Preventing malnutrition through house-to-house services in Kaduna: The ANRiN example

ANRiN logo

By Philip Yatai

LITTLE Naja’atu Gambo of Albarkawa community, Kwarbai B Ward, Zaria City in Zaria Local Government Area of Kaduna State was one year old when her mother died and as such, did not get sufficient breast milk.

Her aunt, Mrs Fatima Aliyu, who raised her, said that Naja’atu at two years old was so skinny and too weak to do anything by herself.

“She cannot speak or crawl, but only sits in one place. Even crying was a struggle for the little girl who looked unhealthy from all indications.

“But this has changed when she was enrolled for the house-to-house delivery of nutrition services under the World Bank-supported Accelerating Nutrition Result in Nigeria (ANRiN) project.

“Naja’atu, who is now two years and two months old, is now learning how to speak, how to crawl and can play by herself,” said her aunt.

Two-year old Naja’atu Gambo with her aunt, Mrs Fatima Aliyu

Similarly, a year and a month old Sauwama Haruna at seven months was very skinny, quiet, and inactive, but witnessed a remarkable transformation when enrolled in the project.

“The now agile and playful little Sauwama started walking at 10 months,” said her 30-year-old mother, Mrs Faiza Haruna.

Also, Mrs Amina Awwal, the mother of one-year Muhammad Awwal, said her little boy was always sick, weak and could not crawl, until he started receiving the services.

Awwal said that her little boy was only not growing stronger by the day, but now crawling, learning how to stand and the recurrence of illness significantly reduced.

These children were among the more than two million pregnant and lactating women, adolescent girls and children under five years reached with cost-effective nutrition services in Kaduna State under the ANRiN project.

One-year Muhammad Awwal with his mother, Mrs Amina Awwal

The disturbing indices of malnutrition in Kaduna State and the need for cost-effective intervention  

Children under five years constitute 1.9 million, representing 19.2 per cent of the estimated 10 million population of the state, 22.1 per cent of which are stunted, according to Nigeria Demographic and Health Survey 2018.

The survey also indicates that 1.1 per cent of the children are wasted, 7.5 per cent underweight, while 17.2 per cent are born with low birth weight.

Similarly, the National Nutrition and Health Survey, 2018 shows that 60.2 per cent of women of reproductive age are anaemic while 44 are thin.

The report further shows that 1.5 of women of reproductive age are of short stature, while 8.2 per cent of them are acutely malnourished.

At the national level, Nigeria has very high rates of malnutrition with stunting, a measure of chronic malnutrition and micronutrient deficiencies, constituting the highest burden since 2008.

According to the World Bank, the long-term nutritional problem in the country shows that two out of every five children under five years of age suffer from chronic malnutrition.

This translates into 14.5 million Nigerian children at risk of either dying or not developing to their full potential.

Micronutrient deficiencies– mainly in vitamin A, iodine, iron, folic acid, and zinc – are a serious problem and despite their high cost-effectiveness, coverage rates of micronutrient supplementation and fortification remain generally low.

It is estimated that 30 per cent of Nigerian children and 20 per cent of pregnant women are Vitamin A deficient, while 76 per cent of children and 67 per cent pregnant women are anemic.

Why nutrition intervention matters  

Maternal and child undernutrition is estimated to be responsible for about 45 per cent of child mortality and 11 per cent of the global disease burden.

Malnutrition, in all its forms, imposes unacceptably high costs – direct and indirect – on individuals, families and nations.

According to a technical brief, “The Cost of Malnutrition: Why Policy Action is Urgent” by the Global Panel on Agriculture and Food Systems for Nutrition, malnutrition is a major impediment to achieving the 2030 Sustainable Development Goals.

The brief estimated impact on the global economy could be as high as US$3.5 trillion per year, or US$500 per individual.

It highlights that adult earnings are reduced by 2.4 per cent for every 1 per cent loss in potential attained height and affects human capital, leading to losses in national economic productivity and economic progress.

Further costs are decreased cognitive ability, poor school performance and educational outcomes, compromised adult labour productivity, and increased health care costs.

Overnutrition also bears a significant cost; at least 2.6 million people die each year as a result of being overweight or obese.

The recent Lancet series on early childhood development estimates that, every year, Nigeria loses about three per cent of its GDP as a result of not addressing the developmental needs of children in the first 1000 days of life.

At the individual level, chronic malnutrition in children is estimated to reduce a person’s potential lifetime earnings by at least 10 per cent.

Mr Sunday Okoronkwo, Executive Secretary, Civil Society Scaling Up Nutrition in Nigeria (CS-SUNN) also said that investment in nutrition would build human capital, adding that early nutrition programmes can increase school completion by one year.

Okoronkwo equally said that investment in the sector would raise adult wages by five to 50 per cent, stressing that children who escape stunting were 33 per cent more likely to escape poverty as adults.

“Also, reduced stunting among children under five years can increase GDP by four to 11 per cent in Asia and Africa,” he said.

Providing cost-effective nutrition services to households in Kaduna communities

Responding to the challenge, the five-year World Bank-supported ANRiN project was designed to increase utilisation of quality, cost-effective nutrition services for pregnant and lactating women, adolescent girls, and children under five years of age.

Two non-state actors – eHealth Africa and the Society for Family Health (SFH) were contracted in 2021 to deliver integrated Basic Package of Nutrition Services (BPNS) and Adolescent Health Services (AHS) to the targeted groups at community level.

Other beneficiaries are also being reached at health facilities and currently the services are being provided in 100 facilities across 12 LGAs in the state.

The BPNS involves increasing knowledge of mothers and caregivers of children from zero to 23 months of age on improved behaviours related to maternal, infant, and young child feeding practices.

Other services include provision of micronutrient powders to children from six to 23 months to improve the quality of complementary feeding and iron-folic acid tablets to pregnant women during pregnancy and counseling during ante-natal care sessions.

There is also the provision of intermittent preventive treatment for malaria during ante-natal care to pregnant women, zinc and oral rehydration solution for treatment of diarrhea among children from six to 59 months.

The project also provides semi-annual vitamin A supplementation to children from six to 59 months of age and semi-annual de-worming among children from 12 to 59 months.

The AHS on the other hand, involves counseling for increased birth spacing amongst married women of reproductive age, particularly adolescent girls, 15 -19 years and provision of a full range of short-term and long-acting reversible birth-spacing methods.

Interpersonal Communication Agent administering Vitamin A to children during service delivery at community level

One of the Interpersonal Communication Agents (IPCA), Ms Samira Ahmed, Limancin Kona Ward, Zaria LGA, who delivered the services directly to the beneficiaries in their homes, described her experience as “life touching”.

“I am going house to house to deliver the services to the beneficiaries, some of the services like Vitamin A and deworming are every six months, while iron-folic acid for pregnant women is every month,” she said.

Her supervisor, Ms Salaha Sambo, Adolescent Health Supervisor, SFH, said that each of the IPCA was given a specific number of communities to provide the services and make referrals to health facilities.

“We are working with community structures like Village Head and other community leaders to ensure that the IPC are doing their job and delivering the services to the targeted beneficiaries.

“The project has also put in place a Grievance Redress Mechanism in communities for beneficiaries to report concerns, complaints, dissatisfaction, and claims or make requests or enquiry,” she said.

Impact of the project on the targeted population

The Project Manager, Dr Zainab Muhammad-Idris, described the ANRiN project as a “key preventive measure” that helps to stem the tide of malnutrition in the state.

Muhammad-Idris said that so far, more than 3.6 million contacts of the targeted groups across the 23 Local Government Areas of the state have been reached with BPNS and AHS in their homes and health centres.

According to her, the objective of the project is to reduce chronic malnutrition, maternal and child mortality rates and in the long run, increase school completion, performance and improve labour force productivity.

“Through strategic partnership, ANRiN is reaching more children and women and saving lives by providing nutrition services to children under five years, and adolescent mothers during pregnancy.

“2022 has particularly been a remarkable year for us because we have been able to reach over three million beneficiaries through the non-state actors and healthcare facilities.

“We will make further inroads this year to ensure that all the beneficiaries enrolled received the complete service packages.”

She added that the project also carried out stakeholders’ mapping of all nutrition programmes and interventions being implemented by partners and government ministries, departments and agencies, and local councils.

She said that the mapping has become a reference document for all partners in deciding where a nutrition intervention should be sited in the state,” she said.

“The project also secured 2.7 million dollars (about N1.1 billion) in 2022 for procurement of Ready-to-Use Therapeutic Food (RUTF) for the treatment of children with severe acute malnutrition,” she added.

RUTF is an energy-dense, mineral- and vitamin-enriched food specifically designed to treat Severe Acute Malnutrition.

From Left: Project Director, eHealth Africa, Accelerating Nutrition Results in Nigeria (ANRiN) Project, Dr Aminu Abubakar; Project Manager, ANRiN Kaduna State; Dr Zainab Muhammad-Idris; Director Public Health, Kaduna State Ministry of Health Dr Hajara Kera; and Project Director, Society for Family Health ANRiN Project, Mr Ibrahim Mohammed, after a one-day Quarterly Stakeholders Meeting on ANRiN Project in Kaduna

The project’s Monitoring and Evaluation Officer, Mr Musa Abubakar, said that out of the 3.6 million contacts reached between July 2021 to Jan. 22, 2023, 815,483 children received Vitamin A and 787,734 received deworming tablets.

He added that 320,155 children received micronutrient powder, 564,028 received zinc/ORS while 477,334 mothers and caregivers of children were counselled on MICYN practices.

“Also, 295,144 pregnant women received iron folic acid, 261,295 others received intermittent preventive treatment for malaria during ante-natal care, while 108,783 adolescent married women received short-term and long-acting reversible birth-spacing methods,” he said.

Also, the State Nutrition Officer, Mrs Ramatu Haruna, said that the number of children under five years dying of malnutrition has decreased from 323 in 2019, to 142 in 2020, and further dropped to 58 in 2021 and 37 in 2022.

The Multiple Indicators and Cluster Survey 2021 also shows some remarkable improvement in exclusive breastfeeding practice which increased to 41.1 per cent in 2021 from the 19.7 per cent recorded in 2017.

The report also indicates that children six to 23 months who received minimum dietary diversity had also increased to 28.4 per cent from 15.8 per cent.

Also, at the recent event held in Abuja, Kaduna State emerged the ‘Best Performing State’ out of the 11 states assessed for the ANRiN project’s community-based nutrition service delivery.

The state emerged as the Best Performing State on Social Behavioural Communication; Partner Mapping and Coordination; Safeguards; and the Most Innovative State.

Kaduna State also emerged the Second Performing State on Fiduciary, and Service delivery at PHC level, while the project manager received the Question Asker Award and Note Taker (documentation) Award.

Leveraging faith-based institution for social behavioural change communication  

On Social Behavioural Change Communication (SBCC), the Project Manager said that beneficiaries, particularly the mothers and caregivers of the children were being counselled on how to adopt good Maternal, Infant and Young Child Nutrition (MICYN) practices.

She added that the SBCC also involves secondary targets including traditional and religious leaders, husbands of the women, fathers of the children and other community members through various communication channels and faith-based approaches.

This, according to her, is very important because everyone has a role to play in contributing to promoting breastfeeding and other MIYCN practices.

To this end, the ANRiN project contracted the Centre for Communication and Social Impact (CCSI) to implement the faith-based component of the SBCC.

Malam Ibrahim Abubakar, State team Lead, CCSI, said that the centre was leveraging on the dignity of faith actors – religious leaders, faith-based groups, organisations, schools, and faith-based institutions to raise awareness on MICYN practices.

Abubakar said that the messages focus on five key areas namely maternal nutrition, early initiation of breastfeeding, exclusive breastfeeding, complementary feeding, and hygiene and sanitation.

According to him, the strategies of demand creation include sermons during services in Church programmes and Friday Juma’a prayer, and other occasions like naming ceremonies, weddings, graduations, and other public gatherings.

“So far, we have trained 115 pastors and imams, and 108 Community Volunteers to assist them and in December 2022 alone, we have reached an estimated 131,000 people with MIYCN messages.

“They include pregnant women, married and unmarried men, women with children under five years, breastfeeding mothers, and mother in-laws.”

State team Lead, Centre for Communication and Social Impact (CCSI), Malam Ibrahim Abubakar; Rev. Giwa Kanda of the Assemblies of God Church, Television, Kaduna; Senior Mobilisation Assistant, CCSI, Mr Sunday John; and ANRiN Community Volunteer, Wheapadu Emmanuel, at Assemblies of God Church, Television, Kaduna.

One of the clerics, Chief Imam of Kaduna Polytechnic, Abubakar Yusuf, acknowledged the prevailing ignorance among mothers and caregivers on the benefits of exclusive breastfeeding and other complementary feeding practices.

Yusuf said he was using the mosque and during naming ceremonies, marriages, and other public gatherings to enlighten mothers, caregivers, including fathers on MICYN practices.

“It was difficult at the beginning because of people holding on to their cultural practices but using religious perspective and provisions in the Quran has helped in changing the mindset of the target groups.

“Currently I am receiving calls from mothers and fathers seeking for more information on what to do in respect of appropriate feeding of the child when in doubt,” he said.

Chief Imam of Kaduna Polytechnic, Abubakar Yusuf

Also, Rev. Giwa Kanda of the Assemblies of God Church, Television, Kaduna South LGA, said the ANRiN project has increased his knowledge on the importance of breastfeeding and adequate complementary feeding.

Kanda said that the faith-based initiative was providing critical information to parents and caregivers using the pulpits during church service and other religious gatherings.

“Due to ignorance, some parents and caregivers link the death of children to witchcraft, but this is changing due to access to critical information on how to adequately feed children,” he said.

Addressing challenges for better results

Stakeholders noted that while progress has been recorded over the years, there is much that needs to be done considering the retrogression in some of the nutrition indicators in the MICS 2021 report.

CS-SUNN has said that Kaduna State needs N6.4 billion to treat 96,488 severely malnourished children in the state, noting that funding remains the critical challenge to addressing malnutrition in the state.

Stakeholders pointed out that although the price of addressing malnutrition can be huge, evidence shows that the cost of doing nothing is immeasurably greater.

They call for more attention to the costs of inaction and urges policymakers, particularly those in economic planning and finance ministries, to invest in nutrition and in actionable food and agriculture policies.(NAN)

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