Integrated management of acute malnutrition in Kenya including urban settings

By Valerie Sallie Wambani

Valerie Wambani is Programme Manager for Food Security and Emergency Nutrition, Division of Nutrition, Ministry of Public Health and Sanitation. She is responsible for coordination of the Kenya’s nutrition response activities, the Nutrition Technical Forum, development and dissemination of guidelines, technical support to district teams and resource mobilisation for implementation response strategy.

The author would like to acknowledge the Permanent Secretary, Director and Head of the Department of Ministry of Public Health and Sanitation, as well as the Department of Family Health and Terry Wefwafwa (Head, Division of Nutrition). The author also acknowledges the work and support of UNICEF Kenya, Concern Worldwide Kenya (special mention to Yacob Yishak and Koki Kyalo), WFP Kenya, Nutrition Technical Forum members and Dolores Rio, UNICEF New York.

Context

Mother and child in Turkana county

Kenya has a population of 38.7 million people, of which 5,939,308 are children under five (U5) years of age. The country is divided into eight provinces: Coast, Eastern, Central, North Eastern, Rift Valley, Nyanza, Western and Nairobi. However, with the new dispensation, these provinces are being phased out to pave way for the 47 counties that will feature more prominently after 2012 in terms of governance. Agriculture, tourism and manufacturing are the mainstay of the economy. Two indicators of nutrition status of U5 children have worsened over the last two decades (see Figure 1), with the Kenya Demographic Health Survey (KDHS) 2008-09 reporting that 35% were stunted (2,096,575 children) and 6.7% were wasted (397,934)¹. However, the prevalence of underweight children has reduced from 22% to 16.1% (956,228). The prevalence of stunting was highest in three provinces: Eastern, 41.9%, Coast, 39.0%, and Rift Valley, 35.7%. Overall, the health status of the population is poor, with an infant mortality rate of 52 deaths per 1,000 live births, an U5 mortality rate of 74 deaths per 1,000 live births, and a maternal mortality rate of 441 deaths per 100,000 live births.

Kenya experienced a serious drought in 2011 affecting the northern parts of the country and also had a mass influx of refugees arriving from Somalia (July 2011). At this time it was estimated that more than 1,500 refugees were arriving each day, many of whom were in very poor condition after travelling for days and weeks to reach the camps. The refugee camp of Dadaab, in particular, was 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 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 months³ (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.

A severely malnourished child (Lakert) referred from a dispensary to Lodwar district hospital

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 from UNICEF, using the first version of the National Guideline on IMAM that had been developed during 2008⁴. 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.

OTP: Outpatient Therapeutic Programme, SFP: Supplementary Feeding Programme

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 <3%. Through gradual expansion of services, geographical coverage of the IMAM programme has increased from 50% for SAM and 39% for MAM in 2009, to 73.9% and 60% in 2011, for SAM and MAM respectively.

New admissions for SAM and MAM continue to increase compared to the same period during 2010. There has been an increase in 78% of new admissions of children suffering from SAM and a 39% increase in new admissions of children suffering from MAM. Additionally an increase of 46% of new admissions of PLW suffering from acute malnutrition has been observed. This increase is largely due to the drought and deteriorating food security situation currently occurring in Kenya and as reported in the mid-season long rains assessment report. The long rains assessment report⁵ reported an increase in the number of food insecure persons from 3.5 million to 3.75 million with pastoralists accounting for 1.5 million in the emergency phase.

Progress on IMAM coverage:

• 34,168 severely acutely malnourished children <5 years
• 91,963 moderately acutely malnourished children <5 years
• 20,346 acutely malnourished pregnant and lactating women.

The nutrition section within the MoPHS estimates that approximately 385,000 children and 90,000 women are currently suffering from acute malnutrition (July 2011). Based on the nutrition and food security situation, the nutrition sector has confirmed that 10 larger ASAL districts have been classified as ‘Under Alert’ (Map 1).

Main partners involved in IMAM implementation in Kenya

The Ministries responsible for health chair the coordination forum for nutrition stakeholders and have developed a partnership framework with clear terms of reference. The main development partners that support the MoMS and MoPHS for IMAM are UNICEF and WFP. UNICEF procures and distributes all the Ready to Use Therapeutic Food (RUTF) supplies to treat SAM, whilst WFP procure and supply products to treat MAM (Corn Soya Blend (CSB) and oil). Both partners also provide considerable support for training, monitoring and supervision of the programme.

Due to capacity constraints within the health service, support for IMAM programming is provided through a number of implementing partners (IPs). The main IPs include Action Against Hunger, Save the Children, World Vision, Food For the Hungry, Concern Worldwide, Mercy USA, Mercy Spain, CAFOD, GIZ, Islamic Relief, MSF-France, MSF-Spain, MSF-Belgium, International Medical Corps, International Rescue Committee (IRC), Merlin, Pastoralists against Hunger, The Good Neighbours’ Community Programme, Samaritan’s Purse, OXFAM, CCF and CARITAS.

Partners are coordinated through the Nutrition Technical Forum (NTF), which is chaired by the MoPHS and co-chaired by UNICEF. This forum was established following the post-election violence of 2008/9 and has continued to steer all emergency operations. Four working groups were also established that report to the NTF: the Capacity Development working group, the ASALs working group, the Nutrition Information working group, and the Urban Nutrition working group. A partnership framework was put in place to guide the engagement of partners with the MoPHS. Through this coordination mechanism, for example, nutrition survey methodology is vetted and results validated before dissemination. It has also strengthened the code of conduct of partners adhering with the ‘three ones’: one implementation plan, one coordinating body and one monitoring and evaluation plan. The main challenge has been some partners withdrawing abruptly from districts without a proper exit strategy, some having only short-term funding and others preferring to operate in areas that are already covered.

Funding of IMAM activities

Funding for nutrition in general remains at very low levels. The proportion of the total Government of Kenya health budget that is allocated for nutrition currently stands at 0.5%, of which more than 75% is for human resource needs, leaving the rest for programme activities.

IMAM programmes are predominantly funded through emergency budgets, provided by both the Government of Kenya and partners, to support commodities, logistics, capacity strengthening and monitoring and evaluation of the programme. The government has continued to increase allocation for IMAM commodities and provided guidelines on type of products to be used. In 2011, partners have received $14,546,811 from a variety of sources to implement IMAM programmes in the country. However, the nutrition sector estimates that a total of $55,694,269 is required to ensure appropriate response up to the end of the year. A considerable gap therefore exists between the funds received and what is required to adequately address the humanitarian crisis that is occurring in Kenya this year. Recently, the programme has received support from the German International Cooperation (€200,000) for procurement of commodities for management of SAM and MAM. World Bank has committed to provide US $12.8 million for commodities and capacity strengthening for the IMAM programme.

Due to the nature of emergency programming, most nutrition programmes are largely short-term and humanitarian in nature. While emergency funds are generally easier to access than longer-term development funds, the resulting programming can often be more 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 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.

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

Mother and child in Turkana county

Following the post-election violence the expansion of IMAM services in the urban slums was accelerated. Using the interim training package 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

¹CBS, MOH, KEMRI, NCPD, ORC Macro, Cleverton, Maryland USA, Centre for Disease control Nairobi, (2008/2009). Kenya Demographic and Health Survey .pp 42-45

²Mwaniki et al, (2002). Anaemia and the status of Vitamin A deficiency in Kenya.

³Source: Micronutrient Initiative

⁴Government of Kenya (2008). Integrated Management of Acute Malnutrition, Guidelines for health workers.

⁵GOK (2011). Long Rains Assessment Report