unicef nigeria final report-designed

SMART Management of Malnutrition Using Smartphones to Improve Children’s Health in Nigeria

SMART Management of Malnutrition Using Smartphones to Improve Children’s Health in Nigeria

Authors

Harpreet GILLIfeyinwa (Uju) IDIGO Michelle KIMAlana NGOHDiptesh SONIKiyeon YOON

May 2014

Acknowledgements

We would like to thank our advisor Eric Cantor for his guidance and advice throughout the project; his expertise was a constant asset to our team. We are also grateful to Eugenia McGill and Ilona Vinklerova of Columbia University’s School of International and Public Affairs (SIPA) for helping ensure that our project ran smoothly and within budget.

The support from Stanley Chitekwe, Chief of Nutrition at UNICEF Nigeria, was essential over the past eight months in achieving our objectives. We sincerely thank the entire nutrition team in Abuja, including Bulti Assaye, Christine Kaligirwa, Umesh Kattel, Pragya Mathema, Dr. Bamidele (Davis) Omotola, Munsyi Seksianto, and Robert Johnston, as well as everyone who facilitated our work in Abuja, including Chinedu Nwosu, Peter Oladele, and Michael Shobo.

We would also like to acknowledge the vital role of the Federal Ministry of Health (FMOH) in leading the implementation of CMAM and sincerely thank the Ministry for being a great resource of information during our first visit to Nigeria. In addition to the Nigerian Government and UNICEF Nigeria, we would like to recognize several other CMAM programme partners we consulted with, including Save the Children, Action Contre La Faim (ACF) and the World Health Organisation (WHO), whose experiences in the field helped inform the direction of this project.

In New York, we would like to extend our gratitude to the UNICEF Innovations team, including Mac Glovinsky and Asch Harwood. Their input was crucial in refining the scope of the project and ensuring its technical feasibility. Nick Oliphant of the UNICEF Health and Monitoring and Evaluation team was also very helpful in sharing best practices on how to make this project sustainable. Prabhas Pokharel of Columbia University’s Sustainable Engineering Lab provided invaluable input on Formhub functionalities and coding issues with Open Data Kit (ODK). Finally, M.E. Hoagland’s assistance with the design of the final report was much appreciated.

ACKNOWLEDGEMENTS

SMART Management of Malnutrition Using Smartphones to Improve Children’s Health in Nigeria3

Table of Contents

I. List of Abbreviations.......................................................................................................5II. Executive Summary.......................................................................................................6III. Introduction..................................................................................................................8IV. Background.................................................................................................................9V. Research Objectives...................................................................................................14VI. Rationale...................................................................................................................15VII. Platform Design.........................................................................................................22VIII. Output.....................................................................................................................24IX. Recommendations.....................................................................................................29X. Conclusion.................................................................................................................35XI. Bibliography...............................................................................................................37XII. Appendices..............................................................................................................39

TABLE OF CONTENTS


Table of Contents List of Abbreviations

ACF - Action Contre la FaimCHEW - Community Health Extension WorkerCHW - Community Health WorkerCMAM - Community Management of Acute MalnutritionCV - Community VolunteerDHIS2 - District Health Information Systems 2FMOH - Federal Ministry of HealthITP - Inpatient Therapeutic ProgrammeIYCF - Infant and Young Child FeedingLGA - Local Government AreaMAM - Moderate Acute MalnutritionMDG - Millennium Development GoalMNCHW - Maternal, Newborn and Child Health WeeksMUAC - Mid-Upper Arm CircumferenceNBS - National Bureau of StatisticsNFP - Nutrition Focal PersonNPC - National Planning CommissionNPHCDA - National Primary Health Care Development AgencyOIC - Officer in ChargeODK - Open Data KitOTP - Outpatient Therapeutic ProgrammeRUTF - Ready to Use Therapeutic FoodSAM - Severe Acute MalnutritionSNO - State Nutrition OfficerSIPA - School of International and Public AffairsSMART Methodology - Standardised Monitoring & Assessment of Relief & Transition MethodologySMOH - State Ministry of HealthSMS - Short Messaging ServiceUNICEF - United Nations Children’s FundWHO - World Health Organisation

I. LIST OF ABBREVIATIONS


Executive Summary


II. EXECUTIVE SUMMARY

Since its launch in 2009, the Community Management of Acute Malnutrition (CMAM) programme has experienced considerable success in Nigeria. By harnessing the power of the community in tackling malnutrition, CMAM has treated nearly 500,000 children in approximately 500 primary health care facilities across 11 states.

With an anticipated reach of one million children by the end of 2014, CMAM’s progressive expansion will require a robust monitoring framework that ensures its continued quality and success. Despite this, the current monitoring process is neither standardised nor sufficient in meeting the programme’s growing logistical and planning needs. Bottlenecks exist at crucial levels of the data management system as significant time and resources are spent filing paper- based forms and generating reports based on data that is often of suboptimal quality.

In partnership with UNICEF, a team from Columbia University has initiated a framework to standardise and facilitate the monitoring of CMAM using new mobile technology. By incorporating smartphones into the CMAM process, UNICEF and Columbia aim to achieve three main goals:

1. Monitor data on a real-time basis 2. Assure the quality of CMAM performance data 3. Analyse data to inform actions and programming

The Columbia University team worked extensively with UNICEF Nigeria’s Nutrition Division to assess the feasibility of smartphone-based monitoring, and subsequently developed a holistic set of smartphone monitoring tools using Open Data Kit (ODK) and Formhub software.

The use of smartphones in the monitoring process can facilitate quicker data analysis and collection, which will allow UNICEF and its partners to respond to issues in a more timely and adequate manner. With a robust monitoring system, problems in underperforming states and regions would be better identified and addressed. In the long term, this process will allow staff to assess key trends to improve the management of the programme on a broader scale.

While smartphone technology provides a unique opportunity to enhance CMAM monitoring, the Columbia University team has identified three key constraints that must be addressed in order for the project to be implemented successfully:

1. Length of the survey 2. Team capacity 3. End-user actionability To prevent survey fatigue and ensure the quality of data, the Columbia University team suggests that UNICEF Nigeria create two different sets of monitoring tools, one short form to collect essential data on key performance indicators every fortnight, and a longer form to be conducted biannually that would gather more detailed information on important, but less urgent data.

Executive Summary


As the implementation of a replacement system requires considerable technological capacity and full-time staff are already stretched by their current workload, the team also advises that UNICEF Nigeria hire at least one new consultant to manage the implementation process. Ideally, this person would be based in Abuja and work closely with state-based consultants in the field to strengthen the monitoring process via smartphones at the local level.

For this initiative to achieve sustainability, the data collected using this new methodology must be actioned by end-users, including state and federal-level supervisors. From the onset of imple-mentation, UNICEF must communicate the benefits of the new system and solicit feedback to secure their buy in. Moreover, the creation of a dashboard with meaningful visuals would make it easier for supervisors to digest the data and take action. To this end, the team recommends UNICEF Nigeria explore the option of using District Health Information Systems 2 (DHIS2), a data aggregation system used by national governments across the globe, including Nigeria.

lf the constraints outlined above are addressed, smartphones could provide UNICEF Nigeria with an opportunity to improve its current monitoring and evaluation process and display technolog-ical leadership in the development field. While initial costs may be high, a smartphone- enabled monitoring process could pioneer the way for similar projects in other sectors. As smartphones become more common in programme implementation, and as coverage and usage increases with greater technological development, less resources and staff training would be required.

Given this positive outlook, the Nutrition Division in UNICEF Nigeria should seek resources and forge partnerships with UNICEF global headquarters and other programme partners with the aim of adapting and replicating the potential successes of this nascent project in other sectors and countries. The knowledge spillovers from such a system could improve programme imple-mentation and monitoring for UNICEF projects across the globe, cementing the organisation’s place as a centre of excellence for innovation in international development.

Introduction

III. INTRODUCTION


Working with development partners such as UNICEF, the Nigerian government has launched a number of interventions to improve the health and nutrition status of the population. One such initiative is the Community-based Management of Acute Malnutrition (CMAM) programme, which treats infants and young children with acute and severely acute malnutrition through a network of primary health care facilities and community-based volunteers.

With the proliferation of new mobile technologies taking hold in recent years, UNICEF Nigeria saw great potential in leveraging smartphones1 to improve the implementation of CMAM, the largest nutrition programme that the international development agency supports. In November 2013, UNICEF Nigeria asked our Columbia University team to assess the feasibility of using smartphone technology to improve the monitoring and evaluation process of the programme and develop a new tool that could ultimately be piloted in selected states.

During a preliminary research visit to Abuja in January 2014, members of the team met with UNICEF Nigeria’s Nutrition Division, federal government officials and programme partners to understand the current systems for collecting and analysing nutrition data, and for monitoring large-scale nutrition projects such as CMAM. The feasibility of adapting a smartphone collection tool was analysed based on the potential benefits and constraints observed during this trip.

After further consultations with UNICEF Nigeria and UNICEF’s Innovation team in New York, the scope of the project was narrowed to leveraging smartphones to enhance the monitoring process of CMAM, which had been conducted primarily with pen and paper to date.

Using Formhub, the back-end platform service developed by Columbia University’s Sustainable Engineering Lab (formerly known as the Modi Lab), the team developed a mobile monitoring tool equipped to collect a comprehensive set of supervision information, including nine different monitoring tools that examine the performance of CMAM against set objectives, as well as the efficiency of the programme’s overall supply chain.

These monitoring tools were tweaked during a follow–up visit to Abuja in March 2014. At this time, Columbia University team worked with UNICEF Nigeria Nutrition Division to refine the tools, lay out a conceptual framework, and develop training resources that would help prepare the local team for the pre-testing phase that would begin in April 2014. The recommendations set forth in this report incorporate our research findings from the past six months of engagement as well as feedback from the pre-testing period in the states of Kano, Kebbi and Katsina.

This report outlines the work of the Columbia University team in facilitating the process of smartphone implementation for the monitoring and surveillance of CMAM. The following pages will detail the work of the Columbia University team, the benefits of implementing such a system, and provide recommendations on how to best proceed with the process moving forward.

In this document, the word “smartphone” refers to both phones and tablets.1

1

Introduction Background


IV. BACKGROUND

i. NigeriaAs the continent’s most populous nation and largest economy, Nigeria is often referred to as the ‘Giant of Africa’. A major producer and exporter of crude oil and petroleum, most recent figures show the country’s GDP exceeding $510 billion. Nigeria is as rich in human resources as it is in natural resources, with a diverse population of nearly 170 million people representing 250 ethnic groups and more than 500 native languages. The Hausa, Yoruba and Igbo are the country’s largest ethnic groups, making up more than 65% of the total population.2 Such demographic complexity is not without obstacles:

Nigeria’s history is marred by the scars of religious and ethnic fighting, the most notable of which is the Biafran war (1967 – 1970) and more recently, a number of deadly terror attacks carried out by the Boko Haram militant group. Plagued by clashes between the predominantly Muslim north and Christian south, the country’s tensions are exacerbated by marked differences in key development indicators, including health and nutrition.3

ii. MalnutritionMalnutrition can be broadly divided into three categories: stunting, wasting and micronutrient deficiencies. Children with stunting are short in height for their age and often experience complications in the development of their mental faculties. Marasmus, or wasting, is a severe form of malnutrition characterised by energy deficiency and low weight-to-height ratio, while micronutrient deficiencies, the result of low Vitamin A intake, can lead to blindness or visual impairment.

The World Factbook.” Last modified April 23, 2014. https://www.cia.gov/library/publications/the-world- factbook/geos/ni.html“BBC News - Is Nigeria on the brink after north-south clashes?” Last modified January 13, 2012. http://www.bbc.com/news/world-afri-ca-16544410.

2

3

Background

National Guidelines for Community Management of Acute Malnutrition. Federal Ministry of Health, Family Health Department, Nutrition Division Nigeria., 2011.Ibid.Ibid.

4

5

6

Source: UNICEF

While malnutrition is a global affliction to which more than 50% of deaths under 5 years of age can be attributed, Nigeria is among 20 countries that account for 80% of all undernourished children in the world.4 UNICEF has put the number of children in Nigeria under the age of five and affected by severe acute malnutrition (SAM) at 20 million annually,5 with one million of these cases resulting in death each year.

As <Figure 2> suggests, the problem does not affect all parts of Nigeria equally. There is a notable degree of variation between the levels of malnutrition in the north compared to levels in the south. Information gathered from the Nigerian Demographic Health Survey in 2008 showed that 41% of children under five years old showed symptoms of stunting, while this rate exceeded 50% in the Northeast and Northwest states bordering Niger and Chad that form part of the desert Sahel region.6


Figure 2: Distribution and Impact of Malnutrition in Nigeria

Background Background

n.d. “Stanley Chitekwe - Chief of Nutrition - UNICEF Nigeria.” Podcast audio. n.d. https://soundcloud.com/unicefafrica/stanley-chitekwe-chief-of.Aminu Abubakar, “Nigeria braced for potential food crisis as forecasters predict short rainy season,” TheGuardian Global Development. March 26, 2014. http://www.theguardian.com/global- development/2014/mar/26/nigeria-food-crisis-short-rainy-season. Accessed April 14, 2014.

7

8


Complicating Factors of Malnutrition Low nutritional diet: The deterioration in children’s nutrition is often seen between the ages of 6-24 months, beginning at the stage when mothers move away from exclusive breastfeeding and start to add complementary foods. Oftentimes, mothers will only feed their children a cereal- based porridge for each of the day’s meals. Malnutrition can result from the lack of variety, inadequate quantities, and low nutritional value of these foods.

Periodic droughts: A major factor affecting mothers’ abilities to feed their children is the fact that the Sahel region in Nigeria experiences drought every two years.7 This can have a serious impact on agricultural output and lead to food insecurity, especially in rural areas. Due to its desert topography, states in the north have consistently lower precipitation levels than the South, making them more vulnerable to climate changes.

Sectarian violence: The increasing sectarian violence plaguing the country is another important factor exacerbating the problem of malnutrition in Nigeria. This is especially true in the northern states, where the unrest has forced some farmers to abandon their land and created food insecurity among communities who heavily depend on agriculture for their livelihoods. The UN estimates that more than 300,000 people have been displaced in the north-eastern states of Borno, Yobe, and Adamawa since a state of emergency was imposed in May 2013.8


Background

Umunna, L. “Securing Private Sector Commitment in Nigeria | Sun Business Network.” Accessed April 25, 2014. http://sunbusinessnet-work.org/news-items/securing-private-sector-commitment-in-nigeria/Ibid.UNICEF. “UNICEF - At a glance: Nigeria - Community-based treatment for malnutrition earns praise in northern Nigeria.” Accessed April 25, 2014. http://www.unicef.org/infobycountry/nigeria_69907.htmlStanley Chitekwe, interview with Obianuju Idigo et al., Abuja, March 24, 2014.

9

10

11

12

Developmental Impact of MalnutritionThe devastating impact of malnutrition is felt beyond the tragedy of parents who lose their children as a result of the condition and its complications. It is estimated that the Nigerian economy loses US$3 billion annually from productivity losses due to stunting as well a further US$2.2 billion from key mineral deficiencies in expectant mothers.9 In describing the business rationale for investing in nutrition initiatives, the Nutrition Society of Nigeria has highlighted the fact that poor nutrition is associated with low productivity, negatively impacting the economic development of the nation and the achievement of the United Nations’ Millennium Development Goals (MDGs).10

iii. CMAM: A Community-Based Approach to Addressing MalnutritionIt was with these factors in mind that the Nigerian government, in collaboration with UNICEF and other programme partners, launched the CMAM programme in 2009.

Prior to the implementation of the programme, children suffering from SAM had to be taken to far-off hospitals or health clinics for treatment. This often resulted in a huge financial burden on their families that could potentially discourage parents to seek treatment for their children in the first place. The programme’s primary goal therefore, was to decentralize treatment facilities to the communities where they were needed so that treatment for malnutrition could reach more children in a timely manner.

The fundamental concept of CMAM is to leverage the knowledge and social bonds of the community to address the barriers to seeking treatment for malnutrition. As a result, the community-based approach ensures that any cultural, ethnic or religious sensitivities are taken into account in the identification and treatment of both moderate and severe acute malnutrition. Through the CMAM network, 500,000 children have been treated since 2009,11 and an estimated one million children will be treated by the end of 2014.12

This community-based approach was made possible with the advent of ready to use therapeutic foods (RUTF), a peanut paste enriched with key minerals and vitamins which can be directly administered to children without adding water or cooking. RUTF provides sufficient nutrient intake for the child to completely recover. Experts from WHO, UNICEF and the UN Standing Committee on Nutrition met in Geneva on 21-23rd November 2005 and published a report

Prudhone, Claudine et al. “WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children.” Accessed April 25, 2014. http://www.who.int/nutrition/publications/severemalnutrition/FNB_0379-5721.pdf?ua=1)

13


Background

recommending that implementing these community-based interventions could transform the lives of millions of severely malnourished children.13

As the programme reaches more children and families, it is crucial that the quality of service does not erode with scale. The proposed smartphone-based system designed by the Columbia University team, detailed further in this report, will help ensure that CMAM’s implementation process is managed properly over the next phase of its growth so that communities in need continue to be well-served.

Background

Research Objectives

14 SMART Management of Malnutrition Using Smartphones to Improve Children’s Health in Nigeria

V. REARCH OBJECTIVES

i. Research QuestionCan smartphone technology improve the delivery of CMAM and if so, how can it be best integrated into the programme’s current data management process?

ii. Research MethodologyIn order to determine the above, the Columbia University team: 1. Reviewed the benefits and shortcomings of adapting mobile tools for CMAM monitoring.

2. Identified challenges and constraints in the current data management process. 3. Explored the best tools and methodology to implement smartphone-enable monitoring.

To meet the research objectives, the Columbia University team utilised various methods of research including desk research, stakeholder interviews and the exploration of new mobile data collection platforms and tools.

• Quantitative and qualitative data collection was used to 1) evaluate the current practices of CMAM reporting and supervision process and 2) assess the feasibility and the cost of implementing the smartphone monitoring of CMAM.

• More than 20 in-person and phone interviews were carried out in Nigeria and New York to determine the capacity and constraints of stakeholders.

• Collaborated with UNICEF Innovation team and Columbia University’s Sustainable Engineering Lab to explore the best option and specific functions of new mobile tool.

During the preliminary stage of the project, a problem tree <Appendix 1> was created to clearly frame the direction of research objectives and to narrow the scope of the project.

Research Objectives Rationale

VI. RATIONALE

National Guidelines for CMAM. FMOH, Nigeria. 2011.14


i. Current PracticesIn order to understand the potential benefits and challenges of reforming the current monitoring system using smartphones, the Columbia University team first assessed the current practices of the CMAM programme in Nigeria, as well as other nutrition programmes.

StakeholdersA number of stakeholders are involved in reporting, monitoring and analysing CMAM data. By identifying relevant stakeholders involved and analysing their roles, the team gained a better understanding of the CMAM implementation process, structure and shortcomings. A number of these key stakeholders were consulted for the purpose of this report, some of whom are outlined in <Appendix 2>.

Reporting: OverviewReporting structure of CMAM is a bottom up process where health facilities record key performance indicators of the beneficiaries. <Figure 3> outlines the current flow of the data management from the community to the national level.14


UNICEF. “Dashboard.” Accessed April 20, 2014. http://sam.rapidsmsnigeria.org.National Guidelines for CMAM. FMOH, Nigeria 2011 Also commonly referred to as Stabilization Care (SC).

15

16

17

There are currently 495 health facilities in Nigeria. At each facility, there are several health workers involved with one Officer in Charge (OIC) who compiles and sends the weekly reports of all patients to the Local Government Area (LGA). Each LGA represents 6-7 health facilities. After receiving the reports, the LGAs send the reports to the state level at the end of each month. The states then send the reports to the Federal Ministry of Health (FMOH).

The UNICEF Nigeria also receives the monthly report where the Nutrition Division collates the report summary into a single Excel file and codes into a traffic-light system that identifies progress for each of the four key performance indicators disaggregated by state and LGA. Reporting of the performance indicators is done manually through pen-and-paper method on a regular basis.

Increasing quality and shortening the duration of the reporting system is essential for an accurate evaluation and swift attention to address the programme needs at health facilities. While labour intensive, reporting is done more systematically than monitoring.

Reporting: RapidSMSIn efforts to strengthen the reporting process of CMAM, UNICEF Nigeria launched RapidSMS – a mobile-phone based Short Messaging Service – in July 2013. With RapidSMS, OICs use their own phones to send free text message reports, which are automatically uploaded to a cloud-based server, allowing UNICEF Nigeria and other CMAM programme partners to examine the situation on the ground in real-time.15 In three states that are currently piloting the platform, RapidSMS has been successful in streamlining data management for reporting to improve timely access of data and eliminating previous bottlenecks and errors caused by inefficiencies in the paper-based method of reporting. While the RapidSMS reporting improved availability of quantitative data such as the performance indicators and stock levels of RUTF, less quantifiable indicators of programme performance and quality of services cannot be captured with this system. Moreover, RapidSMS is not a replacement, but a compliment to the paper-based reporting system.

Monitoring and Surveillance: Supervision ChecklistThe monitoring of CMAM is the top -bottom process where supervisors at each government level, UNICEF Nigeria Nutrition Division or other programme partners conduct field visits to monitor the implementation of the programme. This process is primarily manual and observational. A “Supervision Checklist” provided in the annex section of the National Guidelines for CMAM serves as a template for the supervisory visits.16 The fields in the checklist relate to the accuracy of anthropometric measures, community outreach activities, and Outpatient Therapeutic Programme (OTP) and Inpatient Therapeutic Programme (ITP)17 procedures. The quality of each is measured from poor to average to good, and supervisors report whether or not they discussed the subject with the staff, noting any relevant comments in the margins.

Rationale


For more information about the application of smartphones to SMART survey methods, please see the Nutrition Tech-nical Assistance Visit – Abuja and Northern Nigeria document written by Robert Johnston, UNICEF Nutrition Specialist based in Brussels, and informed by Assaye Bulti, Data Collection Specialist for CMAM in UNICEF Nigeria.Industry Data. Nigerian Communications Commission, n.d. Accessed April 25, 2014. http://www.ncc.gov.ng/index.php/index.php?option=com_content&view=article&id=68&Itemid=70. BuddeComm. “2013 Nigeria - Telecoms, Mobile, Broadband and Forecasts.” Accessed May 1, 2014. http://www.budde.com.au/Research/2013-Nigeria-Telecoms-Mobile-Broadband-and-Forecasts.html.

18

19

20

Rationale

While this checklist serves as a rough guide, it does not allow for systematic analysis and comparisons across states, LGAs, and health facilities. Moreover, the pen-and-paper method is much more susceptible to error and subjective bias of the monitor than smartphone-based data collection.

SMART SurveyUNICEF Nigeria is currently using smartphones in administering SMART surveys, or Rapid Assessment Surveys. SMART surveys were initiated in eight states of northern Nigeria in 2010, and use Standardised Monitoring and Assessment of Relief and Transition (SMART) methods to collect nutrition and mortality data and keep track of the food and nutrition crisis in the Sahel region of Nigeria. The surveys are carried out biannually by outsourced enumerators across the country and helps UNICEF Nigeria with the overall planning and setting of its annual objectives.

Although they are not a part of CMAM, SMART surveys are related to the programme in that they aim to gather nutrition information. A smartphone-based monitoring system would build on the nascent RapidSMS deployment and learn from the SMART survey methodology, strengthening quality implementation of the programme from the top down.18

ii. Assessing the Feasibility of the Project

The Mobile and Telecommunications Industry in NigeriaWith close to 130 million subscribers as of February 201419 and a market penetration of close to 80% of the country’s population, the landscape of the Nigerian telecoms industry would appear to make a compelling case for mobile-based interventions in the country. However, the rapid increase in subscriptions over recent years, growing demand for mobile services and a consolidated mobile operator market have combined to result in an often low quality of service, characterized by network congestion.

Although the market may appear to be highly competitive due to the presence of nine different mobile network operators, in reality, only four have significant market share: MTN (45%), Airtel (21%), Glo (20%) and Etisalat (14%).20 As a result, the Nigerian Communications Commission (NCC), the regulatory authority, has imposed numerous fines and mandates to combat anti-competitive behaviour, such as limited mobile number portability and high cross network connection rates.


Rationale

Coverage MapsThe high subscriber numbers mask the fact that a significant proportion of users are located in the southern, more urban areas of the country, with increasingly sparse and limited coverage in the north. As such, the next major step for mobile network operators lies in expanding and strengthening coverage areas in the northern and more rural parts of the country, a somewhat expensive venture.

Where available, <Figure 5> and <Figure 6> show coverage maps for the top players in the mobile industry in Nigeria. These maps highlight significantly denser coverage in the southern areas of the country.

The Next GenerationAnother key area of focus and expansion for the mobile network operators, and of particular interest for the project, lies in further developing services such as third generation (3G) mobile broadband. The combination of 1) the 4 million21 and increasing smartphone and tablet users in the country, 2) the rapid evolution of mobile shopping, banking, health, government and learning applications, and 3) country- and sector- level focus on investments in revolutionizing the fixed and mobile internet infrastructure, have led to rapid growth in the numbers of mobile internet subscribers in the country. According to a report published by the NCC in early 2013, the 32 million mobile internet subscribers22 in the country account for around 70% of total internet subscriptions in Nigeria (measured as the percentage of internet searches generated on a mobile versus a fixed devise).

Source: GSMA website,https://mobiledevelopmentintelligence.com/network_coverage

Figure 5: MTN Nigeria 2G Coverage Map Figure 6: Glo 2G Coverage Map

Mobility, M. “Nigerian Smartphone Market Figures for 2012” Last modified April 26, 2013. http://mobility.ng/nigeri-an-smartphone-market-figures-for-2012/.Mobility, M. “Nigeria has 32 million mobile internet subscribers” Last modified May 12, 2013. http://mobility.ng/nige-ria-has-32-million-mobile-internet-subscribers-ncc/.

21

22


Rationale

The Economist. “Smartphones in Nigeria: BlackBerry babes.” Last modified December 8, 2012. http://www.economist.com/news/business/21567977-its-devices-are-still-popular-there-africa-wont-save-rim- blackberry-babes.

23

Application to the Monitoring ProjectBased on the above, a strong case can be made for the use of the smartphones in the monitoring of the CMAM project. However, a key consideration in implementing the project on a larger scale lies in the cost of the devises. Despite the high saturation of BlackBerry smartphones in the market, where almost half of all smartphone users have a BlackBerry,23 the rise of other manufacturers such as Huawei, ZTE and Tecno whose handsets are up to 80% cheaper than BlackBerries whilst maintaining much of the same functionality.

iii. Benefits of Smartphone Monitoring

In line with the goals of UNICEF Nigeria’s Nutrition Division, the Columbia University team has outlined three key benefits of using smartphones in the supervision process:

1. Monitoring data in real-time; 2. Assuring the quality of CMAM performance data; 3. Enhancing data analysis to inform programming.

Monitoring Data in Real-TimeMonitoring is an on-going activity that tracks implementation against design. As such, monitoring works best when information can be collected on the progress of an intervention in real-time. This is where smartphone technology adds the greatest value.

The Columbia University team has created the initial monitoring tools and uploaded them into smartphones in a format suitable for piloting. The forms are divided into two tracks: RUTF supply & logistics, and programme. There are four tools for supply & logistics and five tools for programming, making a total of nine monitoring tools covering all levels and categories of supervision <Appendix 3>.

These forms will be uploaded to the smartphones, which will be used by monitors at each level. When a monitor completes the form, the collected data will be stored until the phone detects an Internet signal and is able to send the data to the server. This will allow near-real-time data collection. Although there may be a time lapse between data completion and upload, this gap is negligible compared to the traditional pen-and-paper monitoring process, which takes substantially longer both in collecting the information and entering it into a centralized database.

The smartphone monitoring forms are coded in such a way that the date and time will be automatically recorded when the monitor makes the first and last data entry. This time stamp function allows the supervisor to show when (s)he accessed and completed the monitoring form. In addition, the GPS stamp function enables the supervisor to keep record of the places they visit. With the basic visualization function provided by Formhub, the supervisors can even map out these places in data points <Figure 8>. Both the time stamping and GPS functions will significantly enhance accountability at each level, ensuring that data is valid and field visits are being conducted on a regular basis as expected.


Rationale

Figure 8: Sample Data Visualisation on Formhub

Source: Formhub

Quality Assurance of CMAM Performance DataSmartphone-based monitoring will ensure quality implementation of the CMAM programme through various channels. From communities to states, the multi-faceted monitoring forms cover all levels, creating a comprehensive and inclusive supervision system. In addition, monitors will include a wider pool of professionals, ranging from local and federal government officials, to UNICEF and other programme partners. Such diversity in monitoring will ensure a more endogenous form of accountability <Figure 9>.

The new monitoring system will also make it possible for monitors to check the progress and pinpoint potential bottlenecks in programme and supply logistics, two key components of CMAM. Upon their visit, monitors can consult the report on CMAM performance indicators (including recovery, death, defaulter, and non-recovery rates) submitted by the monitored area and determine whether what is reported upstream is consistent with what is observed downstream. The monitors can also check on the consistency and accuracy of reporting and identify reasons for the poor or strong performance of the monitored areas. This will not only assure the quality of CMAM implementation, but also strengthen the transparency and accountability of the programme relative to the resources used.


Rationale

Figure 9: CMAM Reporting and Monitoring Structure

Data AnalysisAnother benefit of smartphone-equipped monitoring is that it standardises existing monitoring tools and, in doing so, facilitates more robust data analysis. For example, all of the CMAM health facilities that provide outpatient care will be monitored using one form. While conducting continued monitoring at this level, supervisors will be able to observe a trend in one facility over a period of time and, at the same time, conduct cross-facility comparison and analysis. In turn, this methodological and robust data analysis will enhance the quality of the evaluation of the CMAM programme, while the evaluators will be able to assess the impact of the programme in a more systematic way. It is through each of the three key enhancements outlined above that smartphone monitoring will enable CMAM to be delivered in a more rapid, accountable and effective way.


Platform Design

VII. PLATFORM DESIGN

The Columbia University team aimed to develop a mobile monitoring tool that could collect a comprehensive and extensive set of information so as to replace or complement the existing paper supervision checklist. After exploring the strengths and weaknesses of several free open- source systems capable of collecting and processing data, the team decided to use ODK for its ease-of-use and familiarity within the UN system.

i. Technology: ODK and FormhubThe monitoring forms were developed with ODK, an open-source mobile data collection and management tool. ODK has been used for data collection worldwide across various sectors. UNICEF has been one of its major users, and UNICEF Nigeria has also adopted this technology to administer bi-annual SMART surveys.

ODK has the following capabilities: • Builds function that allows the user to design the survey forms; • Collects function that runs on an Android phone or tablet to download and fill-in the survey; • Aggregates function that hosts survey forms and collect survey data in a central server.

The Columbia University team primarily used ODK’s Build and Collect functionalities. In the data building phase, the team created monitoring forms using Microsoft Excel coded in a syntax that is compatible with ODK. The forms with the .xls extension were then uploaded to Formhub, a free open-source data back-end service that is compatible with ODK, and converted to a format that allows them to be access by computers and Android-powered smartphones/tablets.24 Since CMAM monitoring is intended to be implemented by mobile devises, the Formhub forms were downloaded to Android smartphones using ODK Collect application available on Android market. Currently, the Columbia University team has uploaded the monitoring tools to five phones (Samsung Galaxy Tab 3 7.0), which are being used by the Nutrition Division to pre-test and train consultants. The supervisors are expected to fill out the monitoring forms on their smartphones and send the data to the Formhub server. Through the user-friendly data visualization and mapping service available on Formhub, the supervisors can view the data that they or other colleagues have previously submitted.

ii. DesignEach smartphone monitoring tool follows the same form design. The form design is simple and user-friendly. Those who have a basic knowledge of manipulating a touch-based mobile devise (i.e. using touchscreen to scroll down, swipe from one page to another, and tap to enter numerical or alphabetical input) will be able to use the forms after a short training. The Columbia University team recommends an orientation or workshop to be held for monitors to

ODK Collect uses the Android platform, so the users must have an Android device (e.g. Samsung Galaxy, HTC One, Google Nexus, etc.

24


Platform Design Platform Design

receive training, have exercises to test their understanding, and provide feedback. The monitoring forms are user-friendly and simple in their design, as can be seen in <Figure 10>. Those familiar with the user interface of Android will be able to use these forms after training.

iii. UsersCurrent and future supervisors of CMAM will be the primary users of the smartphone monitoring tools. This group comprises of UNICEF Nigeria’s Nutrition Division, government health officials, and other CMAM programme partners. At UNICEF, users will primarily be nutrition specialists and external consultants and the members of the Nutrition Division are currently training government contractors and UNICEF Nigeria’s Nutrition Division on how to use the monitoring tools.

Figure 10: Example Screen Shot of a Smartphone Monitoring Tool


Output

VIII. OUTPUT

i. Monitoring ToolsThe Columbia University team developed monitoring tools based on the two-track approach to CMAM implementation adopted by UNICEF. The two-track approach is comprised of a programme component, and a supply and logistics component. The programme track covers a range of CMAM services, including community outreach, outpatient and inpatient care, as well as other related healthcare initiatives. The supply and logistics track solely examines the stock and delivery of RUTF, micronutrient-enriched peanut pastes used in therapeutic feeding programmes, a critical CMAM commodity.

The programme component of CMAM monitoring provides a benchmark for its overall performance, including the quality of its services and effectiveness of its community outreach, as well as its performance in addressing incidences of acute malnutrition. Meanwhile, the supply and logistics monitoring focuses on tracking the supply and delivery of RUTF and aims to identify weaknesses in current processes and promote efficiency in supply management.

Why Two-track Monitoring?The supply and logistics of RUTF is monitored separately by UNICEF for several reasons. As an effective and easy-to-use remedy in treating severe malnutrition, high volumes of RUTF are being used in the implementation of CMAM. As such, the RUTF takes up a significant proportion of the overall CMAM budget, representing approximately 80% of total CMAM costs in Nigeria and 50% of the programme’s expenses globally.25

Given its importance to the maintenance of the programme, the RUTF’s supply chain is managed and monitored separately from other equipment and medicines. RUTF products are procured by UNICEF and shipped to Lagos, from where it is distributed to State and LGA inventories, as well as to UNICEF headquarters to house emergency inventory.

Once the RUTF supply and logistics is successfully tracked and managed, the form can potentially be extended to include other key medicines (i.e. deworming tablets, anti-malarials, and antibiotics) considering the time and capacity of the supervisors.

Content of Monitoring ToolsAfter consulting with key CMAM stakeholders and reviewing existing monitoring and supervision documents, the Columbia University team developed a total of nine smartphone monitoring tools: five for programme monitoring and four for supply and logistics monitoring. The following tables show the content of each monitoring tool:

UNICEF. “Evaluation of Community Management of Malnutrition Global Synthesis Report.” Last modified 2013. http://www.unicef.org/evaldatabase/files/Final_CMAM_synthesis_FINAL_VERSION_with_ExSum_translations.p df.

25


Output Output

VIII. OUTPUT Figure 11: Content of Each Monitoring Tool

Figure 12: Use of Monitoring Tools at Each Level

ii. Monitoring Uses by LevelThe following table shows the use of monitoring tools disaggregated by level and identifies the levels administering the monitoring:


Output

Federal-level supervisors, as well as UNICEF Nigeria’s Nutrition Division field staff and consultants will monitor CMAM-implementing states. Over time and with further government involvement, federal officials from FMOH, National Planning Commission (NPC), and National Primary Health Care Development Agency (NPHCDA) will also be conducting monitoring visits. Charged with overseeing state-level nutrition activities, SNOs will represent the supervised entity and are expected to provide the relevant information to the supervisors to facilitate monitoring. The monitoring forms used at the state level include the ‘State-level Programme Monitoring’, ‘Warehouse and Inventory Monitoring’, as well as the ‘State Official Feedback’ form for supply and logistics.

At the LGA level, UNICEF, federal and state officials will conduct the monitoring to track activities and assess the performance of CMAM-implementing LGAs. NFP’s will serve as respondents. Supervisors will conduct visits to the relevant facilities such as the RUTF warehouse and provide supervisory guidance to the NFP’s. The tools that will be used include LGA-level programme monitoring, warehouse and inventory monitoring, and market monitoring forms. Market monitoring tools are included at this level as LGA authorities are more likely to be informed than state-level officials about the market leakage of RUTF. The key objectives of monitoring at both the state and LGA level are: 1) to ensure effective data management, 2) to identify any bottlenecks in supply and logistics, and 3) to monitor the frequency of field visits conducted by the respondents.

As primary healthcare facilities constitute the core of the CMAM programme, OTP and ITP sites will require in-depth supervision. Here, the pool of supervisors will be the most extensive, including UNICEF Nigeria’s Nutrition Division, officers from FMOH, NPC, NPHCDA, SNOs, NFPs, and other nutrition/health partners. Supervisors will rely on their own observations, coupled with information provided by the OIC and other health staff present. The supervisors will administer OTP and ITP-level programme monitoring tools. The warehouse and inventory tool will be used to check the facility’s RUTF status and beneficiaries’ feedback and market monitoring tools will be used to identify potential leakage of the commodity in the local market. Along with the previous objective of ensuring effective data management and assessing supply levels for RUTF, OTP/ITP-level monitoring aims at identifying possible bottlenecks that could hamper the effective delivery of CMAM services.

At the community-level, the pool of supervisors will be the same as at the OTP/ITP-level. While gathering observational information and seeking responses from community volunteers, community members, beneficiaries, and other health staff, the supervisors will assess: (1) the effectiveness of community mobilization on early detection of SAM/MAM and community sensitization, and 2) potential leakages of RUTF in the local market. As such, the supervisors will use a combination of community-level monitoring, market monitoring, and beneficiaries’ feedback tools.

CaveatDuring the design phase, the Columbia University team aimed at incorporating the concerns of UNICEF Nigeria’s Nutrition Division as much as possible to the new smartphone monitoring tools. The Nutrition Division provided the team with various constructive insights on monitoring, and in order to err on the side of caution, the Columbia University team added all the


Output Output

questions that were discussed during the meeting. As a result, the monitoring tools have an extensive, lengthy set of questions that are may cause survey fatigue both to respondents and supervisors. After conducting several pre-tests, the Nutrition Division will need to cut down the length of the forms to improve the efficiency and sustainability of the monitoring process.

iii. Other Mid-term DeliverablesIn addition to the aforementioned monitoring tools, the Columbia University team created documents that will facilitate the launch of the new monitoring system. Additional resources developed by the team include a conceptual framework, cost analysis, training guide, video tutorial and pre-test feedback questionnaire.

Conceptual FrameworkThe conceptual framework analyses the challenges that confront the current monitoring system and identifies a need to standardize and consolidate existing monitoring tools. The framework document also makes the case for a smartphone-enabled monitoring system while walking through the benefits of using smartphone in monitoring and supervision. This document is intended for both internal and external use.

Cost AnalysisThe cost analysis conducted by the Columbia University team is an interactive model designed to serve as a framework by which the UNICEF Nigeria nutrition division can estimate the total cost of implementation based on various inputs. This tool, created in Excel, will help the team better recognize the financial effects of changing inputs as they move through the pilot phase and on to implementation.

Figure 13: Cost Analysis


Training GuideTo be distributed during smartphone monitoring orientation or workshop sessions, this training guide serves as an induction document for potential supervisors. The guide provides explanations on the basics of smartphone technology and illustrates the smartphone monitoring and supervision process with screenshots of monitoring forms as they appear on a smartphone screen. In addition, the guide contains a 1-pager sheet with quick reminders for filling out and sending monitoring forms, as well as hardware and software troubleshooting tips. In addition to the training guide, a two-minute long video was created to demonstrate the data visualization functions provided by Formhub.

Feedback QuestionnaireThe feedback of the supervisors who have received smartphone training is valuable since they are the ones who will be using the smartphone tools on regular basis, determining the user uptake level of smartphone monitoring system. For this reason, the Columbia University team developed a questionnaire to be distributed during initial pretesting and piloting. The questionnaire asks trainee’s opinions and comments on the interface, structure, and design of the smartphone monitoring tools in order to a) generate buy-in from supervisors using the current manual supervision process and b) collect end-user feedback to make further iterations.

The complete package of output created by the Columbia University team is intended to provide UNICEF Nigeria with the necessary solid foundation by which to build a holistic new monitoring system. Having designed and built the initial monitoring forms in collaboration with the Nutrition Division in Abuja, the subsequent deliverables provided UNICEF Nigeria with the tools to continue strengthening the nascent system and more into the pretesting and piloting phases.

Output


Recommendations

IX. RECOMMENDATIONS

The Columbia University team has identified three key constraints that must be addressed in order for the project to be implemented successfully.

i. Key Constraints

a) Length of SurveyThe Columbia University team suggests that UNICEF Nigeria create two differentiated sets of monitoring tools: 1) the holistic set of surveys, and 2) a more specific and brief set of forms to focus on key performance indicators.

Based on information obtained during our stakeholder interviews, the Columbia University team believes that the quality of data and motivation of enumerators will likely decline if the forms are too long or time-consuming. By dividing the sets of monitoring tools, the shorter forms would be administered frequently to collect essential data, while the longer forms would be administered less frequently to understand more complex changes and developments. The team recommends that the short forms are conducted bi-monthly, while the longer forms are conducted biannually, if not quarterly. Projected costs of various scenarios are extrapolated in the cost analysis.

b) Team BandwidthWhile this new system will eventually streamline the monitoring process at all levels, its full implementation will require significant time, effort, and resources. The Nutrition Division at UNICEF Nigeria is somewhat overburdened with the regular operations of the programmes currently in place. Not only does full implementation of such a technology-based monitoring system require significant technological capacity amongst staff, it would also require them to allocate significant portions of their existing workstream into a new project. Frequent iterations of monitoring tools will be time-consuming and require a high level of coordination amongst the Nutrition Division to ensure feedback is collected and incorporated adequately. Moreover, reallocating the time and resources of current staff members risk compromising the quality of service delivery of existing projects.

As such it is highly recommended that at least one new consultant is hired to manage the process of implementation. Ideally, the new consultant will have: 1. A strong knowledge of the CMAM programme in Nigeria; 2. A relatively strong ability to adopt and utilize technology (especially data management and analysis software such as ODK, Formhub, Excel, and STATA); 3. A strong knowledge of the progress made to date on using smartphones to improve the implementation of CMAM.

This new consultant should be based in Abuja, and be able to make frequent field visits to collect user feedback and make iterations when necessary. The employee charged with managing the process of implementation should work closely with the UNICEF country office, field-based consultants working with UNICEF, and government workers at the federal, state, and local

Output


levels. He or she must be able to strengthen partnerships with government stakeholders to ensure their data needs are understood and met.

The Abuja-based consultant will oversee the work of the state-based consultants who will be hired to strengthen the monitoring process on a more local level. UNICEF Nigeria may well look into hiring a consultant software developer to assist with the creation of the user interface and linking it with other data visualization software currently available.

c) End-User ActionabilityThe ultimate goal of this new system is to spur action that will improve service delivery. While UNICEF may be able to create and implement a fully-functioning system, ensuring that the intended users – in this case the SNOs, NFPs, OICs, and federal-level health staff – in fact use the information to improve CMAM will require a significant behavioural change. As interviews with other department of UNICEF Nigeria and countries revealed, this problem is not uncommon for technology-based data projects. The RapidSMS pilot in Nigeria has indeed met with similar challenges: a functioning and highly usable dashboard has been developed but is not being used to its full potential. As one interviewee mentioned, data and analysis that is unused is merely “data for data’s sake,” and this does not improve the quality of programming in the long-run.

To avoid this pitfall, UNICEF Nigeria must clearly communicate its intentions for the new monitoring system from the onset of implementation, and when possible solicit feedback from end-users to generate their buy-in. The benefits of the system must be clearly conveyed so that it is seen as reducing their current work stream rather than creating an extra burden of time. Stressing the accountability aspect of this system – in particular the ability to cross-check information between levels and read GPS stamps from specific locations – will likely also generate an awareness of the benefits of usage.

Ensuring that the dashboard consists of key indicators that are specific, measurable, attributable, realistic, and targeted will in turn facilitate greater usage amongst those involved in the implementation process.

ii. Implications for Future UseThe smartphone-based monitoring project provides UNICEF Nigeria with a prominent opportunity to display technological leadership in the monitoring and evaluation field. While projects in polio, emergencies, and other sectors have adopted smartphone technology to various degrees, smartphone usage for monitoring has consequences beyond CMAM and could be adapted to suit the needs of other programmes. A similar system could improve the efficiency of the Maternal, Newborn and Child Health Weeks (MNCHW) initiative, or easily be adapted to community-based Infant and Young Child Feeding (IYCF) programmes.

More broadly, adopting smartphones to improve programme implementation has ramifications for all sectors. A system based on centralised mobile data collection and analysis avoids traditional bottlenecks associated with pen-and-paper monitoring, facilitating a more fluid and transparent implementation process. While the initial start-up costs of implementing this system may be relatively high, such a process will pioneer the way for other sectors and programmes: as smartphones become more common both within programme implementation and monitoring,

Recommendations


and as coverage and usage increases with greater technological development, less training will be required for both government and UNICEF staff, and less resources will be required since smartphone usage will become more common amongst target populations.

Considering these positive trends, the Nutrition Division in UNICEF Nigeria should seek resources and forge partnerships with UNICEF HQ and other programme partners in the hope of adapting and replicating the potential successes of this nascent project in other sectors and countries. The knowledge spillovers from such a system could improve programme implementation and monitoring for UNICEF projects across the globe, cementing the organisation’s place as a bastion for innovation in international development.

iii. Steps to ImplementationThe Columbia University team has outlined the broad steps to implementation below in <Figure 14>. Having completed initial design of the monitoring tools, and with pre-testing currently being conducted in three states, the UNICEF team must begin fully exploring options for front- end data analysis, concomitantly developing this dashboard as the project’s core data needs become more apparent through the pre-testing and piloting stages. Piloting should methodically test the new monitoring system in key states, with pre-identified indicators chosen as benchmarks of success. If piloting proves successful, full implementation should proceed.

Recommendations Recommendations

Figure 14: Steps to CMAM Implementation

a) DesignWhile designing the mobile tool the Columbia University team worked closely with the UNICEF Nigeria Nutrition Division. The team spent two weeks at UNICEF’s Abuja office in March 2014 and discussed the relative strengths and weaknesses of the programme in significant detail,


Recommendations

including covering bottlenecks in service delivery and logistics, the information needs of the country office, and the vision of the programme manager. The team’s questions and concerns at the different stages of the development of the tool were addressed and their suggestions were incorporated to provide a customized monitoring tool that will help fulfil the data requirements of CMAM management and also ensure the efficacy of monitoring efforts among managers at different tiers.26

b) Pre-testIn April 2014, the smartphone tool was pretested in three states: Katsina, Kebbi, and Kano. UNICEF Nigeria nutrition division gathered information from users pertaining to the ease of using the application, time taken to complete the monitoring form, and the quality and length of the content. Users were also asked to provide feedback on how they perceived the new system affecting their current workflow moving forward.

The feedback information obtained from first phase of pretesting will help refine the tool by enabling the testers to identify and remove unnecessary questions in the monitoring forms. This will make the forms compact, precise, and focused on the analytical needs of programme management. The feedback will also help identify gaps in the monitoring tools and strengthen the structure and logic of the questions asked to make the process as intuitive as possible.After the first pre-test of the tool, the Columbia University team recommends that UNICEF Nigeria carry out two complete iterations of the smartphone tools based on the latest findings before piloting the tool in the field.

c) Front-End DevelopmentIt is important that the data collected in the field is fully understood and appropriately informs policy-making. Creation of a front-end dashboard will make it easier for managers to comprehend data quickly and take remedial action if required. Currently, data analysis software such as Tableau27 is available in the market. Such ready-to-use software can create a front end.

Box 4: UNICEF Zambia Formhub and DHIS2 for WASH

Please refer to output section for more detailsTableau Software. “Tableau Software.” Accessed April 20, 2014. http://www.tableausoftware.com/

26

27


Recommendations

Box 4: UNICEF Zambia Formhub and DHIS2 for WASH

consisting of visually meaningful graphs and charts, simplifying the results of the data, which in its raw form may appear obscure and complex.

DHIS2The Columbia University team recommends UNICEF Nigeria explores the option of using DHIS2 for data aggregation and visualization. Developed by the University of Oslo, DHIS2 is a web-based open source information system currently being used by national governments in 30 developing countries across the globe including Nigeria.28 DHIS2 provides a holistic platform by which to manage data and analytics as shown in <Figure 15>. The platform allows users to collect individual data records, either through desktops, laptops, or mobile phones, and visualize the data through custom dashboards.29 By utilizing DHIS2, UNICEF Nigeria would avoid having to create its own dashboard, and would be able to centralize data with government databases in order to contribute to the overall strengthening of the health information system in the country. As <Box 4> shows, UNICEF Nigeria can build on the precedent set by the Zambia WASH project to adopt best practices.30

Recommendations

Figure 15: Sample Dashboard from DHIS2 of HIV Statistics in South Africa

Source: DHIS2

“DHIS 2 In Action.” Accessed April 25, 2014. http://www.dhis2.org/inaction.Accessed April 22, 2014. http://i1-linux.softpedia-static.com/screenshots/DHIS-2_1.png. Glovinsky, Mac. Email message to Diptesh Soni, April 14, 2014..

28

2930


Recommendations

d) PilotAfter pre-testing and initial development of front end, UNICEF Nigeria should pilot the project in three states. Considering that the pilot will be a key determinant of whether or not the project goes to scale, the Columbia University team suggests that UNICEF agree on a handful of key performance indicators reflected in the monitoring tools that would provide evidence that the new monitoring system is improving implementation and the quality of service delivery within CMAM. Examples could include:

• Supervision of Site Visits - Does the data reflect an increase in the frequency of site visits by government officials? Can this be verified through GPS mapping and time-stamping? • Supply and Logistics - Have supervisors been increasingly attending to the logistical needs of OTP facilities? Is this reflected in lower stock-out rates? - Have proper inventory practices been followed? Has this increased over the course of the pilot period? • Beneficiary Feedback - Are beneficiaries reporting either sustained or greater satisfaction with the quality of CMAM services the course of the pilot period?

e) ImplementationAfter the tool is successfully piloted, UNICEF Nigeria will need to train CMAM staff, including state consultants, and government staff at the federal, state, and LGA level in using the application to conduct monitoring instead of pen and paper. The Columbia University team hopes that training of monitors will not only facilitate quicker roll out of the tool within the CMAM programme but will also increase smartphone usage and literacy, which would in turn lay the groundwork for future smartphone-related development initiatives.


Recommendations Conclusion

X. CONCLUSION

Despite an overall reduction in the incidence of stunting over the past two decades, 36% of Nigerian children under the age of five still suffer from the condition and it is clear that SAM continues to be a scourge in the lives of the Nigerian population. Before the launch of CMAM in 2009, Nigeria’s treatment of malnutrition was marked by inadequate community coverage and an absence of quality nutrition interventions, a situation that was exacerbated by a lack of policy coordination among key stakeholders. Since its implementation, the CMAM programme has intervened in the cases of nearly one million children and is making clear strides in a challenging nutrition landscape that was poorly served prior to its implementation.

The community-based approach to tackling malnutrition is proving highly effective because it addresses a number of the root causes identified at the start of the report. The CVs play a vital role, not only in identifying mothers and caregivers whose children have fallen victim to SAM, but in educating these women in the importance of a varied and balanced diet for their children from the age of around six months, when complementary foods are added to breastfeeding.

As we have demonstrated and discussed in the report, CMAM’s success is contingent upon the ability of programme implementers to adequately monitor the programme and to address any subsequent issues that arise. The implementation of monitoring using smartphones will significantly improve the capacity to monitor the programme. Key benefits include:

1. The ability to monitor the programme in real time 2. A reduction in errors during the data collection 3. Improved accountability 4. Increased actionability 5. Simpler and accessible analytics

The plans for implementation and the recommendations which we have outlined assume that smartphones will be used to gather data pertaining solely to the monitoring and supervision aspect of the CMAM programme. However, looking into the near future, the tool may be extended to also include key indicators for evaluation. In a country where mobile penetration is at 77% and there are four million smartphone users, this does not seem outside the realm of possibility. Indeed, as smartphone usage becomes more prevalent across all segments of the population, supervisors will be empowered to gather data using their personal phones in much the same way as tools such as RapidSMS have allowed them to do.

Integrating new mobile technology into the fight against malnutrition is not straightforward. Although the country ranks as sub-Saharan Africa’s second largest smartphone market, behind South Africa, there are a number of challenges to be addressed before we see smartphone usage as widespread as traditional mobile phones are today. The cost of smartphones and the limits of


Conclusion

connectivity continue to hinder greater proliferation. Bust such hurdles are not insurmountable; ever cheaper phones are being manufactured in the hope of capturing large, lower-income markets, while increased investment in telecommunications infrastructure has made widespread connectivity a tangible goal for Nigerian development.

There is a long way to go before malnutrition in Nigeria becomes a remnant of the past. Nonetheless, it is encouraging to see that over the last five years, the CMAM programme has been an essential tool in alleviating the devastating impact of SAM on both the Nigerian population and its economy. Smartphone monitoring is an important step in ensuring that the quality of programme implementation continues to improve the quality of services provided to severely malnourished children, their mothers and caregivers. The impact will not only be felt in the affected families, their communities, and the north of Nigeria, it will also be felt in the whole country, in the form of productive citizens who have the knowledge, ability and capacity to thrive, and to ensure that their own children do the same.


Conclusion Bibliography

XI. BIBLIOGRAPHY

Accessed April 22, 2014. http://i1-linux.softpedia-static.com/screenshots/DHIS-2_1.png.

BuddeComm. “2013 Nigeria - Telecoms, Mobile, Broadband and Forecasts.” Accessed May 1, 2014. http://www.budde.com.au/Research/2013-Nigeria-Telecoms-Mobile- Broadband-and-Forecasts.html.

Abubakar, Aminu. “Nigeria braced for potential food crisis as forecasters predict short rainy season.” The Guardian, March 26, 2014. Accessed April 25, 2014. http://www. theguardian.com/global-development/2014/mar/26/nigeria-food-crisis-short-rainy- season.

“BBC News - Is Nigeria on the brink after north-south clashes?” Last modified January 13, 2012. http://www.bbc.com/news/world-africa-16544410.

“Blackberry Babes.” The Economist, December 8, 2012. http://www.economist.com/ news/business/21567977-its-devices-are-still-popular-there- africa-wont-save-rim- blackberry-babes.

BuddeComm. “2013 Nigeria - Telecoms, Mobile, Broadband and Forecasts - BuddeComm - BuddeComm.” The largest telecommunications research site on the internet - BuddeComm. Accessed May 1, 2014. http://www.budde.com.au/Research/2013- Nigeria-Telecoms-Mobile-Broadband-and-Forecasts.html.

Federal Ministry of Health, Family Health Department, Nutrition Division Nigeria. National Guidelines for Community Management of Acute Malnutrition. 2011.

Industry Data. Nigerian Communications Commission, n.d. Accessed April 25, 2014. http:// www.ncc.gov.ng/index.php/index.php?option=com_content&view=article&id=68 &Itemid=70.

Mobility, M. “Nigeria has 32 million mobile internet subscribers.” Last modified May 12, 2013. http://mobility.ng/nigeria-has-32-million-mobile-internet-subscribers-ncc/.

Mobility, M. “Nigerian Smartphone Market Figures for 2012” Last modified April 26, 2013. http://mobility.ng/nigerian-smartphone-market-figures-for-2012/.

Nigerian Communications Commission. “Industry Data.” Accessed April 22, 2014. http:// www.ncc.gov.ng/index.php/index.php?option=com_content&view=article&id=68 &Itemid=70.


Prudhone, Claudine et al. “WHO, UNICEF, and SCN Informal Consultation on Community- Based Management of Severe Malnutrition in Children.” Accessed April 25, 201http:// www.who.int/nutrition/publications/severemalnutrition/FNB_0379- 5721.pdf?ua=1).

The Economist. “Smartphones in Nigeria: BlackBerry babes.” Last modified December 8, 2012.http://www.economist.com/news/business/21567977-its-devices-are- still-popular-there- africa-wont-save-rim-blackberry-babes.

n.d. “Stanley Chitekwe - Chief of Nutrition - UNICEF Nigeria.” Podcast audio. n.d. https:// soundcloud.com/unicefafrica/stanley-chitekwe-chief-of.

Tableau Software. “Tableau Software.” Accessed April 20, 2014. http://www.tableausoftware. com/.

Umunna, L. “Securing Private Sector Commitment in Nigeria | Sun Business Network.” Accessed April 25, 2014. http://sunbusinessnetwork.org/news- items/securing-private-sector-commitment-in-nigeria/.

UNICEF Australia. “UNICEF child health program improves family nutrition in Nigeria.” Accessed April 25, 2014. http://www.unicef.org.au/Discover/Field-Stories/August- 2013/Bringing-good-nutrition-closer-to-home-in-Nigeria.aspx.

UNICEF. “Evaluation of Community Management of Malnutrition Global Synthesis Report.” Last modified 2013. http://www.unicef.org/evaldatabase/files/Final_CMAM_synthesis_FINAL_VERSION_ with_ExSum_translations.pdf.

UNICEF. “Dashboard.” Accessed April 20, 2014. http://sam.rapidsmsnigeria.org.

UNICEF. “UNICEF - At a glance: Nigeria - Community-based treatment for malnutrition earns praise in northern Nigeria.” Accessed May 6, 2014. http://www.unicef.org/infobycountry/nigeria_69907.html.

UNICEF. “UNICEF - At a glance: Nigeria - Community-based treatment for malnutrition earns praise in northern Nigeria.” Accessed April 25, 2014. http://www.unicef.org/infobycountry/nigeria_69907.html.

“The World Factbook.” Last modified April 23, 2014. https://www.cia.gov/library/publications/ the-world-factbook/geos/ni.html.

Bibliography


Bibliography Appendices

XII. APPENDICESA

ppendix 1: Research Objectives: Problem

Tree


Appendices

Appendix 2: Stakeholder A

nalysis of CM

AM

Implem

entation


Appendices Appendices


Appendices



Appendix 3: Exam

ple Smartphone M

onitoring Tool Developed by the C

olumbia U

niversity Team


Appendices

unicef nigeria final report-designed

Documents