Nigeria Background and A&T Proposed Initiative

1. Executive Summary Every year, millions of children die and many more fail to realize their full potential because of undernutrition in the critical 1,000 day period. Nigeria is home to about 7% of the world's sub-optimally breastfed children and ranks second in countries with high mortality due to sub-optimal feeding. Progress in reducing undernutrition has been hampered by a number of challenges (many of which are not unique to nutrition, but rather are systemic and are operational issues that affect numerous sectors) but unprecedented political attention to undernutrition over the last few years has created a critical window of opportunity in Nigeria. We believe this investment has the potential to lower deaths attributable to sub-optimal breastfeeding through implementation of Alive & Thrive’s (A&T) proven approach, drawing on experience and lessons learned from the program’s first phase.

Because of the size and complexity of Nigeria, the program is proposed to focus on two states, Lagos and Kaduna, with national level advocacy. All four components from A&T’s framework will be applied in the states: (1) advocacy and policy; (2) interpersonal communication and social mobilization; (3) mass communication; and (4) strategic use of data.

The primary learning question for the evaluation in Nigeria will be: Can implementation of the four component framework in Nigeria have an impact on infant and young child feeding (IYCF) behaviors similar to what was observed in Phase I A&T countries? The primary outcomes to be measured will be IYCF practices in the two states where A&T will be implementing all four components—Lagos and Kaduna. The outcomes are related to the WHO-recommendations for optimal breastfeeding and complementary feeding practices for children under 24 months of age. These will include, but may not be limited to: increases in early initiation of breastfeeding (within one hour of birth), increases in exclusive breastfeeding, and increases in minimum diet diversity and minimum meal frequency among children 6-23 months. These will be the primary outcomes of two of the key A&T components: interpersonal communication and community mobilization and mass communication. A&T experiences in other countries have shown that a model that incorporates advocacy for pro-IYCF policies and strategic use of data are effective at achieving the behavioral outcomes listed above due to their positive impact on supportive social norms. Additional outcomes expected from these two components include: improved implementation of IYCF-friendly policies and increased use of data to support IYCF programs and policy.

2. Problem Statement Infant mortality, stunting/wasting, and IYCF Nigeria, the most populous country in Africa with 178.5 million people,1 has some of the world’s lowest maternal and child health indicators. In the last five years, moreover, rates of improvement slowed and the country barely reached the half-way mark toward its 2015 MDG targets. According to the most recent Nigeria Demographic and Health Survey (NDHS-2013),2 under-5 mortality was 128 deaths per 1,000 live births and infant mortality was 69. The neonatal mortality rate hardly changed in the preceding five years, dropping from 41 to 37 deaths per 1,000 live births. The maternal mortality ratio also remained high at 560 per 100,000 live births.

Nutrition indicators have shown a similar pattern of stagnation. The exclusive breastfeeding rate for 0-6 month olds—a practice that can significantly reduce child deaths—has remained unchanged since 1999 at an astounding 17%. Stunting among children under 5, high at 37% nationwide, dropped 3 percentage points over the previous 5 years. But the rate of wasting actually rose— from 14% to 18%. Table 1 shows basic nutrition indicators for children 0-23 months in Nigeria nationally and for the two priority program states of Lagos and Kaduna by richest and poorest socioeconomic status (SES) quintiles.3 The data highlight the distribution of population by wealth in the two states (strongly reflecting the urban vs. rural population divides). The data also highlight the extreme nutritional deficiencies prevalent particularly in Kaduna across wealth quintiles, and the presence of high wasting even among the urban rich in Lagos.

1 World Bank data. Available at: http://data.worldbank.org/country/nigeria 2 National Population commission [Nigeria] and ICF Interntaional (2014). Nigeria Demographic and Health Survey 2013. Aguja, Nigeria, and Rockville, MD, USA: NCP and ICF International. (Henceforth NDHS 2013) 3 USAID has been conducting a review of data quality (especially anthropometry) in the NDHS 2013. At project outset, A&T will consider any issues/implications related to this review and will conduct its own anthropometric survey to establish baseline measures for the project areas. Table 1: Nutritional status of children < 2 year in the richest and poorest* quintiles, nationally and by region (NDHS 2013)+

Indicator National Lagos Kaduna-Urban Kaduna-Rural Poorest – richest Poorest – richest Poorest – richest Poorest – richest

Stunting (% < -2SD) 48 – 14 N/A – 9 N/A – 60 53 – N/A Severe stunting (% < -3SD) 29 – 6 N/A – 1 N/A – 39 39 – N/A Wasting (% <-2SD) 19 – 13 N/A – 17 N/A – 33 44 – N/A Severe Wasting (% < -3SD) 6 – 3 N/A – 3 N/A – 18 19 – N/A

*Note: Wealth quintiles were calculated based on the national sample. In Lagos, the survey identified no women into the two bottom quintiles. In urban Kaduna, the survey identified no women in the poorest quintile. In rural Kaduna, the survery identified women in the richest (top) quintile. Some of the very wide variation in status among these sites may be a function of the way the index was identified and warrants study. +The NDHS survey did not focus specifically on children aged 0-2 and the sample for this subgroup is small. See also footnote (3) on possible issues refarding anthropoetric data quality.

Undernutrition undermines the health and development benefits of country investments. The Foundation 2015-2020 strategy notes: Millions of children die and many more fail to realize their full potential because of undernutrition in the critical 1,000 day period between their mother’s pregnancy and their second birthday. Malnutrition is responsible for nearly half of all under- five child deaths each year. Children who miss out on good nutrition during these 1,000 days never achieve full physical or mental growth, limiting their ability to learn in school and reducing their productivity as adults.

IYCF interventions focus on preventing undernutrition in the 1,000 day window of opportunity. However, causes of undernutrition may be multi-sectoral and, similarly, no single strategy is likely to bring about large-scale change. Determinants may range from basic food security, to wealth and social status, to access to services, to maternal education, to broad-based social norms and cultural beliefs and family practices. The two priority states for this program—Lagos and Kaduna—offer an opportunity to investigate determinants and plan program A banker: “It is just not feasible to exclusively strategies for large populations (10.7 million and 7.3 million breastfeed for six months. Is it that easy? Well, I’d respectively) with distinct urban and rural differences (Lagos state is like to do it, if I don’t have to work. Our workplaces are strictly for business, not for nursing mothers. If mostly urban) and other variations (such as predominant ethnic and you still need your job, you’ll not take your baby religious groups) that to some degree reflect the enormous diversity into a bank.” On pumping milk: “The milk easily of the country. According to WHO guidelines, the level of severe sours and besides, it is better for the baby to suck wasting in rural Kaduna may also require a fundamental difference directly from the source than be fed with a bottle. in emphasis on supplementation vs. prevention. (See Section 3. So, at two months, I had to stop exclusive Scope and Approach for further on the state-level rationale). breastfeeding – using infant formula along with breast milk when I’m available.“ The current status of IYCF practices to be addressed by A&T Why breastfeeding is becoming unpopular, by Priority nutrition practices for children under 2 years of age include mothers timely initiation of breastfeeding (BF), exclusive BF up to age 6 Wole Oyebade, The Guardian (newspaper), months, introduction of complementary foods (CF) around 6-8 months of age with appropriate frequency of meals and diversity of food groups, and continued BF up to two years.

Given the close tracking of urban and rural residence with SES status in the two priority states, one would expect poorer practices in rural areas—but this is not consistently the case. For example, Table 2 shows that in the two states, timely initiation of BF was lowest in largely urban Lagos (only 19%) compared to Kaduna (U-39%, R-35%). Continued BF for children 12-24 months was also lowest in Lagos (75%) compared to Kaduna (U-78%, R-92%).

However, generally in 2013, IYCF practices were poor in both of the priority states. Giving pre-lacteals within the first 3 days was common (Lagos-42%; Kaduna/U-60%, R-66%). The majority of babies received plain water. Further, receiving water was a norm for infants of all ages. Even during the first month of life, most infants nationwide (54%) were given water in addition to breastmilk. By 4-5 months, only 10% of infants nationwide received breastmilk with no additional liquids. The belief that infants require water is the chief reason for the low exclusive BF rate among infants 0-6 months in the priority states (Lagos-37%; Kaduna/U-19%, R-7%).

2 Table 2: Nutrition-related indicators for Nigeria (national), Lagos, and Kaduna (NDHS 2013)

Indicator Nigeria Lagos Urban Rural Kaduna Kaduna Timely initiation of BF (<1 hr) 33 19 39 35 *Prelacteal given during the first 3 days 60 42 60 66 Exclusive BF (<6 mo) 17 37 19 7 Exclusive BF at 4-5 mos 10 20 18 0 Timely introduction of CF (6-8 mo) 64 67 86 80 *Early introduction of CF (4-5 mo) 38 24 40 54 Minimum meal frequency of CF (6-23 mo) 60 46 93 85 Dietary Diversity (> 4 groups) of CF (6-23 mo) 19 11 29 10 Minimum acceptable diet (6-23 mo) 10 3 24 8 Continued BF at 12-15 mos 78 75 78 92 *Infant formula (0-6 mos) 6 12 8 7 *Bottle feeding (0< 23 mo) 16 27 20 13

*These four indicators show percent practicing harmful behaviors; other indicators are for positive behaviors.

Bottle feeding is a particularly dangerous practice and the NDHS 2013 notes that the trend is increasing. In Lagos, 27% of all children under 2 were bottle fed the previous day. Acceptability of the practice is particularly evident when data are disaggregated by age: in Lagos, 42% of children 6-11 months were bottle fed and in urban Kaduna, 39% of children 0-5 months were bottle fed. Giving infant formula is less common but still worrisome, especially in Lagos (12%).

Nigerian infants are typically introduced to complementary foods both too early and too late. According to the NDHS 2013, introduction of solid or semi-solid foods between 4-5 months was especially prevalent in Kaduna (U-40%, R-54%) but also common in Lagos (24%). At the same time, only 64% of children nationwide were introduced to complementary foods “on time” (between 6-8 months). Timely introduction was lower in Lagos (67%) vs. Kaduna (U-86%, R-80%).

The quality and frequency of foods given varies greatly. Nationally in 2013 only 10% of children 0-23 months received a minimum acceptable diet (Lagos-3%, Kaduna U-24%, R-8%). Poor dietary diversity was the biggest factor; only 11% of children in Lagos received the recommended four or more food groups, compared to Kaduna (U-29%, R-10%). Minimum meal frequency was particularly problematic in Lagos (only 46% of children) compared to Kaduna (U-93%, R-85%). See infant feeding practices by age in urban Lagos and rural Kaduna in the figures on the next page.

Figure 1 (a) and (b): Infant feeding practices by age (in months) in urban Lagos and rural Kaduna (NDHS 2013)

Potential determinants of IYCF practices (social and public health context) Policies, services, social norms, and various household characteristics may all be important determinants of the key IYCF practices. Ineffective implementation of the International Code of Marking of Breastmilk Substitutes (BMS) and lack of a policy on maternal workplace protection (Convention 183) are major issues for Nigeria. An even greater problem has been the lack of improvement over time in basic maternal and child health services. Table 3 (following page) shows that in 2013, nationwide coverage of services was two or more times higher in urban areas than in rural areas. Notably, 66% of urban women had skilled attendance at birth, compared to only 23% of rural women. This is a crucial service not only to ensure survival of both mother and baby, but to assist with BF initiation. In contrast, prevalence of a postnatal visit within two days of delivery was high everywhere. This contact is also an important opportunity to help the mother establish exclusive BF. (In rural Kaduna, 46% of visits were by traditional birth attendants [TBAs] and their skill levels may vary.)

Basic coverage and reach problems are also common for child health services. In 2013, care-seeking for child diarrhea (which can be a valuable window for changing IYCF practices) was low in Lagos (42%) and even lower in Kaduna (12%).

Table 3: Health service indicators for Nigeria (national), Lagos, and Kaduna (NDHS 2013) Indicator Nigeria Lagos Urban Rural (urban/rural) Kaduna Kaduna Four or more ANC visits 52 97 60 34 Skilled attendance at birth 38 (67/23) 87 55 20 Postnatal visit (<2 days) 94 94 99 96 Care-seeking for child diarrhea (0-23 mo) 28 (35/26) 42 12

Countdown 20154 emphasizes the challenge for Nigeria in achieving SES equity in services. Those in the two richest quintiles benefit from up to four times better coverage of MNCH services than those in the lowest two quintiles. Moreover, this imbalance is often greater than the basic urban/rural split. Nationwide, only around 10% of the poorest women have skilled attendance at birth and only around 20% have 4 ANC visits. Improving practices through face-to-face counseling will be a challenge given the low use of services by those who are most vulnerable.

Other determinants play less certain roles in IYCF practices and their effects need to be studied. Table 4 provides more information on different household characteristics that may influence practices. (See also, section “3. Scope and Approach”)

Table 4: Maternal/household characteristics and preferences, Lagos, and Kaduna (NDHS 2013) Indicator Lagos Urban Kaduna Rural Kaduna

Religious identification Christian 57%, Muslim 33% Muslim 66%, Christian 21% (more Muslim in rural areas) Ethnic identification Yoruba 58%, Igbo 20% Hausa 54%, Fulani 8% Place of giving birth (public Public = 21%, Private = 57% Public = 47%, Private =7% Publ.=19%, Priv.=1% facility/private/home) Home = 22% Home = 56% Home=80% Maternal literacy 81% 50% 19% Weekly media access by Radio = 60%, TV =73% Radio = 39%, TV = 43% Radio=26%,TV=16% women Household ownership of 97% 91% 63% mobile phone

Given reliance on private providers even by the poorest groups (for maternal delivery but also for advice on common illnesses) engaging this sector will be an important strategy. Religious institutions may be powerful channels for reaching even the “hard to reach” in all areas. In Lagos and Kaduna, the potential of mass media is uncertain before considering factors such as wealth and

4 Available at: http://www.countdown2015mnch.org/country-profiles/Nigeria

4 maternal education. In rural areas, where only 26% of women listen to the radio weekly, use of mass media will be particularly challenging. Although a high percentage of households reported having a mobile phone, access by women is not well known. (Nationally, male ownership is predominant).5

A&T’s Theory of Change

To address these challenges and issues described in the Problem Statement, A&T developed a Theory of Change, which underpins our approach to work in Nigeria and describes the links between the individual barriers and chosen strategies, approaches, and likely impact.

Figure 2: A&TInadequate Theory of resources Change and priority given to Targeted advocacy & IYCF interventions in If we address these barriers… with thesetechnical strategies…….. support at then we can achieve….. MNCH Additional IYCF national and State resources from Few health care levels States and other service contacts stakeholders Improved contacts with during child’s first 2 mothers at 0-24 years Guidelines issued months for BF/CF by State Ministers Inadequate counseling (facility-, of Health to knowledge, skills, and community-, home- prioritize IYCF in motivation of frontline based) all health services health workers to Health care provider support IYCF Mothers supported (public, private, NGO) during pregnancy, Poor families face food orientation, training, at delivery, and up IMPACT insecurity and performance to 2 years to feed improvement in IPC as recommended Lack of social support Identification of foods for recommended Health workers Increase in IYCF available even in food IYCF practices achieve high practices: early insecure households among family coverage & quality initiation of members, community breastfeeding, Social mobilization Perception among leaders, frontline exclusive through Ward Dev. food-insecure health workers breastfeeding, Committees, religious families that minimum dietary associations, NGO recommendations Lack of large-scale diversity, minimum programs are feasible interventions to shift meal frequency social norms, beliefs, Mass and traditional Communities 5 and IYCF behaviors Increase in newborn Broadcasting Board of Governors, Gallup (2014). Contemporarymedia and mobile Media Use in Nigeria. Availableenlightened at: http://www.bbg.gov/wp- to and infant lives content/media/2014/05/Nigeria-PPT-FINAL.pdf phone communication support priority Cultural saved misperceptions and to reach multiple IYCF behaviors audiences and address traditional practices Improved child relevant beliefs and Widespread (e.g., giving water) in health, growth, and misperceptions 5 perception that the first 6 months development recommended Data collection/use to IYCF practices improve interventions are the norm and policies 6 3. Scope and Approach Nigeria’s diverse society (an estimated 250 ethnic groups and as twice as many languages and dialects) offers multiple platforms to drive A&T's approaches to improve IYCF practices in this most populous African country. Its vibrant marketplace (real GDP growth rate rose steadily over the past two years and is expected to reach 5.5 percent by 2017),6 thriving media industry, energetic political dialogue, broad (albeit challenged) public health sector, and religious and ethnic community structures make it a unique place to apply A&T’s prior experience, evidence, tools, and lessons from Phase 1.

Three dichotomies, singularly and intertwined, are factors in shaping Nigeria’s future growth and development and will be critical to take into account when addressing social and health challenges:

 Urban-Rural residence—Nigeria’s current population (estimated by the World Bank at 178.5 million)7 is expected to move from 50% rural in 2012 to 67% urban in 2050, adding 212 million city dwellers.8 Developing an approach to improving IYCF in a dense urban environment will be crucial for sustained impact. Working with public and private health care services and vendors and civil society partnerships developed through the Nigerian Urban Reproductive Health Initiative (NURHI) would add value to A&T’s advocacy and outreach strategies.  Private-public health care service delivery—The GON’s health services, in various stages of improvement and neglect, have a presence in each of the country’s 36 states. But it is the private health sector that accounts for at least 60 percent of health care services utilized in Nigeria,9 including by the poor and most vulnerable populations. Improving and increasing the role of the private sector would accelerate “progress in meeting the health-related MDGs.”10  Digital-broadcast communication—Radio continues to be the most accessed broadcast medium in the country, with 39% of women and 55% of men listening at least once a week (NDHS 2013). But subscribers of mobile phone service are growing rapidly (by 10% between 2012 and 2014, to 83% of the population).11 The most common use of mobile phones in 2014 was for text messaging, but the second most common use was for radio listening.12

These drivers of change will guide A&T’s formative research, program design, and implementation at the national level and in two of the most populous states in Nigeria—Lagos and Kaduna. A&T selected Lagos and Kaduna states in consultation with Foundation colleagues and from the defined pool for the Foundation’s new work on health care in six health focus states (Kano, Kaduna, Bauchi, Niger, Nasarawa, and Lagos). We wanted this infant feeding program to be representative rather than geo- limited. Metropolitan Lagos is still the center of corporate commerce in Nigeria and in the context of maternity leave has a very progressive state Ministry of Health. Coupled with a predominantly private sector health care delivery system, A&T felt that success in Lagos would be more obtainable and likely to be regarded as replicable for some of the largest cities in the south (Ibadan, Port Harcourt, Benin City). We also felt that Kaduna state’s metropolises--Kaduna and Zaria—already offered the opportunity to work in relatively big cities in the north and were more reflective of other areas and cities than would be Kano.

Lagos is Nigeria’s largest city, with arguably the most ethnically and religiously diverse population in the country (though predominantly Yoruba, Igbo, and Christian), and with thriving media and commercial sectors. Lagos also has some of the worst IYCF practices in Nigeria. Improving IYCF practices there would not only yield large-scale change but could offer a model for other large urban areas (Kano, Ibadan). A&T will work at scale (while allowing for control areas for evaluation purposes) in metropolitan Lagos, an urban area comprising 16 of the state’s 20 local government authorities (LGAs) and about 85% of the state’s population. Estimates vary by source but in 2014 the estimated population of metropolitan Lagos was 17.85 million.13

Lagos state has a pluralistic health system with approximately 5,563 service delivery points (SDPs)14, 15 including formal and informal, private-for-profit (commercial), not-for-profit (NGO and FBO), traditional and public sector sites. The vast majority are

6 Available at: http://data.worldbank.org/country/nigeria 7 Ibid. 8 United Nations, Department of Economic and Social Affairs, Population Division (2014). World Urbanization Prospects: The 2014 Revision, Highlights (ST/ESA/SER.A/352). 9 Private Sector Health Alliance,Theory of Change. Available at: http://www.phn.ng/theoryofchange.php. 10 Available at: http://businessdayonline.com/2015/01/nigerias-private-health-sector-key-in-expanding-health-care-delivery/#.Vb-ZCflVhHw. 11 Broadcasting Board of Governors, Gallup (2014). Contemporary Media Use in Nigeria. Available at: http://www.bbg.gov/wp- content/media/2014/05/Nigeria-PPT-FINAL.pdf 12 Ibid. 13 Lagos State Government (2014). Available at: http://www.lagosstate.gov.ng/pagelinks.php?p=6. 14 Health Facilities Monitoring and Accreditation Agency (HEFAMAA). Available at: http://www.lagosstateministryofhealth.com/agency_info.php? agency_id=3 15 Anadach Consulting Group (2015). Scoping Business Practices of the PPMVs in Lagos and Kano, Nigeria: Review of the Business Model for Patent Propriety Medicine Vendors (PPMVs).

7 private, and mostly for profit. While staffing varies significantly depending on LGA and facility type, in general there are adequate numbers of both health facilities and service providers in Lagos state (as compared to Kaduna state).

Kaduna is Nigeria’s third most populous state, with an estimated population in 2012 of about 7.4 million. 16 It has one of the highest stunting rates for children under 5 (56.6% according to SUN/Nigeria). Kaduna state has a more typically mixed population of urban/rural dwellers (33%/67%), ethnicities, and religions (though predominantly Hausa and Muslim), and a mix of public and private sector services. Kaduna will also be the beneficiary of a Bill & Melinda Gates Foundation-funded primary health care (PHC) initiative, which will help revitalize that state’s self-reported challenges in providing PHC to its urban and rural residents. A&T will link up with the initiative’s public and private sector partners (especially the PPMV, maternity hospitals, and private clinics) to strengthen the role of frontline health workers’ knowledge and counseling skills to promote IYCF. We will work through the PHC system to integrate materials and delivery of messaging at opportune times and places, including ANC visits, maternity facilities, outpatient therapeutic feeding (OTF) programs, Community Management of Acute Malnutrition (CMAM) sites, Kangaroo Method Care facilities, and through child welfare services’ immunization campaigns and routine provision of vaccines. A&T will work at scale in most of the 23 LGAs in Kaduna (will neccesarily include control LGAs in Kaduna for evaluation purposes).

Kaduna state operates a pluralistic health system with a total of 4,180 SDPs including formal and informal, private-for-profit (commercial), not-for-profit (NGO and FBO), public sector and traditional sites. While staffing varies significantly depending on facility type and LGA, in general, human resources are less available across clinical cadres than in Lagos state.

Working in these two states will help the GON operationalize the National Strategic Plan of Action for Nutrition (2014‒2019) and develop a model that can be applied to other states. A&T will also work at the national level in concert with public and private sector stakeholders to support the advocacy and data use needs of national nutrition initiatives that are part of the GON’s new Health Sector Component of the National Food and Nutrition Policy.

A&T approach and framework

A&T will utilize the four-component framework (see Figure 3) developed by the project in Phase 1 and now being adapted in other countries. The components include national/state level policy and advocacy; interpersonal counseling through facilities and frontline workers (FLWs) supported by community mobilization efforts; mass communication; and strategic use of data.

16 Federal Ministry of Health (2014). Nigeria State Data Profiles. Available at: http://www.healthynewbornnetwork.org/page/nigeria-data

8 Figure 3: Alive & Thrive Framework for Scaling Up Nutrition

The A&T approach for each of these components is provided below.

Advocacy (Component 1) Advocacy efforts are aimed to motivate policymakers and opinion leaders to create a supportive environment for optimal feeding practices. A&T uses formative research with key policymakers and opinion leaders to determine their knowledge of the important role of exclusive breastfeeding. In Phase 1, we discovered most were not aware of nor had access to an adequate array of IYCF information and evidence. As a result, most stakeholders did not understand the impact of undernutrition on national social and economic development outcomes.

9 A&T’S advocacy team, led by GMMB, will develop a strategy to increase high-level access to information and evidence. The central effort will be an engagement program designed to raise awareness of the impact that IYCF practices have on health and economic well-being. The advocacy team will reach a broad audience of opinion leaders with compelling and actionable information to create an enabling environment—at the national, state, and community levels.

Given recent momentum on nutrition in Nigeria, the time is right for increased attention at both the federal and state levels, particularly to ensure that recent advocacy wins translate into better nutrition outcomes. Recent successes include building capacity at the National Planning Commission to support the finalization of the National Food and Nutrition Policy and a dedicated federal budget line for nutrition. While players like Civil Society Scaling-Up Nutrition in Nigeria (CS-SUNN) are focused on building political commitment for nutrition at the state and federal levels broadly, there is both a need and an opportunity for advocacy specifically related to IYCF.

Editorial: Why grandmothers in Nigeria cannot National Strategic Plan of Action for Nutrition breastfeed”, Paul Adepoju, Managing Editor, HealthNews NG.com, November 11, 2014: “HealthNews NG.com’s A&T will advocate at the federal level and in Lagos and attention has been drawn to a post circulating online and Kaduna to support the successful rollout and attributed to a nutritionist reportedly working in Nigeria with implementation of the National Strategic Plan of Action the UN who said that grandmothers can breastfeed babies if for Nutrition and to ensure budget accountability. The healthy. This assertion is both false and misleading…it is health sector component of the National Food and therefore worthy to urge media outlets and news platforms to Nutrition Policy, the National Strategic Plan of Action for regularly confirm health claims to be scientifically true before Nutrition (2014‒2019), has recently been developed and sharing such with members of the community…Health care costed. While existence of the plan is a major step, funds is not pop, showbiz, politics, or music where wrong have yet to be released due to the change in government information could be tweaked to work in someone’s favor—if wrong health information is passed across, people could die.” and the fact that President Buhari has yet to appoint new ministers. Advocacy at the federal and state levels is vital to support rollout and ensure budget accountability. At the state level, plans are now under development as each state interprets the national policy; these state-specific food and nutrition strategies will then need to be costed and funds allocated.

Code of Marketing of Breastmilk Substitutes A&T will advocate for stronger implementation of the existing Code of Marketing of Breastmilk Substitutes. Overall, Nigeria has a good legislative framework for IYCF: a UNICEF assessment ranked Nigeria’s IYCF legislation and law as “very good.” However, the Code was last updated in 2005 and health worker awareness of the Code is very low. Save the Children collaborated with the National Agency for Food and Drug Administration and Control (NAFDAC)—the regulatory authority mandated to enforce Code compliance—to conduct a survey in 2013 in several states and the FCT and identified numerous Code violations. The study also found very low awareness of the Code among health workers; in one study only one health worker out of 27 had any awareness of the Code. Enforcement has been weak and Code violations continue. An evidence base to promote advocacy and training for full implementation will be built through Code monitoring exercises in Kaduna and Lagos.

Maternity entitlements at the federal and state levels A&T will consider opportunities with both the public and private sectors to expand maternity entitlements by working directly with the state governments in Kaduna and Lagos, as well as with the SUN business network and the Private Sector Health Alliance of Nigeria. Initial discussions with GAIN, convener of the SUN business network in Nigeria, were very positive. In 2009, the 12-

10 week maternity leave was increased to 16 weeks under the Nigerian Labor Law—but this only applies to women working in the federal public service sector. The law does not address the private sector. States are left to interpret the federal policy as they see fit. Employers in the private sector are permitted to formulate their own policies and maternity benefits.

In 2014, the Lagos State Government extended maternity leave (with full pay) for its female employees from three months to six months and allocated three weeks for paid paternity leave (both benefits applicable only for the first two births). There seems to be some momentum on this issue; another state (Enugu) just announced during World Breastfeeding Week that it would also provide six months of paid leave to its government employees.

Baby Friendly Hospital Initiative (BFHI) The BFHI program has not been prioritized in Nigeria; fewer than 5% of health facilities are accredited. Implementation has not progressed due to lack of funding. Given the larger push around health systems strengthening, A&T will assess opportunities to ensure nutrition, and specifically IYCF, are well represented within the various components of the public and private health systems—particularly in secondary and tertiary maternity facilities to strengthen institutionalization of the baby friendly hospital principles and standards of practice.

Newborn Action Plan There is an opportunity for A&T to conduct advocacy around the finalization and launch of a newborn action plan for Nigeria and to engage with the maternal, newborn, and child health (MNCH) community regarding breastfeeding. In October 2014, the Nigerian Government launched a Call to Action to Save Newborn Lives to address the high newborn morality rate. An action plan is currently in development, modeled after the global Every Newborn Action Plan (ENAP) that highlights the importance of early initiation of BF and EBF as important interventions, along with mother-baby-friendly health facilities.

Interpersonal communication and community mobilization (Component 2) A&T’s IPC and community mobilization component centers on face-to-face conversations and activities between frontline workers and mothers or family members at the household, community, and facility level. Evidence shows that IPC interventions can help mothers adopt recommended practices. Community mobilization activities reinforce IPC with mothers, help create shifts in social norms, and lend credibility to messages given by frontline workers and volunteers. Formative research helps to identify the main barriers to adoption of recommended practices. A&T’s program approach addresses these barriers by working through existing community-based IYCF “Water is life and we must give water to our services that can include home visits, ANC sessions, PNC visits, health fora children.” for mothers, and community mobilization sessions with families and “Children on exclusive breastfeeding behave influential members of the community. naughty…they will not want to have any other food. So to avoid this, you introduce food earlier A&T’s strategy for community mobilization is to motivate community to children to get used to it.” members to encourage adoption of recommended IYCF practices. Effective ‒ Female focus group participants community mobilization will be required for stakeholder and community Source: http://nigeria.cietresearch.org/social- acceptance and to reinforce messages delivered by health workers, audits/child-health/malnutrition-breastfeeding/ Community Nutrition Educators (CNEs), and CBOs. A&T will engage relevant government structures at the state and local government levels as partners in community mobilization. In Nigeria, it is envisioned that CBO organizers will raise awareness of IYCF and gain commitment of influential members in the community to take action—

11 including religious leaders, informal health care providers, fathers, traditional birth attendants (TBAs), government health and family welfare staff, school teachers, adolescent girls, and other opinion leaders.

Building the capacity of health workers (antenatal and postnatal links) A&T will identify opportunities during ANC and PNC visits to encourage mothers to practice early initiation and EBF and will provide support for good positioning and attachment. In Nigeria, this is a significant channel for information given the fairly high level of use of these services through both public and private sectors. While there are geographic inequalities in access to PNC services (rural women are half as likely to have had a postnatal check as their urban counterparts), A&T can investigate various strategies to improve frequency and quality of IYCF counseling such as: strengthen IYCF capacity in facilities offering PNC; mobile phone-based PNC followup especially for women delivered at home; and home visits by midwives or other skilled providers to include IYCF counseling.

A&T will apply adult learning theory to build the capacity of health workers in the geographic focus areas to improve their IPC skills and to integrate appropriate IYCF messages (not giving water, introducing CF at six months, feeding eggs to the child every day) into their interactions with women during ANC, PNC, and other visits. Checklists for supportive supervision and refresher training will ensure quality delivery of IYCF counseling and support. A&T will facilitate effective linkages between the CBOs, the CNEs, the Community Health Education Workers (CHEWs), and local government nutrition focal persons in all communities to reinforce messages and provide mothers with support and referrals as needed.

This approach will ensure linkages with the formal health sector and various state initiatives. To not only strengthen but link private sector quality assurance agencies to public sector counterparts, A&T will work with state agencies and licensing and certification boards like the National Association of Patent and Proprietary Medicines (NAPPMED), which oversees the operations of private patent medicine vendors (PPMVs) across all 36 states, and the Board of Traditional Medicine, which oversees registration and regulation of traditional and alternative medical practitioners. A&T will provide orientations on IYCF and help broker stronger ties between the two sectors to achieve IYCF goals. A&T will also engage a range of health worker associations— particularly those with a coordinating and regulatory function within the private sector—including the National Association of Nigerian Nurses and Midwives (NANNM), the Association of Health Workers of Nigeria, and Association of General and Private Medical Practitioners of Nigeria (AGPMPN). In addition, community caregivers who assist in home-based deliveries will also be identified and trained.

Implementation of community and household visits to support IYCF Both Kaduna and Lagos states have strong, distinct, and well defined traditional and religious structures, CBOs, and FBOs (Muslim and Christian) actively involved in community health programs and mobilization. A&T will engage these groups to serve as coordinating structures for IPC and community mobilization activities. A&T builds capacity around the supervisor-FLW-community volunteer triad to improve reach of IYCF into the community and household. This input is coordinated with Ministry systems; A&T also works as a matter of course with individual organizations (with which it has MOUs or subgrants) on program development, implementation, training, financial and program reporting to build the general capacity of the local organizations as needed. In collaboration with community leaders, these organizations will be responsible for selecting and supporting the capacity building of CNE/volunteers to provide household-level support. Criteria for selection will include community acceptance and availability.

12 A&T will apply human centered design approaches as we help these groups to create new prototypes of service delivery models and test these with provider staff and clients. Providers and clients will be challenged to offer their own creative solutions to refine the prototypes, resulting in services and products that are valued by all groups. Logistic support for the household visits and community-level engagement will be channeled through these coordinating groups.

Visits will be conducted on a scheduled basis in assigned enumeration areas within the community. Visits will be timed to coincide with age-appropriate needs and changes in IYCF practices and will focus primarily on the first 12 months, targeting early initiation, EBF, timely introduction of CF, and continued breastfeeding.

Mother support groups will also be established within the communities, facilitated by the CNEs and experienced/model mothers. A&T’s community approach will build on community mechanisms already in place to discuss social and health issues publically, and will involve food demonstrations on CF to promote diversity of foods and encourage timely initiation. Some of these mechanisms are inherent in the administrative conduct of LGA and ward social, political, and economic development initiatives sponsored and directed by the GON. A&T will work with the state MOH and LGA health officials to assess and strengthen these mechanisms by pairing them with additional MOH personnel, NGOs (Save the Children, Society for Family Health), civil society organizations (Federal Organization of Muslim Women’s Associations of Nigeria) and associations (nurse/midwives).

Engagement with the private sector Because the private health sector accounts for more than half of health service delivery in Nigeria, A&T will engage with the private sector as well as the public sector to provide IPC for mothers and families—testing various approaches to determine what motivates current providers and consumers (e.g., public appreciation of behaviors through use of certificates, types of incentives, and digital strategies especially for mobile phone users). The private sector is defined as including for-profit (commercial) providers and not-for-profit (NGO and FBO) providers. For-profit, commercial providers include formal service delivery outlets (such as private hospitals and clinics); traditional birth attendants, especially those who have been licensed by the state MOH; commercial pharmacies; and informal patent proprietary medicine vendors (PPMVs); as well as workplace clinics. The not-for- profit providers include NGO clinics; private provider networks (social franchises) supported by NGOs; and FBO providers such as the Christian Health Association of Nigeria (CHAN).

A&T will develop a process to identify the most appropriate private sector providers and engage them to deliver IYCF messages to mothers and families. The following private and commercial sector players regularly engage in face-to-face communication with mothers and families and are potentially important channels for A&T.

 Commercial clinical: The commercial clinical sector (private hospitals, maternities, and clinics) is a significant contributor to health services in both states; more so in Lagos than Kaduna. The majority of women in Lagos (57%, NDHS-2013) deliver in private facilities, suggesting that this may be a good entry point for promoting optimal IYCF.  PPMVs: This channel is too large to ignore, both in Kaduna and Lagos states as well as in Nigeria as a whole. There are estimated to be over Opportunity to promote IYCF through PPMVs 200,000 PPMVs in Nigeria and high penetration in geographic areas 17 PPMVs approved by Lagos state receive an orientation with limited access to other health services or commodities. PPMVs course, regular text messages, and annual continuing serve as the first line of advice for about 39% of the population for education courses from the MOH. Many PPMVs express health services (mostly treatments for illnesses), and account for 68% the desire for more detailed and frequent training to 18 improve their practice and services. The proliferation of of all pharmaceutical providers. PPMVs are organized in associations these vendors, estimated at 2,500, suggests that they that operate at ward, LGA, state, and federal levels. According to a present a potential channel for promoting optimal IYCF private health sector specialist, the proliferation of PPMVs is in part a practices. Irrespective of state, there is a noted tension response to “the continued lack of well managed health care facilities between PPMV for-proﬁt motivation of running a business and providing optimal healthcare, as well as responsive to consumer needs” and they “provide health care and limited oversight or quality assurance of PPMV activities medication to a significant share of the individuals at the bottom of the (which varies by state). pyramid.”19 Given possible concerns about quality and monitoring of Source: Anadach Consulting, 2015. PPMV activities, A&T proposes engaging with the quality assurance boards which provide orientation and training to this group as a means providing orientations on IYCF and then developing and delivering messaging and materials for their use. A&T is aware that monitoring and regulation will be essential to this potential channel of communication.

17 Nigeria National Bureau of Statistics. Available at: http://www.nigerianstat.gov.ng/ 18 Anadach Consulting Group (2015). Scoping Business Practices of the PPMVs in Lagos and Kano, Nigeria: Review of the Business Model for Patent Propriety Medicine Vendors (PPMVs). 19 Ibid.

13  Pharmacies: In 2013 there were an estimated 16,835 licensed pharmacists in Nigeria but with only 7,584 in active practice.20 There is an under supply of pharmacists, with fewer than 0.5 pharmacists per 100,000 population. This shortage is particularly marked in the rural and less affluent areas of Nigeria. An estimated quarter of practicing pharmacists are based in Lagos. This implies from 10 to 15 pharmacists per 100,000 people there, and suggests pharmacists may be a potential channel for promoting optimal IYCF practices in that state.

Coordination and synergies with existing nutrition programs and initiatives at all levels We will emphasize A&T’s efforts in the context of the FMOH’s operationalization of its National Strategic Plan of Action for Nutrition (2014‒2019), similar to what A&T is doing to help the Government of Ethiopia improve and operationalize its new National Nutrition Program. Alive & Thrive’s proposed activities in Nigeria align very well with the operationalization of the Plan of Action (including the time frame). The Nigeria FMOH is using a framework of IYCF interventions to shape its work through health systems, community structures, and outreach campaigns using the following strategies and select activities: • BCC: promote proper food handling and preparation methods and dietary diversity at ANC clinics, outpatient therapeutic feeding (OTF) program sites, and PHC centers; utilize mass media and information communication technology platforms to promote IYCF • Service delivery: use and integrate IYCF counseling packages through PHC centers, ANC clinics, sites for OTF programs and Community Management of Acute Malnutrition (CMAM), and child welfare clinics; strengthen BFHI; conduct food demonstrations; support PPMVs to provide IYCF information • Capacity building: train all frontline workers (FLWs) on nutrition counseling; develop pre-service curricula; provide food demonstration equipment to community structures; update Community IYCF (CIYCF) counseling package for use by community health workers; train PPMVs on CIYCF • Advocacy and resource mobilization: support states to adopt National Strategic Plan of Action for Nutrition and develop budgets for nutrition activities; mobilize community leaders and community structures to support CIYCF • Research and M&E: conduct formative assessments to determine best practices for BCC in Nigeria; conduct bottleneck analysis of barriers to IYCF coverage at PHC, secondary, and tertiary levels • Coordination and multisectoral partnerships: strengthen intra- and intersectoral collaboration to address IYCF practices; work with agriculture to promote appropriate food production and consumption in the IYCF context • Commodities and equipment: develop IYCF job aids, materials

A&T’s approach will ensure coordination with other existing programs at various levels to exchange lessons learned from implementation and to create synergies where feasible. The FMOH has stated in its National Strategic Plan of Action for Nutrition that it will develop, maintain, and update partner mapping at all levels; this will be an invaluable inventory to ensure coverage and reach of the A&T program through such partnerships—not only through MOH initiatives such as immunization and other services, but across sectors. Supportive supervisory visits will be planned in collaboration with the various focal persons and coordinating structures in the state and LGA levels. In addition, lessons learned from ongoing monitoring and findings from other programs will be integrated into the project.

Figure 4 on the following page summarizes the proposed approaches to the component of interpersonal communication and and community mobilization.

20 Ibid.

14 Mass communication (Component 3) Mass communication is a critical component for reaching scale and impact. A&T’s results in three Phase 1 countries showed that mass communication together with IPC efforts had a combined and mutually reinforcing influence on behavior change. A&T’s mass communication approaches capitalize on the opportunity to reach large audiences throughout the country using multiple channels of broadcast media and high quality TV and radio spots and programming broadcast frequently on entertainment, sports, and news channels. The spots reinforce IYCF messages delivered through IPC and community mobilization. They remind mothers, family members, frontline workers, and a wide range of health providers about priority, age-appropriate practices. Nigeria also offers the possibility of using mobile phones to disseminate messages and engage audiences.

The A&T approach to communication is based on evidence from successful mass media campaigns (supporting nutrition and other interventions)21,22 and theories of behavior change.23 In other countries, A&T worked closely with commercial marketing firms to develop professional campaigns. Several rounds of rigorous concept testing and pretesting ensured that TV and radio spots were memorable and appealing to each audience segment. Messages focused on feasible behaviors that mothers were willing to adopt. Careful media planning has played an important role in the success of A&T mass media campaigns in other countries. In Phase 1, an extensive review of media survey reports (such as Neilsen data that indicate who watches which channels at what times of the day) helped A&T select the best broadcasting channels and achieve the greatest impact with limited resources. In Bangladesh for example, TV spots were aired during World Cup Cricket matches to reach a large number of viewers in a short period of time.

21 Wakefield MA, Loken B, and Hornik RC (2010). Use of mass media campaigns to change health behavior. Lancet; 376: 1261–71. 22 Naugle DA & Hornik RC (2014). Systematic review of the effectiveness of mass media interventions for child survival in low- and middle-income countries, Journal of Health Communication: International Perspectives; 19:sup1, 190-215. 23 Ibid.

15 In Nigeria, radio, TV, and local home videos (Nollywood, based in Lagos) and Kannywood (Hausa film industry based in Kano) will aim to model recommended behaviors and address perceptions of social norms.

Exclusive breastfeeding and child Nationally in Nigeria, the number one topic of interest to 93% of development, Yinka Shokunbi, Daily users of any medium is health and health care. Three-quarters of all Independent, August 24, 2014: Professor Nigerians still consider radio their primary source of news, with Chinyere Ezeaka, Dept. of Pediatrics, University of “word of mouth” and TV following as the most common ways to get Lagos…attributed the poor initiation of breast milk news. However, mobile phone ownership rates are now greater than to newborns to poor support from the health facility rates for TV and radio ownership and growing.24 Examining the personnel, the home and community, as well as factors that shape media audience typologies (ownership and use by lack of will on the part of the mother who has been education, age, gender, religion, ethnicity, wealth, and urban fed fallacies and myths which make her think that breastfeeding a child is old fashioned stuff and that residence) will yield more targeted and therefore efficient and a modern day baby must commence on formula. effective media approaches to changing social norms and IYCF practices of specific audiences. As a starting point, A&T will use these data and other media research findings with its partners to further assess the media landscape in urban Lagos and across Kaduna; develop profiles of potential audiences; identify and prioritize the most appropriate channels (broadcast, mobile phone, public display, or traditional for “media dark” areas) and its combinations as merited; develop the array of messaging needed to inform, motivate, and activate social norm and behavior change; and implement its approaches in conjunction with advocacy and community mobilization efforts.

The NDHS 2013 data on media use in Lagos and Kaduna highlight these features of the Lagos and Kaduna media landscapes:  More urban households in Lagos have TV (92%) than urban households in Kaduna (82%) and in rural Kaduna (17%).  More urban households have a mobile phone in Lagos (97%) and Kaduna (91%) than rural households in Kaduna (63%).  More urban households in Lagos (78%) and in Kaduna (88%) have access to radio than rural households in Kaduna (74%).  In Lagos, Igbo households were over 66 times, and Yoruba households were over 2 times more likely to have access to TV than other ethnicities, while in urban Kaduna, “other ethnicity” households were over 20 times more likely to have access to TV than the majority urban Hausa households.  Mothers who have secondary or higher educational level were over 3 times (Lagos), 19 times (urban Kaduna), and 2 times (rural Kaduna) more likely to have TV than mothers with no education.  In urban Kaduna, Christian households were more than 18 times more likely to have access to TV than Muslim households.  Urban richest, richer, or middle SES households in Kaduna were over 6 times more likely to have access to radio than poorest or poorer urban households.

Strategic Use of Data (Component 4) A&T will emphasize strategic use of data to guide the program from the beginning and throughout implementation in Nigeria. In all countries where A&T works, the team uses data to drive decisions at all program stages to achieve high coverage of activities, depth of influence, and magnitude of behavior change. Rapid feedback loops allow the team to learn quickly about whether an approach is working or not and make adjustments along the way. A&T’s measurement, learning, and evaluation approach emphasizes the learning aspect—seeking to understand not just what the program has achieved, but how it was achieved.

Formative research Formative research is essential to tailor the program for mothers and the local context. In Phase 1 countries, A&T used a series of qualitative and quantitative studies to understand barriers and motivators. Midline process surveys helped confirm field observations and refine strategies.

Formative research was particularly helpful in the early stages of program development:

24 Broadcasting Board of Governors, Gallup. Nigeria Media Use 2014. Available at: http://www.bbg.gov/blog/2014/04/30/bbg-research-series- contemporary-media-use-in-nigeria/

16 • A&T conducted concept testing in villages (Bangladesh) to understand how to frame behavior change messages. The testing revealed surprising results and multiple changes were made to the original concepts for TV spots. Useful information focused on the roles of fathers and grandmothers, what was acceptable for young mothers to say and do, who were culturally appropriate role models, and the prominent position of ‘doctors’ as opinion leaders on IYCF.

• In Bangladesh, formative research showed that what mattered most to mothers were (in this order): benefits to the child (brain development or protection from illness); whether a child ‘seems to like it’; and whether a practice is convenient and do-able. These factors were transformed into the selling points for recommended practices.

In Nigeria, our formative approach will continue from the initial SUN Report on a mother’s comment during interviews, assessments, and desk reviews started during this sensitization visit to health care facilities in proposal process. Targeted focus groups, household observations, Abuja, Nigeria (WBW, August 5, 2015): trials of improved practices (TIPs), and in-depth interviews with “She has not breastfed exclusively and explained mothers in Lagos and Kaduna will yield a clearer picture of that she was not allowed to do so by her parents mothers’ knowledge, self-efficacy, perceptions of social norms, and parents in law. She was asked to give water to beliefs about outcomes of the recommended behaviors, and their her babies with breastmilk from birth. She current practices as well as their responses to trials of new expressed her powerlessness in her own case” practices. Interviews with family members who influence mothers’ beliefs and behaviors and with other key informants will reveal communities’ inhibitors and facilitators (religious, ethnic, economic) and the quality, quantity, and timing of health care and IYCF information and services women avail from the public, private, and traditional health care sectors. More in-depth landscaping of those services as well as media channels—broadcast, mobile phone, and traditional (media dark)—will help A&T and its partners map out the supply and demand of IYCF information, motivation, and support in Lagos and Kaduna. We will also further review and assess relevant programs, such as A&T’s project in Bauchi—a face-to-face plus cell phone breastfeeding promotion intervention integrated into microcredit, which increased the likelihood that women would adopt recommended breastfeeding practices.25

Routine monitoring data In Nigeria, there is no central, unified data collection system for nutrition and thus a lack of readily available information for decision making. A&T aims to help fill these gaps. The approach will involve building local capacity to collect, analyze, and use data at various levels of decision making; identifying essential monitoring indicators and collecting data in real time; using mobile platforms to collect and analyze data; and supporting data quality assurance.

A&T will work to strengthen existing community health information systems (HMIS) through the use of appropriate technology and provide current data to improve program quality and promote evidence-based decision making. A&T proposed to develop a mobile application for the collection and management of household and community-level nutrition data. It is intended that this electronic application will eventually be adopted by the GON for the management of community health interventions. FHI 360 Nigeria’s experience with this approach for routine data collection for OVC programming suggests an electronic application is both feasible and cost effective. The GON currently uses mobile application for routine monitoring from some PHC facilities. A&T could hire a local consultant to develop an IYCF data application using a pre-existing open source platform such as DHIS-2.

A&T’s program monitoring/information system will follow the existing national public health data flow and timelines. Community data will be aggregated at the LGA level before being transmitted to state and national levels. Data Quality Audits (DQA) will be conducted quarterly to assure the quality of program data. Data review meetings will be held monthly at the community level. The meetings will provide an avenue for the CNEs, facility service providers, CBOs, and LGA officials to review performance, provide feedback, and improve program quality. A&T will also produce and disseminate quarterly LGA bulletins and other information products to stakeholders at national and subnational levels.

Impact evaluation A&T will develop a RFA for the overall evaluation design of the Nigeria initiative, which will be competed during the first quarter of implementation.

25 The A&T small grant is at the following link: http://aliveandthrive.org/resources/integrating-microcredit-cell-phone-messaging-and-breastfeeding- promotion-increased-rates-of-early-initiation-and-exclusive-breastfeeding-in-nigeria/.

17 4. Activities A&T will utilize the latest evidence, current state of knowledge, and its global experience (including from other A&T countries) to guide and advise stakeholders at the national level and in the states of Kaduna and Lagos to design, implement, monitor, and evaluate their IYCF programs.

The activities proposed at this time are primarily illustrative and may be modified following further assessment of feasibility and partnership opportunities.

Advocacy (Component 1)

Initial work will focus on continued learning to help define and finalize an advocacy approach that takes full account of the current IYCF landscape for the national level, Lagos, and Kaduna and leads to corresponding work plans, final advocacy goals, and target outcomes. A priority in the early stages will be to define and initiate any research needed to inform a detailed advocacy strategy as well as advocacy communications and materials. Assessment visits to Abuja, Kaduna, and Lagos to meet with a cross-section of government, private (NGO and commercial), faith-based and sectarian civil society organization (CSO), academic, and media stakeholders may include:

 Desk review of existing research to inform detailed national- and state-level strategies (e.g., latest Code monitoring results; maternity protection policies in the public and private sectors; state budget allocations and health insurance acts; and IYCF/nutrition strategies and action plans and their implementation status).

 Opinion leader assessment including a rapid qualitative survey, informal assessment, and online forum to establish a baseline understanding of opinion leader priorities for nutrition as well as barriers and opportunities for greater commitment.

 Decision-maker mapping to understand points of influence and decision-making power as related to IYCF policies.

 Defining new research needs to build the evidence base in support of specific advocacy activities and communications. Examples include Code monitoring or review of BMS marketing practices and implementation studies in Kaduna and Lagos; developing a package of evidence around maternity entitlements; and conducting a “cost of not breastfeeding” study to quantify the costs of not breastfeeding optimally in Nigeria.

 Developing subsequent activities to strengthen applications of policies: trainings for health workers on the Code, and advocacy for the resources needed for full implementation of the Code; advocacy to extend the federal labor law’s maternity leave to six months; additional research in Kaduna on the labor policy to assess potential advocacy opportunities; research to determine how the Lagos maternity leave policy is being implemented and its potential impacts; positioning Lagos as a successful case study for national advocacy; and engaging with GAIN and the SUN business network on improving private sector maternity leave policies and workplace supports.

Strategic advocacy activities that will both lay the groundwork for activities to come and lend early visibility to the A&T project include:

 Defining a compelling narrative for IYCF and child nutrition—and developing powerful advocacy tools. More work is needed to help nutrition stand out among competing priorities and to create a fresh narrative. However, A&T will be sure to coordinate with PRB/RENEW as they have recently released (June 2015) an advocacy video in both Hausa and English called “Malnutrition – Nigeria’s Silent Crisis”, for advocacy at both national and state level. This work will aim to identify innovative methods of telling the story of undernutrition in Nigeria in ways that connect more directly to opinion leader priorities—by making a strong economic argument as well as an emotional and compelling one, and by framing child nutrition as an attainable goal that can be addressed given the right support and attention. It will also be critical to link IYCF and child

18 nutrition to priority issues of interest to Nigerian leadership, such as strengthening national social and economic development outcomes, food and agricultural production, and reducing the prevalence of pneumonia and diarrhea.

 Direct coordination with existing nutrition advocates and other Gates Foundation grantees. Some local, evidence-based advocacy capacity exists through organizations like Champions for Change, Evidence 4 Action, and CS-SUNN. It will be particularly important to collaborate with CSOs involved in budget and resource tracking for MNCH in Lagos and Kaduna. A&T will examine opportunities to join resources and promote best practices through advocacy training and communications products and coordinated approaches.

 Defining and developing advocacy capacity building needs. More work is needed to harmonize activities and build capacity for long-term advocacy planning and implementation. The aim of capacity building efforts will be to create sustained opportunities for coordinated action among partners over the life of the project. Further mapping is needed to understand the landscape and how A&T can contribute. For example, CS-SUNN’s Partnership for Advocacy in Child and Family Health (PACFaH) Project is a three-year social accountability project advocating for the implementation of the National Strategic Plan of Action on Nutrition (NSPAN) at the national level and in three states including Kaduna. They are currently conducting influencer mapping and setting resource mobilization targets.  Champion identification and cultivation. A thoughtful and deliberate approach to identifying and cultivating champions will be critically important nationally and in Lagos and Kaduna. As one example, the FMOH has cultivated Nigeria’s first lady, Aisha Buhari, as a nutrition champion. During World Breastfeeding Week she called on employers in Nigeria to create an enabling environment for mothers to breastfeed and work. Leveraging high-level champions using similar approaches will be key to opening doors and lending voice and visibility to IYCF. A&T’s work will cast a wide net, with considerations for outreach in Nollywood, among political leaders and political spouses (e.g., governors’ wives), and through professional unions and societies.

 Nigeria’s broadcast, print, and digital news media will be central to A&T’s advocacy component. A&T will likely adapt its own model for journalist engagement alongside local models that have been lauded for their successes (e.g., Journalists Against AIDS) in engaging the media to elevate health issues.

 Partnerships. A&T will explore collaboration with unions, medical professional associations, faith-based as well as women’s organizations, and academic institutions to reach specific and joint advocacy goals. One example is a partnership with the Pediatric Association of Nigeria and a prominent university, such as Ahmadu Bello University in Kaduna, to revise and update IYCF curricula in state universities through collaborative work with the Nigerian National Universities Commission.

 Building on existing IYCF advocacy events and developing new events will be important opportunities for joint coordination among partners. A&T will identify specific, complementary ways to elevate key advocacy events such as MNCH weeks (twice per year) and World Breastfeeding Week. In addition, new opportunities will be identified to share evidence with target audiences—for example, utilizing the upcoming Lancet series on breastfeeding as an advocacy opportunity.

Interpersonal Counseling and Community Mobilization (Component 2)

Improving practices through face-to-face counseling will be a challenge in Nigeria given the low use of health care services— especially in rural and poor areas. The following proposed activities focus on households, communities (including CBOs, and FBOs), health workers, and engagement with the private sector.

A&T expects that in both Kaduna and Lagos, multiple individual age-specific, face-to-face contacts and an improved enabling environment will result in improved practices among mothers and families of children under two years. Health workers and community-based workers have important roles in providing individual counseling contacts. Rapid assessments of their current workload (number of pregnant women and mothers of children below two years seen by them monthly), the timing and nature of their contacts, as well as their counseling skills should inform performance improvements plans including training, incentives, and follow up. A&T will develop focused training and systems for supportive supervision to enable them to deliver a quality intervention. Job aids will remind providers of the specific small doable actions (such as not giving water or feeding an egg) to promote according to the child’s age—actions that will have impact and will be perceived by families to be feasible. In addition to existing contacts, additional (new) contacts may be necessary at critical ages such as between 3 and 6 months (when exclusive breastfeeding is at highest risk and complementary feeding may not be initiated in a timely way, and when individual contacts simultaneously tend to decline).

19 A&T will provide strategic technical assistance to the MOH and other service providers in the states of Kaduna and Lagos. This will include, but not be limited to, conducting formative research to identify key priority areas and messaging; developing a behavior change communication strategy and related job aids and training materials; and designing dashboards and data sheets. A&T will work with MOH counterparts and other local partners to ensure that IYCN services and messages are appropriately delivered by frontline workers through strengthened and timely face-to-face contacts, community events (e.g., immunization, vitamin A, growth promotion), and other activities.

A&T will develop training, supervision, and support activities for frontline workers to ensure timely, repeated, individual face-to-face contacts including coaching and demonstrations for mothers. Priority contacts include:  each ANC visit (including the provision of supplements and monitoring/counseling on pregnancy weight gain) to explain the importance and benefits of early initiation, the danger of pre-lacteals, and issues related to exclusive breastfeeding;  the first PNC contact to support breastfeeding initiation and teach position/attachment/maintaining breastmilk supply;  subsequent immunization and sick child contacts (at both the community and facility levels) at least through the first 12 months; ideally, at a minimum, one contact each month from birth up to 6 months of age and another 6 contacts from 7 to 12 months should be achieved for each mother post-delivery.

Community-based approaches will be adopted for women in rural locations, particularly in Kaduna where facility-based delivery and utilization of other RMNCH services is limited. Based on a feasibility assessment, this will be done through CORPs (community resource persons), village health workers (VHWs), and CHEWs under the auspices of the federal task shifting and sharing policy, which explicitly recognizes early initiation of breastfeeding, education on positioning and attachment, and counseling on nutrition and EBF as tasks that can and should be initiated in the community. This includes holding them at PHC posts, secondary health centers, market places/PPMV locations, and community venues. Again, this approach will be done in partnership with NGOs and other development programs, allowing A&T a “light touch” overlay of its evidence-based approaches and technical support onto existing platforms. Training modules, job aids, and messaging will be developed and tailored to the kinds of communication activities to be conducted—whether skilled individual counseling, group health education and motivation sessions, general community orientations and food demonstrations, or age-appropriate low literate messaging between a volunteer and a mother during a household visit.

A&T will work with implementing CBOs and FBOs to map, identify, and target pregnant women in the community to ensure that there are no missed opportunities. This activity will take cognizance of the structures and health-seeking practices of the communities, targeting pregnant women in places where they seek care during pregnancy—ANC in public/private facilities, TBA counsel and services, faith-based service providers and facilities, and others. A&T will ensure that this activity is conducted in collaboration with community leadership structures and community groups. A mapping of the community enumeration areas for targeted high coverage of the community will also be done by CBO partners.

See the Table below for a listing of the various partners in Kaduna and Lagos with which A&T hopes to engage:

Table 6: A&T proposed partners, Kaduna and Lagos

Kaduna Lagos Federation of Muslin Women’s Association of Nigeria PATHS2 National Council of Women’s Societies SPRING Market Women Association CHAI Nazarene Rural Health Ministry Traditional Medicine Board of the MOH SPRING Society for Family Health CHAI Women’s Health Project UNICEF Community Malnutrition Trackers (SAM centers; e.g., Massey Street Children’s Hospital and Lagos State Teaching Hospital) CBOs (TBD)

20 A&T has identified a set of start-up activities for Kaduna and Lagos to be developed to achieve desired results. Those for Kaduna are the following:  Identification and targeting of pregnant women through ANC, TBA services, PPMVs, and community groups

 Targeting of ‘influencers’ (husbands, mothers-in-law, others) through religious, traditional, and community groups

 Sensitization of care providers and birth attendants at places of delivery for early initiation of BF

 Identification and training of CNEs and provision of logistic support for household visits to provide support for EBF (through counselling, demonstrations, etc.) and subsequently for appropriate CF until the child reaches two years of age. This will be supported through selected CBOs  Sensitization and targeted training for TBAs  Integration of counselling on appropriate complementary feeding

 Reproduction of national IYCF training materials and counselling cards

 Use of appropriate mass media messages for reinforcement and wider coverage

 Develop and test a community recognition system for women who successfully practice EBF

The main start-up activities for Lagos are the following:  Identification and targeting of pregnant women through ANC (especially in private facilities), TBA services, PPMVs, community groups, and orphan/vulnerable communities (OVC) enrollment processes in focus LGAs  Targeting of ‘influencers’ (husbands, mothers-in-law, others) through religious and community groups, ward health committees, etc.  Identification and targeting of care providers and birth attendants at places of delivery for early initiation of BF  Assess the potential to work with PPMVS; identify and train PPMVs (who are often the first point of contact for treatment in the community), on IYFC and their role in supporting EBF among their clients and communities  Identification and training of CNEs and provision of logistic support for household visits to provide support for EBF (through counseling and demonstrations) and subsequently for appropriate CF until the child reaches two years of age. This will be supported through selected CBOs.  Reproduction of national IYCF training materials and counseling cards  Engagement with professional associations such as the Association of General and Private Practitioners (facility owners), National Association of Nigerian Nurses and Midwives (NANNM), and the Association of Health Workers of Nigeria to promote, monitor (and correct) practice of initiation within one hour  Engagement with State MOH and Primary Health Care Board (PHCB) to ensure implementation of early initiation of breastfeeding in public facilities and to facilitate linkages to state Community Management of Acute Malnutrition (CMAM) programs and Severe Acute Malnutrition (SAM) centers  Engagement with donors (such as DFID) working on IYCF related activities  Sensitization of health workers in public and private facilities to ensure no missed opportunity for early initiation of BF and EBF counselling in public facilities  Sensitization and targeted training for registered TBAs

Mass communication (Component 3)

The process for developing mass communication strategies will follow the approach of A&T in Phase 1, which was adapted from commercial approaches and informed by social marketing and behavior change principles that recognize the need to address multiple layers of influences:

 Understand the situation: The mass communication campaign strategy will be based on formative research and media audits, taking into account variability in urban/rural media habits and health practices, ethnic groups, key audiences, feasible IYCF behaviors, languages, and the use of broadcast or digital/mobile phone channels to obtain news and information. Additional primary research (rapid assessments of IPC at private and public sector service points, stakeholder and audience focus groups, and in-depth interviews) coupled with desk reviews of audience surveys, listener and viewership data, and further stakeholder interviews with representatives whose programs have conducted mass communication campaigns in the past five years will provide additional guidance. This formative phase offers an excellent 26 Pan American Health Organization/UNICEF (2013). ProPAN: Process for the promotion of child feeding: A tool to improve infant and young child feeding. Washington, DC: PAHO.

21 27 Sanghvi T, Jimerson A, Hajeebhoy N, et al. (2013). Tailoring communication strategies to improve infant and young child feeding practices in different country settings. Food and Nutrition Bulletin;35 (Suppl. 2) 169S-180S(12).