Integrated approaches to tackle under nutrition in Kenya. Final Report

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Integrated approaches to tackle under nutrition in Kenya Final Report September

2 Concerns about under nutrition in Kenya. Poor nutrition is a main cause of mortality especially among the vulnerable. About half (45%) of all deaths among children under five are due to one or more forms of undernutrition such as fetal growth restriction, stunting, underweight, wasting, vitamin A and zinc deficiencies and sub-optimal breastfeeding. 1 Anemia and calcium deficiencies are also reported to be important causes of maternal death (23% and 19% of total deaths, respectively). In addition, children who are deprived of adequate nutrition in utero and in the first 24 months of life, but have rapid growth after the age of two are more susceptible to chronic disease, which is attributable to over a quarter of mortality in low income countries. 2 In Kenya, 790,000 children are estimated to die due to underweight and vitamin A deficiency between 2010 and 2030, if they are not addressed. 3 Equally important, poor nutrition affects economic development and poverty reduction. Chronic undernutrition during the first 1,000 days from conception to the first 24 months of life irreversibly impedes physical growth and cognitive development to reach individual genetic potential. Therefore it limits schooling achievements, and reduces physical productivity, resulting in decrease in income potential in the later life. Also, poor nutrition increases health care and associated expenditures, contributing to poverty. According to the Copenhagen Consensus , each dollar spent on reducing chronic undernutrition through a bundle of interventions 5 could have at least a US$30 payoff. Global productivity losses due to poor nutrition are estimated to be 8% of gross national product (GNP) over the twentieth century at the global level while the estimation is reported to be higher at over 11% of GNP in Africa. 6 The economic costs of undernutrition in Kenya are also vast: unless immediately addressed, Kenya is estimated to lose US$2.8 billion of its GDP annually as a result of stunting. An estimated KES 230 million will also be lost between 2010 and 2030, for example, due to cognitive underperformance and loss of productivity resulting from iodine and iron deficiencies. 7 If the bundled interventions are implemented, Kenya is, however, estimated to benefit the increased earnings at the ratio of between 24 and 76 to one. 8 1 Black et al (2013) 2 REF -Barker at all, Prentice & Moore, Victora at al, etc 3 PROFILES 2010 quoted in Levitt et al (2013; Draft) Reducing chronic malnutrition in Kenya: a situational analysis and recommendations for a multisectoral response 4 Copenhagen Consensus 2012: accessed in April 2014 Following the 2004 and 2008 Copenhagen Consensus projects which provided a clear list of priorities ranked according to their costs and benefits and potential for combating ten of the world s greatest challenges, the third global Copenhagen Consensus was held in 2012 putting together an expert panel including four Nobel laureates to analyze the costs and benefits of different approaches to tackling the world s biggest problems. The aim is to provide an answer to the question: If you had $75 billion for worthwhile causes, where should you start? The Expert Panel identified the most cost effective ways of achieving good in the world across ten topic areas including hunger and nutrition; conflict in fragile states, climate change. 5 Includes provision of micronutrients and complementary foods (only when required), treatments for worms and diarrheal diseases, and behavior change programs 6 Horten and Steckel (2012) 7 PROFILES 2010 quoted in Levitt et al (2013) 8 Copenhagen Consensus

3 The seriousness of under nutrition in Kenya. Kenya suffers from a high level of child undernutrition. More than two million children under five are stunted (35%) and about a million children are underweight (16%, Figure 1). Prevalence of stunting is similar to or even higher than those in neighboring countries with lower per capita gross national income (GNI) such as Uganda and South Sudan (Figure 2). Figure 1. Prevalence of undernutrition, 2008/9 Figure 2. Prevalence of stunting by GNI per capita Source: WHO Global Database on Child Growth and Malnutrition, accessed April 2014 Source: WDI 2014; GNI- 2012, Stunting latest Prevalence of micronutrient deficiency is also very high even though no recent data are available 9. Two third of pre-school children and more than half of pregnant women were anemic ( Figure 3). Vitamin A deficiency was also prevalent among the population, but especially high among pre-school children. 10 Zinc deficiency among children under five was also quite high at 51% (data not shown) Prevalence of child undernutrition and micronutrient deficiencies is much lower in the preliminary report of National Micronutrient Survey (NMS) For example, prevalence of stunting and anemia among children is 26.3% and 32.5%, respectively. However, the figures in the report have not been confirmed by the MOH. 10 WHO Vitamin and Mineral Nutrition Information System (VMNIS). Accessed on May 5, Republic of Kenya (2011). National Food and Nutrition Security Policy 3

4 Figure 3. Prevalence of micronutrient deficiency Source: WHO VMNIS, accessed April 2014 The Most affected by under nutrition. Nutrition status differs significantly by demographic and socio-economic background such as location of residence, wealth quintile, and region. For instance, while about a quarter of children from the richest quintile are stunted, almost one in two children from the poorest quintiles suffer from stunting (Figure 4). Prevalence of stunting also varies considerably by location: less than 20% of children in Wajir and Garissa counties are stunted, but more than 40% of children in Kitui, and Makueni counties are stunted (Figure 5). Boys are more likely to be stunted than girls and prevalence of stunting sharply increases with age in the first two years of life and stabilizes after 24 months (12% for children <6mo; 39% for children 6-23mo; and 38% for children 24-59mo). Figure 4. Prevalence of stunting by characteristics Figure 5. Prevalence of stunting by district 4

5 Source: KDHS 2008/9 Source: MOH, 2013 The Situation in Kenya Prevalence of child undernutrition has Figure 6. Trend in child nutrition status stagnated for the last two decades, even though Kenya has made notable achievements in reducing child mortality since Infant mortality rate (IMR) and under five mortality rate (U5MR) have reduced from 75 and 113 per 1,000 live births in 2003 to 59 and 84 per 1,000 live births in 2008/2009, respectively. However, prevalence of stunting, wasting, and underweight has remained largely unchanged during the same period (Figure 6). Thus, Kenya is unlikely to meet the nutrition and health Millennium Development Goals Source: Statcomplier, 2014 (MDGs) unless significant changes are made in the way the country addresses these challenges. In addition, prevalence of child undernutrition among the marginalized stagnated or even deteriorated, while that among the better off improved. For example, the proportion of children stunted in urban areas was about 10% lower in 2008/09 than that in 2003, while there is little change in rural areas. Prevalence of stunting among children from the top 60% of the households was also lower in 2008/9 compared to 2003, whereas it was even higher among children from the bottom 40% of the households. Figure 7. Trend in prevalence of stunting by characteristics 5

6 Source: Statcomplier, 2014 The (main) reasons as to why Kenya has such a high prevalence of undernutrition. Causal pathways leading to malnutrition lie on multiple factors. According to a most widely used malnutrition framework (Figure 8), malnutrition results directly from inadequate dietary intake and high prevalence of diseases, which are affected by inadequate access to food, inadequate care of mothers and children and insufficient health services and unhealthy environment at the household level. Basic factors such as broader political, economic, institutional, socio-cultural, and environmental factors influence those underlying factors. Figure 8. Causes of undernutrition Kenya has also problems that Source: Mason, J. adapted from UNICEF 2000 pervade all three levels of causes. Prevalence of common childhood illnesses such as fever and acute respiratory infections (ARI) was significantly lower in 2008 compared to 2003, even though diarrhea and fever (proxy for malaria and other acute 6

7 infections) was still prevalent at 17% and 24%, respectively, in Also, less than a third of children were fed appropriately (exclusive breastfeeding up to six months and adequate complementary feeding between 6 and 23 months) during the critical period of first two years. Many factors related to three underlying causes access to foods, care for mothers and children, and health services and healthy environment improved, but marginally (Table 1). These factors also varied quite a bit by household background (data not shown). Table 1. Selected immediate and underlying factors affecting undernutrition in Kenya Dietary intake/ access to food Health status Care for mothers & children Health services & healthy environment Selected basic determinant s Selected indicators Exclusive breastfeeding (% C<6mo) Adequate complementary feeding (% C 6-23mo) Vitamin A supplementation (% C 6-59mo) Foods rich in vitamin A (% C 6-35mo) Adequately iodized salt in the house (% households) Prevalence of diarrhea (% C 0-59mo) Prevalence of fever (% C 0-59mo) Prevalence of ARI (% C 0-59mo) Antenatal care 4+ (% W 15-49y) IFA supplementation (during pregnancy) IFA supplementation for 90+ days (during pregnancy) Delivery by a skilled provider (% W 15-49y) Full vaccination (% C 12-23mo) Children with diarrhea given ORS or RHS (%) Children with diarrhea given optimal feeding (%) Children given deworming medication in 6 months (% C 6-59mo) Children with diarrhea taken to a health facility (%) Children with ARI taken to a health facility (%) Children with fever treated with an anti-malarial drug (%) Improved toilet (% households) Improved water (% households) Improved hygiene practices (e.g., including hand washing with soap)* Food production index ( = 100)** Depth of the food deficit (kcal/capita/day)** Food supply (kcal/capita/day)** 2,007 2,010 Population below minimum level of dietary energy consumption (millions)*** GNI per capita, Atlas method (current US$)**** Urban population (% of total)**** Gross attendance ratio for secondary school Fertility rate, total (births per woman) Source: KDHS 2003 & 2008/09, unless noted using Statcomplier; * Levitte et al (2013) 12 ;**FAOSTAT & WDI; ** **** WDI 12 Levitt et al (2013; Draft) reducing chronic malnutrition in Kenya: a situational analysis and recommendations for a multisectoral response. 7

8 more, same or somewhat less food with ORT or increased fluids, or both; normalized average intensity of food deprivation of the undernourished, estimated as the difference between the average dietary energy requirement and the average dietary energy consumption of the undernourished population (food-deprived) The most important factors (and/or urgent ones) that need to be addressed. An integrated intervention addressing multiple key determinants is needed to realize potential effects to sustain the good nutritional status. Limited data prevent from determining precisely the degree of malnutrition attributable to each cause of malnutrition, if at all possible. Figure 9 below shows the findings from an analysis 13 to measure possible impact of a selected group of activities related to three underlying causes of undernutrition at the national level. According to the analysis, prevalence of stunting among children 6-23mo is 11% lower among those with adequate access to improved water and sanitation, compared to those without. 14 Maternal and child health care (e.g., antenatal care, skilled delivery, and full immunization) and adequate feeding also affected the stunting level by about 7% and 6%, respectively. 15 An example of the possible integrated effect of multiple activities addressing underlying causes of undernutrition on prevalence of stunting is also shown in Figure 10: proportion of children stunted was 11% lower among children with adequate feeding and health care, compared to those children without such feeding and care. Prevalence of stunting was in between when children received either adequate feeding or adequate health care only. According to an observational study of multi-sector intervention addressing household food security, child caring practices, and infectious disease control in Sauri, Kenya, 25% reduction in prevalence of stunting is likely related to interaction between several drivers of changes. 16 However, these data show that, on top of ensuring adequate feeding and care, other measures have to be identified and implemented for decreasing undernutrition to acceptable levels. Thus a sustained intervention addressing multiple determinants of undernutrition is needed to bring down high prevalence of undernutrition, especially stunting. Figure 9. Stunting (6-23mo) by determinants 17 Figure 10. Stunting (6-23mo) by feeding and care 13 Ibid. 14 This analysis did not control for other determinants, thus the effects might be due to the related factors. Also the limited number of children 6-23mo in the data set limits the full analysis. 15 Due to data limitation, comparable multi-factor analyses was not carried out 16 Reman et al (2011). Multisector intervention to accelerate reductions in child stunting; an observational study from 9 sub-saharan African countries. AJCN 17 Ibid. Adequacy was defined as follow: environment: improved sanitation and water per the WHO/UNICEF Joint Monitoring Program definition; feeding - the minimum acceptable diet using feeding frequency and food group diversity measures, according to the respective age of the child; and health-related care antenatal care, delivery by a skilled provider, and full immunization. 8

9 Source: Levitt et al (2013) Source: Levitt et al (2013) The careful identification of the underlying causes and their inter-relations will allow the formulation and implementation of strategies to effectively and sustainably address undernutrition. A set of integrated interventions should be context specific as coverage of basic services as well as socio-cultural, economic and environmental background that affects caring and feeding behaviors, and eventually nutrition status varies widely across the country. For example, wealth is concentrated in Nairobi: nearly all people in Nairobi are in the top 40% of the wealth index, while more than four in five people in North Eastern Province belong to the bottom 40% of the wealth index. Essential services such as delivery by a skilled provider are also concentrated in the better-off areas: almost 90% of births in Nairobi were delivered by a skilled provider, while only a quarter of deliveries were attended by a skilled health worker in Western Province. Infant and young child feeding and caring practices are, however, generally inappropriate regardless of location (Table 2). Therefore, it is important to prioritize an integrated set of activities to improve underlying and immediate causes of undernutrition, especially stunting, based on the locality context, considering the limited (human, material, and financial) resources available. Table 2. Selected causes of undernutrition by province Population in the bottom 40% of the wealth index Women 15-49y received secondary education + Births assisted by a skilled provider Children 6-23m received adequate feeding Children <5y with diarrhea received adequate feeding Province Nairobi Central Coast Eastern Nyanza Rift Valley Western North Eastern National Source: KDHS2008/09 9

10 Political and Institutional context to improve the situation. Kenya s commitment to nutrition stated in the national strategies is somewhat inconsistent, but moving to the right direction. The Constitution of Kenya 2010(Art. 43, (c)) clearly mentions the right of people to be free from hunger and to have adequate food of acceptable quality as well as that of children to basic nutrition, shelter, and health care. However, the Vision 2030, the new long term national economic blueprint aiming at transforming Kenya into a middle income country providing a high quality life to all its citizens by year 2030, is somewhat silent about nutrition, even though there is a strong bi-directional relationship between nutrition status and (equitable) economic growth. The first Medium Term Plan had also limited coverage of nutrition, focusing on mainly food security. The second MTP , which prioritizes policies, programmes, and projects to reduce poverty and inequality including meeting the remaining Millennium Development Goals (MDGs) targets, on the other hand, highlights the importance of good nutrition to health and education and includes flagship projects to improve nutrition in different sectors. However, the rhetoric on nutrition has not been matched with adequate level of resources and enough actions due possibly to limited understanding on the importance of nutrition on health, education, and development and sectoral silos. The National Health Policy (NHP) aims to attain the highest possible health standards in a manner responsive to the population needs, but one of the biggest risk factors and contributors to mortality and morbidity especially among children under five is not covered systematically in the Health Sector Strategic and Investment Plan (HSSIP) Instead, nutrition is identified as a social determinant that the health sector seeks to influence among others such as water and sanitation, education and agriculture, even though various preventive and curative nutrition interventions are mentioned under different strategic objectives. Thus, the nutrition budget as a share of the total health budget presented in the HSSIP is less than two percent. The National Food and Nutrition Security Policy (FNSP) 2011, development of which was led by the Ministry of Agriculture (MOA), provides a framework to address strategic areas to achieve good nutrition but mainly focusing on food security. Assuming that guaranteed food security will automatically lead to adequate nutrition is one main fallacy undermining the formulation of effective multisectoral nutrition interventions. Similarly, the main focus of the Agricultural Sector Development Strategy 2010 is on market oriented production, rather than nutrition-sensitive production. On the other hand, the National Nutrition Action Plan (NNAP) , developed by the former Ministry of Public Health and Sanitation (MOPHS), focuses primarily on high impact nutrition interventions within the health sector. These policy and strategy also do not address some of the key lessons learned from previous efforts (e.g., unclear coordination mechanisms and commitment to fund implementation of the planned activities). For example, the NNAP is short of strategic options other sectors can play (e.g., food diversification by the agriculture sector, etc). Resource gap is also quite large even considering the fact that the NNAP is intended to be a tool to mobilize resources and the majority of funding for nutrition has 10

11 traditionally come from development partners (Figure 11). 18 The budget estimated for nutrition in the HSSIP is only a third of financial resources needed to implement the NNAP even though the Ministry of Health (MOH) is the leading agency for most activities proposed. In addition, actual allocation is likely to be much less as there is a financing gap in the HSSIP and the government s commitment to scale up nutrition for the next five year across sectors is only USD 70 million against USD 272 million needed in health sector alone. 19 While the county governments are supposed to allocate budget to implement the nutrition actions at the county level with devolution, they are unlikely to fill the funding gap as the share of development expenditure allocated to even the overall health sector is only 12% on average. 20 Before devolution, the nutrition funding allocated to districts by the Government was traditionally small ranging from from KES 48,000 to KES120,000 KES per year in FY2011/ Figure 11. Nutrition funding by source Source: GOK/UNICEF 2009/12 mid-term report quoted in Wagah (2011) In addition, the institutions responsible for nutrition action and coordination are too low in the hierarchy without enough convening power or ad-hoc committees rather than being a permanent institution with adequate (human and financial) resources to effectively and efficiently lead the integrated multi-sectoral actions. For example, the MOH has a small unit 22 under the Family Health Department to deal with the nutrition issues that directly and indirectly affect nearly half of child mortality. Likewise, a small section of the Home Economics Unit is responsible for nutrition in the MOA where a food first (and only) approach is dominant. 23 Thus, they do not have enough convening power or authority to call for any action that is under another Ministry. Although Kenya joined the Scaling Up Nutrition (SUN) Movement in September 2012 in the context of a renewed global commitment to eliminate all forms of malnutrition and multiple inter-sectoral committees exist to coordinate responses to food and 18 This unstable source of funding could explain why much of the activity in nutrition focuses on addressing the immediate impacts of food insecurity, famine and other emergencies, with limited actions in medium and long term development nutrition. 19 KHSSIP CRA (2013). County Budgets: Wagah (2011) CHECK FULL REF. 22 Although the nutrition units in the MOPHS and MOMS have been merged in XXX, they seem to be still functioning as two separate units with sub-optimal coordination (e.g., nutrition commodity information not readily available from the former MOMS nutrition team, preparation of two separate proposals, etc) 23 ACF-International (2013) 11

12 nutrition security issues, they are sectoral and technical, and focus mainly on emergency. 24 Currently, there is also no evidence that the new coordinating mechanisms proposed in the FNSP (i.e., the Food and Nutrition Security Secretariat and County Food Security Committees) are fully functioning to ensure integrated multi-sectoral responses to food and nutrition security issues to achieve its goals. 25 What Kenya can do differently to address the situation in a devolved system. In order to minimize challenge and maximize opportunities in addressing nutrition issues in a devolved system, the Government of Kenya might want to consider the following options. Intensify strategic communications to make nutrition an explicit development outcome of the county. While nutrition has been on the national agenda, the main focus has been food security and emergency nutrition responses rather than an integrated multisectoral response to prevent undernutrition that can contribute to the country s development. In order to achieve better outcomes, the Government of Kenya needs to engage all stakeholders from individuals and households to service providers to traditional leaders and decision makers at different levels to create conditions favorable for social change. Concerted and continuous communication efforts are needed: (i) to sensitize the importance of better nutrition on health, education and development outcomes of the country (not just food security) and effective and efficient multisectoral actions to prevent and treat undernutrition (given the limited resources available); (ii) to increase leadership commitment in tackling undernutrition; (iii) to decide ambitious, but achievable nutrition outcome(s) as national development goals; and (iv) to mobilize additional resources for actions in all sectors and levels of the country in order to achieve better nutrition outcomes. The appropriate communications modalities and techniques need to be adjusted to deliver level appropriate, but consistent messages. Focus on priority target groups to produce best outcomes. The government is engaged in multiple flagship initiatives to address development challenges of various sectors. It is therefore unlikely that Kenya can address all the nutrition problems identified and implement proposed strategies/actions in the NNAP at once. Thus, the Government needs to coordinate prioritization of beneficiaries to focus on, and identify a set of cost-effective/efficient strategies and actions to implement in a short term to achieve targeted high impact outcomes. While the stakeholders in Kenya are well aware of the window of opportunity for preventing the irreversible physical and mental consequences of undernutrition to be the first 1,000 days of life, programs still target outside of this window of opportunity as interventions target already underweight children, rather than focusing on prevention of undernutrition. The interventions after this age will not have a significant impact on the productivity and economic growths due to largely irreversibly stunted physical and cognitive development. Governments have to understand that lack of effective measures to decrease chronic malnutrition renders them co-responsible for the underachievements in life of a significant part of their population. 24 ibid 25 FNSP (2011) 12

13 Develop a costed scale up plan to increase coverage of the most cost effective and context specific interventions. Since the overall spending on nutrition is minimal and skewed to emergency responses, coverage of the cost-effective interventions is relatively low. While nutrition interventions are usually very cost-effective, some interventions are less cost-effective than others. For example, community based nutrition programs for behavior change cost USD 53 to 153 per disability-adjusted life-year (DALY) saved, while it costs about 10 times more to save one DALY through distribution of complementary foods (USD 500 1,000). 26 In order to increase coverage of most effective nutrition interventions to prevent and improve undernutrition, the Government of Kenya should develop a costed plan for a limited set of costeffective interventions that can be scaled up to achieve explicit nutrition outcomes. While it might take some time to prepare such a plan, it can facilitate the government s decision in investing in nutrition as the economic analysis can also show the potential benefits and cost effectiveness of various scenarios compared to the investment that the government needs to make. This plan would be best done at the county level as the devolved system can provide opportunities to achieve better nutrition outcomes through the integrated and synergistic approach of addressing key determinants of nutrition in various sectors at the same time. Kenya s recent devolution especially acceleration of the transfer of responsibilities to counties presents many challenges. During the early stage of devolution, many counties, if not all, are likely to face with multiple challenges due to sub-optimal institutional capacity in public financial management, human resource (quantity and quality), high and urgent expectations of equitable service delivery, etc. However, the devolved system can also be a unique opportunity to integrate basic services to improve nutrition under the integrated strategy. The county governments in the devolved setting can: (i) have context specific planning and implementation, rather than implementing vertical programs engineered centrally; (ii) have autonomy over all public services, making multi-sectoral coordination and collaboration easier (including setting up a new office); and (iii) allocate budget directly for nutrition, rather than letting the multi-sectoral team rely on a small portion of multiple sectoral budget items which may not be in sync with the priority actions and make reallocation between actions difficult when needed. As long as there is a strong and consistent political commitment, all of these conditions can make the county governments address a combination of factors affecting undernutrition simultaneously in their respective counties, while improving accountability as budget is directly linked to the nutrition outcomes (rather than sectors). Given the limited capacity especially at the management and leadership levels of the country government in addressing undernutrition, the national government will need to support the counties to come up with evidence-based integrated interventions that (i) are cost-effective and (ii) promote synergies and sustainability at least in the early years of devolution. The health sector can play a key role in this process as it frequently contacts the target group in the window of opportunity and nutrition specific interventions are often implemented through the health sector delivery mechanisms. In some counties, however, nutrition sensitive interventions such as those addressing household food insecurity and poor sanitation infrastructure might be the key drivers of reducing undernutrition. So it will be important to have flexibility in institutional arrangements to meet the needs of different counties. The multi-sectoral technical team 26 Horton et al (2010) 13

14 responsible for supporting the county governments will need to provide the overall management training including Public Financial Management so that the counties will be able to prioritize nutrition, if needed, at the county level. Utilize all available cadres to maximize human resources to deliver nutrition services. The county governments have a limited number of nutrition officers who can be mobilized to implement nutrition interventions if decided to scale up rapidly. Also, given the current budget constraints and higher need for certain cadres of professionals (e.g., doctors), it is unlikely that the country governments will increase the number of nutrition officers significantly in the short and medium term. Thus, the county governments need to utilize other cadres available. For example, home economics officer, agriculture extension officers and community health nurses already provide some nutrition education and promotion at the community level. In order to get the full benefit, it will be important to work towards common goals based on consistent messages that can be used across providers until nutrition becomes everybody s business. Since many of them may be already overworked for other tasks, it is important to clarify division of labor. It will also be vital to involve positive deviants as providers (e.g, community health workers/volunteers) in order to boost the confidence of the targeted families that they can prevent and improve undernutrition in their specific context. Positive deviant families can also help the targeted beneficiary see the outcomes of the improved nutritional status (e.g., children not sick that often and even if ill, the severity and duration is less, etc) and thus build more ownership of the interventions among them. In addition, the national government has a critical role to play in terms of developing a strategy to harmonize the messages, updating training tools and materials that can be used by different cadres, and providing trainer training for the county governments. Given the sheer number of providers to be mobilized and trained as well as limited number of staff even at the national government who can serve as master trainers, innovative training methods (e.g., traditional in person training, followed by dissemination of updates and service reminders by text messages, e-learning courses etc) will need to be used concurrently if multiple counties decide to scale up nutrition specific and sensitive interventions. Generate and utilize relevant evidence to adjust strategies and actions. In order to implement the context specific strategies and actions to improve nutrition, the importance of generating relevant evidence and utilizing evidence to change the course of action cannot be emphasized enough. This is especially relevant as Kenya moves to the devolved system as the county specific data are limited. While the ongoing Demographic and Health Survey will provide the county relevant information in the health sector that can help the county governments plan and implement a set of nutrition specific interventions to address issues faced by each county, this will not provide much information beyond health (and some early childhood education). Therefore, it will be important to continuously generate information, while implementing interventions, to make more appropriate decision and delivery of interventions more effective and efficient. 14