Strengthening capacities for nutrition in Kenya: Developing a new framework
Fridah Mutea is director of Nutrition Programming with International Medical Corps (IMC), Kenya Mission. She holds a BSc in Food and Nutrition from the University of Eastern Africa Baraton.
Irene Mugure Mugo is a national nutrition capacity development officer with IMC with eight years’ experience in general nutrition programming. She has a BSc in Food Nutrition and Dietetics from Egerton University.
Caroline Kathiari is a nutrition capacity development coordinator with the Ministry of Health, Kenya, and convener of the capacity technical working group. She has an MSc in Food Nutrition and Dietetics.
Olivia Agutu has worked as a nutrition officer with UNICEF, Kenya since 2009. She holds a BSc in Food Nutrition and Dietetics from Egerton University.
Lucy Maina Gathigi is a nutrition officer with UNICEF Kenya, specialising in information systems. She holds an MSc in Applied Epidemiology and a BSc in Food Nutrition and Dietetics.
Authors’ note: The views of Olivia Agutu and Lucy Maina Gathigi incorporated in this article are their own and not those of UNICEF.
Introduction
Kenya has made great strides in improving nutrition, particularly from 2009 to 2014. This period saw stunting among children under five years old decline from 35% to 26%, wasting decline from 7% to 4% and underweight decline from 16% to 11%, while exclusive breastfeeding in infants aged 0-6 months almost doubled from 32% to 61%1. Childhood obesity has remained below 5%. The 2015 Global Nutrition report declared Kenya the only country in the world on track to meet all five World Health Assembly (WHA) maternal and child nutrition targets2. Sustaining this progress requires various strategies; one of these is strengthening capacities for nutrition at all levels.
The need for a Kenyan Nutrition Capacity Development Framework (KNCDF)
Capacity development is the process by which individuals, groups, organisations and societies increase and organise their systems, resources and knowledge. This is reflected in their ability at individual or collective level to perform functions and solve problems in order to achieve and sustain development objectives. Capacity gaps at system, organisational and nutrition-workforce level have limited the large-scale implementation of nutrition programmes and communities’ ability to demand services over a number of decades in Kenya.
Before the KNCDF, the nutrition sector did not have a unified, standardised and holistic way of addressing the capacities of the nutrition sector to deliver the intended programme.
Capacity-development efforts were largely focused on ad hoc identification of health-worker training to implement nutrition-specific interventions, such as treatment of severe acute malnutrition. Kenya signed up to the Scaling Up Nutrition (SUN) Movement in 2012, thereby engaging with the SUN networks in addressing malnutrition and advocating for multi-sector nutrition programming. This prompted a rethink of the country’s nutrition capacity-development strategy, prompting an in-depth look at nutrition systems, organisations and technical capacities, as well as the capability of communities to demand their rights and access to nutrition services.
Process for developing the framework
The KCNDF was developed through the Capacity Development Working Group (CDWG) under the leadership of the Ministry of Health (MoH) as the secretariat (through the Nutrition and Dietetics Unit) and involving other stakeholders: line ministries (Agriculture, Water and Education); the regulatory body (Kenya Nutritionist and Dietetics Institute (KNDI)); UNICEF (technical and financial input); implementing partners (International Medical Corps as the chair of the National Capacity Development Working Group); and technical input from other INGOs, including Action Against Hunger, Save the Children, Concern Worldwide, Helen Keller International and representatives from academia. Regular working group meetings were held at the national level, with in-depth involvement of the key stakeholders from the counties (Kenya has a devolved government system) through workshops at national and county level.
Pre-testing at county level
The MoH (National and Kilifi County Governments), with support from International Medical Corps and UNICEF, carried out a pre-test of the KNCDF and its operational guide and tools in Kilifi County in 2016. A core County Health Managers Team (CHMT) comprising three Kilifi County Health Managers was constituted to lead the process, which involved data collection and key informant interviews. Results included:
• System Capacity: The Kilifi County Government had developed/adopted planning documents that included a County Integrated Development Plan (CIDP), County Health Sector Strategic Plan (CHSSP) and County Nutrition Action Plan (CNAP), although health and nutrition activities were not always implemented as stipulated due to budget constraints.
• Policies: The County had some key national policies in place; e.g. the mandatory food fortification policy and the International Code of Marketing of Breast-milk Substitutes, and enforcement at the county level was increasing. County-level bills to be developed included a health bill and maternal and child health bill, but there was a shortage of key nutrition guidelines at facility level.
• Organisational Capacity: Reporting tools were in place in the facilities sampled, including several forums/systems that addressed data quality and performance, and nutrition was integrated in most of these systems. However, forums were not held regularly.
• Technical capacity: Numbers of nutritionists were still below recommended levels, despite County efforts on hiring. Trainings for the nutrition workforce were mostly on nutrition-specific interventions, while emerging issues like non-communicable diseases (NCDs) were neglected. The nutrition workforce reported the need for additional capacity building in order for them to be well equipped in offering nutrition services
• Community capacity: Only 78 Community Units (CUs) – of which only 74 were functional – were established in the county, against the recommended 256 CUs. Some Community Health Volunteers (CHVs) were trained on the basic community health module; however no CHV was trained on the standard community health nutrition module. The community health strategy is operational, but the referral system was not very effective.
The results, disseminated at a one-day meeting with key nutrition stakeholders, emphasised the need for the CHMT to lead all stakeholders in prioritising implementation and addressing the gaps identified. The KNCDF operational guide stipulates that capacity assessments are conducted every two and a half years to allow for the implementation and monitoring of capacity initiatives, guided by the gaps and follow-up actions stipulated by the counties themselves from a capacity assessment.
The pre-test in Kilifi County was critical in informing the final KNCDF operational guide and nutrition capacity3. The Capacity Development Working Group has supported a further six counties in carrying out the same activity. Undertaking a capacity assessment is resource-intensive in terms of technical, human and financial resources, with one assessment costing approximately US$12,000, although costs vary from county to county. The nutrition sector is advocating for the government (national and county) to incorporate this activity into its annual work plans under health and nutrition budget lines, although additional funds may be needed from donors.
Quotes from stakeholders
“We have been here but we did not know all these gaps existed – some of the things brought out by the assessment are shocking.”
County executive committee member for Health, Kilifi County.
“We are now able to quantify our challenges.”
CHMT member, pointing at bar graphs showing the number of nutritionists currently employed compared to the recommended number.
Lessons learnt
• All stakeholders (both at county and national level) need to be involved in the entire capacity-assessment process, with national government giving overall guidance.
• The county must take the lead in the process, as this enables it to better articulate its issues, own the gaps and look for solutions locally. The CHMT needs to take the primary role in conducting assessments and provide direction and leadership in implementing the action plans developed.
• Continued advocacy is needed to ensure budget allocation for the process (and nutrition in general) in county annual work plans due to competing activities at county level.
• Line ministries appreciate their role in nutrition more once they understand the gaps revealed in this process. Currently the assessments are focused on nutrition-specific issues, but in future line ministries may consider including nutrition-sensitive actions.
• The capacity guidelines give a clear road map on how to address capacity matters in nutrition. However, budgetary allocations needed to implement the recommended changes remain a major challenge.
1 Kenya Demographic Health Survey, 2014.
2 Global Nutrition Report Nutrition Country Profile 2015: Kenya. Washington DC. http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/129819/filename/130030.pdf
3 Both documents are still currently in draft format but in use, email: fmutea@internationalmedicalcorps.org