MCNP II programme initiatives
Through key informant interviews with the programme implementers and in consultation with the MCNP II programme documents and reports, the Program activities included upstream support to key stakeholders to provide a positive enabling environment through advocacy, evidence generation, policy support, and resource leveraging. The programme supported the establishment of multi-sectoral platforms creating an environment for coordinated collaboration across the sectors of health, education, WASH, social protection, implementing partners, and the private sector. Besides governance, the programme further supported joint evidence-based planning and budgeting, service delivery monitoring and evaluation, policy change where appropriate, and emergency preparedness and response.
Through C4D, the significant role of men in balancing gender inequalities were ensured by the inclusion of men in the C4D strategies. The father-to-father support groups were formed to facilitate positive behavioural change in feeding practices and to champion the importance to seek services in health facilities. Based on positive findings of the SanNut study in the previous country programme where collaborations with the WASH sector to scale up and strengthen nutrition messaging and counselling in the Community Led Total Sanitation (CLTS) programme were scaled up under MCNP II.
The MCNP II integrated nutrition counselling into cash transfer programmes at scale to promote nutrition-centric responsive safety nets. Building upon the findings of studies conducted in the previous country programme of 2018, the programme explored and advocated for enhanced linkages with agencies focusing on agriculture and livestock regarding food production and increased access to availability and sustainability of appropriate nutritious local foods for young children throughout the year to ensure household resilience and value addition for sustained access to milk for young children throughout the year.
Community-level nutrition service delivery through the Community Health Strategy (CHS), including the Baby Friendly Community Initiative (BFCI), integrated packages of services for children and women of reproductive age, focusing on health, nutrition, WASH, and HIV services were scaled up to ensure that the pathway between improved awareness and enhanced health-seeking behaviour were not hindered by limited access to services.
Relevance, Efficiency, effectiveness, and Sustainability (REES)
Maternal and Child Nutrition Programme II is part of the United Nations Sustainable Development Cooperation Framework (UNSDCF) 2018–2022 [11], the programme evaluation was undertaken in line with the Organization for Economic Cooperation – Development Assistance Committee/United Nations Evaluation Group [10] criteria. The findings are presented under the four evaluation criteria – relevance, effectiveness, efficiency, and sustainability (REES).
Relevance
Interactive discussions with stakeholders confirmed that MCNP II was relevant and aligned to the nutrition situation in Kenya; the government and UNICEF priorities, UNICEF global and regional strategies, and considered gender, equity, human and child rights perspectives.
MCNP II program design was based on a comprehensive analysis of the nutrition situation in Kenya. An analysis of the Kenya nutrition situation identified demand, supply, enabling environment and emergencies as key bottlenecks and barriers to achieving optimal nutrition for children under five and women. This informed the choice of interventions and programme focus counties for MNCP II. The ASAL counties which are prone to high levels of acute malnutrition among children under five years of age were prioritized. Further, the identified bottlenecks informed the program theory of change and alignment of program strategies to achieve the desired results.
The MCNP II result framework was found to be aligned with key Government and Ministry of Health policies including Vision 2030, Medium-Term Plan (MTP) [5], the Kenya Health Sector Strategic and Investment Plan (KHSSIP) 2014–2018 [12], Big 4 agenda [13], Food and Nutrition Security Policy (FNSP) [14] and Kenya Nutrition Action Plan (KNAP) [15]. The Programme is aligned to the social pillar of Vision 2030 on social protection, strengthening the supply chain through the Kenya Medical Supplies Agency (KEMSA) and scaling up community strategy for nutrition. Importantly the program focus on the reduction of maternal and child mortality, an objective of MTP III. While under the KHSSIP, the programme supports the objectives of reduction of mortality, the burden of malnutrition and micronutrient deficiencies, among others. Further, the program is coherent with almost all the key result areas of the KNAP.
MCNP II was aligned with the UNICEF’s Global Nutrition Strategy (2020–2030) [16] strategy that focuses on maternal and child nutrition targeting to reduce stunting [11] and builds on the UNICEF Strategic Plan, 2018–2021, and the 2016 Concluding Observations of the Committee on the Rights of the Child in Kenya. Although the program is largely aligned to these strategies, there are some areas beyond the program coverage, for instance, the burden of overnutrition and obesity; and the adoption of a lifecycle approach covering middle age childhood and elderly.
Donors reported their satisfaction as the programme’s strategic priorities were aligned to their priority focus areas such as systems strengthening and cross-sectoral integration, risk-informed programming and resilience building for nutrition emergencies as well as prioritization of ASAL counties for nutrition-specific and nutrition-sensitive programming.
All 13 target counties implemented community feedback mechanisms, including community dialogues, feedback boxes in health facilities, and other feedback processes to inform program improvements. A reconnaissance with community discussions showed that community members acknowledged the feedback mechanism and community involvement in the programme and made efforts towards gender mainstreaming, citing increased male involvement and father support groups that had been established were effective in garnering spousal support to use health services as detailed in the quotes below.
“They talk about pregnant mothers, children under five, and old age. Then as to whether such a facility is stocked with medicines or not, the community themselves sit down and get involved so they can find out. When my wife is pregnant, I take her to the clinic, she gives birth at the maternity clinic, a month later. If she is sick, I will take her to the hospital, they will bring her back to good health.” – FGD Participant (Male)
“Exactly. Mother-to-mother support. They meet to exchange ideas and support each other. At the end of the day mothers in the mother-to-mother support group are better off compared with those tucked up in the villages. Something else I want to say as a chief of this community is that this community is very vulnerable, and it is facing a lot of challenges. Despite the availability of a hospital, not everyone can get to the hospital and the available CHVs cannot manage to reach to help in every household.” – Community Leader
Gender, equity, and human rights perspectives
Were found to be relevant aligned to the gender equality and human rights policies including session paper No 2 0f 2019 on National Policy on Gender and Development [17] under the Kenya Vision 2030 [18], Convention on Rights of the Child (CRC), [19, 20]. Convention on the elimination of all forms of discrimination against women (CEDAW) [21] as well as human rights of persons with disabilities. Key informants noted that the sex and age disaggregated data is being collected in the Standardized Monitoring and Assessment of Relief and Transitions (SMART) survey. Similarly, gender roles and maternal workload were captured through qualitative ‘Knowledge, Attitude, Behavior, Practice’ (KABP) surveys creating the opportunity for gender sensitization on the reduction of maternal workload to enhance nutrition outcomes in the communities. However, a systematic approach needs to be adopted to include women in programme design and conduct gender-based discussions [22, 23, 17,18,19,20,21].
Effectiveness
Effectiveness relates to the utilization of resources to achieve the intended results. For the MCNP programme the effectiveness was identified on MCNP programme approaches used, advocacy, and value for money for cost-effectiveness. Table 1 provides a comparative analysis between the planned and achieved targets for the 13 focus ASAL counties except for admissions of children with SAM in 2020 and the proportion of facilities that offered SAM services in 2018 and 2020. In 2020, the sector had a SAM target expectation of 88,451 admissions, However, a lower target of 63,443 SAM admissions was achieved through MCNP II.
In 2018, 5 out of 13 counties were implementing plans to improve dietary diversity in children. However, in 2019 and 2020, the planned results were achieved for all 13 counties. In 2018, 7 counties had the existence of a functional national multisectoral committee for nutrition, however, this number rose to 10 counties in 2019 and in 2020, 12 out of 13 counties achieved this result. In 2019 and 2020, all 13 counties have had an existence of emergency preparedness plan for nutrition.
MCNP II programme approaches and innovations
The effectiveness of the programme was associated with the service delivery approaches and innovations, use of technology and tools and alignment to government priorities as key enablers that facilitated the achievement of planned results., Malezi Bora, the child health week was used as an opportunity to reach beneficiaries for health and nutrition services including vitamin A supplementation; the family Mid-arm upper circumference (Family MUAC) for screening of malnutrition at home and self-referrals, integrated Community Management of Acute Malnutrition (ICMAM) are the service delivery models and innovations under the program. Similarly, the use of technology facilitated efficient supply chain management and improved tracking of budget expenditure. The introduction of the Logistic Management Information System (LMIS) to manage the supply chain of essential nutrition commodities contributed to achievements in zero RUTF stock-out rates in the 13 target counties; the Nutrition Financial Tracking Tool (NFTT) was critical for adequate budget allocation and tracking expenditure for nutrition sector and Rapid Pro SMS platform was leveraged for outreach and social behaviour change communication activities.
Key informants also noted that MCNP II established community peer support groups for cascading nutrition knowledge from health workers to the community. CHVs were instrumental in nutrition counselling, supporting community-facility referrals and providing support at the health facilities. Data from the focus group discussions indicated that community members perceived the provision of micronutrient supplements and nutrition counselling effective in improving service delivery. These thoughts are elaborated in the following quotes:
“…But after sensitization, the targeted mothers now know that they need to breastfeed a child for 6 months, and then introduce other foods. Also, they were not buying fruits for children, they would only give ugali with potato soup, in the morning, for lunch and dinner times. But nowadays they give fruits—the local fruits, what is available here” – HCW.
“….the community members are no longer afraid to seek medical attention, they do not fear bringing children, they have really changed” – Community Leader.
“The community members air their problems through CHVs or Traditional Birth Attendants (TBAs); the TBA will bring their issues to the hospital and take the feedback to the community. Then the CHV will talk to the CHEW, who will talk to the In-charge. Then he will give the information to the CHEW, then disseminate it to the CHV then she takes it to the households.” – FGD Participant [24].
Advocacy
The programme fairly fulfilled its role to advocate for women and child nutrition rights through upstream advocacy. Advocacy led to the inclusion of more nutrition activities in county annual work plans and county integrated development plans (CIDPs) for all 13 counties. MCNP II led to the development of women and children-sensitive policies and frameworks. Advocacy efforts led to securing nutrition-specific funding in the programme-based budgets (PBB). The counties of Kilifi, Wajir, Turkana, Baringo, and Samburu, now receive nutrition-specific budgets under the PBB. Further, the programme contributed to the development of terms of references (ToRs) for the multi-stakeholder platforms (MSPs), critical for cross-sectoral advocacy at the sub-national level and coordination with the national level. MSPs were functional in 12 counties, except in Kitui.
Cost-effectiveness of implementation and value for money
Cost-minimization approaches under the programme included Training of the trainers (ToT) trainers who then cascaded the learnings to the sub-counties, reducing the cost for training all sub-county and facility level staff. On-the-Job Trainings (OJT) enabled the programme to directly reach out to the trainees (healthcare workers/facility staff) while reducing logistical costs for training. Integration of nutrition in health outreaches also emerged as a key approach to reducing costs for vertical service delivery.
To reduce the operational and overhead costs, the Value for Money (VfM) policy was leveraged under the Programme Cooperation Agreement (PCA) arrangements with the implementing partners. Before the introduction of the Value for Money (VfM) policy, implementing partners were supporting costs at about 25% of the program costs; however, with the introduction of VFM, IPs’ contribution increased. Similarly, the cost of doing business with implementing partners is reduced. Notably, UNICEF’s contribution to overhead costs was reduced, by about 12–23%. Out of the 15 implementing partners contracted from September 2018, 5 partners contributed more than 25% to the direct program costs and 10 partners contributed at least 15%, as recommended by UNICEF. To achieve value for money, implementing partner overhead ratio should be below 25%. Thus, overall, the value for money and cost-effectiveness of program implementation was moderately achieved, by the time of mid-term evaluation.
Efficiency
Efficiency was associated with the demand and supply of nutrition commodities and supplies, stringent financial management strategies, partnership modalities and cross-sectoral integration.
Table 2 presents a comparative analysis of expenditure ratio, the amount of budget utilized in proportion to the allocated budget. The ideal expenditure ratio should be 100%. For the MCNP II, on one hand, the expenditure ratio was over 100% for the years 2018 and 2019 while on the other hand, it was about 70% for the year 2020.
The utilization of the allocated budget for demand outputs was consistently lower from 2018 to 2020, The supply outputs on the hand, the expenditure was higher than the allocated budget in the first two years of the programme (2018 and 2019) while in 2020, about 0.4% of the total budget was utilized for the supply related programme activities. This was attributed to the reduced funding following the seizure of FCDO’s support in June 2020, and the redirection of funds towards the COVID-19 response. In the first year of the programme’s inception (2018), the expenditure toward output 3 was higher than the allocated budget due to increased efforts toward creating an enabling environment. However, in both 2019 and 2020, the budget was underutilized. unlike output 3, the risk-informed programming budget was underutilized with only about 3% used in the first year of MCNP II inception. However, an improvement was noted in the subsequent years where a higher expenditure in 2019 than the allocated budget was observed. This was attributed to the programme adjustments and shifting priorities during the 2019 drought and the COVID-19 pandemic in 2020.
Nutrition commodities and supplies
Table 3 highlights the planned v/s actual distribution of RUTF under MCNP II. The higher than planned distribution of RUTF supplies for the years 2018 and 2019, were attributed to the evolving demands and nutrition needs of the counties during the programme implementation. Situations like droughts, floods and other nutrition emergencies lead to worsening nutrition situations and increased requirements for RUTF. However, distribution was reduced in, 2020 due to COVID-19.
As shown in Table 4, in 2018, the counties of Baringo, Wajir, West Pokot, Garissa, Marsabit, Kitui, Kilifi, Kwale, Mandera, Tana River and Turkana, distributed more RUTF than the planned threshold of 100%. While in 2019 counties of Kilifi and Tana River. In 2020, Isiolo, Mandera, Wajir and Garissa, had less than 50% RUTF distributed.
Financial management strategies [25]
The Harmonized Approach to Cash Transfers (HACT) approach supported risk management with a focus on reducing transaction costs associated with programme implementation by harmonizing procedures as well as promoting reporting on funds that were disbursed. The funding requests were managed through Funding Authorization and Certificate of Expenditure (FACE), which required authorization from the programme managers before funding allocations. MCNP II adopted appropriate financial management procedures and approaches that collectively contributed toward bringing cost savings and efficiencies.
Partnership modalities
The United Nations Office for Project Services (UNOPS) a partnership modality for engaging with other UN entities provided infrastructure, procurement and project management services for UNICEF to implement program activities and achieve results. Nutrition Support Officers (NSOs) were recruited through UNOPS financially and technically supported by UNICEF. NSOs were embedded in selected ASAL counties for the provision and scale-up of nutrition services, working closely with the GoK County Nutrition Coordinators (CNCs). Quantitative data revealed that engaging NSOs helped UNOPS to reduce its budget from US$4,578,433 to US$3,585,516 translating into savings of US$992,917 while achieving the same results. Importantly, the government contributed towards the programme costs through matching of funds. A total of $250 k (KES 26 M) was obtained from the Government of Kenya. The Counties of Garissa, Marsabit, Turkana, Wajir and West Pokot contributed finances for nutrition SMART surveys in 2018 and 2019. However, there is a need to enhance private sector involvement in programme planning and monitoring and evaluation. For instance, the partnership with the Kenya Private Sector Alliance (KEPSA) on the ‘Building Business Practices for Children’ Partnership, a tripartite partnership between the county government, Unilever and UNICEF to scale Baby Friendly Community Initiative (BFCI) models across industries is one of the key examples of private sector involvement to improve quality, coordination and efficiency.
Cross-sectoral integration
The four thematic/result areas of demand, supply, enabling environment and risk-informed/shock responsive programming focus of MCNP II, have provided opportunities for integration and cross-sectoral programming with health, WASH, livestock and agriculture, education, child protection and social protection sectors as outlined in Table 5. The project bolstered the existing community sanitation initiative with a set of nutrition behaviour-change messages targeted at caregivers of young children. Evaluation of the project found that it improved families’ sanitation practices and nutrition knowledge [23] without adversely affecting other sanitation components, UNICEF scaled the integrated sanitation and nutrition programme to the second county in Kenya, West Pokot. In addition, implementation of the combined programme helped to reduce implementation costs and scale up at a more accelerated pace.
Sustainability
As part of REES, Sustainability assessed to what extent the achievements that had been made over the first half of the programme were likely to continue even when UNICEF support for key programme areas gradually reduced. The programme review provided an insight into decentralization of processes and services, the policy environment for nutrition for children, development and integration of plans and nutrition activities at the county level and system strengthening including capacity building of national and county staff with risk programming and disaster reduction approaches.
The decentralization of processes and services to counties through the new constitution 2010, governance structure in the year 2013/2014, saw health functions devolved to the county governments. To ensure the sustainability of the provision of nutrition services at national and county levels, the MCNP II programme supported the following initiatives.
Capacity building
Through capacity building, UNICEF trained national and county-level staff on Nutrition Financial Tracking Tool(NFTT) to address limited capacities to formulate budgets and financial plans and to improve skills in budget analysis, track expenditures and develop county budget briefs for advocacy and resource mobilization. Additionally, GOK personnel at the two levels of government were trained in the Logistic Information Management System (LMIS) for nutrition commodities to impart them with requisite knowledge and skills to forecast, request and monitor consumption of nutrition commodities at county-level. Under MCNP II, 10 out of 13 counties in ASAL regions were supported with capacity assessment and nutrition financial tracking respectively.
Nutrition action and county integrated development plans
The programme further supported the development of plans including the National Nutrition Action Plan and County-specific Nutrition Action Plans to provide roadmaps for implementation of both nutrition-specific and sensitive interventions at the national and county-level respectively. All the ASAL counties developed county-specific nutrition action plans anchored on the national action plan. County-level leadership were engaged in the development of child-friendly legislation including Community Health Services Bills.
System readiness assessments and strengthening
The Programme supported the development of the Nutrition Programme Maturity Analysis (NPMA) model that enabled the definition and measurement of the level of nutrition programme maturity across the 13 target counties implementing MCNPII. Assessment of system readiness using the NPMA model showed great improvements across the 13 counties between 2018 and 2020. These assessments checked counties’ readiness and self-sufficiency to gradually take up, finance and implement nutrition programmes using domestic financing. Based on the assessment, significant improvements were observed between 2018 and 2020 across each of the MCNP II counties, showing that most of the counties were on a journey to optimize programme maturity aimed at ensuring increased transition to county-led programme implementation integrated programming and cross-sectoral linkages were enhanced through support to establish or strengthen existing multisectoral technical County Nutrition Technical Forums along with the TORs in 9 out of 13 focus ASAL counties)\. However, the functionality of these forums largely depended on donor funding, hence there is a need for more domestic financing to ensure their sustainability beyond the MCNP II.
“UNICEF has been one of our greatest supporters in terms of running the structures in nutrition, especially the convening of nutrition inter-agency coordinating meetings which are cross-sectoral. Also, the nutrition technical forum. Therefore, these are the platforms where the interventions followed by other sectors are brought to the fore. And, we have even been able to strengthen one in agriculture called food and nutrition linkage technical working group which is also now bringing together the nutrition-sensitive players in the food security and nutrition arena”-Respondent, MoH DND.
Despite these initiatives, there are challenges such as sectoral mandates and competing priorities that hamper adequate funding allocation and implementation of nutrition interventions in the sectors. These sectoral challenges have implications for the MCNP II [23].
Direct implementation modality
The programme engaged national and county governments to promote ownership of programme implementation and outcomes by adopting the direct implementation modality (where the Government entity as opposed to Civil Society Organizations and non-government organizations implement components of the programme directly through PCAs. The use of community peer support groups played a crucial role in strengthening and empowering community capacities through increased knowledge around nutrition and activities such as kitchen gardens for sustainability. However, the community also noted that it is important to develop community resource persons to sustain knowledge at the community level.
“…. of these groups up to now even without the support, they are continuing with support from the link facilities. So, some of the interventions are still there, they are sustainable– the mothers there are supporting one another. And the level of awareness I feel and I think though is improving. I have not done an assessment, but you know, you can tell – you are living in this community, I can say that our mothers with the different interventions which have been done geared towards nutrition, there is some level of improvement in terms of knowledge” – Respondent, CHV.
Risk-informed programming and emergency preparedness
Notably, to ensure the sustainability of risk-informed programming and disaster risk reduction approaches, the MCNPII programme supported the development of child-sensitive bi-annual emergency preparedness response plans driven by robust information and surveillance systems at the national and county level.
MCNP II aligned its approaches and contributed to EDE in the ASALs and the Ending Drought Emergencies Country Programme Framework (EDE-CPF) pillars, particularly the Human Capital Pillar, where nutrition and health facilitated GoK’s commitment to end drought emergencies.
In addition, the programme supported the integration of essential nutrition commodities including ready-to-use therapeutic feeds (RUTF) into the GOK supply chain management system as well as scaled-up innovative approaches such as IMAM surge. Currently, 63% of the health facilities are implementing the IMAM surge model. Through MCNP II, the capacity of GoK personnel was strengthened to conduct a bi-annual food security assessment.
Under the MCNP II, UNICEF supported the MOH to develop a business continuity plan for nutrition services within the context of the COVID-19 pandemic and nutrition surveillance and information guidelines.
“Yes, the government through the ministry of livestock, through the ministry of registration, the office of internal security usually warns us about floods, so that we can move because we will get problems.” – Community Leader.
However, some challenges were noted that may affect the sustainability of the implementation of risk-informed programming and DRR approaches. These included: (1) weak multi-sectoral coordination system (2) inadequate adoption of EDE by other line ministries and stakeholders (3) inadequate mainstreaming of EDE into county integrated development plans (4) inadequate financing of innovative approaches for risk-informed programming such as IMAM surge that limited the scope and scale of coverage.
Resource mobilization and transition strategy
UNICEF used a two-pronged approach in resource mobilization through internal and external mechanisms. The key donors for the MCNP II included USAID and UKAID-DFID/FCDO, EU, ECHO, and World Bank. UNICEF has over the last few years successfully implemented multi-year grants which offer flexibility in terms of programming in nutrition.
Figure 2 gives an overview of the funding contribution by different donors and internal resource mobilization by UNICEF (2018–2020) [26].
Percentage contribution to funds by donors and UNICEF (Information Source: MCNP II database 2018–2020)
Lessons learned
The inclusion of males and females in nutrition programming and initiatives such as community peer support groups is gender transformative and has a positive impact on nutrition outcomes that can be scaled up and applied to other nutrition programmes.
The influence on the policy landscape and national and county resource commitment and allocation to nutrition is highly dependent on sustained advocacy for the nutrition sector priorities and needs to be adequately supported for the achievement of intended outcomes.
Cross-sectoral programming such as multisectoral Nutrition Action Plan, multisectoral coordination and multisectoral interventions such as Nutrition Improvements through Health and Education have demonstrated synergies between sectors that have proven effectiveness and efficiency in programming.
Nutrition innovations and approaches such as family MUAC, IMAM surge model, NFTT and NPMA and adaptation strategies contributed to the realization of intended results and provide learnings for other programmes.
Integrated service delivery approaches and innovations such as Malezi Bora, Training of Trainers and On the Job Training are cost-effective for improving service delivery and access.
Leveraging on strategic partnerships with the local CSOs and enhancing community capacity through community peer support groups, use of Community Health Volunteers (CHVs) and community feedback mechanisms were some of the other to enhance local capacity, ownership, and sustainability.
Direct implementation approaches as a health system strengthening strategy to reinforce county leadership, ownership and accountability should be emulated in programme sustainability.