The roll out of IMAM in Kenya’s urban slums

By Koki Kyalo, Claire Orengo, Regine Kopplow

Koki Kyalo is the Urban Nutrition Programme Manager at Concern Worldwide, Kenya. She has worked with Concern Worldwide for five years on nutrition programming in both urban and arid lands areas. She leads and chairs the Kenyan Urban Nutrition Working Group.

Claire Orengo is the Health and Nutrition Coordinator for Concern Worldwide Kenya and sits on the National Nutritional Technical Forum of the Ministry of Health, Department of Nutrition. Previously, she worked with International Medical Corps in Ethiopia and Sierra Leone and Medair in Somaliland and South Central Somalia.

Regine Kopplow is Global Nutrition Advisor with Concern Worldwide. She previously worked in various roles in nutrition programmes in Afghanistan, Malawi and Nepal for Concern Worldwide and in Somaliland and South-Central Somalia for UNICEF.

The authors acknowledge the contributions of the Ministry of Health Kenya and UNICEF Kenya.

The face of poverty in Kenya is changing and the country is facing a new urban crisis. The rate of urbanisation in Kenya is one of the highest in the world. The urban population growth is estimated at 5% annually over the last decade compared to an estimated average 2.3% population growth of sub-Saharan Africa. Over 60% of the urban population in Kenya lives in slums¹; the slum dwellers in Nairobi reside on only 5% of the land. Urban poverty is characterised by lack of employment, lower wages and returns from informal employment, and extremely poor levels of basic services such as housing, sanitation, health care and education. There are increasing numbers of ‘food poor’, those unable to meet all nutritional needs due to expenditure on other basic non-food essentials, and ‘hard-core poor’, who cannot meet their minimum food requirements even if they allocate all their income on food². The poorest urban-dwellers spend up to 75% of their income on staple foods alone.

Living conditions in Korogocho slums, Nairobi

Urban settings have increasingly become unequal settings. Indicators for infant mortality rates (IMR) in Kenya’s slums are significantly worse than the national average; 60 and 95 per 1,000 live births in Nairobi and Kisumu respectively, compared to a national average of 52 per 1,000 live births. However, these figures are severely misleading in relation to the urban poor, given that they are city-wide and include all socioeconomic groups, including those from Nairobi’s leafy suburbs and better off area as well as areas of great depravation. Without disaggregated data, equitable and timely targeting of responses to the areas’ most in need remains difficult. The IMR for the urban poor is much higher; a longitudinal study conducted by the African Population and Health Research Centre (APHRC) between 2003 and 2005 in two slums in Nairobi revealed that the infant mortality rate was 40% higher (96 per 1,000 live births) than that of Nairobi (67 per 1,000 live births) as a whole.

The Child Survival and Development Strategy indicates that 50% of all under-five mortalities in Kenya are associated with malnutrition³. Malnutrition in urban locations can take a number of forms, i.e. stunting, wasting, and micronutrient deficiency. In many instances, different types of malnutrition overlap. Stunting is the predominant form of malnutrition found in urban areas in Kenya. An APHRC surveillance system established in two Nairobi slums found that one in two children was stunted⁴. Further, an APHRC (2013) comparative analysis of stunting trends over the past 6 years indicates a doubling of stunting rates (see Figure 1). The SAM (Severe Acute Malnutrition) rates based on Concern Worldwide (2009) survey results are 1.9% for Nairobi and 4.1% for Kisumu, which together translates to more than 7,000 SAM children. This high prevalence of SAM (>1%) indicates co-morbidity among the SAM cases and in particular, high prevalence of diarrhoeal diseases and HIV related conditions that have further exacerbated malnutrition.

The right to good nutrition is enshrined in the Kenyan constitution (Article 42c) and the National Food and Nutrition Policy. Greater accountability is required to the urban poor and to addressing underlying determinants that contribute to malnutrition. Addressing urban slum conditions such as poor water, sanitation and housing, access to health and education services, health and dignity are apparently a low priority in most government departments. However the Ministry of Health with support from Concern Worldwide and UNICEF has developed an Urban Nutrition Strategy⁵ that is currently going through an approval process for publication.

Source: APHRC

Strategy to increase access of IMAM services in urban slum setting

Prior to the integrated management of acute malnutrition (IMAM) implementation in 2008, the only available nutritional services for SAM were provided through the traditional inpatient care units that existed in the main referral hospitals in urban slums. MoH (Ministry of Health) started to roll-out IMAM and to build the long-term capacity of health staff so that the programme could be sustained and replicated across the big cities of Nairobi and Kisumu. All the activities were planned and implemented by provincial and district level MoH staff with support from partners, most notably Concern Worldwide. Concern Worldwide’s support to MoH consisted mainly of technical assistance, which aimed at improving the technical knowledge in curative and preventative nutritional services within the existing health system. The entry point for urban IMAM was paediatric clinics based in the informal settlements (slums) of Nairobi, supported by a local non-governmental organisation (NGO) Lea Toto, which focused on provision of HIV/AIDS services. Further scale up of IMAM in urban slums was triggered by poor health indicators, as well as socio-economic factors experienced by the urban poor.

The roll out of IMAM in urban slums focused on three of the four IMAM components: inpatient care, Outpatient Therapeutic Programme (OTP) and community mobilisation. Health workers from the Maternal Child Health (MCH) and Out-Patient Department (OPD) were targeted for the IMAM trainings. Until recently, the OTP was viewed by many health staff as a vertical programme and thus there was a perception that it was extra work that needed additional staff for implementation. However, there has been a gradual positive change which has seen OTP almost fully integrated into the routine work of most health facilities. Health workers in the MCH and OPD departments screen children using mid upper arm circumference (MUAC) tapes, in addition to the weight-for-age (WFA) measurements traditionally used.

Currently OTP services are being offered in eight districts in Nairobi and one in Kisumu through MoH and private facilities supported by NGOs (e.g. Concern Worldwide) and Faith Based Organisations (FBOs). There has been remarkable decentralisation of IMAM services, from 30 in 2008 to 107 in 2013. Private health facilities⁶ have been fundamental to the increased geographical coverage of the services. Currently up to 55% of the IMAM services are provided through private health facilities in the urban slums of Nairobi and Kisumu. Between January and June 2013, private health facilities have admitted upto 60% of the SAM admissions. However, coverage assessments of OTP services conducted by Concern (using SQUEAC⁷ methodology) have indicated poor access and coverage despite increased geographical coverage. More importantly, the assessments have provided a wealth of data that sheds light on why access to the urban nutrition programme is challenging, and the extent to which specific characteristics of urban environments affect coverage. Factors affecting coverage include poor health seeking behaviour influenced by both culture and stigma, caregivers are time constrained making weekly OTP follow up visits a significant challenge, a highly mobile community as they seek job opportunities, short term relocation to the rural areas and accidental destruction (like fires) of their homes.

On-the-job training

During the initial roll-out of IMAM, Concern supported the MoH to design and offer flexible theoretical training based at the facility followed by 8 to 12 weeks of on-the-job training. The theory classes were flexible depending on the schedule of the facility and the trainings scheduled on less busy days. The short trainings (one and a half days) were followed by weekly on-the-job training which takes a minimum of three consecutive weekly visits. This was later scaled down to twice a month and eventually to monthly supportive supervision visits once the facility was well versed with the treatment protocols. A standard supervision checklist is used for on-job training and support supervision.

Community mobilisation

The Kenya Community Health Strategy has promoted the use of community health workers (CHWs) to support implementation of IMAM.This is a critical intervention aimed at reducing health inequities, improving the effectiveness of service delivery, and enhancing community access to nutrition services by promoting community ownership and control through the community strategy. Over time, a community strategy has been refined to increase early detection and home follow-ups. Each health facility is served by community units that have assigned a number of CHWs for respective households. The CHWs 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 as they are not paid for services rendered but receive a monthly incentive of 2000 Ksh (£15) per month⁸. The MoH has advovated for the flat rate to regularise the CHW pay. The MoH relies heavily on partners to cover these costs as they are yet to be entrenched in the MoH budgets.

Linkages with other health/nutrition interventions

Currently most OTPs are situated at the MCH which has considerably helped strengthen the linkages for both the caregiver and the child to other MCH services such as immunisation, ante-natal and post-natal consultations and therefore also to primary health care delivery services. In addition, children responding poorly to SAM treatment are referred for HIV and TB screening. Further MUAC screening and referral links to MCH have been established with Comprehensive Care Clinics (CCC), OPD and TB clinics. In addition to IMAM, Concern Worldwide supported the MoH to integrate promotion of breastfeeding and optimal complementary feeding. Referrals of MAM cases and OTP discharges to Supplementary Feeding Programme (SFP) has remained weak. The urban areas are yet to secure long term support for SFP. Currently MoH support is not regular, thus clinics go for months without supplementary foods.

Further, Concern Worldwide has scaled up support to the MoH to increase coverage and quality of twelve high impact nutrition interventions (HINI) in the health facilities. In July 2010, Kenya adopted the HINI package which comprises of breastfeeding, complementary feeding, hand washing, Vitamin A supplementation, zinc supplementation, multiple-micronutrients, deworming for children, iron-folic for pregnant women, salt iodisation, iron fortification of staple foods, prevention and treatment of moderate acute malnutrition, and treatment of severe acute malnutrition.

Health system strengthening; towards sustainable nutrition gains

Concern Worldwide worked with health facilities providing technical support to health facility staff who in turn provided quality nutrition services. However, this approach was not considered to be sustainable (limited engagement with District Health Management Teams - DHMTs) and thus the shift was made towards health systems strengthening, to build the capacity of the DHMTs to support and sustain the skills within the health facilities. Concern Worldwide’s approach to health system strengthening focuses on five key areas: technical, managerial, human resource, finance, and supplies and logistics. This has seen Concern Worldwide increase the scope of support to the DHMT from technical to the other four components of the health system. Although it is a slow and long term investment, it is more sustainable and effective in building nutrition capacity within the MOH. The MoH role in provision of health services to the poor urban population is critical to closing the inequality gap. In recognition of this, Concern Worldwide is now embracing building the capacity of the DHMT through Health System Strengthening to own the process.

Operational issues - training, supplies, logistics, supervision, reporting

In addition to training health workers in health facilities, DHMTs also organise on-the-job trainings and supportive supervision to reinforce health workers skills. The county nutrition office coordinates with the districts to develop supply requests for RUTF (Ready to Use Therapeutic Food) and anthropometric tools that are channelled through UNICEF for support. Though Concern Worldwide has lobbied with the districts to include RUTF and anthropometric supplies in the Districts’ annual plans, this component is not yet fully funded. Further, logistical management of supplies at health facilities remains a challenge. Reporting through the District Health Information System (DHIS) has improved the timeliness and quality of nutrition data (including IMAM indicators).

Successes, key challenges and lessons learned of IMAM urban roll-out

There has been an expansion of services (from 30 to 107 health facilities), with increased admissions and steadily improving performance of the programme. Both cure and death rates are within Sphere Standards recommendations, although default rates (while decreasing) remain high (see Table 1).

Management of acute malnutrition has been included in the district ‘Annual Operational Plans (AOP)’ since 2008 in Nairobi and Kisumu districts. This has ensured that IMAM becomes part of the routine health service delivery in these districts. However, IMAM supplies, such as RUTF, are yet to be funded under the AOP.

The work has mobilised and used existing human resources; CHWs and community leaders. Community linkage has been strengthened between the health facilities, inpatient referral centre and community, thus increasing referrals and home follow-ups of acutely malnourished children.

A number of challenges encountered by the programme are:

Poor staff and capacity retention:

High staff turnover at health facilities continues to be one of the main challenges since the inception of the programme. The Kenya Nutrition Action Plan 2012-2017 outlines integration of IMAM in nurses and medical pre-service training. This important component is yet to get funding.

CHW motivation/remuneration:

The Kenya Community Health Strategy embraces working with CHWs however retention of CHWs is a major challenge due to their ‘volunteer’ status with the low incentive that is also not provided by MoH.

High defaulter rates (above the recommended Sphere standards):

While the default rate is slowly declining, it remains high. Main reasons include migration as families move due to fires, high rents, or for work opportunities and frequent absenteeism as caregivers often prioritise casual work over attendance at health facilities.

Coverage:

Although coverage has improved, it still remains well below Sphere standards. Close location of services in the urban context (seen in the high geographical coverage) is not enough to ensure service coverage. Facility operating hours and the time poor profile of urban slum dwellers contribute to this.

Funding:

Regular and consistent funding for urban poverty alleviation, including addressing chronic malnutrition, remains a challenge. Donors generally look at urban slums as governance and policy issues for national governments and not necessarily areas suitable for sustainable development. Lack of humanitarian indicators for urban settings also excludes humanitarian donors from engaging. Urban areas are highly market dependent. Droughts in rural areas or global food price spikes, for example, can translate into high food prices in urban markets. Economic downturn can affect access to paid employment particularly for the low paid, affecting household incomes. The combined effects of price increases and reduced income can tip those living in chronic poverty into a crisis situation. While the numbers of malnourished children increase substantially, the percentage malnutrition rates remain below internationally recognised emergency indicator levels. However, even low prevalence rates can translate into very large caseloads due to the high population density of urban slums. This makes it difficult to mobilise resources, both in terms of funding from donor agencies and in terms of the motivation of government and key stakeholders to respond. Sphere standards do not address the complexity of urban settings. Concern Worldwide has begun to develop specific humanitarian indicators for slow onset emergencies in urban areas (see field article in this issue of Field Exchange).

A number of key lessons learned include:

• Though slow, working through the MOH system is a more effective and sustainable approach to delivery of IMAM.
• Partnerships with private health facilities in provision of IMAM services are critical in increasing access and increased use of protocols by all health providers.
• In the urban slums, absolute caseloads of malnutrition are often high, even when the prevalence of malnutrition is low. It is important to sensitise stakeholders, especially donor agencies and health staff, on the complex health and nutrition needs affecting urban population and differences with rural populations who until recently, have largely been the recipients of humanitarian programming.

For more information, contact: Koki Kyalo, email: koki.kyalo@concern.net

Jacqueline Mwende who has brought her 12 month old son, Fanwual, to the Concern-supported Mukuru Reuben health clinic in the heart of Nairobi’s Korogocho slums.

The clinic is an oasis amongst the mud, rubbish and noise of the tightly-packed slums, and offers free services to mothers. Fanwual is checked for malnutrition using a MUAC (mid upper-arm circumference) which indicates severe malnutrition. He is given RUTF and Jacqueline is given a supply to take home with her.

Home is a cramped tenement flat on the 5th floor of a rundown block, with no electricity and shared latrines which tenants must pay to use. Jacqueline lives here with her husband and five children, who sleep either on or under two tiny settees.

"My husband cannot find work and I make a little money selling onions, but the rent is very expensive and we can only afford to eat once a day." Her other children should be at school but have been refused because she cannot pay the school fees. "I want a good future for my children" she says, "a good education and that they should eat like other children."

¹Nairobi Urban Sector Profile, 2006

²OXFAM, 2009. Urban Poverty and Vulnerability in Kenya.

³Republic of Kenya, 2008.Child Survival and Development Strategy 2008-2015.

⁴See article in this issue on urban challenges in Kenya that included stunting data (page 49).

⁵The Urban Nutrition Strategy is intended to provide a mechanism through which government will facilitate, in a coordinated manner, the implementation of strategic actions to improve and ensure the nutrition of urban populations.

⁶Private health facilities include those run by NGOs, FBOs and individuals. Beneficiaries are increasingly using these services as they charge subsidised treatment fees, are accessible (often situated inside the slums unlike MoH) and offer quicker services (MoH health facilities experience long queues). Recently, the MoH has begun opening facilities in the slums.

⁷Semi Quantitative Evaluation of Access and Coverage (SQUEAC) Concern Worldwide has monitored the access and coverage of the urban nutrition programme since February 2010. Initially, the SLEAC methodology was used to deter mine access and coverage at the facility catchment but later changed to SQUEAC methodology that has the capacity to determine the access and coverage levels at district level. In addition, the SQUEAC requires low resources as compared to the SLEAC. Since 2010, annual coverage has ranged between 30%-49% (against 70% Sphere indicator) in both Nairobi and Kisumu.

⁸MoH salaries generally start at over 10,000 Ksh per month.