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2012 Kenya: Evaluation of Integrated Management of Acute Malnutrition (IMAM): Kenya Country Case Study



Author: UNICEF Evaluation Office

Executive summary

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Background:

The Government of Kenya (GoK) through the Ministries of Public Health and Sanitation (MoPHS) and Medical Services (MoMS) initiated the Integrated Management of Acute Malnutrition (IMAM) in 2008 with MoPHS in the lead role. IMAM is currently one of 11 High Impact Nutrition Interventions (HINI) adopted by Kenya since August 2010. It is implemented in collaboration with UNICEF, WHO and WFP and implementing partners (IPs) as part of emergency nutrition. Other child nutrition interventions include Infant and Young Child Nutrition (IYCN) and prevention and control of micronutrient deficiencies.

Severe acute malnutrition (SAM) is a major childhood health challenge in Kenya, especially during emergencies. Wasting, a measure of acute malnutrition was estimated at 7% in 2009 but there are huge regional variations such as in Arid and Semi-Arid Lands (ASAL), where food insecurity and drought have affected the population. HIV and malnutrition are intrinsically linked; HIV contributes to 7% of deaths in children under five years of age; an estimated 13,000 children became newly infected with HIV in 2011.

Purpose/Objective:

UNICEF undertook this evaluation to assess IMAM performance and to document key successes, good practices, gaps and constraints in scaling up IMAM in Kenya. The evaluation will contribute to a global synthesis report. Four components of IMAM were evaluated: 1) Community outreach; 2) Outpatient treatment for SAM cases without medical complications; 3) Inpatient treatment for SAM cases with medical complications; and 4) Management of moderate acute malnutrition (MAM).

Methodology:

The criteria of relevance, effectiveness, efficiency, sustainability and scaling up were applied to IMAM components and to cross-cutting issues. Data were obtained from secondary sources, health system databases, observations during visits to sample IMAM sites and interviews with stakeholders. Quantitative data were analysed to determine whether IMAM targets were met and quantitative data supported the analysis. Data collection took place in 21 sites in nine districts. IMAM performance data was analysed from January 2010 to December 2011 for six districts.

Findings and Conclusions:

The key findings and conclusions are organized by evaluation criteria and cross-cutting issues.
Relevance and Appropriateness
The Integrated Management of Acute Malnutrition (IMAM) has been effective in treating SAM cases in Kenya. Demand for IMAM as part of routine health services has increased due to its inclusion in district annual operational plans from 2008 onwards. The IMAM is further strengthened by being part of the HINI. Demand can be further enhanced through more effective community sensitization in tandem with the on-going decentralization of the health system.
Effectiveness – Coverage and Quality of Services
The IMAM has succeeded on average in meeting the Sphere standards for admitted SAM cases. On the job training (OJT) along with effective technical assistance and coordination have strengthened nutrition services. Good practices include mother to mother support groups and targeting IMAM caretakers in livelihood programmes. Services can be improved through providing play space in inpatient treatment facilities, increasing availability of WASH, and more dedication of staff time to counselling. It is important that the GoK provides incentives for Community Health Workers (CHWs) in recognition of their critical roles in case finding, counselling and follow-up.
Coverage. Geographic coverage of health facilities providing outpatient treatment for SAM is below 50% with a wide range between counties; Kinango, Yatta, Kitui and Laikipia have 10-20% coverage. Surveys are needed to accurately determine treatment coverage; coverage methodology has been agreed in 2012 and coverage investigation is now being rolled out.
Community Outreach. Although screening approaches are largely well organized, screening does not reach all children due to vastness of slums and rural areas that cannot be covered by the CHWs, migration, use of traditional healers, lack of transport, and dearth of information about screening opportunities. [...]

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Recommendations:

1. Enhance Government of Kenya ownership and commitment to scaling up and strengthening IMAM within national health services through allocation of more resources.
2. Finalize the draft national nutrition strategy and plan that outlines strategic priorities, ties together sectoral interventions that address the causes of malnutrition, into a master plan which identifies gaps and overlaps and confirms roles for nutrition authority and nutrition coordination.
3. Jointly identify constraints and develop a framework and results matrix for sustainable integration of IMAM within HINI into the national health services.
4. Expand the national IMAM guidelines making linkages to the other interventions or develop them as part of HINI guidelines, including detail on information and monitoring systems and equity and gender equality.
5. Support the health sector to refine and operationalize the community outreach package tied to the community strategy along with developing guidelines for implementation of community outreach and indicators for judging performance. Effectiveness – Coverage and Quality of Services
6. Conduct and ensure funding for regular treatment coverage surveys in districts where IMAM is being implemented.
7. Improve quality of services and infrastructure where needed for outpatient and inpatient treatment facilities particularly through investment in WASH and play spaces. 8. Incorporate IMAM supplies (both equipment and RUTF) into the Kenya Medical supplies authority (KEMSA) as part of the basic essential care package. 9. Strengthen supply and delivery services and increase reliability and sustainability in supply and delivery through a plan to build capacity in the government/MoH logistics system. Cross-Cutting Issues 10. Continue to strengthen joint monitoring and evaluation through regular joint evaluations, a standardized M&E tool, and regular information dissemination. [...]

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