Making a Good Intervention Great: How Smart Targeting Is Transforming Nigeria's Fight Against Child Malnutrition

Every Wednesday at a primary healthcare centre in Jos North, Nigeria, nursing mothers line up with babies strapped to their backs, waiting for a small sachet of nutrient-dense paste. One mother describes her baby crawling and holding objects for the first time. Another watches her child — once tiny and frail — gain strength week by week.

This distribution in Plateau State — funded by the state government and UNICEF through the Child Nutrition Fund — offers an early glimpse of what SQ-LNS can do when it reaches children who need it. Now, the question is how to replicate that impact across the country, cost-effectively and at scale.

Small-quantity lipid-based nutrient supplements (SQ-LNS) are among the most promising tools available to prevent child malnutrition, with evidence showing the packets can prevent nearly one in four child deaths in high-burden settings. Innovations for Poverty Action named it a "best bet." The World Bank's 2024 Investment Framework for Nutrition placed it among the highest-priority interventions for further investment.

The potential for SQ-LNS is clear — but cost-effective delivery at scale is still an emerging challenge. So when the Nigerian government and the Child Nutrition Fund committed almost $40 million to procure SQ-LNS, we saw a critical question embedded in a historic opportunity: could smart targeting unlock the intervention's full potential?

The cost-effectiveness puzzle

In Nigeria, malnutrition burden varies substantially by geography. Delivering SQ-LNS uniformly across a country as large and diverse as Nigeria — where 10 million children under two face vastly different levels of risk depending on where they live — means spreading limited resources across populations with very different needs. National surveys already showed that northern states bear a disproportionate burden – Jigawa, for example, has an under-five mortality rate of more than one  in 10 live births. But what we lacked was the granularity to target within states, down to the ward level, where the variation is even wider.

The $40 million procurement – while significant – would reach less than 10% of Nigeria’s eligible children.

The question was never whether to target the supplements, but how. Without our involvement, the plan was to distribute supply proportionally across 27 states, without accounting for the dramatic differences in malnutrition burden between and within them. We believed that directing supply to the highest-burden wards could make a meaningful difference in lives saved.

What if we could target more precisely?

Through our Deworm the World program, we had already proven the value of  using model-based geostatistics to generate high-resolution maps of disease burden – work has since been incorporated into the World Health Organization’s updated monitoring guidelines. We believed the same approach could transform SQ-LNS delivery. 

We worked with modelers at Australian National University to generate estimates of under-five mortality and stunting prevalence across Nigeria – not just at the state level, but down to individual wards, the rough equivalent of a U.S. municipality –  granularity that national surveys are not designed to produce. 

We used those estimates to build an allocation tool from scratch that combines ward-level data with health surveys and government population figures to generate distribution recommendations. Working with the Ministry of Health, UNICEF, and the World Bank, we developed an allocation plan that prioritizes the highest-burden wards while incorporating partner feedback on state-level priorities.

Targeting SQ-LNS to high-burden wards in northern Nigeria could achieve a cost per DALY averted of around $300 — nearly half the cost of an untargeted approach. And with Evidence Action providing technical assistance to strengthen the government's rollout, the marginal cost-effectiveness of our investment could reach roughly $43 per DALY averted — approximately 15 times more cost-effective than the WHO's threshold for "highly cost-effective" interventions.

Why we moved fast

The government’s $40 million commitment represented an enormous opportunity, and the Ministry of Health was committed to impact-based targeting. But the granular data needed to guide ward-level distribution didn't exist yet, and operational planning at the state level was still in early stages. Through our experience supporting Nigeria's deworming and prenatal vitamin (multiple micronutrient supplements) programs, we knew that robust state-level partner support could strengthen operational planning, supply chain management, and monitoring.

Without strategic targeting, much of the supply could be distributed with minimal follow-up, meaning some children might receive only one or two months of supplementation instead of the intended six.

We saw a time-sensitive opportunity to dramatically increase the impact of the government's investment. So we moved quickly, deploying unrestricted resources to begin work while pursuing additional funding. The window to influence distribution planning was narrow, and the potential return on a relatively modest investment was extraordinary. We have since secured full funding for this work through mid-2027 with a grant from CRI Foundation.

What we're doing — and what it means for children

In partnership with the government, we're supporting the allocation and delivery of SQ-LNS to around 2,000 wards, with most concentrated in northern Nigerian states, reaching approximately 2.5 million children aged 6–18 months. 

With the distribution plan now finalized, our focus is on ensuring that children targeted by the plan are actually reached – and that they receive and consume the full six months of SQ-LNS. We're providing intensive delivery support in nine priority states — Adamawa, Bauchi, Gombe, Jigawa, Kaduna, Kano, Kebbi, Plateau, and Sokoto — that will receive roughly 75% of the allocation. Our work spans health worker training, supply chain monitoring, and robust monitoring and evaluation.

To put this in perspective: without strategic targeting and delivery support, we estimate the procurement would save approximately 860 lives. Our involvement raises that to roughly 3,200 — the difference driven not by more product, but by ensuring it reaches the right children and that they receive the full six months of supplementation.

On the margin, we estimate our investment will increase the impact of the government’s investment by about 250% – also preventing 20,000 cases of stunting, 1,600 cases of severe acute malnutrition, and 32,000 cases of anemia. That translates to approximately $1,000 per life saved and $43 per DALY averted.

Why this matters beyond Nigeria

Nigeria is one of the first countries to undertake a major government-led SQ-LNS rollout, and how it goes could shape whether and how other high-burden countries follow. The approach we're testing — using model-based geostatistics to target a proven intervention to the children who need it most, delivered through government health systems — has the potential to become a replicable model.

We’re already working with state governments and health partners to use the allocation tool to guide future rounds of SQ-LNS procurement in Nigeria. State Nutrition Officers are being trained to use the tool for their own distribution planning and budget advocacy — building the kind of government ownership that outlasts any single program.

It's exactly the kind of outcome our Accelerator — our engine for identifying and scaling the next generation of cost-effective health programs — was built to produce. And it won't be the last.