A total of 17 health facilities were assessed for the extent of integration of NACS in the health system and community function; 2 Hospitals, 3 Health Centre IVs and 12 Health Centre IIIs. Altogether, 17 panel facilitated discussions were conducted to measure the extent of NACS integration in health service delivery. Qualitative data was deductively extracted from the 4 Focus Group discussions, 24 Key Informant Interviews and 22 In-depth Interviews to determine the drivers for integration and to complement the quantitative data. A total of 108 respondents participated in the study and these ranged from linkage facilitators, nurses, clinical officers, midwives, nutritionist, health facility in-charges medical superintendent, District Health Educator and Assistant District Health officer.
The health facility in-charges and staff from the Maternal, Child health and Nutrition participated in the facilitated panel discussion and Focus Group discussions. The District Health Educator, Assistant District Health Educator, Medical Superintendent and Health Facility in charges participated in the Key Informant interviews. Experienced staff in NAC implementation were purposely selected for the In-depth interviews.
Overall integration across health facility level
The health facility mean integration scores for NACS across health system building blocks and community system was 2.9. Hospitals had higher integration scores (3.0) compared to Health Centre IVs (2.8) and Health Centre IIIs (2.8). The overall NACS integration across the health facility level is presented in Figure 2.
Integration of NACs across health systems building blocks
The service delivery function scored a health facility mean score of 3.8. This was followed by health work force (3.7), health information (3.3) and Governance and leadership (3.0). Health financing (2.2) and health supplies functions (1.5) were least integrated with mean integration score of 2.2 and 1.5 respectively. The qualitative data broadened our understanding on the drivers of integration of NACS and are aligned to each of the health system building blocks below.
Governance and leadership
NACS was partially integrated in the governance and leadership function with a mean score of 3.0 across the 3 health facility levels. Hospitals scored 3.2 followed by Health Centre IVs with 3.1 while Health Centre IIIs scored 2.9.
Participants mentioned good leadership as key driver for integration. They described the key ingredients of good leadership as; working as a team to accomplish the common goal, regular supervision of all the staff and ensuring that all the activities are done according to standards, delegation, ensuring that all staff have the necessary knowledge and skills to provide the services, providing regular updates to all the staff, being able to lobby for more financial support, bringing everybody on board and above all being in position to embrace new innovations and sustaining them. This is illustrated by the quote below;
…actually when you compare this facility to other facilities our is leadership is strong and welcoming new ideas. When something is brought on board, it is hard to be dropped because of team work, supervision, the follow up. Are you doing this, are you doing that! Remember it is like this, so something like that, it is backed up continous mentorship, reporting, if something is done and you are not seeing where it is being reported, you are likely to drop it … (IDI_HW_ OSUKURU HCIII)
Health Financing
NACS was second least integrated in financing with a mean score of 2.2 across the 3 health facility levels. The Hospitals scored 2 while both the HCIVs and HCIIs scored 2.3.
Participants commonly mentioned partner support as a key driver to NACS integration. They appreciated the role of partner support arguing that provision of financial and material support facilitated nutrition service delivery. The support ranged from procurement of anthropometric equipment and therapeutic food, capacity building activities, nutrition assessment follow up of malnourished cases, Quality improvement activities, establishment of food demonstration gardens, printing of data collection and printing tools. One important aspect raised by a participant was that partners should instead support the districts to plan strategically and intervene in strategic areas which have long lasting impact other than thinking of giving handouts as this was not sustainable.
The partners should support districts to plan strategically and intervene in strategic areas which can have a long-lasting impact other than thinking of giving handouts, it is not sustainable to give handouts. Handouts can be given inform of therapeutic food for those who are severely malnourished,... So if they have a strategic intervention to look at all that and food fortification…., I know there are some foods which are fortified but we can do more than that. We can have it as a policy, in Kenya, all the maize flour is fortified before you sell with vitamin A and all these other things are in there, so we can look at that as an example (KII_MS_TORORO HOSPITAL)
Health workforce
NACS integration in the health work force function was partial with a mean score of 3.7 across the 3 health facility levels. Health Centre IVs scored 4.3 while the HCIIIs and Hospitals scored 3.7 and 3.0 respectively.
Participants mentioned availability of adequate and competent human resources as a driver for NACS integration. They explained that staff who were passionate, motivated, skilled, committed with a positive attitude and team spirit were instrumental in mainstreaming NACS interventions in health service delivery. An improvement in the health and nutrition status in the clients was a big motivating factor for the health workers to continue with the nutrition service delivery as illustrated by the following quote;
I think nutrition is very important when it comes to health service provision. Because you find that if a client is taking medication but that client is having poor nutrition then you find that the health of that client is deteriorating. So I think that if there is a way of getting all staffs involved in this by maybe giving them the knowledge, or any other way, i think we will have solved many problems. (KII_HW1_ST. ANTHONY HOSPITAL)
Capacity building activities emerged as another key driver. Participants reported that training of health workers, conducting regular Continuous Professional Development and regular supervision enhanced the knowledge and skills of the health workers and was a constant reminder to them to stay focused and adhere to the nutrition guidelines and standards.
….we also have regular CMEs (Continuing Medical Education). They also help to remind people about certain programs. If you do not do it, people will just forget and go for other programs. (KII_MELLA HCIII)
Additionally, the participants appreciated the role that the support staff (Linkage facilitators and Village Health team) played in the provision of nutrition services especially nutrition assessment. The staffing levels of the health facilities was far below standard (<50%) to enable the health workers to conduct nutrition assessment for every client and this is illustrated by the following quote:
Now one is that, those linkages are always available; you know the staffing levels currently in this facility we are like at 50%, and then you are like telling us; MUAC for every client, you know! The provision of the support staff has really helped us a lot (IDI2_ HW2_POYAMERI HCIII)
From the demand side, the participants mentioned patient empowerment as a key driver to integration. They reported that the patient’s rights and responsibilities are pinned on the notice board for the clients knowledge on the available services and what is expected of them. Their knowledge is enhanced through health and nutrition education talks as well as nutrition counselling. As a result, the clients always demanded for the services whenever the health workers had missed out any. The following quote highlights these assertions;
We start with a health talk, and when you check our notice board we have the patients’ rights, those are one of the things spoken about on a daily basis; the patients’ rights and responsibilities and what they should expect when they come to the health facility. And if it is not done then they need to demand (KII_MUKUJJU HCIV)
Health Information
Integration in the information building block was partial with a mean score of 3.3 across the 3 health facility levels. Hospitals and Health Centre IIIs had better integrated nutrition information with a score of 3.6 and 3.7 compared to the Health Centre IV which scored 2.7.
Participants pointed out the availability of data collection, reporting tools and proper documentation as key drivers to NACS integration. They mentioned that there were deliberate efforts to track nutrition integration by reviewing their registers. The regular internal and external support supervision thrusted the health workers to improve on their documentation as supervisors always demanded to review the registers and address the gaps on spot as reflected in the quote below.
Those mentorships, and support supervision, they keep coming and when they come they ask for those registers, when they find that you are not doing it well, they take you through. And the opening of those journals, you open a journal, you have started at this percentage and you want to achieve this you keep on pushing and somehow they embrace it (KII_OSUKURU HCIII)
The quality improvement approaches including performance reviews employed were mentioned as drivers of NACS integration. These ranged from problem analysis to identify gaps and solutions, opening of documentation journals for nutrition projects, use of dash boards to monitor performance, mentorships, learning sessions to share experience and harvest meetings to gather best practices that could be replicated in other health facilities.
The mentorships; structured mentorships were programmed where achievements were aimed at different levels, at different time. So we had a QI project on nutrition and we were monitoring and learning sessions were arranged, so members would go, come back implement and review the performance. So the habit of reviewing performance routinely and dashboard really kept us on our toes.(KII_MS_TORORO HOSPITAL)
Health Supplies
This was among the worst integrated system block with a mean score of 1.5 across the 3 health facility levels. Hospitals scored 2.5 while both HCIVs and HCIIIs scored 1.0.
Participants mentioned that availability of anthropometric equipment, therapeutic foods and data collection tools as drivers to NACS integration. The supplies which ranged from weighing scales, MUAC tapes, height boards, registers and reporting tools were procured and distributed by partners as illustrated from the following quote.
When we get implementing partners and when they come for their assessment, they find that some of us are not trained in NACS, other tools like weighing scales were not there, they had to buy for us then TASO brought for us the MUACS we didn’t have them, the registers also were brought (KII_MELLA HCIII)
The results are presented in Figure 3.
NACS integration in Service Delivery
The results of the NACS integration in the service delivery are presented Figure 4. Overall, NACS was best integrated in-service delivery function with a health facility mean score 3.8. Hospitals performed better (3.9) compared to HCIVs (3.8) and HCIIIs (3.8). An in-depth analysis indicated deworming was best integrated with a mean score of 5 followed by micronutrient supplementation (4.9) and nutrition assessment (4.1). Capacity building activities (3.9) and quality improvement (3.8). Follow up care was the least integrated though better at Health Centre IIIs (2.6) that Hospitals (2.5) and Health Centre IVs (2.0).
Participants mentioned health and nutrition education talks as key facilitator pointing out that this was a source of information for the clients demystifying their myths and misconceptions about malnutrition. Food demonstrations made it even possible to for the clients to in practice what they learnt from the health facilities.
So what they did, we could give health education and also with support from implementing partners like TASO, and world vision, they were so supportive, they could bring the food and facilitate that activity so it really helped so much. (IDI-2_HW_ KIYEYI HCIII)
Integration in Community Support system
The results of the NACS integration in the Community system are shown in Figure 5.
Integration of NACS in the community support system across the 3 health facility levels was partial with mean score of 3.0. HCIIIs had better integration (3.3) than the Hospitals (3.0) and HCIVs (2.7).
Participants alluded to the fact that the community arm was key in integration of health and nutrition services since this provided a continuum of care for clients. Furthermore, they reported that community dialogues changed the community members’ attitude to adoption of optimal nutrition practices consequently reducing malnutrition in the community as reflected in the following quote.
…I think is they communicate people get the information, they take to the villages, and before RHITES-E came they used to have community dialogues, people could go, get a topic and you teach about NACS, they get to know and then say i think we need to change. So that has also made malnutrition to reduce in the community (KII_ KWAPA HCIII)