Tuesday, 8 December 2015

A rare case of policy success? How Kenya’s nutrition sector is on course to meet global targets

During my first term at the University of York one of the issues we discussed during weekly online discussions with students from around the globe was policy failure. It was interesting how frequent it seemed that public systems didn’t live up to citizens’ expectations, no matter which part of the world we were writing from. Policy success appeared as rather elusive.

It therefore is a pleasant surprise to sing to a slightly different tune and consider a more positive trend with regards to the nutrition sector of Kenya’s Ministry of Health. In 2012, the World Health Organisation (WHO) developed a set of 6 targets that were deemed by member states as essential to comprehensively address the main nutrition concerns to be attained by 2025. Through the annual tracking of these targets, the 2015 Global nutrition report showed Kenya as the only country on track to meet all six targets. So, what can explain this positive trend in Kenya’s nutrition sector, what could we learn from it about public policy success?

Before delving into this, it is important to highlight just how complex nutrition issues can be. Malnutrition may appear simply as a food deficit and should hence easily be resolved by providing enough food to the people who lack it, when they need it. But nutrition issues are far more complex than that:

Primarily, nutrition is an outcome, not just of the food ingested, but of how the body handles it – meaning a person with illness, for example a child with diarrhoea, is likely to have a poorer nutrition status compared to a child without, even with equal food intake. Secondarily, complex dynamics affect when and how a child is fed and cared for, such as: the mother’s access to information and education; access to health services; hygiene and sanitation practices and food availability. On a tertiary level these outcomes are again affected by broader state issues: how does the culture perceive a woman’s education – is it encouraged? Does a government prioritise healthcare and facilitate optimal coverage of health services? What about policies that support livelihoods and enable communities to absorb shocks from volatile markets? And of course, there is the issue of political stability.

These factors affect the nutrition situation in complex ways, and to varying degrees. The challenge of sound nutrition policy is being able to address these diverse complex issues appropriately, and all the while in a rapidly changing environment. The interventions required to relevantly address nutrition problems require an understanding of the broader issues’ contribution to nutrition so that these issues are addressed from the three levels previously expounded, and not just at outcome level.

While many little things built up to contribute to the nutrition sector’s success, the overarching one could be strategic positioning. From 2010-2012, the Kenyan government’s nutrition sector together with nutrition-focused UN bodies and non-governmental organisations aligned all nutrition actions and strategies within one global strategy called the scaling up nutrition movement. This led to well-coordinated actions and a harmonised approach that influenced a compelling vision for change. With all actors speaking with one voice, the experience, capacity and opportunities of agencies were amplified.

The sector then sought to address the legal and policy arenas that would provide institutional legitimacy to bring on board influential actors. For example an article on the right to basic nutrition was enshrined in Kenya’s constitution. The sector also developed two guiding policies: a budgeted national nutrition action plan under control of the Ministry of Health that expounded 11 strategic objectives to be adopted and contextualised to devolved counties; and the Kenya Food and Nutrition Security Policy that was developed as a platform to engage ministries that are complementary to nutrition such as education, agriculture and food industries. These two policies are deemed to direct and streamline actions from allied agencies by highlighting government priorities.

This streamlining of actions meant two things: First, at the organisational level, agencies executing a nutrition mandate (local or international) adopted government priorities for nutrition as their priorities. Thus, an agency’s implementation plan was not guided by its resources and the organisation’s priorities but in line with the government’s priorities. Secondly, at implementation level, this reduced the redundant duplication of actors’ efforts as roles were clarified and mapped in line with the harmonised policy. Coupled with a cohesive coordination mechanism, agencies and actors regularly appraised their actions, processes and outcomes against the common sector plan, to adjust off-course actions and reinforce the on-course ones. This gradually led to the identification of actions that were appropriate for a scale-up of nutrition services with the government taking lead in the execution of the services.

So what’s next for Kenya’s nutrition sector? For one, a cautious approach to the successes gained is necessary. The sector needs to appraise the meaning of the gains by looking a little deeper. For instance, while the 2015 Global Nutrition Report revealed no increase in childhood overweight, unfortunately the same report revealed an increase in adult overweight in Kenya. There is also need for increased nuance in linking the underlying causal issues that impact nutrition outcomes, i.e. to elaborate exactly how these issues actually contribute to change. One simple example is how an increase in a woman’s workload negatively impacts on her ability to offer improved care to her child, including having an impact on the time available to feed her child (Hailey, 2015). Such nuance could rally the different sectors that engage women to do so by taking into consideration the impact of empowerment opportunities on the amount of time she spends with her child.

In summary, Kenya has made great strides in combating malnutrition based on the six global priorities. It greatly owes this first to a growing understanding of the complex issues that contribute to malnutrition and then aligning and streamlining policies, and actions, to this understanding. While this is definitely worth celebrating, maintaining a little caution and assessing more thoroughly the meaning of these successes would enable the sector to consolidate the gains made and to build on them, thus, to address the nutrition challenge not just holistically but also sustainably.

Hailey, P. (2015). Theory of Change Framework Nutrition Resilience. Centre For Humanitarian Change.