Nutrition scorecard in Kakamega County, Kenya

Republic of Kenya Republic of Kenya

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Background

At the 14th Task Force Meeting on Food and Nutrition Development convened by the African Union Commission (AUC) in April 2024, Kenya received commendation for its remarkable strides in addressing the triple burden of malnutrition—overnutrition, undernutrition, and micronutrient deficiencies over the past year. This progress is reflected in the Kenya Demographic and Health Survey (KDHS) 2022, which shows significant reduction in the prevalence of stunting among children under five years of age from 26% in 2014 to 18% in 2022.Through the Kenya Nutrition Action Plan (KNAP) 2018-2022, now under revision, the country seeks to accelerate efforts to scale up interventions aimed at eliminating malnutrition.

In the western part of the country, about 30km north of the equator, sits Kakamega County, one of the 47 geographic regions in Kenya. Consisting of 12 sub counties (subregions), Kakamega is home to a population of approximately 1,867,579 people, whose economic activities primarily involve cash crop and food crop farming (Kenya Population and Housing Census, 2019). Kakamega County faces a triple burden of malnutrition due to food shortages and inadequate dietary diversity. According to the 2021 Agricultural Policy, food insecurity in the county stands at 33%, with 60% of households unable to access minimum diverse diets. Furthermore, stunting levels among children under five in the county stand at 12%, with wasting and underweight levels at 2% and 5% respectively (KDHS, 2022).

Nonetheless, the county is committed to addressing the underlying causes of malnutrition, especially among the most vulnerable, including children under five and pregnant and lactating women (PLW), through various programs and interventions. Among these interventions is the decentralisation of the nutrition scorecard in 2021 at both county and subcounty levels.

This followed the development of the national nutrition scorecard in 2019 with support from ALMA in partnership with UNICEF, Save the Children, Kenya Red Cross Society, Action Against Hunger and Terre des Hommes. The scorecard, encompassing 13 national and 17 sub-national indicators across six categories, was officially launched in 2020 and has since been decentralised to 32 counties, including Kakamega County.

  • Malnutrition: The country seeks to accelerate efforts to scale up interventions aimed at eliminating malnutrition.
  • Stunting among children under five: 26% in 2014 18%in 2022
  • 33% Food insecurity: 60%of households unable to access minimum diverse diets
  • The scorecard was officially launched in 2020

Adoption and utilisation of the nutrition scorecard

Without data, decision-making is like walking in the dark. The scorecard has transformed our approach by providing the necessary guidance. We have adopted it for all decision-making processes, ensuring its use in quarterly and strategic meetings, and in discussions with partners and within our team.

Margaret Oyugi – Nutrition Coordinator, Kakamega County

Decentralisation involved identifying key personnel at county and subcounty levels for training on the scorecard. This led to two training cohorts in 2022 and 2023 targeting nutritionists, health record officers, nurses, Health Management Teams (HMT), and nutrition sensitive sector leads. To date, progressive training of Community Health Assistants and promoters continues.

Subsequently, the county has integrated the nutrition scorecard into routine decision-making processes, including:

  • Incorporating the scorecard into all nutrition meetings particularly data review meetings to inform interventions
  • Implementing quarterly reporting from the subcounty using the scorecard
  • Facilitating high-level reporting by the nutrition program
  • Engaging stakeholder and multi-sectoral nutrition platforms and technical working groups (TWGs)

Impact

Case study 1: sustaining Vitamin A supplementation in Kakamega County

Background

For several years, Kakamega County received support for Vitamin A supplementation through a program supported by Helen Keller International. This support involved financial aid at the end of each semester, enabling the distribution of Vitamin A to 90% of the children in the county. However, in late 2023, Helen Keller International announced their plans to close out the program.

Challenge

The withdrawal of support from Helen Keller International posed a significant challenge. The county’s dependence on external assistance meant that, without it, coverage would drop drastically to less than 20%. This necessitated an urgent re-evaluation of the county’s approach to continue providing Vitamin A to children aged 12-59 months.

Strategic response

In response, Kakamega County officials sat down with representatives from Helen Keller International    to discuss the progress made in achieving the Vitamin A supplementation indicator, using the scorecard as an advocacy tool. Recognising the need for a sustainable solution, the county proposed an integrated approach involving multiple departments and community resources. The proposed strategy involved the following:

  • Collaboration with the Department of Education: Training Early Childhood Development (ECD) teachers to drive up Vitamin A administration.
  • Involvement of the Department of Agriculture: Utilising agricultural extension workers to promote and support efforts.
  • Leveraging the Community Health Strategy: Engaging Community Health Promoters (CHPs) to reach children in households.
  • Utilisation of Healthcare Facilities: Training healthcare workers across all county health facilities to incorporate Vitamin A distribution into routine services.

Implementation

In early 2024, the county sought transitional support from Helen Keller International to facilitate the necessary training for this new approach. Helen Keller International agreed and provided 8 million Kenya Shillings (approx. 49,430 USD) in February. This funding was used for a comprehensive six-week training program, which included:

  • Training 927 Early Childhood Development (ECD) teachers from both public and private centres to identify children eligible for Vitamin A administration based on their birthdays.
  • Training 4,250 Community Health Promoters (CHPs) to ensure household coverage.
  • Training staff across all 320 healthcare facilities in the county to integrate Vitamin A supplementation into regular health services.

Outcome

By the end of the semester, with no further external support, the newly trained teachers, CHPs, and healthcare workers successfully distributed Vitamin A, reaching 80% of the children in the county. This marked a significant achievement in the county’s ability to sustain and manage the Vitamin A supplementation program independently and the potential for long-term sustainability. Generally, routine Vitamin A supplementation is very low across the country. Vitamin A supplementation is only high during quarters when Malezi Bora campaigns are conducted.

Case study 2: Implementing a multisectoral approach to nutrition in Kakamega County

Background

In Kakamega County, the need for an efficient data collection system across various sectors became evident as part of the efforts to reduce malnutrition. While the Ministry of Health had a robust data collection platform – Kenya Health Information System (KHIS), other sectors such as Agriculture and Education lacked similar systems. To address this gap, the county initiated a multisector nutrition (MSN) platform aimed at improving data collection and monitoring across all relevant sectors.

Challenge

The primary challenge was the lack of integrated data from non-health sectors. This hindered the ability to assess the contributions of sectors like agriculture, education and water in reducing malnutrition. Without comprehensive data, it was difficult to formulate effective, coordinated strategies.

We realised that not all sectors collect data as efficiently as the Ministry of Health. By developing a joint work plan and indicators, we could monitor contributions from sectors like agriculture and education.

Margaret Oyugi, Nutrition Coordinator for Kakamega County

Strategic response

To address this issue, the county’s multisector team was trained in the nutrition scorecard, eventually inspiring the development of a rudimentary Multi-Sectoral Nutrition (MSN) scorecard, awaiting the revision of the current scorecard to a Multi-Sectoral         Nutrition Scorecard. The MSN scorecard incorporates multi-sectoral indicators, including those from the MOH nutrition scorecard, providing a framework for accountability and action across all relevant sectors. This approach enables nutrition-sensitive sectors to better understand their roles and identify targeted interventions, contributing to Kakamega County’s malnutrition reduction goals.

Implementation and Outcome

With the multisectoral scorecard in place, the next step was to advocate for the use of this data to influence policy and drive community engagement. The county trained “nutrition champions” at both community and policy levels. These champions included political figures, with Prof. Janet Kassily Barasa- the county’s First Lady emerging as a key advocate.

The First Lady’s involvement was pivotal. She leveraged the scorecard data to promote initiatives such as Malezi Bora, a biannual week dedicated to increasing the uptake of crucial health  services. Her advocacy included direct engagement with mothers, highlighting the importance of consistent Vitamin A supplementation for children up to the age of five.

“According to the scorecard, you only come for Vitamin A during the Malezi Bora month,” she would tell mothers, urging them to ensure their children receive the supplement regularly. Her hands-on approach included door-to-door campaigns and public messaging, which resonated with the community. This resulted in other advocacy opportunities which saw Prof. Janet Kassily Barasa speak at a USAID roundtable in October 2023 on her role as a nutrition champion in Kakamega County.

Case Study 3: How Mumias West sub-county enhanced nutrition outcomes through community-led interventions

Background

Milcah Onsere, the Nutrition Coordinator for Mumias West Subcounty, shares the journey of improving nutrition indicators using the nutrition scorecard. In partnership with the African Leaders Malaria Alliance (ALMA) and the county government of Kakamega, nutrition teams were trained on scorecard utilization for decision-making and tracking progress.

Challenge

In the first quarter of 2023, the nutrition scorecard for Mumias West revealed key gaps. Two major indicators were flagged: the haemoglobin (HB) levels for women of reproductive age, with most women having levels below the recommended 11 g/dl, and the extended length of stay for malnourished cases in healthcare facilities.

Strategic response

To address these challenges, Mumias West subcounty organised integrated nutrition open days. These events involved immunisation checks, antenatal care (ANC) assessments, and growth monitoring for young children and infants. They also engaged Community Health Promoters (CHPs) and other partners to collect and analyse data, identifying a high prevalence of underweight children, particularly in Musanda Ward. These resulted in the roll out of a series of interventions including:

Community-based initiatives: The team began by training CHPs on the Baby Friendly Community Initiative (BFCI), which focuses on maternal, infant, and young child nutrition practices. This training aimed to improve both maternal and child nutrition, addressing anaemia prevention and enhancing feeding practices.

Mother-to-mother support groups: CHPs developed support groups, walking with mothers from pregnancy through the child’s first two years to improve nutritional outcomes. These groups provided peer support and education on best practices.

Positive deviance hearth programme: To address the long stay of malnourished children in facilities, CHPs and health workers were trained in the Positive Deviance Hearth program to help rehabilitate malnourished children. This community-based initiative focuses on breastfeeding, maternal nutrition, food security, stimulation, HIV care, and care for sick children.

Intensive assessments: Regular assessments were conducted to monitor the weight and nutritional status of children under five. This process identified 17 severely malnourished children and 117 moderately to mildly malnourished children, all of whom were enrolled in the Positive Deviance Hearth (PDH) Program.

Implementation

The Positive Deviance Hearth program involved the grouping of up to 12 mothers and their children. Mothers were paired with peers who had healthy children to learn positive practices. They attended daily sessions for 12 days, where they learned to prepare nutritious, affordable meals using locally sourced, affordable ingredients. This hands-on approach emphasised the importance of a balanced diet and allowed mothers to learn and replicate these practices at home. After the initial 12 days, CHPs conducted home visits for an additional 10 days, followed by weight checks at 30, 60, and 90 days. The goal was a weight gain of 200 grams after 12 days and 1,200 grams after 90 days.

Outcome

By June 2024, the program achieved remarkable success. Out of the enrolled children, 104 graduated, showing marked improvements in weight, nutritional behavior, and food security at home. The introduction of home gardens, where mothers grew a variety of vegetables, fruits, and Vitamin A-rich potatoes, further supported these gains.

Edith Msunde, a mother of three children (13 years, 8 years, and 2 years) and a hairdresser, shared her experience from the program

I was part of the Positive Deviance Hearth (PDH) training program. We met for two hours daily, learning how to cook nutritious meals. We discovered that we did not have to buy all these foods—traditional vegetables, sweet potatoes, fruits, ground nuts, and eggs—but could set up kitchen gardens even in our small spaces at home to ensure regular and inexpensive access to such nutrient-rich foods.

The training was essential because our children were not eating well. When we started, my youngest child was about 1 ½ years old, but he was underweight at 7 kgs, which was too low for his age. He was also very sickly, and I made frequent trips to the clinic. The doctors would often ask, “Edith, your child is sick again?” It was frustrating because I thought I was doing everything right by buying potatoes and rice from the market. However, I learned that balanced meals including vitamins and proteins were important for his growth, and I needed to also ensure that he had regular meals throughout the day.

I put all of this into practice and the next time we went for a check-up, he had gained some weight. Previously, his hair would not grow well—it looked dusty and took too long to grow. But slowly, he began to improve. He moved from 7 kgs to 12kgs, and the doctor confirmed that he was doing better.

I had given up hope that my child would ever get better. People would gossip because he was too thin (wasted). Now, they look at him and say, “Koka has grown!” I tell them about the lessons I learned from the PDH program on improving my child’s health. Now, they want these lessons too. Today, I am happy to be going about my business with him; he is strong, playful, and happy. I am grateful.

Conclusion

Overall, the nutrition scorecard has been instrumental in transforming nutrition programs in Kakamega County. By enabling data-driven decision-making, fostering multisectoral collaboration, and empowering communities, the county has made significant strides in improving nutritional outcomes.