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Field Article
Figure 1: Trends (% prevalence in U5s) of nutritional
indicators (stunting, underweight and
wasting) in Kenya, 1993–2008
% U5 children
40
35
30
25
20
15
10
5
MDG target
16.2%
MDG target
0 3.05%
1993 KDHS 1998 KDHS 2003 KDHS 2008 KDHS
(WHO)
Stunting Underweight Wasting
MDG: Millennium Development Goal
under considerable pressure, as it was not
designed to hold such vast numbers of people.
Available services were stretched to the limit as
workers tried to cope, both with the new
arrivals and also those who have been residing
in the camp for some time.
Political situation
After a long period of peace and stability, the
fourth multi-party General Election was held
during December 2008 and the results were
highly contested. Violence erupted across the
country, particularly in Nyanza, Rift Valley,
Coast, Western and Nairobi Provinces. It is estimated
that 1,200 people died, with a further
500,000 displaced. A legacy of distrust
remained between the various factions, which
required a team of external negotiators to be
brought in to broker a deal for power sharing
amongst the opposing political parties. One of
the results of the peace deal was that the
Ministry of Health (MoH) was divided into two
separate ministries: the Ministry of Medical
Services (MoMS), which is responsible for curative
services in hospitals and higher-level
health services, and the Ministry of Public
Health and Sanitation (MoPHS), which is
responsible for health services delivered from
health centre, dispensary and community
levels.
Prior to the divide, public health issues
received little attention, with more focus placed
on curative service delivery. Once the MoPHS
was established, nutrition and public health
issues gained more attention and, crucially, a
larger share of the health budget. A new constitution
was developed and promulgated in
August 2010, and currently various legislations
are being put into place to guide governance
A severely
malnourished
child (Lakert)
referred from a
dispensary to
Lodwar district
hospital
V Wambani, Kenya, 2011
under this new dispensation. The various
ministries will once again be combined into an
overall Ministry responsible for Health. The
challenge for nutrition will be to maintain the
increased attention that it has been receiving
once the MoPHS is again subsumed into the
MoH. The new constitution has outlined a
process of decentralisation, whereby the 47
counties will become much more autonomous
with regards to health service provision,
management of budgets, operational issues, etc.
Overall guidance in the form of policies, guidelines
and the like will still emanate from central
level.
A major change outlined in the new constitution
is that Ministers (for health, agriculture,
etc.) will no longer be elected politicians, but
instead will be technicians/professionals nominated
through parliament. It is expected that
this will result in the various ministers being
less interested in ‘politics’ and more focused on
the effective management of their ministries.
This will be in line with the results-based
management system introduced within the
public service in 2005, which will hopefully
encourage a focus on improved performance.
Nutritional status of the population
The devastating effects of micronutrient deficiencies
in pregnant women and young
children are very well known and deficiency
rates remain high in Kenya. Children are particularly
affected by deficiencies of vitamin A
(84%), iron (73.4%) and zinc (51%) 2 . The highest
prevalence of moderate to severe anaemia has
been found in the coastal and semi-arid
lowlands, the lake basin and western highlands
sub regions. Among women, prevalence of
severe to marginal s-retinol deficiency has been
found to be 51%, while severe s-retinol deficiency
is 10.3%, with a prevalence of 55.1%
among pregnant women. The prevalence of
iodine deficiency in Kenya is 36.8%, with goitre
prevalence of 6%. The national micronutrient
survey has been completed and findings will
provide up-to-date data on the micronutrient
status of the population.
With regard to infant and young child feeding
practices, indicators are also poor with only
32% of infants under six months of age being
exclusively breastfed. While this percentage
remains low, it does show improvement from
11% in 2003. The median duration of breastfeeding
in Kenya was found to be 21 months 3
(KDHS 2008–9).
Policy environment and coordination fora
An overall policy framework for Kenya has
been outlined in the ‘Vision 2030’, which aims
to transform the country into a globally
competitive nation with a high quality of life.
The MoPHS strategic plan 2008–2012 aims to
support the implementation of ‘Vision 2030’
and was informed by the Kenya Health Policy
Framework 1994–2010, the second National
Health Sector Strategic Plan (NHSSP)
2005–2010 and the Medium Term Expenditure
Framework 2008–2011. The NHSSP is being
finalised to guide service delivery in the
devolved system of government.
With regard to nutrition, the first food policy
was developed in 1981. Its main objective was
to support self-sufficiency in major foodstuffs,
while ensuring equitable distribution of food of
good nutritional value to the population. This
policy was reviewed in 1994, but maintained
the same objective. Since this time, significant
progress has been made in developing strong
nutrition-related policies to address the stagnant
high malnutrition levels and the
underlying causes.
An example of this is the Food and Nutrition
Security policy, which was developed through a
wide consultative process with local and international
technical support, and subsequently
submitted to Cabinet. However, with the new
constitution coming into force in 2012, it is
currently under review to align it with the new
structures that will shortly be in place. Cabinet
had endorsed the Food and Nutrition Security
policy and the Agriculture Sector Coordinating
Unit (ASCU) is coordinating efforts on governance
structures for implementation of this
policy. The Food and Nutrition Security strategy
will be reviewed through wide stakeholder
consultations. Additionally the ‘breast milk
substitutes’ control bill will be subject to wide
stakeholder discussions to involve civil society
before enactment by parliament, to regulate
practices aimed at protecting appropriate
infant feeding practices.
The MoPHS coordination structure includes
the Joint Inter-Agency coordinating committee,
which provides political and policy direction to
ensure that the sector is working towards
achieving the policy objectives set out in the
Vision 2030 and the Medium Term Plan.
Additionally, the Health Sector Coordinating
Committee has the role of ensuring that the
ministerial strategic plan is implemented so
that sector policy objectives can be achieved.
Meetings are co-chaired by the Permanent
Secretaries of the two sector ministries, MoMS
and MoPHS. There are 16 Inter-Agency
Coordinating Committees (ICCs) and one of
these is focused on nutrition, the Nutrition
Interagency Coordinating Committee (NICC).
At the sub-national level, various governance
structures facilitate provincial and
district implementation of the national strategic
plan. A number of fora have been established,
including the Provincial Health Stakeholders
Forum, the District Health Stakeholders Forum
and the Health Facility Committee and
Community Health Committees. Nutrition coordination
is undertaken at provincial and district
levels with clear terms of reference, through
technical committees of the stakeholders.
Integrated Management of Acute
Malnutrition (IMAM)
Development of IMAM in Kenya
IMAM programming started in earnest during
2007 when the MOH, UNICEF and WHO
entered into a tripartite agreement to respond
to the varied and complex crises that Kenya
regularly faces. The response was undertaken
in partnership with international, local and
faith-based organisations. This initiative
marked a change in the implementation strategy
of the Ministry, to develop stronger
working relationships with partners in order to
help build capacities and strengthen systems.
By 2008, approximately 400 health workers
from districts in the Arid and Semi-Arid Lands
(ASALs) were trained in IMAM with support
2
Mwaniki et al, (2002). Anaemia and the
status of Vitamin A deficiency in Kenya.
3
Source: Micronutrient Initiative
4
Government of Kenya (2008). Integrated Management of
Acute Malnutrition, Guidelines for health workers.
79