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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
Field Article from UNICEF, using the first version of the National Guideline on IMAM that had been developed during 2008 4 . Technical support was provided by partners for District Nutritionists in order to strengthen monitoring and reporting of IMAM activities. The IMAM programme is centered mainly on the management of acute malnutrition in children under five years and pregnant and lactating women (PLW), with some emphasis also given to older children, adolescents and adults. During 2010, Kenya adopted a package of 11 High Impact Nutrition Interventions focusing on infant feeding, food fortification, micronutrient supplementation and prevention and management of acute malnutrition at health facility and community level. These essential nutrition services are integrated into routine health services and have been proven to be efficient at preventing and addressing malnutrition and mortality in children. It is anticipated that 26% of deaths could be prevented if the services are implemented fully and at scale. The package is currently being trialed in three districts of the ASALs. An evaluation will be conducted within the near future, after which the roll out of the package will be done in additional districts/areas. The IMAM programme (as part of High Impact Nutrition Interventions) is being implemented by the MoPHS and MoMS in partnership with UN agencies (UNICEF and WFP) and several implementing partners (IPs) at health facility and community level. The programme focuses on the management of acute malnutrition, with intensive activities being conducted in four provinces of the ASALs, including the whole of North Eastern province and parts of Rift Valley, Eastern and Coast provinces. Data relating to the geographical coverage of the IMAM programme are shown in Table 1. Populations in arid districts continue to experience a prevalence of global acute malnutrition (GAM) of between 15 and 37% (WHO 2006), due to seasonal fluctuations in food security, poor infrastructure and low levels of access to essential health and other social services. The high food and fuel prices of the last two years have dramatically reduced the population’s purchasing power, contributing to the deteriorating food security situation and associated high malnutrition levels. From the weekly IMAM reports provided to the MoPHS, the child case fatality has considerably reduced with most districts reporting
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July 2012 Issue 43 ISSN 1743-5080 (
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The overall aim of the Addis Ababa
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Editorial Éditorial A note on term
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Editorial Éditorial Haile Gebrsela
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Editorial Éditorial governance). S
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Field Article percentage points per
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Field Article sion for relevant sta
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Field Article anisms, especially fo
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Field Article Health and nutrition
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Field article Table 2: Number of he
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Field article MOH, Ghana MUAC measu
Page 29 and 30: Field article Box 1: Outline of the
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Page 33 and 34: Field article feeding (IYCF) practi
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Page 37 and 38: Linear programming to design low co
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Page 41 and 42: Field article Through twice yearly
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Page 45 and 46: Field article The following assessm
Page 47 and 48: Field article Brief history and bac
Page 49 and 50: Field article France and UNICEF sup
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Page 59 and 60: News UNICEF/NYHQ2008-1649/Pirozzi,
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Page 65 and 66: Conference on Government experience
Page 67 and 68: News Update on Minimum Reporting Pa
Page 69 and 70: Field Article Table 1: Nutrition si
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Page 97 and 98: Field Article District training in
Page 99 and 100: Professional profile Dr Nadera Haya
Page 101 and 102: People in aid CMAM Conference, Addi
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