KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022

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REPUBLIC OF KENYAMINISTRY OF HEALTHKENYA NATIONAL NUTRITIONACTION PLAN 2018-2022POPULAR VERSIONDecember 2018

REPUBLIC OF KENYAMINISTRY OF HEALTHKENYA NATIONALNUTRITION ACTION PLAN2018-2022POPULAR VERSION

TABLE OF CONTENTSTable of Contents ivList of Figures viList of Tables viCHAPTER 1 OVERVIEW AND INTRODUCTION TO THE KNAP 2018-202211.1 Introduction 11.2 Rationale for the Kenya Nutrition Action Plan21.3 Kenya Nutrition Action Plan Development Process3CHAPTER 2 KENYA NUTRITION SITUATION ANALYSIS42.1 Introduction 42.2 Causes of malnutrition 62.2.1 Immediate causes of malnutrition 62.2.2 Underlying Causes of Malnutrition in Kenya72.2.3 Basic causes of Malnutrition: 7CHAPTER 3 THE KENYA NUTRITION ACTION PLAN DESIGN FRAMEWORK83.1 Introduction 83.2 Vision 93.3 Mission 93.4 Core values and guiding principles 93.5 Objective of the KNAP 93.6 Expected result or desired change for the KNAP93.7 Key strategies used in KNAP development9CHAPTER 4 KEY RESULT AREAS 11KRA 1: Maternal, new born, infant and young child nutrition (MNIYCN) scaled up11KRA 2: Nutrition of older children and adolescents promoted12KRA 3: Nutrition status of adults and older persons promoted12KRA 4: Prevention, control and management of micronutrient deficiencies scaled up13KRA 5: Prevention, control and management of diet-related risk factors fornon-communicable diseases scaled up14KRA 6: Prevention and integrated management of acute malnutrition (IMAM)ivKENYA NATIONAL NUTRITION ACTION PLAN 2018-2022

strengthened15KRA 7: Nutrition in emergencies strengthened16KRA 8: Nutrition in HIV and TB promoted17KRA 9: Clinical nutrition and dietetics strengthened18KRA 10: Nutrition in agriculture and food security scaled up19KRA 11: Nutrition in the health sector strengthened19KRA 12: Nutrition in the education sector strengthened20KRA 13: Nutrition in water, sanitation and hygiene (WASH) sector promoted20KRA 14: Nutrition in social protection programmes promoted21KRA 15: Sectoral and multisectoral nutrition governance (MNG) including coordinationand legal/regulatory framework strengthened 21KRA 16: Sectoral and multisectoral nutrition information systems, learning and researchstrengthened 22KRA 17: Advocacy, communication and social mobilization (ACSM) strengthened23KRA 18: Capacity for nutrition developed 24KRA 19: Supply chain management for nutrition commodities and equipmentstrengthened 24CHAPTER 5 COSTED ACTION PLAN OF THE KNAP26CHAPTER 6 KNAP MONITORING, EVALUATION, ACCOUNTABILITY ANDLEARNING (MEAL) 28CHPATER 7 LEGAL, INSTITUTIONAL AND COORDINATION FRAMEWORKSFOR THE KNAP 327.1: Introduction 327.2 Legal framework 327.3 Institutional Frameworks 33KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022v

LIST OF FIGURESFigure 1: Sustainable Development Goals 1Figure 2: Snapshot of key milestone during development of KNAP 2018-20223Figure 3: Trends in stunting, underweight and Wasting 1998-20144Figure 4: Breastfeeding status 5Figure 5: Status of complementary feeding5Figure 6: Conceptual framework for malnutrition6Figure 7: Theory of change 8Figure 8: KNAP learning cycle 29Figure 9: Elements of sectorwide partnership34Figure 10: Coordination structure for food and nutrition security implementationframework 34Figure 11: Coordination Organogram 35Figure 12: SUN Coordination Structures 35LIST OF TABLESTable 1: Summary of financial resource needs for the KNAP 2018–2022 Per Key ResultArea 27Table 2: Kenya nutrition targets for 2022/23viKENYA NATIONAL NUTRITION ACTION PLAN 2018-202229

CHAPTER 1: OVERVIEW AND INTRODUCTIONTO THE KNAP 2018-20221.1 IntroductionThe KNAP 2018 - 2022 is the second National Nutrition Action Plan that operationalizesthe National Food and Nutrition Security Policy 2012 and its implementation framework(NFNSP-IF) 2017–2022.Figure 1: SDGs related to nutrition (Source: Global Nutrition Report 2017)The plan is anchored on existing Countrylevel policy and legal frameworks as wellas other global and regional frameworksincluding the African Regional NutritionStrategy (ARNS) 2015–2025, AU PolicyFramework and Plan of Action on Ageing(2002) World Health Assembly (WHA)2025 nutrition targets and the SustainableDevelopment Goals (SDGs) as shown infigure 1.The KNAP is a framework that spells outthe investment required for Kenya toaddress malnutrition in all its forms and forall ages. The plan adopts a multisectoralapproach and promotes cross-sectoralcollaboration to address the socialdeterminants of malnutrition sustainably.In light of devolution and the functionsascribed to the two levels of government,the Kenya Nutrition Action Plan (KNAP)2018–2022 provides an umbrellaframework and guidance to counties,who will in turn develop aligned CountyNutrition Action Plans (CNAPs). The KNAPalso defines both the National and Countygovernment roles relating to the provisionof technical support, advocacy, guidanceand development of capacity for nutritionfor the county governments who areKENYA NATIONAL NUTRITION ACTION PLAN 2018-20221

directly responsible for implementation ofactions spelt out in the plans.1.2 Rationale for the KenyaNutrition Action PlanThe second Kenya Nutrition Action Planwas developed to further accelerate andscale up efforts towards the elimination ofmalnutrition as a problem of public healthsignificance in Kenya by 2030, focusing onspecific achievements by 2022. The threebasic rationales for the action plan are:(a) the health consequences – improvednutrition status leads to a healthierpopulation and enhanced quality of life;(b) economic consequences – improvednutrition and health is the foundation forrapid economic growth; and (c) the ethicalargument – optimal nutrition is a humanright. There is overwhelming evidencethat improving nutrition contributes toeconomic productivity and developmentpoverty reduction by improving physicalwork capacity, mental capacity and schoolperformance.Take IFA supplements with meals to reduce chances ofexperiencing nausea.152KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022

1.3 Kenya Nutrition ActionPlan Development ProcessThe process of development of KNAP2018-2022 was driven by government,specifically the Nutrition and DieteticsUnit (NDU) of the Ministry of Health,and was widely consultative, involvingall key nutrition stakeholders througha multisectoral process that was open,inclusive and built on existing andemerging alliances, institutions andinitiatives. At the national level keyline ministries with nutrition-sensitiveprograms, development partners, civilsociety organizations, NGOs and the2019private sector and Counties participatedin the process. The process ensuredthat the plan is evidence-informed andrecognized successes, challenges andlessons learnt from the implementationof the 2012–2017 NNAP. Evidence wasgathered through desk reviews of relevantdocuments and information from keysectors. The process also ensured thatthe KNAP is results-based and providesfor a common results and accountabilityframework for performance-based M&E.As shown in figure 2, the KNAPdevelopment process comenced in mid2017 with a review of NNAP 2012-2017nad was finalised in April 2019.2018JAN – APRILJUNE - DEC- Editing and Proof reading of KNAP- Designing of KNAP- Developing of KNAP Popular Version- Development and Dissemination of CNAPsOperational Guidelines- Sensitization of Principal Secretaries andDirectors in relevant sectorsKNAP drafts developed; KNAP draft reviewed by various multi-stakeholder consultative fora which included: sector ministries, counties,Donors, NGOs, CSOs and private sector. KNAP validated and finalized.20182018FEB – APRILMAY –JUNERoad map developed; Thematic groups constituted,Secretariat formed; TORs defined; Consultancyareas identified; TORs for consultants developedand adverts sent out. KNAP is part of GoK/MoH RRI;Groups meeting and thematic areas identified.County Matrices developedKNAP – Consultative Forum withCounties and County matricesdeveloped. Development of alisting and links for key KNAPresource documents2018JANDevelopment of KNAP2018-2022 commissioned2017MAY – DECReview of NNAP doneidentifying lessons for newKNAP2016DECReview of NNAP 2012-2017 commissionedFigure 2: Snapshot of key milestone during development of KNAP 2018-2022KENYA NATIONAL NUTRITION ACTION PLAN 2018-20223

CHAPTER 2: KENYA NUTRITION SITUATIONANALYSIS2.1 IntroductionGlobally, malnutrition levels remain unacceptably high and is responsible for ill health thanany other cause. According to the Global Nutrition Report, 2018, it is estimated that thetotal cost of malnutrition is about 3.5 trillion USD per year globally.Trends in Stunting, Underweight and Wasting4035.335333330.33029.626% 1993KDHS(NCHS)KDHS 1998(NCHS)KDHS 2003(NCHS)Stunting2008 KDHS (NCHS)Underweight2008 KDHS (WHO)2014 KDHS (WHO)WastingFigure 3: Trends in stunting, underweight and Wasting 1998-2014Kenya is experiencing triple burdenof malnutrition characterized by thecoexistence of (i) undernutrition asmanifested by stunting, wasting,underweight;(ii)micronutrientdeficiencies; (iii) overweight and obesityincluding diet-related non-communicablediseases (DRNCD). Data from the KenyaHealth Demographic Survey (KDHS) 2014indicates that out of 7.22 million underfive children, nearly 1.9 million are stunted(26 per cent); 290,000 wasted (4 per cent);794,200 (11 per cent) underweight (Seefigure 3). Notwithstanding this, thereare notable geographical and socialdemographic variations in the severity ofmalnutrition in the country.Out of the 47 counties, 9 (19%) haveprevalence of stunting above 30%, a levelcategorized as “severe” and of public healthsignificance. Annual costs for malnutritionrelated to health, education and laborproductivity is estimated between 1.9 and16.5% GDP.The Kenya 2015 STEP wise Survey1confirmed an increasing rate ofMinistry of Health, Kenya, STEPwise Survey for Non-communicable Diseases Risk Factors, Nairobi, 201514KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022

overweight/obesity and diet-related non-communicable diseases (DRNCDs) in adults. Atotal of 28 per cent of adults aged 18–69 years were either overweight or obese, with theprevalence in women being 38.5 per cent and men 17.5 per cent. Similar trends are seenwhen comparing the 2008–2014 KDHS. The proportion of women who were overweightor obese increased from 25 per cent to 33 per cent and those who were obese increasedfrom 7 per cent to 10 per cent. The prevalence of overweight or obesity is higher in urbanareas (43 per cent) than in rural areas (26 per cent).According to the Kenya National Micronutrient Survey of 20112 considerable progressis being made in reducing the prevalence of micronutrient deficiencies, except for zincdeficiency. The prevalence of anaemia was highest in pregnant women (41.6 per cent),followed by children 6–59 months (26.3 per cent) and school–age children (5–14 years) at16.5 per cent. the prevalence of zinc deficiency was high across the population, averagingat about 70 per cent, with pre-school children being 81.6 per cent, school-age children79.0 per cent, pregnant women 67.9 per cent and non-pregnant women 79.9 per cent.Zinc is a vital trace element with many health benefits.3 Deficiency in children can lead togrowth impediments and an increased risk of infection.Notbreastfed1%k plusry foodsNotbreastfed1%Breastmilk pluscomplementary foods15%Percent5038Breastmilk pluswater, othermilk, or othernon-milk liquidsExclusivelybreastfed 23%61%09 KDHS 2014 KDHS57544123Exclusivelybreastfed61%2003 KDHS2008-09 KDHS 2014 KDHS13%32%61%Only 22%consume anacceptablediet5118IYCF 5: Minimum dietarydiversity*Source KDHS 2014Among breastfed childrenIYCF 6: Minimum mealfrequencyAmong non-breastfed children22IYCF 7: Minimum acceptabledietAmong all children 6-23 monthsKDHS 201461%*Source KDHS 2014Figure 4: Breastfeeding statusFigure 5: Status of complementary feedingAn analysis of feeding and care practices in Kenya shows that exclusive breastfeeding rateshave markedly improved from 32 per cent in 2008–9 to 61 per cent in 2014 as shown infigure 4. Timely introduction of appropriate, adequate, and safe complementary foods iscritical at six months when breast milk alone is no longer sufficient to meet the nutritionalrequirements. The 2014 KDHS found that 81 per cent of breastfed children aged 6–9months received complementary foods in addition to breastfeeding, indicating timelycomplementary feeding. However, only 22 per cent of children aged 6 to 23 monthsconsume a minimum acceptable diet, indicating a dire nutritional situation in this agegroup (see figure 5). Furthermore, 49 per cent of children aged 6 to 23 months do notMinistry of Health, Kenya National Micronutrient Survey, Nairobi, 20112Joseph Nordqvist, What are the health benefits of zinc?, NEWSLETTER Medical News Today, 2017. hp3KENYA NATIONAL NUTRITION ACTION PLAN 2018-20225

consume the minimum required number of meals per day, while 59 per cent do notconsume an adequately diversified diet indicating restriction in access to quality diets.4According to the 2015 STEP wise Survey, 95 per cent of adults aged 18–69 years did notconsume the WHO daily recommended five servings of fruits and/or vegetables; fruitswere consumed on average about 2.4 days in a week, and vegetables were consumed fivedays in a week.5 Approximately 20 per cent of adults in this group add salt or salty sauce totheir food before eating; 3.7 per cent consume processed foods high in salt; 83.5 per centoften add sugar when cooking or preparing beverages at home; and 28 per cent alwaysadd sugar to beverages. About 6.5 per cent do not engage in the WHO recommendedlevel of physical activity.62.2 Causes of malnutritionMalnutrition is caused by factors which are broadly categorized as immediate, underlyingand basic as shown in figure 6 below.MalnutritionInadequatedietary intakeHousehold foodinsecurityDiseaseInadequate careImmediate causes relating tothe level of ng causes relating tohouseholds and communitiesNutrition-sensitiveinterventionsBasic causes relating to thestructure and process of societiesGeneral developmentinterventionsUnhealthy householdenvironment and lackof health servicesIncome poverty: employment,self-employment, dwelling, assets,remittances, pensions, transfers etc.Lack of capital: financial, human,physical, social and naturalSocial, economic,and political contextFigure 6: Conceptual framework for malnutrition2.2.1 Immediate causes of malnutritionThe immediate causes include disease and inadequate food intake; this means thatdisease can affect nutrient intake and absorption, leading to malnutrition, while not takingsufficient quantities and the right quality of food can also lead to malnutrition.Ibid4Ministry of Health, Kenya, STEPwise Survey for Non-Communicable Diseases Risk Factors, Nairobi, 20155WHO, Global Recommendations for Physical Activity for Health, 201066KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022

2.2.2 Underlying Causes ofMalnutrition in Kenya2.2.3 Basic causes ofMalnutrition:The underlying causes are food insecurityincluding availability, economic accessand use of food; feeding and carepractices at individual, household andcommunity level; environment and accessto and use of health services (World HealthOrganization, & The World Bank, 2012).The basic causes of malnutrition which actat the enabling environment on macrolevel include issues such as knowledgeand education (literacy), politics andgovernance, leadership, infrastructureand financial resources. Significantchallenges face the country in relationto governance and resource allocation tosocial sectors and indeed development ingeneral limiting the sustainable reductionof malnutrition. Maternal education hasbeen seen to vary across regions and isa key determinant of child survival anddevelopment as intimated in the Kenyademographic health survey report of2014. The distribution of resources furtherpoints to equity challenges especially inthe most disadvantaged counties.Although trends in household foodsecurity (availability, accessibility andstability) have generally improved overthe last three decades in Kenya, foodinsecurity continues to persist due to thestagnation of agricultural production, lowuse of agricultural technology, high foodprices, frequent disasters and the effectsof climate change on the mainly rain-fedagriculture and a decline in resilienceof pastoral livelihoods, especially in theNorthern frontier counties. The foodsecurity situation is further affected byseasonality, with rapid deteriorationduring drought years resulting inemergency levels of acute malnutrition.The KDHS 2014 indicated that only 44.5per cent of households treated their waterusing an appropriate treatment method,however 54 per cent of households didnot treat their water before consumption.Approximately two thirds of Kenyans (66per cent) normally use non-improvedtoilet facilities. A handwashing stationwith soap and water was observed in only49.5 per cent of households. Poor accessto water and sanitation services are amajor factor for morbidity.WHO: Double-duty actions for nutrition. Policy Brief WHO/NMH/NHD/17.27In general nutrition specific interventionsaddress the immediate causes; nutritionsensitive interventions address theunderlying causes while enablingenvironment interventions deals withthe basic or root causes of malnutrition.Addressing all forms of malnutrition atall three levels of causation (immediate,underlying and basic) requires Triple-dutyactions that have the potential to improvenutrition outcomes across the spectrumof malnutrition, through integratedinitiatives, policies and programmes7. Thepotential for triple-duty actions emergesfrom the shared drivers behind differentforms of malnutrition, and from sharedplatforms that can be used to addressthese various forms. Examples of sharedplatforms for delivering triple-duty actionsinclude health systems, agricultureand food security systems, educationsystems, social protection systems,WASH systems and nutrition sensitivepolicies, strategies and programs.KENYA NATIONAL NUTRITION ACTION PLAN 2018-20227

CHAPTER 3: THE KENYA NUTRITION ACTIONPLAN DESIGN FRAMEWORK3.1 IntroductionThe Kenya National Nutrition Action Plan (KNAP) 2018-2022 is organized into threefocus areas: Nutrition-specific, Nutrition-sensitive and Enabling environment. Within thethree focus areas are a set of key results areas with corresponding outcomes, outputs,strategies, interventions and activities that are further costed and presented within animplementation matrix. A detailed monitoring, evaluation, accountability and learningframework (MEAL) that will be mutually tracked and reported on by all sectors responsiblefor the implementation of the KNAP was developed with set targets and a summary ofselect results and indicators (referred to as the Common Results and AccountabilityFramework (CRAF)) put in place to measure the progress in implementation of the resultareas. Further an institutional and legal framework and a risk mitigation plan is also includedto strengthen governance for the KNAP over the five-year period over which the KNAP willbe implemented.The development of the framework was further informed by a theory of change (figure8) which was a methodology that sought to link actions with each other to realize anintended result or outcome. The theory of change was useful in answering “the what,Figure 7: Theory of change8KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022

the how, when and result.” The theory ofchange was used to develop a set of resultareas such that if certain inputs were inplace, and certain activities implementedthen a set of results would be reali

KENYA NATIONAL NUTRITION ACTION PLAN 2018-2022 1 CHAPTER 1: OVERVIEW AND INTRODUCTION TO THE KNAP 2018-2022 1.1 Introduction The KNAP 2018 - 2022 is the second National Nutrition Action Plan that operationalizes the National Food and Nutrition Security Policy 2012 and its implementation framework (NFNSP-IF) 2017–2022.

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