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disjointed and less strategic when relying on
short-term humanitarian funding sources.
Effective connectivity between the humanitarian
and development donors seems to be
somewhat limited in Kenya, resulting in a
degree of inflexibility when addressing the
multiple underlying causes of malnutrition.
Kenya will not be able to reverse the current
trend of increasing rates of stunting without
dedicated longer-term funding specifically allocated
to programmes to address these
underlying causes. Emergency donors have
also asked partners to apply for funds that will
support resilience in communities affected by
drought and hopefully this should shift the
focus to long term sustainable measures.
Challenges to IMAM implementation
The MoPHS, MoMS and partners face many
challenges in the implementation of high quality
IMAM programmes, including:
• Geographical access across the vast and
inaccessible areas of northern Kenya where
rates of malnutrition are highest.
• Ensuring sufficient supplies and reducing
the risk of pipeline breaks.
• Funding gaps when trying to ensure that
the full package of outreach services can be
provided.
• High defaulter rates due to poor follow up.
• Long lengths of stay in the programme due
to sharing of commodities at household
level.
• Insufficient general food distribution rations
due to lack of cereals and the high prices of
fuel and maize. This negatively impacts on
the programme through increased risk of
sharing of the therapeutic and supplementary
rations amongst household members.
• Constraints within the health service, most
notably human resource issues that include
high staff turnover, shortages of staff in
hard to reach health facilities, lack of trained
staff in health facilities, etc.
IMAM implementation within the urban
setting
Kenya is rapidly urbanising and it is projected
that by 2020, 50% of the population will live in
urban areas. Nairobi alone has seen a 46.2%
increase in population size since 1990 (according
to the 2009 census) and is now home to over
3,138,369 people. The majority of this growing
urban population resides in slums or informal
settlements with little access to basic services.
About 50% of the 16 million poor Kenyans live
in the slums/informal settlements in the main
urban centres and 40% are food insecure. The
face of poverty is therefore changing due to this
rapid urbanisation. Urban poverty is characterised
by lack of employment or lower wages
and returns from informal employment
(compared to the formal sector) and extremely
poor levels of basic services, such as housing,
sanitation, health care and education services.
In general, poorer urban households are
particularly vulnerable to changes in market
prices as they are entirely dependent on the
market, both to generate income and to meet
their food and non-food needs. The ‘new face of
hunger’ has seen slum residents adopt negative
coping strategies such as skipping meals, eating
lower priced and less nutritious foods and
cutting back or eliminating expenditures on
health or education services. Other major
constraints to attaining good nutrition status
are inadequate awareness and knowledge on
Mother and child in
Turkana county
nutritionally adequate diets, poor infant and
child feeding practices, limited resource allocation
and capacity to support comprehensive
nutrition programs in the country. Likewise, the
prevalence of malnutrition in urban areas,
particularly in the slums, is expected to be
much higher than the national average (KDHS,
2008-9).
From 2009 onwards, at least three factors
have further compromised the livelihood security
and child survival in Kenya’s slum
populations:
• Loss in food production due to the impact
of the post-election violence in the main
agricultural producing areas in the Rift
Valley.
• Global increases in food and fuel costs.
• Drought developing across the Horn of
Africa.
Overall IMAM strategy
Prior to IMAM implementation the only nutritional
services available for SAM children were
traditional inpatient care units that existed in
the main referral hospitals. As inpatient care
was the only treatment available, the result was
overcrowding of wards, increased risk of cross
infection amongst immune-compromised
patients, pressure on over-stretched and underresourced
staff from increased caseloads and
limited coverage of the affected population.
The MoH started to roll out IMAM and build
the long-term capacity of health staff in order
that the programme could be sustained and
replicated across the big cities of Nairobi and
Kisumu. All the activities were planned for and
implemented by provincial and district level
MoH staff with support from partners, most
notably Concern Worldwide.
Table 2: Performance indicators for the urban IMAM
programme
Year Number of Cured Deaths Defaulters
admissions
2008 1,607 48.4% 2.4% 47%
2009 2,737 67.4% 3.1% 28.1%
2010 4,669 76% 2.0% 21%
Concern Worldwide’s support to the MoH
for IMAM services consisted mainly of technical
assistance, which aimed to improve
technical knowledge in curative and preventative
nutritional services within the existing
health system. The entry point for urban IMAM
was through paediatrics clinics based in the
informal settlements (slums) of Nairobi,
supported by another partner (Lea Toto) that
focused on provision of HIV/AIDS services.
The support for nutrition services was not
limited to HIV positive children but also
extended to HIV negative children who were
malnourished, identified through MoH facilities
in the same catchment areas. The roll-out of
IMAM in urban slums was triggered by poor
health indicators as well as socio-economic
factors experienced by the urban poor.
Additionally, increasing caseloads of paediatric
HIV cases resulted in higher numbers of
malnourished children presenting to the clinics.
At present, OTP services are being offered in
eight districts in Nairobi and one in Kisumu
(Nyanza Province) through MoH facilities (and
with the support of Concern Worldwide). Since
2008, following the post-election violence, OTP
sites increased from 30 to 54. Through support
from the WFP, 58 Supplementary Feeding
Centres (SFCs) have also been established in the
urban slums (Nairobi and Kisumu).
Linkages with other health/nutrition
interventions
Most OTPs are situated at the Maternal and
Child Health (MCH) clinics, which has helped
to strengthen the linkages for both the caregiver
and the child to other MCH services such as
immunisation, ante-natal and post-natal
consultations and to primary health care delivery
services. In addition, children responding
poorly to SAM treatment are referred for HIV
and TB screening.
Operational issues: training, supplies,
logistics, supervision, reporting
Following the post-election violence the expansion
of IMAM services in the urban slums was
accelerated. Using the interim training package
V Wambani, Kenya, 2011
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