Creating a Humanitarian Dashboard for Malnutrition Health Facility Monitoring in Northeast Nigeria: A Special Studies Project Público
Cahalan, Conor (Fall 2019)
Published
Abstract
Background An ongoing complex humanitarian emergency in northeast Nigeria has contributed to global acute malnutrition rates in children exceeding emergency threshold in Borno and Yobe states. Combatting malnutrition is complicated by internal displacement and instability due to ongoing military activity, as well as outbreaks of cholera and measles. Community-based Management of Acute Malnutrition (CMAM) programs, supported by the Nigerian Government, UNICEF, and other non-governmental partners provide therapeutic support for children with severe and moderate acute malnutrition through outpatient services. While supervision of these programs is robust compared to most humanitarian settings, use of the supervision data is limited.
Purpose This special studies project aims to create a dashboard of supportive supervision data that helps project managers identify poorly performing health facilities engaged in acute malnutrition management.
Methods Sample data included all supportive supervision survey results from Borno and Yobe CMAM facilities that were sent to UNICEF between March 2018 and May 2019. Survey results were filtered so that only the newest entry for each facility was represented in the dashboard. Variables from the supportive supervision survey were then synthesized into key indicators that fell into four primary domains of CMAM improvement: supportive supervision and provider motivation, resource availability, firm operational structures, and training. A composite Health Facility score was assigned to each facility based on how it performed across these domains. Facilities that scored in the top fifth and bottom tenth percentiles were flagged in two graphs. Ten additional graphs were generated to explore the above domains individually, depicting where facility assessments occurred; supply of anthropometric equipment, medicines and ready-to-use therapeutic food (RUTF); WASH-related needs; skill- and knowledge-based training needs; and facility morale scores. All graphs, as well as the survey variables used to generate them, were organized into seven screens on a dashboard using Tableau. The dashboard was shared and feedback was elicited from UNICEF nutrition officers.
Results A total of 2,782 entries for facility-level data were used in the dashboard project with a median of five entries (IQR 2-9) per PHC. Upon filtering duplicate entries, 350 unique facilities were represented, 186 in Borno and 164 in Yobe. Overall Yobe had over half (57.1%) of all bottom-performing facilities, despite the conflict being centered in Borno. Data in the supportive supervision domain indicated that 11.1% of facilities had not been visited in over seven months, and large areas of Borno and Yobe were missing facility reports. Regarding the resource availability domain, data suggest that height board status was unknown or unavailable in most (81.4%) facilities, whereas other anthropometric equipment (scale, MUAC tape, thermometer and CMAM manual) was available in the majority (90.4%) of facilities. Over half of multi-item medicinal stockouts were in Yobe. Facilities with ready-to-use therapeutic food (RUTF) stockouts commonly reported medicinal stockouts as well, despite facilities receiving RUTF and medicine from separate sources. Data in the operational structures domain indicate over two hundred facilities (60.0%) were in need of WASH-related support with 45.8% reporting lack of running water. Training data suggested that provider knowledge was generally adequate, however 31.6% reported some form of skills training need, most commonly physical examination. Within the morale domain, 11.6% of facilities were identified as critically low morale, with poorer scores in Borno than Yobe, especially near the capital Maiduguri. The dashboard’s first draft received generally positive feedback from UNICEF nutrition officers in terms of identifying areas that required attention and understanding the dashboard’s organization. Suggestions for improvement included the need to clarify how Health Facility scores and training needs were tabulated, the need to restrict and make clear the data reporting timeframe, and the need to indicate facilities that reported data as a percent of total number of CMAM facilities.
Discussion The dashboard revealed important insights into the state of CMAM operations in Borno and Yobe. Within the supportive supervision domain, areas of Borno and Yobe that were missing facility reports reflected the limitation that supportive supervision data was only being collected in the facilities that were primarily supported by UNICEF. The dashboard will need to be modified to indicate all CMAM facilities, which will require more broad use of the supportive supervision tool by non-UNICEF facilities. In the Adequate Resources domain, children are being triaged and managed within CMAM services using MUAC cutoffs alone, rather than in combination with WHZ scores. MUAC measurement alone may miss a significant number of children in need of nutritional support. Additionally, shortages of CMAM supplies frequently span multiple supply sources, indicating that such facilities are facing broader challenges such as security and funding. The operational structures domain indicated challenges to resourcing clean water. In the Training domain, lacking skills assessments indicate need for refresher training with particular focus on the physical exam. Results from the dashboard itself revealed that this unique tool is an important step toward CMAM process monitoring which is likely to be more user-friendly than data outputs that existed prior. It allows nutrition managers to rapidly identify gaps in CMAM programming and prioritize limited resources to where they are needed most. It will be necessary to validate the indicators that were developed for this dashboard, assess supportive supervision data quality and validity, perform continual evaluation and refinement of the dashboard, and secure buy-in from all partner organizations in the Nutrition Sector to maximize the utility of the dashboard as a monitoring tool.
Table of Contents
Chapter One: Introduction..............................................................................1
Background...........................................................................................................................................1
Concept of Project.................................................................................................................................2
Need.........................................................................................................................................2
Goal..........................................................................................................................................2
Aims.........................................................................................................................................3
Significance..............................................................................................................................3
Chapter Two: Literature Review....................................................................4
CMAM Overview.................................................................................................................................4
CMAM in Nigeria.................................................................................................................................6
Dashboards............................................................................................................................................8
Dashboards in Action............................................................................................................................11
Limitations of Dashboards....................................................................................................................14
Chapter Three: Methods..................................................................................16
Introduction...........................................................................................................................................16
Ethical Considerations..........................................................................................................................16
Population and Sample.........................................................................................................................16
Procedures.............................................................................................................................................17
Survey Instrument....................................................................................................................17
Data Collection........................................................................................................................17
Data Cleaning..........................................................................................................................18
Data Visualization – Single-Subject-Area Graphs..................................................................19
Data Visualization – Summary Graphs...................................................................................25
Data Analysis...........................................................................................................................27
Dashboard Feedback................................................................................................................28
Chapter Four: Deliverable...............................................................................29
Figure 1: Flowchart for Entire Dashboard............................................................................................30
Figure 2: Health Facility Performance Screen......................................................................................31
Figure 3: Site Visits & Facilities per Local Government Area Screen.................................................34
Figure 4: Stock Screen..........................................................................................................................37
Figure 5: Wash Needs Screen...............................................................................................................40
Figure 6: Training Screen.....................................................................................................................42
Figure 7: Morale Screen........................................................................................................................44
Feedback from UNICEF.......................................................................................................................45
Chapter Five: Discussion & Implications.......................................................47
The Public Health Situation..................................................................................................................47
Supportive Supervision & Morale...........................................................................................47
Adequate Resources & Firm Operational Structures...............................................................49
Thorough Training...................................................................................................................52
The Dashboard......................................................................................................................................54
Implications...........................................................................................................................................56
References..........................................................................................................59
Appendix............................................................................................................63
Appendix A: Survey Layout with All Variables Included....................................................................63
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