Severe acute malnutrition (SAM) is a major determinant of mortality and morbidity among children under the age of five years (1). It increases the risk of death from common childhood illnesses such as pneumonia, diarrhoea and malaria, contributing to about 45% of deaths in this age group.  In Nigeria, according to the National Demographic and Health Survey (NDHS) carried out in 2018, 37% of children age 6–59 months are stunted (short for their age), 7% are wasted (underweight for their height: Moderate Acute Malnutrition, MAM = 5 % and Severe Acute Malnutrition, SAM = 2%), 22% are underweight (thin for their age), and 2% are overweight (heavy for their height). This would have been a consequence of poor parental nutrition care as only 29% of children under age 6 months are exclusively breastfed for six months post birth and only 11% of children age 6–23 months were fed a minimum acceptable diet. 
Integrated Community Case Management (iCCM) is a community-based intervention that seeks to achieve equitable access to healthcare services by complimenting and extending public health services to medically underserved communities. It focusses on children under the age of five years, providing timely and effective diagnosis and treatment of the three most common childhood illnesses of malaria, diarrhoea and pneumonia.  Since 2015, Malaria Consortium has been operating iCCM projects in Niger State that train community health workers (CHWs) – also known as community-oriented resource persons (CORPs) in Nigeria – to treat children under five years for malaria, diarrhoea and pneumonia in their homes, and to diagnose and refer cases of severe illness to health facilities. The CHWs operate as part of the primary health care system whereby each CHW is attached to a primary healthcare facility and assigned a healthcare worker in the health facility as supervisor. The supervisors provided mentorship and health commodity management services in support of the CHWs.
Although iCCM is recognised as a strategy for increasing access to life-saving treatment for childhood illnesses, malnutrition is not currently adequately addressed in the Nigeria national iCCM guidelines. Rather Community Health Workers (CHWs) are meant to just screen for SAM and then refer to health facilities for treatment. The Nigeria’s National Policy on Food and Nutrition advocates that management of acute malnutrition, including stabilisation centres addressing the needs of severely ill children with SAM, should be located at health facility level, where personnel with requisite skills and qualifications are be available. [4, 5]. Completing referral for patients with SAM remains a challenge, particularly as the very few facilities that offer care for SAM are located far from many rural communities, where most of the affected children live. In Niger state and most of the states in Nigeria, this model of delivery of SAM treatment is hampered by weak infrastructure, poorly trained staff and inadequate supplies, which are also barriers for households as observed in similar programmes in other countries.  This is coupled with the challenge of poor access to care due to remote communities’ distance from healthcare providers and other high opportunity costs to seeking treatment. 
Providing patients with SAM treatment using the ready-to-use therapeutic food (RUTF) in their own communities, alongside care for other childhood diseases, could improve treatment coverage and reduce the number of children defaulting from treatment which typically takes 8–12 weeks of weekly visits to the health facility before the treatment course is completed.  Promising and cost-effective models for community-level treatment of SAM exist and has been demonstrated in other African countries,  however, adapting these for non-clinical personnel settings has not been studied in Nigeria. This will provide evidence on the safety, effectiveness and acceptability of the models for community-level treatment of SAM cases.
Treatment of SAM cases by CHWs providing iCCM services, is however not without concerns. There are anecdotal fears about the safety of the children due to the limited training and literacy levels of the CHWs, extra workload for the CHWs and effects of adding SAM treatment to the iCCM protocols on the quality of care provided. However, there is evidence that with minimal training, CHWs are able to appropriately treat SAM in the community without compromising treatment outcomes and this can lead to improved access to treatment. [10, 11]
Therefore, in 2017, Malaria Consortium and International Rescue Committee (IRC) contributed to a consortium of implementing partners to test a simplified protocol and tools in four contexts with a goal to determine whether non-clinical CHWs can treat uncomplicated SAM cases using a simplified protocol and tools integrated into iCCM treatment algorithm without medical complications. IRC had previously developed, tested and adapted these innovative and simplified tools in South Sudan.  The human centred design approach was used for the adaptation of the protocol and tools in different context across Africa (Kenya, Malawi, Mali, Nigeria and South Sudan) and piloted to develop an evidence base through a global coalition.
Here presented are the findings from the study conducted in Niger State, Nigeria by Malaria Consortium between July 2017 and May 2018, which focused on the competency of CHWs in following the protocol, effectiveness of the intervention in curing children with SAM and the acceptability of the approach amongst key stakeholders.