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Field Article
spearheaded by UNICEF/WHO, capacity
strengthening was conducted with training of
trainers and practical training on the management
of SAM to be integrated into routine
health services at health facilities. District
Health Management teams (DHMT) have been
supported in the nine districts of Nairobi and
Kisumu to provide training of health staff in
SAM/ MAM service provision. Weekly on-thejob
support was provided to health facility staff.
This was gradually scaled back once staff were
able to implement the protocols correctly.
Reporting on IMAM was also strengthened to
ensure that districts provide accurate and
timely reports to provincial and national levels.
Community mobilisation
The MoH has promoted the use of community
health workers (CHWs) to support implementation
of IMAM. A community strategy has
been refined to increase early detection and
home follow-ups. Each health facility is served
by a group of volunteer CHWs who conduct
community sensitisation, screening in the
community, referrals of SAM/MAM cases,
home follow-up of absentees and defaulters,
and follow-up of inpatient referrals back to
OTP.
The retention of CHWs is a major challenge
due to their ‘volunteer’ status, meaning that
they are not paid for services rendered (they
receive payments during training days only).
The MoH has recently developed a Community
Strategy Policy that states that the community
health extension workers (CHEWs) will be paid
approximately $25 per month. While this is a
relatively small payment, it is hoped that it will
encourage the CHEWs to stay in post for
longer.
Successes in the urban roll-out of IMAM
The main achievements in the urban rollout
include:
Gradual expansion of services has been
reported, as reflected by increased admissions
and steady improvement in performance of the
programme. Both the percentage of cases cured
and percentage of deaths meet Sphere standards
(see Table 2), although default rates
(while decreasing) remain high.
Management of acute malnutrition has been
included in district ‘Annual Operational Plans’
for 2008, 2009, 2010 and 2011 in Nairobi and
Kisumu East. This has ensured that the OTP has
become part of ‘routine health service delivery’
in these districts.
Expansion of the OTP via routine health
centre delivery services has resulted in greater
access to nutrition services with improved
coverage in Nairobi and Kisumu East. A total of
54 health facilities (run by MoH with support
from partners) have now integrated management
of acute malnutrition within their
nutrition services in the urban slums.
The work has mobilised and used existing
human resources: community health workers
and community leaders. Community linkage
has been strengthened between the health facilities,
inpatient referral centres and the
community, thus increasing referrals and home
follow-ups of acutely malnourished children.
Improvements have been made in reporting
and the supply chain for therapeutic products.
However, further work for individual site
stock control and avoidance of supply breakdown
is required to ensure uninterrupted
service provision
There has been expansion of nutrition
support to help districts implement the essential
nutrition package previously formulated by
the MoH with support from UNICEF. Key
activities include strengthening infant and
young child nutrition, micronutrient support,
health and nutrition education and community
mobilisation.
Key challenges for the urban IMAM
programme
High staff turnover at health facilities. Since the
inception of the programme in 2008, repeated
training has often been required as a result of
high staff turnover. At times, OTP services have
been implemented by untrained staff, which
has resulted in poorer quality service provision.
Lack of supplementary feeding to treat cases of
MAM in Nairobi. Until May 2011, there was no
treatment available in Nairobi for MAM cases.
If these children are not treated, they are more
likely to develop SAM. Furthermore, children
discharged from the OTP are likely to relapse if
they are not given protection rations of CSB
because they come from food insecure homes.
High defaulter rates (above Sphere standards).
While the default rate is slowly declining, it
remains high. Main reasons include migration
as families move due to house fires (caused by
type of cooking facilities used), high rents, or
for work opportunities. Additional important
reasons are frequent absenteeism as caregivers
often prioritise casual work over attendance at
health facilities and frequent and lengthy
illnesses of the caregivers due to HIV/AIDS
related complications and other chronic
diseases.
Lack of emergency indicators for urban settings.
Even during times of acute crisis, the malnutrition
rates in urban areas generally remain low.
However, even low prevalence rates can translate
into very large caseloads due to the high
population density of urban slums. As there are
currently no internationally recognised indicators
of crisis in urban areas, it can often be
difficult to mobilise resources. It is also challenging
to motivate government and key
stakeholders to increase their workload when a
clear need has not necessarily been identified.
Other challenges include inadequate storage
for supplies and equipment at health facilities,
difficulties with accurate and timely reporting,
coherent use of data at facility level for planning
purposes, inadequate stock management
of SFP commodities and lack of appropriate
mixing equipment for SFP commodities.
Lessons learned from the IMAM
programmes in Kenya
On-site training and intensive on the job
support are essential for retention of skills and
continuity of care. This also has additional
benefits because staff are not taken away from
the health facility and more staff can be trained
with proper planning.
It is important to sensitize stakeholders sufficiently,
especially donor agencies and health
staff regarding the high caseloads of acute
malnutrition that typify Kenya’s urban slums,
even when the prevalence of malnutrition is low.
Alternative indicators are required to determine
nutritional emergencies in urban areas.
The challenges and problems within the urban
context are considerably different from the
rural context upon which current Sphere standards
and WHO recommendations are based.
The IMAM programme in Kenya has
evolved gradually from one district and a few
selected health facilities to a national
programme covering more than 22 counties
with a trained pool of health workers who are
able to manage acute malnutrition. The policy
environment has enabled partners to support
integration within routine services and to scale
up during emergencies. The government’s role
in funding the programme has increased. The
2011 allocation for emergencies within the
health sector is 150 million Kenyan Shillings,
compared to 65 million Kenyan Shillings in
2010. Guidelines will be reviewed to incorporate
protocols for blanket supplementary
feeding and new products, for example.
Within the health system, the Annual
Operational Plan (AOP) is the planning tool
that highlights key activities, indicating the
contribution of both government and partners.
Partners are invited to participate in the AOP
process and commit to support government
priorities outlined in the plan. In theory, the
resources committed should be disclosed to
determine gaps. However, some partners
would rather state that they will provide technical
assistance in a number of areas than put a
figure in monetary terms, for example, as
reflected in the Division of Nutrition work plan.
The main partners supporting nutrition activities
include UNICEF, USAID/MCHIP
(Maternal and Child Health Integrated
Programme), Global Alliance for Improved
Nutrition (GAIN), Micronutrient Initiative and
WFP.
Recently, the Division of Nutrition has
received credit from the World Bank through
the Health Sector Support Fund for the
drought-affected counties for management of
SAM, moderate malnutrition and blanket
supplementary feeding for vulnerable groups
(including PLW, older persons, widows and
female headed households). The proposal went
through a rigorous process of determining
baseline indicators and monitoring indicators
to track progress towards attainment of set
objectives. All commodities for the management
of malnutrition will be procured by
UNICEF and distributed through the WFP
pipeline to ensure that no parallel systems are
set up. The German Society for International
Cooperation (GIZ) has also provided funding
for emergency activities and these funds must
be utilised by December 2011. These funds
require that UNICEF procures the commodities
and the African Medical and Research
Foundation (AMREF) develops the capacity of
health workers.
The draft concept paper on the devolved
system is in place and modalities are being
discussed regarding the implementation.
County governments will be independent and
expected to raise funds for operations of the
majority of services, including primary health
care services which are a function of the county.
For more information, contact: Ms Valerie
Wambani, email: vwambani@gmail.com,
vwambani_don@dfh.or.ke, +254 715019069
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