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Time to think urban.....Kenya

By Linda Beyer, Valerie Wambani and Koki Kyalo

Linda Beyer is Nutrition Specialist (Infant and Young Child Nutrition and HIV/AIDS) with UNICEF Kenya and is based in Nairobi.

Valerie Wambani, is Programme Manager for Food Security and Emergency Nutrition, Division of Nutrition, MOH Kenya.

Koki Kyalo is the Nutrition Manager for urban programming, Concern Worldwide, Kenya.

This article shares the approach and vision for urban nutrition programming in Kenya from the national perspective. It reflects collaborative work by the Ministry of Health Kenya, UNICEF Kenya and Concern Worldwide.

Understanding the challenges of urban nutrition and food security in Kenya

In Kenya, close to 1 in 3 children live in urban areas (5.2 million) with 1.7 million of these children living in poverty. Households spend up to 75% of their income on staple foods, with price shocks and over reliance on markets resulting in negative coping mechanisms and heavy reliance on street foods. Malnutrition and anaemia rank 4th out of the top 10 causes of mortality for children under 5 years in Nairobi and account for 8.4% years of life lost¹. Stunting affects more than one in two children in urban slums (see Figure 1). Emerging issues are rickets, severe stunting in young children (severe stunting in children under one year of age has doubled over the past six years²), co-morbidities (diarrhoea and HIV/AIDS) and challenges for care practices in early childhood care settings. The difference in child malnutrition between the wealthiest and poorest households is twice as great in urban areas compared to rural locations, highlighting a number of inequities.

Policy framework

There is a strong policy framework for urban nutrition action in Kenya. Recent innovations in urban policy and strategy guidance are:

• Urban Areas and Cities Act (2011) guiding urban governance.
• Urban Policy (Draft 2012) addressing urban guidance.
• Urban Nutrition Strategy (2013-2017) providing urban sector strategies (due out October 2013).

Kenyan government priorities

A key area of action is strengthening information systems and analysis in urban areas, to identify who and where are the most vulnerable. Table 1 outlines the target vulnerable groups and severe acute malnutrition (SAM) caseload faced in informal urban settlements in Nairobi, Kisumu and Mombasa. Since 2008, the Ministry of Health Kenya (MOH) with support from UNICEF and Concern Worldwide has accelerated nutrition interventions in urban contexts, addressing barriers to vulnerable populations, strengthening health systems and ensuring a package of evidence based high impact nutrition interventions (HINI) reach children and mothers.

Table 1: Urban population, target groups and acute malnutrition caseloads
	Nairobi (100% urban)	Kisumu (52% urban)	Mombasa (100% urban)
Total population of informal settlements	1,992,237	300,672	563,622
Children under five years	258,996	64,173	44,102
Pregnant and lactating women	119,534	18,040	33,817
Severe acute malnutrition caseload	8,701	2,875	917

Assessing coverage for HINI has involved strengthening Health Information Systems (HIS) indicators and Community Based Indicators. Further strengthening of analysis of urban vulnerability has involved:

• Sentinel Site Surveillance for urban areas - Nairobi Urban Health and Demographic Surveillance System (NUHDSS) (APHRC)
• Assessing coverage for urban areas (SQUEAC³) which highlight barriers and areas for strengthening response.
• Innovations in mapping urban vulnerability are helping to map vulnerable/at risk populations⁴
• Food Security mapping (see Figure 1).
• Hourly income
• Personal security
• Coping strategies

A second key area of action is acceleration of systems/coverage of HINIs to address disparities in malnutrition in urban informal settlements/slums of Nairobi. Progress in health system strengthening is reflected in improved coverage for Nairobi and Kisumu facilities where HINIs implementation has increased from 26 facilities in 2008 to 102 facilities in 2012, reaching 89% of target health services in urban slums. Coverage for outpatient treatment for acute malnutrition has also improved, with coverage reaching 40 to 50% of target (see Table 2) and achieving global Sphere standards (defaulter rate, recovery rate and mortality rate). Coverage assessments have highlighted barriers to future programming that will inform efforts.

The area of Infant and Young Child Nutrition (IYCN) has seen improved strategies and focus on community level support⁵. Results included improvement in complementary feeding practices (see Table 2). Main strategies have included Trials for Improved Practices (TIPs) which used formative assessment for improved complementary feeding of young children, Mother to Mother Support Groups (MtMSG) and Community Capacity Enhancement (CCE); these approaches have been integrated together to mobilise communities and empower caregivers with knowledge and skills for better practices.

Table 2: High Impact Nutrition Interventions, national targets and achievements in Nairobi and Kisumu (2010-2012)
Focus of Nutrition Programme Support	High Impact Nutrition Intervention	National Target	Nairobi 2010	Nairobi 2012	Kisumu 2010	Kisumu 2012
Infant and Young Child Nutrition	Early initiation of breastfeeding	> 70 %	56 %	71 %	61 %	66 %
	Exclusive Breastfeeding	> 80 %	46%	59 %	46 %	44 %
	Dietary Diversity	> 70 %	38 %	74 %	42 %	73 % *
	Feeding Frequency	> 80 %	4 %	46 %	5 %	81 % *
Micronutrient  Deficiency Control	Vitamin A	> 80 %	76 %	73 %	N/A-	86 %
	Zinc treatment	> 50 %	14.6 %	40 %	N/A	43 %
	Deworming	> 80 %	48.6 %	52 %	30.6 %	53 %
	Iron/Folate	> 50 %	3.6 %	N/A	5.1 %	N/A
IMAM	SAM coverage	> 70 %	32%	39 %	50%	46%

Challenges and constraints

Challenges and constraints to urban nutrition programme support in Kenya include:

• Inadequate resources for health and nutrition programmes at all levels
• Fewer partners supporting urban nutrition
• Transient populations with intra-slum migration
• Limited quality maternity services in informal settlements
• Market level influence: price shocks, infant formula use and sub-optimal complementary foods
• Challenges for working mothers and un-regulated day care settings
• Social challenges and insecurity (HIV/AIDS, substance use and violence)
• Need for strengthened analysis for disparities and interventions

In order to take urban programming to the next level and strengthen nutrition responses in vulnerable urban areas, Kenyan government priorities are:

• To identify gaps to expand urban priorities, identify disparities and strengthen analysis of vulnerabilities including the impact of rising food prices and inequities.
• To undertake further analysis and develop multi-sectoral responses to address underlying causes of early child care (day care settings) including child protection concerns, lack of clean water and proper sanitation. One action is to develop guidelines for minimum standards for day care settings.
• To improve sectoral responses to address disparities in neonatal mortality through investments in maternal newborn care.
• To prevent deaths in children under five years through improved access to health services, improved water and sanitation and prevention strategies for HIV.
• To strengthen the local resource base for urban nutrition response through advocacy for government funding from the devolved governments, include community interventions to improve coverage of HINI and social transfer programmes addressing nutrition security (food/cash vouchers).

For more information, contact: Linda Beyer, email: lbeyer@unicef.org

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Linda Beyer, Valerie Wambani, Koki Kyalo (). Time to think urban.....Kenya. Field Exchange 46: Special focus on urban food security & nutrition, September 2013. p49. www.ennonline.net/fex/46/urbankenya

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