AITH, PEACE & P Y & F ROGR nbs IT E UN SS
NATIONAL NUTRITION AND HEALTH SURVEY (NNHS) 2018
REPORT ON THE NUTRITION AND HEALTH SITUATION OF NIGERIA
JUNE 2018 Foreword
The 2018 National Nutrition and Health Survey (NNHS) was conducted by the National Bureau of Statistics (NBS), in collaboration with the National Population Commission (NPopC) and the Nigeria Federal Ministry of Health. Financial support was provided by the Government of Nigeria, United Nations Children's Fund (UNICEF), United States Agency for International Development (USAID) and Department for International Development (DFID). Technical Support was provided by UNICEF and the Government of Nigeria through NBS.
NNHS is a household survey conducted using Standardized Monitoring and Assessment of Relief and Transition (SMART) methodology. NNHS is conducted annually and this is the third national level survey, the first and second being in 2014 and 2015 respectively. NNHS provides up-to-date information on the situation of nutrition and health and measures key indicators that support the country to monitor progress of Saving One Million Lives (SOML) Program for Result (PforR) initiative and other national and international goals.
National Bureau of Statistic (2018) Main Report, Abuja Nigeria
i | P a g e Foreword
The Federal Government of Nigeria in line with its role of providing strategic direction for the Health Sector initiated the “Saving One Million Lives Programme for Result” (SOML-PforR). This was conceived by the Federal Ministry of Health as a strategy to save the lives of mothers and children by increasing access to, and utilisation of evidence-based, cost-effective and high impact maternal, child and nutrition interventions in Nigeria.
The Programme is a results-focused partnership with the State Ministries of Health. This is financed by a $500million International Development Association (IDA) credit to the Federal Republic of Nigeria over a period of 4 years. It is based on an approach of structuring the flow of resources to pay for results—desired goals, outcomes, and impacts—rather than simply paying for processes or reimbursing activity costs.
The National Nutrition and Health Survey (NNHS) is a household survey using 'Standardized Monitoring and Assessment of Relief and Transition' (SMART) methodology. The SMART methodology is an improved survey method that balances simplicity with technical soundness. It uses a two stage cluster sampling i) Enumeration Areas (EAs)/Cluster as Primary Sampling Unit and ii) The listed Households as Secondary Sampling Unit. The survey has an excellent data quality control mechanism.
This Report is the third national level NNHS survey, the first and second being in 2014 and 2015 respectively. Consequently, NNHS provides up-to-date information on the situation of nutrition and health and also measures the 'Saving One Million Lives Program for Results (SOML-PforR) key indicators and other health related indicators.
Availability of annual SMART Survey reports forms the basis for FGON to provide performance linked disbursement to States based on the quantity and quality of services provided at the Primary Health Care level. The dual benefit of improved health care and the accompanying financial incentive makes the annual NNHS a 'win-win' for the FGON and State governments. This is synonymous to the global paradigm shift of paying for performance to drive efficient and better health outcome.
In conclusion, I urge policy makers and program managers to focus on the outcome of this report and ensure that efforts should be made towards addressing all areas of concern in a concerted and coordinated manner. It is my hope that all stakeholders will play active roles in closing the gaps in the provision of high-quality health services to the Nigerian populace.
Professor Isaac F. Adewole, FAS, FSPSP, FRCOG, DSc (Hons) Honourable Minister of Health, Federal Ministry Republic of Nigeria Abuja. October, 2018.
ii | P a g e Table of Contents
FOREWORD i LIST OF ACRONYMS v EXECUTIVE SUMMARY 1 INTRODUCTION: 10 GENERAL BACKGROUND 10 JUSTIFICATION FOR THE SURVEY 13 OBJECTIVES OF THE SURVEY 14 METHODOLOGY 15 DESIGN 15 SAMPLING 15 TRAINING 17 RECRUITMENT OF INTERVIEWERS AND TEAM ORGANIZATION 18 DATA COLLECTION AND SUPERVISION 20 DATA QUALITY CONTROL, DATA ENTRY & ANALYSIS 21 DATA QUALITY CONTROL 21 DATA ENTRY 21 DATA ANALYSIS 22 RESULTS 23 SAMPLE DESCRIPTION 23 ANTHROPOMETRY RESULTS 25 Acute Malnutrition 25 Acute Malnutrition (WHZ /or Bilateral Oedema) 26 Acute Malnutrition using Mid Upper Arm Circumference (MUAC /or Bilateral Oedema) 32 Underweight 36 Stunting 41 Trends of Acute Malnutrition 47 Dual Malnutrition Deficits 48 Overweight 49 CHILD HEALTH 54 Vaccination Coverage 54 Measles Vaccination 58 Diarrhoea, Oral Rehydration Therapy and Zinc Supplementation Coverage 62 Acute Respiratory Infection (ARI) and Treatment 66 MALARIA 69 Antimalarial Treatment for Children 74 Intermittent Preventive Treatment for Malaria in pregnant women 78 WOMEN NUTRITION 82 REPRODUCTIVE HEALTH 87 Skilled Birth Attendant 87 Contraceptive Prevalence Rate 92 Antenatal Care 95 HIV Testing 99 MATERNAL NEWBORN AND CHILD HEALTH WEEK (MNCHW) 103 Vitamin A 106 Deworming 107 WATER AND SANITATION (WASH) 112 INFANT AND YOUNG CHILD FEEDING PRACTICES 118
iii | P a g e LIMITATIONS, POTENTIAL BIASES AND CHALLENGES FACED 131 CONCLUSIONS AND RECOMMENDATIONS 133 REFERENCES 138 AN NEXES 144 ANNEX 1: DATA QUALITY – PLAUSIBILITY SCORES 146 ANNEX 2: LIST OF INDICATORS 151 ANNEX 3: SURVEY IMPLEMENTATION TIMELINE 150 ANNEX 4: SURVEY TEAM MEMBERS 152
iv | P a g e List of Acronyms
ACT Artemisinin-based Combination Therapy ANC Antenatal Care ARI Acute Respiratory Infection CI Confidence Interval CMAM Community-based Management of Acute Malnutrition DFID Department for International Development DHS Demographic and Health Survey DPT Diphtheria, Pertussis and Tetanus EA Enumeration Areas EFB Exclusive Breastfeeding ENA Emergency Nutrition Assessment EPI Expanded Programme on Immunisation FCT Federal Capital Territory FGON Federal Government of Nigeria FMOH Federal Ministry of Health GAM Global Acute Malnutrition HAZ Height for Age Z-score HH Household IPTp Intermittent Preventive Treatment in Pregnancy ITN Insecticide Treated Net IYCFP Infant and Young Child Feeding Practice KAP Knowledge Attitudes and Practice LGA Local Governmental Area MAM Moderate Acute Malnutrition MDG Millennium Development Goals MNCHW Maternal Newborn and Child Health Week MICS Multiple Cluster Indicator Survey MMR Maternal Mortality Rate MTCT Mother To Child Transmission MUAC Mid-Upper Arm Circumference NBS National Bureau of Statistics NCHS National Center for Health Statistics NDHS Nigeria Demographic and Health Survey NIS Nutrition Information System NMCSP National Malaria Control Strategic Plan NNHS National Nutrition and Health Survey NPopC National Population Commission
v | P a g e NSHDP National Strategic Health Development Plan NSPAN National Strategic Plan of Action for Nutrition ORIE Operational Research and Impact Evaluation ORS Oral Rehydration Salts ORT Oral Rehydration Therapy PBF Predominant Breastfeeding PENTA Pentavalent vaccine PHC Primary Health Care PPS Probability Proportional to Size PSU Primary Sampling Unit RDT Rapid Diagnostic Testing SAM Severe Acute Malnutrition SD Standard Deviation SMART Standardized Monitoring and Assessment of Relief and Transition SOML Saving One Million Lives SP Sulphadoxine Pyrimethamine UCI Universal Child Immunization UNHCR United Nation High Commission for Refugees UNICEF United Nations Children's Fund USAID United States Agency for International Development VAD Vitamin A Deficiency WASH Water Sanitation and Hygiene WAZ Weight for Age Z-score WB World Bank WHZ Weight for Height Z-score WINNN Working to Improve Nutrition in Northern Nigeria WFP World Food Program WHO World Health Organization
vi | P a g e Executive Summary
Introduction:
This report presents the findings of the National Nutrition and Health Survey conducted in 37 domains (36 states and Federal Capital Territory (FCT) between February 19 and June 2, 2018; the third national survey conducted using SMART methodology by NBS, in collaboration with NPopC and the Nigeria Federal Ministry of Health and with technical support from UNICEF. The first NNHS was conducted in February-May 2014 and the second in July-September 2015. The main objective of the NNHS 2018 was to assess the current nutrition status of the population (especially children 0-59 months old and women of reproductive age (15-49 years old) at state, zonal and national levels; to assess infant and young child practices among 0-23 months, and to monitor the progress towards the Saving One Million Lives (SOML) goals which forms the basis for performance linked disbursement to States based on the quantity and quality of services provided at the Primary Health Care level , .
Methodology:
A two-stage cluster sampling methodology was used in selecting 36 clusters in each of the 37 states/domains and 20 households in each cluster. A total of 19,471 boys and girls (sex ratio 1.0) aged 0-59 months from 24857 households in 1,322 clusters (>95 percent accessed) were assessed for anthropometry and health status, of which 8124 children were aged 0-23 months and were assessed for infant and young child feeding (IYCF) practices. A total of 24,985 women aged 15-49 years were assessed for their nutrition status and reporoductive health using the NNNHS steering committe validated tool and protocol.
Data Quality Control
With elaborate and stringent measures put in place to ensure good quality of data, the evaluation report for the quality of the survey using the ENA software shows the quality of the survey is excellent with an overall plausibility score of 5 percent. As shown in Annex 1, the data quality is excellent in 34 states/domains and good in 3 states (Cross River, Kogi and Zamfara) with plausibility scores ranging from 0 to 12 percent. The main quality control measures implemented were: 1) Rigorourus training of surveyors for 6 days (increased from 5) on the survey protocol – including sampling, interviewing and measurement techniques and use of mobile data collection skills by a