Report No. 71430 v1 Federal Republic of Nigeria Community-based Maternal and Child Nutrition and Health Interventions in Nigeria: A Comparative Case Study Analysis on Best Practices Overview Health Nutrition Population (AFTHE) Human Development, Africa Region February 2011 National Planning Federal Ministry of National Primary Health Care Commission Health Development Agency Document of The World Bank Community-based Maternal and Child Nutrition and Health Interventions in Nigeria: A Comparative Case Study Analysis on Best Practices Overview The World Bank 2 Overview This study makes the case that: (i) despite progress on a few key indicators, Nigeria has some of the world’s worst outcomes in maternal and child nutrition and health indicators with high rates of morbidity, malnutrition and mortality; (ii) the situation is particularly bad in the Northern states of Nigeria; (iii) cost-effective interventions are well known from rigorous reviews published in recent years; (iv) coverage rates on almost all these proven interventions are low in Nigeria compared to those seen in many other African countries; and (iv) strategies that mobilize community engagement for better health and nutrition have the potential to dramatically improve the coverage of nutrition and health behaviors and services. The purpose of this study is to enhance our understanding on how to effectively engage in community-based nutrition and health programs aimed to improve maternal, newborn, and child nutrition and health outcomes, particularly in Northern Nigeria. At the heart of the analysis are case studies of four projects, each of which included a community action component for improving nutrition and health outcomes. This report provides the comparative synthesis of these case studies. In so doing, it provides a normative base for designing and planning government programs that support reforms in outcome-based programming for maternal, newborn, and child nutrition and health through program support and investment lending. Central to the report is the discussion on the roles played by various stakeholders – state and local government, NGOs, traditional and religious leaders, and communities themselves – in creating and sustaining community mobilization. The factors considered essential or useful contributors to community mobilization are analyzed. The history of government’s role in Nigerian health care is discussed, as well as the current situation and future possibilities, especially at state and local level. W HY NIGERIA NEEDS C OMMUNITY-BASED P ROGRAMS FOR NUTRITION AND H EALTH The nutritional status of Nigerian children is not good and has shown no improvement since 2003. The 2008 NDHS found that 41% of under-five children suffer from chronic malnutrition (stunting) and 14% from acute malnutrition (wasting). The proportion of children aged 6-35 months that were chronically malnourished increased from 42% in 2003 to 50% in 2008. Figure 1 shows the evolution of stunting prevalence in Nigeria by geographical zone. Although the 1990 division in four Zones is not comparable to the 2003 and 2008 division in six Zones, the message is clear: • The Southern Zones are significantly better off than the Northern Zone; • The Southern Zones have seen significant improvements between 1990 and 2003 while the stunting prevalence in the Northern Zones has remained stagnant; 3 • There have been no significant improvements in stunting rates in both the Southern and Northern Zones between 2003 and 2008; • According to the 2008 data, the stunting prevalence in the Southern Zones is closer to Ghana (28%), Angola (29%) and Mauritania (32%) while in the Northern Zones the rates compare more with Madagascar (53%), Ethiopia (51%) and Guinea Bissau (47%). Figure 1: Stunting rates by Geographical Zone and by survey year 70 1990 2003 2008 60 50 40 30 20 10 0 National North East North West North South East South West South South Central Source: WHO Global Database on Malnutrition and Child Growth While significant gains in childhood and maternal mortality have been made in other developing countries in the past two to three decades, the situation of maternal and child health outcomes remain at a most depressing level in Nigeria. The estimated maternal mortality rate (MMR) ranges between 800-1,500 per 100,000 live births, with marked variation between geo-political zones – 165 in south east compared with 1, 549 in the north east and between urban and rural areas. This results in approximately a little bit more than 50,000 maternal deaths each year. For every woman who dies of maternal causes, at least six newborns die and a further four babies are stillborn. About 5.9 million babies are born every year in Nigeria, and over one million of these children die before reaching their fifth birthday, and 284,000 newborns die every year; sadly making Nigeria the world’s second largest contributor to under-five mortality (U5MR) and maternal mortality ratio (MMR). Many of these deaths occur at home and are therefore unseen and uncounted in official statistics. Most of these deaths or conditions leading to death in the mothers and in the newborns are preventable or treatable largely through proven, cost-effective preventive interventions and early care at household, community, and primary care levels such as promotion of adequate nutrition and weight gain during pregnancy, antenatal care, skilled health workers assisting at birth, access to emergency services and after delivery care for both mother and newborn, promotion of breastfeeding and infant and young child caring and feeding practices, hygiene, sanitation, case management of common illnesses at the home and community management of acute malnutrition. Yet the bulk of public spending in health goes to curative care, or around 70% in 4 2006-2008. As a result, coverage and quality of healthcare services in Nigeria continue to fail women and children. Because malnutrition, morbidity and the majority of perinatal, neonatal, infant and child deaths occur in the home, there is an urgent need to identify solutions at the community level. To achieve Millennium Development Goal 1, 4 and 5 of halving child malnutrition; reducing by two thirds the under-five mortality rate; and reducing by three quarters the maternal mortality ratio between 1990 and 2015, major advances in child and maternal nutrition and health must be achieved through wide-scale implementation of cost-effective interventions in the community. Moreover the health of the mother and newborn are intimately entwined, they must be considered together when planning strategies to improve maternal and child nutrition and health outcomes. It is important to highlight that the peak period of vulnerability for both the mother and newborn is around pregnancy and childbirth. Thus, interventions must largely focus on addressing joint outcomes. Changing health and nutrition outcomes in Nigeria will require greater emphasis on wide-scale implementation of proven, cost-effective measures to save women’s lives and promote healthy child growth. Some of the biggest gains in terms of child growth and survival can be made through actions to improve infant and young child care as well as feeding practices and care of sick children at household and community level accompanied by the delivery of high impact preventive interventions such as immunization, vitamin A supplementation, de-worming, and insecticide-treated bed nets (ITN). Collaboration across all levels is essential, with development partners and target communities involved as key stakeholders in the national response to this seemingly unabating challenge. Most services provided by private and public providers are clinic-based, with minimal outreach, home and community-based services. The services are fragmented, with many vertical disease control programs. Referral systems are weak and even tertiary facilities are used for provision of primary care thus diminishing the continuum of care and making the system inefficient. Also, despite the private sector delivering 60% of health care in the country, private-public partnership is very weak. Several cost-effective interventions for improving the health of mothers and their children have been identified by The Lancet series on Maternal, Neonatal and Child Survival, the same journal’s series on Sexual and Reproductive Health and Maternal and Child Undernutrition, and WHO/UNICEF’s Regional Child Survival Strategy for Asia. Despite this evidence, in Nigeria, scarce resources are often not allocated where they will have the biggest impact. For example, acute respiratory infection – the leading cause of child mortality – attracts less than 3% of donor funding globally, even though it accounts for 25% of the burden of disease. Nutrition programs also remain chronically under-funded, despite evidence from the 2008 round of the Copenhagen Consensus that five of the ten most cost-effective interventions for helping the poor are related to nutrition. Donor funding for family planning has decreased, despite its long-standing recognition as a cost-effective program. More specifically, community and household-level interventions have highest impact, but are given lowest priority. The health system in Nigeria is set up in such a way that allocation of human, material and financial resources favors facility-based, curative care. Where community- 5 based programs have been set up, they tend to operate on a small scale, with little support from the formal health system. The low coverage and poor performance of the health system contribute to a high mortality rate of otherwise preventable deaths, including neonatal conditions, pneumonia, malaria, diarrhea, HIV/AIDS, measles, injuries and others. P AST ATTEMPTS TOWARDS C OMMUNITY-BASED NUTRITION AND H EALTH P ROGRAMS Nigeria has made various incomplete and unsuccessful attempts in the past twenty years to bring services in health and nutrition closer to the population and to create an enabling environment for community action for nutrition and health. Nigeria embraced Primary Health Care (PHC) in the mid-eighties. However, implementation beyond facility-based clinical care remains weak. Most of the reforms were poorly executed and failed to deliver on improving maternal and child nutrition and health outcomes. As a result, PHC is in a prostrate state because of poor political will, lack of accountability, gross under funding, and lack of capacity at the LGA level, which is the main implementing body. Although national policies are broadly supportive, and the draft Health Bill holds the potential to reinvigorate primary health care services with increased funding and new mechanisms, institutional fragmentation has tended to weaken accountability relationships and hindered the effective implementation of reforms to date. For example, the proportion of PHC facilities providing immunisation services range from 0.5% in the North-West zone to 90% in the South West and South East Zones. Also the capacity to provide basic emergency obstetric services is very limited as only 20% of facilities are able to provide this service. This limited coverage of basic health services, which results from poor access to information and services results in under utilisation of services. Only 58% of women receive antenatal care from a professional with coverage levels, ranging from 31% to 87%, and deliveries under the supervision of a trained birth attendant ranging from 9.8% to 81.8%. The lowest figures are from the North East and North West zones. Similarly, nutrition, which provided the springboard for community strategies in several sub- Sahara African countries (e.g., Ghana, Senegal, Tanzania, Ethiopia) has received minimal attention from the Nigerian Government, despite widespread malnutrition in the entire country and in rural areas in particular. Nutrition has suffered from the awkward institutional location in government with responsibility for broad policy development housed in the NPC and the NCFN, public health policy development housed in the Federal Ministry of Health’s underfunded Division of Nutrition; and implementation of mostly narrow vertical interventions by the NPHCDA. Official responsibility for nutrition policy broadly considered lies with the National Planning Commission (NPC). A National Committee on Food and Nutrition (NCFN) was established in the NPC to develop the National Policy on Food and Nutrition (2002), coordinate nutrition activities across the sectors, mobilize resources for nutrition, and provide oversight on nutrition in recognition of the cross-sectoral nature of action necessary to improve nutrition. Several problems have been highlighted concerning NPC’s role in coordinating nutrition activities and its commitment to nutrition and to an effective NCFN is often felt to be wanting. First, the 6 Commission is staffed by economists and planners and only in 2002 was a nutritionist brought on as staff at NPC to be responsible for the activities of the NCFN. Secondly, there are no signs that nutrition is privileged in the allocation of government resources by virtue of the presence of the secretariat of the NCFN in NPC. Indeed, the fact that virtually all costs for nutrition programming in Nigeria are borne by donors indicates that the NPC lacks necessary influence in this regard (Benson, 2008). The Federal Ministry of Health has one Division dedicated to nutrition but in the past five years, there has been no budgetary allocation to the Division. Most state ministries of health have comparable nutrition units responsible for coordinating all nutrition activities in the health sector of the state. As at the Federal level, the state-level nutritionists complain of poor funding for carrying out their responsibilities. Technical activities in the public sector that are explicitly identified as being nutrition oriented are those related to PHC. The NPHCDA is the principal institution responsible for seeing that nutritional deficiencies are directly addressed by health workers in communities across Nigeria. This work is done through programs in child growth monitoring, demonstrations of the preparation of locally adapted nutritious food and food preservation techniques, vitamin A and iron supplementation programs, and advocacy for exclusive breast-feeding. Interest in community-based health and nutrition has increased with the adoption of the IMNCH Strategy. A new momentum for maternal and child health culminated with the adoption of the National Integrated Maternal, Newborn and Child Health (NIMNCH) Strategy by the Federal Ministry of Health and the development partners in March 2007. This strategy primarily aims at improving nutrition, maternal and child health in line with the MDGs 1, 4 and 5. It builds on and incorporates other strategies, guidelines and policies that have been functioning at various levels, e.g., the Primary Health Care strategy, the Integrated Management of Childhood Illnesses (IMCI), the Baby Friendly Hospital Initiative (BFHI), and the strategic guidelines for infant and young child feeding. The NIMNCH Strategy organizes the interventions by three service delivery modes, i.e., the household and community-based services, the population services (e.g., vitamin A supplementation, immunization, deworming), and clinical care. Together these health care services are the most relevant for addressing the health care problems of ordinary families; they are also most crucial for addressing the MDGs that relate to health. However, little information is available about these services, in particular household and community-based services, and the systems that provide them. Most maternal and child care takes place in and around the home. However, the implementation capacity to influence these family practices has not adequately been assessed and analyzed. Moreover, there are great differences across the country in living standards, climate, health threats, quality of governance, and the patterns of state and local government (LGA) services to which people have access. So increasing understanding of what is needed to consolidate and scale up the implementation of the NIMNCH Strategy is a high priority. However, the lack of a functioning system for supporting community action has meant that the family and community mode of delivery of the strategy has so far received less attention (and funding) than the outreach and clinical care modes of delivery. 7 C OMPARATIVE C ASE STUDIES With the objective of getting a better understanding of best practices in launching and sustaining nutrition projects in Nigeria, four different projects were selected for detailed case study analysis. The cases that were chosen are the Safe Motherhood Initiative (SMI under PATHS1) in Jigawa State, COMPASS in Nasarawa and Kano States, PRRINN-MNCH in Katsina State, and GINA Phase II in Kano State. Table 1: Basic Project Information Project COMPASS GINA II PRRINN-MNCH SMI/PATHS1 Donor USAID (USA) USAID (USA) DfID (UK) & DfID (UK) Norway Main Focus Basic education, Child survival, Maternal health Maternal health Areas child survival, nutrition and improved and improved family planning / obstetric care obstetric care reproductive health Intervention Interactive radio Growth monitoring Emergency Emergency examples instruction transportation transportation PD Hearth, other scheme scheme Pre and in-service food preparation teacher trainings demonstrations Community Community savings scheme savings scheme School health and Microcredit nutrition (de- scheme Community-based Community-based worming, physical information information examinations) Increasing small- dissemination dissemination scale production Organization of and processing of outreach events to micro-nutrient rich educate foods communities about malaria Boreholes, water prevention and pumps treatment. PD Hearth Location Nassarawa, Kano, Kano, Katsina, Jigawa, Kano, Lagos, Bauchi, Akwa Ibom, Zamfara, Yobe, Enugu, Kaduna, FCT Nassarawa Jigawa, Kano Ekiti (management) Implementa- May 2004 – April Jan. 2006 – Jul. Oct. 2006 – Dec. June 2002- June tion period 2009 2007 (18 months) 2012 2008 (5 years) (6 years) # LGAs 51 3 21 6 #Communities 203 9 92 for MNCH 36 initial, rolled out to 90 8 The case studies of COMPASS, SMI/PATHS1, and PRRINN-MNCH focused on community- based initiatives within each project, and did not seek to review the totality of the projects’ interventions. All projects were/are funded by bilateral donors, namely, USAID, DfID and the Norwegian Agency for Development Cooperation. SMI and PRRINN-MNCH were health oriented and targeted pregnant women, but with the intention to add more children and women health and nutrition interventions to the same community mobilization platform. COMPASS was a health and nutrition project that also integrated education components. However, for the purpose of this study, we focused mainly on the health and nutrition components. GINA in Kano State was a nutrition project with a strong focus on agriculture interventions combined with nutrition communication interventions such as growth monitoring and Positive Deviance (PD) Hearth. (Table 1). Figure 2: Project’s location by State COMPASS, SMI and PRRINN-MNCH were longer-term, large-scale initiatives while GINA was a small, short duration project. PRRINN-MNCH in Katsina State had only six months of implementation, even though a similar platform had been rolled out in other states before. PRRINN-MNCH is the only project that was operative at the time of the study which allowed for direct observation of the implementation. The other three projects had already closed which made analysis of their sustainability possible. PATHS1 has subsequently been succeeded by PATHS2. Only the SMI under PATHS1 is discussed here. The projects were located in 9 Northern States (Kano, Katsina and Jigawa) and one of them, COMPASS, was studied in both a northern state (Kano) and a state in the North Central Zone (Nassarawa). COMPASS was the largest project, covering 51 LGAs in total, followed by PRRINN-MNCH and SMI (21 and 6, respectively). GINA had the lowest coverage, at 3 LGAs (See Figure 2). Data collection and methods were informed by a common study framework that outlined key “dimensions� of successful community-based health and nutrition programs. The framework was developed during a one week methodology workshop organized jointly by WB consultants in Nigeria and the WB team and held in Abuja in April 2010. The framework’s dimensions included: 1. Using and strengthening existing community organizations – This dimension looked at: (i) community involvement, participation and influence in design, planning, implementation, M&E; (ii) Adaptability and flexibility of design and implementation to social, religious and environmental contexts; (iii) Degree of integration of activities, actors and resources; (iv) Ability of community members to hold project responsible for fulfilling program goals and objectives; and (v) Creation of new structures and actors and their relation to existing structures; 2. Extent to which project is embedded in and catalyzes policy environment and engages stakeholders – This dimension looked at: (i) Political and Financial stakeholder involvement and support; (ii) Extent to which stakeholders are brought together for building alliances and coalitions for change; (iii) Use of advocacy and strategic communication; and (iv) Use of existing protocols, guidelines and tools; 3. Cost effectiveness – This dimension looked at: (i) Choice of intervention, i.e., direct and proven cost-effective interventions and multisectoral nutrition and health sensitive interventions; (ii) Budget categories and cost structure; and (iii) Monitoring and evaluation of cost-effectiveness; 4. Financial capacity – This dimension looked at: (i) Funding base, i.e, single donor or multiple sources of funding including the national budget; and (ii) Resource mobilization strategy including short-term opportunistic fund raising and long-term sustainability planning; and 5. Management capacity – This dimension looked at: (i) Human resource and capacity management including technical capacity, career development, performance evaluations, team building, recruitment, training, supportive supervision, mentoring/coaching, reward system, attrition levels; (ii) Subsidiarity and decentralization of roles and responsibilities; and (iii) Financial management, including funding flow and financial arrangement. This framework was organized into a matrix and informed each case study. In addition to the five dimensions, a number of sub-dimensions were developed to increase granularity. The complete matrix can be found in the Annex D of the main report. Three open-ended questionnaires were developed to guide the collection of data and information across each dimension for: (i) project management staff and frontline personnel; (ii) community members; and (iii) other stakeholders (e.g. LGA and State Government personnel, NGO staff). The data collection involving community members was mainly through focus group discussions or workshops. Key informants including project staff and other stakeholders were invited for 10 individual in-depth interviews. In addition, each case study is supported by a desk review of project documents. K EY F INDINGS The case studies provided a wealth of information on best practices in community-based programming for improved nutrition and health. It also highlighted some common pitfalls and “least best� practices. What follows is: (i) a set of key findings pertaining to the organization and system development of community-based nutrition and health interventions which have important implications for the sustainability of community nutrition and health programs; followed by (ii) a set of important design-relevant findings on ways to enhance results in community-based strategies for improved nutrition and health. Organization of community-based nutrition and health interventions 1. Community-based services (delivered in the community and by the community) need to have a more prominent role in the delivery of basic nutrition and health services. In the cases studied, community engagement is used mainly as a channel to increase demand for health services in facilities. Yet, community-based approaches are particularly relevant for interventions which involve behavior change at the household level such as birthing practices, neonatal care practices, infant feeding practices, and hygiene, all of which have great importance for maternal and child health and nutrition, which do not necessarily require direct support form health facilities for consumables or for technical supervision. The dire situation of many primary health care facilities and the high costs associated with: (i) their upgrading; and (ii) developing enhanced stewardship of the sector, implies that there is potentially more to gain by emphasizing community action for nutrition and health. That said, community-mobilization has the long-term potential of creating and voicing demand for good quality of services for the community members when in need. 2. Community-based strategies need to be part of system development. Many initiatives are led by donors and perceived as pilot experiences. As a result, sustainability has been problematic. Project design needs to contemplate the long-term sustainability supported by government structures. This implies that government structures become actively engaged in the activities from project conception to evaluation. Moreover, given the fragmented and complex nature of the Nigerian health system, all levels of government need to be involved for an effective delivery of services at the community. The appropriate engagement of State and LGA levels is particularly crucial to improve the coverage of unmet demand for and enhance sustainability of community-based nutrition and health services. 3. Community-based nutrition and health programs should seek ways to more effectively use the comparative advantage of NGOs. NGOs often represent community interests more effectively then the bureaucratic and/or vertical public sector. By virtue of being less bureaucratic, they are more flexible in the way they engage with different communities in terms of organization and cohesion, social norms and religion, infrastructure, wealth and other characteristics. Generally, NGOs also have more experience with community organization and development than the public sector. Hence, in many ways, NGOs can contribute to the 11 successful implementation of community-based nutrition and health programs. Yet, so far, there has been limited experience in Nigeria in developing effective public-private partnerships of this sort. In some cases, NGOs have been used as a vertical stop-gap measure without strategically anchoring their contribution in a broader approach of community mobilization and development. The resulting lack of sustainability then is often incorrectly blamed on NGOs rather the strategy (see next point). 4. Given the inherent involvement of many actors and stakeholders in community- based programs, community-based programs should clearly define roles and responsibilities in order to avoid misunderstandings and duplication, but also to enhance coordination and accountability. The cases provided various examples of unclearly defined roles and responsibilities undermined the efficiency of the project. The roles and responsibilities should stipulate “who does what� but also “who reports to whom�. As for institutional roles and responsibilities, the use of Memoranda of Understandings (MOU) and other contractual agreements have shown to be useful tools. Accordingly, the use of NGOs requires careful planning and consideration to ensure that their role builds on their comparative advantage and is complementary to that of other stakeholders. When properly done, using NGOs to implement community-based nutrition and health programs is as sustainable as if not more than any other strategy to reach results; it costs money, and requires training, supervision and monitoring, but most importantly, it builds capacity. 5. Community-based nutrition and health programs should dedicate a major part of their resources on developing strong and lasting support mechanisms for community members and community (support) groups. Community-based action for nutrition and health implies the active involvement of community members (often known as “volunteers�). These community members and community groups play a most important role in bringing about change, and therefore are essential stakeholders in community development for better nutrition and health. The identification and mobilization of local structures and resources available and capable to provide adequate support to the community mobilization efforts is a critical factor in the performance of community-based programs. The cases showed that the change process at community level quickly erodes after projects close as that puts an end to the support and guidance mechanisms. 6. Community-based nutrition and health programs should agree on a common set of outcomes and related activities but provide space for operational flexibility at the local level in developing appropriate and effective mobilization strategies. The case studies showed that communities generally are very flexible to accommodate different project needs. However, due to the differences in the ways communities are organized, rigid mobilization strategies generally have not worked well. By allowing more operational flexibility (without compromising on results and related activities), there will be scope for learning-by-doing, a principle that has worked well for community strategies in other countries. 7. For community-based nutrition and health services to be scaled up, programs should decentralize the management of operational support and supervision. As local representatives of government in charge of local development, LGA have a role to play, but also can bridge the distance between state level leadership and community action for nutrition and health, and allow for a more flexible approach to community mobilization activities that take into 12 account the local context and cultural norms and characteristics. However, issues of capacity need to be addressed through a gradual approach of capacity enhancing activities aimed at strengthening the implementation, coordination, monitoring and stewardship roles at the State and LGA levels.. 8. Given the political, institutional and organizational differences between individual states, community-based programs should adopt a state-by-state identification of the most appropriate lead agency for community mobilization. By virtue of its vertical hierarchical organization, the SMOHs are not necessarily best equipped to take the lead in the mobilization and organization of community action for nutrition and health. While SMOHs have an important role to play in the guidance and supervision of the activities at community level, other institutions can complement that role in the areas of community mobilization and organization. 9. Community-based program should follow an emerging design of gradually building the critical mass of mobilization for maternal and child nutrition and health. Rather than starting with an all out, all-at-once approach to stakeholder mobilization and involvement, community-based programs are best served by starting with a relatively simple design in order to focus on community action and results. From there, the program can seek out the formal involvement by other stakeholders and broaden the stakeholder base around the program. Achieving results 10. Community-based nutrition and health programs should focus on the achievement of selected outcomes through the use of results frameworks, the inclusion of proven interventions, and the application of a results-based project design. Programs which do not link the inputs/outputs with specific results and have broad objectives will be less effective in achieving and documenting crucial results for the MDG targets. The biggest initial gain on selected results can be made by scaling up proven cost-effective interventions which in turn will inform the program on underlying factors of ill-health, malnutrition and death and thus to additional (indirect) interventions. 11. Programs aimed at effective community mobilization for maternal and child nutrition and health should take the time to introduce the objectives and strategies to the formal and informal authorities and stakeholders concerned. Effective community-based nutrition and health programs depend on the involvement of formal, traditional and religious authorities, as well as community stakeholders such as men and grandmothers. Advocacy visits and community meetings are all proven strategies to inform the stakeholders and obtain their support. The case studies also showed the importance of paying due respect to the lines of authority in the sequence of sensitizing and mobilizing stakeholders at the different levels. 12. Monitoring systems should start with and be based on community monitoring. Community monitoring enhances community ownership of the program objectives but also provides the means to effectively link the informal, horizontal community structures with the formal, vertical public systems. The case studies showed that without good monitoring that originates at community level, the link was quickly lost and timely support became unavailable. 13 There is an urgent need for improved understanding of the benefits of local monitoring both among project planners and community members. 13. Community-based programs should translate actions and interventions into visible results that communities can own and monitor. In the case studies, safe motherhood was carried successfully by communities because they experienced (and monitored) the dramatic fall in maternal mortality. Conversely, immunization proved to be more difficult to sell at community level as it wasn’t clear to communities what result was being achieved. This principle lies at the heart of growth monitoring and promotion (making growth visible to mothers and communities), Positive Deviance Hearth (using the demonstration of results in the health of children to promote the impact of good caring practices to treat and prevent malnutrition). Similarly, experiences from elsewhere in the region and beyond provide examples of the importance and ways to translate interventions into visible and “monitorable� results. Many of these experiences are in the area of child health and nutrition. 14. Community-based programs aimed at behavior change should consider ways to combine integrated comprehensive communication approaches, e.g., individual counseling, with normative communication strategies as well as focused social marketing campaigns around key messages. The safe motherhood initiative created very good results by saturating communities with information regarding the need to reduce delays in seeking emergency obstetric care. However, pregnant women, mothers and communities need access to more comprehensive information on the broader spectrum of issues in maternal, newborn and child health and nutrition in order to enhance healthy growth in women and children. For example, counseling during pregnancy and early childhood can effectively address information needs as they arise at individual level. Such needs cannot be taken care of by social marketing campaigns. Yet, normative communication and social marketing campaigns are very effective to raise the visibility of specific key messages. 15. Special attention should be given to equity issues in community-based programs by ensuring the inclusion of hard-to-reach and vulnerable groups. Vulnerable groups of women among the poor are often hard to reach and in dearest needs of the services and interventions in community-based nutrition and health programs. Strategies that have been employed to promote inclusiveness and equity include communication, community monitoring, and membership in committees and community groups. Improved mechanisms of inclusion of vulnerable households are needed which requires joined thinking of project planners and communities alike. 16. Community-based programs for nutrition and health should systematically track and document the cost of implementing community-based nutrition and health programs. One limitation of the study is the lack of baseline data on community-based (maternal and child health and nutrition strategies) financing in Nigeria. Based on limited information from programs in other countries, there is some reference data available as to what community-based health and nutrition programs tend to cost per mother/child per year, or per capita per year. This will improve the information basis on the cost of these programs and thereby the forecasts necessary for budget preparation. 14 M OVING FORWARD As a result of the looming end date of the MDGs, high level political support for the Integrated Maternal, Newborn and Child Health Strategy; and revamping of the Primary Health Care service delivery system, there is a real policy opportunity to build the systems necessary for sustainable community engagement for maternal and child nutrition and health. In order to seize this opportunity, the authors suggest that the states in Northern Nigeria take some bold decisions in favor of building sustainable community-based programs for maternal and child nutrition and health by 2015. The actions should comprise the following: • Identify and convene stakeholders from all levels to: (i) disseminate the study results; and (ii) reach consensus on the need to build sustainable systems for community-based health and nutrition action as well as a road map on how to get there; • Design strategies for community mobilization and community action for mother and child nutrition and health that: i. agrees on a set of common outcomes and interventions – based on the specific health and nutrition problems of each state, the strategy should focus on evidence-based cost-effective interventions; these interventions should include at least some interventions of high perceived value to the community to enhance adoption and ownership; ii. organizes communities around specific activities and interventions using a flexible mix of community implementers and community groups through participatory, consensus-building approaches to community mobilization; and iii. ensures regular close and continued support to the community structures through the involvement of NGOs, LGAs and public health service providers in clearly defined responsibility arrangements for mobilization, guidance and reporting as an integral part of the Primary Health Care system; • Pilot community service delivery in a number of LGAs with the goal to scaling up the initiative throughout the state by adopting a learning-by-doing approach to building the capacity for a flexible, decentralized and inclusive management structure; • Re-allocate, mobilize and increase resources from LGA, state and federal health budgets for the sustainable program-wise implementation of the community-based strategies; while donor funding is attractive and useful to kick-start the process, national stakeholders should recognize the common pitfall of its time-bound nature that has caused and still causes the loss of numerous best practices in ensuring better services for nutrition and health to poor communities. 15