A into NIDs. The program assisted the FMOH in developing a module on vitamin A supplementation that was integrated into the NIDs training module. The program also built the capacity of health workers in integrating vitamin A into NIDs at national level in 2001. As NIDs was phasing out, the program piloted a Child Health Week in Lagos state in 2003 as a possible transition strategy for vitamin A supplementation. In 2004, BASICS II conducted Child Health Weeks in Abia, Lagos and Kano States. Based on the lessons learned of the pilot phase, the FMOH should decide if Child Health Week is the appropriate vitamin A transition strategy for Nigeria.

3.3.2

Technical Support for Policy Formulation

The program provided technical assistance for advancing vitamin A supplementation program, policy analysis and action planning, the development of guidelines such as HIV and infant feeding guidelines, nutrition plan of action for food and nutrition, and the national guidelines for micronutrients. The programs main partner at the national level was the Nutrition Partners Group.

Policy Analysis and Advocacy Planning: PROFILES Although the child malnutrition rates are very high in Nigeria, awareness on the magnitude of the problem and how to address the problem seemed not to be properly grasped. The program supported the adaptation of the policy analysis and advocacy tool PROFILES to the Nigerian context. This built the capacity of nutrition experts from various sectors to develop and use PROFILES to raise awareness, engage stakeholders to build a coalition, and plan for improving nutrition in Nigeria.
PROFILES is a highly effective computer-based process for estimating the far-reaching consequences of malnutrition, assessing the short-and-long range benefits of combating nutritional deficiencies, and communicating these findings to decision makers.

The capacity building of nutrition experts and program planners from various sectors led to coalition building and the formation of Nutrition Partners Group (NPG). The NPG brings together all players in nutrition in Nigeria. The secretary of the group is housed in the National Planning Commission and is chaired by a qualified nutritionist. The NPG meets once a month. HIV and Infant Feeding Guidelines The program provided technical input into the development of HIV and infant feeding guidelines.

3.3.3

Communicating/Informing National-Level Partners on State ENA Activities

The program continuously informed the NPG on the process, outputs, and outcomes of the implementation of ENA in the states. This effort led to the recognition by the FMOH of ENA as
12

an appropriate strategy for improving child nutrition in Nigeria. In the national plan of action, the FMOH (through the National Primary Health Care Development Agency (NPHCDA) and development partners) plans to integrate ENA into health services through the training of health workers, to conduct integrated PHC/CAPA ENA activities to create awareness, and to mobilize communities to utilize available nutrition services within PHC services.

3.4

ENA in the States and LGAs

The main partners at the state level were the State Ministry of Health (SMOH) and LGA officials. Other partners included the other line ministries such as agriculture, community development, education, and information, as well as all other state and LGA nutrition players. Four major strategies were implemented: Advocacy and communication; System strengthening; Community-based approach to improving child nutrition (Engaging and strengthening partnership between government, health workers from the public and private sector, and communities enhancing capacity to improve child health and nutrition); and Communication for behavior change (CBC).

These strategies unfolded in a two-step process. Advocacy and communication and system strengthening were implemented at the state and LGA level, while the community-based approach and CBC were implemented in PHC, communities, and households.

3.4.1

Advocacy and Communication

The target groups for advocacy and communication were LGA officials and partners. The program used information generated by the PROFILES exercise to inform and sensitize the program partners on the effects of mild and moderate malnutrition on child mortality and morbidity, and to seek the political will and commitment to incorporate ENA interventions into health services and into community network activities. The advocacy activities raised the awareness of the LGA key partners on the magnitude of malnutrition and the advantage for the state, LGA, and the community to improve the nutrition of women and children. 3.4.2 System Strengthening

The system strengthening focused on building the capacity of health workers of the public and private health sectors on a) the introduction of vitamin A into NIDs and b) on the ENA approach and how to integrate ENA interventions in maternal and child health services. In 2001, the program incorporated a session on vitamin A supplementation into the NIDs training module and trained vaccinators on vitamin A supplementation during NIDs. The program worked with the state partners to develop the ENA training manual and job aids for health workers. The program used a cascade training approach to build the capacity of health workers in the PHCs. The cascade training approach consisted of training state facilitators as trainers, who then in turn trained LGAs facilitators as trainers of health workers. State facilitators and LGAs facilitators train officers-in-charge and health workers on the ENA approach, how to use job aids to integrate ENA interventions into maternal and child health services (as summarized in Table 6), and how to educate caregivers on how to improve infant feeding practices.
13

Table 6: Nutrition Activities in Maternal and Child Health Services Nutrition Activities in Maternal Services Promote adequate diets and reduced workloads during pregnancy and after delivery Implement the Ten Steps of the Baby Friendly Hospital Initiative (BFHI) wherever births take place and do not accept free and low cost supplies of breastmilk substitutes, feeding bottles, and teats Give postpartum vitamin A to women at delivery Routinely screen for severe anemia and treat or refer women for severe anemia Give prenatal iron/folate supplements to all pregnant women Nutrition Activities in Child Health Services Observe and assess breastfeeding, provide individual counseling for mothers to establish effective exclusive breastfeeding for infants 06 months of age and maintain breastfeeding for at least two years Assess complementary feeding and promote continued breastfeeding for at least two years, and provide individual counseling to ensure that children 624 months of age have adequate energy Give preventive doses of vitamin A supplements every 6 months to all children 659 months of age Give preventive iron supplements to all low birth infants and to all infants, 6 months and older Weigh all children to see if they are growing well Screen, treat, and refer children for severe malnutrition, severe anemia, and clinical signs of vitamin A deficiency

The program equipped health workers with CBC materials such as home health booklets, infant feeding plans, and job aids to facilitate the integration of ENA into health services and the communication with caregivers. The health workers learned that the key contacts where ENA should be integrated include: Prenatal contacts; Delivery and immediate postpartum; Postnatal contacts; Immunization contacts; Sick child visits; and Well-child visits.

The expected outcomes for the ENA system strengthening include: a) capacity for health workers to communicate ENA messages to caregivers enhanced, b) ENA interventions integrated and implemented in maternal and child health services, and c) OICs capacity to supervise CAPA nutrition activities built.

3.5

ENA at PHC, Community, and Household Levels

The target audiences at the PHC, community, and household levels include community members and leaders, public and private health workers, parents, and caregivers. The program used the community-based approach to engage all parties to work together to improve child health and nutrition. The locus of effort to improve child survival is the community and the operational unit for the effort is the PHC catchment area under the management of the health district (if functioning)

14

and the LGA. The program and its local partners understand the community in the PHC catchment area to comprise three components: Community structures/organizations (e.g. leadership, community-based organizations (CBOs), NGOs, associations, etc.); Private sector health providers (e.g. traditional birth attendants (TBAs), traditional healers, private clinic staff, etc.); and Public health service providers. The community-based approach expects to create new working and personal relationships among community representatives and private and public health providers. It strives to create community understanding and ownership of child-health issues leading to local decision-making and cooperation. It seeks to empower all partners and is designed to achieve sustainable change through action at community/catchment area level. The program staff worked to bring these three components together in the PHC catchment area to think about child health issues, set goals for child survival, establish objectives, plan interventions, take action to improve local practices/services, and assess their own activities. The heart of the process is a three-day catchment area planning meeting where representatives from local structures and organizations/associations join with private and public health providers to plan and take action. It should be noted that the program staff did not directly do the work, but rather their task was to advocate, assist, train, encourage, and support state and LGA multisectoral partners to develop, institutionalize, and constantly monitor the community-based approach. For ENA, the program engaged and strengthened the capacity of health workers and community members to improve child nutrition through two mechanisms: Catchment area planning and action (CAPA) on ENA; and Capacity building of a network of Community Health Promoters (CHPs).

3.5.1

Catchment Area Planning and Action (CAPA) on ENA

Using the CAPA process, CAPA on ENA engaged representatives of community groups and leaders to identify and address child nutrition problems in their communities. Because CAPA members came from existing community groups and associations, working with CAPA members was expected to contribute to expanding the ENA knowledge and skills acquired to increased number of community members. The program trained state and LGA CAPA facilitators, who in turn trained CAPA members in each CA. The CAPA training/meeting was a participatory learning process for both participants and facilitators. The objective of the module was to facilitate a step-by-step method by which communities and governments will plan and sustain child survival activities with emphasis on increasing the number of children exclusively breastfed from 0 to 6 months of age and on appropriate complementary feeding. CAPA training/meeting session topics are listed in the box below and included group discussion, plenary, and interactive sessions (not straight lectures).

15

CAPA Training/Meeting Sessions Session 1: How are we doing with immunization? Session 2: Malaria prevention and treatment Session 3: Key practices of infant and child feeding Session 5: The health of our children and its effects on the community Session 6: Reasons why many children in the community are not healthy Session 7: Identifying solutions to the problems Session 8: Developing a work plan Session 9: Starting the work plan Session 10: Implementing the work plan

CAPA training on nutrition was launched after CAPA members were trained on immunization and had gained some experience in mobilizing communities to use immunization health services. CAPA training on nutrition was integrated with training on malaria prevention and treatment. During the training/meeting, CAPA members were sensitized on nutrition problems and were encouraged to offer solutions and work together. At the end of the training/meeting, each CAPA member developed a workplan on how to sensitize and mobilize community members to improve child nutrition. CAPA members were equipped with CBC materials such as infant feeding posters and home health booklets to assist them in community mobilization. They also provided a list of community volunteers, called community health promoters, to be trained to deliver ENA messages to caregivers. In each catchment area, CAPA committee members were to meet on a monthly basis with the OICs to discuss their activities, the outputs, and their experiences. OICs were mandated to meet monthly with and supervise CAPA members.

3.5.2

Capacity Building of a Network of Community Health Promoters (CHP)

Using the cascade training approach, the program first trained state CHP facilitators, then state facilitators trained LGAs facilitators. State and LGA facilitators in turn trained CHPs in each CA. CHPs were oriented on ENA messages and how to use CBC materials to carry out counseling sessions or group education on the promotion of exclusive breastfeeding, appropriate complementary feeding, the importance of vitamin A supplementation, and the appropriate nutrition and care of the sick child. The key behaviors that CHPs were to encourage mothers to practice are listed in the box below.
Key Behaviors Promoted by CHPs 1. For newborns: Put the newborn to breast within one hour of birth and allow the mother and the baby to remain together 2. For infants: Breastfeed exclusively from 0 to 6 months 3. For infants and children: From 6 months, provide appropriate complementary feeding and continue breastfeeding until 24 months 4. For women, infants, and children: Consume vitamin A rich foods and/or take vitamin A supplements 5. For all sick children: Administer appropriate nutrition and care a. Continue feeding and increase fluids during illness b. Increase feeding after illness c. Give dosages of vitamin A to measles cases 6. For pregnant women: Take iron/folate tablets 7. For all families: Use iodized salt every day

16

During the training, CHPs were encouraged to plan and carry out their activities in the communities during community gatherings and home visits. CHPs were equipped with CBC materials such counseling cards, home health booklets, and infant feeding plan posters and leaflets to carry out individual counseling and group education. CAPA members were mandated to supervise CHPs activities. The first field visits made a few months after the CHP training revealed that the number of households to be reached by CHPs was too large. Additional CHPs were therefore trained to reach increased numbers of caregivers in the community. A CHP assessment conducted one year after the CHP training revealed some weaknesses in the CHPs communication skills. The program designed and carried out a second round of refresher training for CHPs to sharpen their communication skills and also to train them in mobilizing communities to support exclusive breastfeeding in the context of HIV/AIDS. The reason for including HIV/AIDS at this point of time was because HIV/AIDS was becoming a major preoccupation in communities and messages on not to breastfeed at all were being disseminated by some health workers to lactating mothers. In a context where most women of reproductive age group did not know their HIV status, CAPA members and CHPs were trained to mobilize communities members to use voluntary counseling and testing (VCT) centers and to counsel HIV negative or unknown HIV status mothers to breastfeed exclusively their infants from 0-6 months.

3.6

Communication for Behavior Change

Three features characterized the CBC component of the program: A rigorous process of developing ENA messages grounded in the reality of each state and a consistency of messages delivered through various channels of communication; The development and use of a set of CBC materials to enhance the communication with caregivers during individual counseling and group education; and The use of multimedia communication to reinforce messages disseminated through each communication channel and to reach increased numbers of caregivers. ENA Adaptation among States

3.7

Given the ecological and cultural diversity of the program area, the program managers decided to launch the ENA implementation sequentially in each state, to select ENA interventions to be implemented in each state according to the state needs and priorities, and to work with key partners in each state to adapt the tools to be used to implement ENA. This sequential approach helped develop the expertise in ENA and accelerate the implementation process from one state to another. Lagos state served as the pilot area where interventions and tools were developed and launched in one LGA in 2001, and were later adjusted and used to scale up in other program LGAs in Lagos State. The revised tools and the lessons learned in Lagos state were thereafter adapted to suit the contexts in Kano and Abia states. The program selected ENA interventions to be implemented in each state according to each state needs and priorities. While exclusive breastfeeding, complementary feeding, and vitamin A supplementation were implemented in all the three states, the action of nutrition and care of malnourished children was also implemented in Kano state because the northern states of Nigeria have higher rates of child malnutrition. Developing and using a sustainable strategy to rehabilitate malnourished children in Kano state was a priority for the SMOH. Therefore, the program
17

assisted Kano state to design and to pilot the Positive Deviance/Hearth model for nutrition rehabilitation. The program worked with key partners in each state to adapt the training to the level of the staff and the needs of the state. The ENA messages were based on the infant feeding practices and food availability in each state. Training materials were adapted to be culturally sensitive. All CBC materials were translated into the main local dialect and pre-tested before the dissemination. The list of materials and tools adapted for each state are listed in Table 7.
Table 7: ENA Materials and Tools Adapted in Each State State-Level PROFILES System Strengthening ENA training manual for health workers Job Aids (ENA and PMTCT) Community Component CAPA for nutrition and malaria

CHPs training manual Counseling cards Home health booklet Infant feeding plan poster and leaflet PD training manual

3.8

PTMTCT/Infant Feeding Options in Kano and Lagos States

USAID/Abuja invited the program to participate in the review and enhancement of HIV and infant feeding guidelines. As optimal breastfeeding practices were being challenged by rumors of the presence of HIV in the breastmilk of HIV-infected lactating women, SMOH in Lagos and Kano states decided to address the issue. The strategy was to involve state facilitators in the development of the PMTCT/infant feeding options job aids and to train health workers in selected LGAs where VCT services were available. Additionally, as previously mentioned, CAPA and CHPs members were trained to sensitize community members on the use of VCT services and the importance of breastfeeding exclusively from 0 to 6 months for HIV-negative or unknown HIV status lactating women. The strategy was successful, and the SMOHs are planning to scale up the training of health workers and CAPA and CHPs. 3.9 The Positive Deviance (PD)/Hearth Model in Kano State

As mentioned, the program introduced an innovation in the rehabilitation of malnourished children in Nigeria. Upon the request of the Kano SMOH, the program built the states capacity for designing and implementing the Positive Deviance (PD)/Hearth model for nutrition. PD/Hearth is a community-based rehabilitation of malnourished children and emphasizes enhanced feeding practices, active and responsive feeding, and good hygiene. The approach builds on the recognition that recommended and successful feeding practices already exist in the community. The positive deviant families (families practicing recommended practices) are identified as well as families with malnourished children. A PD inquiry is conducted to identify the successful practices of positive deviant families that are used as the basis of PD sessions for the rehabilitation of malnourished children. The PD/Hearth model brings together, community, and health workers and uses locally available foods to rehabilitate malnourished children. PD sessions are the training ground for parents and health providers. Children participating in PD sessions are followed up for three to six months to ensure that the practices are sustained. Based on the success of PD in Kano State, the SMOH gave an award to the program in recognition of its support for PD/Hearth.

18

4. PROGRAM ACHIEVEMENTS This section describes the programs achievements at the national and state levels and the perceptions of program partners and beneficiaries on the achievements. Evidence shows that the strategies and tools developed and used at the national, state and community levels have yielded significant results. The technical leadership of the program led to recognition of ENA at the national level and the integration of vitamin A supplementation into NIDs. Scaling up ENA interventions in health services and in communities through NPHCDA became the strategy for providing adequate nutrition, family health services in PHC centers, and other health services to communities. Scaling up ENA interventions created awareness and mobilized communities to use the available nutrition services in the National Plan of Action for Food and Nutrition in Nigeria. Stakeholders in Abuja have acknowledged the programs contribution in the development of HIV and infant feeding guidelines for Nigeria and the active participation of the program in the NPG. The program equipped each SMOH with trained and experienced ENA facilitators for the LGA, PHC, and community levels. The program also equipped each state with a stock of training manuals and CBC materials to sustain PHC and community ENA activities and to scale up ENA interventions in additional LGAs. Health workers have acquired good knowledge of ENA messages and have been educating caregivers. The program also successfully launched Child Health Weeks in Abia, Kano and Lagos states. The program empowered community leaders and groups to improve child nutrition in 155 catchment areas in 20 LGAs. More than 4,000 CAPA members and CHPs were trained and equipped with CBC materials; they have acquired a thorough knowledge of ENA messages as result of their training. CHPs and CAPA members are reaching increased numbers of caregivers. As illustrated in Table 8, the 2003 ICHCS revealed that caregivers demonstrated a very good knowledge of ENA messages, and exclusive breastfeeding and appropriate complementary feeding practices had surpassed the strategic objectives target and the national figures as a res ult of CAPA members and CHPs mobilization and education of the community.
Table 8: ICHCS Results Indicators % of children breastfed within one hour of delivery % of infants < 6 months exclusively breastfed % of mothers 1549 years of age with knowledge of exclusive breastfeeding % of children 6-8 months breastfed and given solid foods % of women breastfeeding their child 023 months % of mothers who know that vitamin A is important 10 34 2000 2002 34 26 48 23 85 57 2003 36 34 58 51 86 60

19

4.1

Achievements at the National Level

One of the programs major focuses at the national level has been to influence policy formulation and to build the capacity of the national nutrition program. The major achievements include: Development of vitamin A supplementation guidelines and building capacity to integrate vitamin A supplementation into NIDs. Successful piloting of Child Health Week as a transition strategy for vitamin A supplementation Building the capacity of a cadre of national experts on PROFILES Use of PROFILES to continuously advocate for nutrition in various forum including in the National Plan of Action for Food and Nutrition Recognition of ENA as an appropriate strategy to improve child nutrition in Nigeria Inputs in the HIV and infant feeding guidelines

Further descriptions of these achievements are provided below.

4.1.1

Vitamin A Supplementation

All members of the Nutrition Partners Group at the national level have acknowledged the programs contribution to advancing vitamin A supplementation in Nigeria, as listed in Table 9.
Table 9: Contribution to Advancing Vitamin A Supplementation at the National Level Activity Participation in meetings for the national guidelines development Integration of vitamin A into NIDs Outputs/Outcomes National guidelines on vitamin A Module on vitamin A integrated into NID training module in 2001 Capacity of health workers built on how to integrate vitamin A into NIDs in 2001 Post-NIDs vitamin A supplementation transition strategy Child Health Weeks piloted in three states in 2003 2004 in collaboration with other partners

The program assisted the development of a vitamin A module that was included in the NIDs training module. The program also piloted Child Health Weeks in Abia, Kano, and Lagos states, which were very successful. Caregiver turnout was important due to the free distribution of materials. According to the SMOH, Child Health Weeks have reinforced the relationship between health workers and caregivers (Caregivers have rediscovered the health facility). However, Child Health Weeks are supply dependent, and the FMOH should secure the development partners commitment to provide vitamin A capsules prior to the event.

4.1.2

Policy Analysis and Action Planning: PROFILES

20

PROFILES was one of the innovations that the program introduced in Nigeria. PROFILES was unfolded in a three-step process, the activities, outputs and outcomes of which are listed in Table 10.
Table 10: PROFILES Activities, Outputs, and Outcomes Activities Development and adaptation of PROFILES Outputs/Outcomes PROFILES adapted to the Nigeria context Coalition built and alliance for nutrition and the NPG formed Capacity of 10 nutrition experts built in adapting and using PROFILES in 2001 Awareness raised on the multi-sectoral character of nutrition, and coalition and alliance built and NPG formed Capacity built of different groups such as Agriculture, Nutrition, and Gender group Increased demand for the program to present PROFILES at various forums such as the nutrition network meeting in 2001 and the launching day of the National Policy on Food and Nutrition

Training of nutrition experts on PROFILES

Presentation of PROFILES in various forums

The institutions to be trained on PROFILES were defined, based on their capacity, willingness, and credibility to advocate for nutrition at national and state level. These institutions included the University, and the Ministries of Agriculture, Education, Information, and Finance. Demographic and economic data from Nigeria were gathered to adapt PROFILES to the Nigeria context. Then the adaptation of PROFILES to the Nigeria context continued through the capacity building of Nigerian experts in the use of data collected for analysis. The program trained 10 Nigerians in the use of demographic and economic data from Nigeria to show the effect of malnutrition on the mortality and economy as a whole. Participants in the workshop prepared a PowerPoint presentation for advocacy for various audiences. Each participant developed an action plan on their use of PROFILES to advocate for nutrition. The presentation of PROFILES led to the understanding of the multi-sectoral aspect of nutrition and the need for coalition building and alliance for advancing nutrition. The Nutrition Partners Group was formed and instituted a monthly meeting. The NPG brings together representatives from all institutions carrying out nutrition activities in Nigeria such as Ministries of Health, Education, Information & Strategy, Agriculture & Rural Development, Women Affairs & Poverty Alleviation, Finance & Economic Planning, Universities, and research institutes. PROFILES was an eye-opener to various political and decisions makers on the importance of good nutrition for any sector of the development. The demand for presenting PROFILES grew significantly at the national level, and the program was requested to present PROFILES to various meetings such as on the launching day of the National Policy on Food and Nutrition. The National Plan of Action of Food and Nutrition in Nigeria plans to adapt and use PROFILES to advocate at all levels of government and to communities. The federal Ministry of Information plans to conduct a serialized production and airing of documentaries on PROFILES for nutrition advocacy to elicit public responsibility.
21

4.1.3

National Plan of Action and Nutrition Forum

The program contributed to the development of the National Plan of Action for Food and Nutrition, which led to the recognition of ENA as an appropriate approach to improve the nutritional status of children in Nigeria. As a result of the programs successful communication and advocacy activities, ENA will be scaled up in Nigeria through the NPHCDA, which plans to integrate ENA into health services through the training of health workers and through integrated PHC catchment area planning and action on ENA. The Nutrition Partners Group and the National Committee on Food and Nutrition commended the program for its active participation in every nutrition forum at the national level. The program gave support to the Nutrition Policy Framework and participated in the Agriculture, Nutrition, and Gender Group meetings. The program also took the lead in organizing some NPG meetings.

4.1.4

HIV and Infant Feeding Guidelines

HIV/AIDS poses a serious threat to the breastfeeding for children from 0 to 2 years of age as information on the presence of HIV virus in the breastmilk of HIV-infected mothers was widely disseminated. Under the leadership of USAID, the task force on nutrition developed national HIV and infant feeding guidelines for infants born to HIV-positive mothers. The program reviewed and provided input to enhance the content of the HIV and infant feeding guidelines. The main purpose of the document was to enable health workers to provide adequate guidance to HIV positive pregnant women regarding the feeding options of their baby.

4.2

Achievements at the State level

The program achievements at state level include both significant outputs and outcome that are described below. Table 11 provides an overview of key program components and lessons learned for each state and at the national level.

22

Table 11: ENA Implementation at the State Level State / National Communication and Advocacy
The program approached the SMOH to present the ENA approach and secure input on how to move forward LAGOS -

Program Components System Strengthening

Training of Trainers for state facilitators 100 health workers trained Evidence of counseling on infant feeding -

Community Component
> 1000 CHPs trained CAPA members / CHPs counseled and sensitized caregivers on nutrition -

Lessons Learned
PROFILES adopted but not used Integration in progress Need additional training for health workers on screening and management of malnutrition and micronutrient deficiencies Need to streamline roles of OICs/services providers and CAPA members/CHPs to avoid conflict Promote income generating activities to motivate CAPA/CHPs Involve males and institute Fathers Days Saturate communities with CBC materials Child Health Weeks should be institutionalized Multi-sectoral approach is key for sustainability Need to target physicians in future training and plan for newcomers Refresher training needed for CAPA/CHPs on vitamin A and PMTCT/infant feeding options Messages on EBF should be emphasized Special support is needed for other ministries to integrate ENA PD/Hearth should focus on nutrition and not on drugs PMTCT: need for expansion of the orientation to more LGAs ENA: Scaling up planned through PLACO

Ongoing advocacy to secure and maintain state support and momentum

KANO -

Advocacy meeting with state officials -

ABIA

21 state CAPA nutrition facilitators, 30 LGA facilitators, 70 OIC and 145 health workers from public and private health facilities (except physicians) trained to integrate ENA in MCH services Additional training for selected group on PMTCT and PD/Hearth Effective counseling on ENA acknowledged 13 state, 15 LGA facilitators, 15 OICs, and 64 service providers trained in ENA Integration in progress but not completed

460 CAPAC members, 2089 CHPS trained in proper use of CBC material Services appreciated by communities

549 CAPA members and 1015 CHPs trained CBC materials extensively used

NATIONAL

PROFILES process was used to build coalition and alliance for nutrition Awareness raised on the multi-sectoral nature of nutrition Increased demand for presentations

Input on HIV and infant feeding guidelines developed ENA recognized as part the National Food and Nutrition Plan of Action National Partners Group supported by the program

Need to involve and target the physicians and private sector providers The focus on the community has been beneficial The link between malnutrition and disease should be emphasized to better convince mothers Radio and television should be explored as additional means of expanding message dissemination Child Health Week should be better planned with emphasis on community mobilization Need for support to all agencies to implement ENA ENA CBC materials used to support LGA for scaling up Programs contribution to shifting the vision from a biochemical and medicalized to prevention

23

4.2.1

Results in Lagos State

Lagos was the first state where the program launched nutrition activities on the ground. The ENA approach was implemented in nine predominantly urban LGAs in Lagos State. The project has worked with PHCs from the public and private sectors in the nine LGAs. The ENA interventions implemented in Lagos state included exclusive breastfeeding (EBF) and PMTCT/infant feeding options, appropriate complementary feeding (ACF), and vitamin A supplementation. The majority of the population was Yoruba, and most men and women in the project area worked in small trades out of their homes. Womens working to contribute to household incomes was a requisite in urban areas. This lifestyle has had profound repercussions on the infant feeding practices in Lagos State. Referring to the ENA framework, Lagos served as the demonstration site where ENA interventions were piloted and refined before moved to Kano and Abia states. Three years of program implementation in Lagos has led to significant improvement in the knowledge and feeding practices of young children in the focus LGAs in Lagos state, as shown on the Table 12.
Table 12: Changes in the Knowledge and Rate of EBF, ACF, and vitamin A Supplementation in BASICS II Focus LGAs in Lagos State as of November 2003. Indicators BREASTFEEDING % of mothers 1549 years of age with knowledge of exclusive breastfeeding % of mothers initiating breastfeeding within an hour % of mothers exclusive breastfeeding % of women who encouraged other women to breastfeed exclusively APPROPRIATE COMPLEMENTARY FEEDING % of women breastfeeding their child 023 months % of children 68 months receiving semi-solid foods and breastmilk % of children 911months receiving semi-solid foods and breastmilk VITAMIN A SUPPLEMENTATION % of mothers who know how important for children 623 months to receive vitamin A % of children 623 ever received vitamin A 77 67 74 72 12 25 64 49 50 12 29 60 32 39 76 56 25 36 60 2000 2002 2003

Exclusive Breastfeeding The 2003 ICHCS results on EBF among children under six months revealed that significant increases in EBF rates were achieved during the period 2000 to 2002 and were maintained but not improved during the period 2002 to 2003.

24

The percentage of mothers 1549 years of age with accurate knowledge of EBF rose from 29% to 60% and 56% in 2000, 2002, and 2003. The percentage of mothers initiating breastfeeding within the first hour decreased from 32% to 25% between 2002 and 2003. The percentage of mothers who reported practicing exclusive breastfeeding rose from 12% to 39% and 36%, in 2000, 2002, and 2003. The percentage of mothers who encouraged other mothers to breastfeed exclusively stabilized from 76% to 60% between 2002 and 2003.

These trends confirmed the effects of the mothers urban lifestyle on the feeding practices of young children. The results of the qualitative study on the attitudes, beliefs, and perceptions of health workers, CAPA members, CHPs, mothers, and caregivers in the project area revealed that the mothers and caregivers knowledge of EBF are good, however the practices do not always follow. Caregivers indicated that an increased number of mothers were initiating breastfeeding on time; however the 2003 ICHCS shows a decrease in this practice. A few caregivers mentioned giving water with breast milk in the first six months. This information could reflect either the usual feeding practices of children from 06 months in Lagos state or messages given by health workers who have not been trained or who are convinced about EBF. To accelerate the scaling up of healthy behaviors/practices, the program encouraged all caregivers to become CHPs; however, the percentage of mothers spreading the word about EBF has not increased. EBF practices seem to have reached a ceiling to 6076% in Lagos. This situation requires some programmatic attention to help address the barriers to EBF in the state. Most caregivers and mothers have a good knowledge of messages on EBF.

Appropriate Complementary Feeding Practices The 2003 ICHCS survey revealed: A decrease between 2002 and 2003 in children from 023 months breastfeeding. A significant increase (p < .05) in children from 68 months and 911 months receiving porridge, cereals, or solid foods in addition to breastmilk.

Although an increased number of children from 611 months of age were receiving appropriate complementary foods and breastmilk, in the qualitative study mothers explained that they sometime have a hard time buying the locally available complementary foods recommended for children. Complementary foods are often introduced either too early or too late. Some mothers find the messages on appropriate complementary foods difficult to do. Parents and in laws advised the mothers to start giving vegetables and liver from three months. Mothers usually stop breastfeeding their child when they resume work outside of their home.

Vitamin A Supplementation The 2003 ICHCS revealed that almost 74% of children of 623 months of age surveyed received vitamin A at some time in the past. Given the changing face of NIDs, the program has explored Child Health Weeks as another strategy to deliver vitamin A to children of 659 months of age. Child Health Week was piloted in all the LGAs in Lagos State in 2003 and 2004. Program partners in the state acknowledged that 2004 Child Health Week was successful. Adequate supplies, involvement of more partners, community involvement, and well-planned and early

25

community mobilization were identified as the key factors for the success of Child Health Week. However, CBC materials such as posters, handbills, etc. were not available in 2004, and fewer mothers/caregivers turned out. Advocacy to the political class was not adequate and the planning was not timely. With adequate community mobilization, motivation, and effective supervision by all stakeholders, more children could be covered. Mothers and caregivers cited the free distribution of commodities as the reason why Child Health Week was successful. Most of the program partners who were involved in planning and implementing Child Health Weeks are convinced that the event is an appropriate vitamin A supplementation transition strategy. Mothers/caregivers now know that the PHC exists to serve them and their children. Record keeping was still a problem for the mothers who did not bring their health cards to the health facilities. Reasons include ignorance on the need for cards, scarcity of cards, cost of cards, etc. There is a need to stress the importance of health cards to mothers and caregivers. Home health booklets produced by the program in collaboration with SMOH if adopted could help to address the problem.

How Program Outcomes Were Achieved in Lagos State As indicated in the Table 13, communication and advocacy, health system strengthening, and a community-based approach for improved feeding practices were the main strategies that have led to the positive changes in the infant feeding practices in Lagos State.
Table 13: ENA Program in Lagos State INPUTS Training IMPLEMENTATION / ACTIVITIES Advocacy Monitoring Operational Plans Systems Strengthening Community Mobilization (CAPA) Community Health Promoters Impact Indicators PERFORMANCE Cluster Surveys

Training Modules

CHP Assessment

(See Table 11 for details on the implementation.) The box below lists milestones in the ENA program in Lagos State.

26

ENA Milestones in Lagos State 1999 2000 KAP survey and Trial of Improved Practices (TIPS) Study Module development Messages/CBC materials development State-level training Technical training of health workers from public and private sector CAPA training State-level training LGA-level training CAPA training (completed in November 2001) CHPs training PMTCT/infant feeding option SMOH training Training of health workers in LGAs Training of additional CHPs Refresher training of CHPs

Aug 2001Jun 2002

Aug 2001

Mar 2002Nov 2003 Oct 2003

FebMay 2004

4.2.2

Results in Kano State

ENA was launched in Kano State in early 2002. According to the 2003 DHS report, Kano State was among the Northern States of the country with high level of malnutrition. The ENA interventions implemented in Kano State included EBF and PMTCT/infant feeding options, ACF, vitamin A supplementation, and appropriate nutrition and care of the malnourished and sick child. The program was implemented in nine LGAs in Kano State, among which four were from urban areas and five were from rural areas. ENA was launched first in the urban area and was moved to rural areas. The population in Kano State is mostly Hausa and Muslim with a strong respect of tradition and religious values. Because the program already gained experience in implementing ENA in Lagos state and given the interest of the Kano SMOH to improve the nutritional status of children in the state, ENA was implemented more quickly in Kano state than in the other states. The program supported PHCs from the public and the private sector in the state. After nearly two years of implementation of ENA in Kano State, the program has yielded significant positive changes in the feeding practices of children, as shown in Table 14. The 2003 ICHCS revealed significant increase in the EBF and ACF practices in the program area.

27

Table 14: Changes in the Knowledge and Rate of EBF, ACF, and Vitamin A Supplementation in BASICS II Focus LGAs in Kano State as of November 2003 Indicators BREASTFEEDING % of mothers 1549 years of age with knowledge of exclusive breastfeeding % of mothers initiating breastfeeding within an hour % of mothers exclusive breastfeeding % of women who encouraged other women to breastfeed exclusively APPROPRIATE COMPLEMENTARY FEEDING % of women breastfeeding their child 023 months % of children 68 months receiving semi-solid foods and breastmilk % of children 911months receiving semi-solid foods and breastmilk VITAMIN A SUPPLEMENTATION % of mothers who know how important for children 623 months to receive vitamin A % of children 623 ever received vitamin A 40 38 38 85 37 38 86 43 56 3 21 31 38 20 13 45 52 34 12 2000 2002 2003

Exclusive Breastfeeding Significant increases of EBF rates were achieved from 2000 to 2003 in the project area: The percentage of mothers 1549 years of age with accurate knowledge of EBF rose from 21% to 31% and 45% in 2000, 2002, and 2003. The percentage of mothers initiating breastfeeding within the first hour decreased from 38% to 52% between 2002 and 2003. The percentage of mothers who reported to practice exclusive breastfeeding rose from 3% to 20% and 34% in 2000, 2002, and 2003 The percentage of mothers who encouraged other mothers to breastfeed exclusively stabilized to 13% between 2002 and 2003.

The qualitative study carried out in July 2004 in the project area with program partners and beneficiaries have confirmed the trends in the EBF practices. The study revealed that the knowledge of CAPA members, CHPs, caregivers, and mothers on EBF was good. Increasing numbers of grandmothers, mothers, and in laws have claimed to be convinced by CAPA members and CHPs on EBF messages. Mothers/caregivers claimed that an increased number of mothers are practicing EBF. Despite the positive attitude toward exclusive breastfeeding, health workers, CAPA members, CHPs and caregivers have acknowledged that EBF is the most difficult to practice because mothers and caregivers think that the child may die if not given water.

28

Moreover, some grandmothers, in-laws, and husbands are opposed to exclusive breastfeeding. The 2003 ICHCS results revealed that in general mothers who are breastfeeding exclusively are not advising other mothers to do the same. The positive trend toward EBF needs to be supported by increased community mobilization and support to EBF practices by community leaders, health workers, and CHPs.

Appropriate Complementary Feeding The 2003 ICHCS survey has also revealed positive trends toward ACF in general. A significant increase (p < .05) in continued breastfeeding for children from 023 months between 2002 and 2003; and A significant increase (p < .05) in children receiving porridge, cereals, or solid foods in addition to breastmilk from 68 months and 9 11 months.

Health workers, CAPA members, CHPs, caregivers, and mothers confirmed that appropriate complementary feeding and continued breastfeeding are the behaviors that mothers are practicing the most because the corresponding ENA messages emphasize the use of locally available foods for appropriate complementary feeding.

Vitamin A Supplementation The 2003 ICHCS measured vitamin A supplementation through NIDs. The knowledge of caregivers on the importance of vitamin A supplementation for children and the vitamin A coverage have not improved. Vitamin A supplementation has negatively been affected by resistance to polio immunization in the northern part of the country. NIDs have been the main conduit for vitamin A supplementation in Nigeria.

Child Health Week The Governor attended the launching of Child Health Week in 2004. According to LGAs and health workers, the event was a success. Attendance was overwhelming, however some mothers did not bring their child for vitamin A supplementation because they thought it was polio in disguise, and some CAPA/CHPs do not know the appropriate age group for vitamin A supplementation. According to OICs and LGA coordinators, Child Health Week should be held in Kano in the future because it helps us rebuild confidence and thrust among women to patronize health facilities. One PHC coordinator stated, CHW [Child Health Week] should continue even without the stance of SMOH. Suggestions from stakeholders on ways to improve Child Health Week include: SMOH should ensure adequate publicity, materials, and supplies; Use mass media to mobilize people; LGAs should provide adequate working materials; CAPAC should mobilize and inform the community on the importance of vitamin A; Collection and use of data for planning and decision making should be emphasized; and

29

Others sectors and partners such as MOH, Education, LGAs (both directorate and ministry), JHU, UNICEF, and UNDP should participate in the planning and implementation. Positive Deviance/Hearth The program successfully introduced Positive Deviance (PD)/Hearth, an innovation in the rehabilitation of malnourished children, in Nigeria. Before ENA, Kano SMOH has been confronted with sustaining good nutritional status in children after they have been rehabilitated. Rehabilitation in Kano was facility based. Children suffering from malnutrition are admitted in the hospital and are properly fed for 10 to 12 days after which they are discharged. Most of these children come back a few months later and are readmitted for malnutrition again. The program worked with the Kano SMOH to design and carry out PD sessions in Kano state. The program oriented the Kano SMOH on the PD concept. The program and the SMOH drafted the training module and decided to pilot PD in Maramara in an urban CA. The Kano SMOH contacted the health workers in the PHC and the CHPs in Maramara to prepare for PD/Hearth intervention. Positive deviant families and malnourished children were identified, and PD inquiries were carried out. PD sessions were planned and caregivers were invited to contribute by providing the foods and participating in different tasks such as cooking the meals, washing children hands, feeding children, and keeping the place clean. CHPs worked closely with caregivers, and health workers and the program staff helped facilitate the PD sessions The community-based rehabilitation of malnourished children has been one of the most successful components of the ENA program in Kano State. The Kano SMOH gave an award to the program as recognition of its successful support to the Kano SMOH in piloting PD in urban and rural areas of Kano. The success of PD in Kano State can be attributed to the design and implementation of the intervention and its outputs and outcomes, which deserve description in detail. The following presents the characteristics of the PD design in Kano state: PD in Kano state addressed an identified need and was SMOH driven Malnutrition in children is a public health problem in Kano state, and the Kano SMOH had been looking for a more efficient approach to help improve and sustain the nutritional status of malnourished children. The design of PD in Kano was state driven; most decisions on where and how to start PD came from the SMOH. The program and Kano state worked closely from the inception of PD. After an orientation on PD, all the steps and materials were developed with Kano SMOH. This led to the full ownership of PD by the Kano SMOH. PD is a striking innovation that shifts the responsibility of rehabilitating malnourished child from the hospital to the family The facility-based rehabilitation of children that was practiced in Kano state puts all the responsibility on the hospital, including supplying for all needs of the malnourished child. There were serious questions on how to sustain the approach, given the fact that most families did not succeed in maintaining the nutritional status of rehabilitated children after the children returned to their homes. PD is a striking innovation that shifted the responsibility of rehabilitating and maintaining the nutritional status of the child on the family. Families and communities participated in PD, which offered the opportunity to share nutrition messages and put them into practice. There was a systematic approach in designing and implementing PD Given the scope and magnitude of malnutrition both in rural and urban areas of the state, Kano SMOH decided to pilot PD in an urban CA in Maramara and then draw the lessons

30

learned to help expand in urban and rural areas. The lessons learned in Maramara helped revise and enhance the content of the PD training manual.

Characteristics of the implementation of PD/Hearth in Kano included: Using the existing capacity within the Kano SMOH The Kano State Deputy Nutrition Coordinator took the lead in the activity and worked to determine the energy and nutrient contents of the meals given to children. By doing so, she insured that practices that were promoted were scientifically sound and accepted by the SMOH. Building capacity within the SMOH, the PHCs, and the communities Designing and piloting PD in Maramara was training ground for both Kano state and the program. Strengthening the partnership between the PHCs and communities During PD sessions, health workers spent time working closely with CHPs and caregivers, which reinforced their partnership. PD sessions also offered mothers the opportunity to spend some enjoyable time out of the house with their peers and to gain more knowledge and skills on infant feeding. Using an easy approach that reinforces existing practices and values the local food Health workers, community members and caregivers were amazed by the easiness of practices that were promoted. When a malnourished child was admitted in the hospital for rehabilitation, parents did not know what was given to the child to improve her/his nutritional status. PD demonstrated that existing foodsif properly combined, cooked, and served in a hygienic mannerwere as good, or even better than expensive imported and processed infant foods. Emphasizing improved feeding practices, good hygiene, and responsive feeding PD sessions offered the opportunity to health workers, community members, and caregivers to cook and give the recommended quantity of nutritious meals, practice hand washing, and responsive feeding. They witnessed the cooperation and willingness of children to eat when parents interacted nicely with them, unlike force-feeding, which is a common practice in the area. Combining curative and preventive measures In addition to feeding malnourished children, caregivers were educated on the improved feeding practices to maintain and improve the child nutritional status. Innovating community monitoring of the rehabilitated children The monitoring of the children that participated in the PD sessions was carried out by CHPs. Most CHPs were illiterate and could not properly use the scale and report accurately the weight. The program designed a monitoring system using a tool called a Shakir strip that suited the level of CHPs in the area to monitor the nutritional status of children. Thus the program demonstrated that it is possible to design and implement community monitoring, which enables community members to follow up the children and increases the community ownership.

31

The outputs and outcomes of PD/Hearth in Kano included: Training manual and tools adapted to the local context The PD training manual has undergone several revisions building on the lessons learned from PD sessions held in urban and rural areas. The context, the food, the measurements, and the stories in the PD manual are from Kano state. Capacity built in Kano SMOH, LGA, PHC, and communities The program has equipped the SMOH with a pool of state and LGA PD facilitators selected OICs, health workers, and CAPA members/CHPs who have been trained in PD and could help expand PD in the state. PD sessions were a training ground for health workers and communities. Adults learn better when they put into practice the recommend behavior, and the PD sessions provided health workers and caregivers the opportunity to put into practice messages that have been promoted. Nutritional status in children improved and sustained Children participating in PD/Hearth sessions have shown steady improvement in their nutritional status several months after the sessions concluded. The improved and sustained weight gain in children that have participated in the PD sessions was a radical difference from the facility-based rehabilitation being practiced in Kano State. Heath workers and communities convinced of the importance of prevention PD/Hearth nutrition has been a powerful way to demonstrate the benefits of good nutrition to health workers and communities. The mothers that have participated in the PD sessions reported that they have seen the improvement in the health of their child and that they were still practicing what they were taught during PD sessions. Fathers of children whose children have participated in PD session have also noticed a positive change after the PD/Hearth sessions. One father commented, The child looks more healthy and energetic than before. Practices learned through PD being sustained by parents Parents of children who participated in PD sessions claimed that they were continuing to feed the child the same foods that were recommended during PD/Hearth sessions. Messages from the sessions have been disseminated to all households in the community, including those that did not participate in the PD/Hearth sessions. On mother said, We teach other women how to feed their children with nutritious foods. PD became LGA, PHC, and community driven The information on the success of PD sessions spread in the LGAs and in communities; as a result, the demand for PD grew significantly. As PD was moving along, the program role and input was reduced significantly, and the PD sessions on the ground were designed and implemented by health workers and communities. Some health workers that participated in the pilot PD/Hearth sessions decided to design and implement PD in their own home CAs.

PMTCT in Kano State In 2003, information that an HIV-infected mother can transmit HIV through breastmilk to the infant spread in the program area and threatened the promotion of optimal breastfeeding

32

practices. The program discussed and reviewed with the SMOH the implications of HIV for infant feeding practices. The program seized the opportunity to build the capacity of health workers on infant feeding options in the context of HIV/AIDS using the recommendation of the national HIV and infant feeding guidelines. The program trained state facilitators and LGAs facilitators on PMTCT/infant feeding options in Lagos and Kano. The facilitators reviewed and adapted PMTCT job aid to each context. State facilitators trained later on health workers on PMTCT/infant feeding options.

How the Program Outcomes Were Achieved in Kano State As in Lagos state, communication and advocacy, systems strengthening, and community mobilization for improved infant practices were the key strategies that contributed to these achievements. (See Table 11 for details on implementation.) As highlighted in the box below, implementation of ENA has been very intense since early 2002.
ENA Milestones in Kano State Early 2002 Mar 2002 Jun 2002 Jul 2002 Jul 2002 Advocacy to SMOH to present the ENA approach Development of ENA materials and tools Training of trainers for technical training Training of OICs and health workers Leadership training on ENA Training of LGAs CAPA facilitators in urban areas Training of CAPA facilitators in rural LGAs Training of state facilitators as CHPs facilitators

Aug 2002

AugSep 2002 Training of CHPs in urban areas MarJul 2003 Training of CHPs in rural areas

Positive Deviance/Hearth Dec 2003 Design of PD in Maramara in urban area Training Feb 2004 Mar 2004 Training of State PD facilitators Training of LGAs PD facilitators PD in rural areas

PMTCT Infant Feeding Options Feb 2004 Training of State and LGA facilitators Training of health workers

33

4.2.3

Results in Abia State

ENA was launched in Abia State during the last 24 months of the program. The ENA interventions implemented in Abia State included, EBF, ACF, and vitamin A supplementation, and were implemented in two LGAs in Abia state, Aba South and Aba North, which have the highest population density in the state. The two LGAs are mostly located in urban areas, and only one catchment area among the 15 covered by the project in Abia state is located in a rural area. Most men and women in the program area are traders and earn their living from the informal sector. The program has worked mostly with 15 public health facilities, of which three were PHCs and 12 were health posts for outreach services (for immunization mainly). Despite the late introduction of ENA in the state, increased knowledge of and enhanced practices regarding EBF, ACF, and vitamin A supplementation in children from 659 months has been seen in the program LGAs, as shown in the Table 15. The ENA outcomes in Abia state were achieved after just 12 to 18 months of CAPA member and CHP sensitization and education on ENA messages in the 15 CAs covered by the project.
Table 15: Changes in the Knowledge and Rate of EBF, ACF, and Vitamin A Supplementation in BASICS II Focus LGAs in Abia State as of November 2003. Indicators BREASTFEEDING % of mothers 1549 years of age with knowledge of exclusive breastfeeding % of mothers initiating breastfeeding within an hour % of mothers exclusive breastfeeding % of women who encouraged other women to breastfeed exclusively APPROPRIATE COMPLEMENTARY FEEDING % of women breastfeeding their child 023 months % of children 68 months receiving semi-solid foods and breastmilk % of children 911months receiving semi-solid foods and breastmilk VITAMIN A SUPPLEMENTATION % of mothers who know how important for children 623 months to receive vitamin A % of children 623 ever received vitamin A 68 59 59 66 28 82 61 60 39 11 45 56 30 15 40 70 39 29 65 2000 2002 2003

Exclusive Breastfeeding The analysis of trends in EBF rates revealed consistent and significant increases since the ICHCS conducted in 2000:

34

The percentage of mothers 1549 years of age with accurate knowledge of exclusive breastfeeding jumped from 45% to 70% from 2000 to 2003. The percentage of mothers initiating breastfeeding within the first hour increased by 9%. The percentage of mothers who reported to practice exclusive breastfeed rose from 11% to 29% from 2000 to 2003. The percentage of women who encouraged other women to breastfeed exclusively increased from 40% to 65% from 2002 to 2003.

These trends highlighted by the quantitative survey (ICHCS) were consistent with the results of a qualitative survey that looked at attitudes, beliefs, and perceptions of health workers, CAPA members, CHPs, mothers, and caregivers in Abia state about breastfeeding practices for children from 0 to 6 months of age in the project area. The in-depth interviews with health and community workers and the focus group discussion with mothers and caregivers revealed that most health workers in public PHCs, CAPA members, CHPs, mothers, and caregivers in the project area have acquired good knowledge of the key messages on breastfeeding from 0 to 6 months. These messages are being passed on effectively to mothers. They all reported that increased numbers of mothers were exclusively breastfeeding. However, a certain number of constraints and barriers have been identified, including: Fear of mothers that an infant cannot survive without water; Belief that infants under six months of age need additional foods; The reality that mothers have to go back to the market and continue to generate income for the family; therefore, they give water and prepare other foods that the baby will eat when they are away from home; Pressure of parents, neighbors, and mothers-in-law on the mother to give the child water and food. One mother noted, This is my first experience; I wanted to do EBF, but my mother kicks against it and says she brought me up on breast milk, pap, and water and I survived, so, why wont my son survive with breast milk and water? Also, grandmothers do not allow young women to practice EBF because they believe that the childs fontanel may not close if they are exclusive breastfed. Inadequate knowledge and conflicting messages from some health workers about EBF. Some of these health workers claimed that the reason why EBF was being promoted is to avoid contamination from unclean water. They said to mothers that if the mother can afford to buy clean water, she should give clean water to the child under six months of age. Health workers from the private sector in Aba North and South have not been trained on EBF and are not promoting exclusive breastfeeding for infants from 0 to 6 months.

Caregivers, parents, and in-laws seemed to be puzzled by EBF practices. According to their tradition, infants from 0 to 6 months have always been given water and foods, and they have been trying to preserve the tradition by preventing their daughter to breastfeed exclusively. On the other hand, they have reported that they have seen exclusively breastfed infants that look plumpy and healthy. They have asked to be trained on EBF in order to advise the young mothers to do so. Considering the stages of behavior adoption that include awareness, knowledge, contemplation, intention, action, and maintenance, grandparents and in-laws seem to be seriously contemplating EBF as a practice they can promote.

35

Appropriate Complementary Feeding The World Health Organization recommends that children should be breastfed up to the age of 23 months and should be introduced to complementary feeding from the age of 6 months. The results of 2003 ICHCS in Abia state revealed: A very significant decrease (p < .05) in continued breastfeeding from children from 0 up to 23 months. A significant increase in children from 69 months of age receiving porridge/cereals/solid foods and breastmilk in the prior 24 hours. A significant decrease in the proportion of children 911 months of age fed porridge/cereals or semi-solid foods and breastmilk.

These results showed that almost two-thirds of children 9 months of age received only complementary foods. The in-depth interviews with health and community workers revealed that both groups have a good knowledge of appropriate feeding practices messages for children from 6 months of age and older. The focus group discussion with mothers revealed that giving appropriate complementary foods is among the practices that the mothers are implementing the most because the messages emphasized the use of locally available and affordable foods. However, while mothers are giving appropriate complementary foods, most of them stop breastfeeding. The main constraint for appropriate feeding practices (not giving breastfeeding while giving foods) for children from 6 months of age and older is the fact that mothers have to go back to work and leave their child behind to be fed foods alone. While the appropriate complementary feeding seemed to be practiced quite easily by a number of mothers, it appears that the results of the quantitative study do not really match the results of the qualitative study. One could say that the easiness to adopt the behavior may only be apparent, but there is still a need to advocate for continued breastfeeding

Vitamin A Supplementation The 2003 ICHCS in Abia state sought to examine coverage rates at the population level and revealed that more than half of children 6 to 23 months of age received vitamin A at some time in the past. The 2003 ICHCS also revealed that the percentage of mothers who know the importance of vitamin A for children 6 to 23 months of age decreased from 68% to 59% Child Health Week took place in all LGAs in Abia state. Caregivers know about Child Health Week and relate it to immunization and vitamin A supplementation. CAPA members were involved in mobilizing communities and distributing vitamin A, which resulted in a high turnout of mothers. According to the SMOH, the pilot 2004 Child Health Week in Abia state was successful and very appreciated by mothers because vitamin A was available and free of charge.

How the Program Outcomes Were Achieved in Abia State These outcomes were achieved using the same strategies as in Lagos and Kano, namely: Regular communication and advocacy to the state to present the ENA approach and get state input in adapting ENA to the Abia state context;

36

System strengthening with emphasis on building the capacity of the state, LGA, and PHC to integrate ENA into health services; and A strong community component to empower the community leaders and promoters to mobilize caregivers and mothers for the adoption of key ENA practices.

(See Table 11 for the details on the implementation.) The box below presents the milestones in ENA program implementation in Abia state.

ENA Milestones for Abia State 2000 2002 Integrated Child Health Survey Integrated Child Health Survey II Development and production of CBC messages and materials ENA approach presented to the state officials SMOH facilitators trained LGAs facilitators trained OICs and service providers trained CAPA members and CHPs trained Integrated Child Health Survey III

Aug 2002 Sep 2002 Nov 2002 Nov 2002Mar 2003 Nov 2002Jun 2003 Nov 2003

37

5. KEY SUCCESS FACTORS

Key factors in the design and implementation of the Essential Nutrition Actions program that contributed to its success in Nigeria are listed below and will be elaborated further in the next chapter on lessons learned. Working at the federal level developed an enabling policy environment while focusing on achieving results at the state level has been an effective approach. Maintaining flexibility in the design and implementation of the ENA interventions at the state level enabled adaptation to the state context. Involving academia (high-ranking professors) in the process of ENA design and implementation was critical in building a broad coalition for the endeavor. Involving end users in the design of CBC and training materials was helpful in raising their awareness and increasing their commitment to undertake the program. Initiating the formation of a Nutrition Partners Group at the national level has been instrumental in the national consensus and coalition to support ENA. Using convincing advocacy tools such as PROFILES has helped put nutrition on the priority list for policy makers and program planners at federal and state level. Building capacity in using PROFILES to build a national coalition for nutrition and continuously advocating for ENA has contributed to maintaining interest and momentum for nutrition. Having the SMOHs interest and commitment in the program has defined the outputs and outcomes and the initiatives to ensure sustainability. Encouraging the integration of ENA into health services has contributed to enhancing CBC activities with caregivers. Linking the health system with community structures has been helpful for the recognition and motivation of CAPA members and CHPs. Integrating ENA into non-traditional contact points has been effective in reaching out to increased number of caregivers. Empowering communities to mobilize caregivers and parents for improved feeding practices has contributed to enhanced knowledge and practices on EBF and ACF. Designing and producing CBC materials that take into account the reality of the program area and that are translated in the prevalently spoken language has been effective in supporting CBC with caregivers.

38

Using the practical and curative approach of PD/Hearth has convinced caregivers on the benefits of good nutrition and has engaged communities to prevent malnutrition. Being creative and using community measurement in PD/Hearth to monitor the improvement in the nutritional status of children has helped ensure community-level monitoring of the nutritional status of children who participated.

39

6. LESSONS LEARNED

6.1

Policy Environment PROFILES has been identified as a powerful advocacy tool that has helped raise the awareness at the federal and state levels on the impact of malnutrition on infant mortality and on the benefits of good nutrition for the national economy. PROFILES has led to coalition building and the creation of NFCN comprising key partners from various ministries and institutions involved in nutrition in Nigeria. The program has built the capacity of a group of experts in Nigeria in the use of PROFILES to continuously advocate for good nutrition for children. These experts include lecturers in the University and program managers in various states. As a result, the recognition of the importance of nutrition in various states has been developed. The continuous and convincing advocacy has led to 1) the introduction of vitamin A into NIDs and the development of vitamin A guidelines, and to 2) the recognition of ENA at the national level as an appropriate strategy to improving nutrition of Nigerian children. The National Plan of Action on Food and Nutrition intends to scale up ENA in all states and envisages integrating ENA in the training of health workers and community volunteers. However, given the magnitude and scope of malnutrition in children in the country, there should be more aggressive and consistent advocacy to improving children nutrition through effective approaches such as ENA. The action plan developed by the experts after the PROFILES workshop has not been implemented. Advocacy for improving the nutritional status of children has not reached all stakeholders at the federal and state levels, and nutrition programs have not yet been allocated increased federal and state resource allocation. Community leaders have not been targeted for advocacy; they are not always convinced of the benefits of good nutrition for their community and the country. Advocacy should target stakeholders at federal, state, and community levels.

6.2

ENA Program Implementation Approach Using vitamin A supplementation, PMTCT, and ENA as examples, the program has proven that influencing policy environment, strengthening the health system through capacity building and supply of relevant materials and tools, and partnering with communities to mobilize for behavior change were the key ingredients to combine for successful and sustainable program. The decision to start with policy formulation or system strengthening depends on the intervention and the level of interest of the federal or state authorities. No matter where a program decides to start, policy formulation, system strengthening, and partnering with communities for sustained behavior change should be linked and be mutually reinforcing. Scaling up of any intervention needs to be backed up by appropriate policy. Starting with policy formulation: To support vitamin A supplementation for children ages 659 months, the program focused on the policy level first, which helped integrate vitamin A supplementation into NIDs. The program later helped build capacity to

40

integrate vitamin A into NIDs and piloted Child Health Weeks as a possible transition strategy for vitamin A supplementation as NIDs is phasing out. The program also supported the development of HIV and infant feeding guidelines at the federal level, and has built the capacity of the states, OICs, and health workers on PMTCT/Infant feeding options. Starting with system strengthening: The design and implementation of ENA was state driven. From the beginning, the project presented the ENA approach to the states and secured the states input and approval. The program kept the federal level and the NPG regularly informed on the outputs and outcomes of ENA in the states through the Nutrition Partners Group meeting. The continuous communication and advocacy at the federal level has led to the recognition of ENA as an appropriate and effective approach for improving child nutrition in Nigeria and to incorporate ENA in the National Plan of Action for Food and Nutrition.

6.3

The Leadership Role and Ownership of the SMOHs The higher ENA is on the SMOHs priority list, the greater are the level of state ownership and outcomes. From the beginning of the project, the program has approached each SMOH to present the ENA approach and to secure the SMOHs input to shape the design and the implementation of ENA to the local context. The program asked the SMOH to review the ENA materials such as the training manuals and CBC materials to make them more culturally sensitive. This expanded the SMOHs role in each state in the design and materials of the ENA interventions. The SMOH also played a leading role in the stakeholders group for the state, which will contribute to sustainability and scaling up. The SMOH leadership role and ownership has varied considerably among states. Comparing the achievements of ENA in each state, the level of the SMOHs commitment and interest has defined the level of ownership of the program and the type of outcomes and initiatives. For example, in Kano State, in addition to EBF, ACF, and vitamin A supplementation, the SMOH expressed the need for support to address the appropriate nutrition and care of the malnourished child, which has led to the design and implementation of a very successful Positive Deviance/Hearth model. In addition, the Kano SMOH invited the Governor to the launch of Child Health Week, and his presence set the tone of the event and attracted the participation of other sectors.

6.4

System Strengthening Capacity building at all levels has been identified by all partners as one the major strengths of the program. The program has equipped all three states with a pool of state and LGA ENA facilitators who have good experience in training health workers and community volunteers. State facilitators have also gained experience in CBC material development. In all three states, the capacity of the health workers and community volunteer has been built to deliver ENA messages. Due to the lack of commodities and support supervision, ENA has not yet been fully integrated into the maternal and child health (MCH) services. However, some level of

41

integration of ENA into MCH services in all three states has occurred. Health workers have been trained to counsel caregivers on EBF and ACF. This confirmed that ENA interventions could be integrated smoothly into MCH services. ENA was also smoothly integrated into malaria and immunization services. Several mothers in Abia state have mentioned PMD as a source of information on ENA. The PMD training manual includes a section on the proper feeding of the sick child. A session on vitamin A supplementation was included into the NIDs training module. During Child Health Week, ENA, malaria, and immunization services were provided. The program did not build the capacity of partners to monitor and evaluate ENA activities. Furthermore, ENA outputs and outcomes were not included into the HMIS. ENA activities, outputs, and outcomes were not properly reported at the LGA and state. Including ENA interventions in the support supervision checklist and entering ENA outputs and outcomes in the HMIS are necessary for full integration of ENA in the health services. The link between the health system and the network of community volunteers through CAPA and CHPs has developed because both health workers and community volunteers understand the importance of working closely together. Health workers have acknowledged the contributions of CAPA members and CHPs in the dissemination of ENA messages in the communities, in conducting group education, and in distributing vitamin A supplement on Child Health Weeks. CAPA members and CHPs would like to meet with the OICs more regularly to help address the problems they encounter and to enhance their credibility and status in their communities.

6.5

Flexibility in Implementing ENA The program has successfully demonstrated that ENA can be effectively implemented in ecologically, culturally, and economically diverse environments such as Abia, Kano, and Lagos states. The project has adapted and implemented ENA to each states needs, food availability, cultural reality, and existing health system capacity.

6.6

Multi-Sectoral Collaboration Through the NPG, the project has involved other key partners from other line ministries at the state level through advocacy and training. However, other line ministries have not transmitted their new knowledge and skills on ENA to their agents in the field and have not resulted in the implementation of any ENA intervention in their sector. Other line ministries and sectors involved in the training on ENA have ongoing activities on the ground with mothers and fathers. The reason for involving them in ENA was to strengthen partnership, increase coverage to help enhance ENA impact. Multisectoral collaboration must be backed by policy changes to enable program implementers to include ENA interventions into their daily activities, or else this type of collaboration will not achieve the expected results. The project has not fully benefited from the collaboration from the private sector. Most health workers from the private sector have not attended the ENA training when they were invited. Using the National Plan of Action on Food and Nutrition for

42

leverage, the SMOH should ask the private sector to comply with the plan and to disseminate the ENA messages.

6.7

The Community-Based Approach (CAPA) The program was known in Nigeria for its successful CAPA model that demonstrates communities are important partners for improving child health in Nigeria. Because ENA promotes behavior changes that occur at the household level, the community component with its network of CAPA and CHPs has contributed significantly to the improved feeding practices in the last three years of ENA implementation in Nigeria. The CAPA model has been described as the successful innovation that should last forever. The CAPA model has also demonstrated that community volunteers can effectively assist in: Community mobilization for the use of health services; and The delivery of health services in the health facility (distribution of vitamin A supplementation and nutrition education during Child Health Weeks) and in the community (delivery of nutrition messages).

CAPA members and CHPs need and demand increased support and recognition to continue to mobilize caregivers for improved feeding practices. Regular support supervision from the OICs, supply in CBC materials, and involvement in other health events in the community will keep them updated in skills and knowledge, enhance their visibility, and maintain their momentum. The CAPA model should be expanded or at least harmonized with existing models. The community-based approach focuses its effort on the community comprising community-based organizations and structures, private sector providers, and public sectors providers. The program has demonstrated the effectiveness of the communitybased approach in improving infant feeding practices. However, the catchment area is not an administrative division; moreover, there are other models that are being used to deliver health services in Nigeria such as the ward system. The government should encourage development partners and the states to look into all models and harmonize them. The use of PD/Hearth for treating malnutrition has been a powerful means to demonstrate the effect of good nutrition. PD/Hearth should also be used for addressing and preventing malnutrition.

6.8

Communication for Behavior Change The project has compiled critical information and has gained a good understanding of the infant feeding practices in the three states that has led to the development of ENA messages and CBC materials that the states and other partners should capitalize on. However, the communication strategy of the project has neglected some caregivers (in-laws, and grandmothers) and fathers who are important players on issues related to family feeding practices.

43

All providers (from public and private sector) have not been trained on ENA, which led to the dissemination of conflicting messages. SMOH should urgently address the problem in order to avoid their negative effects on the feeding practices. The program has focused mainly on the use of interpersonal and traditional channels for the dissemination of ENA messages. The use of radio has been scanty and limited to special events such as Child Health Week. Radio could reach a larger population and reinforce the messages that are being disseminated through other channels. Radio broadcasts of ENA messages is an opportunity that each state should use to strengthen the dissemination of knowledge.

6.9

Scaling Up The program made an initial investment that should allow low-cost expansion of ENA in the three states using the existing resources and building on ENA lessons learned. Each state should use the existing pool of trained state and LGAs facilitators to scale up ENA activities in others LGAs. The program has already planted the seed for easy and rapid scale up of ENA in Nigeria. The three states where the project was located represent the three main different ecological and cultural regions of the country. The tools developed in each state for each level and the already tested CAPA model can be used to scale up ENA in the neighboring states.

6.10

Sustainability As the project is closing, the challenge is to engage the federal and state in scaling up ENA in the country. The NCFN has already taken up the responsibility of federal and state expansion of ENA. The PHC in the SMOH will be the ENA implementing agency in each state. Each state has recommended that each implementing partners in the state should build on ENA achievements and lessons learned. The LGA and the community component have been identified as where leverage should be made to scale up ENA in each state. However, the SMOH should ensure that sufficient support is provided to the LGAs, CAPA members, and CHPs.

44

7. THE WAY FORWARD FOR ENA IN NIGERIA

This section presents the outputs of the stakeholders meetings held at the national level in Abuja and in each of the three states of Abia, Kano, and Lagos. The stakeholders meeting was an important step for designing the future of ENA in Nigeria and involved the key stakeholders from all levels to reflect on the program achievements and the lessons learned and to plan for the future. The methodology was participatory. Credible Nigerian lecturers with international recognition in the nutrition arena facilitated the meetings. The way forward for each state or level represents their commitment to improve, sustain, and scale up ENA in Nigeria.

7.1

Next Steps for ENA at the National Level

Even before the end of the project, stakeholders at the national level acknowledged the projects innovative and successful approaches to improve child nutrition and incorporated these approaches into the National Plan for Food and Nutrition for scaling up. The FMOH recognized the need to scale up ENA to at 20% least of the states in order to achieve the Millennium Development Goals. The following are the steps the federal level agreed upon:

7.1.1

Policymaking The government will issue a policy statement for the integration of ENA into development programs. The FMOH will develop guidelines for the implementation and scaling up of ENA for review at the session/meeting of the National Council of Health. The FMOH will use ENA to reinforce nutrition in HIV/AIDS and PMTCT through EBF. The FMOH/NPHCDA will incorporate micronutrients on the essential drugs list. The NCFN will use PROFILES tools to continuously sensitize and mobilize for resource allocation and capacity building in ENA.

7.1.2

Community-Based Approach to Nutrition The NPHCDA will conduct integrated PHC catchment area planning and action on ENA and will conduct CHP training in PHC catchment areas. The NCFN will disseminate widely the Kano state PD/Hearth experience and the available ENA training and CBC materials/tools for replication. The NCFN through the State Commission for Food and Nutrition will support the CAPAC capacity building in developing proposals for credit facilities.

7.1.3

Integration of ENA into Health Services The NPHCDA will integrate ENA into health services through the training of health workers.

45

7.1.4

Information Dissemination The Federal Ministry of Information and National Orientation (FMINO) will organize mass media to propagate desired individual and institutional behavior change to sustain the implementation of ENA. FMINO will design a communication package on ENA with technical input from relevant partners.

7.1.5

Integration of ENA into Pre-Service Training The government will encourage University lecturers from various institutions in the country to include ENA into their curricula.

7.1.6

PD/Hearth FMOH will encourage field visits by other SMOHs to Kano to learn from the Kano PD/Hearth model.

7.2

Next Steps for ENA in the States

There are a lot of similarities among the next steps for ENA in Abia, Kano, and Lagos states. Each state will ask development partners to build on ENA achievements and lessons learned for developing a new nutrition program in the state.

7.2.1

Policymaking The SMOHs will continuously raise awareness on the importance of good nutrition for the country and the community by using PROFILES and targeting all sectors and community leaders. The SMOH will encourage and seek commitment from various sectors to buy in, integrate, and implement ENA within their ongoing activities to widen coverage and maximize impact.

7.2.2

System Strengthening The States will integrate ENA into existing services. SMOH facilitators will conduct supervision to help trained staff properly integrate ENA into MCH services, including minimizing staff transfers and inadequate means (logistics, funds, and materials). The SMOH will ensure that SMOH staff trained in ENA build the capacity of other staff in the health facility before being transferred. SMOH will keep track of trained health staff in ENA and encourage and support them to train other staff in ENA. The SMOH with LGAs will design an integrated supervision package (including ENA) for their staff at all levels, for example (e.g. supervision of LGAs by SMOH, supervision of PHCs by LGAs). By so doing, SMOH will enhance the smooth integration of ENA into various programs and will reduce the costs of the supervision. If necessary, the SMOH will seek technical and financial support from development partners.

46

The SMOH will work with development partners to include ENA indicators in the HMIS and will build the capacity of HODs, MCH Officers, and OICs in the use of data/information for planning and decision making.

7.2.3

Capacity Building Special effort will be made to reach staff from the private sector. SMOH will write a letter to the private sector to stress the importance of ENA for the FMOH, NPHCDA, and the state. This letter will invite the private sector to send participants to refresher training and to ensure that the knowledge and skills acquired will be shared with other staff members and will be integrated in the MCH services. The content of ENA training modules should be updated in the area of PMTCT. SMOH and LGAs facilitators to include updated information on PMTCT as a session during the refresher training for health workers, CAPA members, and CHPs. Each state should tap into the existing pool of trained facilitators and use existing materials to strengthen ENA capacities at the PHC and community levels. SMOH will seek the support from development partners to conduct annual ENA refresher training for health workers, CAPA members, and CHPs.

7.2.4

The Community-Based Approach (CAPA) CHP and CAPA/PLACO committee member services are well appreciated by the community. However, more support is needed to render their services more effective. SMOH with the support of development partners and other sectors will continue to support CAPA/PLACO activities. LGAs will provide additional resources to OICs to improve the supervision of CAPA/CHP activities. LGAs will explore the possibility of institutionalizing CAPA through community ownership and income-generating activities integrated into CAPA programs. LGAs will involve CAPA/CHPs in all child health and other development activities to increase their visibility, recognition, and motivation. The PHC departments will support the CAPAC/CHP structure and motivate the participants by supplying materials required for their activities.

7.2.5

Communication for Behavior Change Messages on ACF have been well practiced, but there is still some resistance to the practice of EBF. There is a need to continue reinforcing messages and to raise more awareness on the practice of EBF. SMOH and LGAs will review the ENA CBC strategy to target mothers-in-law, fathers, and all other influential community members for ENA messages and seek their support in promoting recommended practices. SMOH and LGAs will build the capacity of the media on ENA messages and engage them in disseminating effective ENA messages. SMOH and LGAs facilitators will organize refresher training for CAPA members and CHPs to strengthen their interpersonal communication skills and to teach them how to target mothers-in-law, fathers, and other influential community members.

47

SMOH will encourage other sectors to collaborate in the dissemination of ENA messages to ensure high coverage and increase impact.

7.2.6

Child Health Week Despite the late mobilization of the community, there was general consensus that the June 2004 Child Health Weeks were a success and caregivers responded massively. CAPA and CHP members were readily available for action. SMOH will continue to support LGA officials in on organizing the CHW on regular basis. SMOH will seek financial support from the private sector and development partners and will leverage state, LGA, and community resources. SMOH and partners should start planning for subsequent rounds soon to allow LGAs enough time to mobilize their resources. SMOH will make the CBC materials available on time. SMOH will engage LGAs to design and implement subsequent Child Heath Weeks and will identify other mechanisms that help maintain high the commitment and motivation of LGAs. The SMOH will ensure that OICs involve CAPA members and CHPs in community mobilization and in the micro-planning of activities. SMOH will commend the LGAs that have the highest achievements in coverage during Child Health Week.

7.2.7

PMTCT A great number of health workers and CHPs have not been trained in PMTCT. SMOH will seek financial support from partners to expand the training and the use of the PMTCT job aids. SMOH and partners will expand the training to health workers in the LGAs. SMOH and partners will expand the training down to CAPA Committee level.

7.2.8

PD/Hearth In Kano state, SMOH will use the experience gained in the PD demonstration sites to provide technical support to LGA and CAPAC/PLACO members to scale up PD/Hearth gradually to all LGAs. Additional training materials will be developed. FMOH will encourage field visits by other SMOHs to Kano to learn from the Kano PD/Hearth model.

7.2.9

Sustainability and Scaling up SMOHs will promote sustainability and scaling up by supporting LGAs in embarking on ENA, promoting successful initiatives,2 and recommending to other development partners to build on ENA achievements for nutrition programs.

One non-program LGA (Osisioma), learning from BASICS-supported LGAs, has used its own resources to implement ENA activities and to support Child Health Week in its communities.

48

There was a consensus at the state-level stakeholders meeting that the NCFN in each state will work closely with the state PHC to implement and scale ENA interventions in the state. SMOH and the NCFN will intensify the involvement of multi-sectoral ministries and departments at all levels in the planning, implementation, and monitoring of ENA interventions. SMOH and NCFN will coordinate ENA activities in the state. The SMOH will also support and provide guidance to the integration of ENA into partners on-going activities for those organizations interested in scaling up ENA interventions in their program areas. SMOH and partners will tap in the pool of trainers/facilitators to train health workers, CAPA members, and CHPs to scale-up ENA interventions in the state. SMOH will equip health workers, CAPA members, and CHPs with ENA CBC materials and job aids to deliver effective services. SMOH, LGAs, and partners will design a monitoring and evaluation plan and build the capacity on the use of data for planning and decision making.

49