The findings are presented under the four evaluation criteria – relevance, effectiveness, efficiency and sustainability.
Relevance:
Relevance reports on ; to what extent MCNP II was aligned to the nutrition situation in Kenya; the government and UNICEF priorities, UNICEF global and regional strategies, considering gender, equity, human and child rights perspectives. Additionally, it presents findings on the adaptability of the programme to the changing programming and resource landscape.
Relevance to nutrition situation: Evidence from the desk review triangulated with information from key informants’ interviews revealed that MCNP II program design was based on comprehensive analysis of the nutrition situation in Kenya. Extensive review and use of findings from multiple studies and reports was done. This process enabled identification of key bottlenecks and barriers to achieving optimal nutrition for children under five and women and thus informed the choice of interventions and program focus counties for MNCP II. Bottlenecks and barriers that were identified from analysis of the nutrition situation in Kenya, were categorized into four program result areas – demand, supply, enabling environment and emergencies. ASAL counties which are prone to high levels of acute malnutrition among children under five years of age were prioritized. Further the identified bottlenecks informed the program theory of change as well as identification and alignment of program strategies to achieve the desired results.
Relevance to resource and programming landscape including government and UNICEF priorities
The MCNP II result framework was found to be aligned to key Government and Ministry of Health policies including Vision 2030, Medium-Term Plan (MTP)[5], the Kenya Health Sector Strategic and Investment Plan (KHSSIP) 2014–2018[11], Big 4 agenda[12], Food and Nutrition Security Policy (FNSP)[13] and Kenya Nutrition Action Plan (KNAP) [14]. For instance, there is alignment to the social pillar of the Vision 2030 which entails social protection, strengthening KEMSA and scale up of community strategy for nutrition; reduction of maternal and child mortality objective of MTP III; objectives such as reduction of mortality and burden of malnutrition and micronutrient deficiencies under KHSSIP, among others. The program is coherent with almost all the key result areas of the KNAP.
MCNP II was noted to be aligned with the UNICEF’s Global Nutrition Strategy (2020–2030)[15]. This strategy is also focused on maternal and child nutrition and targeted towards reduction of stunting. MCNP II is part of the United Nations Sustainable Development Cooperation Framework (UNSDCF) 2018–2022 [16], and builds on the UNICEF Strategic Plan, 2018–2021, and the 2016 Concluding Observations of the Committee on the Rights of the Child in Kenya. Although, the program is largely aligned to these strategies, there are some areas beyond the program coverage, for instance, burden of overnutrition and obesity; and adoption of lifecycle approach covering middle age childhood and elderly.
Donors reported their satisfaction as the programme’s strategic priorities were aligned to their priority focus areas such as systems strengthening and cross-sectoral integration, risk-informed programming and resilience building for nutrition emergencies as well as prioritization of ASAL counties for nutrition-specific and nutrition-sensitive programming.
Opportunities for cross-sectoral integration
MCNP II has four thematic/result areas, namely, demand, supply, enabling environment and risk informed/shock responsive programming that provide greater opportunity for integration and cross-sectoral programming. The thematic focus is to address the evolving nature of maternal and child malnutrition (through protection and promotion of diets, services and practices that support optimal nutrition and growth for all children, adolescents, and women). The programme has provided opportunities for implementation of integrated programming with health, WASH, livestock and agriculture, education, child protection and social protection sectors as outlined in Table 1. Utilizing prior evidence from research that suggested that combined interventions for improving nutrition and sanitation practices, could reduce mortality among children under five years by 15% [17], UNICEF supported Kitui County to design an integrated Sanitation and Nutrition programme (SanNut). The project bolstered the existing community sanitation initiative with a set of nutrition behavior-change messages targeted at caregivers of young children. Evaluation of the project found that it improved families’ sanitation practices and nutrition knowledge [18]. Since the programme improved families’ sanitation practices and nutrition knowledge without adversely affecting other sanitation components, UNICEF scaled the integrated sanitation and nutrition programme to a second county in Kenya, West Pokot. In addition, implementation of the combined programme helped to reduce implementation costs and scale up the combined programme at a more accelerated pace.
Table 1: Synergies with nutrition sensitive sectors
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Health
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WASH
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Livestock and Agriculture
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Education
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Child Protection
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Social Protection
|
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• Integrated community case management (iCCM)
• Baby Friendly Hospital Initiative (BFCI) at basic and comprehensive emergency obstetrics care facilities
• Integration of vitamin A supplementation (VAS) into expanded immunization programme supply chain
• Integrated management of acute malnutrition (IMAM) surge and integrated outreach
• Integration of nurturing care in BFCI/Maternal infant young children nutrition(MIYCN)
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• Nutrition integrated into community led total sanitation (CLTS)
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• Modeling and scaling of integrated programming-milk value chains food security and Agri-nutrition frameworks
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• Maternal education, VAS in early childhood development center
• Nutrition in school curriculum
• Completion of education for girls
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Link BFCI with birth registration
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• Nutrition improvements through Cash and Health Education (NICHE)
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However, the overall governance in the nutrition sector requires further strengthening. There is a need to institutionalize a structure to effectively coordinate the multi-sectoral efforts. There is already a defined structure in place, the Food and Nutrition Security (FNS) Council and thus, the efforts can be channelized to expedite the process to establish of this council. This would require extensive coordination and contribution from different sectors.
Response to COVID-19
It was noted that the MCNP II program design was modified in a systematic manner, based on evidence and priority setting, to align with nutrition priorities during COVID-19. Additional interventions were included to respond to the pandemic in a timely and adequate manner. For instance, one of the key adaptations made was on nutrition surveillance, where Family MUAC, an approach that allows caregivers to take an active role in screening their children for malnutrition using color coded tape for measuring mid upper arm circumference (MUAC) and referring them for treatment, was scaled up. This ensured timely identification and referral of malnourished children for treatment. During the pandemic, one of the key challenges faced by the programme was declining numbers of beneficiaries seeking essential nutrition and health services at the facilities. Between March and May 2020 outpatient service utilization among children under 5 dropped by 45% while antenatal care attendance decreased by 15% (UNICEF, 2020). UNICEF supported the Ministry of Health to develop a business continuity plan that focused on continuity of the essential services, nutrition surveillance and information.
Gender, equity and human rights perspectives
Evidence from the desk review indicated that the strategic approaches/objectives of MCNP II were aligned to the gender equality and human rights policies such as session paper No 2 0f 2019 on National Policy on Gender and Development[19] under the Kenya Vision 2030[20], Convention on Child Rights (CRC),[21], [22] Convention on the elimination of all forms of discrimination against women (CEDAW)[23] as well as human rights of persons with disabilities. Key informants noted that the sex and age disaggregated data is being collected in the Standardized Monitoring and Assessment of Relief and Transitions (SMART) survey. Similarly, gender roles and maternal workload was captured through qualitative ‘Knowledge, Attitude, Behavior, Practice’ (KABP) surveys. It was noted that gender sensitization on reduction of maternal workload to enhance nutrition outcomes was undertaken in the communities. Father-to-father support groups were formed to facilitate positive behavioral change on feeding practices and championing the importance to seek services in health facilities. All 13 target counties implemented community feedback mechanisms, including community dialogues, feedback boxes in health facilities, and other feedback processes to inform program improvements. A reconnaissance with community discussions showed that community members acknowledged the feedback mechanism and community involvement in the program. The community agreed that the programme made efforts towards gender mainstreaming, citing increased male involvement and father support groups that had been established were effective in garnering spousal support to use health services. However, a systematic approach needs to be adopted to include women in programme design and conduct gender-based discussions.
“They talk about pregnant mothers, children under five, and old age. Then as to whether such a facility is stocked with medicines or not, the community themselves sit down, get involved so they can find out. When wife is pregnant, I take her to the clinic, she gives birth at the maternity clinic, a month later. If she is sick, I will take her to the hospital, they will bring her back to good health.” – FGD Participant (Male)
“Exactly. Mother-to-mother support. They meet to exchange ideas and support each other. At the end of the day mothers in the mother-to-mother support group are better off compared with those tucked up in the villages. Something else I want to say as a chief of this community is that this community is very vulnerable, and it is facing a lot of challenges. Despite the availability of a hospital, not everyone can get to the hospital and the available CHVs cannot manage to reach to help in each and every household.”– Community Leader
Effectiveness:
Effectiveness assessed the extent to which MCNP II attained the programme results, contributed to national and sectoral priorities, and achieved value for money. This assessment considered, programme outcomes; contribution to national and sectoral priorities; role of advocacy and cost effectiveness and value for money.
Realization of planned programme outcomes
The MCNP II has targets to reduce mortality and stunting through multiple strategies including increased access to vitamin A supplements; reduced severe acute malnutrition (SAM) among children by ensuring that all children with SAM receive appropriate care through increased admissions of children under 5 years and reduced stockouts of SAM supplies. Further, the programme targeted to create demand for iron and folic acid among pregnant women, increasing dietary diversity in children and women, using risk-informed approaches for preparedness to address emergencies, and supporting the existing national multi-sectoral committee for nutrition to remain functional in the sector. From the mid-term evaluation, the planned targets were achieved across all the key indicators defined in the results framework. These included, increased uptake of vitamin A among children, increased uptake of IFAS among pregnant women among others as detailed in Table 2 which provides a comparative analysis between the planned and achieved targets for the 13 focus ASAL counties except for admissions of children with SAM in 2020 and proportion of facilities that offered SAM services in 2018 and 2020. Looking at the current pace at which the programme has achieved its planned targets and has gone beyond, it is likely that MCNP II results will also be achieved before the end of programme cycle by June 2022.
Table 2: Comparative analysis between planned and achieved targets for MCNP II results framework indicators
In 2018, 5 out of 13 counties were implementing plans to improve dietary diversity in children. However, in 2019 and 2020, the planned results were achieved for all the 13 counties. In 2018, 7 counties had existence of functional national multisectoral committee for nutrition, however, this number rose to 10 counties in 2019 and in 2020, 12 out of 13 counties have achieved this result. In 2019 and 2020, all 13 counties have had existence of emergency preparedness plan for nutrition.
Service delivery approaches and innovations, use of technology and tools and alignment to government priorities were noted as key enablers that facilitated the achievement of planned results. For instance, Malezi Bora, the child health week was used as an opportunity to reach beneficiaries for health and nutrition services including vitamin A supplementation; the family Mid-arm upper circumference (Family MUAC) for screen of malnutrition at home and self-referrals, integrated Community Management of Acute Malnutrition (ICMAM) are some of the examples of service delivery models and innovations under the program. Similarly, the use of technology has facilitated efficient supply chain management and improved tracking of budget expenditure. For instance, the introduction of Logistic Management Information System (LMIS) to manage supply chain of essential nutrition commodities contributed to achievements in zero RUTF stock-out rates in the 13 target counties; Nutrition Financial Tracking Tool (NFTT) was critical for adequate budget allocation and tracking expenditure for nutrition sector and Rapid Pro SMS platform was leveraged for outreach and social behavior change communication (SBCC) activities.
Key informants also noted that MCNP II established community peer support groups for cascading nutrition knowledge from health workers to the community. CHVs were instrumental in nutrition counselling, supporting in community-facility referrals and providing support at the health facilities. Data from the focus group discussions indicated that community members perceived provision of micronutrient supplements and nutrition counselling effective in improving service delivery. Additionally, interactions with community members showed that they perceived the use of CHVs for Family MUAC and mother-to-mother support groups as some of the effective approaches.
“…But after sensitization, the targeted mothers now know that they need to breastfeed a child for 6 months, and then introduce other foods. Also, they were not buying fruits for children, they would only give ugali with potato soup, morning, lunch and dinner. But nowadays they give fruits—the local fruits, what is available here” – HCW
“….the community members are no longer afraid to seek medical attention, they do not fear bringing children, they have really changed” – Community Leader
“The community members air their problems through CHVs or Traditional Birth Attendants (TBAs); the TBA will bring their issues to the hospital and take the feedback to the community. Then the CHV will talk to the CHEW, who will talk to the In-charge. Then he will give the information to the CHEW, then disseminate it to the CHV then she takes it to the households.” – FGD Participant
Contribution to national and sectoral priorities
The programme was found to be in coherence with the national and sectoral priorities including reducing stunting and implementing high impact nutrition interventions. By achieving improvements in its planned targets such as the vitamin A supplementation and treatment for severe malnutrition it contributed towards the planned targets of the sector. For instance, in the year 2020, the SAM sector priorities were 88,451 out of which a target of 63,443 SAM admissions was achieved by MCNP II. It also supported government in operationalization of the strategies through implementation frameworks and roadmaps. For instance, UNICEF supported the development of strategies and policies on Maternal, Infant and Young Child Nutrition (MIYCN). The technical support included content development and designing of policies, guidelines, strategies, training packages and assessment tools. The following outputs were secured: 1) Implementation framework for securing a breastfeeding friendly environment at workplaces, 2) National framework for implementation of breast milk substitute (Regulations and Control Act, 2012, [24] Training package for the community health volunteers on BFCI, 4) National Maternal Infant and Young Child Nutrition Policy Guidelines, 5) Operational guidance for Maternal Infant and Young Child feeding in emergency 6) BFCI assessment tools.
Advocacy Approach
It was evident from the desk review and key informants’ interviews that the programme fairly fulfilled its role for upstream engagement to advocate for women and child nutrition rights. Advocacy led to inclusion of more nutrition activities in county annual workplans and county integrated development plans (CIDPs) for all 13 counties. MCNP II led to the development of women and children-sensitive policies and frameworks. Advocacy efforts led to securing of nutrition specific funding in the programme-based budgets (PBB). For instance, counties like Kilifi, Wajir, Turkana, Baringo, and Samburu, are now receiving nutrition specific budgets under the PBB and this was because of the sustained advocacy actions. This ensured accessing and securing actual allocated funds during the budget process. Further, the programme contributed towards development of terms of references (ToRs) for the multi-stakeholder platforms (MSPs) which are critical for cross-sectoral advocacy at sub-national level as well as to ensure coordination with the national level. MSPs are now functional in 12 counties, except in Kitui.
Cost-effectiveness of implementation and value for money
It was noted that cost-minimization approaches were leveraged under the programme to save implementation costs. For instance, training of the trainers (ToT) approach helped reduce cost on training at the county level because it allowed fewer healthcare personnel to be trained. The trainers then cascaded the learnings to the sub-counties, reducing the cost for training all sub-county and facility level staff. On-the-Job Trainings (OJT) ensured practical skills were learned with minimal training and opportunity costs. This approach enabled the programme to directly reach out to the trainees (healthcare workers/facility staff) while reducing logistical costs for training. Integration of nutrition in health outreaches emerged as a key approach in reducing costs for vertical service delivery.
To reduce the operational and the overheads costs, the Value for Money (VfM) policy was leveraged under the Programme Cooperation Agreement (PCA) arrangements with the implementing partners. Before the introduction of Value for Money (VfM) policy, implementing partners were supporting costs at about 25% of the program costs; however, with the introduction of VFM, IPs’ contribution increased. Similarly, the cost of doing business with implementing partners reduced. Notably, UNICEF’s contribution to overhead cost reduced, by about 12–23%. Out of the 15 implementing partners contracted from September 2018, 5 partners contributed more than 25% to the direct program costs and 10 partners contributed at least 15%, as recommended by UNICEF. To achieve value for money, implementing partner overhead ratio should be below 25%. The overhead ratio was less than 15% for 5 partners while for 10 partners it was between 15% and 25%. Thus, overall, the value for money and cost-effectiveness for program implementation was moderately achieved, by the time of mid-term evaluation.
Efficiency
Efficiency assessed the achievement of programme results through efficient use of resources. This component reports on efficient programme implementation approaches, partnership modalities, priority setting for resource allocation, coordination and monitoring.
Efficient programme implementation approaches
Budget allocation and utilization ratio
Table 3 presents a comparative analysis of expenditure ratio, that is, amount of budget actually utilized in proportion to the budget. The ideal expenditure ratio must be 100%. It is noted that for the MCNP II, the expenditure ratio was over 100% for the years 2018 and 2019. On the other hand, it was about 70% for the year 2020.
Table 3: Budget allocation and utilization ratio across four outputs from 2018-2020
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Output areas
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Expenditure ratio (2018)
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Expenditure ratio (2019)
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Expenditure ratio (2020)
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Demand
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63%
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17%
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22%
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Supply
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103%
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153%
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0.4%
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Enabling environment
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135%
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17%
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13%
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Emergencies
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3%
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258%
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74%
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Total
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154%
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133%
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71%
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The utilization of funds from the allocated budget for demand output was consistently lower throughout 2018 to 2020. On the other hand, for the supply side, in the first two years of programme (2018 and 2019), the expenditure was higher than the allocated budget for the output. However, in the year 2020, about 0.4% of the total budget was utilized for the supply related programme activities. This was attributed to the end of the support by major donor, FCDO in June 2020, and to the redirection of funds towards the COVID-19 response. Similarly, the utilization of funds from the allocated budget for output 3 (an enabling environment) was lower in both 2019 and 2020. However, in the first year of the programme inception (2018), the expenditure was higher than the allocated budget. This was because the programme increased its efforts towards creating an enabling environment in the initial year of its inception. Utilization of funds for output 4(risk-informed programming) was about 3% in the first year of MCNP II inception. However, an improvement was noted in the next two years and in the year 2019 the expenditure was higher than the allocated budget. This was attributed to the programme adjustments and shifting priorities during the 2019 drought and the COVID-19 pandemic in 2020.
Comparative analysis of forecasted and distributed nutrition commodities and supplies
The Table 4 highlights the planned v/s actual distribution of RUTF under MCNP II. It was evident, that, overall, for the years 2018 and 2019, the RUTF supplies distributed were higher than the planned distribution. This was attributed to the evolving demands and nutrition needs of the counties during the programme implementation. For instance, situations like droughts, floods and other nutrition emergencies can lead to worsening of nutrition situation and increased requirements for RUTF. However, for the year 2020, it was lower than the planned distribution due to the COVID-19.
Table 4: RUTF supplies planned v/s distributed
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2018
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2019
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2020
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Supplies
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Planned
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Distributed
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Planned
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Distributed
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Planned
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Distributed
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RUTF
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39,063
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77,529
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69,814
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71,811
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52,474
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22,707
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Table 5: Planned v/s actual distribution of RUTF in counties (*all figures in %)
Table 5 highlights the planned v/s actual distribution of the RUTF in the counties. It was noted that for the year 2018, in some of the counties such as Baringo, Wajir, West Pokot, Garissa, Marsabit, Kitui, Kilifi, Kwale, Mandera, Tana River and Turkana, the distribution of RUTF was more than the planned threshold of 100% of RUTF distributed. In the years 2019 and 2020, for counties of Kilifi and Tana River, the actual distribution was less than 50% of the planned supplies. Similarly, in Isiolo, Mandara, Wajir and Garissa, in 2020, the actual distribution was as less than 50%.
Stringent financial management strategies
From the findings, UNICEF was guided by different financial policies and procedures to manage the disbursement of funds and reporting of expenditures including using the Harmonized Approach to Cash Transfers[25] and UNICEF financial rules and regulations. The HACT approach supported risk management with a focus of reducing transaction costs associated with programme implementation by harmonizing procedures as well as promoting reporting on funds that are disbursed. The funding requests were managed through Funding Authorization and Certificate of Expenditure (FACE), which required authorization from the programme managers before funding allocations. It was evident from the review that MCNP II adopted appropriate financial management procedures and approaches that collectively contributed towards bringing cost savings and efficiencies.
Partnership modalities such as with government and nutrition support officers enhance efficiencies
Besides, partnership with the implementing partners, other partnership modalities also contributed towards enhancing programme efficiencies. For instance, utilizing nutrition support officers (NSOs) for implementing programme activities led to cost savings. The United Nations Office for Project Services (UNOPS) is a partnership modality for engaging with other UN entities. UNOPS provided infrastructure, procurement and project management services for UNICEF to implement program activities and achieve results. The Nutrition Support Officers (NSO) approach was one of the key partnerships and programme support approaches delivered through UNOPS and supported financially and technically by UNICEF. Under this approach, the NSOs were recruited by UNICEF under UNOPS and were embedded in selected ASAL counties for provision and scale up of nutrition services, working closely with the GoK County Nutrition Coordinators (CNCs). Evidently, hiring NSOs helped UNOPS to reduce its budget from US$4,578,433 to US$3,585,516 translating into savings of US$992,917 while achieving the same results. Further, importantly, the government as the key implementing partner also contributed towards the programme costs. Matching funds of $250k (KES 26M) were obtained from the government. Counties such as Garissa, Marsabit, Turkana, Wajir and West Pokot contributed finances for nutrition SMART surveys in 2018 and 2019. Notably, there is a need to enhance private sector involvement in programme planning and monitoring and evaluation. Partnership with the Kenya Private Sector Alliance (KEPSA) on the ‘Building Business Practices for Children’ Partnership, a tripartite partnership between county government, Unilever and UNICEF to scale Baby Friendly Community Initiative (BFCI) models across industries is one of the key examples of private sector involvement to improve quality, coordination and efficiency.
Sustainability
As part of REES, Sustainability assessed to what extend the achievements that had been made over the first half of the programme were likely to continue even when UNICEF support for key programme areas gradually reduced. The programme review provided an insight into decentralization of processes and services, policy environment for nutrition for children, development and integration of plans and nutrition activities at county level, system strengthening including capacity building of national and county staff. with and risk programming and disaster reduction approaches.
Decentralization of processes and services to counties
Following promulgation of the 2010 Constitution of Kenya, it ushered in a devolved governance structure in the year 2013/2014, which saw health functions devolved to the county governments. In order to ensure sustainability of provision of nutrition services at national and county levels, MCNP II programme supported the following initiatives.
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Development of child friendly nutrition policies and guidelines
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Capacity Building: UNICEF trained national and county level staff on Nutrition Financial Tracking Tool(NFTT) to improve skills on budget analysis, track expenditures and develop county budget briefs for advocacy and resource mobilization. The training also aimed to address limited capacities to formulate budgets and financial plans. Additionally, GOK personnel at the two levels of government were trained on Logistic Information Management System (LMIS) for nutrition commodities to impart them with requisite knowledge and skills to forecast, request and monitor consumption of nutrition commodities at county level. Under MCNP II, 13 and 10 counties in ASAL regions were supported with capacity assessment and nutrition financial tracking respectively.
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System Readiness Assessments: UNICEF supported development of Nutrition Programme Maturity Analysis (NPMA) model that enabled definition and measurement of the level of nutrition programme maturity across the 13 target counties implementing MCNPII. Assessment of system readiness using NPMA model showed great improvements across the 13 counties between 2018 and 2020. These assessments checked counties’ readiness and self-sufficiency to gradually take-up, finance and implement nutrition programmes using domestic financing. Based on the assessment, significant improvements were observed between 2018 and 2020 across each of the MCNP II counties, showing that most of the counties were on a journey to optimize programme maturity aimed at ensuring increased transition to county-led programme implementation.
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Development of plans including National Nutrition Action Plan and county specific action plans to provide roadmaps for implementation of both nutrition specific and sensitive interventions at the national and county level respectively.
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Integration of nutrition into County Integrated Development Plans through financial and technical assistance from UNICEF including the Nutrition Support officers (NSOs) based at the county level. NSOs played a crucial role in building capacities of the county level staff, mobilizing resources as well as engaged with county level leadership and advocated for development of child friendly legislations including Community Health Services Bills.
Systems strengthening and cross-sectoral integration
The evaluation showed that MCNP II contributed not only to system strengthening in health but also in social protection, education, Water Sanitation and Hygiene and agriculture sectors through integrated programming and enhancement of cross-sectoral linkages by supporting multisectoral technical forums and development of multisectoral strategies and programmes as indicated in Box 1. Noting the importance of multi-sectoral coordination and cross-sectoral advocacy, UNICEF supported the establishment and/or functioning of County Nutrition Technical Forums along with the Terms of reference (TORs) in 9 out of 13 focus ASAL counties). Under MCNP II, existing structures such as Nutrition Inter Agency Coordination Committee (NICC) and National Technical Forum were strengthened. However, functionality of these forums largely depended on donor funding, hence there is need for more domestic financing to ensure their sustainability beyond the MCNP II.
“UNICEF has been one of our greatest supporters in terms of running the structures in nutrition, especially the convening of nutrition inter-agency coordinating meetings which are cross-sectoral. Also, the nutrition technical forum. Therefore, these are the platforms where the interventions followed by other sectors are brought to the fore. And, we have even been able to strengthen one in agriculture called food and nutrition linkage technical working group which is also now bringing together the nutrition sensitive players in the food security and nutrition arena”- Respondent, MoH DND
Box 1: Key Multi-Sectoral Initiatives
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• Nutrition Improvements through Cash and Health Education (NICHE) programme: NICHE-I was piloted through a randomized controlled trial in Kitui from January 2017 to June 2018. The pilot phase beneficiaries included orphaned and vulnerable children who received additional cash top-up and nutrition counselling. The trial proved that the combined package of the cash-top up and nutritional counselling delivered through a cash transfer programme improved young children’s feeding practices and quality of mothers’ diets, though not stunting. The next phase, NICHE II is being implemented by the GoK through UNICEF’s technical support across five counties – Kitui, Kilifi, Marsabit, Turkana and West Pokot. As part of NICHE II, an additional cash top-up of Ksh 500 (up to a maximum of ksh 1000 per household) offered to Kenya National Safety Net Programme (NSNP) beneficiary households which has a child under two years or a pregnant or lactating woman. The households receiving the cash-top up also offered intensive nutrition counselling (and child protection counselling in Kilifi) by utilizing the community health strategy platform and Baby Friendly Community Initiative approach. NICHE programme targets to reach 41,583 households in next three years (2019-2022) in all the five counties.
• Integrated Sanitation and Nutrition Intervention (SanNut): First piloted in Kitui, the programme focused on integrating sanitation and nutrition messages and included community members like chiefs, the administrators, the county Commissioners in implementing programme activities. Inclusion of key community members enhanced the community accountability. Evaluation of the project found that it improved families’ sanitation practices and nutrition knowledge [18] Since the programme improved families’ sanitation practices and nutrition knowledge without adversely affecting other sanitation components, UNICEF scaled the integrated sanitation and nutrition programme to a second county, West Pokot.
• Technical and financial support to Early Childhood Development (ECD) programming in Samburu and Isiolo. The programme included technical and financial support for improving dietary diversity for children, promotion and protection of MIYCN, leveraged health systems platforms helped improve quality of care of newborns in Samburu, West Pokot, and Garissa. Financial and technical support for CHMT and Healthcare worker trainings to improve skills in nutrition service delivery and support the formation and functioning of county level multisectoral platforms to address malnutrition. By 2020, all 13 counties were implementing plans/programmes to improve diversity of diets in children.
• Technical support to integrate adolescent programming in Samburu. UNICEF supported the Samburu county adolescent nutrition survey to address the gaps highlighted by the Ministry of Health which included nutrition, generation of evidence to address data gaps. With the Centre for Behavior Change Communication as a key partner, pilot adolescent programming was introduced in Samburu in 2019. The programme targeted about 3,000 adolescent girls and boys and identified 12,000 social influencers. SBCC strategy was developed in collaboration with government line ministries, county governments, UNICEF and other partners. A theory of change for adolescent programming was developed and lessons learnt documented.
• Family MUAC in Turkana, Isiolo, Nairobi, Marsabit, Kisumu and Tana River counties. The objective was to enhance detection of acute malnutrition for referral by child caregiver at community level. The programme was introduced in 2019 in collaboration with MoH, Concern Worldwide, Action Against Hunger and Kenya Red Cross Society. MCNP II successfully piloted the approach and expanded the coverage for early identification of early SAM case and trimely treatment.
• Livestock for health programme in Marsabit county included supporting farmers through provision of animal fodder, and in buying and selling of cattle for sustainable employment and business opportunities as part of strategy to cushion farmers from ravaging drought in the pastoralist areas.
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Despite these initiatives, there are challenges such as sectoral mandates and competing priorities that hamper adequate funding allocation and implementation of nutrition interventions in the sectors. These sectoral challenges have implications on the MCNP II.
Approaches to enhance ownership and local capacity for sustainability
The programme engaged national and county governments to promote ownership of programme implementation and outcomes by adopting the direct implementation modality (where the Government entity as opposed to Civil Society Organizations and non-government organizations implement components of the programme directly). The local Civil Society Organizations (CSOs) were involved in programme implementation through PCAs. At the same time, sensitization of policy makers and community members on gender was done. It was also noted that the community peer support groups have played a crucial role in strengthening community capacities. This was also agreed during the focus group discussions by the community members. They mentioned that the community has been empowered with increased knowledge around nutrition and activities such as kitchen gardens and this ought to be beneficial for sustainability. However, the community also noted that it is important to develop community resource persons to sustain knowledge at the community level.
“…. of these groups up to now even without the support, they are still continuing with support from the link facilities. So, some of the interventions are still there, they are sustainable– the mothers there are supporting one another. And the level of awareness I feel and I think though is improving. I have not done an assessment, but you know, you can tell – you are living in this community, I can say that our mothers with the different interventions which have been done geared towards nutrition, there is some level of improvement in terms of knowledge” – Respondent, CHS
Risk-informed programming and disaster risk reduction approaches
Notably, to ensure sustainability of risk informed programming and disaster risk reduction approaches, the MCNPII programme supported:
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Development of child sensitive bi-annual emergency preparedness response plans driven by robust information and surveillance systems at the national and county level.
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Health system strengthening approach to complement Ending Drought Emergencies (EDE): MCNP II aligned its approaches and contributed to EDE in the ASALs. The MCNP II was further aligned with the Ending Drought Emergencies Country Programme Framework (EDE-CPF) pillars, particularly the Human Capital Pillar, where nutrition and health facilitated GoK’s commitment to end drought emergencies. NDMA is the custodian of the EDE-CPF, with UNICEF and the Ministry of Education serving as co-chairs on Pillar Three, the Human Capital Pillar. UNICEF further contributed to Pillar Four and Six, which deals with sustainable livelihood and Monitoring and Evaluation, respectively. In addition, the programme supported integration of essential nutrition commodities including ready-to-use therapeutic feeds (RUTF) into GOK supply chain management system as well as scaled-up innovative approaches such as IMAM surge. Currently, 63% of the health facilities are implementing the IMAM surge model.
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Through MCNP II, capacity of GoK personnel was strengthened to conduct bi-annual food security assessment.
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Development of strategic and agile partnerships that allowed nutrition sector leverage the comparative advantage of each partner. For example, partnership between UNICEF and Kenya Red Cross Society allowed the sector to build capacity to rapidly expand and scale-up services as part of early action as well as during a full-scale emergency response. In addition, under the MCNP II, UNICEF supported the MOH to develop a business continuity plan for nutrition services within the context of COVID-19 pandemic and nutrition surveillance and information guidelines.
“Yes, the government through the ministry of livestock, through the ministry of registration, the office of internal security usually warns us about floods, so that we can move because we will get problems.” – Community Leader
However, some challenges were noted that may affect sustainability of implementation of risk informed programming and DRR approaches. These included: (1) weak multi-sectoral coordination system (2) inadequate adoption of EDE by other line ministries and stakeholders (3) inadequate mainstreaming of EDE into county integrated development plans (4) inadequate financing of innovative approaches for risk informed programming such as IMAM surge that limited the scope and scale of coverage.
Resource mobilization and Transition Strategy
UNICEF used a two-pronged approach in resource mobilization through internal and external mechanisms. The key donors for the MCNP II included USAID and UKAID-DFID/FCDO, EU, ECHO, and World Bank. UNICEF has over the last few years successfully implemented multi-year grants which offer flexibility in terms of programming in nutrition.
Figure 2 gives an overview of the funding contribution by different donors and internal resource mobilization by UNICEF (2018–2020)[26]. Further, it was noted that the programme does not have a formal transition strategy and there is need to develop one. Other areas of improvement include enhancing the involvement of non-government organizations (NGOs)/CSOs in planning, policy formation and M&E and strengthening their capacities. Further, gender based and human rights related sensitization sessions for policymakers and the community are conducted on ad-hoc basis; instead, a more structured process could be initiated. notably, community involvement in the transition process is also on ad-hoc basis and yet to be streamlined.