Mid-term evaluation of Maternal and Child Nutrition Programme (MCNP II) in Kenya

As much there has been a 40% reduction in stunting among children under 5 years [1], according to the Global Nutrition Report of 2021, malnutrition persists in the under-fives. Close to 150 million are stunted, 45.4 million are wasted and 38.9 million are overweight [2, 1] Despite progress showing that 27% of 194 countries are on track to meet stunting goals, the world is off track to meeting five out of six global Maternal, Infant and Young Child Nutrition (MIYCN) targets; stunting, wasting, low birth weight, anaemia, and childhood overweight [2].

Kenya is classified as a low-middle-income country (LMIC) with a population of 47.5 M (males: 23.5 M; females: 24 M) with an under-five population of about 6 M (KNBS, 2019). In 2020, Kenya was on course to meet the Sustainable Development Goals (SDGs) for stunting, wasting, underweight and exclusive breastfeeding [3]. The stunting level reduced from 35.3% in 2008–2009 to 26% in 2014, while underweight and wasting prevalence reduced from 16.1% and 7% to 11% and 4%, respectively [4]. The policy environment in Kenya is aligned to achieve the SDGs. For instance, the current Medium-Term Plan [5] has mainstreamed the SDGs. Further, mainstreaming of SDGs in performance contracting, actions plans and sub-national County Integrated Development Plans (CIDPs), 2018 -2022, positioning Kenya to better implement the SDGs. The Government prioritized the “Big 4 Agenda” focusing on Food and Nutrition Security that accelerates SDG 2. Multi-stakeholder engagement forums such as Parliamentary Caucus on SDGs and Business, Kenya Private Sector Alliance and Council of Governors for the sub-national governments through the devolved government system that oversee the implementation and progress of SDGs as the conceptualization and implementation of interventions will be targeted to the local needs and constraints such as agro-ecological, socio-economic, and political variations. Kenya’s Beyond Zero campaign, aimed at eliminating all preventable maternal and child deaths by 2023 is also a key step towards achieving SDG 3 (good health and well-being including maternal and child health). Despite this progress, Kenya is still facing the triple burden of malnutrition characterized by the coexistence of undernutrition as manifested by wasting, underweight and stunting; micronutrient deficiencies; and overweight and obesity including diet-related noncommunicable diseases.

The Cost of Hunger study in 2019 estimates Kenya lost 6.9% of its Gross Domestic Product due to undernutrition [6]. Huge geographic disparities especially in the Arid and Semi-Arid Lands (ASAL) regions exist and are associated with the inequitable allocation of resources, chronic poverty, and cyclical emergencies. As a result of these repeated crises and limited capacities to absorb shocks, children in the ASAL areas experience multiple deprivations of their rights to health, adequate food and nutrition, and safe water amongst others—and remain disadvantaged compared to the rest of Kenya. Stunting prevalence remains very high (above 30%) in West Pokot, Kitui, Kilifi, Narok, Samburu, Mandera, Uasin Gishu, Bomet and Tharaka Nithi [4, 7].

Women’s micronutrient status and dietary diversity in the ASAL areas are poorer as compared to other regions in Kenya, and this situation has had minimal changes in the last two decades [8] Since the total government budget allocation to health increased from 7% in the financial year (FY) 2017/18 to 9.2% in FY 2018/19 [9], a gradual progression towards the Abuja Declaration target of 15% for Kenya, the nutrition sector stands to benefit from the devolution.

Despite such progress in the overall health sector funding, the nutrition sector remains grossly underfunded. Counties’ expenditure on nutrition is about 0.8% of the total county budgets which is inadequate for the nutrition sector needs in the counties.

This midterm evaluation was undertaken after two years of MCNP II implementation and aimed to evaluate the relevance, effectiveness, efficiency, and sustainability of MCNP II based on the Organization for Economic Cooperation – Development Assistance Committee/United Nations Evaluation Group [10] criteria. The evaluation also identified key successes and lessons learned and covered aspects of gender, human rights, and equity sensitivity of the program.

The evaluation was executed using a non-experimental concurrent mixed method approach. The quantitative data on key indicators from the programme’s result framework were collected through a desk review of programme reports and relevant documents detailed under the data collection section.

Further, The Theory of Change Additional file 1: Annex 1 was used as a guide for the logical relationships between strategies, activities, and the results chain. Before the evaluation, a comprehensive review of processes and approaches was undertaken to understand the strengths and gaps in programme implementation and complement the evaluation findings.

The [10] evaluation matrix used included key evaluation questions, sub-questions (probes), primary and secondary key indicators and data sources.

The MCNP II program was identified as an important programme aligned with the Kenya nutrition situation and priorities and the relevant policy frameworks of the Government of Kenya. Although slightly different focus, the study by Masters et al. (2017) [27] to fill evidence gaps about the costs and impacts of nutrition-sensitive interventions relied on consultations for priority setting to ensure accuracy and relevance for policymaking, similar to the significance of MCNP II to the government [15, 11, 28, 19].

MCNP II was designed to address the geographic inequities, given its focus on the arid, semi-arid counties and urban informal settlements. Imwati and Harrison (2019) using secondary data from the 2014 Kenya Demographic and Health Survey [29] modelled various causal factors of malnutrition in ASAL areas of North Rift Kenya. The duo’s results indicated that geographical factors such as temperature, enhanced vegetation Index, Illiteracy and drinking water sources had an association with malnutrition whereas the highest association was between emperature and malnutrition. Therefore, the selection of ASAL for the MCNP II implementation where the programme objectives and plans and resource allocation were aligned to the specific county needs based on priority setting exercises was timely, thus, addressing the geographic inequities.

The strategic approaches of MCNP II were aligned to the gender equality and human rights policies and conventions community feedback mechanisms by males and females from vulnerable communities ensured community participation. Other studies have also highlighted the central role of gender in nutrition. A study by Muraya et al. [30] stated that gender dynamics is one of the key social determinants of maternal and children’s nutrition status and is a key contributory factor to poor nutrition [31]. According to the Consultative Group on International Agricultural Research (CGIAR), gender transformative approaches orient the need to move away from burdening women with the responsibility for equality and engage men and women together as agents of change [32]. MCNP II was uniquely positioned by involving both women and men in gender-based discussions. The involvement of fathers has been shown to improve relationships with wives and fathers can become more involved in sharing responsibilities with their wives despite going against traditional norms [33].

However, the programme can be further strengthened by adopting a more gender transformative approach. Further, the programme can enhance its coherence and relevance to these strategies by expanding its scope to areas such as non-communicable diseases and adopting a lifecycle approach to include middle age childhood.

MCNP II was effective across all the four planned output areas of supply, demand, enabling environment and emergencies. By mid of the programme, the planned targets had been achieved for all the MCNP II indicators, except, the number of admissions for severe acute malnutrition in the year 2020, which was affected by the COVID-19 pandemic due to reduced hospital visits [34].

The programme moderately achieved cost-effectiveness and value for money during the first half of the programme. A systematic review by Njuguna et al. [35] found that most costs of the nutrition programs were on personnel and therapeutic feeds. The engagement of community health workers was found to be cost-effective in the treatment of uncomplicated SAM. According to Wilfold (2017) [36] and Njuguna et al. [35], the integration of outpatient and inpatient care of undernourished children through the CMAM program is cost-effective [36]. MCNP II explored integrated programming through its cross-sectoral initiatives and diversified partnerships. This is supported by a study by Levin et al. [37] and Abdulahi et al. [38] highlighted that multi-sectoral nutrition programmes should explore integration into routine services for economies of scale to lower costs. Similarly, MCNP II made efforts toward health systems strengthening through integrated approaches at the community level.

Despite the stringent financial cash flow management and strong monitoring strategies being adopted the optimal utilization of resources was yet to be achieved by the midterm. Resource allocation was based on priority setting exercises and comprehensive situational analysis where MCNP II adopted partnership modalities that contributed towards enhancing programme efficiencies that led to improved efficiencies and cost savings.

The gains achieved in MCNP II have been sustained across two years for all programme results. The programme has contributed to the devolution process by influencing policy, budgeting, planning and monitoring and supporting capacity development. The NSO approach at the counties was instrumental towards the achievement of results for HiNi and critical to building the capacities of the county level staff, mobilising resources, engage with leadership at the county level to advocate and direct their focus on specific areas of nutrition and support multi-sectoral coordination,

The programme provided opportunities for integrated programming with health, Water Sanitation and Hygiene (WASH), livestock and agriculture, education, child protection and social protection sectors through the scale-up of NICHE and SanNut initiatives. Prior evidence from research suggests that combined interventions for improving nutrition and sanitation practices could reduce mortality among children under five years by 15% [22, 23]. The integration helped to reduce implementation costs and scale up the combined programme at a more accelerated pace.

To strengthen systems, MCNP II focused on building local capacities and enhancing local ownership. These findings agree with other similar systems strengthening projects aimed at improving the nutrition and health of pregnant women and newborns in Kenya. According to Kung’u et al. [39], key approaches for systems strengthening include building commitment, coherence, accountability, capacity, and leadership by community sensitization and early dialogue and engagement of political and community leaders as part of stakeholder dialogue and agreement on common results' framework;

However, MCNP II lacks a formal transition strategy and hence, there is a need to develop one. While formulating the transition strategy, it will be imperative to undertake a phased approach to ensure that the process is gradual and progressive. According to FAO [40] several strategies are recommended to allow for programme transitions and ensure sustainability. There is a need to consider institutionalization of components of the programme into selected relevant sectoral activities. The nutrition activities must be included in the budgets and plans of nutrition-sensitive sectors. There is a need to assess programme resources and accordingly, plan for handover to the local governments through a consultative process including community participation to allow for institutionalization and ownership. The county government’s commitment and buy-in, especially for human resource development are crucial. Notably, Inadequate funding for emergency response due to challenges in mainstreaming the EDE has led to, delays in scaling up the IMAM surge.

Though MCNP II is made efforts to secure buy-ins from donors, there is a need to diversify partnerships. However, there is also an indication from the traditional UNICEF donors of declining support as a factor of COVID 19 impact. This calls for the need to rapidly enhance engagement with actors like the private sector to further diversify the funding basket. Similarly, there is recognition that as donor support declines, there should be a progressive increase in investment by the government. This informs the continued advocacy efforts with national and county governments to enhance public financing for nutrition.

To conclude, the programme is moving in the right direction for all four evaluation criteria of REES. The findings highlighted areas that have worked well for MCNP II and have potential implications for the overall nutrition sector and other programmes. Relevance and coherence to the community and other stakeholders’ needs and the alignment to the government priorities and existing structures are key enablers for programme success. Further, gender sensitivity is critical for nutrition programming including the involvement of males and community peer support groups. MCNP II demonstrated synergies between sectors for cross-sectoral and multi-sectoral initiatives and the cost-effectiveness of Integrated service delivery approaches and innovations. The direct implementation approach worked well in terms of enhancing the county leadership, ownership and accountability. Technical and donor agencies should move towards a more enabling role and promote local capacity development for programme success. There is a need to strengthen public–private partnerships to enhance results for children. The programme has also demonstrated a successful example of public–private partnerships through the Baby Friendly Community Initiative (BFCI). However, there are larger sectoral challenges and gaps in the programme that need mitigation. As MCNP II comes to an end, there is a need to develop a transition strategy through a consultative process with all relevant stakeholders including community participation. The transition strategy can focus on areas that have worked well. In collaboration with the counties, It will be beneficial to develop resource mobilization plans that explore opportunities for multi-year funding and emerging donors while encouraging the inclusion of critical nutrition costs in the national and county budgets. There are still gaps that UNICEF can support and provide technical assistance, such as capacity development, financial planning and nutrition governance and multi-sectoral coordination mechanisms including the need to operationalize the Food and Nutrition Security (FNS) Council through sustained advocacy. Efforts should be made to achieve a more gender transformative role through systematic and sustained initiatives around gender sensitization and improving awareness that can translate into practices. There is also a need to strengthen UN guided approach of ‘Delivering as One’. The Nutrition section should  explore more inter-agency collaboration opportunities for improved nutrition outcomes and peer-to-peer learning from other UNICEF-supported programmes in Kenya.