SITUATION ANALYSIS AND COMMUNITY CONSULTATIONS IN THE NUTRITION SECTOR IN KENYA

VOLUME I: SITUATION ANALYSIS

by

John Thinguri Mukui

Report prepared for the Ministry of Planning and National Development and UNICEF-Kenya, Nairobi

July 2003

TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS ......................................................................................................................................iv BACKGROUND TO THE STUDY .............................................................................................................................................. 6 INTRODUCTION........................................................................................................................................................................ 6 OBJECTIVES OF THE STUDY ............................................................................................................................................... 7 OUTLINE OF THE REPORT .................................................................................................................................................. 7 CONCEPTS AND DEFINITIONS ............................................................................................................................................... 9 FOOD, NUTRITION AND HUMAN RIGHTS .................................................................................................................. 9 RELATIONSHIP BETWEEN INCOMES AND NUTRITION ....................................................................................10 NUTRITION AND INFECTION ..........................................................................................................................................12 FOOD SECURITY IN AN URBAN CONTEXT OR THE URBAN FACTS OF LIFE ..........................................12 INTRA-HOUSEHOLD DISTRIBUTION OF FOOD .....................................................................................................13 FEEDING HABITS IN KENYA .................................................................................................................................................15 FOOD REGIMES .......................................................................................................................................................................16 INFANT AND CHILD FEEDING .......................................................................................................................................18 FOOD RESTRICTIONS ...........................................................................................................................................................20 EMERGING ISSUES .................................................................................................................................................................22 WHAT OTHERS SAY ...............................................................................................................................................................25 FINDINGS OF THE KENYA PARTICIPATORY IMPACT MONITORING ..............................................................28 GUCHA DISTRICT ...................................................................................................................................................................28 KWALE DISTRICT....................................................................................................................................................................28 MAKUENI DISTRICT ..............................................................................................................................................................29 MANDERA DISTRICT.............................................................................................................................................................30 TRANS MARA .............................................................................................................................................................................30 VIHIGA DISTRICT ...................................................................................................................................................................31 SUMMARY AND CONCLUSION .........................................................................................................................................32 INDICATORS OF NUTRITIONAL STATUS ALONG THE LIFECYCLE ...................................................................33 MATERNAL NUTRITION AND FETAL MALNUTRITION ......................................................................................33 PROTEIN ENERGY MALNUTRITION ............................................................................................................................34 MICRONUTRIENT MALNUTRITION ..............................................................................................................................36 INFANT AND UNDER-FIVE MORTALITY ....................................................................................................................40 BREASTFEEDING .........................................................................................................................................................................42 IMPORTANCE OF BREASTFEEDING .............................................................................................................................42 SITUATION ANALYSIS ..........................................................................................................................................................42 NATIONAL POLICY ON INFANT AND YOUNG CHILD FEEDING..................................................................44 SOME DETERMINANTS OF MATERNAL CHILD HEALTH ........................................................................................47 THE CARE OF PREGNANT AND POSTPARTUM MOTHERS ................................................................................47 PROPORTION OF ONE-YEAR OLD CHILDREN IMMUNIZED AGAINST MEASLES ................................48 POPULATION WITH SUSTAINABLE ACCESS TO AN IMPROVED WATER SOURCE ................................49 POPULATION WITH ACCESS TO IMPROVED SANITATION...............................................................................50 THE GENESIS OF KENYAS FOOD AND NUTRITION POLICY...............................................................................51 A SHORT JOURNEY THROUGH HISTORY ...................................................................................................................51 NUTRITION RESEARCH UNDERTAKEN UNDER GOVERNMENT PROGRAMMES .................................56 MAIN GOVERNMENT AGENCIES IN PROMOTION OF NUTRITION.............................................................57 THE COMMUNITY-BASED NUTRITION PROGRAMME.........................................................................................60 OVERVIEW OF THE CURRENT FOOD AND NUTRITION POLICY ..................................................................61 SUMMARY OF THE DISTRICT AND COMMUNITY CONSULTATIONS.................................................................63 OBJECTIVE OF THE DISTRICT AND COMMUNITY CONSULTATIONS .........................................................63 THE GENERAL ECONOMIC SITUATION .....................................................................................................................63 INFANT AND YOUNG CHILD FEEDING .....................................................................................................................65 MATERNAL HEALTH AND NUTRITION ......................................................................................................................68 NUTRITION AND HIV/AIDS ..............................................................................................................................................69 NUTRITION AND EMERGENCIES ..................................................................................................................................72 WATER AND SANITATION .................................................................................................................................................73 FOOD AND NUTRITION ......................................................................................................................................................76 COORDINATION OF NUTRITION ACTIVITIES ........................................................................................................79 REFERENCES ..................................................................................................................................................................................82 TABLE 1: NUTRITIVE VALUE OF SELECTED FOODS (per 100g of edible portion) ..............................................98 TABLE 2: NUTRIENTS IN DIFFERENT TYPES OF FOODS .........................................................................................99 TERMS OF REFERENCE .......................................................................................................................................................... 100 VOLUME II: SUMMARY OF DISTRICT AND COMMUNITY CONSULTATIONS .............................................. 104

INTRODUCTION ........................................................................................................................................................................ 104 OBJECTIVE OF THE DISTRICT AND COMMUNITY CONSULTATIONS ...................................................... 104 PARTICIPATORY RESEARCH TOOLS USED IN COMMUNITY CONSULTATIONS ................................. 104 SELECTION OF THE SAMPLED DISTRICTS AND STUDY SITES .................................................................... 105 TRAINING OF FIELD STAFF ........................................................................................................................................... 105 DOCUMENTATION AND REPORTING ...................................................................................................................... 106 THE GENERAL ECONOMIC SITUATION ....................................................................................................................... 107 THE DEFINITION AND CAUSES OF POVERTY ..................................................................................................... 107 ATTRIBUTES OF WEALTH GROUPS ............................................................................................................................ 110 COPING MECHANISMS...................................................................................................................................................... 110 INFANT AND YOUNG CHILD FEEDING........................................................................................................................ 113 BREASTFEEDING PRACTICES ....................................................................................................................................... 113 COMPLEMENTARY FEEDING AND WEANING OF CHILDREN .................................................................... 114 IMMUNIZATION AND GROWTH MONITORING AND PROMOTION ......................................................... 115 HOW MOTHERS IDENTIFY MALNOURISHED CHILDREN .............................................................................. 116 MAJOR CHILDHOOD DISEASES.................................................................................................................................... 117 HEALTH AND NUTRITION PROGRAMMES FOR PRESCHOOL AGE CHILDREN .................................. 118 MATERNAL HEALTH AND NUTRITION ......................................................................................................................... 119 ANTENATAL, PERINATAL AND POSTNATAL CARE........................................................................................... 119 CARE AND FEEDING OF PREGNANT AND POSTPARTUM MOTHERS...................................................... 121 TABOOS ON FEEDING OF PREGNANT AND POSTPARTUM MOTHERS .................................................. 121 NUTRITION AND HIV/AIDS................................................................................................................................................. 122 PREVALENCE OF HIV/AIDS ........................................................................................................................................... 122 WHAT THE COMMUNITIES KNOW ABOUT HIV/AIDS ...................................................................................... 122 THE MOST VULNERABLE GROUPS IN THE COMMUNITY .............................................................................. 123 HIV/AIDS AWARENESS AND BEHAVIOR CHANGE............................................................................................ 123 NUTRITION INFORMATION SPECIFIC TO HIV/AIDS ........................................................................................ 125 COMMUNITY AND HOME-BASED CARE FOR THE INFECTED AND ORPHANS................................... 125 EFFECT OF INFECTION ON THE IMMEDIATE FAMILY ................................................................................... 126 MOTHERTO-CHILD TRANSMISSION OF HIV ....................................................................................................... 127 NUTRITION AND EMERGENCIES ..................................................................................................................................... 128 INTER-HARVEST NEAR-FAMINES ............................................................................................................................... 128 FOOD RELIEF PROGRAMMES ....................................................................................................................................... 128 SCHOOL FEEDING PROGRAMMES ............................................................................................................................. 130 WATER AND SANITATION ................................................................................................................................................... 132 COMMUNITY ACCESS TO SAFE WATER ................................................................................................................... 132 COLLECTING WATER AND ITS IMPACT ON THE HOUSEHOLD ................................................................. 133 ENVIRONMENTAL PROTECTION AND WATER SUPPLY ................................................................................. 133 SAFE SANITATION AND HYGIENE ............................................................................................................................ 134 FOOD AND NUTRITION ........................................................................................................................................................ 136 HOUSEHOLD CONSUMPTION OF FOOD ................................................................................................................. 136 FOOD TABOOS ...................................................................................................................................................................... 138 FOOD PREPARATION METHODS ................................................................................................................................ 138 INTRA-HOUSEHOLD ELEMENTS OF FOOD PRODUCTION AND CONSUMPTION............................. 140 COORDINATION OF NUTRITION ACTIVITIES ........................................................................................................... 142 INDIVIDUAL LEVEL ........................................................................................................................................................... 142 HOUSEHOLD LEVEL .......................................................................................................................................................... 142 COMMUNITY LEVEL .......................................................................................................................................................... 142 GOVERNMENT DEPARTMENTS ................................................................................................................................... 143 ANNEX ONE: CHECKLIST OF SOME ISSUES COVERED IN THE COMMUNITY CONSULTATIONS .. 147 ANNEX TWO: THE PARTICIPATORY TOOLS USED DURING COMMUNITY CONSULTATIONS ......... 151 BARINGO DISTRICT ................................................................................................................................................................. 153 1. DISTRICT CONSULTATIONS ................................................................................................................................. 153 2. COMMUNITY CONSULTATIONS ......................................................................................................................... 157 BONDO DISTRICT ..................................................................................................................................................................... 162 1. DISTRICT CONSULTATIONS ................................................................................................................................. 162 2. COMMUNITY CONSULTATIONS AT UHANYA FISH LANDING BAY ................................................. 167 3. FOOD AND NUTRITION ISSUES IN MARANDA DIVISION .................................................................... 172 GARISSA DISTRICT.................................................................................................................................................................... 175 1. DISTRICT CONSULTATIONS ................................................................................................................................. 175 2. COMMUNITY CONSULTATIONS ......................................................................................................................... 180 KILIFI DISTRICT ......................................................................................................................................................................... 185 1. DISTRICT CONSULTATIONS ................................................................................................................................. 185

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2. BRIEF DESCRIPTION OF THE COMMUNITIES VISITED ......................................................................... 190 MWINGI DISTRICT .................................................................................................................................................................... 194 1. DISTRICT CONSULTATIONS ................................................................................................................................. 194 2. COMMUNITY CONSULTATIONS ......................................................................................................................... 200 NAIROBI PROVINCE ................................................................................................................................................................ 203 1. DISTRICT CONSULTATIONS ................................................................................................................................. 203 2. COMMUNITY CONSULTATIONS ......................................................................................................................... 207 THIKA DISTRICT ........................................................................................................................................................................ 214 1. DISTRICT CONSULTATIONS ................................................................................................................................. 214 2. LIVELIHOODS IN GATUANYAGA LOCATION............................................................................................. 224 VOLUME III: CONCEPT PAPER ON NATIONAL NUTRITION POLICY ............................................................. 226

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ABBREVIATIONS AND ACRONYMS

ACC/SCN AEZ AFP AIDS ALRMP ARI ASAL BIG BIMAS BMI BPSAAP CBNP CBO CBS CCD CCF CDC CED CHANIS CHW CRC DANIDA DDC DDO DICECE DM DO DSDO ECD FAO FGD FGM FLTC FNPU FNSP FORCUS GMP GoK GPT GTZ HBC HEB HIV HRAP ICCFN ICN ICROSS IDA IDD IDS IECD IGA IUGR KARI United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition Agro-Ecological Zone Acute Flaccid Paralysis Acquired Immunodeficiency Syndrome Arid Lands Resource Management Project Acute Respiratory Infection Arid and Semi-Arid Lands Breastfeeding Information Group Business Initiatives and Management Assistance Services Body Mass Index Baringo Pilot Semi-Arid Area Project Community-Based Nutrition Programme Community Based Organization Central Bureau of Statistics Community Capacity Development Christian Childrens Fund Centers for Disease Control and Prevention Chronic Energy Deficiency Child Health and Nutrition Information System Community Health Worker Convention on the Rights of the Child Danish International Development Agency District Development Committee District Development Officer District Centre for Early Childhood Education Diabetes Mellitus District Officer District Social Development Officer Early Childhood Development Food and Agriculture Organisation of the United Nations Focus Group Discussion Female Genital Mutilation Family Life Training Center, Department of Social Services Food and Nutrition Planning Unit, Ministry of Planning and National Development Food and Nutrition Studies Programme Families, Orphans and Children Under Stress (self-help group) Growth Monitoring and Promotion Government of Kenya Graduated Personal Tax Deutsche Gesellschaft fr Technische Zusammenarbeit (German Technical Cooperation) Home-Based Care Home Economics Branch, Ministry of Agriculture Human Immunodeficiency Virus Human Rights Approach to Programming Inter-ministerial Coordinating Committee on Food and Nutrition International Conference on Nutrition International Community for the Relief of Suffering and Starvation Iron Deficiency Anemia Iodine Deficiency Disorder Institute for Development Studies, University of Nairobi Integrated Early Childhood Development Income Generating Activity Intrauterine Growth Retardation Kenya Agricultural Research Institute

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KCPE KDDP KDHS KEBS KEPI KePIM KICOSHEP KSh KWAHO KWS LBDA LBW MALD MCH MICS MOH MTCT NACC NALEP NASCOP NCC NGO NPAN NPEP PANS PEC PEM PGH PHC PLA PLWA PRSP PSI PSRI SACDEP SFP SHN STD TB TBA UMMK UNAIDS UNDP UNEP UNICEF URTI VAD VCT VDC WEHMIS WFP WHO WSC

Kenya Certificate of Primary Education Kilifi District Development Programme Kenya Demographic and Health Survey Kenya Bureau of Standards Kenya Expanded Programme on Immunization Kenya Participatory Impact Monitoring Kituka Community Development Programme Kenya Shillings Kenya Water for Health Organisation Kenya Wildlife Service Lake Basin Development Authority Low Birth Weight Ministry of Agriculture and Livestock Development Maternal Child Health Multiple Indicator Cluster Survey Ministry of Health Mother-to-Child Transmission (of HIV) National AIDS Control Council National Agriculture and Livestock Extension Programme National AIDS & STI Control Programme Nairobi City Council Nongovernmental Organization National Plan of Action for Nutrition National Poverty Eradication Plan Participatory Approach to Nutrition Security Poverty Eradication Commission Protein-Energy Malnutrition Provincial General Hospital Primary Healthcare Participatory Learning and Action People Living With AIDS Poverty Reduction Strategy Paper Population Services International Population Studies and Research Institute, University of Nairobi Sustainable Agriculture Community Development Programmes School Feeding Programme School Health and Nutrition Sexually Transmitted Disease Tuberculosis Traditional Birth Attendant Ushirika wa Maisha na Maendeleo - Kianda (Kibera) Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Environment Programme United Nations Childrens Fund Upper Respiratory Tract Infection Vitamin A deficiency Voluntary Counseling and Testing Village Development Committee WEM Integrated Health Services World Food Programme World Health Organization World Summit for Children

CHAPTER ONE

BACKGROUND TO THE STUDY INTRODUCTION

1.1. The nutrition status of the population is important both in determining its productive capacity and as a proximate measure of its wellbeing as the nation seeks to achieve equitable and sustainable human development. 1.2. In the first two decades of independence, the country achieved tremendous improvement in the nutrition status of her population. However, since the early 1990s the country started loosing the gains it had made and since then the situation has either stagnated and in most cases it has become worse. This is despite sustained efforts by the government and many other agencies to promote nutritional wellbeing of Kenyans. After the International Conference on Nutrition (ICN) in 1992, Kenya developed her National Plan of Action for Nutrition (NPAN) with the following objectives: The incorporation of nutrition objectives and actions into national, sectoral and integrated development plans, and the allocation of the necessary human and financial resources for achieving these objectives; The development of specific nutritional interventions directed at particular problems or population groups; and The generation of information from community-based actions for the nutritional assessment of problems and implementation of appropriate intervention measures

1.3. These efforts have not yielded the desired outcomes and the NPAN has only been partially implemented. The major reason is that interventions have not been supported by an appropriate regulatory and policy framework; there has been inadequate funding of nutrition activities; and lack of any sustained effort to draw a national consensus. The nutrition plan is embedded in food policy (therefore focusing on production and ignoring aspects of food utilization)1, and has no known owner or custodian (hence poor coordination between various arms of government involved in nutrition activities). 1.4. The Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN), coordinated by the Food and Nutrition Planning Unit (FNPU) of the Ministry of Planning and National Development, is therefore in the process of developing a policy framework under which the nutrition activities will be implemented. To achieve this, the committee set up a taskforce with a mandate of coming up with a draft national nutrition policy. Members of the Taskforce were drawn from the Ministries of Agriculture, Health, Education and Science and Technology, and Planning and National Development; Office of the President, World Health Organization (WHO), UNICEF, Kenya National AIDS & STI Control Programme (NASCOP), Community-Based Nutrition Programme (CBNP), and the University of Nairobi (Department of Food Science, Nutrition and Technology). 1.5. The proposed nutrition policy will contain a set of principles, objectives, priorities and decisions which will form an integral part of the national development planning, and provide the population with the necessary social, cultural and economic conditions essential for optimal nutrition and dietary wellbeing. It is envisaged that the policy will enable Kenyans to obtain better nutritional status, which will in turn result in greater productivity and enjoyment of wider social and economic benefits. The emphasis will be on providing an enabling environment for the improvement of nutritional status of all population groups, in

1 A nutrition policy is expected to link up with other aspects of development e.g. human rights, education, health, behavioral practices (e.g. intra-household food discrimination, and coping strategies to deal with short-term insufficiency of food), gender (interaction of biological roles with nutritional status including the cyclical loss of iron and childbearing), demographic change (fertility and mortality rates, and effect of rising population on food availability), environment (farming in areas of high ecological vulnerability, the narrow consumption base in urban populations, and environmental contamination), crises (as good nutrition relieves the social unrest underlying violent conflict, and decreases human vulnerability that transforms systemic shocks into humanitarian disasters).

addition to specific focus on vulnerable groups (e.g. children, women of childbearing age, nutrition in HIV/AIDS, and nutrition in emergencies). 1.6. The Taskforce has identified the following as the key policy areas: nutrition and human development, nutrition and socioeconomic development, nutrition and HIV/AIDS, nutrition and poverty, and nutrition in emergencies. The proposed policy has the following objectives: to improve the nutritional status of all Kenyans, reduce the incidence of diet-related diseases and the impact of diseases on quality of life, improve the quality of life of people living with HIV/AIDS, provide a common platform under which nutrition activities are implemented, and provide a policy and regulatory framework for all players in the sector.

OBJECTIVES OF THE STUDY

1.7. The Taskforce has identified community capacity development as one of the major strategic pillars of the policy. It has therefore strongly recommended community consultations and participation in the policy making process. The study will be required to capture community perceptions of the manifestations, causes and consequences of malnutrition. The communities should suggest likely solutions, resource needs and key partners in interventions. 1.8. The study will consist of a community consultation report and a report on the situation analysis of the nutrition sector. The task will be based on studies already undertaken and documented e.g. PRSP consultations, baseline surveys by CBNP, and surveys and studies done by GoK/UNICEF. Where gaps are identified, the consultant will arrange community visits to consult directly with selected communities. 1.9. The study was required to adopt a Human Rights Approach to Programming (HRAP) with special emphasis on Community Capacity Development (CCD) and focus on the rights of women and children. Using HRAP/CCD, the study was to capture the following information from a community perspective: the overall understanding of the problem of malnutrition and identification of the most vulnerable groups, causality analysis, role analysis, capacity gap analysis, communities coping mechanisms, partnership analysis, and candidate actions. The report was required to use the Triple A approach when drawing conclusions on community perceptions and recommending issues and strategies for discussion in the policy drafting process. According to UNICEF (1997), the Triple A approach of Assessment, Analysis and Action is a means of identifying what caring behaviors exist within a community (assessment), how caring can most effectively be enhanced (analysis), and what can be done to support good caring practices or change less satisfactory practices (action). 1.10. The second part of the study was a situation analysis based on studies and existing information on investments in the sector in the last 15 years, trends in the levels of malnutrition, child nutrition, school nutrition, nutrition and management of HIV/AIDS, infant and young child feeding, community nutrition and support, urban nutrition, and emergency nutrition. The report was also to identify lessons learnt, major gaps, and make recommendations on areas that should be addressed by the policy. To beef up the community consultations and the situation analysis reports, the study included consultations with district level implementers in a few selected districts to capture their perceptions on nutritional issues.

OUTLINE OF THE REPORT

1.11. The analytical framework that dictated the organization of the report was based on separating the elements of inputs, outputs and impact. The inputs that generate nutritional outcomes include food habits, maternal child health (including child immunization), access to water and sanitation2, and breastfeeding.

In the process of eating, one end of the alimentary canal is ingress and other egress (Miller, 1997). What you eat is literally incorporated into the self, and thus what was part of the external world becomes part of the self. At egress, part of the self becomes part of the external world. Sanitation is therefore about interring the self, bit by bit, which could be the underlying cause of use of pits and the taboos surrounding the sharing of sanitation facilities in some communities; while the use of euphemism (privy) to describe latrine suggests that some kind of privacy and discretion in these matters is to be striven for.

The outputs can be measured by protein-energy malnutrition and prevalence of micronutrient deficit disorders. The impact indicators include infant- and under-five mortality and maternal mortality. 1.12. The major inadequacy of the statistical outputs of nutrition surveys is that they are generated by two-way classification tables (row and column headings) e.g. breastfeeding practices versus mothers education, or versus household income. There are hardly any studies that try to interrogate survey data for relationships e.g. between breastfeeding practices, mothers education and household income (notable exceptions are Deolalikar, 1996; and Kenya and Macro International Inc, 1994). This is the major reason why qualitative sources of information are necessary to generate plausible hypothesis and to explain statistical outcomes. For this reason, the study contains two chapters, one from the material collected in most rural communities in Kenya under the general heading of district socio-cultural profiles during the early eighties, and the second on information gathered during the September 2001 KePIM exercise by the Ministry of Planning and National Development. 1.13. The first chapter of the situation analysis covers concepts and definitions. The concepts covered are nutrition from a human rights perspective, relationship between food consumption and household incomes, nutrition in an urban context (the rural-urban food transition), the causal link between nutrition and ill health, and intra-household elements in food consumption. 1.14. The second chapter covers Kenyas cultural beliefs and practices and how they influence feeding habits. The main source of information is the socio-cultural profiles prepared by the Institute of African Studies, University of Nairobi, on behalf of the Ministry of Planning and National Development in the early eighties. The third chapter contains the lessons learnt on food and nutrition, based on the Kenya Participatory Impact Monitoring (KePIM) undertaken by the Ministry of Planning and National Development in September 2001. 1.15. The fourth chapter uses a lifecycle approach in gauging the nutrition status of the population. It includes maternal nutrition and fetal malnutrition (including birth weight in children), child anthropometrics, and infant and under-five mortality. The fifth chapter covers breastfeeding practices and the national policy on infant and young child feeding. Breastfeeding is viewed as an input to both nutritional status and a very important component of childcare, e.g. the role of breastfeeding in motherinfant bonding. 1.16. The seventh chapter covers the care of pregnant and postpartum mothers (births attended by skilled health personnel), maternal mortality, immunization coverage, and the main indicators of water and sanitation (access to safe water and access to sanitation). Among the commonest diseases in young children are diarrhea, dysentery and intestinal worms. These diseases reduce the absorption of nutrients and so cause or help to cause malnutrition. These common diseases can be prevented by elementary rules of hygiene (e.g. sanitary latrines, safe water, clean home and clean food), hence the need to include access to safe water and sanitary means of human waste disposal in the analysis. 1.17. The eighth chapter covers the developments in food and nutrition policy in the last two decades, to piece together the genesis of the current food and nutrition policy. One strand of policy is the developments emanating from the 1974 FAO World Food Conference that set in motion the setting of food and nutrition policies in FAO-member countries. This finally led to the formation of the Food and Nutrition Planning Unit in the Ministry of Planning and National Development in 1979. The policy received further stimulus from the 1990 World Summit for Children and the 1992 International Conference on Nutrition. This is the same policy link within which the UNICEF national plan of action has been implemented. The second strand is the paradigm shift in treatment of serious cases of child malnutrition from facility-based to food-based, community-centered nutrition programmes. The third historical thread in policy development is the growth of nutrition and nutrition-related activities in the organizational functions of the ministries of health, agriculture and education. 1.18. The ninth chapter is a summary of the report of the district and community consultations.

CHAPTER TWO

CONCEPTS AND DEFINITIONS

2.1. The proposed nutrition policy will incorporate a number of key principles. First, it will take a human rights approach to food and nutrition planning. Consequently, the analytical framework for this background study was to apply a human rights approach to programming during the collection of information. This entails the active participation of communities in policy design, which was somehow achieved through community consultations as a data-gathering tool. 2.2. Secondly, the policy will use a lifecycle approach that traces nutrition from intrauterine feeding, through breastfeeding, preschool feeding, and adult feeding. Thirdly, the policy will focus on nutrition policy which is not necessarily embedded in food and nutrition policy. This is because food policy tends to focus on aggregate food supply and ignores the ability of households to afford the food, and generally covers production (e.g. bags of maize) and neglects the components of food utilization.

FOOD, NUTRITION AND HUMAN RIGHTS

2.3. According to the UNICEFs State of the Worlds Children 1998, nutrition has been expressed as a right in international human rights instruments since 1924, either in the form of non-binding declarations or conventions and covenants which are treaties carrying the force of law. The 1924 Declaration of the Rights of the Child was adopted after World War I by the League of Nations. The Declaration affirms that the child must be given the means needed for its normal development, both materially and spiritually and states that the hungry child should be fed. 2.4. The 1948 Universal Declaration of Human Rights, adopted by the United Nations General Assembly, proclaims that everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services. It also affirms that motherhood and childhood are entitled to special care and assistance. 2.5. In 1959, the United Nations General Assembly unanimously adopted the Declaration of the Rights of the Child. The Declaration states that children shall be entitled to grow and develop in health, and that children shall have the right to adequate nutrition, housing, recreation and medical services. 2.6. The 1966 International Covenant on Economic, Social and Cultural Rights adopted by the United Nations affirms the right of everyone to an adequate standard of living, including adequate food, and the fundamental right of everyone to be free from hunger. The covenant also mandates States to take steps to realize this right, including measures to improve methods of production, conservation and distribution of food. This was followed by the 1986 Declaration on the Right to Development, which calls for all States to ensure equal opportunity for all in access to health services and food. 2.7. The 1989 Convention on the Rights of the Child establishes as international law all rights to ensure childrens survival, development and protection. The convention mandates States to recognize childrens right to the highest attainable standard of health and to take measures to implement this right. Among key steps, States are mandated to provide medical assistance and healthcare to all children, with an emphasis on primary healthcare; combat diseases and malnutrition within the framework of primary healthcare through the provision of adequate nutritious foods; and provide families with information about the advantages of breastfeeding. 2.8. In the 1990 World Declaration and Plan of Action on the Survival, Protection and Development of Children, world leaders committed themselves to give high priority to the rights of children. The main nutrition goal in the plan of action is reducing severe and moderate malnutrition by half of 1990 levels among children under-five by the end of the century. The seven supporting nutrition goals are: reduction of low-weight births to less than 10% of all births; reduction of iron deficiency anemia in women by one third of 1990 levels; virtual elimination of vitamin A deficiency; empowerment of all women to exclusively breastfeed their children for the first six months; institutionalization of growth monitoring and promotion;

and dissemination of knowledge and supporting services to increase food production to ensure household food security. 2.9. The community consultation process in this study is supposed to adopt a human rights approach with special emphasis on community capacity development (CCD). A human right represents a specific relationship between an individual who has a valid claim on something and another individual, group or institution (including the State) who has a duty to respect, protect, facilitate and fulfill the rights of the claimholder (Haddad and Oshaug, 1999). Except for the very young child, all individuals have both valid claims (rights) and duties. For example, a school-age child is the primary claims/rights-holder regarding the right to basic education. The childs caretakers, often the parents, are the immediate duty-bearers. In order to meet their duties, the parents must have a certain capacity. This capacity requires that they can claim their own rights and the second or higher-level duty-bearer can meet their duties (e.g. school teachers, administrators, community leaders). 2.10. There are several positive aspects of the use of human rights as a basis for programming. First, as observed by Haddad and Gillespie (2001), the human rights-based approach to nutrition programming now being advocated and articulated by many United Nations agencies demands a focus on capacity simply because any duty-bearer (such as a childs primary caregiver or a government) cannot be held accountable unless the capacity exists for such duties or obligations to be carried out. Capacity development is relevant for individuals, households, communities, organizations, formal and non-formal institutions, government institutions, NGOs and society as a whole. Individuals, therefore, need capacity to both claim their rights and meet their duties. 2.11. Secondly, the human rights approach focuses on accountabilities and identifies specific dutybearers, whose capacities must be strengthened to meet their duties. The identification of claimants and duty-bearers assist to identify the relationship between various agents in society and the critical processes that need to be strengthened or made more accountable to achieve desired progress. 2.12. Finally, a human rights approach to programming attempts to break the culture of accommodation to poverty (Galbraith, 1979). As Galbraith observes, people of affluence and associated capacity for expression have recourse against the state they can be heard in condemnation of political behavior of which they disapprove, and they have the sanction of sacking the offender. Their politicians and officials respond to their behavior, act with a caution, decorum, attention to individual rights, that come to be assumed. The poor in the poor country have no similar capacity for assertion. Poverty makes the task of daily survival far more compelling. 2.13. The accommodation of the poor to their poverty is borne out of their experience with vagaries of nature, and culture and history of the people. Galbraith (1979) argues that, the deeply rational character of accommodation lies back, at least in part, of the central instruction of the principal world religions. All, without exception, urge acquiescence, some in remarkably specific form. The blessedness that Christianity accords to the meek is categorical. The pain of poverty is not denied, but its compensatory spiritual reward is very high. The poor pass through the eye of the needle into Paradise; the rich remain outside with the camels.

RELATIONSHIP BETWEEN INCOMES AND NUTRITION

2.14. Students of food economics normally describe the relationship between incomes and nutrition via Engels law (the percentage of income allocated to food) and Bennetts law (the percentage of calories supplied by starchy staples). The income-diet linkage is expressed in terms of three principal relationships: the percentage of the income allocated to food, the proportion of food energy derived from various commodity groupings, and the shifts in the relative importance of specific commodities within these groupings (Poleman, 1981). 2.15. Christian Lorenz Ernst Engel, the originator of what was later canonized as Engels law, observed that the smaller the family income, the greater will be the proportion of it spent on food. The basis for the empirical validity of Engels law is straightforward. Unlike nonfood goods and services, there is an upper limit to ingestion of food energy due to the limited capacity of the human stomach.

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2.16. The operation of Engels law has been observed between countries at different levels of economic development, in a country over time, and among income classes at a particular time. However, the Engels law may not manifest itself strongly at the lowest end of the income spectrum. The abjectly poor the people near starvation will use an increase in income first to enlarge food intake, which implies that there is a minimum threshold income below which the Engels law may fail. 2.17. The diets of the poor have a number of things in common. First is the high proportion of the calories and a fair share of the protein from foods composed principally of starch. The starchy staples are cereals and starchy fruits, roots and tubers. The dietary cornerstone will either be served steamed or boiled (as with rice and potatoes), as leavened (wheat) or unleavened (maize) bread, or as a doughy paste or stiff porridge (cassava, yams, and plantains). It will normally be accompanied by side dishes or sauces, which will contribute considerable protein and the bulk of the fat, vitamins and mineral content. A second characteristic of the poor peoples diet is that the protein in these sauces and side dishes will tend to be more vegetable than animal in origin. The diets of the poor are dominated by the starchy staples due to their cheapness. 2.18. Bennetts law, named after Merrill K. Bennett, is based on the percentage of total calories supplied by the starchy staples. It states that the richer one becomes, the smaller becomes ones dependence on energy supplied by the cheap starchy staples (Bennett and Peirce, 1961; cited in Poleman, 1981). 2.19. In addition to the decline in the caloric contribution of the starch staples, the principal dietary modifications associated with a rise in income are: The replacement of proteins of vegetable origin by those derived from animal products, A steep rise in intake of separated fats (e.g. oils, butter, margarine) and of un-separated animal fats through increased consumption of meat, fish and dairy products; and a reduction in the unseparated vegetable fats contained in the starch staples, and Increase in consumption of sugar and sugar-sweetened foods 2.20. After Bennett, the increased incidence of cardiovascular disease in developed countries has been linked to higher intakes of fat and sugar. There are also quality adjustments that take place within the food groups as income rises. In the developed countries, the changes are more apparent among the meats, where lamb and mutton are perceived as inferior and beef is preferred (with the tender steak savored by the wealthy). In developing countries, quality adjustments occur among the starchy staples. In West Africa, rice, wheat and yams will be substituted for maize, millet and cassava; consumers in tropical Asia start to recognize quality differentiations in rice; while rice are substituted for maize in Mexico. 2.21. In the context of measurement of poverty, Bennetts law ensures that as income rises, rich households consume calories that are more expensive (Behrman and Deolalikar, 1987; Bouis, 1992; Bouis, 1994). Distribution of welfare using calorie intake will concomitantly appear more egalitarian than that derived using money-metric food expenditures (Mukui, 1994a). 2.22. Food poverty is generally described as set within utility space, where utility is measured in terms of calorie intake. However, the minimum non-food expenditure required could also be taken as measurable within the same utility space (i.e. calorie intake) if we take the non-food items to be the basic needs that ensures than an individual does not need to take more than the required minimum calorie allowance. For example, an individual who does not have the minimum clothing, shelter and medical care would require a higher minimum calorie intake. The minimum non-food items might be more economically acquired than the supplementary food intake required to compensate for lack of, say, clothing and shelter; while food energy can be more effectively increased by raising food-to-energy conversion through reduction in gut parasites, i.e. medical care (Lipton, 1988). For this reason, it is normally prudent to analyze access to basic health services, water and sanitation, basic education and shelter as part of basic ingredients to proper food habits, food preparation and absorption. 2.23 A different type of dietary transition took place during the colonial period. As observed by Kepkiewicz (2010), dietary trends in East Africa throughout the colonial period can be generalized as a move from self-sufficiency to a decrease of food security. This decrease in food security is reflected in an

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increased dependency on outside food sources for many native populations. Other common dietary trends include a decreasing amount of millet and sorghum; an increasing amount of white maize; a decreasing amount of wild leaves, fruits and vegetables; an increasing amount of European vegetables; as well as the replacement of breakfast foods by tea. For example, changes in the Kikuyu diet included a shift in staple products such as millet and indigenous beans to white maize; and a decrease in the consumption of meat, milk and legumes. In regards to the Maasai, dietary changes were decreased consumption of milk, meat and blood. While Maasai supplementation of their dietary staples with agricultural products seem to be a fairly routine procedure during times of scarcity, the replacement of staples in the Kikuyu diet with white maize seems to be a drastic reordering of dietary patterns which led to nutritional deficiencies.

NUTRITION AND INFECTION

2.24. Nutrition status has an effect on infections, and infections have an effect on malnutrition (see Latham, 1976). There are several means by which infection affects nutrition status. First, bacterial (e.g. typhoid fever) and some other infections lead to an increased loss of nitrogen from the body. Full recovery is dependent upon the restoration of these amino acids to the tissues once the infection is overcome. Secondly, infections, especially if accompanied by a fever, often lead to loss of appetite, and therefore to reduced food intake. Other infectious diseases commonly cause vomiting, with the same result. 2.25. Thirdly, dietary deficiency may reduce the bodys resistance to infections. Finally, some intestinal parasites (e.g. hookworms) cause intestinal blood loss and considerable loss of iron. Hookworm disease is a major cause of iron deficiency anemia in many countries. The roundworm is quite large and studies have suggested that it may reduce absorption of proteins and vitamin A. 2.26. The Food and Agriculture Organization (1966) states that, among the commonest diseases in young children are diarrhea, dysentery and intestinal worms. These diseases reduce the absorption of nutrients by the child and so cause or help to cause malnutrition. These common diseases can be prevented by elementary rules of hygiene e.g. sanitary latrines, clean water, clean home and clean food. Other infections that can help to cause malnutrition include skin infections (cause unbearable itching and lack of sleep, with consequent loss of appetite and malnutrition), malaria, and bilharzia through loss of blood and iron deficiency anemia.

FOOD SECURITY IN AN URBAN CONTEXT OR THE URBAN FACTS OF LIFE

2.27. According to Maxwell (1998, 1999) the nature of urban food insecurity has changed from the problem of feeding the cities (or maintaining aggregate supply) to that of access at household and individual level. The responses of urban households to economic crisis are normally the focus of efforts to combat poverty and food security. There has been a tendency toward household-level responses of coping and adaptation and de-politicization of urban food insecurity problems. Formal programs have emphasized individual-centered approaches of poverty, such as training, credit and other self-help mechanisms. The study also argues a case for examination of poverty for a particular location rather than looking at poverty from rural/urban comparisons. 2.28. The causes of malnutrition and food insecurity in urban and rural areas are different due to a number of phenomena of urban life (Ruel, Haddad and Garret, 1999). Ruel et al (1999) argues that urban facts of life include greater dependence on cash income, weaker informal safety nets, greater labor force participation of women (and its consequences for childcare), lifestyle changes (mainly relating to diet and exercise patterns), greater availability of public services but questionable access by poor slum dwellers, greater exposure to environmental contamination, and governance by a new set of property rights. 2.29. Urban people are more dependent on food purchases, and factors that determine cash income thus become important determinants of urban food security. Other factors include food prices and efficacy of the urban marketing system e.g. bad roads linking producing areas to the cities, and intra-urban food distribution systems. Households can however reduce their reliance on cash income for food in a number of ways, including urban agriculture.

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2.30. The rural-urban nutrition transition is characterized by changes from diets rich in complex carbohydrates and fiber (mainly food staples) to more varied diets with higher proportions of fat, refined sugars and meat products. Urban diets are generally higher in refined cereals and sugars and in animal products, and lower in staple foods. Greater dietary diversity may have a positive impact on micronutrient malnutrition, but the higher refined sugar content combined with sedentary lifestyles and overall environmental contamination increases the risks of obesity, cardiovascular diseases, certain forms of cancer and other chronic diseases. However, there are isolated cases (e.g. South Korea) where rapid economic change has not been accompanied by increased fat intake and obesity due to retention of traditional diets (Popkin, Horton and Kim, 2001). 2.31. The rural-urban divide in food consumption patterns have been observed on the Kenyan scene. According to Nyanyintono (1981), the major difference between rural and urban consumption patterns are that urban dwellers consume about 20% less maize and virtually no millet or sorghum. They consume more wheat (bread, flour) and rice and more sugar, fats, and meat than the rural dwellers. Most of the foodstuffs are purchased. The rural dweller, on the other hand, consumes more potatoes and cassava and other tuber foodstuffs. Cassava can be a year-round food or is planted as a hunger breaker if the seasons prospects for other crops look bleak by the mid-rains (Romanoff, 1992; Awa, 1996). 2.32. The rural-urban divide also extends to production of breast-milk and breastfeeding practices. Hatloy and Oshaug (1997) shows that the production of human milk is generally lower in urban than rural areas, and urban mothers are likely to wean their children earlier than rural mothers. Urban women are more inclined to early weaning and less inclined to breastfeeding. Causes mentioned are changing lifestyles, an increasing workload and time constraints on women, separation of child and mother for long hours due to work outside the household, change in employment pattern, and perceptions that breastfeeding is timeconsuming and old-fashioned.

INTRA-HOUSEHOLD DISTRIBUTION OF FOOD

2.33. Economic theory assumes that self-interest dominates all other motives. According to sociobiologists and economists (see mainly Becker, 1976), altruism toward siblings, children, grandchildren, or anyone with common genes is one of the enduring traits of human behavior. Rationality related to genetic selection has therefore been added to individual rationality familiar to economists. This implies that each person in the family or household strives to maximize the households total income. 2.34. As Jacoby (1997) argues, the theory of altruism implies that public transfers targeted toward children (e.g. school feeding programmes) are largely neutralized by the household by reallocation of resources away from the child toward other members of the household. This means that the benefit targeted towards children would not stick to the beneficiary (the so-called flypaper effect). Jacoby (1997) provides the most direct test to date of virtually no intra-household reallocation of calories in response to school feeding programs. 2.35. A second violation of the theory of altruism is through food discrimination in the household especially towards women and children. Discrimination against women in access to food takes various forms. First, food taboos, especially in sharing various parts of a slaughtered animal, are a cultural and political expression of the underlying gender relations, and can therefore be changed by a cultural and political response. Some parts of an animal (e.g. gizzard) are taken as symbols of male authority. 2.36. Secondly, discrimination in the sharing of food directed specifically at children (not indirectly through pregnant mothers) varies from community to community, and its impact on nutritional outcomes therefore varies. Many authors (see Blankhart, 1974) have argued that the underlying causes of malnutrition in Kenya are not so much lack of food as limited knowledge and deep-rooted traditional habits particularly in the field of feeding small children. In some communities (e.g. the Kipsigis), babies of only ten days old are given gruel by forced feeding, while among the Kamba weaning is introduced gradually and may last up till the age of three years (van Luijk, 1974). Among the Mijikenda, the choice of weaning foods is considered particularly harmful to childs health and nutrition, to the extent that it neutralizes the positive impact of prolonged breastfeeding characteristic of the communities.

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2.37. Thirdly, food proscriptions directed at pregnant women especially by the livestock keepers in the arid and semi-arid areas were (and still are) based on avoidance of maternal mortality. This was more pronounced among the women of the desert, rather than the daughters of the lake (Lake Victoria and the Indian Ocean coastline) and hoe cultivators (in the rest of the country). 2.38. The mode of production in a particular community therefore affects both intra-household elements in food consumption and its production. The three major modes of production are huntergatherers (and fishing), hoe cultivators, and livestock keepers. Among the hunter-gatherers and livestock keepers, the responsibility for hunting (fishing) or livestock husbandry is mainly left to men, which might imply a relatively lower workload for women. Hoe cultivation is almost entirely a womans responsibility, hence the common view of the man as a cause of poverty in such households. However, the women workload in the dry (livestock) areas is increased by longer distances to water sources, compared with areas inhabited by hoe cultivators. 2.39. Another violation of altruism is through coping strategies (fallback mechanisms) to deal with shortterm insufficiency of food that do not affect all household members equally (Maxwell, 1996) e.g. maternal buffering (the practice of a mother deliberately limiting her own intake in order to ensure that children usually recently-weaned toddlers get enough to eat). Haddad et al (1996) provides a framework for the analysis of the potential for sex and age biases in nutrition and food intake, and the consequences of promale culture for nutrition.

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CHAPTER THREE

FEEDING HABITS IN KENYA

3.1 In the study of human nutrition, the social sciences are as important as the natural sciences (Del Monte Corporation, 1969). Attempts to change food habits or regimes (principles, norms, rules and procedures around which actors expectations converge) require knowledge of the practices, attitudes and beliefs of groups and individuals towards food, and choice of particular foods. Food habits are group habits that reflect the way a culture standardizes individual behavior in relation to food so that the group comes to have a common eating pattern3. Dietary patterns depend upon and are conditioned by circumstances such as foodstuffs available through primary production and markets, patterns of social relations within the family and community, and ideas and practices related to health and illness (Passin and Bennett, 1943; May, 1957; Lee, 1957; Fathauer, 1960; Eppright, Pattison and Barbour, 1964; Yudkin and McKenzie, 1964; Lowenberg, Todhunter and Savage, 1968; Shifflett and Nyberg, 1978; Hertzler, Wenkam and Standal, 1982). 3.2. As part of the Mosaic Law, there are animals that one may or may not eat (Leviticus, chapter 11; Deuteronomy 14: 1-21; Simoons, 1994; Simoons, 1998; Holden, 2000; Allen, 2002). Hebrews preferred vegetable foods, soups, eggs, curds, honey, bread, etc to animal food. Animal food was mainly a feature of entertainments (see, for example, Genesis 18:7; I Samuel 16:20; Luke 15:23). Bees were numerous and honey plentiful in Palestine, evidence Leviticus 20:24 (I will give you as an inheritance, a land flowing with milk and honey), Deuteronomy 32:13 (he nourished him with honey from the rock), and Matthew 3:4 (His Johns food was locusts and wild honey). In addition, weaning time was a festal occasion (Genesis, 21:8) and probably came late (2 Chronicles, 31:16). It is not apparent whether the prohibitions were based on odds of a physical outcome (e.g. pathological) or a possible link between the physical (eating prohibited food) and the spiritual (e.g. contamination of the spirit). Fish and Fish (1995) also claim that the dietary habits of the traditional Kalenjin (specifically the Kipsigis) were very close to those of the Mosaic laws given in the books of Leviticus and Deuteronomy. It was a taboo among the Kipsigis to eat pork (including wild pig, forest hog and tame pig) or rabbit4. 3.3. Food habits in the villages of East Africa depend mainly on the sort of farming carried out in the locality, not necessarily on the income of the people (FAO, 1966). For example, the inhabitants of Buganda, the richest and most progressive part of Uganda, live on starchy roots and fruits because these grow there better than grains, pulses and animal products. The food habits tended to make protein-energy malnutrition more common in Buganda than the rest of Uganda, although it is the richest region. 3.4. The most comprehensive information base on food habits in Kenya was collected as part of the district socio-cultural profiles conducted by the Institute of African Studies, University of Nairobi, during the eighties on behalf of the Ministry of Planning and National Development. The study covered Narok, Kajiado, Elgeyo-Marakwet, South Nyanza, Marsabit, Machakos, Muranga, Siaya, Kilifi, Kwale, Embu, Meru, Taita Taveta, Baringo, Busia, Bungoma, Turkana and Samburu districts. Narok covered what is now Narok and Trans Mara; Elgeyo-Market the present-day Keiyo and Marakwet districts; South Nyanza (Homa Bay, Migori, Rachuonyo, Kuria, Suba); Marsabit (Marsabit and Moyale); Machakos (Machakos, Makueni); Muranga (Muranga, Maragwa, and a part excised to Thika district); Siaya (Siaya, Bondo); Kilifi
3 Zoosemy (animal metaphors through which complex and abstract entities in human behaviour are understood) common in many languages do not appear to have much bearing on food taboos. Examples include pig for ill-natured person and glutton; donkey for stupid, uncouth person; bitch for mean, spiteful female; sheep as unthinking imitator or overly obedient person; and cow for unpleasant and stubborn person (Kleparski, 1990; Kleparski, 2002). Similarly, the corresponding food metaphors (foodsemy) do not appear to have much bearing on taste or nutritive value of food e.g. bread as a synonym of money (as in breadwinner); sugar as kind or handsome; and cabbage for stupid. 4 In the Devils Garden, Allen (2002) argues that food taboos were so important to our ancestors that they often starved to death rather than violate them, and at least half of the worlds current populationfrom cow-crazy Hindus to kosher Jews to young Western vegetariansstill live with severe dietary restrictions on a daily basis. For many, these laws are crucial in defining themselves in relationship both to God and to their fellow humans, and fundamentally shape the societies in which they live. He adds that the laws about forbidden food tell us quite a lot about the nature of pleasure and can turn the daily meal into a meditation on humanitys relationship to the delicious and the revolting, the sacred and the profane.

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(Kilifi and Malindi); Embu (Mbeere, Embu); Meru (Tharaka-Nithi, Nyambene, Meru Central); Baringo (Baringo and Koibatek); Busia (Teso and Busia); and Bungoma (Mt Elgon and Bungoma) districts. 3.5 Del Monte Corporation (1969) had also conducted a detailed study on food habits in Kenya. One of its observations was that the male family members are in a favored position in quantity and quality of food they receive. That is, when there is a limited amount of food in the family pot or a limited amount of animal protein in the stew, the father and sons, especially older boys, receive proportionately more food or meat than the mother or daughters receive. It is probably only among the Kikuyu that feeding habits traditionally favored women. Anderson (1937) observed that it has been noticed that the women, or probably only the young women, are better nourished than the men. The young women undoubtedly eat a greater quantity of food than the men, and before marriage do less manual work. The reason for this custom is probably connected with the aesthetic values in the marriage market of rounded carves due to a generous subcutaneous adipose deposit.

FOOD REGIMES
3.6. In Narok district, ugali seems to be acquiring the status of a staple food for the Maasai due to reduced milk output. This is especially true in times of scarcity because ugali is more filling when satiety is the basic consideration. The new foods are acceptable due to changing environmental conditions and immigrants into the district. The immigrants are mainly agriculturalists who come with their own culinary habits, which the Maasai prefer to add to rather than substitute for their traditional diet. Fruits are particularly popular with children, but are less popular with older people, and the latter do not care very much about fruits as an important food item. 3.7. The diet of the Maasai is heavily influenced by seasonality. During drought, the most hard-hit in terms of nutritional intake are the mothers, children and the old who have to stay at home while young men take goats and cattle away into the hills in search of pasture. While there may be little milk for the herders, there is absolutely none for those who remain at home. For people who rely heavily on a milk diet, this causes great hardship. People are now forced to eat ugali and kale (sukumawiki) both of which have to be purchased at a dear price. 3.8. The traditional diet of the Keiyo and Marakwet was predominantly meat, milk and blood supplemented by sorghum and millet which were cultivated, while wild fruits and vegetables were gathered from the forest. At present, they are coming to depend more and more on cultivated and purchased cereals (maize, millet, sorghum) which form their basic staple diet but there is still heavy reliance on the gathering of vegetables and fruits from the forest or bush. Vegetables are preserved by drying them in the sun, which is a process of dehydration. When needed for cooking the dry vegetables are first soaked in water to restore the water content. 3.9. The traditional diet of the Tugen was predominantly meat, milk and blood, supplemented by sorghum and millet which were cultivated. Wild fruits and vegetables were gathered from the forest. Men had their favorite parts of the animal which were for them alone. Any person daring to eat them would violate tradition. These parts were the tongue, the liver and the heart. The authors conclude that the diet of the Tugen was and is still rich and varied. 3.10. In South Nyanza and Siaya, the staple food and drink are made from cereal grain flour. Traditionally, millet and sorghum are the predominant cereals. However, maize is being used increasingly. Millet and sorghum is mixed with the dried drought-resistant root tuber (cassava). The most common change in diet is the increasing dislike for ugali made from sorghum flour in favor of ugali made from maize flour. Consequently, the cultivation of sorghum in the whole district is declining rapidly. 3.11. The authors note that another important change, at least for South Nyanza, has been dislike of porridge (uji) and preference for tea and coffee, which affects both nutrition and incomes negatively. Tea and coffee require sugar and bread to constitute an acceptable food/drink, and these items require money to purchase. The changes in dietary practices have monetary implications, and the only avenue for rural farmers to improve their monetary income is through cultivation of fiber crops (such as sugarcane and cotton) and sale of livestock.

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3.12. The staple diet for the Akamba was and still is maize mixed with various types of beans such as pigeon and cowpeas, nzavi (bonavist beans) and mbumbu (lablab purpureus). Other types of food include finger millet, sorghum, bananas, sweet potatoes, yams, pumpkins, arrowroots and sugarcane. 3.13. The Kikuyu often vary their food from time to time with the method of preparation and different combinations but the ingredients considered as staple are almost the same. Traditionally a lot of sorghum and millet was consumed in various forms e.g. as muthura and fermented porridge (ucuru). When cooked whole they were mixed with legumes like pigeon peas, beans, njahi (bonavist beans) and mashed with vegetables and potatoes. These were mainly consumed before the 1950s. Beans were preferred instead of the more nutritious njahi and pigeon peas because beans have a short maturity period, and have higher yields. In 1931, Orr and Gilks published a comprehensive study comparing the health status of the Maasai (meat eaters) and Kikuyu (vegetarians) which shows that Maasai men were 5 inches taller and women 3 inches taller than the Kikuyu men and women living in the same region, while Maasai men were typically larger in the chest and narrower in the abdomen than Kikuyu men5. 3.14. The authors of the Kilifi socio-cultural profiles note that the inhabitants tend to overcook vegetables, a problem that seems to be widespread in many non-western societies e.g. among the Digo, Giriama, Samia, Meru and Embu. In this way, most of the nutrients from the vegetables are lost. The rationale for overcooking was palatability most of the vegetables such as some types of mnavu (African nightshade) have a bitter taste and need to be boiled for a long time to reduce the bitterness, make them soft and therefore more palatable. However, even the vegetables that are not bitter such as mchicha (pigweed) are also overcooked. 3.15. The traditional crops in Taita Taveta were those required for food and drink. The first missionaries to settle there found the Saghala cultivating sweet potatoes, sorghum, pumpkins, a pumpkinlike plant, cowpeas, bananas, maize, beans and sugarcane. The main crops nowadays are bananas, beans, maize, certain vegetables and fruits, cotton and coffee. Cowpeas, green grams and pigeon peas are important in some areas. The authors note that, although game parks, particularly Tsavo East and Tsavo West national parks, play a valuable conservation role and generate foreign exchange for the country, Taita Taveta alone contributes about 47% of the total area of Kenyas national parks. 3.16. The Samburu socio-cultural profiles give an important case study of impact of undercooking of animal products on human health. Tapeworm and tinea (ringworm) are among the commonest parasites among the Samburu, mainly because of the communitys habits of meat preparation. All meat is eaten irrespective of whether or not it comes from a dead or sick animal. Epidemics of poisoning from eating bad meat are frequently observed at the District hospital. It is also a traditional practice to eat some parts of an animal raw. Kidneys and sometimes liver are eaten while still warm from the animal. 3.17. According to the early explorers, the Turkana will eat anything, even dogs, but more recent accounts draw the line at dogs and perhaps jackals and hyenas. There seem to be few foods or animals that cannot be eaten but rather more that are not normally taken according to custom, for example certain birds (open bill, stork, marabou stork, sacred ibis, secretary bird, vulture, eagle, hornbill, crow), snakes and most insects. The impression is that almost all avoidance is due to taste rather than principle and if the need is great enough the objection can be waived. One of the disturbing childrearing practices among the Turkana is that dogs are expected to consume any faeces and lick the buttocks clean, which is the path to contracting hydatid disease (Wandeler et al, 1993; Harragin, 1994; WHO/OIE, 2002; Macpherson, 2005).

Malinowski (1945) observed that the Maasai need more gruel and the Kikuyu more steak, but we cannot spoonfeed the former nor fork-feed the latter. He adds that the Masai, through the age-long formation of their habits, have developed a cultural attitude which makes them simply dislike vegetable food and despise agriculture. The Kikuyu object equally to an excessive diet of meat, though from time to time they like to gorge on a slaughtered animal see also Worthington (1936) and Worthington (1938).

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INFANT AND CHILD FEEDING

3.18. Due to the emphasis on breast-milk supplemented by cows milk, the Maasai of Narok and Kajiado introduce solid food to the children very late, at the age of 1 years. Weaning among the Maasai is generally done when the child is one to two years. It has to be done in wet season when there is plenty of milk available. The main health problem related to diet which affects children is lack of vitamins because vegetables are not utilized. Conventionally, Maasai do not eat vegetables either home grown or wild. 3.19. Among the Maasai, some unusual illness, for instance a child failing to thrive, may be attributed to witchcraft or a curse or to the uttering of harmful words, literally a bad mouth (enkutuk torono). 3.20. Among the Keiyo and Marakwet, the initial food for a newborn baby is breast-milk and juice from a local plant whose roots are boiled as medicine. The medicine is given to the baby twice a day for three weeks, and is supposed to clean the childs stomach. Boiled soup from meat is also given for good health. Breastfeeding continues up to the period of the next conception (traditionally this was approximately two and a half years). Along with breastfeeding, other foods were introduced at about the age of six months when the teeth started to grow and marked the beginning of the weaning phase of the child. 3.21. The Baringo socio-cultural profile covers the Tugen, Pokot and Ilchamus (Njemps). Among the Tugen, newborn babies were given water and breast-milk. After two weeks, traditional medicine from the roots of a local herb were mixed with cows milk and given to the infant to remove any diseases, especially stomach upsets. At four months, babies were given cows milk to supplement the mothers breast-milk. This continued up to six months of age when millet porridge was introduced especially for children of mothers without enough breast-milk. Weaning took place after two years, at which the infant was introduced to adult diet. Among the Pokot, infants up to three years of age were not allowed to drink milk mixed with ash (iwuthi) because it was believed that their stomachs could not digest it easily. 3.22. The feeding and weaning methods in Siaya were reported as slightly different from what used to be thirty to forty years ago. Children then would be breastfed for a minimum of 2 years but quite a number continued for 3-6 years. Complementation started from the second month with porridge made from finely ground sorghum flour and sour or fresh milk added. It was force-fed to the infant about three or four times a day. 3.23. According to South Nyanza and Siaya district socio-cultural profiles, the Luo believe that if either parent commits adultery, their children will be affected by chira, an illness which leads to chronic thinning and debility. Consequently, kwashiorkor was formerly thought to be a result of witchcraft (iro), curse (kuongruok) or through ignoring, not necessarily consciously, some kind of relationship taboo (chira). 3.24. In Marsabit district, weaning is done in the wet season between eight and twelve months of age. It has to be done in wet season when there is plenty of animal milk. 3.25. Among the Akamba, the newborn used to rely entirely on breast-milk. Breastfeeding was done for as long as possible, until the child has grown up and could walk and talk. 3.26. In Kilifi, immediately after birth a baby is given a concoction prepared from the muhungula root to clean the stomach and prevent infection. Slowly the child is introduced to adult food although foods like cassava and some meals have to be pre-masticated. The impact of urbanization on child feeding was evident e.g. among mothers employed in plantations. These mothers had little time for the children, and left them under the care of ayahs (house helps). 3.27. The incidence of child malnutrition in Kilifi and Kwale is very high arising from the feeding habits especially at the stage of supplementation, accompanied by traditional beliefs surrounding child health. Although all mothers breastfeed for a long time, health problems arise as from 6 months when the milk is inadequate for the child and the supplements are not adequate in terms of nutritional value. Among the Mijikenda, the basic weaning foods (notably maize porridge and cassava) are low in nutritional value particularly for a young and growing child. The child cannot consume enough of the starchy foods in order

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to gain adequate protein. In addition, the use of traditional medicine and the attribution of the incidence of malnutrition to either moral transgression or witchcraft place the childrens health at risk, as hospital treatment is usually committed in the advanced stages of the condition. Kwashiorkor or marasmus is not viewed in relation to food availability and quality. For example, marasmus is attributed to adultery on the part of the childs parents. The danger with the belief is that at the level of treatment, therapy is usually directed to the offenders (the presumed adulterers) rather than the victim (the child) who may continue to suffer. 3.28. In Taita Taveta, the child is fed first with warm water mixed with salt and sugar and then nursed at the breast from the first day. The mother is given honey mixed with water to strengthen her and clean her system. Traditionally, Taita and Taveta babies are given solid food soon after birth. Roast bananas mashed and mixed with milk and honey commonly known as kibulu (Taveta) is fed to the baby. The mother chews the kibulu and feeds the child mouth-to-mouth, simultaneously with breastfeeding. This continues for a long time until the child is consuming more solid food than milk. 3.29. Among the Mbeere, a child with kwashiorkor was regarded to have been bewitched and consequently only a diviner (mundu mugo) could provide the treatment. The cause of marasmus was attributed to adultery on the part of the mother with her secret lover, hence its local name murimu wa anyanya (the disease of friends, lovers). Among the Embu, kwashiorkor was attributed to a curse or breaking of a taboo within the clan such as adultery. In both cases, there was no link between the mode of feeding, types of food, and the incidence of malnutrition. 3.30. Among the Meru, children are breastfed for long periods, i.e. an average of two to three years and among the Tharaka until the child is able to run errands. There is also adequate food after weaning. Malnutrition cannot be identified by local terms, which may be because malnutrition was probably a rare health problem in the traditional setting. However, there was no link or association between diet and malnutrition as a health condition. 3.31. Among the Iteso, an infant has only mothers milk for the first three months, after which it is also given porridge made from finger millet, ghee and milk. For the Luyia, mothers milk is supplemented from the beginning with porridge of cassava and sorghum flour. From the seventh to eighth month, the child may start eating staple foods. In the case of the Luyia groups (that comprise the Luhya ethnic cluster), what is regarded as food (staple) consists of flour of cassava and sorghum which is prepared into a thick cake (obusuma). Among the Iteso the traditional staple food (akima kakinyet) used to consist of finger millet mixed with ghee. Thus, both groups practiced and still practice mixed feeding. 3.32. The Busia district socio-cultural profile makes an important contribution to the link between weaning foods and child malnutrition. The Iteso eat finger millet, which ranks higher in food value than the cassava and sorghum eaten by the Luyia groups. It is also these staple foods which are fed to infants during the weaning period in the form of porridge. Because of the higher food value in the Teso staple, there is lower incidence of malnutrition except in very poor homes where the food is simply not available. Traditionally, among the Iteso, there existed no term for marasmus/kwashiorkor, as they say such health conditions were rare. 3.33. On the other hand, malnutrition seems to have existed among the Luyia groups for a long time. Traditionally malnutrition is not in any way associated with food intake; conversely, food may not be used as a remedy for such a disorder. Ekhira (marasmus) refers to a disorder and is thought to be an affliction induced by a breach of or deviation from a social norm, particularly adultery on the part of either of the childs parents. The Samia believe that malnutrition is caused by either adultery or obusura (the evil eye). 3.34. Among the Bukusu, infants were given fresh milk in addition to their mothers breast-milk. After about 6 months, they were accustomed to more solid foods e.g. bananas and potatoes. After one year, they were given food just like any other children in the family. Among the Samburu, infants are breastfed and also given the available milk.

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FOOD RESTRICTIONS
3.35. According to the Busia district socio-cultural profiles, the food consumed in a community is a cultural culinary expression of that particular group. The prohibitions, otherwise known as food taboos, may prevent a particular group from getting access to certain foods. In some cases prohibited foods, especially those of animal origin, may be considered totemic. These totemic animals are believed to have a special connection between the living and the supernatural world. Sometimes, far from totems, food may be associated with other kinds of misfortunes. 3.36. There are various traditional norms among the Maasai on food and eating habits, governed by age and sex. These categories include pregnant mothers and morans referred to as rampau. For example, expectant mothers follow certain food habits, especially during the latter stages of pregnancy. Pregnant women among the Maasai have a very frugal diet. They are literally starved from three months of the pregnancy onwards. She is expected to reduce the normal amount of milk that is drunk. This is particularly adhered to in the case of a first pregnancy. For women who have delivered twice or more, starvation is not so strictly enforced though it is still observed. The main reason given is that this prevents the baby from growing too big and thus presenting a difficult delivery. 3.37. The eating of mutton is also controlled. To avoid the fetus or the mother putting on extra weight she is forbidden to mix milk with starchy foodstuffs. The authors conclude that, one cannot really talk of food taboos in the strict sense among the Maasai. A pregnant Maasai woman is not supposed to eat the meat of any animal that has died of disease as the same may kill the unborn baby, mother or both. She is only supposed to eat meat from an animal that is killed while it is healthy. 3.38. In general, the Keiyo and Marakwet people manifest very few food taboos. The few there are seem to be based on the peoples ideas about health and are limited to certain stages of the individuals lifecycle, notably to pregnant women and uninitiated boys and girls. For example, a pregnant woman is prohibited from eating honey and eggs, the rationale being that if she does, the baby will be too big, so presenting difficulties at the time of delivery. For the same reason, she was only allowed to drink a little milk. Meat was to be eaten with caution. In addition, the meat consumed had to be ascertained to be free of contamination. She was therefore not allowed to eat the meat of a cow that was suspected to have died of disease (as the disease might be transmitted to the fetus via the mother) or one which had met its death during delivery (as the mother might die during delivery based on the principle of association). The authors conclude that the Marakwet food prohibitions are not a reflection of ignorance but are illustrative of the peoples sound knowledge and ideas about the close relationship between food and human health. 3.39. Very few taboos are practiced among the Tugen. The few that exist are based on the peoples ideas about health and are limited to certain stages of the individuals lifecycle. For example, pregnant women consumed meat that was ascertained to be free of contamination. A pregnant woman was not allowed to eat the meat of a cow that was suspected to have died of disease, for example, anthrax or swollen ear glands (as disease might be transmitted to the fetus via the mother). She was also not allowed to eat meat from an animal which had met its death during delivery (as the mother might also die during delivery). Thus, pregnant Tugen women cannot be said to be malnourished because they have few food taboos. 3.40. The few food taboos that are manifested among the Pokot are limited to certain individuals like pregnant mothers and spiritual leaders (werkoiyon). It is a taboo for a werkoiyon to eat liver or drink blood. It is believed that if he does so then his fortune-telling power will disappear. Pregnant women were not allowed to drink the milk of a cow that had been bitten by any wild animal or a snake, or to eat its meat (especially the intestines and the hooves). It was believed that the newborn baby would have the same marks as the bitten cow or camel if the mother broke the taboo. During the rainy season, when armyworms (kiptelek) attacked grass, pregnant women were not allowed to drink milk or eat meat of cattle, goats, sheep and camels. This was a precaution against the fear that armyworms might have been swallowed by the animals while grazing and thus poisoned their milk and meat. If these were consumed by a pregnant mother, the fetus would subsequently be poisoned.

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3.41. On the whole, there are very few food taboos observed by the Ilchamus community. The few that exist are limited to pregnant women. Pregnant women were not allowed to eat the meat of a sick animal, as the fetus will be destroyed. A pregnant woman is not allowed to eat the meat of a goat, sheep or a cow that has been partly eaten by a wild animal, as the newborn infant will have the scratches of the partially eaten animal. 3.42. Among the Luo, women of childbearing age and older are not supposed to eat chicken. Eggs are also prohibited before children developed speech. Other food taboos exist e.g. about fish, goats and birds. Most taboos are not strictly followed now and no harm is observed. 3.43. Some food regulations among the Akamba were based on age, sex and social status. This was especially true of the regulations on who should or should not eat certain parts of an animal. For various distinct reasons, females were not allowed to eat the tongue, neck, head, spleen, kidney, lungs, rectum, heart and the genitalia. For example, if a woman ate the genitalia of a he-goat, she would look down upon her husband and assume equality with him, and could not eat the tongue lest she became too talkative and irresponsible to the extent of revealing family secrets. 3.44. Among the Akamba, some food proscriptions were based on a possible link between the physical consumption of the proscribed food item and the supernatural. For example, some professional individuals in the community were expected to avoid various foods, for instance, traditional medicine men should avoid eating the meat of sheep as their medicines would become less powerful. 3.45. During pregnancy, Akamba mothers were to avoid foods such as honey, hard maize, millet porridge mixed with milk, bananas, cheese and meat. All these foods were believed to cause overdevelopment of the fetus utero and hence difficulties during delivery. 3.46. According to socio-cultural factors for Muranga district, the older generation could not eat meat from small animals like rabbits. They claimed these were for small boys. The Kikuyu never ate fish, as these were associated with the Lake Victoria people. The Ameru also did not eat fish. 3.47. Most of the food taboos in Kilifi affect pregnant mothers and children. Once pregnant, a mother is advised not to eat eggs, drink milk or eat meat as the baby would be too big leading to a difficult delivery. Children were not given eggs as there was the fear that they may not be able to talk. They were not given meat; at most they would be given only the soup. This was to dissuade children from greed and theft. Beans were also not given to children as it was believed that their stomach would swell. The food taboos directed to mothers and children in the nine Mijikenda tribes were detrimental to their health in that all of them were protein-rich foods. 3.48. In Kwale, infants are prohibited from foodstuffs that are protein-intensive (e.g. meat, eggs and green vegetables), as the children would end up stealing them or being greedy for them. The only thing they are given is soup in small quantities. Among the Digo, girls were not allowed to eat sheep or chicken till after marriage and delivery of a child. A pregnant mother was not allowed to eat the meat of an animal that was suspected to have died of disease or one which had met its death during delivery. Pregnant mothers were not allowed to eat eggs or sugarcane for fear of giving birth to babies without hair. A majority of the Digo and Duruma children and pregnant women are normally malnourished because of food taboos which deny them high protein foods. The denial of high quality protein foods to children also causes very high infant mortality rate in Kwale district. 3.49. Among the Taita, there were no special food taboos reported for pregnant women or other categories. 3.50. Among the Iteso, there are hardly any food restrictions affecting pregnant women, except for wild fruits which it is believed may cause abortion. 3.51. Food prescriptions and proscriptions among the Luyia are made with reference to the mothers and fetus health. A pregnant mother is encouraged to eat a lot of local vegetables, particularly omutere, especially towards the end of the pregnancy. Omutere is believed to ease the delivery of the baby. She is

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advised to eat intestines (believed to be of medicinal value) so as to give birth to a baby free of infections. Eating of groundnut sauce (esifuluko) is also encouraged. Taboos include meat of an animal killed by a leopard as the baby may be born with sores and rashes on the body. The mother should not eat meat of a pregnant animal as this may lead to complications during delivery the baby may get stuck, be stillborn or both mother and baby may lose their lives. Here the food taboos are based on the principle of association. On the whole the food proscriptions are few and not total in that, in the case of meat, the restrictions are waived so long as it is properly slaughtered. 3.52. In Bungoma district, Bukusu women were not allowed to eat chicken, eggs and some types of wild game. Women were also prohibited from eating meat of eenduuyu (rabbit, hare), eemuuna (squirrel), likhanga (guinea fowl), and eesiindu (quail, known in Kikuyu as ngware, kamakia arume or kaburutuki). Among the Teso and a few Bukusu communities, a hamster called esitelie (plural ebitelie) is a delicacy. Expectant mothers were not allowed to consume meat from pregnant dead animals. Such animals were a sign of bad luck. The expectant mothers were preferably given mrere (jute leaves). It is believed that this vegetable lessened labor pains and shortened the process of delivery. The vegetable was therefore specifically given to women on term pregnancies. Expectant women were not allowed to eat wild fruits because the general belief was that these could cause abortions. Old women were not allowed to eat eggs or chicken for fear that they would develop a wound on the back. 3.53. An example of food prohibition based on totemic association with that animal is the elephant among some Bukusu clans such as Batukwika and Bakoi which do not eat meat of elephant. The belief is that elephants in the beginning could utter words just like human beings6. 3.54. Among the Sabaot, no people were allowed to eat fish, monkey, baboon, wild pig, snake and others. There was a taboo against eating fish because some species of the latter (e.g. eel) resemble snakes and therefore were placed in the category of snakes. The only people allowed to eat snakes (the cobra), were the laibons. The snake was served to him by a girl who has not experienced menarche or a woman who has reached menopause. Women were not allowed to eat meat from a cow that died during calving or any other cow in calf. Expectant women were not allowed to eat ordinary foods. They were given milk from a cow that is not known to have been sick previously. 3.55. Among the Samburu, a great deal of nutritious food is still prohibited. It is an abomination to eat chicken, for instance, or any of its products, since chicken are regarded as birds. The Samburu do not believe in eating wild animals or vegetables which they consider an inferior dish. Urbanization and other forms of social change are modifying these attitudes.

EMERGING ISSUES
Food Regimes 3.56. Although the socio-cultural profiles were prepared almost two decades ago, they generate important lessons for policy. In addition, a lesson from a particular district may be generalized to other parts of the country. For example, the shift in food habits away from traditional crops (e.g. sorghum and millet) in favor of maize and maize products has led to a shift in national production patterns in line with demand. 3.57. Among the Maasai, ugali seems to be acquiring the status of a staple food due to reduced milk output. Fruits are popular with children, but older people do not care very much about fruits as an
The Bukusu taboo on elephant meat is consistent with the Pythagorean belief in the transmigration of souls, or metempsychosis (souls of individuals circulate or transmigrate from body to body, and can reappear in the bodies of other creatures), and therefore we need to avoid killing and eating the animals into which human souls can be reincarnated (Sandywell, 1996; Pomeroy et al, 1999; Alcock, 2006; Osborne, 2007). For example, Pythagoras found someone beating a puppy, and told him to stop (Osborne, 2007): Once he was present when a puppy was being beaten, they say, and he took pity and spoke this word: Stop! Do not strike it, for it is the soul of a man who is dear. I recognized it when I heard it screaming.
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important food item. During drought, the hardest hit are mothers, children and the old who have to stay at home while young men take goats and cattle away into the hills in search of pasture. 3.58. The Keiyo and Marakwet are coming to depend increasingly on cultivated and purchased cereals (maize, millet, sorghum). The Keiyo and Marakwet have traditionally practiced the technology currently marketed by home economists on preservation of vegetables after drying them. 3.59. Among the Tugen, men had their favorite parts of the animal which were for them alone. Any person daring to eat them would violate tradition. These parts were the tongue, the liver and the heart. The authors conclude that the diet of the Tugen was and is still rich and varied. 3.60. Among the Luo, millet and sorghum are the predominant cereals, but maize is increasingly being used. The most common change in diet is the increasing dislike for ugali made from sorghum flour in favor of ugali made from maize flour. Another important change has been dislike of porridge and preference for tea and coffee, which affects nutrition and incomes negatively. 3.61. In most communities in Kenya, the preparation methods of traditional leafy vegetables lead to a decrease of the nutritive value of cooked food. These include chopping before washing (loss of watersoluble vitamins, namely, vitamin B complex and C), repeated boiling and discarding the boiling water (destroys vitamin C which is the most unstable vitamin), and addition of salt (loss of vitamins B1, B2 and niacin) see Kimiywe, Waudo, Mbithe and Maundu (2007). The inhabitants of Kilifi tend to overcook vegetables. One of the factors that contribute to food insecurity in Taita Taveta is that most of the district is occupied by Tsavo East and Tsavo West national parks. 3.62. The Samburu provide an important case study of impact of undercooking of animal products on human health. Tapeworm and tinea (ringworm) are common because of undercooking meat. It is also a traditional practice to eat some parts of an animal raw. 3.63. The culinary apartheid generated by ethnic-based food habits affect the returns to various modes of production, and hence the countrys income distribution profile. It also determines the internal demand systems for particular modes of production, namely, hunter-gatherers, hoe cultivators and livestock keepers. Consumer education among the hoe cultivators to boost fish consumption would have profound impact on their nutritional status (mainly iron as fish is a rich source of iron) and on the economies of the people of the lake. The terms of trade between the hoe cultivators and the livestock keepers have tended to go against the livestock keepers, as measured by the change in ratio of livestock to cereal prices (see Swift, 2006). The huge socioeconomic divide between the people of northern Kenya (regarded by southerners as north of Kenya) and those in the south (referred by the northerners as down-country) need to be narrowed to reflect the huge benefits accruing to the country from northern Kenya (the meat reservoir). Infant and Child Feeding 3.64 Most of the communities attributed symptoms of malnutrition (e.g. kwashiorkor and marasmus) to witchcraft, curse, or violation of a taboo by the childs parents. Since malnutrition was not in any way associated with food intake, food was rarely used as a remedy for such a disorder. This was true of the Maasai (witchcraft, curse or uttering of harmful words), Luo (if either parent commits adultery), Mbeere (adultery on the part of the mother), Embu (curse or breaking of a taboo within the clan such as adultery), Mijikenda (adultery on the part of the childs parents), Luyia (adultery on the part of either of the childs parents) and Samia (adultery, or the unwarranted malevolence of others evil eye). 3.65. Although breastfeeding is universal, in some instances, it was initiated immediately after delivery, and breast-milk may be given alongside other foods from a very early age. For example, among the Keiyo and Marakwet, the initial food for a newborn baby is breast-milk and juice from a local plant, which is given to the baby for three weeks to clean the childs stomach. Among the Tugen, newborn babies were given water and breast-milk. After two weeks, traditional medicine was mixed with cows milk and given to the infant to remove any diseases, especially stomach upsets. In Kilifi, immediately after birth a baby is given a herbal concoction to clean the stomach and prevent infection. In Taita Taveta, the child is fed first with warm water mixed with salt and sugar and then nursed at the breast from the first day. Traditionally,

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Taita and Taveta babies are given solid food soon after birth. Among the Bukusu, infants were given fresh milk in addition to their mothers breast-milk. 3.66. In some communities e.g. the Maasai, solid food is introduced to the children late, at the age of 1 years. In most pastoral communities (e.g. Narok, Kajiado, Marsabit), weaning is generally done in wet season when there is plenty of animal milk available. The main health problem related to both children and adults is the low consumption of vegetables. Among the Luo, complementation with porridge started from the second month. 3.67. Kilifi provides lessons on (a) the impact of urbanization, (b) the relationship between complimentary and weaning foods and nutrition outcomes, and (c) traditional beliefs surrounding child health. For example, mothers employed in plantations had little time for the children, and left them under the care of ayahs. Secondly, the incidence of child malnutrition is very high arising from the feeding habits especially at the stage of supplementation. Although all mothers breastfeed for a long time, health problems arise as from 6 months because the basic weaning foods (notably maize porridge and cassava) are low in nutritional value. Finally, the attribution of the incidence of malnutrition to either moral transgression or witchcraft places the childrens health at risk as hospital treatment is usually sought in the advanced stages of the condition. 3.68. The difference between the Iteso and Luyia in the types of complimentary and weaning foods also provides an important lesson. The Iteso give children porridge from finger millet, which is higher in nutritional value than the cassava and sorghum given to Luyia children. Consequently, there is lower incidence of malnutrition among the Iteso. Food Restrictions 3.69. Food prohibitions in most communities were governed by age and sex. Some prohibitions were based on the perceived impact on human health, social status especially with respect to gender, and a possible connection between the physical and the supernatural, witness the case of totemic animals e.g. the elephant among some Bukusu clans. 3.70. The relationship between food and human health was mainly with respect to children and pregnant women. In Kilifi, children were not given eggs, as there was the fear that they may not be able to talk. In Kwale, pregnant mothers were not allowed to eat eggs or sugarcane for fear of giving birth to babies without hair. In most communities (e.g. the Maasai, Keiyo, Marakwet, Akamba, Kilifi, Sabaot), expectant mothers follow certain food habits, especially during the latter stages of pregnancy, to prevent the baby from growing too big and presenting a difficult delivery. 3.71. Among the Maasai, Keiyo, Marakwet, Tugen and Ilchamus a pregnant woman is not supposed to eat the meat of any animal that has died of disease. In some instances, the effect is by association e.g. that eating meat of a cow that had met its death during delivery will lead to delivery complications in the mother (among Keiyo, Marakwet, Tugen, Luyia and Sabaot). Among the Pokot, Ilchamus and Luyia, pregnant women were not allowed to drink the milk of a cow that had been bitten by any wild animal or a snake, or eat the meat of such an animal (the baby would have the same scratch marks as the bitten cow or camel). 3.72. The link between the physical and the supernatural had a number of illustrations. For example, it is a taboo for a Pokot spiritual leader to eat liver or drink blood, as his fortune-telling power will disappear. Among the Akamba, traditional medicine men were to avoid eating the meat of sheep, as their medicines would become less powerful. 3.73. Other food taboos were based on the presumed impact of diet on subsequent behavior of the target group. For example, if an Akamba woman ate the genitalia of a he-goat, she would assume equality with her husband, and could not eat the tongue lest she became too talkative. In many communities, the gizzard signified authority and was therefore eaten by men, sometimes specific to the head of the household (e.g. among the Akamba, Luo, Luhya and Kisii).

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3.74. Some food restrictions were a part of traditional preventive medicine during pregnancy. Among the Iteso and Bukusu, pregnant women were not allowed to eat wild fruits as it was believed they might cause abortion. A pregnant Luyia mother is encouraged to eat a lot of local vegetables (particularly jute plant - omurere) to ease the delivery of the baby, eat intestines to give birth to a baby free of infections, and eat groundnut sauce. 3.75. There are food restrictions where the connection with the physical (pathological) or the spiritual is not apparent. For example, among the Luo, women of childbearing age and older are not supposed to eat chicken; and eggs are prohibited before children developed speech. Bukusu women were not allowed to eat chicken, eggs and some types of wild game, while old women were not allowed to eat eggs or chicken. Among the Sabaot, all people were not allowed to eat fish, monkey, baboon, wild pig and snake. The Kikuyu and the Meru never ate fish as these were associated with the Lake Victoria people. Among the Samburu, it is an abomination to eat chicken or any of its products since chicken are regarded as birds. The Samburu do not believe in eating wild animals or vegetables which they consider an inferior dish.

WHAT OTHERS SAY

3.76. The above analysis does not imply that the traditional dietary habits of Kenyan communities were not lacking in some nutrients. Among the Kikuyu, for example, yellow maize was more common a century ago, and the change to white maize and reduced consumption of indigenous green vegetables contributed to the occurrence of vitamin A deficiency (Jansen, Horelli and Quinn, 1987). In addition, their diet was deficient in butter, milk, eggs, fruit, vegetables and meat. 3.77. Some writers have given the right of place to the age-long custom of the native inhabitants to drink limited quantities of freshly-fermented unfiltered home-brewed beer, full of yeast cells as an essential supply of vitamin B complex (see, editorial, East African Medical Journal, 1943; cited in Jansen, Horelli and Quinn, 1987). The authors go further to censure the well-intentioned but misguided efforts of the local churches and grandmotherly governments directed to cutting out this essential supply of vitamin B complex from the native diets7. 3.78. There are several analytical reports of the cultural food systems in communities in Kenya e.g. Nyanyintono (1981). He starts from the premise that people eat what they can afford provided it is defined as food in their culture. The material culture includes the tangible or physical e.g. the actual foodstuffs, tools and utensils used to cultivate, harvest, store and preserve food. The non-material culture includes the knowledge, belief systems, taboos and norms the non-tangible elements which underlie the food systems of a society. For example, North Americans, Kikuyu, Maasai and many cattle keeping societies consider beef a staple food but the cow is a sacred animal among the Hindu and eating beef is sacrilegious. 3.79. Some communities e.g. the Luyia wean the child on the normal diet of adults; the only difference is in the consistence of the food. The food must be almost fluid so the child can be fed from the palm of the mother or nurse. Many flour-eating tribes wean the child on porridge. Usually the weaning diet is mainly starch in a dilute form. The child has to take large quantities of the food in order to absorb enough but many children are too young to eat enough of the food (Nyanyintono, 1981). 3.80. Among the Samburu, the prescribed eating habits ensure that the child is healthy and is not overweight so that the mother does not get into serious delivery problems (Mukui et al, 2001). The
Grandmotherly is probably used here in the sense of being protective and indulgent. An earlier comparable use is Gavit (1922): Ignorant, with no political education, these new members of the Commonwealth took service at once in the party organization, and blindly followed the word of command. Coming from countries the inhabitants of which were languishing in wretchedness and degradation, as in Ireland, or gasping under the vexatious regime of police-ridden and grandmotherly governments, as in Germany with its Polezei-Staat, the immigrants could not resist the seduction of the word democrat, and joined the ranks of the Democratic organization wholesale, bound hand and foot. It also fits into Scotsburn (1898) description of the Socialist State as aiming to to rule and regulate (in order to prevent all tendency to variation) every detail of the individuals life with such thoroughness as shall out-Herod in the grandmotherliness of all grandmotherly governments that have ever gone before. Or Bernard Shaw (1900): At present we govern India despotically and bureaucratically, treating the native as a child who must be governed for his own good. This is the kind of government that really deserves the epithet grandmotherly.
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expectant mothers are not allowed to eat blood, offal and the head of animals. Other taboos include not to (a) drink milk from sick cows (lkulup) especially those suffering from foot and mouth disease; (b) eat meat of a cow that has died; (c) take colostrum (manang and nkirimo); (d) eat meat from cows with swollen glands (laini) or drink milk from other peoples cows; (e) eat meat pierced with a stick (ruket) to protect her from giving birth to a child with holes in the ear pinnas; (f) eat the hump otherwise she gives birth to a child with hunchback and ringworms on the head; and (g) eat leftovers. However, due to lack of adequate milk and meat, the expectant mothers are also forced to eat foreign foods e.g. tea, ugali and maize. 3.81. Other taboos to be observed by pregnant Samburu mothers are not directly related to feeding. For example, they are not allowed to engage in sexual activities. It is believed that having sex would result in baby not being able to walk. They are also discouraged from drinking water that had been stepped on or drunk by elephants or warthogs to ensure that she does not give birth to a deformed child; and looking at a deformed/handicapped person otherwise she gives birth to a child with same deformity. When she passes near a homestead where people have shifted as a result of deaths of family members, she is supposed to take dry cow dung and put it on her head to protect herself and the foetus from getting the diseases the people of the homestead died of. Among the Turkana the taboos may vary by clan. Some are instructed not to laugh at disabled people, not to drink water that has been stepped on by wild animals (e.g. elephants), not to face backwards when moving or imitate sounds of various animals; while all clans do not allow pregnant mothers to drink animal blood. 3.82. Among the Kipsigis, some taboos pertain to women regarding fertility, reproductive health and babies (see JICA, 1998). Pregnant women should not eat eggs, sweet potatoes, chicken, sugarcane, nor honey because it was believed that such foods would make the unborn baby too big and thus cause complications during delivery. Like many communities in Kenya, the Kipsigis perceived river water to be safe to drink (toiyon beek), identical to the Kikuyu saying that ma ruui matiri mugiro (river water is not prohibited, from the verb giria or prohibit). 3.83. One of the earlier studies of Kenyas food regime (see Nyanyintono, 1981) saw the husband as an important part of care, especially with respect to overall nutrition status in the family. For example, some cultures insist on a husband eating meals at home (at least eating the evening meal). The advantage of a man eating meals at home are that he notices what the family is eating or not eating; and the wife is encouraged to take care about what is served for meals and that way the quality of food eaten in a family can be improved. 3.84. Other studies suggest that mothers are more likely to allocate resources under their control to children than are fathers (see Haddad, 1992, in the case of Ghana). Studies based on the Kenyan situation also suggest that children living in female-headed households sometimes grew better than might have been expected based on family income, because intra-household distribution practices favored children more in these households than in households headed by men (e.g. Kennedy and Peters, 1992; and Onyango, Tucker and Eisemon, 1994). 3.85. Whyte and Kariukis (1991) article on malnutrition and gender relations in western Kenya perceived nutrition problems as embedded in gender and family relations. In the context of marital and familial conflict, a woman may leave home for a period of time and leave the children under the care of someone else; husbands may devote all their attention and resources to another wife (or woman); men who are away working may neglect their wives and children; husbands who are at home may not always be supportive; children begotten on the grass (the children of unmarried mothers) are normally left behind when the mother marries as her husband may not feel obliged to support the child as he does his own biological children; and a sexually active grandmother may not want to hold her grandchild for fear of exposing it to chira. 3.86. Consequently, in situations of marital conflict, male labor migration, and impoverishment, women must rely on support from others; thus, health education should be addressed to husbands, grandmothers and mothers-in-law as well as the mothers. For example, extreme thinness was often called by the term chira, and almost all the causes of chira have to do with the transgression of principles governing sexuality and seniority. The authors demonstrate that childcare is never simply a question of the relation between child and adult; it is always also a matter of relationships among adults. Children are treated as symbols of

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adult relationships. There is need for proper analysis of the impact of power and gender relations on child and family nutrition. Food habits, taboos and faddisms are a matter of popular culture and everyday democracy at household and community levels. 3.87. According to a recent empirical investigation in four districts (Kiminyo et al, 2000) the mothers who took extra food during pregnancy were Kisumu municipality (39%), Migori (5%), Kisumu district (40%), and Kwale (0%). In the rural districts (Migori, Kisumu and Kwale), most mothers reported that they serve food to their husbands first, followed by the child. In addition, most mothers reported no change in workload during pregnancy and lactation. There is an urgent need for the various ministries dealing with nutrition (principally Health and Agriculture) to prepare an update of the current food habits and taboos, using their extensive field personnel in the districts.

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CHAPTER FOUR

FINDINGS OF THE KENYA PARTICIPATORY IMPACT MONITORING

4.1. As part of the process of implementing the Poverty Reduction Strategy Paper (PRSP) within the framework of the National Poverty Eradication Plan (NPEP), the Government of Kenya, with the support of the Social Policy Advisory Services (SPAS) project of the German Technical Cooperation (GTZ), conducted a participatory impact monitoring exercise, known as the Kenya Participatory Impact Monitoring (KePIM). The purpose of the exercise was to assess the effectiveness of some poverty-focused policies and programmes using participatory tools and methodologies. The four main policy areas were food security, water and sanitation, primary healthcare, and basic education. This first phase of the KePIM exercise covered Gucha, Kwale, Makueni, Mandera, Vihiga and Transmara districts in September 2001. 4.2. In each district, three study sites were selected where the research teams held participatory assessments with the communities. In Gucha, the study sites were Nyansore sub-location in Nyamarambe division, Mukubo sub-location in Kenyenya division, and Riontweka sub-location in Nyacheki division. In Kwale, the KePIM exercise was conducted in three villages, namely, Mwamivi village (in Tiwi location, Matuga division), Ngonzini village (Kinango location, Kinango division) and Mgombezi village (Lunga Lunga location, Msambweni division). In Makueni, the study was conducted in Mtito Andei Town Council, Kithuki village in Kithuki location, and Imale Village in Tulimani division. In Mandera, the study was conducted in Dareqha sub-location in Khalaliyo division, Darwed community in Takaba division, and Elwak Township in Elwak division. In Trans Mara, the study sites were Ilookwaya community in Kirindon division, Lolgorian community, and Romosha community in Pirrar Division. The study sites in Vihiga were Kaptech sub-location in Tiriki East division, Magui sub-location in Vihiga division, and Emmaloba sublocation in Luanda division.

GUCHA DISTRICT
4.3. In Gucha district, the study sites were in Nyansore, Mokubo and Riontweka. Food production in Nyansore is low due to land fragmentation, poor seeds and poor farming methods. The local dietary habits are not diversified, with overreliance on maize. Women and children are often overburdened in food production. For example, children indicated mothers spend more time on the farms than fathers. Women in Mokubo said they till the land, while men pocket the income arising from the sale of farm produce and are the final decision makers on how the income is used. In Riontweka, the community said that drunkenness among household heads, particularly men, was one of the causes of poverty. 4.4. The communities said that poverty affects women and children most. The findings from the three study sites show that in times of food shortage, men are served first, and other family members get the remaining share. An elderly woman added that it is better for a man to die first in a household than a woman as homes headed by widows often tend to prosper than those headed by widowers. 4.5. In Riontweka, women and children toil in the tea farms, while some men drink all the proceeds from tea sale and leave their households to languish in poverty. In some households, women have the responsibility for feeding their families. 4.6. Some families cope with poverty by changing their eating habits e.g. foregoing one of the three meals and eating a light meal e.g. taking porridge during the day. However, some community leaders said that the communities must change eating habits and stop relying on only ugali. They should also increase their consumption of other foods grown in the community e.g. bananas and African (sweet) potatoes.

KWALE DISTRICT
4.7. One of the coping mechanisms has been the shift in dietary patterns. In the morning, people take tea mostly without milk with previous nights ugali or cassava leftovers. A few individuals would have porridge for breakfast. In some cases, breakfast is taken at around 11.00 am so that lunch can be skipped. Deep fried cassava is taken as snack by some community members over lunch hour instead of having a full meal. Some community members eat ugali with salty water instead of vegetables while others eat coconut

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for lunch. For supper, ugali with beans or kipande cha papa (a piece of dried shark meat) is what is mainly eaten8. The fish is not fried but boiled in salty water. Some children go to school without breakfast. At lunch hour, the children remain at school, as they know there is no food at home. The community hardly eats fruits. 4.8. There are seasonal variations in food supply, and food stress is more pronounced during dry spells, mostly January to March. During this time, the only available food is cassava and children are given priority and adults take very little. At lunchtime, adults may eat raw cassava and/or coconut to keep them going or have nothing during the day and only take one meal at night. During food shortages, the shortterm coping mechanisms include skipping some meals especially breakfast and lunch, while long-term strategies include reducing the amount of food eaten, and consumption of locally available foods like cassava, coconut, and local green vegetables. 4.9. In Mwamivi village, access to food has diminished over the past 5-10 years, and the types of foodstuffs consumed have changed. The poor, especially women, have been most affected and have resorted to employment as maids in well-off households to boost household income and food availability. The families purchase food from the shops to supplement own production.

MAKUENI DISTRICT
4.10. In Imale site, most households eat three meals a day when there is sufficient food, while some of the poorer households eat only twice daily. In times of shortage, this will be reduced to once, and the quality of the meals is never really considered. The majority survives on carbohydrates, and is not fussy about diet except for some invalids and small children who need special diet. 4.11. In times of food stress, men get preference, followed by children and women. Some of the coping mechanisms in times of food stress include reducing food intake; changing diet including eating more fruits; some men abandon their families to become alcoholics while others opt to separate from their wives; while some women may engage in prostitution (orphaned girls may also resort to this). There has been a reduction of food variety away from indigenous foods such as cassava, sorghum and millet, in favor of planting maize, beans and peas. This is because the indigenous crops require regular monitoring in terms of scaring away birds since the children who used to do it attend school. They reported that this could have reduced nutrient intake, and recognize that there will be a high incidence of disease if they continue to abandon indigenous foods. 4.12. In Kithuki, food is available when the rains are adequate. When food is available, the community eats three meals a day. Breakfast consists of porridge and ugali with tea; lunch is maize, beans, cowpeas and dengu; supper is ugali, kale, green grams and milk. Men commented that it is difficult for anyone to have a balanced diet (you eat what is available), and this affects nutrition. 4.13. Kithuki site was an exception in that they said there is more food available than in the past and people have started to plant drought-resistant crops. Generally, most of the food consumed is from own farms and only purchase when there are no rains. There is a demonstration center in the community, which trains them on good farming methods they also receive irregular visits from the agricultural extension officer facilitated by World Vision. However, men have no information about nutrition. Women leaders receive nutrition information from World Vision who in turn passes it on to the community. This has included showing methods of baking wimbi (millet) and muvya (sorghum bicolor) cakes, which are more nutritious. 4.14. In Mtito Andei, the women defined nutrition as a state where children are given a balanced diet as lack of proper nutrition may cause malnourishment (kwashiorkor and marasmus), and lack of sufficient blood (and thus anemia). To prevent this, they receive information on nutrition in public hospitals, through public officers (home economics), social workers, through the media (television and radio), through posters and private clinics.
8

Incidentally, Kipande cha Papa is also the title of song by Jamhuri Jazz Band, which graphically captures the poverty situation in these coastal communities.

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MANDERA DISTRICT
4.15. The communities identified high levels of poverty, ignorance and eating habits as the main causes of poor nutrition standards. At the household level, poverty results in reduced intake of meals in terms of quantity and diversity, increased incidence of sickness, increased dropout rates for school-going children, increased family breakup (divorces), and prohibitive demands on the mother. All the target groups identified mothers as the most vulnerable. A mother in Elwak urban center lamented: Mothers do not eat until the father and the children have all eaten, nor sleep until the crying child (because of hunger) sleeps while the men walk around in town and eat anywhere! 4.16. In Dareqha sub-location, the community said that access to food has been decreasing in the last 35 years, which has resulted in hunger and general weakness, while children had no strength or energy and some suffer from malnutrition. During the El Nino rains, all foodstuffs became very expensive (a kilo of sugar went up to KSh 120), and dietary changes included food rationing, and some people became anemic. Health deteriorated and veins protruded because of hunger, while the youth said the tagoley (very poor) were most affected and mothers and their children suffered most. 4.17. The Darwed community defined wealth groups strictly based on food availability: those who take one meal a day (breakfast only), two meals (breakfast and lunch) and three meals (breakfast, lunch and supper). The community says that out of every 10 people, seven can only afford one meal, two only afford two meals, and only one person affords three meals a day. The food consumed is normally maize. 4.18. Over the past 5 years, food has been inadequate. The El Nino rain washed away their crops and was later followed by prolonged drought. The main foods consumed are carbohydrates. The community mostly depends on relief food, but some of them purchase food by selling firewood and fencing materials. The local sources of livelihoods are livestock and some farming (millet). 4.19. In Elwak Township, one of the coping mechanisms includes reducing meals from three to one per day. There was consensus that mothers suffer most. There has been a decline in the quality of food consumed. They used to take a meal and milk but now take yellow maize. Mothers work longer hours in order to sustain the family (normally 13 hours a day).

TRANS MARA
4.20. In Ilookwaya, the community practices maternal buffering where a woman feeds her husband first, followed by the children, and she eats whatever remains after feeding the family. However, the community generally believes that it should not allow somebody to sleep without eating. During times of food stress, a woman suffers most because she eats after she has fed her husband first and children second. 4.21. In Lolgorian community, men are given a bigger portion of food. Among the children, girls eat smaller portions than boys do. The culture stipulates that children should be served first following their age (from the youngest), followed by the mother and lastly men. Men said that, in times of shortage, children are given first priority, followed by the husband (man) and lastly woman (wife). This differs from the womens view that husbands are given first priority followed by male children, female children and lastly women (wife). In general, however, in times of shortage, the two groups that suffer most are women (since it is their responsibility to ensure that children and men have food first) and girls of 10 years and above. 4.22. In recent years, there has been a dramatic change in the types of food consumed, particularly for children, women and young men. This entails eating fish, eggs, chicken, ugali, beans, vegetables, and fruits (such as avocado), which are new to the Maasai community. These changes have come about because of the influence of other communities and inter-marriages, and improve the peoples nutrition they no longer rely on one source of food. Old people (those above 60 years) have not changed their diet.

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4.23. In Romosha community, there have been changes in the types of foodstuffs consumed by the community. They have started to eat additional foods like bananas, fruits, chicken and eggs, and sweet potatoes, whereas in the past they only consumed ugali, vegetables, milk, meat, beans and potatoes. This change has come about due to diminishing food from livestock. Consequently, there has been an improvement in the nutritional status since they have a variety unlike ten years ago when they had to depend on a few types of food. 4.24. During food shortage characterized by a shortage of maize, the intra-household distribution of food consumption changes. The children and the husband are fed first and the mother eats whatever remains, but men said that at these times they allow the children to eat first. During this period, food prices are very high, forcing families to sell livestock and lease out farms. The community received nutrition information from the home economics department of the Ministry of Agriculture during one of the field days held at the farm of one of the community members.

VIHIGA DISTRICT
4.25. In Emmaloba sub-location, land holdings are small and unproductive, and they therefore mostly rely on purchased food. They do not eat quality food but only eat to get satisfied. The poor can eat at least two meals a day while the middle class can afford three meals. The rich can take what they want at any time they feel like. There is food stress especially before harvest, but preference is given to children, followed by the husband, and finally women. 4.26. Ten years ago, there was a large variety of food, but nowadays people eat only one kind of food. The livestock is mainly for commercial purposes rather than home consumption so that they can buy other necessities e.g. maize and processed foodstuffs. They do not get any assistance to improve land productivity. The community has some information on nutrition from health centers and the media but do not apply it. 4.27. In Kaptech sub-location, the quality of food has declined because people have specialized in growing similar crops (i.e. maize only). Tea has replaced crops like millet and sorghum that used to be planted in the area. However, the variety of food at the household level depends on the income of the individuals. 4.28. Women said that they are the main breadwinners when men are away and in times of shortages, and are responsible for ensuring the entire family is satisfied before they eat. They are also the main cultivators of staple food crops (e.g. vegetables, bananas, maize, beans and potatoes) as well as tea which is the main cash crop. They are not allowed to eat certain foods (e.g. gizzard) and during circumcision, they are not allowed to eat any food from the initiates. They are the most affected during food shortages together with the children. 4.29. In Magui community, people used to have 3 to 4 meals per day and the quality of food was high and good because they used to grow food rich in proteins like beans and millet. Today, many people eat one or two meals a day. Women said that they feed men first while others said that they give children the first priority. Some families give more food to children compared to other family members. 4.30. Generally, in Vihiga district, women are the main cultivators of staple food crops (e.g. vegetables, bananas, maize, beans and potatoes) and the main cash crop in the area (tea). Women are not allowed to eat certain parts of the chicken like gizzard. During breastfeeding, they do not eat fish. They also ensure that the entire family is satisfied before they eat. 4.31. There have been some diseases affecting food crops like cassava mosaic, which almost wiped out the crop, but new disease-resistant, high-yielding and early-maturing varieties are being introduced in the farms. There is also a programme for upgrading local cows where the community is given some bulls or cows to crossbreed with the local ones.

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SUMMARY AND CONCLUSION

4.32. The communities pointed out the deleterious effect of long-term weather changes on production of both crops and livestock. Among the livestock keepers in the arid areas, a major drought is expected every four years, leading to dependency on relief food. There has also been land degradation in most parts of the country due to wanton cutting of trees and overgrazing, and the bleeding of soils through soil erosion. 4.33. Though brewing illicit brew is mentioned as a coping strategy, brew taking is widely acknowledged as a cause of poverty. Children may drop out of school, the family nutrition situation declines, and time spent drinking could have been used more productively (Kenya, 2002). 4.34. Most communities mentioned the low prices of food during harvests and high cost of food during times of food stress as a major cause of food insecurity. Small-scale farmers sell food after harvest at very low prices (and hence earn meager incomes) and purchase food at high prices during times of food stress. Paradoxically, sale of food is a sign of distress, not excess. 4.35. Most of the communities visited reported that they do not receive assistance from agricultural extension officers. In other words, there is no continuous process that unites the developmental efforts of the people with those of Government authorities (see also Kopiyo and Mukui, 2001). 4.36. The gender differences are deeply embedded in the culture of the communities, and the intrahousehold dynamics relate to (a) responsibility for food production, and (b) consumption of food. Women are the main breadwinners (in the sense of hours spent in search of livelihoods, home care and fetching water and firewood), but do not have control over family resources including income. This was especially evident in the cash crop economies e.g. in the tea growing area of Gucha district where women tend tea plants and men pocket the proceeds from tea. 4.37. Generally, it was agreed that in times of food shortage, women feed their husbands first, then the children, and finally the women. The only difference between the communities was whether the child or the father ate first, and the fact that the woman eats last was not in dispute in all the communities. Apart from differences in quantities of food served various family members, women are not allowed to eat some types of food, which can lead to specific malnutrition disorders. For example, in Vihiga, women are not allowed to eat some parts of chicken (e.g. gizzards) and do not eat fish during breastfeeding. 4.38. Reducing the quantity and/or quality of food was one of the most common coping mechanisms. This implies taking fewer meals per day (which leads to malnutrition among children), and change of food (e.g. from ugali to cassava in Kwale). 4.39. The quality of food consumed is declining over time, as people no longer grow foods rich in proteins such as beans and millet. Overall, there is a move towards a national diet of maize and maize products and uni-polar definition of food security in terms of access to maize. It is only in Trans Mara and Makueni (Kithuki study site) districts where the communities said they have better access to a wider variety of foods compared to the past. 4.40. Most communities share water points with livestock, and in some cases with wild animals. Due to land pressure, people have settled near water sources, and water from latrines seep to the water sources, or human waste deposited in open bush is washed directly to the water sources. Other sources of water pollution are washing clothes at the same sources where drinking water is drawn; people bathing in the same water sources; and dangerous chemicals used by farmers during irrigation farming. These factors have polluted drinking water and led to an upsurge of waterborne diseases, some of which have direct impact on nutrition.

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CHAPTER FIVE

INDICATORS OF NUTRITIONAL STATUS ALONG THE LIFECYCLE

5.1. Most studies on nutritional status of the population tend to focus on preschool children. However, there is a new consensus around the theme of nutrition throughout the lifecycle. The analysis of nutritional status using a lifecycle approach starts from intrauterine growth retardation (represented by birth weight at term), to feeding during preschool age, adolescence and adulthood. This change is due, in part, to growing realization of the link between fetal under-nutrition and chronic diseases later in life (ACC/SCN, 2000). Undernourished adolescent girls and women give birth to underweight and often stunted babies. These children are less able to learn as young children and are more likely themselves to be parents to infants with intrauterine growth retardation and low birth weight, and so on ad infinitum. Under-nutrition that occurs during childhood, adolescence and pregnancy has an additive negative impact on the birth weight of infants. The analysis also includes micronutrient malnutrition because inadequate intake of nutrients (e.g. vitamin A, iron and zinc) exacerbates the effects of fetal growth retardation. 5.2. The 1956 groundbreaking contribution by Gmez et al titled Mortality in Second and Third Degree Malnutrition, which is a classic in the history of nutritional sciences, provided information on clinical profiles of child malnutrition and their associated risk of mortality. Gomez and his colleagues showed that severe malnutrition has a significant effect on mortality. Onis (2000) showed that mortality increase with worsening nutritional status when malnutrition was severe, but mild and moderate degrees of malnutrition had little predictive power. Onis (2000) states that malnutrition, rather than acting in a simple additive fashion, multiply the number of deaths caused by infectious disease; while Rice, Sacco, Hyder and Black (2000) state that a strong and consistent association exists between nutritional status, illness and mortality. For this reason, infant and under-five mortality are included as nutrition indicators.

MATERNAL NUTRITION AND FETAL MALNUTRITION

Nutritional Status of Women 5.3. The report of the 1993 Kenya Demographic and Health Survey (KDHS) states: maternal nutritional factors, including low caloric intake or low gestational weight gain, low pre-pregnant weight, and maternal shortness or young age at pregnancy, are the most important determinants of poor fetal growth or intrauterine growth retardation (IUGR) in developing countries. IUGR infants have a higher risk of perinatal mortality and other adverse outcomes. Additionally, women who gain too much weight given their pre-pregnancy weight for height have a higher risk of delivering a high birth weight baby, which may result to increased rates of prolonged labor, shoulder dystopia, caesarean delivery, and birth trauma. 5.4. The assessments of nutritional status in non-pregnant women represent ranges of the healthy populations studied and do not necessarily represent the ideal or desirable situation. Weight is predominantly a measure of current nutritional status, and it has been found that women who weigh less than 40 kg are at a high obstetric risk. Height is a measure of past nutritional status as well as the genetic potential of the individual (including the cumulative effect of social and economic status over generations). Women whose height falls below 145 cm have been found to be at a greater risk of maternal mortality than taller women, partly due to its association with small pelvic size, which can result in obstructed labor. The body mass index (BMI), which was originally developed to diagnose obesity, is used to assess chronic energy deficiency (CED) of lactating women or non-pregnant non-lactating women. Data from wellnourished populations show a normal range maternal BMI is between 21.5 and 23.1. 5.5. Overall, the mean height of the surveyed mothers (mothers with young children) was 159 cm and less than 1% were under 145 cm. Excluding women who were pregnant or had had a recent birth, the mean weight of mothers was 55.8 kg, and only 1.4% were less than 40 kg. Although the mean BMI for nonpregnant non-lactating women (22.3) and for lactating women (21.7) were within normal range, an estimated 10.9% of lactating women and 7.5% of non-pregnant non-lactating women met the criterion for chronic energy deficiency, or a BMI of less than 18.5.

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5.6. The 1993 KDHS shows that the important determinants of CED among Kenyan women are ethnicity, whether the mother has an underweight child, mothers level of literacy, household possession score, and whether the mother had assistance at her last birth. A mother is not likely to be malnourished if she is Luhya, her child is not underweight, she is literate, and was attended by trained health personnel during delivery. 5.7. The mean height of mothers measured in the 1998 KDHS was 160 cm, and about 1% was less than 145 cm in height. Women who had not attended school had slightly lower mean height than their educated counterparts. In addition, women of Coast and Eastern provinces are much more likely than women in other provinces to be short in stature. 5.8. The mean BMI index of weighed and measured mothers (excluding pregnant women and those who are less than three months postpartum) was 21.9, with 11.9% having a BMI below 18.5, reflecting a nutritional deficit. Rural women were more likely to have low BMI than urban women, and those with secondary education were less likely to have low BMI than their less educated counterparts. Among the provinces, Coast, Eastern and Rift Valley had the highest percentages of women who had a BMI below the cut-off of 18.5. Birth Weight and Size at Birth 5.9. The 1993 KDHS shows that mothers were able to report birth weights for 45.7% of the children. Among those children weighed, the incidence of low birth weight was 8.4%. The report notes that this is higher than the incidence of low birth weight in the US of 7%, though less than in many developing countries. In the 1998 KDHS, among births for which a birth weight was recorded, about 8% were less than 2.5 kg. 5.10. The 2000 Multiple Indicator Cluster Survey showed that, out of the live births weighed at birth, about 9.3% were underweight (below 2,500 grams). Other than Northeastern province where the rate was deceivingly low at 2.3% because the survey only covered urban clusters in the province, the provincial means of underweight children are in the range of 8.4-10.0%. The ratio of children not weighed at birth but whose mothers considered small (as opposed to large or average) was 14.0%. The analysis includes both birth weight (for children whose weight at birth was recorded and available to survey enumerators) and size at birth (as reported by the mothers based on personal impressions). 5.11. Deolalikar (1996) interrogates the 1994 fifth nutrition survey database for relationships between various anthropometrics indicators and maternal and household characteristics. He found that maternal education is consistently significant in determining child nutrition status in Kenya across all nutrition indicators. Another robust finding is the significant but numerically small elasticity of child nutrition with respect to household per capita expenditure. The most interesting finding is that marginal deficits in birth weight are not likely to be permanent. He concludes that, infants appear to be amazingly resilient, making up for birth weight deficits completely within the first year of life via biological catch-up growth.

PROTEIN ENERGY MALNUTRITION

Prevalence of Underweight in Children Under Five Years of Age 5.12. The indicators of Protein-Energy Malnutrition (PEM) are (a) underweight (the proportion of under-fives falling below minus 2 and minus 3 standard deviations from the median weight-for-age of the reference population), (b) stunting (the proportion of under-fives falling below minus 2 and minus 3 standard deviations from the median height-for-age of the reference population), and (c) wasting (the proportion of under-fives falling below minus 2 and minus 3 standard deviations from the median weightfor-height of the reference population). 5.13. The 1989 KDHS did not have an anthropometrics module. However, the 1993 KDHS obtained data on weight and height of all children under-five and whose mothers were interviewed in the KDHS. Overall, 32.7% of Kenyan children were classified as stunted and 12.2% as severely stunted. Stunting was highest among children of 12-23 months (40.3%). Stunting was also more prevalent among rural children

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(34.2%) than urban children (21.5%). The proportion of stunted children was highest in Coast province (41.3%) and Eastern (39.4%), and lowest in Nairobi (24.2%). The 1993 KDHS states that the high levels of stunting at the Coast have been observed in the previous nutrition surveys, but the appearance of Eastern province in the league of high stunting regions may be associated with drought conditions prior to the survey. 5.14. An estimated 5.9% of the Kenyan children were wasted and 1.2% severely wasted. Wasting was highest for children of 12-23 months of age (10.0%). The highest prevalence of wasting was recorded in Coast province (10.6%), followed by Rift Valley (7.9%) and Eastern (6.8%). 5.15. The 1993 KDHS reported that 22.3% of the Kenyan children under-five were moderately and severely underweight for their age, and 5.7% severely underweight. As with other anthropometrics indicators, underweight was highest among children of 12-23 months (31.6%), the period which is characterized by weaning (gradual termination of breastfeeding) and highest incidence of diarrhoea. The prevalence of underweight children was higher among children in rural areas (23.5%) than urban areas (12.8%). Children in Coast (31.7%) and Eastern (28.8%) are much more likely to be underweight than children from other provinces. 5.16. The 1993 KDHS showed a clear age-specific proportion of children suffering from stunting and wasting. The prevalence of stunting starts to rise precipitously at about 1 month of age and continues to rise until about 18 months of life when it affects nearly one in two children. Wasting increases rapidly between 6 and 12 months of age and stays high through 24 months of age. Between 12 and 24 months, about 10% of the children are affected. Wasting levels then decline to about 5% in the third year. Underweight (which reflects both chronic and acute nutritional status) follows roughly the same pattern as stunting but picks earlier, at about 12 months, due to the rapid rise in wasting. Since these results are based on cross-section data, it cannot be concluded with any certainty whether these are actual trends in nutrition indicators or whether they reflect deficits accumulated in the first two years after birth. 5.17. The 1993 KDHS states that malnutrition has a synergistic relationship with disease that causes an increase in the risk of mortality. It postulates that 38% of all deaths that occur before age five are related to malnutrition. Mild and moderate malnutrition contributes 34% and severe malnutrition contributes only 4%. Among children under five years of age, stunting was positively associated with low birth weight (or mothers report of infant size at birth), gender of child (boys had a greater level of stunting), not breastfeeding at time of survey, reason for stoppage of breastfeeding (worst for those weaned because their mothers were pregnant), incidence of diarrhea, and low maternal education. 5.18. The 1994 fifth nutrition survey showed that 33.6% of the children were moderately and severely stunted and 14.7% were severely stunted. The stunting levels were highest in Eastern province (38.5%), followed by Coast (38.3%), Western (37.0%) and Nyanza (36.4%). A reported 7.8% were moderately and severely wasted and 2.1% severely wasted. Wasting was highest in Northeastern province (25.4%), followed by Rift Valley (8.2%) and Eastern province (7.8%). The national prevalence of underweight in children was 22.5%, with the highest recorded in Northeastern (30.0%) followed by Coast (27.0%), Eastern (26.7%), Western (26.3%), Rift Valley (24.6%), Nairobi (22.0%), Nyanza (20.0%) and Central (13.9%). 5.19. The report of the fifth nutrition survey investigates the household characteristics that might be correlated with child nutrition indicators. The report shows that indicators of stunting and underweight were correlated with sickness in the two weeks before the survey (mainly diarrhea and malaria). The report concludes that a malnourished child is likely to fall ill and a sick child to become malnourished. The percentage of stunted children tended to decrease with the level of mothers education. In addition, households that had no stunted children had higher mean household expenditures (especially on protein foods) than those with stunted children. However, a comparison of mean household expenditures of households with wasted children and those without wasted children does not depict a clear relationship, probably because wastage is more of a consequence of short-term deficiencies. Households with no underweight children were spending more on food items than those with underweight children. 5.20. The prevalence of underweight children (moderate and severe) in year 2000 was reported in the Multiple Indicator Cluster Survey (MICS) at 21.2%, with the severely underweight at 5.7%. The proportion

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of stunted children was estimated at 35.3%, and 14.7% for those severely stunted. The proportion of wasted children was estimated at 6.0%, and 1.4% for those severely wasted. The proportion of low weight children at birth was also a high 8.4% (according to KDHS, 1998), coupled with a declining trend in the period of exclusive breastfeeding, which implies poor initial conditions for children (due to poor maternal health) and the nutritional conditions under which they are reared. 5.21. The report of the MICS compares child nutrition indicators generated by the MICS and those of the 1998 KDHS. The comparison shows that the proportions of underweight moderate to severe was 22.1% in KDHS and 21.2% in MICS, and severely underweight were 4.8% and 5.7%, respectively. The proportion that was moderately to severely stunted was 33.0% in KDHS and 35.3% in MICS, while those severely stunted were 12.7% in KDHS and 14.7% in MICS. The proportion of moderately and severely wasted children was 6.1% in KDHS and 6.0% in MICS, while the proportion of severely wasted children remained the same at 1.4%. 5.22. The proportion of underweight in children has remained around 22% in the whole of the nineties. As shown in the KDHS (1993, 1998), Fifth Nutrition Survey (1994) and MICS (2000), Kenya has not made any gains in child nutrition in the last decade. The regional distribution of underweight in children underfive shows that Eastern and Rift Valley provinces have been consistently below the national average, while Nairobi and Central have been consistently above the national average. Coast province has been consistently above the national average except for year 2000, while the low proportion of underweight in children in Northeastern province in year 2000 is probably because the survey only covered urban areas of the province. 5.23. The provinces that reported the highest proportions of underweight in children in year 2000 MICS were Rift Valley (24.9%), Eastern (29.6%) and Coast (21.1%). The same pattern of regional disparities in underweight children was observed in the 1998 KDHS. Coincidentally, the 1998 KDHS showed that Coast, Eastern and Rift Valley provinces had the highest percentages of women (excluding pregnant women and women less than 3 months postpartum) who had body mass index (weight in kilograms divided by squared height in meters) below the cutoff point of 18.5 (reflecting a nutritional deficit). This implies that there is food stress in the provinces or some areas within the provinces that undermines the nutritional base of the mothers and their children.

MICRONUTRIENT MALNUTRITION
5.24. The World Summit for Children goals on micronutrient deficiencies were (a) to reduce iron deficiency anaemia in women by one third of the 1990 level, (a) to virtually eliminate iodine deficiency disorders (IDD), and (c) to virtually eliminate Vitamin A deficiency (VAD) and its consequences, including blindness. On nutritional anaemia, the 1992 National Plan of Action for Nutrition stated that, since the prevalence of nutritional anaemia among women in Kenya is unknown, the Government will undertake or commission studies to determine the prevalence of nutritional anaemia among women and children. On IDD and VAD, the Government was to undertake nationwide surveys to determine their prevalence. Generally, real progress has being made in combating iodine deficiency, some progress has been made in combating vitamin A deficiency, but little has been achieved in the area of iron deficiency. 5.25. Zinc is a trace mineral essential to all forms of life because of its fundamental role in gene expression, cell development and replication. Zinc deficiency is a condition characterized by short stature, impaired immune function, skin disorders, cognitive dysfunction and anorexia. Zinc deficiency is largely related to inadequate intake or absorption of zinc from the diet, although excess losses of zinc during diarrhea may also contribute. The health outcomes of zinc deficiency include risk and/or severity of diarrhea, pneumonia, malaria, measles, physical impairment, visual impairment or blindness, and mortality. 5.26. The nutrition section in the then Division of Family Health, with financial support from UNICEF, undertook a micronutrient survey in February 1994. The main objectives of the survey were to (a) determine the prevalence of Vitamin A, iodine and iron deficiencies in Kenya, (b) determine the possible causes of the deficiencies where they occur, (c) determine the geographical distribution of these deficiencies, and (d) identify the groups at risk. The survey was carried out in 49 districts and entailed clinical assessments, interviewing for frequency of food intake, and available food resources.

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Iodine Deficiency Disorders 5.27. The Kenya National Micronutrient Survey of 1994 records a goiter rate of 16%. In a study of 45 districts, only three (Taita Taveta, Kajiado and Uasin Gishu) did not have an IDD problem. Twenty-nine were classified as mild iodine deficiency areas with 5-19% prevalence. Moderate deficiency occurred in eight districts with prevalence of 20-30%; while severe iodine deficiency occurred in five districts with prevalence greater than 30% (see the 1998 Situation Analysis of Children and Women in Kenya). 5.28. In various surveys carried out between 1962 and 1974, goitre was found to be highly prevalent in the highland parts of western Kenya (see, for example, Bohdal, Gibbs and Simmons, 1968; Hanegraaf, 1974). As a result of these surveys, iodination of salt started on a voluntary basis around 1970 (Alnwick, 1988). In 1978, legislation was introduced as part of the Food, Drugs and Chemical Substances Act, which stipulated that all table salt or salt for general household use sold in Kenya should contain 33.7 mg of potassium iodate per kilogram of salt, or if the salt did not contain iodine it should be conspicuously labelled that this salt does not supply a necessary nutrient. The regulation allowing un-iodated salt to be sold was amended in 1988 to require all manufacturers and distributors of salt for domestic consumption in Kenya to iodinate their salt. 5.29. Currently, the Food, Drugs and Chemical Substances Act (cap. 254) restrict the sale of table salt which does not contain the required potassium iodate. Meetings are regularly conducted with salt manufacturers on the restriction of sale of iodized salt, and easier channels of manufacturers access to potassium iodate have been created. The Ministry of Healths public health officers and Kenya Bureau of Standards inspectors conduct spot-checks in the salt manufacturing firms and on salt sold in the market. According to the 2000 MICS, the percentage of the population consuming adequately iodated salt was 90.7%, a rate that the report states is relatively high and therefore good. However, the supervision needs to be strengthened by sensitising extension officers on the usefulness of doing more field and on-site (i.e. salt manufacturing factories) spot-checks, while the Ministry of Health also needs to supply more kits for such spot-checks. 5.30. The public health education system has not been as successful on the need for iodine in the salt and the systems of handling table salt in wholesale and retail outlets, during transportation and in the households, to prevent loss of iodine in iodated salt. For example, during storage, potassium iodate slowly decomposes to elemental iodine, which evaporates (Alnwick, 1988). The rate of decrease will probably depend on temperature and humidity during storage, nature of packaging material, extension of exposure to light, and duration of storage. Partial loss of iodine occurs if the salt is put too early during cooking, is kept in open containers or in damp places. A costless activity would be to sensitise the public media, so that the media can cover the issues of the consequences of iodine deficiency and handling of salt as part of their normal reporting or feature articles (Mukui, 1994b). Vitamin A 5.31. Vitamin A rich foods are consumed by a majority of children in Kenya, but the availability is seasonal. The 1994 micronutrient survey conducted in 14 districts showed the presence of VAD in all the districts covered. Nyeri, Meru and Nakuru districts had a moderate prevalence (10-19%) while Mombasa, Kwale, Kitui, Kisii, Kisumu, Bungoma, Baringo, Garissa, Mandera and South Nyanza had a severe rate of above 20%. The most affected children were aged 6-24 months due to poor feeding practices such as being fed on porridge, with or without milk. 5.32. The 1999 micronutrient survey examined iron deficiency anemia (IDA), vitamin A deficiency (VAD) and zinc deficiency among children, women and men. Vitamin A deficiency among women and children was high, as 88% of preschoolers and 51% of women were found to be vitamin-A deficient (mild to moderate). These findings follow a trend reported in 1994. 5.33. Vitamin A is an essential micronutrient for normal functioning of the visual system, growth and development, maintenance of epithelial cellular integrity, immune function, and reproduction. Vitamin A deficiency occurs when body stores are depleted to the extent that physiological functions are impaired. It

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is linked to the nature of foods available and feeding practices. Clinical deficiency of vitamin A is defined by the presence of night blindness, bitots spots, corneal xerosis and/or ulcerations, and xerophthalmiarelated corneal scars. 5.34. Only a little vitamin A is needed to keep a person healthy and seeing well. Adding some oil or fat to the food helps vitamin A to be absorbed from the gut. Vitamin A is stored in the liver. Therefore, people and particularly children can eat enough vitamin A-rich foods when they are in season to give them a store of vitamin A that lasts them for several months afterwards. The strategies to overcome VAD include (a) dietary diversification, (b) food fortification, (c) vitamin A supplementation, and (d) public health and disease control measures. The first two strategies are food-based approaches and are preferred long-term strategies because their benefits go beyond the prevention and control of micronutrient deficiencies. 5.35. The dietary deficiency strategies include (a) increasing small-scale production of vitamin A rich foods through home gardening, school-based gardening programmes, and small animal, poultry and fish production, (b) maintaining vitamin A levels in commonly eaten foods through improving food storage and preservation, improving food safety, and better food preparation at household level, (c) plant selection and breeding to increase vitamin A levels (e.g. genetic modification of staple foods to enhance vitamin A availability), (d) promoting, protecting and supporting breastfeeding, and (e) nutrition education that promotes the consumption of vitamin A-rich foods by young children and women. 5.36. Food fortification is the addition of nutrients to commonly eaten foods to maintain or improve the quality of a diet. A fortification programme is usually undertaken in response to dietary, biochemical or clinical evidence of nutrient need. Periodic supplementation that provides high-dose vitamin A capsules both to children from 6 months to 5 years and beyond and to mothers soon after childbirth has proved to be a very valuable intervention. Children should receive supplements at least twice a year. 5.37. Vitamin A is available from animal sources in the form of retinol and from dark green leafy vegetables and yellow and orange non-citrus fruits and vegetables in the form of provitamin A carotenoids (which can be converted by the body into vitamin A). Foods rich in retinol include colostrum, breast-milk, liver, eggs and whole milk. Vitamin A from plant sources is less easily absorbed and utilized by the human body it is less bioavailable than the vitamin A coming from animal products. In developing countries, most of the vitamin A consumed comes from plant sources and thus is in a less bioavailable form. Moreover, vitamin A from plant sources is usually found in large amounts in only a few fruits and vegetables, many of which are highly seasonal. This means that low-income populations may suffer from both chronic mild-to-moderate vitamin A deficiency and severe seasonal deficiencies. 5.38. Tropical and subtropical plant foods rich in beta-carotene include dark green leafy vegetables, fruits (e.g. mango, passion fruit, papaw, avocado, orange and loquat), orange-fleshed sweet potato, pumpkin, carrot, red palm oil and red pepper. According to Ruel (2001), there is need to integrate strategies to promote changes in behavior along with home gardens, i.e. nutrition education. One of the projects that have demonstrated behavior change is the production of new varieties of sweet potatoes (Ruel, 2001; Oyunga, Hagenimana, Kurz and Low, 1998). Home gardening and promotional and education interventions have a great potential to improve vitamin A nutrition especially when they are combined. 5.39. Heat treatments such as deep-frying, prolonged cooking and baking, and a combination of multiple preparation and processing methods result in substantial losses of provitamin A carotenoids. Simple modifications such as cooking with the lid on, reducing the time lag between peeling or cutting and cooking, and limiting the overall cooking, processing, and storage time can improve retention. 5.40. Appropriate preservation techniques can increase availability throughout the year: Vitamin A is found in large amounts in only a few foods, many of which are highly seasonal. In addition, its ingestion during period of abundance may not be sufficient to maintain adequate status throughout the year, and postharvest losses are often substantial for some vitamin A-rich foods. For example, mangoes ripen quickly and the population cannot consume the whole harvest over the short period when they are available.

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Iron 5.41. According to Ruel (2001), iron can be obtained from both animal and plant sources. Iron from plants (nonheme iron) is less bioavailable than iron from flesh foods (heme iron) such as meat, fish and poultry. Heme iron is highly bioavailable (15-35% is absorbed); whereas nonheme iron is absorbed much less easily (only 2-20% is absorbed). The main reason is that nonheme iron is affected by compounds present in the plant foods that inhibit its absorption. The most potent inhibitor of nonheme iron absorption is phytic acid, which is present in large quantities in most cereals and legumes often the main staple foods in the populations with scarce resources. Where consumption of iron absorption inhibitors is high (tannins as found in coffee and tea), low dietary intake of iron-rich foods is likely to be particularly indicative of levels of IDA. 5.42. Two principal forms of direct intervention are available: (a) supplementation, the distribution of hematinics (iron and/or folate) in tablet or (in the case of infants and young children) liquid form, and (b) fortification, where the hematinic is supplied by adding it to some foodstuff. Fortification also includes adding some facilitator of iron absorption such as ascorbic acid. Ruel (2001) observes that investments in reducing micronutrient malnutrition have traditionally focused disproportionately on supplementation and fortification programs and policies to the detriment of food-based approaches, which focus on increasing the amount of micronutrients consumed in the diet and on making a larger share of these nutrients bioavailable (readily absorbed by the human body). 5.43. by: Food-based strategies can increase the amount of vitamin A and iron available for body functions Increasing the production and availability of foods high in these nutrients, Increasing consumption of these foods through nutrition education programs to change their eating behavior, Making vitamin A and iron more easily absorbed by the body (more bioavailable), By breeding new varieties of plants that contain larger amounts and more bioavailable micronutrients.

5.44. If food is cooked in an iron pot, it absorbs a considerable amount of iron from the pot, and this becomes a significant source of iron. In the Kenya case, the dominant cooking pot material is aluminum (Kenya and UNICEF, 2000). Compared with vitamin A, production and education interventions to increase the supply and intake of iron from plant foods have not been popular. Although home gardens, fishponds and animal husbandry have been associated with higher iron intake and iron status, there is a tendency to sell home-produced animal products rather than increasing the own-consumption of these products. 5.45. According to Jansen, Horelli and Quinn (1987), the incidence of anemia varies greatly in different parts of Kenya, but the coastal region is the most severely affected. A great majority (70-90%) of the anemias at sea level are of the iron-deficiency type. Anemia in the areas close to Lake Victoria is less frequent than by the Indian Ocean. Anemia is considered to be mostly iron deficient and due to parasitic diseases. 5.46. According to the 1999 national micronutrient survey, as a population group, preschool age children are likely to bear the largest burden of anemia. The peak prevalence of all anemias and moderateto-severe anemia in majority of clusters was observed among 6-12 months-olds. However, it would appear that the risk of being anemic was uniformly distributed among the 6-60 months-olds in the semi-arid lowland clusters in Garissa and the Lake Basin. In contrast, the pattern of distribution of anemia in other areas and especially the highlands decreased with increasing age. There was higher prevalence of anemia among children in the Lake Basin than coastal children. 5.47. In general, the 1999 national micronutrient survey suggests a high likelihood of a larger burden of anemia among preschool age children than at the advent of independence. The prevalence of anemia among non-pregnant mothers followed a similar pattern to that of children. The largest burden of anemia was borne by the semi-arid clusters in Garissa district. The coastal and Lake Basin sub-regions followed

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with more than two thirds of mothers being anemic. In the western highland clusters and some of dry humid and semi-humid midland clusters, nearly half (41-50%) of the mothers were anemic.

INFANT AND UNDER-FIVE MORTALITY

Infant Mortality Rate 5.48. During the period 1960-1990, infant mortality rate consistently declined from 122 to 63 per 1,000 live births. However, the earlier gains have begun to fizzle out, as the infant mortality rate has consistently increased to about 77 in year 2000. The 1989 Population and Housing Census recorded infant mortality rate at 66 per 1,000 live births. However, according to the KDHS, the infant mortality rate increased from 58.6 during 1979-89 to 62.5 in 1983-93 and climbed up to 70.7 during 1988-98. The geographical distribution of infant mortality rates depicts a mortality bowl, with low mortality in the center of the country (Central, Nairobi, Rift Valley and Eastern provinces) and high mortality in the coast and in the west (Western and Nyanza). The 1989 KDHS expresses concern that the reported infant and under-five mortality rates might be overestimated, which implies that the onset of the decline in child mortality indicators was achieved later than is currently assumed. However, the 1993 KDHS reported that it is unlikely that the mortality rates in the 1989 KDHS are underreported, but the rates for the previous periods are more questionable, a factor that should be considered in determining Kenyas long-term trend in childhood mortality indicators. 5.49. The 1989 KDHS shows that the infant mortality rates are higher in rural areas compared with urban areas, decrease as the education of the mother improves, are higher for males than females, are highest for children born to mothers under age 20, are highest for first births and births 7 and above, and decrease with increase in birth interval. 5.50. The 1993 KDHS adds that, children born to women who obtained both antenatal and delivery care by medically trained personnel have considerably lower mortality than children whose mothers received only antenatal or delivery care. In addition, a childs size at birth is an important determinant of its survival. The report concludes typically, infants and children have a greater probability of dying if they are born to mothers who are especially young or old, if they are born after a short birth interval, or if they are of high birth order9. Under-Five Mortality Rate 5.51. During the period 1960-1990, the under-fives mortality rate consistently declined from 192 during 1960-64 to 94 per 1,000 live births during 1990-94 (Ahmad, Lopez and Inoue, 2000). However, the rate has climbed up to an estimated 98 during 1995-99, with an estimate of 100 in 1999. The 1989 Population and Housing Census recorded under-five mortality rate at 113 per 1,000 live births. However, according to the KDHS, the under-five mortality rate increased from 90.9 during 1979-89 to 93.2 in 1983-93 and climbed up to 105.2 during 1988-98. The geographical distribution of under-five mortality rates also depicts a mortality bowl, with low mortality in the center of the country (Central, Nairobi, Rift Valley and Eastern provinces) and high mortality in the coast and in the west (Western and Nyanza). Coincidentally, malaria morbidity and mortality shows a similar epidemiological bowl, although this does not imply that malaria is the main determinant of child mortality. The under-five mortality rate for Nyanza during 1988-98 is exceptionally high at 198.8 compared with the national average of 105.2. 5.52. However, the five-year interval for which the mortality rate is computed may provide misleading policy options, and it is more interesting to focus on mortality within various age cohorts. For example, the mortality data based on the 1998 KDHS showed that 25.7% of the child deaths occurring in the first five years of life take place within one month after birth (neonatal mortality), 67.2% within the first year, and the remaining 32.8% in the remaining 1-4 years. Similarly, the Kenya Fertility Survey, 1977-78, estimated that 40% of all infant deaths take place in the neonatal period (Mott, 1982; cited in Melgaard, Kimani and Mutie, 1987). This implies that the causes of mortality among neonates, children between one and 12 months, and 1-4 year old differ at the national level and in various geographical regions. According to the
9

Birth order is defined as a persons rank by age among his or her siblings.

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United Nations Statistics Division (2002), deaths during the first week of life are mostly due to malnutrition in the mother and fetus leading to low birth weight, and to birth asphyxia and other delivery-related problems, both of which are compounded by poor antenatal care and lack of skilled birth attendants.

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CHAPTER SIX

BREASTFEEDING IMPORTANCE OF BREASTFEEDING

6.1. According to the FAO (1979), breast-milk is a complete food for the first several months of an infants life. It contains a large number of factors that can help prevent disease, and provides active as well passive immunity. Breastfeeding is especially protective against diarrhea; and beestings (Wall, 2002) a.k.a. colostrum (the first milk after parturition child birth) contains immunologic properties to protect the child against disease. Breastfed infants are freer from cows milk allergy. The psychological implications of breastfeeding are extensive, especially in fostering mother-infant bonding. Breastfeeding is also important in delaying the postpartum return of fertility in the mother, especially when lactation is un-supplemented and prolonged. 6.2. According to Hatloy and Oshaug (1997) infancy is the only period in life when humans obtain nutrition security by consuming one food, breast-milk. When the mother breastfeeds her child, all of the three conditions for nutrition security (food security, adequate care, and protection against diseases) are provided simultaneously. The authors challenge economists, statisticians, and others who are involved in the generation of health and food statistics to include human milk in their calculations of food supply, availability of food and nutrients, and economic value of food. The ACC/SCN (1998) suggests that breastfeeding need to be appropriately recognized by putting colostrum on the immunization schedule, including breast-milk on the essential drugs list, including breast-milk in national food balance sheets and Gross National Product, and as environment-friendly and a family planning option.

SITUATION ANALYSIS
6.3. The Kenya Fertility Survey, 1977-78, conducted under the World Fertility Survey Programme, solicited information on full breastfeeding and breastfeeding (not necessarily exclusive breastfeeding) for the penultimate pregnancy prior to the survey. The national mean period of full breastfeeding was estimated at 3.5 months. However, the statistics have not been widely used as baseline information on Kenyas infantfeeding practices since they included the latest offspring regardless of the offsprings age at the time of the survey. Indeed, the period between the penultimate pregnancy and interview was 37 months and over for 65% of the index offspring. In addition, a quarter of the mothers interviewed were over 40 years of age at the time of the survey. The breastfeeding statistics in the Kenya Fertility Survey, 1977-78 cannot therefore be associated with any specific time period. 6.4. In 1982, the Central Bureau of Statistics undertook a survey of Infant Feeding Practices on 980 lowand middle-income Nairobi women who had given birth in the previous 18 months. Sampling was done using the CBS national sample frame based on the 1979 population census. The survey showed a common pattern of almost universal successful and prolonged breastfeeding overlaid with widespread supplementation with infant formula in the first six months of life (Kenya, 1984). The report noted that negative results of this unnecessary use of breast-milk substitutes include a drain on family income, shorter intervals between births (due to the effect of breastfeeding on the length of amenorrhoea - the period to the return of menses), and increased child morbidity. The correlation between breastfeeding and fertility was considered important because only 18% of the women surveyed reported using any form of birth control since the birth of the index child. 6.5. The survey included questions on influences on feeding practices. While 77% of the women surveyed had given birth in a healthcare facility, only 14% recalled receiving any information on infant feeding at that time, and half of this 14% reported being wrongly told that exclusive infant formula feeding was best for the child. 6.6. The surveys which have collected household-based information on breastfeeding include the 5 nutrition surveys (1977, 1978-79, 1982, 1987, 1994), the three KDHS (1989, 1993 and 1998), and the 2000 MICS. The focus of our analysis will only be based on the fourth (1987) and fifth (1994) child nutrition surveys, the three rounds of KDHS, and MICS.

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6.7. The fourth rural nutrition survey solicited responses on (a) whether the child was breastfeeding at the time of the survey, (b) number of months breastfed, and (c) whether the child had breastfed in the two weeks preceding the survey. The survey did not solicit responses on the use of breast-milk substitutes and infant formula. The published survey results only reported on district- and national-level estimates of (a) still breastfeeding, without giving the age cohorts, and (b) average length of any breastfeeding. The mean breastfeeding period was 16.1 months, with the lowest recorded in Narok (13.2 months) and the highest in Meru (18.7 months) and Laikipia (18.8 months). 6.8. The 1989 KDHS solicited responses on (a) whether the child was breastfeeding at the time of the survey, (b) whether the child was exclusively breastfeeding, (c) age of child when mother stopped breastfeeding, and (d) the use of itemized breast-milk substitutes and infant formula. The published results refer to the number of months breastfeeding (not necessarily exclusively). The mean number of months of any breastfeeding was 19.5 months in the rural areas (compared with 16.1 months obtained from the 1987 rural nutrition survey) and 18.8 months in the urban areas. 6.9. The 1993 KDHS questions on breastfeeding were largely similar to those in the 1989 KDHS, but solicited additional information on the age of child when breast-milk substitutes and infant formula, as well as other types of food, were introduced on a regular basis. The survey showed that the mean duration of breastfeeding, not necessarily exclusive, was 21.1 months, 19.6 months in urban areas and 21.5 months in the rural areas. The mean length of exclusive breastfeeding was 0.5 months and 0.7 months for exclusive breastfeeding and plain water only. 6.10. The 1993 KDHS asked mothers about breastfeeding status of all the last-born children under five, if the child was being breastfed, and whether various types of liquids or solid food had been given to the child yesterday or last night. Children who are exclusively breastfed receive breast-milk only, while those who are fully breastfed include those who are exclusively breastfed and those who receive plain water in addition to breast-milk. 6.11. The practice of initiating breastfeeding within the first hour after birth was reported in only 56.9% of all births. Over 65% of the mothers in Central, Eastern and Rift Valley provinces put their newborns to breast within an hour, while the lowest were reported in Coast (39.3%) and Western (38.7%). Initiation of breastfeeding within the first hour of birth was lowest among younger mothers. 6.12. In the first month of life, only 26.8% of the children were exclusively breastfed, while an additional 17.7% breastfed in addition to plain water only. The overall duration of exclusive breastfeeding in Kenya was 0.5 months, while those mothers with no education registered a mean of 0.6 months of exclusive breastfeeding. The mean number of months of fully breastfeeding (breastfeeding and plain water only) was 0.7 months, and was highest in Central (1.4 months) and Western (1.0 months) among the provinces, and among mothers with no education (1.0 months) when tabulated against mothers highest grade reached. The type of personnel who assisted in child delivery did not appear to influence subsequent breastfeeding practices. 6.13. A supplementary report to the 1993 KDHS stated that the infant feeding behavior that poses the greatest threat to child nutrition status and heath is the short duration of exclusive breastfeeding. The early introduction of water, liquids, and complementary foods puts infants at risk of diarrhea because of pathogen contamination. In addition, it reduces the time the infant suckles the breast (which reduces maternal breast-milk supply) and shortens the length of postpartum amenorrhea (which puts women at risk of pregnancy in the absence of other methods of contraception). The report recommended that qualitative research be undertaken to understand the reasons behind the early introduction of water, liquids, and complementary foods and to identify public health messages that may be effective in promoting exclusive breastfeeding as the safest and most nutritious infant feeding method for infants less than about 6 months of age. 6.14. The 1994 fifth nutrition survey targeted children aged 6-60 months, and for the first time covered the arid and semi-arid districts of Wajir, Mandera, Garissa, Isiolo, Marsabit, Samburu and Turkana. The mean length of any breastfeeding was 15.9 months, and 2.5 months of exclusive breastfeeding. Eastern

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province reported the highest length of any breastfeeding at 17.2 months, followed by Northeastern (16.9), Western (15.9), Nyanza (15.8), Rift Valley (15.7), Coast (15.6), Central (14.9) and Nairobi (14.0). The mean number of months of exclusive breastfeeding was 2.5 months, with only a few districts reporting a mean of four or more months, namely, Isiolo (4.1), Marsabit (4.2), Homa Bay (4.0), Samburu (4.2) and Turkana (4.0). 6.15. The survey also reported the first complementary feeding given to children. A reported 31.3% of the children had been given some milk other than breast-milk, compared with commercial infant formula (3.1%), maize/millet porridge (26.0%), fortified porridge with additives such as margarine, oil, sugar and milk (19.3%), semi-solids such as mashed potatoes, bananas and avocados (11.7%), and water and sugar (5.3%). 6.16. The 1998 KDHS collected data on feeding patterns of children under three years of age, including initiation of breastfeeding, introduction of complementary and weaning foods, and use of feeding bottles. According to the 1998 KDHS, colostrum, which is contained in the very first breast-milk after delivery, has been shown to be highly nutritious and to contain a high concentration of antibodies which protect babies from infection before the childs immune system has matured. To facilitate early initiation of breastfeeding, women delivering at home and in health facilities in Kenya are encouraged to ensure that their newborn babies are breastfed soon after birth and thereafter on demand. Bottle feeding is discouraged and mothers are educated to breastfeed exclusively until the child is 4-6 months old. 6.17. The 1998 KDHS showed that 58% of children were breastfed within an hour and 86% in the first 24 hours after delivery. Initiation to breast within one hour of delivery was highest in Central (80.1%) and lowest in Coast (43.6%) and Western (40.6%) provinces. Delivery at a health facility and assistance in delivery by medically trained personnel were associated with higher rates of breastfeeding within an hour of delivery. 6.18. Exclusive breastfeeding is not common as only 28% of children under two months and 17% of children under four months of age are fed only breast-milk. Most children under two months are given just plain water (18.3%) and other foods and liquids (53.4%) in addition to breast-milk. 6.19. At the national level, the median duration of any breastfeeding is 20.9 months, the same as that estimated from the 1993 KDHS. The mean duration of exclusive breastfeeding is 0.5 months, and full breastfeeding (exclusive breastfeeding or breastfeeding and plain water only) is 0.7 months. Median length of breastfeeding tends to be longer in rural areas (21.5 months) than urban areas (18.9 months), and among uneducated women (25.2 months) compared with primary education (20-22 months) and secondary education (19.1 months). 6.20. The MICS showed that only 16.2% of the children 0-3 months of age were exclusively breastfed, and the rate is slightly higher for male children (17.9%) than female children (14.3%), and higher for urban (22.6%) than rural areas (13.7%). Within the first month after birth, 1.0% was not breastfeeding, 24.5% were exclusively breastfed, while an additional 24.3% had breast-milk and water only, 42.2% had breastmilk and liquids only, and 8.1% had breast-milk and solid/mashy food. At 4-5 months, only 2.8% was exclusively breastfed, and the proportion receiving breast-milk and solid/mashy food increased to 55.2%. 6.21. Similarly, the Kenya and UNICEF Learning Communities Baseline Survey 2002 found that exclusive breastfeeding for children aged 0-3 months is quite low (less than 40%) in all the communities. In one community in Nairobi, the women observed malnutrition is caused by laziness since in older days mothers used to work hard and feed their families. These days some mothers just sit and wait for their husbands. This is causing a lot of problems, malnutrition being one of them. This introduces an important dimension of gender relations, whose impact on food and nutrition in Kenya has not been adequately researched or documented (see the analytical framework in Silberschmidt, 2001).

NATIONAL POLICY ON INFANT AND YOUNG CHILD FEEDING

6.22. There are possibly only two elements of Kenyas nutrition policy that are clearly articulated. First, are various food quality standards specified in the relevant legislation (e.g. on salt iodination) and other

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standards on food and hygiene. The second is the national policy on infant and young child feeding practices which includes a national code of marketing of breast-milk substitutes (International Nutrition Communication Service, 1983). The Government adopted a national code of marketing of breast-milk substitutes in July 1983. Explicit attention was drawn to the dangers of using breast-milk substitutes in situations of poverty, poor sanitation and illiteracy. The Director of Medical Services issued a directive to all medical personnel and staff of religious agencies, specifying actions to be taken to support appropriate breastfeeding practices. Guidelines include restrictions on the use of prelacteal feeds (any fluid other than breast-milk given first time to a newborn) and on posters and samples provided by manufacturers; initiation of breastfeeding immediately after delivery; provision for rooming-in; and scheduling maternity ward timetables for the convenience of the mothers rather than the staff10. The infant and young child feeding practices required every facility providing maternal child health services to: 6.23. Adhere to the national infant feeding policy, which should be routinely communicated to all health staff and be strategically displayed; Train all healthcare staff in skills necessary to implement this policy; Provide information to all pregnant and lactating mothers and their partners on the benefits and management of breastfeeding; Assist mothers initiate breastfeeding within the first 30 minutes of birth; Give newborn infants no food or drink other than breast-milk unless medically indicated; Show mothers how to breastfeed and to maintain lactation even if they should be separated from their infants; Practice rooming-in as the separation of mothers and infants may cause difficulties in the establishment of breastfeeding; Encourage breastfeeding on demand; Encourage and actively promote exclusive breastfeeding for infants up to six months; Provide information and demonstrate to mothers how to introduce and prepare appropriate and nutritious complementary foods to their infants after six months; Encourage mothers to breastfeed for at least 24 months; Foster the establishment of breastfeeding support groups and other support groups and refer mothers to them on discharge from hospital or clinic; Not accept any free samples and supplies of breast-milk substitutes; Not allow any publicity by the manufacturers or agents of breast-milk substitutes; and Not give any feeds using bottles or teats. The specific guidelines on HIV and infant feeding practices include: Information on benefits of breastfeeding; Prevention and management of breastfeeding problems (abscess, mastitis, breast and nipple disease); Appropriate complementary feeding; Promote good maternal nutrition and self-care; Provide vitamin A supplements, iron, folic acid and zinc; Counsel on child spacing; Promote treatment of infections; Reduction of HIV infections; Risk of mother-to-child transmission (MTCT) of HIV; Information on voluntary counseling and testing (VCT); and Reinforcing risk reduction to couple

10 Prelacteal liquids increases the risk of introducing early infections to a newborn, reduces the practice of exclusive breastfeeding, reduces the chance of child accessing colostrum as it is normally available for one to two days after birth, and the child may aspirate the fluid into the air passages and lungs which may even result in death (PrezEscamilla, Segura-Milln, Canahuati and Allen, 1996).

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6.24. For mothers not tested for HIV, the current guidelines specify the need to promote and support breastfeeding, encourage and avail information on voluntary counseling and testing, and reinforce risk reduction. Untested women with features of clinical AIDS are supposed to be managed as if positive. However, for pregnant mothers diagnosed as HIV negative, the guidelines specify reinforcing risk reduction, and promoting breastfeeding. 6.25. HIV-positive mothers are supposed to be given information on feeding options, cost of the options, information and skills on how to reduce/avoid MTCT, and allow the mother and partner to make informed choice. 6.26. For HIV-positive mothers who choose to breastfeed, the guidelines specify support and encourage exclusive breastfeeding, prevention and management of breastfeeding problems, discourage breastfeeding in case of breastfeeding problems (cracked nipples, mastitis or abscess), and provide relevant antiretroviral. For HIV-positive mothers who chose not to breastfeed, there is need to demonstrate safe preparation and storage of chosen milk, demonstrate cup and spoon-feeding, counsel on the care of the breasts to avoid engorgement, and provide reliable family planning methods by four weeks. Previously, the point of reference was the Sessional Paper No. 4 of 1997 on AIDS in Kenya, which stated that women with HIV will be advised to avoid breastfeeding their children and use alternative feeds. 6.27. The current policy is in accordance with the 1997 WHO, UNICEF and UNAIDS Policy Statement on HIV and Infant Feeding which emphasizes the need to protect, respect and fulfill human rights. The infant feeding policy is made with the best interests of the mother and baby as a pair. The elements include to: Prevent HIV infection in women of childbearing age, Develop and promote voluntary and confidential counseling and HIV testing services which are committed to informed consent and protection of confidentiality, Strengthen antenatal care services and encourage attendance, Implement interventions to prevent MTCT, Strengthen family planning services, Protect, promote and support breastfeeding as the best infant feeding choice of uninfected women and women whose HIV status is not known, and Prevent commercial pressures for artificial feeding.

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CHAPTER SEVEN

SOME DETERMINANTS OF MATERNAL CHILD HEALTH THE CARE OF PREGNANT AND POSTPARTUM MOTHERS
Proportion of Births Attended by Skilled Health Personnel 7.1. Information on maternal care is normally solicited on antenatal care (provider, number of visits to the antenatal care provider, and tetanus toxoid injections), place of delivery, and attendant assisting during delivery. The World Health Organization (WHO) database shows that the proportion of pregnant women who receive antenatal care in Kenya is about 95%, 44% of deliveries take place in health facilities, and skilled health personnel attend 45%. 7.2. Information on attended and unattended births during child delivery is available from the 1994 Welfare Monitoring Survey and the three KDHS (1989, 1993 and 1998). The 1989 KDHS included traditional birth attendants but did not solicit information on whether the TBAs were trained or not, while the 1993 and 1998 KDHS distinguished between trained and untrained TBAs. The global UNDP Human Development Report recommends that attended births should include doctor, midwife, and trained traditional birth attendants. Since the respondents of a household-based survey are the mothers who have given birth, it would be difficult to collect reliable data on whether the TBAs who assisted were trained or not as the beneficiary of such services may not know. In addition, TBAs, whether trained or untrained, can neither predict nor cope with serious complications. Consequently, the analysis considers attended births are those that take place under the supervision of personnel with medical training doctors, nurses and trained midwives. 7.3. According to the 1998 KDHS, at the national level, births attended by untrained TBAs were only slightly lower than those attended by trained TBAs. The proportion of births attended by doctor/midwife in Nairobi (76.4%) and Central (68.6%) was the same order of magnitude as unattended births in Western (67.0%), Coast (63.8%), Nyanza (61.8%) and Rift Valley (60.9%). This gives an overall share of attended births of 44.3%. However, it is worrisome that the proportion of attended births has been declining in the last decade, from 50.0% in 1989 to 45.4% in 1993 and 44.3% in 1999. The bigger share of attended births in 1998 is by nurse/midwife (32.0%) rather than doctor (12.3%). Maternal Mortality Ratio 7.4. Maternal mortality is defined as the death of a woman while pregnant or within 42 days (6 weeks) of a termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. 7.5. Maternal deaths in a population are essentially the product of two factors: the risk of mortality associated with a single pregnancy or a single live birth, and the number of pregnancies or births that are experienced by women of reproductive age. Maternal mortality ratio is defined as the number of maternal deaths in a population divided by the number of live births. The maternal mortality ratio therefore incorporates obstetric risks (e.g. haemorrhage and prolonged or obstructed labour) and frequency of pregnancy (fertility rate). A policy to reduce maternal mortality ratio has therefore to deal with both excess fertility and pregnancy safety. In addition, high fertility may increase obstetric risk as pregnancy complications are normally aggravated by higher number children born to one mother, through low birth intervals and giving birth at relatively older age. 7.6. The recent and reliable source of maternal mortality was the 1998 KDHS using the sisterhood method (verbal autopsy of surviving sisters). The method entailed collecting information from female respondents on deceased female siblings covering whether the index sibling was pregnant when she died, or death occurred during childbirth, or died within six weeks of the birth of a child or pregnancy termination. For the period 0-9 years before the survey (1989-1998), maternal deaths represented 27% of all deaths to women aged 15-49. The rate of deaths due to causes related to pregnancy and childbearing was 0.994

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maternal deaths per 1,000 woman-years of exposure. The maternal mortality rate was converted to a maternal mortality ratio per 100,000 live births by dividing the rate by the general fertility rate of 0.168 operating during the same period to give a ratio of 590 maternal deaths per 100,000 live births. 7.7. In high fertility settings, women face this risk several times during their lives, and fertility is therefore taken into consideration in computing maternal mortality as it includes the cumulative risk of maternal death. 7.8. According to the report of the United Nations Statistics Division, measuring maternal mortality is notoriously difficult except for countries with comprehensive registration of deaths and good attribution of causes of death (multiple decrement statistics). A number of process indicators can monitor progress towards reduction of maternal mortality. The most relevant process indicator is the percentage of all births attended by skilled health workers (doctor, nurse or midwife), which unfortunately has not recorded any improvement in the last decade. It is therefore important to track trends in indicators that have a direct bearing on maternal mortality e.g. proportion of women who deliver with the assistance of a skilled healthcare provider, access to antenatal and postpartum care, and access to family planning information and service to prevent unwanted pregnancy and unsafe abortion. Health workers with midwifery skills attend births, and provide mothers with basic education about prenatal and postnatal care for themselves and their children. 7.9. The foundations for maternal risk are often laid in girlhood. For example, women whose growth was stunted by malnutrition are vulnerable to obstructed labor, and the risk of childbirth is greater for women who have undergone female genital mutilation (FGM). In Kenya, the women reported in the 1998 KDHS as having body mass index below the threshold (11.9%) and those who have undergone FGM (37.6% of responding mothers and 24.1% for their eldest daughters) face additional maternal risk at childbirth. However, recent enabling legislation in Kenya has outlawed FGM for girls below 18 years, which might reduce its overall incidence if enforcement measures are put in place. In addition, only 34.4% of the eldest daughters were circumcised by skilled health personnel (7.1% by doctor and 27.3% by nurse/midwife) and 16.6% used a shared razor blade, which also increases the risk if HIV/AIDS infection.

PROPORTION OF ONE-YEAR OLD CHILDREN IMMUNIZED AGAINST MEASLES

7.10. The Kenya Expanded Programme of Immunization (KEPI) started in 1980. According to the WHO/UNICEF Review of National Immunization Coverage 1980-1999, the reported coverage levels using administrative data were high in the eighties and early nineties. However, the withdrawal of donor staff from KEPI Central Management Unit in 1995 led to a decline in the routine data reported. Therefore, most of the officially reported numbers are underestimating actual coverage. The more reliable source of trend data on immunization is the numerous immunization coverage surveys in 1987, 1992, 1994, the KDHS (1989, 1993 and 1998) and the MICS (1996 and 2000). 7.11. The concern for measles immunization coverage is premised on two considerations, namely, measles is the last vaccine within the immunization schedule that should ideally end at the age of 9 months, and measles is the commonest vaccination-preventable disease. For example, Kenya data shows that the number of reported cases of neonatal tetanus declined from 1,612 in 1990 to 132 in year 2001, polio declined from 1,528 to 0 in the new millennium, pertussis from 7,404 to 285, measles from 77,072 to 11,304, while diphtheria increased from 1 to 6. 7.12. Neonatal tetanus occurs as a result of unhygienic birth practices when tetanus bacteria enter the body through the umbilical stump following childbirth, through cutting the cord under unsterile conditions. It strikes between the 3rd and 28th day after birth, killing 70-100% of its young victims. Since most deaths occur at home before the babies reach their second week of life, the number of cases is vastly underreported, hence the reference to neonatal tetanus as the silent killer. A community study of neonatal tetanus in Meru, Tana River and Kisii districts undertaken during 1984-85 showed that tetanus deaths mainly occurred in children born at home (Melgaard, Kimani and Mutie, 1987). This probably indicates both poorer hygienic conditions during deliveries and poor utilization of antenatal health services (i.e. tetanus vaccinations) by mothers delivering at home.

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7.13. The WHO/UNICEF estimates show that measles immunization coverage for children 12-23 months increased from 65% in 1986 to 78% in 1990, 84% in 1993, but declined to 76% in 2000. According to the KDHS, the immunization coverage increased from 63% in 1989 (adjusted due to survey methodology) to 79% in 1993, but declined to 65.4% in 1998 and 60.8% in 2000. In addition, the proportion of children who had not received any vaccine increased from 3.3% in 1993 to 5.7% in 2000. 7.14. There are several concerns in immunization coverage as shown in 2000 MICS. First, there is a high dropout rate from one polio vaccine to the next and a high dropout rate from one DPT vaccine to the next. Secondly, the change in coverage from one vaccine to the next in the immunization schedule is not consistent, which implies that the recommended immunization schedule is not adhered to. The 1994 immunization survey undertaken as part of the Fifth Nutrition Survey also showed that immunization coverage for each vaccine for children below 12 months (those immunized on schedule) was lower than for those of 12-23 months. It is therefore necessary to address the twin issues of raising the immunization coverage and the need to follow the recommended immunization schedule where the measles vaccine completes the child immunization schedule at the age of nine months. 7.15. Finally, the percentage of children aged 12-23 months vaccinated against childhood diseases was lower in MICS (2000) than in KDHS (1998) for each and for all antigens collectively (BCG, DPT 1-3, Polio 1-3 and measles). The proportion of children who had not been vaccinated was 2.7% in the KDHS and 5.7% in the MICS.

POPULATION WITH SUSTAINABLE ACCESS TO AN IMPROVED WATER SOURCE

7.16. Access to safe water covers piped water, roof catchments, and protected springs and wells. Access does not imply reliability of water sources. 7.17. Some of the more recent household survey-based sources of information on access to safe drinking water are the 1989, 1993 and 1998 KDHS and the 2000 MICS. Taking clean water sources to include only protected wells, boreholes, piped water and rainwater, the 1989 KDHS shows that access to safe water was 48.1% at the national level, 38.2% in the rural areas, and 95.4% in urban areas. The lowest access rates were recorded in Rift Valley (33.2%), Western (34.2%) and Nyanza (35.8%) provinces. The highest access was recorded in Coast province (67.2%) due to the provinces high access to piped into residence (24.4%) and public tap (32.7%), compared with the rural mean of 11.6% and 6.6%, respectively. 7.18. The 1993 KDHS reports an overall rural access rate to safe drinking water regardless of distance to water source of 47.6%, with a high 72.7% in Coast and Western (73.7%) and a low 28.7% in Nyanza. The access rate for urban areas was 90.8%, giving a national access rate of 55.9%. The 1998 KDHS reports an overall rural access rate to safe drinking water of 55.0%, with a high 75.6% in Coast and a low 35.3% in Nyanza. The access rate for urban areas was 91.3%. 7.19. The 2000 MICS reports an overall rural access rate to safe drinking water of 43.5%, with a high 67.1% in Coast and a low 44.0% in Nyanza. The access rate for urban areas was 89.7%. This shows that there has been no improvement in access to safe drinking water in the past decade. In addition, due to the legends used in the surveys, the estimates include wells without differentiating protected and unprotected wells, thereby slightly overstating access to safe water. 7.20. According to the 1999 Population and Housing Census, only 30.0% of households had access to piped water, compared to 31.9% recorded in 1989. Rural households were worse off than their urban counterparts, with 14.9% having access to piped water compared to 74.7% for urban areas.

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POPULATION WITH ACCESS TO IMPROVED SANITATION

7.21. The Public Health (Drainage and Latrine) Rules, a 1960 subsidiary legislation made under the Public Health Act (cap. 242 of the Laws of Kenya), set outs the definitions and minimum construction standards for various types of excreta disposal facilities e.g. water closets, pail closets and pit-closets. The Sanitation Field Manual for Kenya (1987) gives details of technical specifications for construction of various types of sanitary means of excreta disposal, including the means of excreta disposal that are not considered sanitary from a health standpoint. The sanitary means of excreta disposal include septic tank, ventilated improved pit (VIP) latrine, alternating twin-pit VIP latrine, pour flush; but excludes aqua privy, bucket latrine systems, and composting latrine. 7.22. The 1989 KDHS solicited information on the type of toilet facility used by the female respondents. The choices were flush toilet, pit latrine and other. The results showed that 84.1% had sanitary means of excreta disposal (flush toilet and pit latrine), comprising a high 94.4% in urban areas and 82.0% in rural areas. Within rural areas, the lowest access was in Coast province (63.1%) and the highest in Central (97.7%). 7.23. The 1993 KDHS solicited information on the toilet facility the household had. The list included own-flush toilet, shared flush toilet, traditional pit toilet, VIP toilet, no facility/bush/field, and other. The 1993 national access to sanitary means of excreta disposal was recorded at 81.8%, with a high 94.1% for urban areas and a low 78.9% in rural areas. Within rural areas, the lowest access was in Nyanza province (69.1%) and the highest in Central (96.8%). 7.24. The 1998 KDHS reported access to sanitary means of excreta disposal of 84.6%, with a high 96.0% for urban areas and a low 81.1% in rural areas. Within rural areas, the lowest access was in Coast province (72.4%) and the highest in Central (98.9%). The national access to safe sanitation therefore declined from 84.1% in 1989 to 81.8% in 1993 and recorded a slight increase to 84.6% in 1998. The 2000 MICS reported a national access rate of 81.1%, with 76.6% for rural areas and 94.8% for urban areas. The access rate has therefore remained the same for over a decade, mainly because of lack of progress in Coast, Eastern, Nyanza and Rift Valley provinces. North Eastern province has been excluded in most surveys while the 2000 MICS only included its urban clusters. 7.25. The emphasis in the surveys is on the type of toilet that the household uses, and not the toilet they may have, and thus puts a clear distinction between ownership and use. However, due to the specificity of concepts used by the health authorities (e.g. an almost full pit latrine or a flush toilet without water is not counted as latrine but as health hazard), access to safe sanitation may be slightly overstated. Since household survey methodology relies mostly on self-reporting rather enumerators observation and inspection, appropriate details about the sanitary facilities are not normally collected. 7.26. The 1999 Population and Housing Census showed that 82.5% of the households had access to decent sanitary facilities (main sewer, pit latrine, septic tanks and cess pools). Nairobi and Central had the highest access at 97.0% and 99.1%, respectively. They were followed by Western (94.6%), Eastern (84.0%), Nyanza (80.3%), Rift Valley (72.3%) and Coast (68.9%), while the lowest access was in North Eastern province at a meagre 19.4%.

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CHAPTER EIGHT

THE GENESIS OF KENYAS FOOD AND NUTRITION POLICY A SHORT JOURNEY THROUGH HISTORY
Background 8.1. The recent history of Kenyas food and nutrition history goes back, at least in part, to the 1975 workshop on food and nutrition held at the Institute for Development Studies (IDS), University of Nairobi (Westley, Johnston and David, 1975). The workshop brought together participants from government, universities, Food and Agriculture Organization, and the World Health Organization. The workshop was probably in response to the 1974 World Food Conference, which emphasized the need to include nutrition considerations in development programmes. The Conference called for broad measures for the elimination of hunger and malnutrition, and for the implementation of national food and nutrition policies through which these measures could be executed. 8.2. The IDS workshop identified three elements of a national food and nutrition policy. The first element is a strategy for rural development which fosters widespread improvements in productivity and output and which is designed to improve the pattern of income distribution while at the same time achieving the required expansion of food production. The second element consists of measures to influence the combination of foods produced and the processing techniques employed to improve the quality of the diet available to all segments of the population. The third element includes a variety of measures such as nutrition-related health activities and nutrition intervention programmes, which have a more direct impact on the nutritional status and health of particular segments of the population. 8.3. The workshop addressed the specific problem of setting up an institutional unit within the Kenya government, which would be responsible for the national food and nutrition policy. It was recommended that the unit could be part of the Ministry of Finance and Planning, in which case it would act primarily as a technical advisory body with policy decisions being taken by a high-level inter-ministerial committee. 8.4. The workshop further suggested that research on nutrition in Kenya could be expanded if Government more actively specifies topics to be studied by researchers coming from overseas; directing them towards practical, important problems. 8.5. The workshop identified some contradictions in Kenyas development in relation to nutrition. For example, one problem is the concentration on maize production and the overdependence on maize as the mainstay of the national diet. The quantity and quality of protein available in maize is inadequate, and failure of the maize crop leads to famine. Secondly, nutrition deficiencies can occur when cash crops are introduced into an area, so planners must make certain that sufficient land is set aside for growing food crops. Thirdly, when farm families shift from food crops (for home consumption) to cash crops, men gain greater control of the familys resources in the form of cash earnings, whereas before women had greater control of the resources in the form of food. 8.6. Fourthly, processing, storage and marketing of foods must be assured. The report goes on to mention postharvest losses, need for vegetable dehydration for longer shelf-life, and need to encourage consumption of sheep and goat milk. At the institution level, the meeting evaluated the existing mother and child centers which provided food for infants and young children together with nutritional education for the mothers. The workshop recommended a paradigm shift towards community-based project for preschool children in areas where children under five were most at risk. 8.7. The 1975 workshop was followed by an inter-country workshop held at the Institute for Development Studies in 1976 on nutrition planning and policy for African countries (Latham and Westley, 1976). The seminar covered the process of formulation of nutrition plans and policies. For example, child nutrition was expressed in an epidemiological framework, where the agent is the diet required by the child, the environment is the family, the community and the ecology, and the host is the child itself. The report noted that some of the major shortcomings in the official food and nutrition policy

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implemented by the Ministry of Agriculture were (a) emphasis on cash crops at the expense of food crops for subsistence, and (b) national deficiency of legumes. In the same year, IDS released a paper on nutrition and infection in national development (Latham, 1976). 8.8. The research report (Latham, 1976) mainly dwelt on how nutrition status affects infections, and how infections have an effect on malnutrition. It noted that there are several pathways through which infection affects nutrition status. First, bacterial (e.g. typhoid fever) and some other infections lead to an increased loss of nitrogen from the body and full recovery is dependent upon the restoration of these amino acids to the tissues once the infection is overcome. Secondly, infections, especially if accompanied by a fever, often lead to loss of appetite, and therefore to reduced food intake. Other infectious diseases commonly cause vomiting, with the same result. Thirdly, intestinal parasites (e.g. hookworms) cause intestinal blood loss, and there is therefore considerable loss of iron. Hookworm disease is therefore a major cause of iron deficiency anemia in many countries. The roundworm (ascaris lumbricoides) is quite large (15 to 30 cm long), and studies have suggested that it may reduce absorption of both protein and vitamin A. Malnutrition affects infection because dietary deficiency may reduce the bodys resistance to infections. 8.9. The report recommended the use of simple, relatively inexpensive nutrition programs to control specific nutritional problems, the most important of which are vitamin A deficiency (which is a major cause of blindness), iodine deficiency (leading to goiter and endemic cretinism), and anemia (due to iron or folate deficiency). 8.10. In 1985, an inter-country workshop was held as a tripartite undertaking of the FAO, the Food and Nutrition Planning Unit of the Ministry of Planning and National Development, and the Institute for Development Studies of the University of Nairobi (Ruigu, 1986). The workshop stated that the 19th session of the FAO conference in 1977 requested the Director-General of FAO to suggest methods for ensuring that nutritional considerations are, when appropriate, adequately included in the FAOs planning and execution of agricultural projects and programmes. The World Conference on Agrarian Reform and Rural Development in 1979 resolved that nutritional considerations should be explicitly considered in the planning, design and implementation of rural development projects. It is in response to these concerns that FAO developed a methodology for integrating nutrition into agriculture. This method was subsequently field-tested in 1980 with projects either recently undertaken or in the planning stage in six countries: Kenya, Zambia, Sri Lanka, Philippines, Haiti and Peru. Establishment of a Food and Nutrition Planning Unit 8.11. In 1979, the government set up the Food and Nutrition Planning Unit (FNPU) in the Ministry of Planning and National Development, which was charged with the responsibility of integrating food and nutrition considerations into overall development policy and planned or ongoing programmes, in order to alleviate hunger, malnutrition and poverty among vulnerable groups in the country. 8.12. According to Otieno (1986), prior to the establishment of the FNPU there were two alternative proposals. One was a coordinating body in the form of a separate statutory body such as the National Food and Nutrition Commission as was the case in Tanzania, Zambia and Ethiopia. All of these came under the Ministries of Health in the respective countries. The second alternative was to set up a unit within an operational ministry such as Health or Agriculture. The setting up of a statutory body was not in keeping with government policy at that time, as a review of the performance of statutory bodies was universally disappointing (see Kenya, 1979a; and Kenya, 1982b). Such organizations, if attached to operating ministries such as Health and Agriculture, are unable to operate effectively because they tend to be identified with the activities of that ministry alone, thus leading to only a partial treatment of nutrition matters in public policy formulation. 8.13. The report added that its location in the Ministry of Planning and National Development has several advantages. First, the Ministry is charged with the coordination of development planning and policy formulation for the nation as a whole. Secondly, the Ministry has considerable weight in determining budgetary allocations for various programmes and projects of the various ministries and departments due to its traditional close links with the Ministry of Finance. Another positive aspect of the location of the

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FNPU in the Ministry of Planning and National Development was that food and nutrition considerations could be looked at from a broader multi-sectoral perspective. Since its establishment in 1979, the FNPU went about achieving coordination through the Inter-ministerial Coordinating Committee on Food and Nutrition to achieve its objectives. 8.14. Some of its achievements were (a) the preparation of policy statements on food and nutrition in the 1979-1983 Development Plan, (b) inputs in the preparation of the Sessional Paper No 4 of 1981 on National Food Policy, (c) review of budgets in ministries dealing with food and nutrition activities, (d) localized nutrition surveys (e.g. the Magarini Settlement Scheme in Malindi district), and (e) various studies on food and nutrition in selected areas of the country through collaboration with the African Studies Center, Leiden, Netherlands. 8.15. The Unit had substantial inputs into the 1979-83 and 1984-88 national development plans, national food policy and strategies, and rural and agricultural development policies e.g. inclusion of food security and nutrition within the goals of ASAL development. In 1980, the FNPU, in collaboration with the FAO, organized a national workshop to sensitize policy makers on the need to include nutrition targets in national development plans and explicitly integrate nutrition objectives into the articulation of development policies and the selection, design, implementation and evaluation/monitoring of projects. The Unit assisted in integrating the FAO nutrition planning procedures into the Baringo Pilot Semi-Arid Area Project (BPSAAP). 8.16. The Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN) Unit requested the Institute for Development Studies to coordinate a Food and Nutrition Workshop, which was held in September 1980 (Migot-Adholla and Nkinyangi, 1981). In many ways, the discussions were a direct followup to those of a workshop which took place in 1975 when food and nutrition were first given serious attention at a national forum. The meeting took stock of the activities of the Food and Nutrition Planning Unit, and agreed that the Unit will also attempt to formulate broad food and nutrition objectives and to evaluate the impact of various development programmes on nutritional status of the recipients. The report noted that food availability is not a guarantee for adequate nutrition because peoples ability to absorb the nutrients is hampered by infestation of parasites. In addition, there are nutrition problems in some areas with predominant monoculture cash cropping, whether in plantations or on individual land holdings. 8.17. The 1979-1983 Development Plan devoted considerable space to food and nutrition. The Plan mainly focused on protein-energy malnutrition since it considered micronutrient malnutrition (anemia, goiter and vitamin A deficiency) as probably overrated by some analysts. The Plan identified particular nutrient deficient groups to include (a) smallholders whose income is low (particularly in Western and Nyanza provinces), (b) those involved in cash crops but experience pre-harvest near-famines, (c) the urban poor, (d) pastoralists, and (e) preschool children and pregnant and lactating mothers. 8.18. The Plan recognized the role of the Family Life Training Programme in the Ministry of Housing and Social Services in preventing malnutrition and poor health among children by giving mothers instructions on preventive health measures. The programme also treated malnourished children by providing a high protein-calorie diet. The Plan proposed the establishment of an additional ten new Family Life Training Centers (FLTCs) in districts with high incidence of malnutrition. 8.19. The Plan vested the overall coordination of food and nutrition-related policies on the Food and Nutrition Planning Unit. The Plan proposed a strengthening of existing planning divisions in all relevant ministries so as to incorporate nutrition impact of planned development projects. 8.20. The 1984-88 Development Plan assessed the long-term changes in food production, availability (taking into account exports, imports, seed and livestock feed requirements, and storage losses), trends in nutritional status of the population, and nutritional deficiency among specified vulnerable groups. The Plan noted that the availability of some food items had improved over the years, while others had recorded significant fall (e.g. cassava, sorghum, millet). The Plan cautioned that there are still many families with nutritional deficiency due to poverty, bad food habits, and lack of adequate understanding of the nutritional value of different food items.

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The Sessional Paper No. 4 of 1981 on National Food Policy 8.21. The 1979-83 Development Plan acknowledged that about 30% of the population suffered from some kind of malnutrition. According to the Kenya country position paper to the 1992 International Conference on Nutrition, within the Plan period, Kenya experienced one of its most severe droughts, in 1979-80. This challenging reality led to speedy preparation of the Sessional Paper No. 4 of 1981 on National Food Policy, mainly to achieve self-sufficiency in food production and ensure that the population has accessibility to a nutritious diet. 8.22. The Sessional Paper stated that there is a clear need for a national food policy which will set guidelines for decision-making on all major issues related to food production and distribution. The overall objectives of this policy were to: Maintain a position of broad self-sufficiency in the main foodstuffs in order to enable the nation to be fed without using scarce foreign exchange on food imports; Achieve a calculated degree of security of food supply for each area of the country; and Ensure that these foodstuffs are distributed in such a manner that every member of the population has a nutritionally adequate diet.

8.23. The paper noted that a significant proportion of the population, particularly preschool age children, is malnourished as a consequence of inequalities in the distribution of purchasing power, seasonal localized food shortages, and lack of nutritional education. The overall objective of nutritional policy was to overcome this situation. 8.24. One of the policy recommendations was to encourage the production of certain highly nutritious food crops (e.g. beans, peas and groundnuts) as they provide more protein and calories per kilogram and, in the high and medium potential areas, per hectare than do beef and other meats. The report also emphasized the need to move from consumption of sifted maize meal to granulated maize meal, as the latter is more nutritious. Finally, the report recognized the positive association between reduction in income inequalities and the nutritional status of the population, and the need to reinforce the status of vulnerable groups through specific nutrition intervention programmes (e.g. school milk, preschool feeding, pregnant mothers, and Family Life Training Centers). 8.25. The paper proposed the formation of five committees, namely, increasing food production, agricultural inputs, processing and marketing, nutrition, and mid- and long-term policy issues. The report paid homage to the Food and Nutrition Planning Unit and the Inter-ministerial Coordinating Committee on Food and Nutrition, especially their role in coordinating the activities of the various organizations and agencies involved in nutrition. The 1994 National Plan of Action for Nutrition (NPAN) 8.26. A number of nutrition-related goals were adopted and agreed upon at the World Summit for Children (WSC) of 1990 and International Conference on Nutrition (ICN) of 1992. These goals include 50% reduction in severe and moderate malnutrition among children under five; reduction of low birth weight rates to less than 10%; reduction of iron-deficiency anemia in women by one third; virtual elimination of iron deficiency disorders and vitamin A deficiency; empowerment of all women to breastfeed their children exclusively for four to six months and to continue breastfeeding, with complementary food, well into the second year; institutionalization of growth monitoring and promotion; and to increase food production to ensure household food security. In 1992, Kenya prepared a National Programme of Action (NPA) to operationalize the World Summit Declaration and Plan of Action for the Survival, Protection and Development of Children in the 1990s. 8.27. On nutritional anaemia, the Kenya NPA stated that, since the prevalence of nutritional anaemia among women in Kenya was unknown, the Government will undertake or commission studies to determine the prevalence of nutritional anaemia among women and children. On IDD and VAD, the Government was to undertake nationwide surveys to determine their prevalence. The NPA added that since no reliable estimates of maternal mortality were available, the immediate plan was to determine the

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current rate of maternal mortality. Consequently, the Population Studies and Research Institute (PSRI), with financial support from UNICEF, conducted a Kenya Maternal Mortality Baseline Survey during JuneJuly 1994. 8.28. The ICN adopted the World Declaration and Plan of Action for Nutrition, which provided a framework and guidelines for countries to develop and strengthen their national plans of action to promote the nutritional wellbeing of their populations. The country position paper to the 1992 ICN evolved into a National Plan of Action on Nutrition in 1994. The aim of the National Plan of Action was to develop three main lines of action: The incorporation of nutrition objectives and actions into national, sectoral and integrated development plans, and the allocation of the necessary human and financial resources for achieving these objectives; The development of specific nutritional interventions directed at particular problems or groups; and The generation of information from community-based actions for the nutritional assessment of problems and implementation of appropriate intervention measures.

8.29. The Plan lamented that little was known about the extent and severity of micronutrient deficiencies in Kenya. However, localized studies carried out in the past indicated various micronutrient deficiencies in specific parts of the country. The Plan noted that the preliminary results of the 1994 national micronutrient survey to determine the extent and severity of vitamin A, iodine and iron, deficiency suggest that these are a public health problem locally. 8.30. The implementation of the NPAN has not been encouraging because most of the activities in the Plan were generic (not specific), the themes and subsequent activities were not prioritized, most activities were implemented on an ad hoc (piecemeal) basis, there has been inadequate funding, and lack of mechanisms to develop a consensus. The funding constraint is mainly attributed to severe economic crises and the limited donor support to Kenya throughout the nineties. Despite the activities of various agencies (e.g. ministries of health and agriculture, and various programs supported by bilateral and multilateral agencies), there has been little coordination and harmonization of activities, or a review of the programs to understand the aggregate impact of all the programs. The Sessional Paper No. 2 of 1994 on National Food Policy 8.31. The Sessional Paper started by acknowledging that a significant proportion of the population, particularly preschool age children, is malnourished as a result of inequalities in the distribution of purchasing power, seasonal localized food shortages and lack of nutritional education. The overall objective of nutrition policy was to overcome this situation through increasing production, increasing the production and consumption of more nutritious foods, improving the distribution of purchasing power, and implementing specific market intervention programmes as and when necessary. 8.32. The Government was to improve nutrition education offered in schools and informal nutrition education offered by the ministries of Health and Agriculture, and encourage nongovernmental organizations to step up their emphasis on nutrition education. The highly nutritious food crops include beans, peas and groundnuts as they provide both more protein and calories per kilogram and, in the high and medium potential areas, per hectare than do beef and other meats. The food items of animal origin mentioned in the policy include fish and non-conventional food animals e.g. game animals, ostriches, rabbits, wild birds, etc. 8.33. The Paper noted that Government policies aimed at reducing inequalities in the distribution of income have the effect of mitigating the nutritional problem. The nutritional effects of these policies were to be reinforced by the expansion of specific nutrition intervention programmes, namely, school milk, preschool feeding, pregnant mothers programmes, and the Family Life Training Centers. Priority was to be given at all times to programmes which improve the nutritional status of children and lactating mothers.

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8.34. There are several points to note. First, the aspects of nutrition policy in the Sessional Paper are reproduced from Sessional Paper No. 4 of 1981 on National Food Policy. This may imply that there was no coordination between the preparation of the 1994 Sessional Paper and the 1994 National Plan of Action on Nutrition. Secondly, the 1994 Sessional Paper was not distributed through the Government Press, and has therefore received very limited circulation.

NUTRITION RESEARCH PROGRAMMES

UNDERTAKEN

UNDER

GOVERNMENT

8.35. According to Jansen, Horelli and Quinn (1987), during 1976-79, a team from the African Studies Center (ASC), Leiden, was responsible for the Nutrition Intervention Research Project (NIRP), an extensive evaluation of nutrition programmes in Central province. This project was carried out in cooperation with the Ministry of Health and the Department of Social Services. The project concentrated in particular on impact evaluation of the major nutrition programmes: the Nutrition Field Workers (NFW) of the Ministry of Health, the Preschool Health Programmes (PSH) of the Catholic Relief Services, and the Family Life Training Centres (FLTCs) of the Department of Social Services. 8.36. The results of these studies were reported as somewhat disappointing, in the sense that the impact of the different interventions on the beneficiaries was far from impressive. The studies noted that particularly little effect appears to result from the educational activities, and that any impact of the interventions was probably more related to (supplementary) feeding activities. Other studies (e.g. Amolo, 1979) proposed that alleviation of malnutrition requires community-based approach with emphasis on, among other things, education at primary and secondary school levels to include food science, nutrition, childrearing habits, and preventive health as a national programme. 8.37. In 1983, the FNPU, together with the African Studies Center of Leiden, Netherlands, initiated the joint Food and Nutrition Studies Programme (FNSP). The objective of the FNSP was to assist the FNPU with the analysis of contemporary trends and future needs concerning food and nutrition in Kenya with the aim of providing data necessary for the formulation of national food and nutrition policies, as well as more localized programmes and interventions. The programme was policy-oriented and also meant to serve as a training ground for junior members of the FNPU staff. According to Hoorweg (1993), Phase 1 of the programme lasted from 1983 to 1989, while Phase 2 started in September 1989. With the completion of phase 1 in 1989, the programme was transferred to Kenyan research institutes. The latter phase has also been associated with a broadening of the research themes beyond the nutrition impact of various development projects and programmes e.g. urban agriculture (see Foeken and Mwangi, 1998; Foeken and Owuor, 2000; Mwangi, 1995; and Mwangi and Foeken, 1996), and impact of seasonality on nutritional status (e.g. Kigutha, 1995). 8.38. For example, several studies used a quasi-experimental design to measure the impact of irrigation programs on nutritional status. A typical design would compare, say, resident tenants, nonresident tenants, individual (rice) growers, and farmers not connected with rice farming in any way. The general verdict was that introduction of cash crops, in individual farms or plantations, or on irrigation schemes, did not improve and sometimes worsened the nutritional status of the populations. 8.39. The study by Kigutha (1994, 1995) in a community in Nakuru district showed that energy intakes did not reach the recommended levels even when the households were apparently food secure. The failure by the children to consume adequate amounts of energy during harvest months was attributed to the low quality of the diets, which were high in bulk and low in fat and in animal products. She argued that in most agricultural communities, body weight is maximal shortly after harvest period, while the minimum is achieved during pre-harvest cultivation, usually in the wet season. The time when food availability is lowest coincides with the period when agricultural work is at its peak during the wet season. As such, the energy demand is greatest during this period, but the food supplies are low. When periods of food shortages coincide with periods of heavy physical work, people experience negative energy balance and lose weight. It is also the period of intensive labor input by the mothers, which means that the amount of care given to the children is much less in the wet season than during the dry season.

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8.40. The nutrition studies conducted in the last two decades have had profound impact on the design and implementation of policy. For example, the socio-cultural profiles produced in the early eighties and other food and nutrition studies had tremendous influence on analytical work in international organizations (e.g. UNICEF) and in the design of their programs in Kenya. 8.41. The 1984 Situation Analysis of Children and Women in Kenya used the nutrition surveys to derive an association between malnutrition, illness (especially malaria) and mortality. The report concluded that child mortality and morbidity rates are higher than the national average in the three provinces (Coast, Nyanza and Western) with greatest prevalence of stunting. The report also dwelt on the cultural beliefs and practices with respect to nutrition, especially intra-household bias in allocation of food, the feeding of mothers during pregnancy and lactation, and child feeding (mainly weaning foods). The report noted that fish is not consumed in some communities because it is believed to contain the reincarnated souls of the dead. Thus, in some communities, fish and eggs are not part of the diet although they are less expensive sources of protein than animal meat. 8.42. The report also analyzed the impact of pattern of production (especially competition between cash crops and food crops) on nutrition. Increased cash crop acreage tends to reduce food consumption from subsistence production. Income from cash crops is either too low to offset the rising prices of food or else spent on nutritionally inferior foods. For example, the report attributed malnutrition in Mumias and Kaimosi to an agricultural and marketing policy which favors cash crops over food crops. 8.43. The 1992 Situation Analysis of Children and Women in Kenya also used the findings of research in Kenya. The report dwelt on the need to reduce Kenyas dependence on maize by altering the household consumption patterns in favor of the traditional staple foods (e.g. millet, sorghum and tubers such as cassava and sweet potatoes). The production of the latter foods has declined over time, displaced in many areas by maize and cash crops. In arid and semi-arid areas, the introduction of these new crops has seriously destabilized the staple food supply. The 1998 Situation Analysis of Children and Women in Kenya incorporated the findings of the Kenya National Micronutrient Survey of 1994 (on iodine deficiency) and the 1996 Multiple Indicator Cluster Survey (on the proportion of households that use iodized salt). 8.44. Some of the surveys undertaken in the nineties were motivated by the desire to report on Kenyas status in meeting the World Summit for Children end-decade goals, both as baseline and end-of-decade indicators. The baseline and mid-decade indicators included the 1994 fifth nutrition survey, the 1994 maternal mortality survey (undertaken by the Population Studies and Research Institute), the 1996 Multiple Indicator Cluster Survey, the 1994 National Micronutrient Survey on iodine deficiency disorders, and the 1994 national survey of Vitamin A deficiency. Some of the sources of the end-of-decade indicators were the 1999 National Micronutrient Survey (anemia and the status of iron, vitamin-A, and zinc) and the 2000 Multiple Indicator Cluster Survey.

MAIN GOVERNMENT AGENCIES IN PROMOTION OF NUTRITION

8.45. There are several institutions in the organization of Government that are involved with nutrition, the main ones being the ministries of agriculture and health. However, the Ministry of Education is in charge of the school-feeding programme (SFP) in the arid and semi-arid lands (ASAL), de-worming of school children in the ASAL in collaboration with the ministry of health, and planting of fruit trees. The SFP provides midday meals in targeted ASAL districts and selected urban slums in Nairobi (Mukuru and Kariobangi slums) in a bid to improve enrolment, enhance retention, and reduce dropout and repetition rates. The SFP is a joint effort between the Government and the World Food Programme. 8.46. The Ministry of Planning and National Development is in charge of coordination of nutrition activities, monitoring of the nutritional status through occasional nutritional surveys (conducted by the Central Bureau of Statistics), and is the convener of the GoK/UNICEF programme of cooperation in Kenya. The DANIDA-funded community-based nutrition programme falls under the Department of Social Services. The municipalities where health and primary education functions have been delegated by

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the central government may be involved in nutrition in the preschools and in rehabilitation of malnourished children in the health centers11. 8.47. The Government has been giving free maize since the 1920s, but in the last decade or so, the amount of food relief has risen considerably. The three major problems with the Government system were lack of targeting (food used for political purposes), inadequate allocations for final transportation of food (a portion of maize consequently went to pay the transporters), and corruption (diversion and theft). 8.48. In early 2000, a new system the Community Based System for Food Aid Distribution was introduced. The system had three major characteristics: (a) greatly improved targeting even at the national level, (b) reduced role of Government and correspondingly high role of NGOs, and (c) community participation and involvement in targeting. The role of NGOs was enhanced since each district was required to have a lead NGO to coordinate the food relief efforts in that district. Ministry of Agriculture 8.49. The national food policy, as outlined in the Sessional Paper No. 2 of 1994 on National Food Policy, encompasses food security, nutrition, pricing and marketing, agricultural inputs, research and extension, processing, trade, and resource development and land use. The main objective of food security policy is to ensure an adequate supply of nutritionally balanced foods in all parts of the country, and includes promoting drought-tolerant crops such as sorghum and millets in the dry areas. 8.50. The policy paper recognizes the fact that global or national food security does not necessarily ensure household or individual food security. The policy paper has therefore outlined strategies to improving household food security e.g. incentives to farmers for improved agricultural production, improved extension services, improved health and nutrition education, provision of emergency food relief, and food-for-work programmes for the rural poor. 8.51. The nutrition policy is aimed at increasing the production and consumption of more nutritious food, improving distribution of purchasing power, implementing specific market intervention, and collection and analysis of information on the nutritional status of the population. The nutrition activities in the Ministry are implemented by the Home Economics Branch (HEB), alongside other extension activities. 8.52. The main objective of the Home Economics Branch is to improve the nutritional status and household food security of farm families in the country. The specific objectives are to promote dietary diversification through promotion of kitchen gardening and rearing of small livestock; promote better eating habits and increased consumption of indigenous and underutilized foods; promote gender-friendly, time-saving and energy-efficient technologies and practices; improve household incomes through promotion of income generating activities; educate farm families on the need to plan their families in relation to available household resources; and develop coping mechanisms to address the needs of families affected and infected by HIV/AIDS. 8.53. The activities are divided into three general themes, namely, food and nutrition, appropriate technologies, and integration of HIV/AIDS. Food and nutrition activities include promotion of kitchen gardening, promotion of consumption of underutilized and traditional foods, food preparation, food preservation, food processing, and nutrition education. 8.54. The appropriate technologies include energy-efficient and timesaving technologies and practices, income generating technologies, and home management (health and sanitation technologies, and home
Parliament in 1969 passed the Local Government (Transfer of Functions) Act, which transferred functions from local authorities, except municipal councils (Nairobi, Mombasa, Nakuru, Kisumu, Kitale and Eldoret), to the central government in relation to education, public health, roads, and collection of the Graduated Personal Tax (GPT). The Local Government (Transfer of Functions) Act was replaced by Legal Notice No. 41 of 1970, which amended the relevant enabling legislation specific to health (Public Health Act, Malaria Prevention Act, and Food, Drugs and Chemical Substances Act), education (Education Act), and relevant sections of the Local Government Regulations of 1963. Between 1969 and 1974, the GPT was progressively transferred to the central government, which weakened the financial position of local authorities.
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improvement technologies). Population education is geared to planning families in relation to available resources, and offers enriched and integrated HIV messages e.g. how to manage the infection with appropriate diet. The HEB utilizes group approach to disseminate information. The main activities include kitchen gardens; demonstrations on food preservation (e.g. sun-drying, sugar and acid preservation); and promotion of indigenous foods (e.g. cassava, sweet potato, and cereals such as millets and sorghum), legumes (such as pigeon peas and njahi) and small animals. 8.55. To create change in food-related behavior, HEB conducts training sessions on nutrition education. Nutrition education is aimed at increasing the nutritional knowledge and awareness of the rural population, promoting desirable food behavior and nutritional practices, and increasing diversity and quantity of family food supplies. There has also been a remarkable achievement in use of improved stoves and fireless cookers. The energy-saving stoves save on cost of cooking fuel, reduce women workload, and make it economical to prepare foods whose consumption has declined due to high energy costs (e.g. githeri). 8.56. The strategy also involves measures to reduce the difference between consumption and absorption. The factors that affect the margin between consumption and absorption include combinations of vitamins and minerals, anti-nutrients (e.g. phytates which block the absorption of iron), storage (e.g. sunlight and infestation damage), processing (positive e.g. minerals added from utensils, negative e.g. refining that removes nutritious components from food), and cooking (positive for fermentation, and negative for heat denaturing of proteins). 8.57. The constraints include inadequate funding of nutrition activities, lack of data, disintegration of extension groups, limited involvement of the Branch in food security issues, duplication of activities by other organizations, lack of resources to enable wider circulation of booklets prepared by HEB, and lack of recognition of the role of nutrition in development by policy makers and the general community. 8.58. Some of the lessons learnt include (a) the need for collaboration with other organization, (b) need for coordination of activities by various agencies to ensure non-duplication and diversification of activities, (c) the advantages of group approach to ensure wide and cost-effective coverage of the population, and (d) collection and analysis of data is important for monitoring and evaluation of any programme. The efforts of HEB to bring about behavior change have been supported by issuance of publications by government and nongovernmental institutions on Kenyas traditional food crops (see Maundu, 1999), farming handbooks (see, for example, Information Research and Communication Center, 1997), and food preparation methods (see Kenya, 2003). Ministry of Health 8.59. The elements of the program are mainly infant and young child feeding, micronutrients, growth monitoring and promotion, integrated early childhood development (IECD), nutrition and HIV, and dietetics. The guidelines for infant and young child feeding are given in chapter six. 8.60. The Division of Primary Health Care in the Ministry of Health advocates for production, consumption and preservation of micronutrient-rich foods, and activities that promote community weaning foods and community diagnosis of malnourished children. They are also responsible for vitamin A and iron supplementation through static and mobile health facilities countrywide, and monitors production and consumption of iodized salt right from the manufacturers to the household level. 8.61. The ministry of health implements a national schedule for vitamin A supplementation covering lactating non-pregnant mothers (once at birth or within 4 weeks after birth), infants 9-11 months (once during measles vaccination or any other contact), and children 1-5 years (every 3-6 months). The ministry monitors compliance and quality assurance as outlined in the enabling legislation on iodination of salt, mainly through the National Public Health Laboratories in collaboration with the Kenya Bureau of Standards. The ministry also collaborates with the ministry of agriculture in creating awareness on the need to fortify foods and the necessary food diversification to achieve the necessary iron intake. The ministry is in the process of developing guidelines for fortification of foods to make them rich in vitamin A, and to identify the necessary food vehicle for vitamin-A fortification.

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8.62. The department trains in growth monitoring and promotion (GMP), conducts growth-monitoring activities, analyzes the data collected, undertakes nutrition education, and gives nutrient supplementation to the malnourished children. The GMP is essentially a preventive programme based on monitoring the growth of children. When any danger signs are detected, health workers are supposed to discuss with the parent about the necessary remedial actions to be undertaken by the mother and the health staff. Remedial actions may include breastfeeding practices, supplementary and weaning foods, and treatment if the malnourishment is accompanied by pathological symptoms of disease. The data from all the health facilities is entered into a national database called Child Health and Nutrition Information System (CHANIS). 8.63. Early childhood development programmes in Kenya cater for children from birth to 8 years and for women of reproductive age. The programme emphasizes holistic growth and development of the child that integrate health, nutrition, socialization, emotional, motor skills and cognitive development. However, the formal center-based ECD programme reaches less than half of the eligible preschoolers, and does not cater for 0-3 years. The integrated program has been developed to also cover those outside mainstream ECD services through sustainable community-based interventions and programmes. The main objectives of the programme are to (a) strengthen the knowledge and capacities of parents and other caregivers to better care for their young children, (b) improve the status of health and nutrition of children 0-8 years, (c) raise enrolment and improve quality of education in preschools above existing levels, (d) enlist the support of other government departments and organizations not usually involved in ECD activities, and (e) raise the level of awareness about ECD within communities. 8.64. The dietetics function involves the development of guidelines on hospital feeding diets, for both regular diet and diets specific to the health condition of a patient. The special diets include pediatric nutrition (including children up to 14 years), modified consistency (soft or liquid diet for those who cannot tolerate solid foods), fiber-restricted diet (for the management of acute gastro-intestinal disorders), highfiber, calorie-controlled diets (e.g. for obesity, hypertension, diabetes mellitus with excess weight), fatcontrolled diets (liver disease, cardiovascular disorders), protein controlled diets (e.g. for renal and hepatic disorders, pregnancy and lactation), and sodium-restricted diets (hypertension, congestive heart failure, renal diseases and cirrhosis abnormal liver condition). It also includes dietary management in HIV/AIDS. The district and lower-level hospitals are supposed to domesticate the diet manuals prepared by the ministry of health to reflect health problems normally found within their catchments, but Kenyatta National Hospital observes all types of complications, as it is a referral hospital.

THE COMMUNITY-BASED NUTRITION PROGRAMME

8.65. During the struggle for independence, many heads of families were killed or imprisoned (or detained) and, as a result, mothers and their children suffered severely. The growing children suffered because food production was cut drastically. The Kenya Red Cross began to gather children under five years in village health centers and similar places, where they gave them milk from skimmed milk powder (Kenya, 1983). The occasional powder milk was provided by Catholic nuns whom children in central Kenya called cucu wa iria (milk grandmother). Later, the Kenya Red Cross felt that setting up Nutrition Rehabilitation Centers would assist the poorest mothers because they would also be given clothing and other help depending on their needs. 8.66. At the time, the programmes activities, though still working to alleviate child malnutrition, targeted affected children and mothers through a network of nutrition centers that fed and taught worst-case victims of malnutrition. In the early seventies, the programme changed its name from Nutrition Rehabilitation Centers to Family Life Training Programme under the Department of Social Services. The main aims of the programme were to assist individual families by training mothers in key areas of family welfare, prevent malnutrition and poor health among children by giving mothers instruction on preventive health measures, and treat malnourished children by providing a high protein-calorie diet. 8.67. However, during the period of the mothers absence from home with the malnourished child (while in the Family Life Training Center), other activities at home were affected (e.g. taking care of other children, fetching water and firewood, and economic activities), and they returned to the same environment of low food intake (despite having better knowledge on nutrition). The mothers were also reluctant to share knowledge with neighbors since the Centers were viewed as prisons. The International Nutrition

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Communication Service (1983) observed that to some, there is a stigma attached to attendance at Family Life Training Centers. It is viewed as a great shame to go and reflects badly on the family. Husbands are sometimes a big obstacle to entering this program. In addition, the coverage of the program was low as a Center normally covered a community within a radius of about 25 km. The Centers were therefore expensive and very small-scale in coverage, and operated as expensive boutiques available only to a small percentage of the affected population analogous to most HIV/AIDS programs nowadays (see Haddad and Gillespie, 2001). It was therefore found necessary to rehabilitate the children within their own environment through a community-based nutrition programme and enhancement of the home economics extension services normally provided by the ministry of agriculture. 8.68. According to Kenya and DANIDA (1999), the Community Based Nutrition Programme is an evolution of the Family Life Training Programme, which was initiated by the Government of Kenya in 1974 when it took over the responsibility of running Family Life Training Centers earlier established by the Kenya Red Cross. Since 1979, the Danish government has supported the programme with assistance provided in three phases. The first phase (1980-85) focused on the construction of 3 new Centers and by 1987, 14 centers had been built in 13 districts. The second phase (1985-90) centered on attempts to improve the nutrition rehabilitation of the malnourished families, while the bridging phase during 1990-94 helped the programme move from center-based rehabilitation of malnourished children to a communitybased approach. The third phase of the programme (1994-98) piloted a community-based approach to nutrition security where emphasis was put on improving nutrition knowledge and practices by exploring participatory approaches based on Participatory Learning and Action (PLA), strengthening inter-sectoral collaboration, equity, and establishing a system of technical support and management. During this phase, a participatory approach called PANS (participatory approach to nutrition security) was developed. 8.69. PANS refers to a concept aimed at improving community nutrition in some 13 districts of Kenya where the Community Based Nutrition Programme (CBNP) is being implemented by the Ministry of Home Affairs, Heritage and Sports. The programme is supported financially by DANIDA. The 13 districts covered by the programme are Kilifi, Kwale, Makueni, Kirinyaga, Maragua, Kiambu, Baringo, West Pokot, Bungoma, Busia, Bondo, Nyando and Mbeere. 8.70. The CBNP has a broadened target audience and a new approach that tackles the underlying causes of malnutrition itself. The UNICEFs conceptual framework on the causes and effect of malnutrition is the backbone of the programmes intervention strategies. According to this framework, the main underlying causes of malnutrition are concentrated around food insecurity, inadequate care for the child and mother, and inadequate healthcare. The programme aims to enhance the capacity of communities to initiate, plan, implement and monitor activities which promote the health and general development of children. There is, however, a small fund the Community Initiative Fund (CIF) set aside for financial support to the communities for the implementation of their action plans (see Makokha, 2002).

OVERVIEW OF THE CURRENT FOOD AND NUTRITION POLICY

8.71. In summary, the current food and nutrition activities fall under three major themes, which also have their own distinct history and independence in the implementation process. First, is the communitybased program which grew out of the nutrition rehabilitation centers opened in the fifties, which is funded by donors and coordinated by the Department of Social Services in the Ministry of Culture. Secondly, are the activities of the Home Economics Branch of the Ministry of Agriculture, the nutrition division of the Ministry of Health, and school feeding programme in the Ministry of Education, Science and Technology. 8.72. Thirdly is the Ministry of Planning and National Development which has retained some measure of legitimacy as a coordinating authority (despite limited activity) due to the Ministrys role as the convener of the GoK/UNICEFs Programme of Cooperation. In recent years, there has been an attempt to bring together the government departments, donor agencies, and civil society organizations on food and nutrition under the auspices of the Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN). 8.73. As stated earlier, the main constraints to the implementation of the 1994 NPAN have been lack of a national strategy that encompasses the interests of all stakeholders, underfunding of nutrition activities, and lack of a continuous process through which community-based nutrition concerns find their way to the

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national planning processes. Other policy documents (e.g. the PRSP and the Development Plans covering the nineties) also take a limited view of nutrition as an output (consequence of poverty) and not an input (nutrition interventions can reduce poverty).

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CHAPTER NINE

SUMMARY OF THE DISTRICT AND COMMUNITY CONSULTATIONS OBJECTIVE OF THE DISTRICT AND COMMUNITY CONSULTATIONS
9.1. The Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN), coordinated by the Food and Nutrition Planning Unit (FNPU) of the Ministry of Planning and National Development, is in the process of developing a policy framework under which the nutrition activities will be implemented. To do this, the committee set up a taskforce with a mandate of coming up with a draft National Nutrition policy. The Taskforce has identified community capacity development as one of the major strategic pillars of the policy. It has therefore strongly recommended community consultations and participation in the policy making process. The objective of the fieldwork is to capture community perceptions of the manifestations, causes and consequences of malnutrition. The communities should suggest likely solutions, resource needs and key partners in interventions. 9.2. Using Human Rights Approach to Programming, the study was to capture the following information from a community perspective: communitys overall understanding of the problem of malnutrition and identification of the most vulnerable groups, causes of the problems, identification of rights-holders and duty-bearers, capacity gap analysis among duty-bearers, coping mechanisms, and candidate actions. The study was also to capture the perceptions of district level implementers on nutritional issues. The district and community consultations were conducted in Baringo, Bondo, Garissa, Kilifi, Mwingi, Nairobi, and Thika districts.

THE GENERAL ECONOMIC SITUATION

The Causes of Poverty 9.3. The causes of poverty were related to the specific sources of livelihoods in the communities. For example, among the livestock keepers (Baringo and Garissa), one of the causes of poverty was recurrent drought and floods, and unreliable rainfall. The frequent droughts often deplete the family livestock, which is the mainstay of the populations, forcing people to migrate to towns in search of relief food. The districts therefore have a poor base for food security and nutrition. 9.4. Among the hoe cultivators, the problems were mainly inadequate and unreliable rainfall, low adoption of food production technologies, gender issues in allocation of labor for farming activities, wild animals and pests, and quality and consistency of agricultural extension services. 9.5. In Thika, the areas most hit by poverty are the semi-arid areas and the mushrooming slums in Thika, Ruiru and Juja towns. The dry areas hardly grow enough vegetables, in addition to general shortage of other foods. There are nutrition problems as most people work in the plantations and in private coffee farms. 9.6. In Bondo, the problems cited as cause of low yields include low quality seed varieties and retrogressive cultural practices that are a hindrance to freedom of choice in farming. In Kilifi, people prefer to plant local maize because hybrid maize is more affected by pests during storage, and pounding of hybrid maize produces smaller pellets. In Mwingi, dairy and poultry production of improved breed is practiced on very low scale. Sahiwal bulls are reared to improve the quality of local breeds. However, Mwingi has made substantial progress in adoption of new fruit varieties (for sale and local consumption). 9.7. In Kilifi, a cause of poverty was heavy workload on women including tilling the land. Women spend more time on the farm, in addition to childcare and other household chores. In addition, it is men who attend agricultural training, but the training is never translated practically because it is women who are mostly in farming and the men do not pass the knowledge to their wives. 9.8. In Bondo, pests and wild animals that annihilate the crops include squirrels, monkeys and birds. In Garissa, the crops mainly attacked by pests are tomatoes, onions and bananas. The Mwingi farmers

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attributed most of the losses at farm-level and during storage to the great grain borer (locally known as Osama). In Garissa, the district departmental heads cited constraints on improvement of crop yields as lack of access to farm inputs, limited extension coverage due to the vastness of the district, and nomadic lifestyle that makes it difficult for continuity of dissemination of extension messages. The growing of millet and sorghum is not popular in a number of districts due to its labor intensity and the need to protect them from birds. 9.9. The environmental factors and the crisis brought about by over-mining of the environment were mentioned. In Baringo, for example, destruction of water catchments has resulted to drying up of water points. 9.10. The contribution of land issues to poverty varied from district to district and community to community. For example, in Baringo, the constraint was communal land ownership in the lowlands and parts of the midlands. In addition, a community in Baringo felt that their most fertile land was converted to a game reserve. In Kilifi, the average land holding is about 6 acres, but there are many squatters along the coastline. In Thika, child malnutrition is highest among landless workers in the plantation sector. 9.11. In Baringo, other problems cited were lack of services and infrastructure e.g. shortage of health facilities and personnel, the few operational dams are far from the community, long distances to school, lack of cooperative societies (for credit and marketing of cotton and cowpeas), while boreholes and irrigations schemes are inadequate. 9.12. Other causes were of a personal nature. For example, the contribution of partaking of illicit brews, including palm wine in Kilifi, was mentioned in a number of places, especially as a drain on family resources. In Baringo, drunkenness interfered with childcare because mothers with young children were also involved in heavy drinking. In Baringo, another cause of poverty cited was lack of entrepreneurship and thus limited involvement in income-generating activities. 9.13. Several communities mentioned lack of capital as major impediment to improvement in livelihoods e.g. unaffordable fishing gears in the case of Bondo. 9.14. The general economic decline was an important factor and manifested itself in high rates of unemployment. This was highlighted by the youth in Baringo, and in the urban areas of Nairobi and Thika where wage employment is the main source of household income. 9.15. The seasonal fluctuations in prices were mentioned in all the areas visited. During seasons of food deficit, food prices tend to rise while the prices fall during surplus period. After harvest, farmers sell food at throwaway prices to meet domestic expenditure requirements. In Mwingi, for example, the grain traders purchase and store food for resale during periods of scarcity. 9.16. In most cases, the food crops grown and livestock kept may dictate the local diets, although in some cases it was the reverse. In Kilifi, for example, the keeping of rabbits and pigs is minimal because most of the residents are Muslim. It is rare for birds (poultry) and livestock to be slaughtered for family consumption, as they are seen as a source of income. They only slaughter chicken and turkey for visitors; and eggs are rarely eaten and are either sold or kept for hatching. 9.17. The main causes of poverty in Nairobi are economic, environmental health and social. The major economic factors are lack of employment opportunities, high cost of living, poor governance, and poor access to basic infrastructure and urban services. The social factors include difficulties faced by vulnerable groups, social breakdown within the family structures, insecurity, and high population growth due to ruralurban migration. Environmental health factors include lack of proper liquid waste management, poor solid waste collection and disposal, lack of potable water, and lack of affordable and accessible healthcare services.

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Coping Mechanisms 9.18. In most parts of the country, only a minority of the population affords to feed itself throughout the year from own production. There is normally a period of food stress after the entire harvest is depleted through sale and/or home consumption. Therefore, inter-harvest near-famines are common, especially for those outside the money economy who cannot afford to buy (adequate) food during these periods. The phenomenon of inter-harvest near-famines was observed in Bondo, Garissa, Kilifi, Mwingi, and the lower zones of Thika district. Since most households in Nairobi depend on purchased foods, household food availability depends on incomes rather than household food self-sufficiency. 9.19. The coping strategies among the livestock keepers (in Baringo and Garissa) include herding strategies during drought (e.g. moving livestock to other grazing grounds), migrating to peri-urban and urban centers in search of food, casual labor and petty trade. In Baringo, additional coping mechanisms include reducing number of meals, change in diet, eating wild roots and fruits, sending children to school if there is a school feeding programme, and slaughter of small stock for home consumption. The pastoralist dropouts in Garissa are among the poorest people in the district. In Garissa, the social support systems were highlighted whereby able households give support to vulnerable ones in terms of food or cash. 9.20. In Kilifi, the coping strategies in times of food stress include eating less, seeking manual jobs, and girls work as house helps. Other coping mechanisms include charcoal burning, casual jobs (e.g. petty trade), selling local brew, hunting, and selling makuti (coconut leaves). 9.21. In Mwingi and Thika, the Government is assisting the local communities to devise long-term strategies of minimizing food insecurity through public education in food management and energy saving. For example, in Mwingi, the two most notable programs are (a) promoting consumption of sorghum and millet using simple innovative products, and (b) promoting the use of cowpea leaves through preservation. 9.22. In Thika, the home economists and nutritionists promote kitchen gardens and encourage preservation of fruits and vegetables (but the adoption rate is low). The home gardens include small livestock, fruit (avocado, pineapple, papaw, guava, oranges, passion fruit, mango, lemon and watermelon), and traditional vegetables (e.g. kale, amaranth, spinach, tomato, cowpeas, pumpkin, onion and nightshade). They are promoting production and consumption of soya beans since meat has become very expensive and soya is rich in protein. The department is also promoting small stock e.g. rabbits, poultry and dairy goats. 9.23. The home economics staff said that home gardens improve nutrition of the household as people eat fresh vegetables handled under hygienic conditions, save income, is environment-friendly (can use waste for compost), and is convenient (can even harvest at night). The home economics staff hold cooking demonstrations e.g. on soya production and utilization. This involves incorporating soya in all the dishes e.g. githeri, porridge, cake and mandazi (East African donuts). As a result of collaboration between health and agriculture departments in Thika, kitchen gardens have also been established in two health facilities. 9.24. On a positive note, remittances formed an important supplementary source of income in Mwingi. However, in most cases, the recipients were mainly spouses. It is not a common practice for grownup children to remit money to their parents. Most of such remittances were spent on purchase of livestock and seeds and to meet health expenses.

INFANT AND YOUNG CHILD FEEDING

Breastfeeding and Weaning Practices 9.25. In Baringo, breastfeeding of newborns start immediately for those born in health centers, but after two or three days for those born at home because they first start with herbal feeding to clean/clear the babys stomach. After one month, the baby is given cows milk, and at 4 months start taking porridge mixed with milk. At 6 months other foods are introduced like ugali, and at 1 years start eating adult food. 9.26. Mothers in Bondo district initiate breastfeeding immediately on delivery. They can even breastfeed for two years unless the mother gets pregnant. Complementary feeding normally starts with porridge, cows

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milk and fruits. From six months, other types of food are added e.g. mashed potatoes, bananas and vegetable soup. Some introduce ugali at the early age of 6 months. Most women in the area are peasants, and time for breastfeeding is therefore not a problem. Under-five mortality in the district is mainly accounted for by malaria. 9.27. The communities in Garissa believe that colostrum is unclean milk and therefore not suitable for babies. Infants are introduced to breast-milk three days after birth. During this period, the infant is fed on milk and water. The community does not practice exclusive breastfeeding since cow milk is given alongside breast-milk in the first 5 months. Complementary feeding is introduced after 5 months and consists of potatoes and uji. Children are weaned off breast-milk at the age of 2 to 3 years. 9.28. In Kilifi, exclusive breastfeeding takes about 3 months, after which children are introduced to water and complementary foods like porridge. In Bogarash village, some mothers take up to three days before initiation of breastfeeding, during which newborns are given a solution of water and sugar. The child is breastfed exclusively for 2-3 months. Thereafter, children are given maize porridge twice a day, which is increased to three times as the child grows older. Children are introduced to adult foods at the tender age of 9 months, but might dilute the food (e.g. ugali) to avoid choking. 9.29. In Mwingi, some mothers indicated that the majority of children took 2-3 hours before the first breastfeeding, while others are breastfed immediately after delivery. Complementary feeding was introduced at any time between 3 to 6 months, while the child is breastfed in the first 2 years. 9.30. Most women in a Kibera community breastfeed immediately after birth. Exclusive breastfeeding takes 3 to 4 months, although the TBAs talked of advising the mothers to introduce fruits as early as a month or two. Some children are given porridge as complimentary food as early as 2 weeks. However, the child is breastfed for up to 2 years unless the mother gets pregnant. 9.31. In Thika, there is late initiation of breastfeeding and early introduction of complementary foods. Even a mother who delivers in hospital may not initiate breastfeeding immediately after birth, and breastfeeding on demand does not normally take place. The mothers have no problem with giving the children colostrum, and they understand it is nutritious. Very few mothers exclusively breastfeed beyond one month, as they start giving water mixed with glucose, other types of milk, and papaws and bananas as early as two weeks. By the age of three months, breastfeeding is normally down to only morning and evening. At three months, they give the child uji, cow milk, mashed potatoes, mashed bananas and papaw. The children get constipation and other unnecessary infections. The child is also left with other caregivers, especially in towns. The children get off the breasts after 18-24 months, while some stop as early as 12 months especially for working mothers. 9.32. In some high potential areas of Thika district, there may be few cases of child malnutrition because people work for many hours, and may not have enough time for their children. In the lower zones, there are more cases of malnutrition since most people earn little in the flower farms and coffee plantations, have little time for their children, and mothers stop breastfeeding very early. 9.33. In Nairobi, the food taboos depend on the rural home (meaning ethnic group) of the family or household. Among the Luhya, children may not be fed on eggs, lest they become dumb. Immunization and Growth Monitoring and Promotion 9.34. The mothers in Baringo, Bondo and Mwingi complete the immunization schedule up to measles, but there is no growth monitoring after completion of the immunization schedule. In Garissa, growth monitoring is done for children under 5 years of age. Immunization coverage is low because majority of births occur at home and children are not presented for immunization unless they are sick. Indeed, one of the constraints cited as hindrance to improvement of child health and nutrition in Garissa was that mothers do not take children to clinics regularly.

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9.35. During growth monitoring for children in a Bamako clinic in Kilifi, it was found out that lack of nutritious diets was the main cause of underweight in children, and the community therefore started food demonstration (types of food and food preparation methods) at the Bamako site. 9.36. Most of the young girls in a Nairobi slum who give birth do not normally take their children for immunization, but the TBAs and the parents encourage them to take the babies to the clinic. Immunization figures from administrative records in Thika district are dropping e.g. 2002 were lower than for 2001. Vitamin A is supposed to be supplemented every 6 months up to five years, but they do not come back after measles immunization. The Akorino and Kavonokia religious sects do not take their children for immunization. There is malnutrition especially in the flower farms and coffee estates among the children of plantation workers. How Mothers Identify Malnourished Children 9.37. Mothers in Baringo identify malnourished children by observing their body size, whether a child is eating well or not, and frequency of sickness. If they realize that the child is malnourished, they take it to the health facility. At the health facility, the nutritionist gives mothers nutrition information on how to feed their children and families. However, most mothers do not follow the advice because they may not afford the recommended food, lack of time to prepare the food, and reckless behavior e.g. drunkenness by the mother. The mothers reported that, traditionally they used to know malnourished children because the childs skin feels loose on pinching; child appears miserable; has no normal development; could lift the child and feel the weight; and take long to start sitting, crawling, or walking. 9.38. Mothers in Garissa said that child malnutrition is manifested through loss of appetite, stunting, mental retardation, skin disease, weak joints, enlarged stomach, changes in hair color, diarrhea, and increased vulnerability to diseases. In some cases, children resort to eating soil. 9.39. In Kilifi, a mother knows whether the child is malnourished by feeling the weight of the child with her hands. Some mothers do not follow, and some resent, the child nutrition advice given at the clinics, as some feel that they are doing the best they can for their children. According to the MOH, malnutrition is the number one cause of child deaths in Kilifi district. 9.40. Mothers in a community in Mwingi indicated that they were able to identify malnourished children by observing the hair (turning brown) and frequency of illness. Such children were taken to hospital or were given nutritious food. 9.41. Women in Kianda (Kibera) cited the manifestations of child malnutrition as the child becoming thin, having no appetite, and eventually developing a big stomach. The sickly child is taken to hospital, but the nutrition advice given may not be strictly followed due to lack of resources at the household level. 9.42. Among the Samburu, beads are tied around the wrist, waist and ankles to monitor child growth and development (Mukui et al, 2001). The mother watches these beads in order to determine whether her child is growing up well. As the baby grows, the beads will tighten. This is a good sign. The mother is supposed to untie the string and add one or two beads. The mother continues doing this until the child is big. This method has continued to be used alongside other GMP measures. In most other communities in Kenya, the beads would probably be decoration or talisman (an object held to act as a charm to avert evil and bring good fortune). Major Childhood Diseases 9.43. The major childhood diseases in most districts were reported as diarrhea, malaria, pneumonia, and colds and flu. The major difference was the sequence of events undertaken to restore health. For example, in Bondo, some parents of children suffering from diarrhea start with herbal medicine since health facilities are far apart. Diarrhea in children is mainly caused by types of complementary feeding, weaning foods and childcare. In Kilifi, worm infestation was also cited as a major childhood disease, in addition to malaria and diarrhea. The community in Kilifi believes that those children who get sick because of the evil eye (kijicho)

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do not recover because there is no treatment. In Mwingi, the first line of action for most diseases is to take the child to hospital. 9.44. In the Kibera slums, some childhood diseases are related to nutrition and the nature of the environment e.g. scabies (caused by dirty conditions), eye infections (too much dust), diarrhea (caused by eating unclean food), ringworms, ear infection, rickets and kwashiorkor. In the slums, very few children are taken to a doctor when they are unwell. Most of them are given over-the-counter drugs (e.g. aspirin), mothers boil herbs gathered from the river, or administer traditional medicine purchased from the Maasai itinerant traders. Others wait for a cold to cure by itself, while a few others take the child to the nearby missionary clinics.

MATERNAL HEALTH AND NUTRITION

Antenatal, Perinatal and Postnatal Care 9.45. The district health personnel in Baringo reported that the proportion of pregnant women who attend antenatal clinics is low because they are busy on the farms. At the health centers, pregnant women are advised to eat food rich in nutrients but the actual consumption of all these foods depends on availability and access at home. Most of the women deliver at home because of long distances to health facilities, high cost of healthcare, TBAs are easily available within the community, and fear of harassment (unkind treatment) from nurses. 9.46. In Bondo, women are advised to eat omena (dagaa), beans, sorghum, and (if can afford) liver and eggs. However, few follow the advice, as the food available has to cater for the whole family. There is no iron deficiency in a normal healthy mother in the area as mothers eat a lot of fish (fish has a lot of iron). The majority of the children are born at home due to emergency conditions, and long distances to hospital. 9.47. In Garissa, majority of deliveries occur at home with assistance of trained TBAs. The community reported that special diet is recommended for lactating mothers, and consists of porridge, milk, liver and beans. Few women attend antenatal and postnatal clinics. 9.48. Kilifi reported that only a small proportion of pregnant mothers attend antenatal clinics. The factors mentioned were ignorance (lack of knowledge), while the consent of husbands is normally required before attending antenatal and postnatal clinics. The causes of neonatal deaths were reported as anemia and tetanus (pepopunda)12. 9.49. The attendance at antenatal clinics in Mwingi district is low due to long distances to nearest health facility, lack of money for transport, and poor transport network. There is a significant proportion of women who deliver at home. 9.50. Most Nairobi mothers attend antenatal clinics in the health centers operated by the Nairobi City Council, although the mothers start attending clinic late in pregnancy. Most deliveries in the slums take place at home sometimes with the help of TBAs, mainly because they cannot afford the requisite maternity fees. 9.51. The Kibera community reported that attendance of pregnant mothers to antenatal clinics is quite low, and only about 50% of those who attend continue regularly until delivery. TBAs provide antenatal care to majority of the women. The majority delivers at home with the help of TBAs. Pregnant mothers do not encounter many problems since any condition or a disease that may pose a problem (e.g. high blood pressure) is detected early enough and referred to hospitals by TBAs. They reported that there are many cases of stillbirths. Some children die during childbirth due to fetal distress and premature births, especially those born at home.

The Swahili names for other vaccine-preventable diseases are dondakoo (pertussis), kifaduro (diphtheria), surua (measles), polio (poliomyelitis), homa ya ini (hepatitis type B), homa ya uti wa mgongo (meningitis) and kichomi (pneumonia).

12

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9.52. The ministry of health in Thika trains TBAs on safe delivery and other aspects of maternal child health. The health personnel said that TBAs have become too brave, as they wait for too long before seeking professional help, which can lead to cerebral palsy. Some TBAs even try to deliver twins and breech presentation (legs and buttocks first). Care and Feeding of Pregnant and Postpartum Mothers 9.53. Traditionally, pregnant women in Baringo are advised not to overfeed, and specifically not to eat eggs because the unborn baby will be too big. They also continue with their daily activities, with no reduction in workload. However, the women are fed well after delivery. 9.54. In Bondo, there is no special feeding of pregnant mothers, and their workload does not normally change. Mothers in Kilifi continue with their normal duties, as they do not have much choice. Pregnant mothers eat the same foods as the rest of the family. There is no special diet for postpartum mothers. 9.55. The Kibera community said that pregnant women do not reduce their normal workload. The women said that lactating mothers normally get special diets for about 2-3 months after birth. Among the Kikuyu, the foods given to women after delivery include soup and njahi. However, in most cases, pregnant and postpartum mothers eat the normal family diet of sukumawiki and ugali. Consequently, the mothers are not well fed, and most are anemic and underweight.

NUTRITION AND HIV/AIDS

Prevalence of HIV/AIDS 9.56. In most districts (e.g. Bondo, Kilifi, Mwingi and Thika), the prevalence of HIV/AIDS has recorded a decline in the last few years. However, only districts with sentinel sites were able to give precise estimates, while others like Bondo estimates using hospital admissions. It is only Garissa that reported that prevalence of HIV/AIDS is low. 9.57. However, the communities in Bogarash (Kilifi) and Waita (Mwingi) reported AIDS as one of the main adult diseases, while Dera village (Kilifi) cited HIV/AIDS awareness and behavior change as one of the recurring themes in community theatre. In Thika district hospital, AIDS was reported as number two in the top ten causes of mortality in the hospital, after broncho-pneumonia. What the Communities Know About HIV/AIDS 9.58. Most communities know AIDS is a killer disease, and know its modes of transmission and prevention. However, some people in Baringo believe that HIV/AIDS is caused by witchcraft. Similarly, some communities in Bondo are reluctant to associate any death with HIV/AIDS, but may relate the symptoms with violation of customs and beliefs. In Kilifi, there is still a strong belief that any illness is a result of witchcraft and kijicho (evil eye) although the evil eye may be inherited and does not necessarily imply malevolent intent. 9.59. In Nairobi and Thika, the communities are aware about modes of transmission of HIV, including how to minimize mother-to-child transmission (perinatal and breastfeeding). However, it was reported in Thika that people do not use the knowledge e.g. when they take local brew they forget about protected sex. The Most Vulnerable Groups in the Community 9.60. The vulnerability to infection was largely determined by demographic (age-gender) profile and occupation. In Baringo, the vulnerable groups were reported as the youth in the urban areas and drunkards in the rural areas. In Bondo, there is high concentration of HIV/AIDS incidence along the beaches. A fishing community in Bondo reported that HIV/AIDS travels by road and lake. An elderly man in Bondo said that HIV/AIDS is high among the youth, but old men do not have the virility to make them vulnerable.

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9.61. In Kilifi, the health personnel suspected that the rate of transmission increases during traditional ceremonies e.g. funerals and weddings. HIV was reported as closely related with polygamy and single women. A village chairman in Thika reported that AIDS is common, partly because of old men moving with young prostitutes or an old man marrying a young wife who is likely to stray. A youth group in Ruiru reported that the population groups most vulnerable to infection are 24-35 year old women, and male youth of 15-24. In the coffee estates, women have no bargaining power in relation to safe sex. 9.62. A community in Kibera reported that the most vulnerable groups are the youth (because of idleness) and adults (because of drunkenness). The infection rate is highest among those under 35 years of age. The majority has not accepted the use of male condoms. Despite the high level of awareness, the rate at which youths in the community are having unprotected sex is increasing. HIV/AIDS Awareness and Behavior Change 9.63. In Baringo, the district departmental heads reported that although there is high level of awareness, there has been minimal behavior change. In Bondo, AIDS awareness has worked, especially in fish-landing bays, and the business interactions between young men and girls in the beaches is rarely related to sex. 9.64. In Garissa, the district departmental heads reported that the majority of the population is aware of the disease. However, they also reported that there are no home-based care programmes or home visits targeting people living with HIV/AIDS. HIV/AIDS has also been integrated in the school curriculum where pupils are taught on the basic facts and coping strategies. 9.65. In Kilifi, death through AIDS has had a very significant impact on the peoples awareness. The Ministry of Health is the lead agency in creation of awareness, with the support of other government departments and nongovernmental organizations. In Dera village (Kilifi), a theatre group includes behavior change on HIV/AIDS in its community theatre. 6.66. In Mwingi, the high level of awareness has failed to trigger a change in behavior. A prototype community in a slum area of Nairobi reported that there is high awareness of HIV/AIDS but little behavior change. The youth lamented that girls are not interested in discussing AIDS matters. The communities in Thika district had a similar story: high level of awareness and low behavior change. For example, a self-help youth group at Ruiru has behavior change as one of its main missions, and includes community theatre on, say, condom efficacy. 9.67. The gender relations in different study sites had profound effect on an individuals odds of getting infected. For example, in Nairobi it was reported that girls are not interested in discussing AIDS matters, while in Garissa a woman may not consent to a man who insists on using a condom. In Thika, women working in plantations generally have low bargaining power in relation to safe sex. It is important to study and understand the dynamics of gender relations and their impact on health and nutrition outcomes, as a guide in the design and implementation of community-based programmes. Nutrition Information Specific to HIV/AIDS 9.68. In Baringo and Bondo, community health workers (CHWs) and nutritionists provide information on nutritious diet for those infected with HIV/AIDS, but practice of the same depends on household access to the recommended foods. The groups most at risk of infection are normally the breadwinners, and the rest of the family cannot therefore afford a proper diet. Those engaged in home-based care have a hard time convincing people to eat what they cannot afford. 9.69. In Garissa, nutritional counseling is given to those seeking treatment at the provincial general hospital. Some people believe that camel products (meat, milk and urine) and herbs (such as neem tree) can cure HIV. Other interventions believed to cure HIV include eating a lot of boiled meat, and prayers. In Kilifi, health workers advise HIV patients to eat balanced diet, but this rarely happens due to the food situation at the household level.

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9.70. Thika health staff said that there is a gap in nutrition advice since a nutritionist is rarely invited to advise the infected person so as to delay the onset of sickness and reduce the likelihood of opportunistic infections. However, TB (one of the opportunistic infections) is also a disease of the environment as it is most common in the crowded settlements e.g. Kiandutu slums. The HIV-positive adults are advised to eat a balanced diet and food rich in vitamins e.g. indigenous vegetables and all types of fruits. Those who can afford the recommended diet do buy. However, HIV/AIDS drugs are expensive and the patients may value drugs more than food in the management of HIV. 9.71. In Nairobi, the community participants said that it is difficult to give a balanced diet to people living with AIDS due to the low economic status of most households. Community and Home-Based Care for the Infected and Orphans 9.72. In Baringo, the infected and orphans are supported by NGOs and other organizations through food, drugs and education (school fees for orphans). They are encouraged to stay within their family setups and the orphaned children to stay with relatives. 9.73. In Bondo, the National Aids Control Council works at the grassroots through support to CBOs. One of the most common areas of interest among CBOs is home-based care for AIDS patients. For example, Victoria Women Group undertakes home-based care for the infected, and for orphans. They have established an orphans center, which has now reached Primary Class 2 and will be a feeder school with up to Class 4. In the school, the children are fed and receive micronutrient supplementation (e.g. folic acid tablets, Vitamin B complex) through porridge. The porridge is given to both the infected (to boost immunity) and orphans. 9.74. In Mwingi district, there are several home-based care programmes initiated by the Catholic Church and several CBOs. The National Aids Control Council has funded organized groups to implement AIDSrelated activities. In Kibera, children orphaned by AIDS are under the care of immediate relatives. However, there are feeding programmes for children, mothers, the aged and HIV/AIDS patients, which are run by church organizations. A youth self-help group in Thika has introduced home-based care, and opened a daycare center for the orphans and the vulnerable (whose parents are in the advanced stages of AIDS). Effect of Infection on the Immediate Family 9.75. The district departmental heads in Baringo said that the disease has had a big effect in increasing household expenditure. One of the NGOs operating in Baringo stated that the main challenges to the success of its programme have been HIV/AIDS, drunkenness, and illiteracy. The district departmental heads and the general community in Bondo district stressed that, with the onset of HIV/AIDS, the productive population has been reduced and this has increased stress on incomes. 9.76. Although the prevalence of HIV/AIDS is generally on the decline in Kilifi district, the health staff commented that it has led to loss of income due to lower productivity, poverty (especially if the infected is the breadwinner), diversion of household income towards medical care, sale of property to meet medical expenses, and care of the orphans. Despite the general statements about the prevalence of HIV, the community in Bogarash village still reported HIV as one of the main adult diseases, in the same league with malaria and typhoid. 9.77. In Thika, HIV/AIDS has devastated families e.g. use a lot of money for drugs, the infected was probably the breadwinner, children drop out of school, adolescent girls get married early or go looking for jobs, is an emotional drain on grandparents, and increased child labor. Due to the interrelatedness of HIV/AIDS with livelihoods, the home economics staff incorporates family life education (e.g. HIV/IDS awareness and childcare and development) in their regular activities.

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Mother-to-Child Transmission of HIV 9.78. A health nurse in Baringo said that mother-to-child transmission of HIV/AIDS could be minimized through drugs administered to a mother just before birth, and exclusive breastfeeding. In Bondo, VCT services were introduced recently, and HIV-positive mothers are provided with drugs to prevent mother-to-child transmission. However, some community members believe that an infected pregnant mother will always give birth to an infected child. The community members are therefore not aware that antiretroviral drugs can reduce mother-to-child transmission during birth, although the drugs are available in the district hospital. Health personnel advise HIV-positive mothers not to breastfeed, but some mothers do not follow the advice because they do not have the means to buy breast-milk substitutes. 9.79. In Kilifi district, the health personnel advise HIV-positive lactating mothers not to breastfeed. In Mwingi, HIV-positive mothers are advised not to breastfeed, but most of the mothers are unable to afford breast-milk substitutes. At the district hospital, there were no drugs to prevent mother-to-child transmission. 9.80. In Thika, HIV-positive mothers are advised to make informed choices, have proper feeding during pregnancy, and are booked for delivery in any of the two hospitals (Thika and Gatundu). A HIV-positive mother is given antiretroviral drugs (nevilapine) once she gets into labor and the newborn given nevilapine syrup to reduce the chance of mother-to-child transmission. However, very few community members know about this service, as training is focused on hospital staff and not the field staff. The HIV-positive mothers are advised not to breastfeed, and those with ability to provide breast-milk substitutes follow the advice. In Kibera, the TBAs advise mothers not to breastfeed their children if they know they are HIVpositive, and to give their children formula or fresh milk.

NUTRITION AND EMERGENCIES

9.81. The consultations raised concern about long-term weather changes and environmental degradation that may have long-term impact on food security and other aspects of livelihoods. Major droughts are expected every four years, and the arid and semi-arid areas are perennially either in an emergency stage or recovering from an emergency. The food-based relief programmes during drought or when recovering from drought were the focus of community and district consultations. 9.82. A number of studies conducted under the auspices of the Food and Nutrition Studies Programme focused on the effects of seasonality on food production and its impact on nutrition. Food harvested by most subsistence farmers is normally not sufficient to feed the family until the following season, either because of the small quantity harvested or sales made immediately after harvest, hence the reference to inter-harvest near-famines. In the dry season, people purchase cereals by a standard measure (a gorogoro), hence the reference to Kenyas rural economy as the gorogoro economy (see Cohen and Odhiambo, 1989; cited in Whyte and Kariuki, 1991)13. Food Relief Programmes 9.83. The districts covered by the study which receive food relief on a regular basis are Baringo and Garissa. In Baringo, the communities said that the relief food is not nutritionally adequate as it is only maize and beans. Bondo does not receive food relief on a regular basis. However, there was a motion passed by Parliament on 31 July 2002 to include Bondo and other contiguous districts in the Lake region as arid and semi-arid areas, ostensibly to make them eligible for food relief. 9.84. In Garissa, some of the constraints to improvement of health and nutrition include dependency on famine relief, maize given as relief food is not suitable for children under 5 years of age, and MOH is not involved in relief food to advice on quality of ration. The community is fully involved in the process of food aid, right from identification of beneficiaries to actual food distribution. In some areas, malnourished

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A gorogoro is the standard unit for buying and selling maize in Western Kenya. A gorogoro is a volume measure equivalent to roughly 2.25 kg of dry maize kernels.

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children are given supplementary feeding in form of porridge flour. Children with low weight-for-height (severely malnourished) are given nutritious biscuits and vitamin A capsules. 9.85. In Kilifi, food relief is mainly given in Ganze, Kaloleni and Bamba divisions. The quantities are not enough and the timing is not regular. They said that the relief food therefore has no impact on nutrition. There are food relief committees that assist in identifying the needy households in the distribution of food. 9.86. In Mwingi district, food relief used to be a political tool especially during election years, particularly in the lower divisions of the district. However, coordination has improved through the use of communitybased committees for targeting needy households. A lead agency is identified to coordinate all relief efforts in the district. Unlike in the past when food was used as a political tool, food-for-work and communitybased approaches of targeting the poor have reduced dependency since people are aware that they can be independent by growing more food. 9.87. The community in Kibera said that it has never received any major food relief from the government. There are, however, some programmes such as the Catholic Relief Services that target certain groups, e.g. elderly, orphans and sickly. In Thika, the little food relief allocated to the district is distributed to every administrative division regardless of need. There are no NGOs dealing with food relief. School Feeding Programmes 9.88. Out of 357 primary schools in Baringo, 355 are covered by the school-feeding programme (SFP), and the remaining two volunteered not to. The preschools attached to the primary schools benefit from the SFP. The rest of the preschools depend on their own arrangements. Due to the free primary education programme introduced in January 2003, more pupils have enrolled leading to food shortage. The SFP improves enrolment and general performance of the pupils. 9.89. The SFP in Garissa is supported by WFP in collaboration with the Government. The local community provides water, firewood, salt and other ingredients in addition to facilitating the cooking. The food consists of a midday meal for both preprimary and primary schools. The benefits of SFP were cited as increased school enrollment, enhanced learning and retention, and improved school performance. 9.90. In Kilifi, the SFP is in 38 primary schools in the dry areas of the district. The 38 schools with school feeding programmes are normally among the top in Kenya Certificate of Primary Education (KCPE) in the district. The SFP in Mwingi district provides food to about 200 out of a total of 353 primary schools. The communities contribute by supplying firewood and water. The communities also supply beans during periods of good harvest. One of the most important achievements of the SFP has been the significant increase in primary school enrolment. 9.91. In Nairobi, there is no policy on feeding in primary schools. Currently, school feeding largely depends on initiative of parents and school management. Many schools have kiosks that sell junk food (snacks) that are expensive but lack vital nutrients, and thus negatively affect child health. Some children carry packed lunch consisting mainly of starch-based foods, which also lack vital nutrients. In addition, because of lack of feeding programmes, neighboring communities get opportunity to sell food to children often in unhygienic conditions.

WATER AND SANITATION

Community Access to Safe Water 9.92. Although the consultations did not yield precise estimates, access to safe water in most districts and communities is low. In Baringo, for example, the main sources of surface water (mainly in the highlands) are rivers, pans, dams, and lakes while underground sources (mainly in the lowlands) are boreholes. In general, animals and humans use the same sources of water, and the water is polluted. However, efforts are being made to prevent pollution through stopping encroachment of the rivers upstream.

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9.93. The vast area of Bondo district does not get clean water, as the majority of the population depends on untreated water from dams, ponds, rainwater and the lake. In Maranda division, the sources of water are dams which contain stagnant water. Livestock use the same water sources, which makes the water dirty and brown in color. 9.94. In Baringo, women and girls fetch water for domestic use on a daily basis. In Bondo, gender roles is of major concern, mainly because the district has acute shortage of surface water and women have to travel long distances to fetch water, leaving inadequate time for food preparation. 9.95. In Kilifi district, piped water and electricity are only available in the densely populated areas along the tarmac roads from Mombasa-Malindi and Mombasa-Nairobi up to Mariakani Town. The main sources of water in Kilifi are pans, dams, rivers and shallow wells. The water sources are unprotected and open to contamination. 9.96. The main sources of water in Mwingi include dry riverbeds, shallow wells, Tana River, boreholes and springs, and rock catchments (to a small extent). Domestic animals and wildlife share the same water sources with humans. 9.97. The sources of water in Nairobi include treated piped water, boreholes (the water has too much fluorine), water vendors especially in the slum areas (water may be contaminated during handling), river water for drinking (e.g. the upper parts of Nairobi River before it becomes polluted), and polluted river water (for washing and bathing). The water points in Kibera are not sufficient to serve the whole community. Sometimes the water they buy is salty. 9.98. When there is a serious shortage of water, some students in Kibera fail to go to school so as to assist their parents to search for water. In schools, water is not sufficient and students bring it from home. In informal schools, kids carry water to school almost every day. Thika district is characterized by high water seepage, cultivation up to the rivers, destruction of catchments, and high soil erosion. Consequently, rivers have become streams. 9.99. A resident of Gatuanyaga said that one of the common diseases is typhoid because human waste is washed to the river, where people draw water for drinking and cooking. In Ruiru, it was reported that although there is piped water in some areas, typhoid is still common because most people use borehole water, as they cannot afford piped water. Environmental Protection and Water Supply 9.100. All the communities visited reported that they are slouching towards environmental bankruptcy (a description borrowed from Timberlake, 1988; see also Rocheleau, Steinberg and Benjamin, 1995, for a Kenyan narrative). For example, key informants in Baringo district said some causes of the worsening poverty situation are diminishing water resources and declining quality of soils due to overuse (including overgrazing) and soil erosion. The community recommended that a national nutrition policy should put more emphasis on environmental conservation (soil and water) for sustained food supply. 9.101. The majority of the poor in Nairobi live in informal settlements, which account for approximately 55% of its population and occupy 5% of the total residential area. A small proportion of urban agriculture is based on wastewater irrigation and river irrigation (along the Nairobi River which is likewise polluted). There are risks of accumulation of heavy metals during crop growth and contamination of vegetables during handling. The crops grown along the roadsides also pick up lead from the vehicle fumes. A study conducted on cowpeas sold in Nairobi vegetable markets showed significantly elevated levels of lead and cadmium, probably originating from airborne particulates from motor vehicle exhausts, industrial emissions, and uptake of the metals from the soil (Tumbo-Oeri, 1988). Safe Sanitation and Hygiene 9.102. The communities in Baringo have knowledge on safe drinking water and the need to boil water before drinking. The information is received from health workers, but in practice, they do not boil it. The

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main problems related to water and sanitation is shortage of water and pollution of water sources. There is also knowledge on personal hygiene practices but it is not followed. 9.103. Generally, less than 20% of the Bondo households have pit latrines. However, this varies with season since many pit latrines collapse during the rainy season (because of the type of soils and floods). Given the variations in latrine coverage, the onset of rains determines the seasonal calendar of waterborne diseases, which are mainly experienced at the beginning of the dry season and beginning of the wet season. Cholera is endemic in both periods, while malaria is common. 9.104. The Bondo fishing community (Uhanya fish landing bay) said that the only source of drinking water is the lake. Some people do not boil drinking water, but the majority does, and even a small percentage uses chlorine. They said that un-boiled water from the lake causes typhoid, diarrhea and vomiting. The majority has pit latrines, and the majority uses them. The ones who do not use toilets is because they refuse to share (e.g. with wifes mother) or if a toilet is too near the boys hut (simba) the parents cannot use it. Toilets cannot be dug on swampy and sandy areas e.g. as in Kayomo area. 9.105. Although most people in Maranda division are aware of the need to boil drinking water, very few do so. They argue that boiled water loses taste. The households are aware of the need for clean sanitation, and have toilets. The tradition is that parents and grownup siblings (especially married sons and their families) should have separate toilet facilities. 9.106. Some of the constraints to improvement of health and nutrition in Garissa include lack of clean and safe drinking water, poor management of environment and sanitation, lack of designated garbage disposal sites, and lack of proper latrines particularly in the rural areas. The strategies should therefore include provision of safe drinking water, and to conduct training on proper hygiene and sanitation. 9.107. In most of Kilifi district, sanitation coverage is high, but very low in Bamba and Ganze (hence the common reference to kajembe mkononi hoe at hand). Bogarash village has clean piped water. Very few boil water before drinking because they assume piped water is already safe. Only about half of the homesteads have pit latrines. The mothers make sure that they wash their children regularly. 9.108. The residents of Dera village reported that some of the areas have access to piped water where the community members pay KSh 5 per 20 litres of water. During dry spells those without access to piped water travel up to 6 km to get water. Walking long distances in search of water drains the energy levels of women. Most households do not boil water before drinking despite the awareness created through community resource persons e.g. CHWs. Only an estimated 1% of the households have access to a toilet. 9.109. The main water sources in Mwingi district are unprotected. The water is contaminated, which explains the high incidence of diarrheal diseases. Although people are aware about the need to drink safe water, disposal of waste and promotion of personal hygiene, the practice has been poor. This has been explained by the extreme water scarcity, which makes water availability more critical than the question of its safety/quality. 9.110. The community members in Mwingi complained that water consumed in the community was polluted. Humans share the water sources with animals. Most families have toilets (about ) while the rest use bush. Although most of the members understood that unsafe water should be boiled, they did not boil water as they felt the process was tedious and time-consuming. They indicated that they always washed vegetables before cooking, washed hands before handling food, and washed fruits before eating. 9.111. The Kibera community said that they drink treated tap water, but do not boil before drinking since they assume it is safe. There is usually an outbreak of waterborne diseases (e.g. cholera, typhoid, diarrhea, dysentery and skin rashes) especially among children due to dirty water from rivers and contaminated pipe water (in case of burst pipe thereby water mixing with sewage). They consider it expensive to boil water. They proposed that the government should treat water properly to avoid the need to boil it. 9.112. The disposal of human waste is through pit latrines. The toilets are not emptied (exhausted) regularly when they get full. The pit latrines are within the Kibera settlement, which leads to poor

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sanitation. They also use flying toilets (use of plastic bags for defecation, which are then thrown into ditches, on the roadside, or simply as far away as possible), where the waste flows on the surface when it rains. 9.113. There is poor drainage in Kibera. The CBOs and youth groups involved in sanitary work in the village provide the community with polythene bags to dispose garbage but instead people dump the waste in open spaces and the rivers. The male youth drain stagnant water in the paths in an attempt to control mosquito breeding. 9.114. The children said that some of the common childhood diseases are scabies (caused by dirty conditions), eye infections (too much dust), diarrhea (caused by eating unclean food), ringworms, ear infection, measles, rickets and kwashiorkor. The children said that their parents do not allow them to boil water because of lack of cooking fuel (kerosene). The schools have no water at all, and children complained of lacking drinking water while at school.

FOOD AND NUTRITION

Household Consumption of Food 9.115. In Baringo, the quantity and quality of food consumed is not adequate. It is not nutritious as it is mostly maize and beans and little vegetables and fruits. There has been no change in the types of foodstuffs consumed in the last decade. 9.116. The main types of food in Bondo district are fish, vegetables (e.g. kale), meat, beans and ugali. Most of the kale and maize is imported from outside the district. Sorghum is mainly mixed with maize or dried cassava before taking it to the millers. The consumption of sorghum has also declined due to change in tastes towards substitutes such as rice. The community imports only basic foodstuffs (e.g. maize), which implies that there is nutrition deficiency and lack of variety, especially during the dry season. There is poor dietary diversity and overreliance on fish and ugali as the main food types. Traditional foods that were rich in nutrients and were drought-resistant and disease-resistant have been neglected. 9.117. During food stress, the main meal in Maranda division is ugali and omena. The ugali consists of maize and sorghum flour, as maize and sorghum ugali is heavy, and a small portion can feed more household members than plain maize meal. Cassava is also dried and mixed with sorghum to prepare ugali. Omena is a favorite dish at this period because it is cheap and easily available. There is very little vegetable production except traditional varieties like osuga (black nightshade), mrenda (jute plant) and others which grow wild. In times of stress, the main sources of livelihoods are remittances from family members working elsewhere, and earnings from casual jobs e.g. bush clearing, charcoal burning and selling firewood. 9.118. A chicken is slaughtered for a visitor, when a member of the family comes back home, or during a festive season e.g. Christmas. Eggs are rarely eaten, and are normally allowed to hatch, as chicken is a favored delicacy. 9.119. The traditional foods in Garissa consist of meat and milk (fresh or fermented). Maize is pounded into grits and prepared with milk (to make ambula) or boiled together with beans to make githeri. Sorghum is pounded into flour or fried. Tea is a very popular beverage taken with high concentration of sugar. Malnutrition is common because of underutilization of nutritious foods particularly vegetables due to cultural beliefs and taboos. One of the causes of malnutrition is poor diet e.g. taking strong black tea with ugali. 9.120. The common types of food in Mwingi district include githeri, muthokoi (a traditional dehulled maize dish), rice, green grams, beans, meat, kinaa (a cake made of a mixture of sorghum/millet and milk), and millet/sorghum porridge. The popularity of ugali has been improving over time. The popularity of muthokoi is confined to rural areas. Muthokoi is time demanding in terms of cooking, and is therefore accorded least preference in urban areas. A community in Mwingi indicated that they eat food to fill the stomach. The members noted that there had been a change in diet over time e.g. from millet porridge (for breakfast)

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towards white tea (with milk). The community felt that the change in eating habits has been detrimental to their health since the food eaten in the past made people strong but now people are relatively weaker. 9.121. The community consulted in Kibera said it does not have proper knowledge of what is a nutritious diet, and said they eat to fill their stomachs. Very few could explain what is meant by a nutritious diet. All they said was that they eat kales, beans, and occasionally fish and fruits. The food eaten comprises of kale and ugali and in rare cases githeri. 9.122. Ugali is becoming popular in Thika and is normally eaten with vegetables and beans. The increasing popularity of ugali is because it is faster to cook in terms of time and fuel consumption because firewood is becoming scarce. Adult malnutrition is low. In the public hospitals, there are diabetic cases that are not obese. However, private doctors observe a different diabetic population where obesity might come in. 9.123. People in Thika have changed feeding habits e.g. away from arrowroots. People used to mash food with bananas, but now consumption of bananas is low, as most people grow them for sale or ripening. They have replaced bananas with Irish potatoes. Food has also become expensive and has less protein e.g. kale and ugali diet. Some of the elderly men of over 50 years are sick (diabetes and hypertension) probably because they no longer get the indigenous foods. For most old people, their children live far away from home (e.g. in towns) and visit them once a month, if at all. Unlike men, women can visit and stay with their grownup offspring for short or long periods, leaving their elderly husbands unattended. The common emphasis on women and children as vulnerable groups ignores that men are also potentially vulnerable in nutritional terms. 9.124. As argued in Mukui (2002), in Kenya the demand for traditional crops, especially vegetables, is low. One of the outcomes of the agricultural extension messages of the sixties and the seventies was the structural shift in production systems and consumer demand from traditional ground-hugging crops (e.g. sweet potatoes and traditional legumes and vegetables) to cash crops (e.g. tea and coffee) and new seed varieties (e.g. hybrid maize). The traditional ground-hugging crops tended to provide their own canopy and mulch that assisted in regeneration of the soil. The new crop varieties are more dependent on imported inputs or inputs with high import content e.g. fertilizers and pesticides. The unique definition of food security in terms of maize availability threatens the viability of food production systems, and has resulted in intermittent food insecurity. 9.125. For example, sweet potato has been receiving increasing attention from agriculturists and ecologists interested in developing the worlds sustainable production systems because it can grow on soils of limited fertility, is relatively drought-tolerant, provides good ground cover, and is usually cultivated without fertilizer or pesticide (Oyunga, Hagenimana, Kurz and Low, 1998). In addition to the high starch content, sweet potato roots are one of the major food sources of carotenoids along with apricots, carrots and peaches. The color intensity of the flesh roots differs from one cultivar to another, and varies from white to deep orange. The intensity of the orange color of flesh roots is correlated with carotenoids content. Food Taboos 9.126. In a community in Bondo, women do not eat the tail or gizzard of a chicken; these parts are reserved for the household head or the eldest son if the household head is not in. However, women can eat the said chicken parts in the absence of any man in the household. 9.127. Some of the food taboos in Garissa include: women do not eat eggs; girls are forbidden from taking tea (it is believed that tea will make them fat); all types of birds (e.g. chicken), rabbits and fish are rarely eaten by any community members; and green leafy vegetables are for livestock. 9.128. The food taboos in Nairobi depend on the ethnic group of the index household. For example, among the Dholuo, a woman may not eat the tongue of livestock. Among the Dholuo, Luhya and Gusii, the gizzard and back (tail) of chicken is reserved for men; while wings, neck, leg, liver and intestines are for women and children. Among the Luhya, children may not take eggs, lest they become dumb; and women do not eat fish soon after delivery. Among the Gusii, old women do not eat chicken and eggs.

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Food Preparation Methods 9.129. The food preparation methods are related to the culture of the people, the competing demands for time, and the cost of cooking fuel. The main type of cooking fuel in the rural areas is firewood. In Mwingi, for example, commercial charcoal production is discouraged due to concerns of environmental conservation. It is therefore Government policy in the district that charcoal should only be harvested from dead wood. Thika and Nairobi reported shifts to fast cooking foods due to cost of fuel and the short time available for cooking, thereby avoiding cooking foodstuffs like maize and beans. 9.130. The nutrition and health staffs in Thika sensitize people on the need to avoid overcooking, while undercooking may be dangerous in case of meat as parasitic worms (e.g. liver flukes and tapeworm) may survive. Overcooking of vegetables destroy vitamin A, while overcooking meat denature (destroy) proteins. Food may also be prepared under unhygienic conditions e.g. cutting of vegetables may cause typhoid if not cleaned or if washed with polluted water. 9.131. In Baringo, the method of cooking vegetable does not seem to denature food, e.g. kale is first washed, cut, and then fried for 5 minutes. 9.132. In Kibera, kale is cut then washed, thus washing away most of the nutrients. Some people buy ready chopped vegetables where nutrients are lost while washing, and tend to overcook vegetables. Some people even go to the extent of boiling the sukumawiki for about 5 minutes (and throw away the water) so that the color is washed off to remove the green color. Others fry it for over 20 minutes ndio iive mzuri (overcooking). Due to the high cost of cooking fuel, the households prefer foods that cook fast, which has led to reduction in traditional foods such as githeri. 9.133. The ministry of agriculture in Thika assists communities in environmental conservation through energy-saving jikos. This encourages mothers to cook foods they were not cooking before (e.g. githeri) by reducing expenses on fuel. There is less denaturing of food when you use the fireless cooker, and thus better preservation of nutrients. Some households in Thika have taken the production of fireless cookers as a business, thus assisting in social marketing (of the cookers) in their normal pursuit of commercial interests. 9.134. In Thika, they normally overcook vegetables when they should do it for only 10 minutes. They are also supposed to wash vegetables before cutting (not the other way round). In the urban areas, there is a habit of shredding vegetables before selling them, and are cleaned again when the buyer reaches home. Intra-Household Elements of Food Production and Consumption 9.135. In Baringo, men normally work very few hours per day e.g. in farming or herding. Women on the other hand are responsible for all household chores (e.g. cooking and other aspects of home making), milking cows, grazing cattle, farming, fetching water and firewood, going to the market, and childcare. The male youth are also involved in farming. However, due to the high levels of unemployment, the youth are idle most of the time, and would prefer to be busy doing something. In a typical Baringo household, men are served first followed by children and women last. During food stress, women are most affected, especially elderly women. Milk is mainly given to the young children. 9.136. In Bondo, young women are involved in small-scale businesses e.g. selling tomatoes and frying fish for sale. Young men are in fishing as employees; old women are only involved in farming; and old men are in fishing and burning charcoal. There are no jobs for the youth, even those who have completed the secondary school cycle. 9.137. In a typical household in Garissa, the head of household (the man) and other male members are served first, followed by children, and lastly the mother. The famous nyirinyiri is a delicacy only reserved for men. A husband is never aware that her wife has missed a meal and is a taboo for the woman to reveal that she has missed a meal. This only becomes evident when, for instance, she falls sick and it is diagnosed that she is anemic and need blood transfusion.

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9.138. Communities in Kilifi said that children start working at an early age, but as boys grow older, they reduce their involvement in farming activities to imitate their fathers. There is child labor e.g. girls working as housemaids and in some cases their salaries are paid directly to their mothers. Boys normally work in the shopping centers selling small items e.g. groundnuts. Both men and women work together in the farms, although there is a tendency for women to spend more hours in farm activities than men do. The food eaten is the same for all family members including the number of meals per day. 9.139. At a general level, every member of the family in Mwingi is involved in agricultural activities. However, men are more involved in activities requiring effort (such as ploughing and opening up bushes) while women and children take part in activities that are time-intensive (planting, sowing seeds, weeding, harvesting). During times of food stress, Kibera people said that women and children may eat less or go hungry for the men to eat. Girls have no time to play due to heavy demands of household chores which takes them until evening. Most parents and guardians leave their houses very early (5 am) and leave the responsibility of all household chores to the girls.

COORDINATION OF NUTRITION ACTIVITIES

Individual and Household Levels 9.140. The human rights approach to programming entails analyzing coordination of activities right from the individual and household levels to national and international levels. The most extreme case cited was the need for international cooperation in ensuring local food security (fishing in Bondo) by defining territorial rights in the lake as the fishermen reported cases of harassment by a neighboring country. At the individual level, there were cases where the instinct of self-preservation was not evident. This was most evident in the case of HIV/AIDS where it was reported that there was high awareness in all districts, but little by way of behavior change. The members of Akorino and Kavonokia religious sects do not take their children for immunization. 9.141. At the family or household level, there was coordination in some cases, but in other cases the household was at war with itself. This was most evident in the intra-household allocation of labor (gender and age divide) and food (mainly gender divide), lack of improved diet for pregnant and postpartum mothers, and lack of change in workload during pregnancy. On a positive note, one of the sources of livelihoods mentioned in Bondo and Mwingi were remittances from relatives working elsewhere. Community Level 9.142. It appears that the youth feel neglected. The youth at Uhanya beach in Bondo did not have any registered organized group, and those formed in the past had collapsed. The youth in Kibera reported that they are neglected because they are poor and the community has no trust in them. The youth has initiated community theatre and assist in sanitation and garbage disposal, but the community does not reward them for their efforts. 9.143. The role of TBAs featured in every district in their advice to mothers during antenatal care, referral of pregnancy complications to hospital, and assistance during delivery. However, there may be capacity gaps in the training of TBAs. For example, in a Nairobi slum, TBAs talked of advising the mothers to introduce fruits as early as a month or two after birth. 9.144. Governance at the local level was also cited as one of the constraints to development in Thika district, namely, the mismanagement of cooperative societies that has led to a decline in crop and livestock production. Government Departments 9.145. Beyond the household are government departments, civil society organizations (e.g. NGOs and CBOs) and churches. The coordination between individuals and households on one hand, and the rest of the system on the other, was mixed.

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9.146. There has been coordination between the National Aids Control Council (NACC) and CBOs in support of community-based programs on HIV/AIDS, especially home-based care. This was cited by local communities in Baringo, Bondo, Mwingi and Thika. The community-based programmes have also solicited for support from other agencies e.g. churches and private companies. 9.147. In case of nutrition and HIV, very few community members in Thika know that there are drugs to reduce the chance of mother-to-child transmission during birth. In addition, nutritionists are not invited by medical personnel to advice the HIV-positive people on nutrition. 9.148. According to communities in Baringo, Garissa, Kilifi and Mwingi, there are community-based food relief committees, which are involved in the identification of beneficiaries and the actual distribution of relief food. 9.149. The relationship between home economists and the communities was generally positive. However, in most areas, the communities reported that the quality and availability of agricultural extension services were inadequate. In Kilifi, a contributory factor was lack of technology transfer within households as the men are trained but do not pass the knowledge acquired to the women. 9.150. The veterinary department (in the ministry of agriculture) inspects animals slaughtered in Thika town, while the ministry of health is in charge in the rest of the district. There is room for jurisdictional disputes since the Public Health Act vests power of meat inspection on health staff. 9.151. There were issues of capacities of nutritionists to undertake the assigned activities (e.g. inadequate training and exposure for both the district nutritionist and the community health workers), difficulties in implementation of activities (e.g. lack of funds for rehabilitation of critically malnourished children and for demonstration of best practices), and understaffing. In most districts, nutrition issues are not seen as priority even in the allocation of the cost-sharing funds. 9.152. In most areas, community members indicated that they do not receive any information on nutrition (apart from mothers through MCH clinics). The district departmental heads in Nairobi recommended that the nutrition units in the Organization of Government be reorganized, harmonized and given specific guidelines; intensify and expand nutrition programmes; and equip doctors and nurses with nutrition knowledge (and how to incorporate the knowledge in their activities). 9.153. The department of social services undertakes community mobilization for group formation on behalf of other agencies. The department acts as the midwife of most community-based programs, although the host government departments and NGOs do not normally involve the department of social services after the programs take off. 9.154. The DANIDA-funded community based nutrition programme is coordinated by the department of social services, and works with the relevant government departments and civil society organizations. The programmes main achievement is to build relationships between government departments and coordinates their activities at the local level. The program also assists to build relationships between the government departments and the communities, and facilitates community-based government programs on nutrition and related development issues. 9.155. Most districts reported that the nutritional value of various foods and the importance of balanced diet are taught at both primary and secondary school levels as part of the curriculum. 9.156. In Thika, the topic of nutrition is included in all training of community health workers in the district. The cooperation between the departments of agriculture and health is evident in the kitchen gardens established in Kirwara health center and Mitumbiri dispensary for demonstrations. 9.157. In Nairobi, one of the major constraints to improvement of nutrition is lack of knowledge and failure of the relevant authorities to attach sufficient importance to nutrition issues. Consequently, funding and facilitation for such programmes are scarce. In addition, nutrition is not incorporated in the national

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HIV/AIDS programme. The NGOs operating in Garissa cited constraints to food and nutrition to include limited collaboration among stakeholders, inadequate support of nutrition activities, and poor feeding habits at the community level. 9.158. They identified the necessary strategies to include collaboration by relevant actors and coordination of their activities at the local level, deployment of more nutritionists, allocation of adequate funds to support nutrition activities, harmonization of activities of home economists and nutritionists, facilitating training on nutrition at community level, and including nutrition in the training curriculum for nurses.

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TABLE 1: NUTRITIVE VALUE OF SELECTED FOODS (per 100g of edible portion)

Food Cereals and Grain Products Maize, white, fresh on cob Maize, white, dried Maize, white, flour, 6080% extraction Sorghum, whole grain Sorghum, flour Millet, finger, whole grain Millet, finger, flour Millet, bulrush, whole grain Millet, bulrush, flour Rice, lightly milled, parboiled Rice, milled, polished Wheat, flour, 85% extraction Starchy Roots and Tubers Cassava, fresh Cassava, flour Irish potato, raw Sweet potato, yellow, raw Sweet potato, pale, raw Yam, fresh Yam, flour Arrowroot, raw Legumes and Nuts Beans, dried Pigeon peas, dried Soya beans, dried Green grams, dried Cowpeas, dried Groundnuts, dried Coconut, mature kernel, fresh Vegetables and Vegetables product Beans/peas, fresh, shelled Amaranth leaves, raw Pumpkin leaves, raw Cowpeas leaves, raw, fresh Cassava leaves, raw Sweet potato leaves, raw Pepper, sweet green, raw Carrots, raw Tomato, raw Okra, pods, raw Okra, leaves, raw Fruits Banana, ripe, raw Papaw, raw Avocado, raw Orange or tangerine, raw Mango, ripe, raw, without skin Energy (kcal) 165 345 335 345 335 315 320 340 335 335 335 340 Protein (g) 5.0 9.4 8.0 11.0 9.5 7.4 5.6 10.0 5.9 7.0 7.0 11.0 Fat (g) 2.1 4.2 1.0 3.2 2.8 1.3 1.4 4.0 3.5 0.5 0.5 2.0 Calcium (mg) Iron (mg) 3.6 3.6 1.1 11.0 10.0 17.0 54.0 21.0 39.0 1.7 1.7 3.6 Beta-carotene (ug) 0 0 0 20 20 25 25 25 0 0 0 Vitamin C (mg) 0 0 0 0 0 1 0 3 0 0 0

16 6 26 28 395 315 22 17 9 9 36

140 320 75 110 110 110 310 94 320 310 405 325 320 570 390

1.2 1.6 1.7 1.6 1.6 1.9 3.4 1.8 22.0 20.0 34.0 25.0 23.0 23.0 3.6

0.2 0.5 0.1 0.2 0.2 0.2 0.4 0.1 1.5 1.3 18.0 1.2 1.4 45.0 39.0

68 66 13 33 33 52 20 51 120 160 185 64 49 21

1.9 3.6 1.1 2.0 2.0 0.8 1.1 1.2 8.2 5.0 6.1 7.0 5.0 3.8 2.5

15 0 12 1800 35 15 0 0 0 28 28 30 3 8 13

31 4 21 37 37 6 0 8 1 0 0 2 1 2

104 45 25 45 90 49 44 35 22 35 58 82 30 120 44 60

8.2 4.6 4.0 4.7 7.0 4.6 2.0 0.9 1.0 2.1 4.4 1.5 0.4 1.4 0.6 0.6

0.2 0.2 0.3 1.0 0.2 0.8 0.1 0.2 0.2 0.6 0.1 0.1 11.0 0.4 0.2

22 410 475 255 300 160 29 35 10 84 530 9 21 19 28 24

1.8 8.9 0.8 5.7 7.6 6.2 2.6 0.7 0.6 1.2 0.7 1.4 0.6 1.4 0.1 1.2

20 2300 1000 700 3000 2620 730 6000 380 190 730 90 300 400 730 2400

25 50 80 56 310 70 140 8 26 47 59 9 52 18 46 42

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Food Meat, Poultry and Eggs Beef, moderately fat Goat, moderately fat Mutton, moderately fat Pork, moderately fat Liver, beef Poultry Egg, hen Fish and Fish Products Fish, average fillet Fish, dried Small dried fish Milk Cows milk, whole fresh Goats milk, fresh Oils and Fats Salad oil Cooking fat Ghee Margarine, fortified Sugars Sugar Sugarcane

Energy (kcal) 235 170 255 410 135 140 140 115 255 320 79 84 900 890 885 745 375 54

Protein (g) 18.0 18.0 17.0 12.0 19.0 20.0 12.0 22.0 47.0 44.0 3.8 3.4 0 0 0 0 0 0.6

Fat (g) 18.0 11.0 21.0 40.0 4.7 6.5 10.0 3.0 7.4 16.0 4.8 4.9 100.0 99.0 98.0 83.0 0 0.1

Calcium (mg) 11 11 10 11 8 10 45 32 1000 3000 145 160 0 0 2 10 0 8

Iron (mg) 3.6 2.3 2.0 1.8 10.0 1.1 2.0 1.7 4.9 8.5 0 0.1 0 0 0.4 0 0 1.4

Beta-carotene (ug) 5 (24) 0 0 0 180 (810) 60 (75) 300 (150) 0 0 0 80 (27) 0 (25) 0 0 230 (270) 680 0 0

Vitamin C (mg) 0 15 0 0 0

1 1 0 0 0 0 3

Source: Home Economics Branch, Ministry of Agriculture and Livestock Development; based on West, Pepping and Temalilwa (1988). Note: The numbers in parentheses are retinol content in microgram; - indicates unknown; 0 indicates trace.

TABLE 2: NUTRIENTS IN DIFFERENT TYPES OF FOODS

Food Cereals Starchy roots and fruits Beans and peas Oil seeds e.g. coconut, sesame, sunflower Fats and oils Dark/medium green leaves Orange vegetables Orange fruits Citrus fruit Milk Eggs Meat Fish Liver Rich Source of: Starch, fibre Starch, fibre Starch, protein, some minerals, fibre Fat, protein, fibre Fat Vitamins A, C, and folate Vitamins A and C Vitamins A and C Vitamin C Fat, protein, calcium, vitamins Proteins, vitamins Protein, fat, iron Protein, iron Protein, iron, vitamins Moderate Source of: Protein, B vitamins, many minerals Some minerals, vitamin C if fresh, vitamin A if yellow B vitamins B vitamins, some minerals Vitamin A if orange Protein, minerals Fibre Fibre Fat, minerals (not iron)

Source: Home Economics Branch, Ministry of Agriculture and Livestock Development, 2003

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TERMS OF REFERENCE
Terms of Reference for consultant to undertake community consultations and situation analysis of the nutrition sector INTRODUCTION The nutrition status of the population is important both in determining its productive capacity and a proximate of its wellbeing as the nation seek to achieve equitable and sustainable human development. In the first two decades of independence, the country achieved tremendous improvement in the nutrition status of her population. However, since the early 1990s the country started loosing the gains it had made and since then the situation has either stagnated and in most cases it has become worse. This has been despite sustained efforts by the Government and many other agencies to promote nutritional wellbeing of Kenyans. After the International Conference on Nutrition (ICN) in 1992, Kenya developed her National Plan of Action for Nutrition (NPAN) with the following objectives: i ii iii The incorporation of nutrition objectives and actions into national, sectoral and integrated development plans, and the allocation of the necessary human and financial resources for achieving these objectives; The development of specific nutritional interventions directed at particular problems or groups; and The generation of information from community-based actions for the nutritional assessment of problems and implementation of appropriate intervention measures.

These efforts have not yielded the desired outcomes and the National Plan of Action for Nutrition has only been partially implemented. The major reason for this is that interventions have not been supported by an appropriate regulatory and policy framework. The Inter-Ministerial Coordinating Committee on Food and Nutrition (ICCFN), coordinated by the Food and Nutrition Planning Unit (FNPU) of the Ministry of Planning and National Development, is therefore in the process of developing a policy framework under which the nutrition activities will be implemented. To do this, the committee set up a taskforce with a mandate of coming up with a draft National Nutrition policy paper. Members of the Taskforce are drawn from the following organizations: Ministry of Agriculture Ministry of Health Ministry of Education, Science and Technology Office of the President World Health Organization UNICEF NASCOP Ministry of Planning and National Development CBNP University of Nairobi The proposed nutrition policy will contain a set of principles, objectives, priorities and decisions which will form an integral part of the national development planning and provide the population, within a specified time, with the necessary social, cultural and economic conditions essential for optimal nutrition and dietary wellbeing. It is envisaged that the policy will enable Kenyans to obtain good nutritional status, which will in turn result in greater productivity and enjoyment of wider social and economic benefits. The Taskforce has identified the following as the key policy areas: i Nutrition and human development ii Nutrition and socioeconomic development

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iii iv v

Nutrition and HIV/AIDS Nutrition and poverty Nutrition in emergencies

The policy has the following objectives: To improve the nutritional status of all Kenyans; To reduce the incidence of diet-related diseases and the impact of diseases on quality of life; To improve the quality of life of people living with HIV/AIDS; To provide a common platform under which nutrition activities are implemented; and To provide a policy and regulatory framework for all players in the sector. OBJECTIVE OF THE CONSULTANCY The Taskforce has identified Community Capacity Development as one of the major strategic pillars of the policy. It has therefore strongly recommended community consultations and participation in the policy making process. The Taskforce, with support from UNICEF, is hiring a consultant to capture community perceptions of the manifestations, causes and consequences of malnutrition. The communities should suggest likely solutions, resource needs and key partners in interventions. As part of the consultancy, the consultant will, from the community consultation report and work already done, come up with a situation analysis report of the nutrition sector. WORK METHODOLOGY The task will basically be based on studies already undertake and documented e.g. PRSP consultations, baselines done by CBNP and those done by GoK/UNICEF. Where gaps are identified the consultant will arrange community visits to consult directly with communities and inform the process. For the whole policy drafting process, a Human Rights Approach to Programming (HRAP) has been adopted with special emphasis on Community Capacity Development (CCD) and focus on the rights of women and children. The consultant will be expected to adopt this approach. In preparing the report it is highly recommended that the consultant also use Triple-A approach drawing conclusions on community perceptions and recommending issues and strategies for discussion in the policy drafting process. SPECIFIC TASKS I. Using HRAP/CCD the consultant is expected to capture the following information from a community perspective: 1. The overall understanding of the problem of malnutrition and identification of the most vulnerable groups; 2. Causality analysis; 3. Role analysis; 4. Capacity gap analysis; 5. Communities coping mechanisms; 6. Partnership analysis; and 7. Candidate actions II. From the Preliminary Workshop Report and other studies done, prepare a situation analysis report. The report should have information on, but no restricted to, the following areas: 1. Investment in the sector in the last 15 years;

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2. 3. 4. 5. 6. 7. 8. 9.

Trends in the levels of malnutrition; Child nutrition; School nutrition; Nutrition and management of HIV/AIDS; Infant and young child feeding; Community nutrition and support; Urban nutrition; and Emergency nutrition

The report should be able to identify lessons learnt, major gaps and make recommendations on areas that should be addressed by the policy. Tables and graphic presentations should be used to capture trends over the past 15 years. The report should be able to capture regional disparities using various techniques such as tables, maps, graphs etc. III. To beef the community consultations and the situation analysis reports the consultant will be expected to work with a team (drawn from the Taskforce) that will undertake consultations in a few selected districts. The team will be seeking to capture the perceptions of nutritional issues and recommendations of the district level implementers. Based on the findings of the community consultative process, the consultant will be expected to advise the team on the areas to focus on. With assistance from the team, the consultant will be expected to produce the district consultations report. IV. To offer suggestions and comments on the concept paper which will be developed by the Taskforce DURATION The duration of this consultancy will be 35 man-days broken down as follows: 1. 2. 3. 4. Community consultation Situation analysis Districts consultation Concept paper 15 days 8 days 10 days 2 days

EXPECTED OUTPUTS The consultant will be expected to submit the following at the end of the contract: Community Consultations report Situation Analysis report Districts Consultations report MANAGEMENT OF THE CONSULTANCY The consultant will be hired by the funding agencies and the terms of the contract will based on the regulations of the contracting agency. The contracting agency will act under the recommendations of the Taskforce and together will be responsible for the supervision of the consultant. The consultant will report on progress to the Taskforce at least once per week based on a schedule mutually agreed upon.

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SITUATION ANALYSIS AND COMMUNITY CONSULTATIONS IN THE NUTRITION SECTOR IN KENYA

VOLUME II: SUMMARY OF THE DISTRICT AND COMMUNITY CONSULTATIONS

By

John Thinguri Mukui

Report prepared for the Ministry of Planning and National Development and UNICEF-Kenya, Nairobi
July 2003
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VOLUME II: SUMMARY OF DISTRICT AND COMMUNITY CONSULTATIONS CHAPTER ONE INTRODUCTION OBJECTIVE OF THE DISTRICT AND COMMUNITY CONSULTATIONS
1.1. The nutrition status of the population is important both in determining its productive capacity and a proximate of its wellbeing as the nation seek to achieve equitable and sustainable human development. The Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN), coordinated by the Food and Nutrition Planning Unit (FNPU) of the Ministry of Planning and National Development, is in the process of developing a policy framework under which the nutrition activities will be implemented. To do this, the committee set up a taskforce with a mandate of coming up with a draft national nutrition policy. 1.2. The proposed nutrition policy will contain a set of principles, objectives, priorities and decisions which will form an integral part of the national development planning and provide the population with the necessary social, cultural and economic conditions essential for optimal nutrition and dietary wellbeing. It is envisaged that the policy will enable Kenyans to obtain good nutritional status, which will in turn result in greater productivity and enjoyment of wider social and economic benefits. 1.3. The Taskforce has identified the following as the key policy areas: nutrition and human development, nutrition and socioeconomic development, nutrition and HIV/AIDS, nutrition and poverty, and nutrition in emergencies. The Taskforce has identified community capacity development as one of the major strategic pillars of the policy. It has therefore strongly recommended community consultations and participation in the policy making process. 1.4. The objective of the fieldwork is to capture community perceptions of the manifestations, causes and consequences of malnutrition. The communities should suggest likely solutions, resource needs and key partners in interventions. At the same time, the study was to include consultations in a few selected districts, to capture the perceptions of the district level implementers on nutritional issues. 1.5. The study is expected to adopt a Human Rights Approach to Programming (HRAP) with special emphasis on Community Capacity Development (CCD) and focus on the rights of women and children. It was also recommended that the report should use the Triple A approach when drawing conclusions on community perceptions and recommending issues and strategies for discussion in the policy drafting process. 1.6. Using HRAP/CCD, the study was to capture the following information from a community perspective: (a) the overall understanding of the problem of malnutrition and identification of the most vulnerable groups, (b) causality analysis causes of the problems, (c) role analysis identification of rightsholders and duty-bearers, (d) capacity gap analysis why the duty bearers do not seem to be able to perform their duties as expected, (e) communities coping mechanisms, (f) partnership analysis, and (g) candidate actions.

PARTICIPATORY RESEARCH TOOLS USED IN COMMUNITY CONSULTATIONS

1.7. The tools used include community resource map, service map, Venn (chapatti) diagrams, wealth ranking, problem bag, problem ranking, visioning matrix and visioning matrix discussion (situation ten years ago, the present, where they expect to be ten years from now under the present circumstances, and where they would desire to be ten years from now). The visioning matrix discussion included the reasons for the change and the interventions necessary to move to the preferred future. 1.8. Information was collected through focus group discussions (FGD) and key informant interviews. The focus group discussions aimed at discussing specified topics in detail with a small group of concerned

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people. The tool was particularly useful when applied to mothers in relation to, say, their nutritional knowledge for self and child. Key informant interview was for specific individuals with specialized information e.g. agricultural extension workers, schoolteachers, midwives and nurses. Their perspectives may complement or differ from that of the community. 1.9. Time-lines were used to trace the root causes of the problems they encounter, and included shortterm (seasonal within a one-year timeframe) and long-term (historical) calendars. The long-term calendar shows historical profiles and trend analysis and is used to discuss changes in availability of resources, changes in access to services, and major political or economic changes over time. The seasonal calendars were used to show changes over one year in, say, food availability. There were also daily (24-hour) calendars for women, for men, and for youth. 1.10. The interview schedule could begin with a session on introduction and village resource map, a session on community service map, a session on Venn diagrams and visioning matrix, a separate section on visioning matrix discussion, session on problem bag and wealth ranking, focus group discussions with men and women separately, and a final feedback session with the community. 1.11. The community consultations attended by a wide cross-section of community members were guided by the principle of appreciative inquiry: the recognition that inquiry and change are not separate moments, and hence inquiry is intervention (Whitney and Trosten-Bloom, 2002). The questions we ask set the stage for what we find, and what we discover becomes stories out of which the future is conceived and constructed. As a corollary, people and communities move in the direction of their questions. Secondly, the visioning process assumes that current behavior is guided by images of the future, and the expectation ahead of them becomes a mobilizing agent.

SELECTION OF THE SAMPLED DISTRICTS AND STUDY SITES

1.12. The districts were selected to include diverse child nutritional status, food stress, agro-ecological zones, HIV prevalence, female literacy and incidence of poverty. The criteria led to the selection of the following districts: Bondo, Kilifi, Baringo, Ijara, Thika and Nairobi. However, some amendments were made by (a) increasing the number of districts by adding Mwingi, and (b) replacing Ijara with Garissa for logistical reasons. The survey instruments (interview guides) were pre-tested in Bondo, and amendments made based on the experiences gained during the pretests.

TRAINING OF FIELD STAFF

1.13. The training of field staff for the district and community consultations was conducted in Nairobi during 14-15 April 2003. The main topics covered during the training were (a) PRA techniques, (b) human rights approach to programming, (c) interviewing techniques, and (d) checklists of issues to be covered during community consultations. The consultant was assisted in training by Kenneth Waithiru, Leonard Obidha and Eliud Moyi from the Ministry of Planning and National Development. 1.14. During the training, the participants emphasized the need for proper messages to be passed during community mobilization to avoid misunderstanding. It was agreed that, in the analysis of local institutions, the researchers should not ignore the churches if the communities mention them, as churches may have impact on feeding habits and health seeking behavior. 1.15. The participants requested to be provided with a definition of a village in the context of the community consultations. They were informed that a community or village may refer to (a) the catchment area of the local people participating in the consultations, or (b) the catchment area for a particular communal facility e.g. primary school or health facility, or (c) the way a village is locally defined and delineated. It was agreed that the concept of village would use local definitions and boundaries. 1.16. In a general community meeting, there are tendencies for some community members (e.g. women and girls) not to participate during discussions. The researchers were therefore to ensure that they have separate group discussions with women. It is important to talk to children e.g. on their daily feeding.

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1.17. It was emphasized that key informants at the local level go beyond lower level administration and government departments. It should include community resource persons, e.g. traditional healers, village elders and traditional birth attendants. 1.18. The visioning and visioning matrix discussion should be pegged on the 10 years prior to the fieldwork. This includes the reference period for study of changes in food habits. 1.19. The participants agreed that the checklist of issues was not exhaustive, and should be taken as the minimum number of study elements in community consultations. Food security should also include livestock. It is important to note that small stock and poultry might be very important for food security. Access to food should go beyond own production, and include sales of own produce, purchases and consumption. Emergencies should go beyond droughts to include, say, floods, displaced persons, fires, armyworms, cattle rustling, etc. 1.20. In every major item of data/information collection, the researchers were to strive to know (a) the existing knowledge and thereby derive the gap in knowledge, (b) the sources of that knowledge, and (c) what the community practice and the reasons for discrepancy between what they know and what they practice. 1.21. The training did not include all the researchers involved in the district consultations. The only people who attended the training were those based in Nairobi. For example, in the districts, key contacts were the district development officers, although they had not been trained or even properly briefed in advance.

DOCUMENTATION AND REPORTING

1.22. Each district team was responsible for preparing the draft report of the district consultations. Some of the problems in the original draft reports were that the drafts excluded some issues which were in the checklists; some reports used the checklists as questionnaires (and were consequently too brief and unclear); and some issues were too general (e.g. people are encouraged to eat more calories, proteins and vitamins). Fortunately, most of the desired information had been collected, but some had not found its way to the reports of the district and community consultations. The district research teams were requested to beef up the draft reports so as to include any relevant information that was picked during fieldwork. 1.23. The district reports were used to prepare a synthesis document where information from the districts was grouped under eight themes: the general economic situation, infant and young child feeding, maternal health and nutrition, nutrition and HIV/AIDS, nutrition and emergencies, water and sanitation, food and nutrition, and coordination of nutrition activities. The synthesis document (this volume) was further shortened to a chapter in the situation analysis (Volume I).

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CHAPTER TWO

THE GENERAL ECONOMIC SITUATION THE DEFINITION AND CAUSES OF POVERTY

2.1. In Baringo, poverty is generally defined in terms of food insecurity, and an estimated 80% of the population is food poor. The causes of poverty were identified as (a) unreliable rainfall, (b) recurrent drought and floods, (c) destruction of water catchments resulting to drying up of water ponds, (d) the rough terrain, (e) lack of entrepreneurship and thus limited involvement in income generating activities, (f) insecurity, (g) communal land tenure (e.g. in the lowlands and part of the midlands), (h) poor marketing strategies for honey and horticultural products, and (i) high rates of unemployment. Land tenure is individual ownership in the highlands, both individual and communal ownership in the midlands, and purely communal in the lowlands. Drought is a common occurrence in this district (severe ones occurred in 1994 and 2000). 2.2. A part of the community land was designated as game reserve, which the community feels is in the most fertile area. The community cited other problems to include shortage of health facilities (only one dispensary with one clinical officer), the few operational dams are far from the community, long distances to school, lack of cooperative societies (for credit and marketing of cotton and cowpeas), while boreholes and irrigations schemes are inadequate. One of the NGOs operating in the area said that the main challenges to development are high population growth, HIV/AIDS, drunkenness, and illiteracy. 2.3. The economic base of Bondo district is fisheries, agriculture, and retail trading. The district produces animal products (meat, milk), cereals (maize, sorghum, cassava, potatoes and finger millet), pulses (cowpeas and beans) and oil crops (groundnuts and simsim). The district suffers severe food shortages, and most of the food consumed comes from other places. A big proportion of the population depends on fishing, as agriculture does not do well. When there are no rains, there is general lack of vegetables, and fish (mainly omena) has to be eaten in all meals (from breakfast to supper). Although the area has adequate rains that can make the community sufficient in local food needs, only about 25% of the arable land is utilized. Most families hardly harvest enough to last a year, and the produce is usually sold at throwaway prices (especially immediately after harvest) only to purchase food more expensively later. 2.4. Some of the causes of low yields include inadequate rains, expensive inputs, low quality seed varieties, and problems related to land preparation. The key production challenges are prolonged drought and poor soils, and retrogressive cultural practices. 2.5. The main sources of livelihoods in a community in Bondo are fishing, peasant farming, business and livestock. In order of importance, the fish harvested locally are Nile perch, tilapia and omena. The high harvest season for Nile perch is April-September; tilapia May-August; and omena January-April. The low harvest season for all fish varieties is September-December. Nile perch is harvested entirely for sale in major towns (Kisumu, Nairobi and Mombasa) and some exported overseas after further processing. The local consumption for tilapia and omena is 20% and 60%, respectively. Local consumption of omena is high due to its affordability at the household level. 2.6. Farm produce includes maize, potatoes, cassava, beans (wairimu), green vegetables and tomatoes. Maize is planted in April-May and harvested between July and August. An average family harvests two to three bags of maize, which lasts about 3-4 months. Beans are inter-cropped with maize. An average family harvests one bag of beans that lasts about three months. Potatoes and cassava are available throughout the year. Each family harvests about four bags of finger millet per year, which normally lasts for 4 months. Green vegetables (kale, tomatoes and onions) are grown throughout the year. The main periods of food stress are March-August and January-February. 2.7. The main problems encountered are preservation of fish, fluctuations in prices, unaffordable fishing gears, security and safety of fishermen, insecurity, hospitals are very far, communication, poor road network, and territorial rights in the lake.

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2.8. According to tradition, if a son is still in his fathers compound, he (or his wife and children) cannot initiate any farming process (e.g. tilling, weeding and harvesting). At all stages, the process is initiated by his parents. In the event that both parents are dead, the eldest son within the parents compound (or his wife) initiates the process. This process is a hindrance to freedom of choice in farming, and lead to low yields in crop production as some people may either plant late or not plant at all. 2.9. In addition, a typical community is bushy and there are many pests and wild animals competing to annihilate the crops. The squirrels attack the seeds immediately they are planted. Whatever escapes the squirrel is at the mercy of the common weeds. The weeds are followed by monkeys, which are so fierce they even attack the residents. Then comes the birds singing, dancing and pecking. The result is very little harvest. After harvest, the farmer tends to sell a part of the produce to finance other household expenditures, which is a further drain on food security. Cattle are sold to raise funds for major expenditures e.g. school fees, hospital bills and funeral expenses. Cattle are used to pay dowry, and the slaughter of cattle and goats is a main feature of all funerals. 2.10. There are occasional droughts in Garissa that recur almost after every two years such that the district is always either preparing for drought or is in a drought-related emergency e.g. food relief. Most people have lost their livestock, which is the mainstay of the population. The frequent droughts often deplete the family stock forcing people to migrate to towns in search of relief food. The district therefore has a poor base for food security and nutrition. Most of the milk produced is consumed at the household level. There is also a lot of waste due to lack of milk preservation technologies. 2.11. The main types of food grown in the district are tomatoes, bananas, watermelons and sweet melons, mangoes and onions. The crops mainly attacked by pests are tomatoes, onions and bananas. The causes of food insecurity include frequent crop failure due to prolonged droughts, lack of access to farm inputs, limited extension coverage due to the vastness of the district, flooding in case of irrigated agriculture, and nomadic lifestyle that makes it difficult for continuity of dissemination of extension messages. 2.12. The main sources of income in a Garissa community were identified as sale of livestock, sale of milk, petty trade, sale of water, remittances from relatives, firewood and charcoal business, brokerage in livestock trade, sale of local herbs, TBA fee, circumcision fee, divorce compensation, and assistance from NGOs. 2.13. The major food crops grown in Kilifi are cassava, maize, cowpeas, green grams, rice, beans (little), sweet potatoes and horticulture (e.g. tomatoes). The tree crops are coconut, cashew nuts, mangoes, oranges and citrus trees, while cotton is being introduced. Farmers have a problem in timing the planting of beans because rains normally destroy them when they are flowering. The farmers prefer cowpeas because they eat both the leaves and the beans. 2.14. The maize yield per hectare is low (5 bags per hectare), while agriculture staffs say it is possible to harvest 15-20 bags with right seeds and right crop husbandry. The food harvest lasts the family for only 3-4 months (around September-December), when they afford two to three meals a day. For the rest of the year, they normally eat about one meal a day. They use cassava to make ugali, and can be boiled or roasted. The growing of millet and sorghum is not popular. 2.15. Livestock include cattle (dairy and indigenous breeds), goats, sheep, poultry and donkeys. There are about 500,000 poultry (layers, broilers) kept for commercial and household purposes. The keeping of rabbits and pigs is minimal because most of the residents are Muslim. Beekeeping is also encouraged. It is rare for the birds (poultry) and livestock to be slaughtered for family consumption, as they are perceived as a source of income. 2.16. The main sources of employment along the coastline are fishing, tourism and trade. In the hinterland, the sources of livelihoods include hunting, charcoal burning, selling of palm wine (mnazi) and selling makuti. There are also people specialized in climbing the palm trees, and do it for a fee.

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2.17. The causes of poverty are lack of rains, lack of money to buy farm implements, lack of access to extension services, low levels of education, and heavy workload on women including tilling the land. They expect extension services to deteriorate because the government is not recruiting new extension staff. Women spend more time on the farm, in addition to childcare and other household chores. The drinking of illicit brew was cited as a major problem. In addition, it is men who attend agricultural training, but it never translates to productivity because it is women who are mostly in farming and the men do not pass the knowledge to their wives. 2.18. The average land holding is about 6 acres, but there are many squatters along the coastline. Men mainly spend their income on mnazi, while women spend their income on food, education and health. Most families have one meal per day. 2.19. The farmers in Dera village (Kilifi) have begun to embrace new technologies in food production. There is an active extension officer who visits them, and this boosts their morale mainly because he makes return visits to check on progress. The food lasts 2-5 months depending on the number of people in the household, but the average is 3 months. Children normally eat three meals and adults 2 meals. However, during times of severe food stress, food consumption declines and is mostly cassava for all the meals. In most cases, they only slaughter chicken and turkey for visitors; and eggs are rarely eaten and are either sold or kept for hatching. The main method of cooking is boiling using firewood. The main types of food are ugali and omena, coconut milk, mabuyu (baobab seeds, fruits), mangoes and madafu (coconut juice). 2.20. The main crops grown in Mwingi district include cereals (maize, sorghum, millet), legumes (beans, cowpeas, green grams, njahi and pigeon peas), cash crops (cotton, sunflower, coffee), fruits (mangoes, papaws, oranges), and vegetables (kales, tomatoes, onions). The vegetables are mainly grown under irrigation. The staple food consists of maize, sorghum and millet. The main types of livestock are local breeds of cattle, goats, sheep, donkeys and poultry. Dairy and poultry production of improved breed is practiced on very low scale. Sahiwal bulls are reared to improve the quality of local breeds. 2.21. The district is able to produce enough food for local consumption during good years. However, even in years when the harvest is good, crop produce and livestock are sold to meet domestic expenditure requirements. Usually, the food produced can last for only 2-3 months due to heavy sales soon after harvest. Apart from maize supplied as part of relief food, most of the maize purchased is produced within the district. The grain traders purchase and store food for resale during periods of scarcity. During seasons of food deficit, food prices tend to rise while the prices fall during surplus period. 2.22. Some of the common fruits grown include mangoes, grafted citrus fruits, non-grafted citrus fruits, and guavas. Grafted citrus fruits are adapted to local climate, and therefore ripen during the dry season, while guavas include both local and improved varieties. A large proportion of fruits produced are consumed locally and the balance sold outside the district. There are also wild fruits that supplement local production. 2.23. The Mwingi farmers attributed most of the losses at farm-level and during storage to the great grain borer. The community members noted that the sale of food (not necessarily surplus food) is common. However, immediately after harvest, prices fall to very low levels. The money realized from sales is used for school uniforms, school fees, clothing, health expenses (especially drugs and treatment), and domestic use. Although food supply in the district has improved over the last 5 years, local food production does not meet the local food demand. As such, food stress cycles are regular. During periods of food stress, the most vulnerable are women and children. Most men migrate to towns in search of jobs. There has been a rise in the number of cases of hypertension and diabetes especially among elderly people (60+ years). 2.24. In Nairobi, poverty is defined in terms of inadequacy of income, lack of basic needs, and lack of access to productive assets as well as to social infrastructure. The majority of the poor lives in informal settlements, which accounts for about 55% of the population and occupy 5% of the total residential area. The main causes of poverty in Nairobi are economic, environmental health and social. The major economic factors are lack of employment opportunities, high cost of living, poor governance, slow growth in industrial sector, lack of secure land tenure, and poor access to basic infrastructure and urban services. The

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social factors include difficulties faced by vulnerable groups (including female-headed households, street children, disabled, the elderly and AIDS orphans), social breakdown within the family structures, insecurity, and high population growth due to rural-urban migration. Environmental health factors include lack of proper liquid waste management, poor solid waste collection and disposal, lack of potable water, and lack of affordable and accessible healthcare services. 2.25. Since Nairobi is an urban area, most food consumed comes from outside. Food produced in Nairobi urban agriculture is insufficient to meet consumption needs. The crops grown are mainly horticulture (kale, spinach and tomatoes). There are also some livestock production activities mainly poultry, dairy cows, and goats and sheep. Most men are engaged in wage or salaried employment and women undertake all household chores with the assistance of children. One issue of concern is the use of contaminated (sewage) water for irrigation, as the vegetables accumulate heavy metals during growth, which are harmful to health. The crops grown along the roadsides also pick up lead from vehicle fumes. 2.26. There are a number of constraints to urban agriculture. First, there are no proper programmes to reach as many urban farmers as required, and there is no mass media programme for that purpose. Secondly, the farmers are normally squatters, and there are therefore no incentives for proper utilization as the farms could be repossessed anytime. Thirdly, there is theft of mature produce before harvest. 2.27. Agricultural activities and types of crops grown in Thika district are heavily determined by rainfall patterns. Tea, coffee and dairy farming are the dominant economic activities in the northern and western parts of the district. In the semi-arid areas to the east with low and unreliable rainfall, cattle rearing and production of drought-resistant crops are the main preoccupation of farmers. The areas most hit by poverty are semi-arid areas of Ruiru division, Gatuanyaga, Munyu and Ngoriba in Municipality division, and most parts of lower Kakuzi division. Other pockets of poverty are slum areas in Thika, Ruiru and Juja towns. The dry areas (e.g. Kakuzi) hardly grow enough vegetables, in addition to general shortage of other foods. They grow pigeon peas and a little maize which only lasts a few months after harvest. There are nutrition problems as most people work in the plantations and in private coffee farms.

ATTRIBUTES OF WEALTH GROUPS

2.28. The wealth ranking exercise was not conducted exhaustively in all the district and community consultations. For example, in Baringo, the only information collected was that livestock is kept as a status symbol, not for sale or slaughter. The number of wives and children is considered a symbol of status and wealth. 2.29. To assess the social status of households, a community in Garissa uses the number of livestock as an indicator. The rich (a reported 10% of the households) were identified as owning camels (more than 40), cattle (more than 100), goats (more than 200), and have property such as shops. The middle income (50% of the households) own camels (about 10), cattle (about 20) and goats (80 to 100). The poor (40%) own camels (none), cattle (1 to 5), goats (2 to 5), and collect firewood that they sell to the rich to generate income. 2.30. In Kilifi, wealth was defined in terms of land size, number of livestock, and family size (number of wives, children). According to this classification, the very poor include squatters in Bahari Division. The Kilifi District Development Programme (KDDP) has added the very poor as a poverty class distinct from the poor using the ability to have a meal per day as the criteria. From their findings, there are households who eat one meal in two days. In general, poverty manifests itself in the inability by the majority of the people to access basic needs.

COPING MECHANISMS
2.31. The poverty situation in Baringo was reported as getting worse due to increase in population (causing strain on the land and other resources), poor economic growth, diminishing water resources, and soils becoming poorer. The coping strategies cited include moving livestock to other grazing grounds, migration to trading centers to wait for food relief, casual labor, reducing number of meals, changing diet (e.g. porridge instead of ugali, and honey in place of vegetables to eat together with ugali), eating wild roots

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and fruits, children sent to school if there is a school feeding programme, and slaughter of small stock for home consumption (and may also consume dead livestock). 2.32. During the dry spell, they slaughter the small stock, mainly goats and to a lesser extent sheep. Some animals die during droughts and floods. Cattle-rustling is rampant during September-December when the initiates are released after one-month confinement. This is the period when most initiates get married and therefore raid cattle for dowry. Primary education is free, and most schools have school feeding programs, which reduces the familys burden on food. 2.33. In event of prolonged drought that lead to loss of the only source of livelihood (livestock), some pastoralists of Garissa migrate to peri-urban and urban centers in search of food. Such pastoralist dropouts are among the poorest people in the district. Their coping strategies include farming, casual labor and petty trade. Camel owners are considered to be food secure. 2.34. Some of the short-term and long-term coping mechanisms in Garissa were identified as (a) special programmes to address poverty (e.g. restocking households that have lost their livestock), (b) capacity building in farming, (c) provision of irrigation kits, (d) support to income-generating activities, (e) social support systems (able households give support to vulnerable ones in terms of food or cash), (f) migration, (g) herd separation (separate milking herd, and strong and weak herds where the strong ones go to far distances in search of pasture and water), and (h) preservation of meat and milk using traditional methods. 2.35. In Kilifi, the coping strategies in times of stress include eating less food, looking for manual jobs, and girls work as house helps during January-February (but return home during planting and harvest periods). Other coping mechanisms include charcoal burning, casual jobs (e.g. petty trade), selling local brew, hunting, and selling makuti. Many people have resorted to farming, unlike before when they depended mostly on animals. They said people prefer to plant local maize because hybrid maize is more affected by pests during storage, and pounding of hybrid maize produces smaller pellets. 2.36. The programmes in Mwingi district aimed at minimizing food insecurity and improving the nutritional status include public education on food management and energy saving. The two most notable programs are (a) promoting consumption of sorghum and millet using simple innovative products, and (b) promoting the use of cowpea leaves through preservation. There are also special programs to boost production of sunflower and cotton to ease financial stress at the household level. Since sorghum and millet (though nutritious) are labor intensive, most farmers were abandoning these crops. Public education has been used to popularize innovative products from these crops e.g. sorghum pillau, sorghum chapatti and sorghum/millet pancakes. The target has been members of women groups who are trained in these methodologies so that they can train their other group members. 2.37. A community in Mwingi said that those most affected by food stress are women and children. Men migrate to towns. However, households cope with such stress by borrowing from neighbors (to repay back later in kind), selling livestock, selling land, sale of family labor, and relief food. During the past 10 years, access to food has worsened, which has even led to breakup of families. On a positive note, remittances formed an important supplementary source of income. In most cases, the recipients were mainly spouses. It is not a common practice for children to remit money to their parents. Most of such remittances were spent on purchase of livestock and seeds and to meet health expenses. 2.38. One of the coping strategies employed by the poor in Nairobi include looking for some little land on the outskirts, along the roads, railway line etc, to do some urban farming. People also tend to reduce the number of meals and the quantity consumed, and in the process become malnourished. The food allocation is biased towards the man who is served first and gets the biggest ration. The children and mother eat last. 2.39. The ministry of agriculture in Thika district is putting special emphasis on traditional vegetables (e.g. cassava leaves) and fruits (avocados, pineapples, papaws, guava and oranges), and intends to promote gooseberry. The farmers are advised on how to grow the crops and optimal mix of various crops grown. They are promoting production and consumption of soya beans since meat has become very expensive, and soya is rich in protein.

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2.40. Some farmers harvest enough to take them to the following season. The seasonal price fluctuations are too high. The government therefore encourages preservation of fruits and vegetables (e.g. kales and pumpkins) through drying, but the adoption rate is low. The department of agriculture trains on valueadding preservation of fruits and vegetables that can last three years e.g. making chutney. 2.41. The department of agriculture promotes kitchen gardens. The home gardens include small livestock, fruit trees, and all kinds of vegetables including traditional vegetables. The major types of vegetables grown are kale, amaranth, spinach, tomatoes, cowpeas, pumpkins, onions and nightshade (managu). Fruits include papaws, bananas, passion fruit, pineapple, avocado, mangoes, oranges, lemons, guava and watermelons. The department is promoting small stock (e.g. rabbits, poultry and dairy goats). Rabbit is white meat. In the case of poultry, efforts are being made to improve local birds by keeping hybrid cockerels to get heavier birds that also lay more eggs. 2.42. The home economics staff said that home gardens improve nutrition of the household as people eat fresh vegetables handled under hygienic conditions, save income, is environment-friendly (can use waste for compost), and is convenient (can even harvest at night). In case of purchased vegetables you are never sure when they were harvested. The home economics staff hold cooking demonstrations e.g. on soya production and utilization. This involves incorporating soya in all the dishes e.g. githeri, porridge, cake and mandazi. Traditional vegetables have higher nutritive value than cabbages. Some traditional vegetables also require very little care e.g. amaranths scattered on the ground grow naturally. Traditional vegetables are high in calcium and iron. Others have iodine whose deficiency is linked to goiter. 2.43. As a result of collaboration between health and agriculture departments in Thika, kitchen gardens have also been established in Kirwara health center and Mitumbiri dispensary for demonstrations and the communities have responded well in getting the idea into their homes. The nutrition section (in the department of health) cooperates with the home economics staff of the ministry of agriculture to train women groups on home economics and nutrition.

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CHAPTER THREE

INFANT AND YOUNG CHILD FEEDING BREASTFEEDING PRACTICES

3.1. In Baringo, breastfeeding of newborns start immediately for those born in health centers, but after two or three days for those born at home because they first start with herbal feeding to clean/clear the babys stomach. It was reported that the health of children who first receive herbal feeding was better than for those who were breastfed immediately after birth. The period of exclusive breastfeeding is short because they are very busy with other economic activities. 3.2. During community consultations, the mothers said that, after delivery the baby is given water first then breastfed after several hours. After one month, the baby is given cows milk, and at 4 months start taking porridge mixed with milk. At 6 months, other foods are introduced like ugali, and at 1 years start eating adult food. 3.3. During antenatal care, mothers in Bondo are advised to initiate breastfeeding immediately on delivery. They even breastfeed for two years unless the mother gets pregnant. Complementary feeding normally starts with porridge, cows milk and fruits. From six months, other types of food are added e.g. mashed potatoes, bananas and vegetable soup. Some introduce ugali at the early age of 6 months. If weaning is not done properly (e.g. immediate stoppage of breastfeeding) a child may get marasmus or kwashiorkor. In most families, mothers have enough time to breastfeed. Only a small minority (e.g. teachers) are working class and therefore breastfeed at night and during weekends. Most women in the area are peasants, and time for breastfeeding is therefore not a problem. The district health staff said that if children are properly weaned and immunized on schedule, they are ready to go to school at the age of five. Under-five mortality in the district is mainly accounted for by malaria. 3.4. The communities in Garissa believe that colostrum is unclean milk and therefore not suitable for babies. Its consumption is associated with delay of commencement of talking. There is also a cultural belief that breast-milk is only available 2 to 3 days after birth (i.e. until the umbilical cord falls off). The initiation of breastfeeding therefore takes place 2-3 days after birth, and children are in the meantime given water and cows milk. 3.5. Community consultations in Garissa confirmed the findings of the district consultations that infants are introduced to breast-milk three days after birth. The community believes that breast-milk production only starts once the umbilical cord has fallen off. During this period, the infant is fed on milk and water. It is also a cultural belief that the first milk (colostrum) is unclean and that if fed, the child will take long before it can talk. The community does not practice exclusive breastfeeding since cows milk is given alongside breast-milk in the first 5 months. Complementary feeding is introduced after 5 months and consists of potatoes and uji. Children are weaned off breast-milk at the age of 2 to 3 years. 3.6. In Kilifi, exclusive breastfeeding takes about 3 months, after which children are introduced to water and complementary foods like porridge. Mothers in Bogarash village reported that some newborns are first given a solution of water and sugar before initiation of breastfeeding. Some mothers take up to three days before initiation of breastfeeding as the mothers attend to some traditional ceremonies before initiation of breastfeeding. There is exclusive breastfeeding for about a month, after which they start introducing porridge (mainly maize porridge with salt/sugar). The child is occasionally given water mixed with salt and sugar to prevent constipation and ease the bowels. Children are introduced to adult foods at the tender age of 9 months, but might dilute the food (e.g. ugali) to avoid choking. 3.7. Mothers in Dera village said that before breastfeeding the baby for the first time, a solution of salt, sugar and water is given to the child. The child is breastfed exclusively for 2-3 months regardless of whether it is a boy or a girl. Thereafter, children are given porridge (mainly maize porridge with salt/sugar) twice a day, which is increased to three times as the child grows older.

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3.8. In a community in Mwingi, mothers indicated that the majority of children took 2-3 hours before the first breastfeeding. However, there were cases of babies breastfeeding immediately after delivery. Complementary feeding was introduced at any time between 3 to 6 months, while the child is breastfed in the first 2 years. 3.9. Most women in a Kibera community breastfeed immediately after birth (within half an hour or so). Exclusive breastfeeding takes 3 to 4 months, although the TBAs talked of advising mothers to introduce fruits as early as a month or two. However, the child is breastfed for up to 2 years unless the mother gets pregnant. 3.10. The mothers in Kibera reported that, in the past, breastfeeding took long (beyond two years). The feeding of children and adults was on demand, and children were given traditional foods. During the last decade, breastfeeding practices have changed e.g. by reducing the period of exclusive breastfeeding. Children are introduced to adult foods (e.g. sukumawiki and ugali) at very early age. 3.11. All mothers in Kianda breastfeed their children. Breastfeeding begins immediately after birth, maybe after 30 minutes. Some children are given porridge as complimentary food as early as 2 weeks. Mothers breastfeed for up to 2-3 years. Some mothers do not have breast-milk, which they believe to be due to lack of proper food and psychological problems. The under-fives eat the same food with the rest of the family, but may get a meal between the main meals (e.g. porridge and fruits). 3.12. The health personnel in Thika reported that mothers breastfeed their children but the problem is late initiation of breastfeeding and early introduction of complementary foods. Even a mother who delivers in hospital may be separated from the newborn, and may not immediately demand the baby especially after caesarian section. In private hospitals, babies and mothers normally sleep on separate beds, and breastfeeding on demand does not therefore take place. The private hospitals are generally not babyfriendly, although this may also be true of government hospitals especially with respect to late initiation of breastfeeding. The mothers have no problem with giving the children colostrum, and they understand it is nutritious. 3.13. Very few mothers (including health personnel) in Thika district exclusively breastfeed beyond one month, as they start giving water mixed with glucose, other types of milk, and papaws and bananas as early as two weeks. According to the health staff, there is a serious knowledge gap among mothers. Mothers say they give children food at such early age to prevent crying. They continue breastfeeding and giving other types of foods and by three months, breastfeeding is normally down to only morning and evening. At three months, they give the child uji (wimbi, soya, maize, etc), cow milk, mashed potatoes, mashed bananas, and papaw. The children get constipation and other unnecessary infections. The child is left with other caregivers, especially in towns. The mental development of the child is therefore not adequate. The children get off the breasts after 18-24 months, while some stop as early as 12 months especially for working mothers.

COMPLEMENTARY FEEDING AND WEANING OF CHILDREN

3.14. The district departmental heads said that the children of Baringo are introduced to complementary foods after 3 months, in the form of uji, potatoes, and ugali softened with milk. 3.15. Based on community action plans in Bondo under the Community Based Nutrition Programme, the program is supporting feeding and rehabilitation centers and follow-up activities, and training on food preparation especially weaning foods. During community consultations, the mothers said that they initiate breastfeeding within five minutes and exclusively breastfeed for 3 months. In the third month, cows milk is introduced, and at 5 months porridge mixed with milk, mashed bananas plus avocado and potatoes. At around 6 months, they add other foods e.g. eggs, ugali, soup and fish steak. When children have been completely weaned, food availability affects everybody and is not specific to children or mothers. 3.16. The communities in Garissa ranked the main problems as poverty, poor diet, malnutrition, childhood diseases, lack of exclusive breastfeeding, and drought. The community perceives nutritious foods

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for children as including milk, uji and eggs. In many cases, children eat the same meals as adults. The women complained of husbands leaving home without leaving any provisions for food for the children. 3.17. The normal feeding of the under-fives in a low-income community in Nairobi is tea at breakfast, uji at 10 am, lunch with the rest of the family, uji at 4 pm and finally the same supper with the rest of the family. In some families, children eat the same foods and at the same time with adults. The food taboos depend on the rural home (meaning ethnic group) of the index family or household. Among the Luhya, children may not feed on eggs, lest they become dumb. 3.18. The children in a Kibera community said that they do not get enough food, which is usually rice, beans, ugali, potatoes and a few fruits. Most of the children have only one meal a day, and milk is rarely in their diet. Almost all of them do not take breakfast and lunch. The foods are mainly carbohydrates (ugali, rice, porridge and githeri). 3.19. In the upper Gatanga area of Thika, which is a tea zone and grows food crops, there may be few cases of child malnutrition because people work for long hours, and may not have enough time for their children. In the Gatanga lower zone, there are more cases of malnutrition since most people do not own land, depend on purchased food, and earn little in the flower farms and coffee plantations. Most parents spend time working in the farms and have little time for their children, which include stopping breastfeeding very early. In Kakuzi there are nutrition problems as most people work in the plantations and in private coffee farms. Children lack adequate attention from parents and are not well fed because the families are poor. Even for employed mothers, the quality of child feeding is poor, and is mainly uji especially when mothers are working in the plantations. Some cases of malnutrition are brought to Thika district hospital from Nairobi (e.g. Githurai), Machakos (e.g. Manyatta) and Maragua districts.

IMMUNIZATION AND GROWTH MONITORING AND PROMOTION

3.20. The women in Baringo have knowledge on immunization, and follow the immunization schedule up to the end. Growth monitoring stops after the last immunization (measles) unless the child is sick. The community concurred with key informants at the district level that immunization schedule is followed, but there is no growth monitoring after completion of the immunization schedule. 3.21. In Bondo, immunization coverage for year 2002 was 57%. Mothers in Bondo said that they take children for immunization on schedule up to measles (angiew). Growth monitoring and promotion is conducted monthly at the static health facilities and at the community level (at the latter by trained CHWs). The nutrition section is also involved in rehabilitating severely malnourished children in the hospital. Some of the key constraints include inadequate training for both the nutritionist and the community health workers, and high child malnutrition levels in the district (with an average of 30% undernourished). There are capacity and logistical difficulties in implementation of activities e.g. inadequate funds for program activities, rehabilitation of critically malnourished children, and for demonstration of best practices. 3.22. In Garissa, growth monitoring is done for children under 5 years of age. Immunization coverage is low estimated at 65% for measles because majority of births occur at home and children are not presented for immunization unless they are sick. In Garissa district, nutrition education is only given at the provincial general hospital family planning clinic and the pediatrics unit. The prevalence of malnutrition is high and is linked to poverty and illiteracy. There has been an increase in bottle-feeding because of influence of refugees, which is suspected to be one of the contributory factors to child malnutrition. One of the constraints cited as hindrance to improvement of child health and nutrition was that children do not attend clinics regularly. 3.23. The community reported that majority of children in the study area in Garissa are taken for immunization. Malnutrition is common during the dry seasons of Jilal and Haga. It was reported that about 40% of children under-five years are malnourished. 3.24. The Bogarash community (Kilifi) said they identify malnourished children just by feeling the weight. Children are most affected during times of food stress because they eat the same meals as adults and consequently experience shortage of essential foods like milk. Mothers reported that in the clinics, they

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are advised to feed their children with milk, eggs, beans, bananas, mchicha (and other traditional vegetables), but most are unable to provide because they cannot afford. 3.25. During growth monitoring for children in a Bamako clinic in Dera village, it was found out that lack of nutritious diets was the main cause of underweight in children, and the community therefore started food demonstration (types of food and food preparation methods) at the Bamako site. 3.26. During 2002 measles campaign, Mwingi district achieved the target of 95%. It has been the practice that mothers bring children for immunization up to 9 months. However, thereafter, attendance to clinics has been very low, and most mothers thus miss vital health information. 3.27. Out of 740 children (400 boys, 340 girls) monitored by Migwani Child and Family Programme during the month of April 2003, 54% were of normal status, 23.4% had mild malnutrition, 19.1% had moderate malnutrition and 3.6% had severe malnutrition. Some NGOs have noted that, despite awareness on the problem of malnutrition through public education, parents still have a problem in identifying cases of moderate malnutrition. However, the parents are able to identify severely malnourished children. 3.28. The Migwani Child and Family Programme management recommended that the mandatory age for growth monitoring should be reviewed to cover children over five years. After five years, parents do not take their children for growth monitoring even when the children suffer from malnutrition. It was also recommended that nutrition education should be taken up in the school curriculum right from primary to secondary school level. 3.29. Malnutrition is evident especially in the slum areas of Nairobi. Health staffs give advice at the clinics, at the community level and at seminars. They advice on complementary feeding and weaning foods, although most mothers give their children mashed potatoes and bananas, and very little proteins and fruits. Some of the women give complementary foods as early as one to two months. 3.30. Most of the young girls in a Nairobi slum who give birth do not normally take their children for immunization, but the TBAs and the parents encourage them to take their babies for clinic. Most of the girls leave the babies under the care of the childs grandmothers, while others take care of their own babies. 3.31. The health staff in Thika said that in a clinic, only a negligible number of children (say one in a month) would be reported as malnourished, while in the hospital wards you see few cases of anemia, marasmus and kwashiorkor. The malnourished children in the wards will normally show about two immunization visits in the health cards, and thus have irregular attendance to clinics and incomplete immunization schedule. In the hospital child clinic, they get few cases of kwashiorkor and marasmus and most of these children will be underweight related with sickness (e.g. coughing and diarrhea) rather than nutrition. There is malnutrition especially in the flower farms and coffee estates among the children of the workers. 3.32. Immunization figures from administrative records in Thika district are dropping e.g. 2002 were lower than for 2001. Vitamin A is supposed to be supplemented every 6 months up to five years, but they do not come back after measles immunization. The Akorino and Kavonokia religious sects do not take their children for immunization.

HOW MOTHERS IDENTIFY MALNOURISHED CHILDREN

3.33. Mothers in Baringo identify malnourished children by observing their body size, whether child is eating well or not, frequency of sickness, and by tying a string around the waist and wrist. If they realize that the child is malnourished, they take it to the health facility. At the health facility, the nutritionist gives mothers nutrition information on how to feed their children and families. However, most mothers do not follow the advice because they may not afford the recommended food, lack of time to prepare food, and reckless behavior e.g. drunkenness by the mother. The mothers reported that, traditionally they used to know malnourished children because the childs skin feels loose on pinching; child looks miserable; child takes long to start sitting, crawling, or walking; child has no normal development; and mother could lift the child and feel the weight.

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3.34. Mothers in Garissa said that child malnutrition is manifested through loss of appetite, stunting, mental retardation, skin disease, weak joints, enlarged stomach, change in hair color, diarrhea, and increased vulnerability to diseases. The consequence of malnutrition is death. In some cases, children resort to eating soil. 3.35. In Kilifi, the health personnel said that a mother knows whether the child is malnourished by feeling the weight of the child with her hands. Some mothers do not follow, and some resent, the child nutrition advice given at the clinics, as some feel that they are doing the best they can for their children. According to the MOH, malnutrition is the number one cause of child deaths in the district. 3.36. Mothers in a community in Mwingi indicated that they were able to identify malnourished children by observing the hair and frequency of illness. When the hair turns brown and the child falls sick frequently, it was likely that the child was malnourished. Such children were taken to hospital or were given nutritious food. Most mothers indicated that they took their children for growth monitoring. 3.37. Women in Kianda (Kibera) cited the manifestations of child malnutrition as the child becoming thin, having no appetite, and eventually developing a big stomach. The sickly child is taken to hospital, but the nutrition advice given may not be strictly followed due to lack of resources at the household level.

MAJOR CHILDHOOD DISEASES

3.38. The major childhood diseases in Baringo were reported as diarrhea, malaria, pneumonia and kalaazar (visceral leishmaniasis or dumdum fever). However, the community said that the main childhood diseases are pneumonia, malaria, diarrhea, colds and flu, and did not mention kala-azar as a child disease. 3.39. According to health personnel in Bondo, when a child falls sick, some parents start with herbal medicine since health facilities are far apart. Herbal medicine works for diarrhea, while neem tree (mwarubaine) that grows in the area is used to treat malaria. In general, the management of diarrhea depends on the level of education. The majority in the interior (especially the illiterate) starts with traditional healers, then to shopkeepers, and normally reaches the health facilities when they are already serious clinical cases. Diarrhea in children is mainly caused by the types of complementary feeding, weaning foods and childcare. Parents with the right knowledge use oral rehydration therapy in the management of diarrhea. Diarrhea can be controlled by local fluids e.g. porridge. According to one of the communities, at around 3-6 months, the common childhood diseases are diarrhea and vomiting, and stomachache. The traditional treatment is sorghum (mtama) porridge and herbal medicine. 3.40. A community in Garissa reported that the major childhood diseases are malaria and diarrhea. The traditional treatment of malaria includes covering the patient with fresh goatskin smeared with fresh goats blood. It is believed that this enhances sweating thus treating the malaria. Diarrhea is treated at home using traditional herbs. 3.41. The Bogarash community (Kilifi) cited the major childhood diseases as malaria, diarrhea and vomiting, fever, coughs and flu, and worm infections. The sick children are taken to hospital although some first take them to traditional healers. The community believes that those children who get sick because of the evil eye (kijicho) do not recover because there is no treatment. 3.42. The main childhood diseases in Mwingi include malaria, diarrhea, respiratory tract infections (RTI) and intestinal worms. De-worming programmes have been initiated as well as public education campaigns to improve the management of RTI and diarrhea at the household level. 3.43. Childhood diseases in a community in Mwingi include measles, pneumonia, smallpox, intestinal infections, and malaria. For most of these diseases, the first line of action is to take the child to hospital. 3.44. The children in Kibera said that the most common childhood diseases were colds and flu, scabies, headaches, eye infections, diarrhea, chest pains, ringworms, ear infection, measles, rickets, kwashiorkor and polio. The women said that in the past, the common diseases among children were diarrhea and skin

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diseases. Currently, skin diseases, malnutrition and worm infections are common. The children know the causes of most of the diseases, especially malaria, but they say their families cannot afford mosquito nets. Very few children are taken to a doctor when they are unwell. Most of them are given over-the-counter drugs (e.g. aspirin), mothers boil herbs gathered from the river, or traditional medicine purchased from the Maasai. Others wait for a cold to cure by itself, while a few others take the child to the nearby mission clinics.

HEALTH AND NUTRITION PROGRAMMES FOR PRESCHOOL AGE CHILDREN

3.45. When Christian Childrens Fund started its program in Baringo in 1981, it set up an agriculture demonstration farm and rehabilitated mothers with malnourished children in the form of a family life training programme. At any given time, there were on average 12 mothers with malnourished children who spent a period of 3 weeks at the rehabilitation center. During their stay, they were trained on good nutrition, food security, health and hygiene, and safe drinking water. However, after 1987, the program became community-based where poor households benefited from projects e.g. passing the gift heifer project, seedlings, micro-enterprise development, and food security.

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CHAPTER FOUR

MATERNAL HEALTH AND NUTRITION ANTENATAL, PERINATAL AND POSTNATAL CARE

4.1. The district health personnel in Baringo reported that the proportion of pregnant women who attend antenatal clinics is low because they are busy on the farms, while pregnant school dropouts do not attend because they do not want to be known that they are pregnant. At the health centers, pregnant women are advised that food rich in nutrients include eggs, liver, meat, green leafy vegetables, fruits (with yellow, orange, red color) and milk. However, the actual consumption of all these foods depends on availability and access at home. They are also given iron supplementation at the health facilities. 4.2. Most of the women deliver at home because of long distances to health facilities, high cost of healthcare, TBAs are easily available within the community, and fear of harassment by nurses. It was reported that very few children die before the age of two and that most child deaths occur from two years onwards. In a womens focus group discussion, some of the issues that came up were that (a) mothers start attending antenatal clinics from four months of pregnancy, (b) they receive iron supplements at the clinics, (c) the workload is not reduced until delivery, and (d) their diet does not change from that of other family members even during pregnancy. 4.3. The district health personnel in Bondo said that during antenatal care, mothers get anti-malaria drugs. They are advised to eat omena, beans, sorghum, and (if can afford) liver and eggs. However, few follow the advice, as food available has to cater for the whole family. There is no iron deficiency in a normal healthy mother in the area as mothers eat a lot of fish (fish has a lot of iron). There is however some demand for iron supplements due to malaria. 4.4. The community said that the majority of the children are born at home due to emergency conditions, long distance to hospital, and delivery services are only available at Bondo district headquarters. However, the local delivery systems through TBAs (nyamrerwa) are relatively safe. They reported that the proportion of low birth weight children is likely to be very small. There are very few cases of neonatal deaths. 4.5. In Garissa, majority of deliveries occur at home with assistance of trained TBAs, mainly due to lack of knowledge on the importance of the MCH clinics. Mothers who attend antenatal and postnatal clinics are given nutrition lectures, and anemic mothers given iron supplements. The community reported that special diet is recommended for lactating mothers, and consists of porridge, milk, liver and beans. Few women attend antenatal and postnatal clinics. The women reported low infant mortality (in the first year of life). 4.6. Kilifi reported that only a small proportion (about a ) of pregnant mothers attends antenatal clinics. The factors mentioned were ignorance (lack of knowledge), while the consent of husbands is normally required before attending antenatal and postnatal clinics. In the clinics, pregnant women are given advice on diet, but end up taking the same diets as the rest of family members. There are very few newborns who are either overweight or underweight. The causes of neonatal deaths were reported as anemia and tetanus (due to low immunization rate of pregnant mothers). Postpartum mothers take the same diets as the rest of the family. 4.7. An estimated half of births in Bogarash (Kilifi) take place in health facilities while the balance is taken care of by TBAs who are not trained. The proportion of low birth weight babies was reported as high. The cause of death in the first month was mainly due to tetanus (pepopunda). 4.8. Majority of the mothers in Dera village does not attend antenatal clinics due to traditional beliefs and long distances (over 10 km) to the nearest health facilities. Those who visit antenatal clinics are screened for anemia, given iron and folic supplements, malaria treatment and advised on feeding. Most

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women deliver at home. The cause of child deaths in the first month of life was mainly due to tetanus (pepopunda). 4.9. Even though nutrition advice is provided during clinic visits in Mwingi, there are pregnant women who do not attend clinics and women who visit the clinics but avoid taking the health education lessons. The attendance to antenatal clinics in the district is low due to long distances to the nearest health facility, lack of money for transport, and poor transport network. There are a significant proportion of women who deliver at home. In addition, the health personnel felt that mothers should be exposed to programmes that impart health education long before pregnancy, since some pregnancy outcomes are determined by conditions prevailing at the pre-conception stage. 4.10. The community members in Mwingi said that the majority of mothers attended antenatal clinics. Mothers who attend clinics are given information on proper feeding and childcare, but many ends up with poor feeding since they cannot afford the recommended diet. Although most mothers deliver at home, they noted that the number of children who die in the first month after delivery was low. The community members indicated that they did not receive any information on nutrition, apart from mothers through MCH clinics. 4.11. Most Nairobi mothers attend antenatal clinics in the health centers operated by the Nairobi City Council, although the mothers start attending clinic late despite the services being free. This could be due to competing demands for time or lack of awareness on the importance of attending clinic early. There are many cases of anemia. Those who attend antenatal clinics are given iron supplements. Most deliveries in the slums take place at home, sometimes with the help of the TBAs, mainly because they cannot afford the requisite maternity fees. 4.12. The community reported that attendance of pregnant mothers to antenatal clinics is quite low, and only about 50% of those who attend continue regularly until delivery. TBAs provide antenatal care to majority of the women. The majority delivers at home with the help of TBAs. Pregnant mothers do not encounter many problems since any condition or a disease that may pose a problem (e.g. high blood pressure) is detected early enough and referred to hospitals by the TBAs. 4.13. They reported that there are many cases of stillbirths. Some children die during childbirth due to fetal distress and premature births, especially those born at home. There are many cases of STDs and other infections due to poor sanitary conditions that lead to child infections and some child deaths. 4.14. The ministry of health in Thika trains TBAs on safe delivery and other aspects of maternal child health. The mothers in the area also have traditional knowledge on safe delivery practices, especially in noncomplicated cases. The health personnel said that TBAs have become too brave, as they wait for too long before seeking professional help, which can lead to cerebral palsy. Some TBAs even try to deliver twins and breech presentation (legs and buttocks first). 4.15. During antenatal services, there is counseling of mothers (e.g. on nutrition, prevention of diseases, and need for early health seeking) and treatment of malaria. They are given ferrous sulphate and folic acid supplementation, treated for worms (though not regular because worm infestation is not common in the district), and advised on the need for a balanced diet (e.g. protective foods like fruits and vegetables). Pregnant mothers are given malaria treatment during 16-24 weeks from conception and again during 24-36 weeks regardless of whether they have malaria. 4.16. There are cases of birth asphyxia (suffocation, lack of oxygen) and injuries during childbirth. This is true for both home and hospital deliveries. Most child deaths in the hospital nursery in the first 28 days are due to asphyxia or infection. The district hospital gets about one case per month of spina bifida, because of inadequate development of the central nervous systems (encephally). The most severe cases are due to nutrition problems of the mother e.g. lack of folic acid and possibly vitamins. Giving folic acid and other supplements during pregnancy may not eliminate this problem, and ideally, remedial actions should be taken before conception. In such instances, nutrition issues have to come before conception.

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4.17. Neonatal tetanus is very rare in Thika district. The hospitals only get umbilical cord infections, which are treatable with antibiotics.

CARE AND FEEDING OF PREGNANT AND POSTPARTUM MOTHERS

4.18. Traditionally, pregnant women in Baringo are advised not to overfeed, and specifically not to eat eggs because the unborn baby will be too big. They also continue with their daily activities, with no reduction in workload. This sometimes leads to premature births. However, the women are fed well after delivery. The community reported that most mothers deliver at home. After delivery their diet improves as they take milk, ugali, wimbi porridge, honey, water, and slaughter a goat if can afford. The mother rests for one month. 4.19. A women group in Bondo said that, in feeding of the unborn baby (intrauterine feeding), the ideal diet would be tea, milk, oranges, porridge (sorghum), ugali, rice, avocados, vegetables and mangoes. There is no special feeding of pregnant mothers. The actual situation is that the feeding of pregnant mothers is ugali (flour from the local maize miller), porridge (maize), fish and vegetables. Their workload is supposed to be low, but is high for some. A key informant in Maranda division said that pregnant mothers do not get any preference and eat the same foods as the rest of the household members. However, they eat a lot of soil, which they pick from anthills and demolished mud houses, and those who can afford buy special stones to chew. 4.20. Although health workers advice mothers in Kilifi to reduce their workload during pregnancy, the women continue with their normal duties, as they do not have much choice. Bogarash village reported that there is no reduction in a womans workload during pregnancy, unless the husband has the financial ability to recruit casual labor in the farm and house when needed. The feeding of postpartum mothers includes chicken and ugali. 4.21. Pregnant mothers in Dera eat the same foods as the rest of the family. There is also no reduction in the workload of pregnant mothers. There is no special diet for postpartum mothers. 4.22. Some cases of nutrition deficiencies among pregnant mothers in Nairobi are attributed to some cultural beliefs such as not eating eggs, especially for women from Western province, to avoid the unborn child growing too big. There is normally no change in workload during pregnancy. 4.23. The Kibera community concurred that pregnant women do not reduce their normal workload, because there is no one else to do it for them. The women said that lactating mothers try to eat some special foodstuffs such as chapatti, nyama, mboga, kienyeji/irio, beans, carrots, soup, and drink chocolate or cocoa. The special feeding lasts a period of 2 to 3 months after birth, although it depends on household finances. However, in most cases, pregnant and postpartum mothers eat the normal family diet of sukumawiki and ugali. Consequently, the mothers are not well fed, and most are anemic and underweight. Among the Kikuyu, the foods given to women after delivery include soup and njahi.

TABOOS ON FEEDING OF PREGNANT AND POSTPARTUM MOTHERS

4.24. Due to traditional beliefs, women in Baringo reported that pregnant mothers are barred from eating (a) meat of dead goats whose lungs appear infected as child will develop the same symptoms, (b) livestock with infected ears as this will affect hearing of child, (c) livestock with skin disorders as it might cause skin diseases on the child, (d) milk from snake-bitten cow or goat as it will bring bad luck, and (e) meat or milk of goats saved from the jaws of a leopard as this may bring bad luck.

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CHAPTER FIVE

NUTRITION AND HIV/AIDS PREVALENCE OF HIV/AIDS

5.1. The district and community consultations in Baringo did not give indications on whether the prevalence of HIV/AIDS is increasing or decreasing. The district departmental heads in Bondo estimated HIV/AIDS prevalence at around 30%, while bed coverage for HIV/AIDS and related causes was around 50%. The estimated infection rates are from hospital admissions, as there are no sentinel sites in the district. The general community and members of Victoria Women Group concurred that the prevalence of HIV/AIDS has gone down in recent years. It is only Garissa that reported that prevalence of HIV/AIDS is low. 5.2. Kilifi district also reported a decline in the prevalence of HIV/AIDS from 10% to 7% during 1997-2002. One of the sites for community consultations (Bogarash) reported AIDS as one of the main adult diseases; while the second site (Dera village) cited HIV/AIDS awareness and behavior change as one of the recurring themes in community theatre in the village. 5.3. Mwingi district also reported that the prevalence of HIV/AIDS has been falling in the last 5-7 years. However, a community in Waita location still reported HIV/AIDS as one of the main adult diseases in the area. From the sentinel sites, HIV prevalence in Thika has declined from around 34% in 1999 to 18% in 2002. The top ten causes of mortality in Thika district hospital, in descending order, are bronchopneumonia, AIDS, malaria, pulmonary tuberculosis (PTB), diarrhea, anemia, dehydration, meningitis, diabetes and congestive heart failure.

WHAT THE COMMUNITIES KNOW ABOUT HIV/AIDS

5.4. Most of the communities know AIDS is a killer disease. For example, a youth group in Baringo said that they have knowledge that AIDS is a killer disease, and know its modes of transmission and prevention. However, some pastoralists in Baringo believe that HIV/AIDS is caused by witchcraft. The youths said that they need more training on HIV/AIDS, especially as trainers to teach their fellow youth and parents/adults in the interior. They also should be facilitated with teaching aids, posters, videos, condoms, and education materials. 5.5. Some communities in Bondo district are well aware of the consequences of AIDS infection, although they are reluctant to relate or associate any death with HIV/AIDS. The patients who are in a state of denial (but have full symptoms of AIDS) may relate the symptoms with violation of customs and beliefs, and deaths due to illnesses with symptoms of AIDS are normally attributed to violation of taboos. In Kilifi, there is still a strong belief within the communities that any illness is a result of witchcraft and kijicho (evil eye). In Thika, the communities are aware about modes of transmission of HIV e.g. unprotected sex with an infected partner, through infected blood if there is an opening on the skin, and how to minimize mother-to-child transmission (perinatal and breastfeeding). However, the people do not use the knowledge e.g. when they take local brew they forget about protected sex. 5.6. Community consultations in Kibera showed that the community has knowledge about HIV/AIDS, how it is transmitted, and ways of prevention. A focus group of children in Kibera showed that children are aware that AIDS is spread through unprotected sex, having sex with more than one partner, and through contaminated needles and open wounds. The children recommended that people should abstain (from sex), keep one partner, or use condoms if you really must do it. The children were also aware that there was prostitution among adults due to poverty, when girls are looking for money for survival.

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THE MOST VULNERABLE GROUPS IN THE COMMUNITY

5.7. In Baringo, the vulnerable groups were reported as youth in the urban areas and drunkards in the rural areas, but the most affected group are adult men. In Bondo, there is high concentration of HIV/AIDS incidence along the beaches due to the high densities of population. Most of the widows and old men relocate to the beaches with the hope of earning a living. Once on the beaches, the widows befriend the relatively younger men who run fishing businesses. There are also higher incidences in towns such as Bondo district headquarters. 5.8. A fishing community in Bondo reported that HIV/AIDS travels by road (and gave members of the research team as an example) and lake (e.g. boats bringing food from Uganda). An elderly man said that HIV/AIDS is high among the youth, but old men do not have the power (virility) due to the types of food they eat and methods of food preparation e.g. too much fat, and reduction in time used to cook omena. This would imply that better nutrition would improve male virility, and consequently lead to higher incidence of HIV/AIDS. 5.9. In Kilifi, the health personnel suspected that the rate of transmission increases during traditional ceremonies e.g. funerals and weddings. HIV was reported as closely related with polygamy and single women. 5.10. A village chairman in Gatuanyaga, Thika, reported that AIDS is common, partly because of old men moving with young prostitutes or an old man marrying a young wife who is likely to stray. He was of the opinion that condom use has increased promiscuity. An infected young man can deliberately remove a condom during intercourse to pass on the infection to a partner. A youth self-help group in Ruiru reported that the population groups most vulnerable to infection are 24-35 year old women, and male youth of 1524 years. In the coffee estates, women have no bargaining power in relation to sex. Poverty has made women powerless, especially in negotiating safe sex. The high-risk groups include workers in industries, coffee estates, flower farms, General Service Unit (GSU) camp, Prisons Staff Training College, the military barracks (Kahawa), and the effects of the Nairobi-Thika highway especially on commercial sex trade. 5.11. A community in Kianda location of Kibera division reported that the most vulnerable groups are the youth (because of idleness) and adults (because of drunkenness). The infection rate is highest among those under 35 years of age. Their perspective of the spread of the disease is that somebody infected with STDs tends to have more urge for sex, thereby engaging in promiscuity. The majority has not accepted the use of male condom. 5.12. Despite the high level of awareness, the rate at which youths in the community in Kianda location are having unprotected sex is increasing. The youth do not use condoms, and have adopted an attitude that catching HIV/AIDS is an accident or bad luck. They said that condoms ni kama kula sweet na karatasi yake (using a condom is like eating a sweet with its wrapper).

HIV/AIDS AWARENESS AND BEHAVIOR CHANGE

5.13. In Baringo, the district departmental heads reported that although there is high level of awareness due to activities of many agencies e.g. NGOs and health workers, there has been minimal behavior change. The chairperson of Kabarnet Community Development Programme (KACODEP) also observed that people are getting de-stigmatized and are volunteering to be tested for HIV/AIDS. 5.14. In Bondo, awareness was high because of the combined efforts of public health officials dealing with HIV/AIDS up to the grassroots level. For example, along the beaches in Bondo, the practice of sex (with female fishmongers) for fish (from fishermen and boat-owners) is hardly there any more due to awareness creation over the last decade. A womens group also reported that AIDS awareness has worked, especially in fish-landing bays, and the business interactions between young men and girls in the beaches is rarely related to sex. 5.15. In Garissa, the district departmental heads reported that the majority of the population is aware of the disease. However, they also reported that there are no home-based care programmes or home visits

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targeting people living with HIV/AIDS. HIV/AIDS has also been integrated in the school curriculum where pupils are taught on the basic facts and coping strategies. 5.16. In Kilifi, awareness of the existence, modes of transmission and consequences of infection is high. Death through AIDS has had a very significant impact on the peoples awareness. The ministry of health is the lead agency in creation of awareness, with the support of other government departments (e.g. education, agriculture, social services, provincial administration), AIDS control units in other government ministries, and nongovernmental organizations in the area (e.g. Plan International and KDDP). In Dera village, a theatre group was started as an awareness tool since the community had problems accepting new ideas. Some of the issues covered in the theatre include behavior change in HIV/AIDS, and benefits of new technologies in farming 5.17. In Mwingi, the high level of awareness (estimated at 99%) has failed to trigger a change in behavior. VCT centers are important in influencing behavior change, and the absence of VCT centers may be one of the contributory factors to lack of behavior change. 5.18. A prototype community in a slum area of Nairobi (Kianda location of Kibera division) reported that there is high awareness of HIV/AIDS but little behavior change. The common routes for creating awareness include community programmes through seminars, churches, and the grapevine (normal discussions among neighbors and friends) or what is sometimes referred to as LAN (local area network). Interactions between the infected and the uninfected are normal and friendly, due to the level of awareness created by various community-based organizations operating in the area. The youth said they learnt about AIDS through seminars, neighbors, radios, TV and magazines. The youth lamented that girls are not interested in discussing AIDS matters. 5.19. Other issues of concern to the youth that are linked to HIV/AIDS and STI infections were (a) sexual abuse of children by older people in exchange for chips and little money, (b) video and TV shows that have drained childrens morals, (c) a few cases of rape of young girls by their fathers and community members, and (d) mode of dressing, character and influence of grownup girls that has brought immorality among younger girls. The children said they heard about AIDS from other people, on television, on videos at the DOs offices, and videos in schools. They said that dawa yake ni kifo (its medicine is death). 5.20. In their seasonal calendar, the Kianda community said that the period January-March is characterized by economic hardships due to school fees, and there is therefore high rate of STI infection due to mothers engaging in commercial sex to settle the high bills. During April-June, there are high conception rates due to cold weather and limited movement/activities, followed by high rates of abortion during July-September (those conceived in the second quarter). During October-December, there is high rate of STI infections among the youth due to promiscuity during the Christmas holidays. 5.21. The communities in Thika district had a similar story: high level of awareness and low behavior change. For example, FORCUS (Families, Orphans and Children Under Stress) Self-Help Group has behavior change as one of its main missions. This include theatre on condom efficacy, where they discount myths surrounding the condom e.g. lubrication has a virus, condoms break, virus can penetrate the pores, and use of condom reduces pleasure. Plan Internationals STI/HIV program in Thika uses the so-called HICDAM approach (Hearing the information, Internalizing, Conceptualizing, Deciding, Action, and Maintaining). People have information but are not ready for behavior change, and HICDAM is therefore designed to bring about behavior change. Plan International works on the premise that control of HIV starts with knowing ones status. 5.22. The gender relations in different study sites had profound effect on behavior change and the extent to which an individuals attitude towards safe sex is either respected or compromised by the other sex partner. For example, in Kianda area of Kibera, the male youth reported that girls are not interested in discussing AIDS matters. In Thika, women working in plantations generally have low bargaining power in relation to safe sex. In Garissa, a survey conducted by UNICEF and the Government in 2002 reported that condoms are not well known and a woman will refuse to budge if shown a condom. In Kilifi, a district departmental head suspected that the rate of transmission increases during traditional ceremonies (e.g.

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funerals and weddings), that is, within an environment where normal gender relations may be highly compromised.

NUTRITION INFORMATION SPECIFIC TO HIV/AIDS

5.23. In Baringo, CHWs and nutritionists provide information on nutritious diet for those infected with HIV/AIDS, but practice of the same depends on household access to the recommended food. The community recommended that the proposed nutrition policy should include a boost to funding nutrition and HIV/AIDS, especially for home-based care. 5.24. Although the communities in Bondo are being trained on home-based care, the feeding of the infected normally depends on the familys income. The groups most at risk of infection are normally the breadwinners, and the rest of the family cannot therefore afford a proper diet. Those engaged in homebased care have a hard time convincing people to eat what they cannot afford. Probably only 1% affords the requisite meals. Since food increases immunity, some people die faster, and some cannot even afford hospital bed. The community at Uhanya fish landing bay said that they understand that the infected like chicken and fried meat. However, they only receive special diet when it is available, as an improved diet is not sustainable on a regular basis. 5.25. In Garissa, nutritional counseling is given to those seeking treatment at the provincial general hospital. Some people believe that camel products (meat, milk and urine) and herbs (such as neem tree) can cure HIV. Other interventions believed to cure HIV include eating a lot of boiled meat, and prayers. In Kilifi, health workers advise HIV patients to eat balanced diet, but this rarely happens due to the food situation at the household level. 5.26. Thika health staff said that there is a gap in nutrition advice since a nutritionist is rarely invited to advise the infected person so as to delay the onset of sickness and reduce the likelihood of opportunistic infections. However, TB (one of the opportunistic infections) is also a disease of the environment as it is most common in the crowded settlements e.g. Kiandutu slums. The HIV-positive adults are advised to eat a balanced diet and food rich in vitamins e.g. indigenous vegetables and all types of fruits. Those who can afford the recommended diet do buy. Unless the patient puts food in the same rank as drugs, he is not likely to purchase the recommended food. However, HIV/AIDS drugs are expensive and the patients may value drugs more than food in the management of HIV. The downside is that it takes long for well-fed, HIV-positive people to be suspected of being sick as they appear healthy, and may therefore spread the disease. 5.27. In Nairobi, the government departmental heads said that nutrition is not incorporated in the national HIV/AIDS programme. The component of nutrition is not recognized or internalized, which has implications for funding on nutrition issues in relation to HIV/AIDS. During community consultations, the participants said that it is difficult to give a balanced diet to People Living With AIDS (PLWA) due to the low economic status of most households.

COMMUNITY AND HOME-BASED CARE FOR THE INFECTED AND ORPHANS

5.28. In Baringo, the infected and orphans are supported by the civil society (e.g. NGOs) and other organizations through food, drugs, and education. They are encouraged to stay within their family set-ups and the orphaned children to stay with relatives. A local NGO, Kabarnet Community Development Programme (KACODEP), was started in 2001 to assist orphans and those living with HIV/AIDS, and has received support from various sources including the National Aids Control Council. They mainly provide food (e.g. finger millet, eggs, beans, green grams and milk), drugs and herbs. They also pay school fees for the orphans, and so far have supported 78 orphans and 29 infected adults. 5.29. In Bondo, the National Aids Control Council works at the grassroots through support to community-based organizations. Community based organizations have been active in mobilizing resources for their projects. One of the most common areas of interest among CBOs is home-based care for AIDS patients. For example, Victoria Women Group undertakes home-based care for the infected, and for orphans. They have established an orphans center which has now reached Primary Class 2 and will be a

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feeder school with up to Class 4. In the school, the children take breakfast, lunch, plus 3 pm uji. The uji comprises of cassava, beans, njugu, maize, sorghum and soya beans. They add folic acid tablets, Vitamin B complex, sugar and lime. The porridge is given to both the infected (to boost immunity) and orphans. They currently support 110 orphans and another 67 clients (infected or with AIDS-related infections). Some are in a state of denial although have all symptoms but may relate the symptoms with customs and beliefs. The group has also received support from Futures Group (which has phased out), UNDP and the International Community for the Relief of Suffering and Starvation (ICROSS). 5.30. The Mwingi district departmental heads and the general community reported the main adulthood diseases to include malaria, HIV/AIDS, TB and typhoid. There are several home-based care programmes initiated by the Catholic Church and several CBOs. Community based organizations have been very active in providing food, clothing, school fees (for orphans), and through guardian-orphan support. The National Aids Control Council has funded organized groups to implement AIDS-related activities. 5.31. A youth group in Kibera said that close relatives hide the infected because they have brought shame to the family. Children orphaned by AIDS are under the care of immediate relatives. However, there are feeding programmes for children, mothers, the aged and HIV/AIDS patients, which are run by church organizations. 5.32. FORCUS Self-Help Group in Ruiru (Thika) introduced home-based care after group members were trained as community health workers. The CHWs identify patients and train caregivers (e.g. friends, family members of the infected person) on how to take care of the patients. In 2002, the group opened a daycare center for the orphans and the vulnerable (whose parents are in the advanced stages of AIDS). The orphans and vulnerable children in the center are not infected. The center was also involved in informal education of the children, but in 2003 sent some to primary school because primary education became free but retained only younger ones at the center for preschool education. The group has received financial and material support from the National Aids Control Council and nearby companies, churches and wellwishers. The group members advise HIV-positive pregnant mothers not to breastfeed as the child can get infected, and of the availability of antiretroviral drugs. 5.33. In the morning, the children at the center go through some education. At 10 am, they take porridge (mixed flours), and get lunch and 4 pm tea before they go home. They have 21 children, eight of whom are in primary. For those in the nearby primary school, the group members deliver porridge to them at 10 am, the children go to the center for lunch, and come for porridge at 4 pm after school. 5.34. Plan International supports some orphans with school fees (for those in secondary school), others in vocational training, and a few cases with food and food supplements at their homes. They do not have centers, and do not even encourage daycare centers.

EFFECT OF INFECTION ON THE IMMEDIATE FAMILY

5.35. The district departmental heads in Baringo said that the disease has had a big effect in increasing household expenditure. One of the NGOs operating in Kiture area, Christian Childrens Fund (CCF), stated that the main challenges to the success of its programme have been high population growth, HIV/AIDS, drunkenness, and illiteracy. 5.36. The district departmental heads and the general community in Bondo district stressed that, with the onset of HIV/AIDS, the productive population has been reduced and this has increased stress on incomes. 5.37. Although the prevalence of HIV/AIDS is generally on the decline in Kilifi district, the health staff commented that it has led to loss of income due to lower productivity, poverty (especially if the infected is the breadwinner), diversion of household income towards medical care, sale of property to meet medical expenses, and the care of orphans. Despite the general statements about the decline in the prevalence of HIV, the community in Bogarash village still reported HIV as one of the main adult diseases, in the same league with malaria, typhoid and gonorrhea.

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5.38. During the district PRSP consultation process in Thika, one of the causes of poverty was identified as the high incidence of HIV/AIDS. HIV/AIDS has devastated families e.g. uses a lot of money for drugs, the infected was probably the breadwinner, children drop out of school, adolescent girls get married early or go looking for jobs, is an emotional drain on grandparents, and increased child labor. Due to the interrelatedness of HIV/AIDS with livelihoods, the home economics staff incorporates activities in home management (e.g. sanitation, management of family resources human and non-human, personal hygiene) and family life education (e.g. HIV/IDS awareness, and childcare and development) in their regular activities. 5.39. The social factors in explaining poverty in Nairobi include difficulties faced by vulnerable groups (including female-headed households, street children, street families, disabled, the elderly, and AIDS orphans), social breakdown within the family structures, insecurity, and high population growth due to rural-urban migration. During a focus group discussion, the women also raised concern that most men spend almost all their income on alcohol.

MOTHERTO-CHILD TRANSMISSION OF HIV

5.40. A health nurse in Baringo said that mother-to-child transmission of HIV/AIDS can be minimized through drugs administered to a mother just before birth, and exclusive breastfeeding without any complementary foods. In Bondo, VCT services were introduced recently, where mothers are counseled and then tested, and if positive provided with drugs to prevent mother-to-child transmission. The vertical transmission is high but the actual rate is not known. Health personnel advise HIV-positive mothers not to breastfeed, but some mothers do not follow the advice because they do not have the means to buy breastmilk substitutes. The mothers say that it is not possible to avoid breastfeeding unless you separate the child from the mother. However, the community at Uhanya fish landing bay believe that an infected pregnant mother will always give birth to an infected child. The community members are therefore not aware that antiretroviral drugs can reduce mother-to-child transmission during birth, although the drugs are available in Bondo district hospital. 5.41. In Kilifi district, the health personnel reported that HIV status of most lactating mothers is not known, and they therefore continue to breastfeed. The health personnel advise HIV-positive lactating mothers not to breastfeed. In Mwingi, HIV-positive mothers are advised not to breastfeed, but to give the babies breast-milk substitutes. However, most of the mothers are not able to afford the alternative foods. At the district hospital, there were no drugs to prevent mother-to-child transmission. 5.42. Thika district has 10 VCT centers, where pregnant mothers are advised to go for tests. Those who are HIV-positive are advised to make informed choices, have proper feeding during pregnancy, and are booked for delivery in any of the two hospitals (Thika and Gatundu). A HIV-positive mother is given antiretroviral drug (nevilapine) once she gets into labor and the newborn given nevilapine syrup to reduce the chance of mother-to-child transmission. However, very few community members know about this, as training is focused on hospital staff (maternity, nurses) and not the field staff. The HIV-positive mothers are advised not to breastfeed. Those who accept the advice are given a small amount of breast-milk substitute. The mothers with ability to provide breast-milk substitutes and cows milk are able to avoid breastfeeding the child. 5.43. In Kibera, the TBAs advise mothers not to breastfeed their children if they know they are HIVpositive, and to give their children formula or fresh milk.

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CHAPTER SIX

NUTRITION AND EMERGENCIES

6.1. In the district and community consultations, the researchers understood nutrition and emergencies in the context of food relief and school feeding programmes. The wider issue of relief and development, especially recovery after an emergency (e.g. drought) was only dealt with in the case studies of Baringo and Garissa. 6.2. The consultations raised concern about long-term weather changes and environmental degradation that may have long-term impacts on food security and other aspects of livelihoods. Major droughts are expected every four years, and the arid and semi-arid areas are perennially either in emergency stage or recovering from an emergency. The food-based relief programmes during drought or when recovering from drought were the focus of community and district consultations.

INTER-HARVEST NEAR-FAMINES
6.3. In most parts of the country, only a minority of the population affords to feed itself throughout the year from own production. There is normally a period of food stress after the entire harvest is depleted through sale and/or home consumption. Therefore, inter-harvest near-famines are common, especially for those outside the money economy who cannot afford to buy (adequate) food during these periods. In Baringo, for example, the main planting season is March/April, and harvest in August. Thus, food is available in August-December while food stress is mainly during January-May. The coping strategies include migration to trading centers to wait for food relief, changing diet, slaughtering small stock for home consumption, looking for wild roots and fruits, and sending children to school when there is a school feeding programme. 6.4. The same phenomenon of inter-harvest near-famines was observed in Bondo, Garissa, Kilifi, Mwingi, and the lower zones of Thika district. Since most households in Nairobi depend on purchased foods, household food availability depends on incomes rather than household food self-sufficiency. The main problem is that during food stress, prices of food are high, but very low immediately after harvest. For example, although most families in Bondo and Mwingi hardly harvest enough to last to the next harvest, the produce is usually sold at throwaway prices (especially immediately after harvest) only to purchase food more expensively later. Apart from maize supplied as part of relief food, most of the maize purchased by households in Mwingi is produced within the district. The grain traders purchase and store food for resale during periods of scarcity. During seasons of food deficit, food prices tend to rise while the prices fall during surplus period. Some of the approaches to reduce food deficit during dry periods include kitchen gardening, provision of drip-kits (for irrigation) and container gardening. 6.5. A number of studies conducted under the auspices of the Food and Nutrition Studies Programme focused on the effects of seasonality on food production and its impact on nutrition (see, for example, Kigutha, 1994 and 1995). Food harvested by most subsistence farmers is normally not sufficient to feed the family until the following season, either because of the small quantity harvested or sales made immediately after harvest, hence the reference to inter-harvest near-famines. In the dry season, people purchase cereals by a standard measure (gorogoro), hence the reference to most of Kenyas rural economy as the gorogoro economy (see Cohen and Odhiambo, 1989; cited in Whyte and Kariuki, 1991).

FOOD RELIEF PROGRAMMES

6.6. The main economic activities in Baringo are crop and livestock production, although they have been relying on relief food because of adverse weather conditions in the last four years. Initially food distribution followed the World Food Programme guidelines where everyone received some food. From the year 2000, the target has been free rations for the most needy and food-for-work for the able-bodied. The method is working well and is reducing dependency. However, the communities said that the relief food is not nutritionally adequate as it is only maize and beans. World Vision has also supported

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Government efforts in emergency relief and disaster management, while ACTIONAID has assisted with provision and distribution of relief food through CBOs in its area of operation. 6.7. Bondo does not receive food relief on a regular basis. However, there was a motion passed by parliament in July 2002 to include Bondo and other contiguous districts as arid and semi-arid areas, ostensibly to make them eligible for food relief. The health personnel recommended that the district nutritionist should be involved in relief food because often the food does not provide adequate nutrition and there may be need for supplementation. 6.8. In Garissa, the causes of food insecurity include crop failure due to prolonged drought, and flooding in case of irrigated agriculture along the banks of Tana River. Most people have lost their livestock, which is the mainstay of the population. In event of prolonged drought that led to loss of the only source of livelihoods (livestock), the pastoralists would migrate to peri-urban and urban centers in search of food. Such pastoralist dropouts are among the poorest people in the district. 6.9. Some of the constraints to improvement of health and nutrition include dependency on famine relief, maize given as relief food is not suitable for children under 5 years of age, and MOH is not involved in relief food to advice on quality of ration. The District Agriculture and Livestock Extension Officer (DALEO) said that some of the strategies to reduce food insecurity should include discouraging free famine relief to avoid dependency, and issuing relief food that consists of balanced diet. 6.10. Care-Kenya is a secondary distributor of WFP-funded food aid during droughts and other emergencies such as the El Nino. In addition, it runs local community programmes that include drought recovery and mobilization and coordination of pastoralist groups. 6.11. The Arid Lands Resource Management Project (ALRMP) has established drought early warning system in both Garissa and Ijara districts to monitor environmental conditions (rainfall and pasture situation), rural economy (livestock and crop production), and human welfare (milk consumption, nutritional status of children under five, monitoring of relief food, and supplementary feeding). The community is fully involved in the process of food aid, right from identification of beneficiaries to actual food distribution. 6.12. Traditionally the Balambala community (Garissa) led a pastoralist way of life, migrating from place to place in search of pasture and water. They looked for other ways of survival after losing their livestock to successive droughts (especially the 1984 drought). During 1990-1996, the community had good farm plots, which were swept away during El Nino rains. In 1992, there were tribal clashes during which their livestock were stolen and some people lost their lives, leaving families widowed and children orphaned. The community has adopted coping strategies characteristic of sedentary communities, e.g. petty trade, casual labor and farming. 6.13. The community benefited from relief food during the following periods of prolonged drought: 1984, 1992, 1996, and 2000/2001. Malnourished children are given supplementary feeding in form of porridge flour (3 kg per child per fortnight). Children with low weight-for-height (severely malnourished) are given nutritious biscuits and vitamin A capsules. 6.14. Food relief is mainly given in Ganze, Kaloleni and Bamba divisions of Kilifi district. The food relief consists of maize, beans and cooking fat. The quantities are not enough and the provisions are erratic e.g. receive 2-5 kg of maize and 1 kg of beans occasionally. They said that food relief therefore has no impact on nutrition. There are food relief committees that assist in identifying the needy households in the distribution of food. The residents of Bogarash village in Kilifi reported that the community has never received any relief food since 1996 although they do not grow enough food to meet local needs. 6.15. The main sources of relief food in Mwingi district have been the Government, WFP, GTZ, Catholic Diocese of Kitui, and ACTIONAID. Initially, food relief in Mwingi district was used as a political tool, with a lot of food provided during election years particularly in the lower divisions of the district. However, coordination has improved through the use of community-based committees for targeting the needy households. A lead agency is identified to coordinate all relief efforts in the district. GTZ has been

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instrumental in initiating the food-for-work programme. Through the food-for-work programme, the communities receive multiple benefits through improved food supply, better infrastructure, and soil conservation. Unlike in the past when food was used as a political tool, food-for-work and communitybased approaches of targeting the poor have reduced dependency since people are aware that they can be independent by growing more food. 6.16. The community in Kibera said that it has never received any major food relief from the government. Those affected during the clashes sparked by rent riots received some food. There are, however, some programmes such as the Catholic Relief Services that target certain groups, e.g. elderly, orphans and sickly. 6.17. In Thika, the little food relief allocated to the district is distributed to every administrative division regardless of need. The area most affected by food shortages is Kakuzi, but generally there is no place in the district where people are dying of hunger. There are no NGOs dealing with food relief.

SCHOOL FEEDING PROGRAMMES

6.18. Out of 357 primary schools in Baringo, 355 are covered by the school-feeding programme (SFP), and the remaining two volunteered not to. The preschools attached to the primary schools benefit from the SFP. The rest of the preschools depend on their own arrangements. The types and amounts of food given are maize (150g/day/child), beans (40g/day/child) and oil (5g/day/child). Due to the free primary education program, more pupils have enrolled leading to food shortage. Such food shortages affect school attendance negatively and sometimes the schools close down when there are delays in food delivery, as the children do not come to school. The SFP improves enrolment and general performance of the pupils. 6.19. Two key informants in Bondo reported that the nutritional value of various foods and the importance of balanced diet are taught in school as part of the curriculum. There are also demonstration farms in schools. They recommended that every school should have a demonstration farm; micronutrient supplements should be made available in schools accompanied by the requisite training for the concerned staff; and that nutrition education for parents and teachers should be promoted. 6.20. The SFP in Garissa is aimed at cushioning school-going children from walking long distances to and from school to obtain lunch from their homes. It is supported by WFP in collaboration with the Government. The local community provides water, firewood, salt and other ingredients in addition to facilitating the cooking. The food consists of a midday meal for both preprimary and primary schools. Each child is entitled to 150g maize, 40g beans or pulses and 5 g oil per day, which are deemed adequate. 6.21. The benefits of SFP in Garissa include increased school enrollment, enhanced learning and retention, and improved school performance. Other nutrition-related activities include integration of nutrition and better health in the primary school curriculum. At Standard three to four, pupils are introduced to the concept of balanced diet and the main food groups. 6.22. In Kilifi, the SFP is in 38 primary schools in the dry areas of the district, namely, Ganze, Bamba, and Vitengeni divisions. The rations contain yellow maize, beans, dengu (green grams), yellow split peas, and cooking oil. The daily ration for a child is 150 g maize, 40 g peas or beans, and 5 g of cooking oil. The dropout rates in the district are high, especially in areas where there is no SFP. The 38 schools with school feeding programmes are normally among the top in KCPE in the district. 6.23. The WFP-supported SFP in Mwingi district provides food to primary schools directly through the District Education Office. The SFP operates under two sub-programmes, namely, the regular (continuous) school feeding and the expanded (emergency) school feeding. The regular school feeding is the one implemented during normal years on a continuous basis. However, the expanded programme is implemented during periods of drought and extreme food stress. All schools under the SFP receive maize, beans and cooking oil to make lunch for all students in the school. In addition, all schools under the expanded programme receive corn soya milk to make porridge for students at 10 am break.

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6.24. The district has 353 schools. Currently, there are 96 schools under regular school feeding while 103 schools have been placed under the expanded programme. About 154 schools are not covered under any of the programmes. The communities contribute by supplying firewood and water, as none of the primary schools in the district has piped water within the compound. The communities also supply beans during periods of good harvest. 6.25. One of the most important achievements of the SFP has been the significant increase in primary school enrolments. Some of the constraints the programme has faced include long delays in delivery of food from WFP to the district stores, poor roads that make food be dropped several kilometers from schools, and use of commercial transport (at considerable expense to the district education office). 6.26. In Nairobi, there is no policy on feeding in primary schools, other than midday meals in Mukuru and Kariobangi slums in a bid to improve enrolment, enhance retention, and reduce dropout and repetition rates. Currently, in preschool and primary school, organized child feeding largely depends on initiative of parents and school management. In some schools, feeding is mainly undertaken by NGOs and churches as part of the effort to retain children in school or other humanitarian or sectarian interests. NGO efforts are confined to schools with catchments in informal settlements. Many schools have kiosks that sell commercial beverages and confectionery. Unfortunately, the kiosks sell junk foods (snacks) that are expensive but lack vital nutrients, and thus affect childrens health negatively. Some children carry packed lunch consisting mainly of starch-based foods, which also lack vital nutrients. In addition, because of lack of feeding programmes, neighboring communities get opportunity to sell food to children, often in unhygienic conditions.

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CHAPTER SEVEN

WATER AND SANITATION COMMUNITY ACCESS TO SAFE WATER

7.1. In Baringo, the surface water sources provide 90% of the water needs and the underground sources the remaining 10%. The surface water sources are normally fresh while the underground sources are salty. The main sources of surface water (mainly in the highlands) are rivers, pans, dams and lakes. The underground sources (mainly in the lowlands) are mainly boreholes. In general, the water is polluted and animals and humans use the same sources of water. However, efforts are being made to prevent pollution through stopping encroachment of the rivers upstream. 7.2. The vast area of Bondo district does not get clean water, and even Bondo town water treatment plant constructed during the colonial era broke down. In the whole of Bondo, wholesome water coverage is around 40% - which include hand-dug wells (e.g. in Bondo division) and treated community water supply (e.g. in Uyoma). The majority of the population depends on untreated water from dams, ponds, rainwater and the lake. The health department rarely undertakes testing of water quality since the Government chemist charges them a lot of money for testing water. 7.3. The main source of water in Maranda division is dams. The dams contain stagnant water, and the dangers of waterborne diseases are real. Livestock (cattle, goats and sheep) use the same water sources, which makes the water dirty and brown in color. The few households who have roofed their houses with corrugated iron sheets harvest rainwater for drinking. The nearest piped water facility is at Bondo Teachers College where 20 litres of water costs two shillings. 7.4. The drainage pattern for Kilifi district is formed by seasonal rivers, which drain into Sabaki River and Indian Ocean. The rivers and streams are Kambeni, Nzovuni, Goshi and Wimbi. High population densities are found in Bahari, Kikambala and Kaloleni Divisions along the tarmac roads from MombasaMalindi and Mombasa-Nairobi up to Mariakani Town. These areas are well supplied with piped water and electricity. 7.5. The main sources of water in Kilifi are pans, dams, rivers and shallow wells. The water sources are unprotected and open to contamination. An estimated 24% of the district population has access to safe water. The communities have been sensitized on the need to boil water before drinking, but most community members believe that boiled water loses taste. In some places, e.g. in Bamba and Ganze, there is virtually no water during the dry season. 7.6. The main sources of water in Mwingi include dry riverbeds, shallow wells, Tana River, boreholes, piped water (from Kiambere Water Project), roof catchments, springs, and rock catchments (to a small extent). Largely, the water consumed in the district has high microbial content. Domestic animals and wildlife share the same water sources with humans. 7.7. The sources of water in Nairobi include treated piped water, boreholes (the water has too much fluorine), water vendors especially in the slum areas (water may be contaminated during handling), river water for drinking (e.g. the upper parts of Nairobi River before it becomes polluted), and polluted river water (for washing and bathing). The polluted water contributes to a range of skin ailments. An estimated 52% of the piped water is unaccounted for as it is tapped through illegal connections (for irrigation, car wash, domestic and industrial use). This has forced residents to go without clean water, and distorted the price of piped water in the city. 7.8. Many schools in Nairobi go for days without tap or clean drinking water, which is a hazard to health. Due to lack of school feeding programmes, neighboring communities sell food to children often in unhygienic conditions.

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7.9. The water points in Kibera are not sufficient to serve the whole community. The community fails to get enough water because of illegal connections and bursting of water pipes. The pipes are narrow (thus do not supply enough water) and rusty. In the dry seasons, water is sold at KSh 5 and may go for as high as KSh 20 per jerrican. The community does not know the source of that water. Sometimes the water they buy is salty. 7.10. When there is a serious shortage of water, some students fail to go to school so as to assist their parents to search for water. In schools, water is not sufficient and students bring it from home. In informal schools, kids carry water to school almost every day. 7.11. In Thika district, the highlands to the west form water catchments and watersheds of most of the rivers, which flows towards the lowlands of the southeast parts of the district. All these rivers flow from the Aberdare ranges to the west towards southeast to form part of the Tana and Athi river drainage systems. However, the district is characterized by high water seepage, cultivation up to the rivers, destruction of catchments, and high soil erosion. Consequently, rivers have become streams. 7.12. A resident of Gatuanyaga said that one of the common diseases is typhoid because human waste is washed to the river, where people draw water for drinking and cooking. Some people treat river water with some chemical bought in Thika town to make it look clear (and then boil it), but only few afford to do this anyway. In Ruiru, it was reported that although there is piped water in some areas, typhoid is still common because most people use borehole water, as they cannot afford piped water.

COLLECTING WATER AND ITS IMPACT ON THE HOUSEHOLD

7.13. The community calendar for women in Baringo shows that washing utensils and personal hygiene (washing of face and bathing) are regular activities. Women and girls have therefore to fetch water for domestic use on a daily basis. 7.14. The district departmental heads in Bondo said that gender role is of major concern, mainly because the district has acute shortage of surface water and women have to travel long distances to fetch water, leaving inadequate time for food preparation.

ENVIRONMENTAL PROTECTION AND WATER SUPPLY

7.15. All the communities visited reported that they are slouching towards environmental bankruptcy (a description borrowed from Timberlake, 1988). For example, key informants in Baringo district listed the causes of poverty to include unreliable rainfall, recurrent drought and floods, and destruction of water catchments resulting to drying up of water ponds. Some animals die during droughts and floods. Some of the causes of the worsening poverty situation are diminishing water resources and declining quality of soils due to overuse (including overgrazing) and soil erosion. The community listed their main problems to include water and soil erosion. The community recommended that a national nutrition policy should put more emphasis on environmental conservation (soil and water) for sustained food supply. 7.16. Some of the causes of food insecurity and poverty in Garissa district include frequent crop failure due to prolonged droughts, flooding in case of irrigated agriculture, and poor access to water. 7.17. The majority of the poor in Nairobi live in informal settlements, which account for an estimated 55% of its population and occupy 5% of the total residential area. The environmental manifestations of poverty are overcrowding, lack of proper liquid waste management, lack of solid waste collection and disposal, lack of potable water, poor drainage, and lack of affordable and accessible healthcare services. A small proportion of urban agriculture is based on wastewater irrigation and river irrigation (along the Nairobi River which is likewise polluted). There are risks of accumulation of heavy metals during crop growth and contamination of vegetables during handling. The crops grown along the roadsides also pick up lead from vehicle fumes. A study conducted on cowpeas sold in Nairobi vegetable markets showed significantly elevated levels of lead and cadmium, probably originating from airborne particulates from motor vehicle exhausts, industrial emissions, and uptake of the metals from the soil (Tumbo-Oeri, 1988).

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7.18. The normal seasonal calendar in Kibera shows that most rain falls during April-June period. The floods wash down structures along the valley, people drown and property is destroyed, and there is a high incidence of thuggery as any alarm raised cannot be heard by neighbors due to the heavy rains. There is also increased incidence of diarrhea and vomiting, and typhoid because of draining garbage and sewage into peoples compounds and use by some families of rainwater for drinking and cooking.

SAFE SANITATION AND HYGIENE

7.19. The communities in Baringo have knowledge on safe drinking water and the need to boil water before drinking. The information is received from health workers, but in practice, they do not boil it. The main problems related to water and sanitation is shortage of water and pollution of water sources. There is also knowledge on personal hygiene practices but it is not followed. 7.20. Generally, less than 20% of the Bondo households have pit latrines. However, this varies with season since many pit latrines collapse during the rainy season (because of the types of soils and flooding). For example, latrine coverage in Madiany division is low because of types of soil, and some parts are rocky. In the areas near the beaches, the water table is very high. Given the variations in latrine coverage, the onset of rains determines the seasonal calendar of waterborne diseases, which are mainly experienced at the beginning of the dry season (around September) and beginning of the wet season (April-May). Cholera is endemic in both periods, while malaria is common. 7.21. The Bondo fishing community (Uhanya fish landing bay) said that the only source of drinking water is the lake. Some people do not boil drinking water, but the majority does, and even a small percentage uses chlorine. They said that unboiled water from the lake causes typhoid, diarrhea and vomiting. The majority has pit latrines, and the majority uses them. The ones who do not use is because they traditionally cannot share toilets with designated people (e.g. with wifes mother) or if a toilet is too near the boys simba (hut), the parents cannot use it. Toilets cannot be dug on swampy and sandy areas, as in Kayomo area. 7.22. Although most people in Maranda division are aware of the benefits of boiling drinking water, very few do so. They argue that boiled water loses taste. Most households keep drinking water in traditional pots for cooling. The households are aware of the need for clean sanitation, and have toilets. The tradition is that parents and grownup siblings (especially married sons and their families) should have separate toilet facilities. 7.23. Some of the constraints to improvement of health and nutrition in Garissa include lack of clean and safe drinking water, poor management of environment and sanitation, lack of designated garbage disposal sites, and lack of proper latrines particularly in the rural areas. The strategies should therefore include provision of safe drinking water and conducting training on proper hygiene and sanitation. 7.24. In most of Kilifi district, sanitation coverage is high, but very low in Bamba and Ganze (hence the common reference to kajembe mkononi hoe at hand). Plan International has undertaken training and awareness on sanitation in some areas of the district. 7.25. Bogarash village has clean piped water. Very few boil water before drinking because they assume the piped water is already safe. Only about half of the homesteads have pit latrines. Mothers make sure that they wash their children regularly. 7.26. The residents of Dera village reported that some of the areas have access to piped water where the community members pay KSh 5 per 20-liter of water. During dry spells, those without access to piped water travel up to 6 km to get water. Walking long distances in search of water drains the energy levels of women. Most households do not boil water before drinking despite the awareness created through community resource persons e.g. CHWs. Only an estimated 1% of the households have access to a toilet. 7.27. The main water sources in Mwingi district are unprotected. The water is contaminated, which explains the high incidence of diarrheal diseases. Sanitation coverage is not very high. Although people are aware about the need to drink safe water, disposal of waste and promotion of personal hygiene, practice

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has been poor. This has been explained by the extreme water scarcity, which makes water availability more critical than the question of its safety/quality. 7.28. The community members in Mwingi complained that the water consumed in the community is polluted. Humans share the water sources with animals. Most families have toilets (about ) while the rest use bush. Although most community members understood that unsafe water should be boiled, they did not boil water as they felt the process was tedious and time-consuming. They indicated that they always wash vegetables before cooking, wash hands before handling food, and wash fruits before eating. 7.29. The Kibera community said that they drink treated tap water, but do not boil before drinking since they assume it is safe. There is usually an outbreak of waterborne diseases (e.g. cholera, typhoid, diarrhea, dysentery and skin rashes) especially among children due to dirty water from rivers and contaminated pipe water (in case of burst pipe, thereby water mixing with sewage). They consider it expensive to boil water. They proposed that the government should treat water properly to avoid the need to boil it. 7.30. The disposal of human waste is through pit latrines. The toilets are not regularly emptied (exhausted) when they get full. The pit latrines are within the settlement, which leads to poor sanitation. They also have flying toilets, where the waste flows on the surface when it rains. 7.31. There is poor drainage. The CBOs and youth groups involved in sanitary work in the village provide the community with polythene bags to dispose garbage but instead people dump waste in open spaces and the rivers. The male youth drain stagnant water in the paths in an attempt to control mosquito breeding. 7.32. The children in Kibera said that some of the common childhood diseases are scabies (caused by dirty conditions, especially not bathing for up to one week), eye infections (too much dust), diarrhea (caused by eating unclean food), ringworms, ear infection, measles, rickets and kwashiorkor. The children said that their parents could not allow them to boil water because of lack of cooking fuel (kerosene). The schools have no water at all, and children complained of lacking drinking water while at school.

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CHAPTER EIGHT

FOOD AND NUTRITION HOUSEHOLD CONSUMPTION OF FOOD

8.1. In Baringo, food produced is mainly maize and beans, with no surplus for sale. The quantity and quality of food consumed is not adequate. It is not nutritious as is mostly maize and beans and little vegetables and fruits. There has been no change in the types of foodstuffs consumed in the last decade. 8.2. The main types of food in Bondo district are fish (Nile perch and omena), vegetables (e.g. kale), meat (mainly local, but also import meat animals from other areas), beans and ugali. Most of the kale and maize is imported from outside the district. In most areas, the maize grown lasts for a maximum of 5 months, but Rarieda and Madiany grow relatively more maize and sorghum. Sorghum is mainly mixed with maize or dried cassava before taking it to the millers. The relatively more educated people prefer maize to sorghum. The consumption of sorghum has also declined due to change in tastes towards substitutes such as rice. It is felt that sorghum is less tasty compared to the substitutes. The community imports basic foodstuffs (e.g. maize), which implies that there is nutrition deficiency and lack of variety, especially during the dry season. 8.3. At the community level, there is poor dietary diversity and overreliance on fish and ugali as the main food types. Traditional foods that were rich in nutrients and were drought-resistant and diseaseresistant have been neglected. Most families cook fresh fish from the lake. 8.4. The normal breakfast in a community in Bondo is tea (with ugali, nyoyo or boiled potatoes) and uji (porridge). Lunch and supper consists of mainly fish, ugali and vegetables. The first plate is given to mzee (the household head), followed by boys, while girls eat with the mother in the kitchen. The mzee gets the highest ration. This feeding arrangement lasts to old age. 8.5. Twenty years ago, there was more income; so people ate what they wanted e.g. could not take a week without eating chicken, eggs or meat. However, these foods are currently almost nonexistent. Twenty years ago, the diets consisted of fish, ugali, sorghum porridge, potatoes, cassava and cow milk. There also used to be nyoyo (githeri) maize and beans but not anymore since maize and beans are very expensive, require a lot of cooking fuel, and require much maize per cooking. Currently, it is the same dish, less quantity, and there is no nyoyo. 8.6. During food stress, the main meal in Maranda division (Bondo) is ugali and omena. The ugali consists of maize and sorghum flour, as this is preferred to maize flour alone. The maize and sorghum ugali is heavy, and a small portion can feed more household members than plain maize meal. Cassava is also dried and mixed with sorghum to prepare ugali. Omena is a favorite dish at this period because it is cheap and easily available. Dagaa is used to prepare a wide variety of dishes, and the time taken to cook the fish depends on whether it is fried or boiled. In times of stress, the main sources of livelihoods are remittances from family members working elsewhere, and earnings from casual jobs e.g. bush clearing, charcoal burning and selling firewood. 8.7. Indigenous breeds of chicken are kept for home consumption. A chicken is slaughtered for a visitor, when a member of the family comes back home, or during a festive season e.g. Christmas. Consumption of dead carcasses is widely practiced, as the community trusts their methods of treating and preserving carcasses of dead animals to prevent transmission of diseases. Eggs are rarely eaten, and are normally allowed to hatch, as chicken is a favored delicacy. 8.8. The lack of adequate food almost throughout the year has led to child malnutrition, while lack of food diversity means poor nutrition for the whole community. There is high dependence on fish (tilapia and omena) for protein, and a general lack of vegetables. There is very little vegetable production except traditional varieties like osuga, mrenda and others which grow wild. During drought, vegetable prices are very high. The catch of Nile perch is high but it is mainly exported because the community has less preference for it compared to other types of fish.

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8.9. The traditional diet in Garissa comprised of meat and milk (taken fresh or fermented). The current diet consists of meat, milk, sorghum (either fried or pounded) and maize. Milk is drunk fresh or fermented e.g. kalba (fermented cow milk) and susa (fermented camel milk). Maize is pounded into grits and prepared with milk (to make ambula) or boiled together with beans to make githeri. Sorghum is pounded into flour or fried. Tea is a very popular beverage taken on average four times per day and with high concentration of sugar. There has been limited progress in diet diversification among the rural communities. In Dadaab and Liboi, vegetables are consumed because of the influence of refugees and outsiders residing there. There is a high incidence of anemia. Malnutrition is common because of underutilization of nutritious foods particularly vegetables due to cultural beliefs and taboos. 8.10. The types of food purchased by a Garissa community are maize, beans, sugar, milk, oil, meat, potatoes, spices, fruits (such as bananas, mangoes and papaw) and occasionally kales. The community perceives nutritious foods to include meat, beans and vegetables, although vegetables are rarely eaten due to cultural beliefs. For children the food comprises of milk, uji and eggs. About 25% of the community is capable of eating a nutritious diet. The women complained of husbands leaving home without leaving any provisions for food. 8.11. Many households cannot afford three meals a day. Breakfast consists of tea with sugar for adults; and uji made from maize flour enriched with milk for children. Lunch is mainly maize and milk, while supper is beans and rice. Many families cannot afford supper. One of the causes of malnutrition is poor diet e.g. taking strong black tea with ugali. 8.12. The common types of food in Mwingi district include githeri, muthokoi, rice, green grams, beans, meat, kinaa (a cake made of a mixture of sorghum/millet and milk), and millet/sorghum porridge. A small proportion (20-30%) of the population in the district can afford a nutritious diet. In the past, ugali was not a popular dish, but its popularity has been improving over time. The popularity of muthokoi is confined to the rural areas. Muthokoi is time demanding in terms of cooking, and is therefore accorded least preference in urban areas. 8.13. In a community in Mwingi, most of the members did not understand what was meant by a nutritious diet. Instead, they indicated that they eat food to fill the stomach. They indicated that even if they understood the concept of good nutrition, they do not have the capacity to provide such to their families. They indicated that out of those present during the community consultations, none of them could afford a nutritious diet. They argued that it would be foolhardy to strive to obtain a nutritious diet when they could hardly afford a basic provision of three meals a day. 8.14. The community members noted that there had been a change in the popularity of some meals over time. For instance, most families have shifted consumption from millet porridge (for breakfast) towards white tea (with milk). The community felt that the change in eating habits has been detrimental to their health since the food eaten in the past made people strong but now people are relatively weaker. 8.15. The community consulted in Kibera said it does not have proper knowledge of what is a nutritious diet, and said they eat to fill their stomachs. Very few could explain the meaning of a nutritious diet. All they said was that they eat kales, beans, and occasionally fish and fruits. They estimated that only about 2% of the people access a nutritious diet. Fruits are a dream to many. 8.16. The upper tea zone of Thika district grows food crops (maize, beans, avocados, potatoes and some bananas). The main food eaten is githeri (a mixture of maize and beans), carrots and potatoes. Ugali is also becoming popular and is normally eaten with vegetables and beans. The increasing popularity of ugali is because it is faster to cook in terms of time and fuel consumption because firewood is becoming scarce. They overcook vegetables. They also consume more cabbages than dark green vegetables and therefore lack some vitamins. This also leads to shortage of iron, and the lack of vitamins lead to frequent illnesses. 8.17. Adult malnutrition is low, as the staple food is githeri. In the public hospitals, there are diabetic cases that are not obese. In the public hospitals, health staff run the risk of advising some diabetics to eat less fat, which could make them go off fat completely if they currently eat meat rarely, say, once a month. If

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pancreas fails to produce insulin, diabetes sets in. However, private doctors observe a different diabetic population where obesity might come in. 8.18. In the last 8 years, weather has been very poor, and most people have therefore been feeding mainly on githeri and ugali. In the river valleys where arrowroots used to grow, the farmers currently grow crops which can fetch money (e.g. snow peas, kales, French beans). People have changed feeding habits e.g. away from arrowroots. People used to mash food with bananas, but now consumption of bananas is low, as most people grow them for sale or ripening. They have replaced bananas with Irish potatoes. Food has also become expensive and has less protein e.g. kale and ugali diet. 8.19. Some of the elderly men (wazee) of over 50 years are sick (diabetes and hypertension) probably because they no longer get the indigenous foods. For most old people, their children live far away from home (e.g. in towns) and visit them once a month, if at all. Unlike men, women can visit and stay with their grownup offspring for short or long periods, leaving their elderly husbands unattended. Many widows live alone after they lost their husbands during the Emergency or after. The common emphasis on women and children as vulnerable groups ignores the fact that old men are also potentially vulnerable in nutritional terms.

FOOD TABOOS
8.20. In a community in Bondo, women do not eat the tail or gizzard of a chicken; these parts are reserved for the household head or the eldest son if the household head is not in. However, women can eat the said chicken parts in the absence of any man in the household. 8.21. Some of the food taboos in Garissa include: women do not eat eggs; girls are forbidden from taking tea (it is believed that tea will make them fat); all types of birds (e.g. chicken), rabbits and fish are rarely eaten by any community members; and green leafy vegetables are for livestock. 8.22. The food taboos in Nairobi depend on the rural home (meaning ethnic group) of the index family or household. For example, among the Dholuo, a woman may not eat the tongue of livestock (e.g. cattle and goats). Among the Dholuo, Luhya and Gusii, the gizzard and back (tail) of chicken is reserved for men; while wings, neck, leg, liver and intestines are for women and children. Among the Luhya, children may not be fed on eggs, lest they become dumb; and women do not eat fish soon after delivery. Among the Gusii, old women do not eat chicken and eggs.

FOOD PREPARATION METHODS

8.23. The method of cooking vegetable in Baringo does not seem to denature food. For example, kale is first washed, cut, and then fried for 5 minutes. 8.24. In Bondo, the main type of cooking fuel in the rural areas is firewood, and charcoal in the urban areas. It is easy to get firewood in Maranda and Nyangoma divisions since they have a larger proportion of bush cover. In comparison, it is not easy to get firewood in Rarieda and Madiany divisions. A community in Bondo said that the main type of cooking fuel is firewood. They also buy charcoal from Uganda (delivered directly to the fishing town by boat). There is currently a tendency of semi-cooking foods e.g. omena. 8.25. The main process of food preparation in a Kilifi community is to boil (whether it is maize, cassava or other foods), and then add tomatoes and local vegetables e.g. managu, mchicha, mnavu, mchunga (wild lettuce known as muthunga in central Kenya). 8.26. The main types of cooking fuel in Mwingi include firewood, charcoal, kerosene, and gas (to a small extent, in urban areas). Wood and charcoal are available locally, and some is sold to neighboring districts/towns. Commercial charcoal production is discouraged due to concerns of environmental conservation. It is therefore Government policy in the district that charcoal should only be harvested from dead wood. In most areas, there has been serious forest depletion by commercial charcoal dealers.

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8.27. The food eaten in Kibera comprises of kale and ugali and in rare cases githeri. There are problems with food preparation methods. The githeri is boiled and salted ready for eating and very few fry it. Kale is cut then washed, thus washing away most of the nutrients. This is preferred because it is an easy meal to prepare. Some people even go to the extent of boiling the sukumawiki for about 5 minutes (and throw away the water) so that the green color is washed off. Others fry it for over 20 minutes ndio iive mzuri (overcooking). Due to the high cost of cooking fuel (charcoal and kerosene), households prefer foods that cook fast, which has led to reduction in traditional foods such as githeri. 8.28. The ministry of agriculture and livestock development in Nairobi promotes food security through indigenous and underutilized foods (such as soya, cassava, sorghum, millet and traditional vegetables), food processing (e.g. sorghum processing which promotes digestibility), technology that saves time and energy (energy saving jikos), diversification of eating habits, and kitchen gardening and keeping small animals. 8.29. The promotion of consumption of indigenous food in Nairobi is picking up, although most people still eat ugali, sukumawiki, meat or fish. Most people do not prepare the food in the right way. Some people buy ready chopped vegetables where nutrients are lost while washing, and tend to overcook vegetables. In addition, the common use of paraffin for cooking is a source of air pollution in poorly ventilated houses, and the fumes get into the food. Finally, there is a shift to fast cooking foods due to cost of fuel and the short time available for cooking, thereby avoiding cooking foodstuffs like maize and beans. 8.30. In Nairobi, one of the major constraints to improvement of nutrition is lack of knowledge and failure of the relevant authorities to attach sufficient importance to nutrition issues. Consequently, funding and facilitation for such programmes are scarce. Secondly, nutrition is not incorporated in the national HIV/AIDS programme. The component of nutrition is not recognized or internalized. In order to respond to the above concerns, it is necessary to (a) reorganize and harmonize the nutrition units in government and give them specific guidelines, (b) equip doctors and nurses with nutrition knowledge and how to incorporate the knowledge in their activities, and (c) boost economic growth and household incomes as poverty does not allow them to have proper diets. 8.31. The public health officers in Thika said that they educate people on proper diet and all aspects of health, and food hygiene all the way from planting to storage. They sensitize people on the need to avoid overcooking, while undercooking may be dangerous in case of meat as parasitic worms (e.g. liver flukes and tapeworm) may survive. Overcooking of vegetables destroy vitamin A; while overcooking meat denature (destroy) proteins. Food may also be prepared under unhygienic conditions e.g. cutting of vegetables may cause typhoid if not cleaned or if washed with polluted water. 8.32. The ministry of agriculture in Thika assists communities in environmental conservation through energy-saving jikos. This encourages mothers to cook foods they were not cooking before (e.g. githeri) by reducing cost of fuel. The fireless cooker can release womens labor since it needs no attention. There is less denaturing of food when you use the fireless cooker, and thus better preservation of nutrients. Some households have taken the production of fireless cookers as a business, thus assisting in social marketing (of the cookers) in their normal pursuit of commercial interests. There is over 60% adoption of energysaving jikos. 8.33. In Thika, they normally overcook vegetables when they should do it for only 10 minutes. They are also supposed to wash vegetables before cutting (not the other way round). In the urban areas, there is a habit of shredding vegetables before selling them, and are cleaned again when the buyer reaches home. There is an increase in obesity and diabetes because people have become more sedentary (less exercise). There is malnutrition especially in the flower farms and coffee estates among the children of the workers. 8.34. Public health officers are in charge of inspection of meat and all types of food. However, the veterinary department inspects animals slaughtered in Thika town, while the ministry of health is in charge in the rest of the district. The veterinary department only inspects meat at the slaughterhouse while health staffs follow up to the retail level. The Public Health Act vests power in health staff to prosecute offenders in a court of law, but the veterinarian has no such powers.

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INTRA-HOUSEHOLD CONSUMPTION

ELEMENTS

OF

FOOD

PRODUCTION

AND

8.35. In Baringo, women and children take care of livestock when grazing around the homes. However, when there is drought, men take livestock to where there is pasture. In crop farming, both men and women are involved although it is mainly women. Household chores are the sole responsibilities of women and girl children. Child labor does not affect their education because families have small parcels of land to work on. 8.36. In Baringo, the main planting season is March-April, and harvest in August. Thus, food is available in August-December while food stress is mainly during January-May. In a household, men are served first followed by children and women last. During food stress, women are most affected, especially elderly women. Men are well fed and at times sell livestock to take care of themselves at the market centers. Milk is mainly given to young children. 8.37. The daily calendars drawn by the communities show that, men normally work very few hours per day e.g. in farming or herding. Women on the other hand are responsible for all household chores (e.g. cooking and other aspects of home making), milking cows, grazing cattle, farming, fetching water and firewood, going to the market, and childcare. The male youth are also involved in farming. However, due to the high levels of unemployment, the youth are idle most of the time, and would prefer to be busy doing something. 8.38. The main types of business in a Bondo fishing community are fishmongers, fish hawkers, hotels and bars, general shops, and food sellers from Uganda (who sell up to the retail level to individual consumers). Young women are involved in small-scale businesses e.g. selling tomatoes and frying fish for sale. Young men are in fishing as employees; old women are only involved in farming; and old men are in fishing and burning charcoal. There are no jobs for the youth, even those who have completed the secondary school cycle. The people who look after livestock are paid workers since children go to school. Mothers are in charge of farming, and are sometimes assisted with paid labor using ox-plough. The youth (boys) go to look for jobs. They do not assist their mothers in farming when young, but may assist after completing school. 8.39. In a typical household in Garissa, the head of household (the man) and other male members are served first, followed by children, and lastly the mother. In fact, the best and sweet foods are for the father. The famous nyirinyiri is a delicacy but is only reserved for men. The preserved meat can last for up to one year. This practice is so inbuilt that even the children know that they are not supposed to eat such foodstuffs. A husband is never aware that her wife has missed a meal and is a taboo for a woman to reveal that she has missed a meal. This only becomes evident when, for instance, she falls sick and it is diagnosed that she is anemic and need blood transfusion. 8.40. Communities in Kilifi said that children start working at an early age, but as boys grow older, they reduce their involvement in farming activities to imitate their fathers. There is child labor e.g. girls working as housemaids and in some cases their salaries are paid directly to their mothers. Boys normally work in the shopping centers selling small items e.g. groundnuts. 8.41. In Kilifi, children are most affected during times of food stress because they eat the same meals as adults and consequently experience shortage of essential foods like milk. Livestock does not appear to feature in the diet and is mostly for commercial use. 8.42. Both men and women in Bogarash work together in the farms, although there is a tendency for women to spend more hours in farm activities than men do. The children also assist in the evenings (after school) and during weekends and school holidays. The food eaten is the same for all family members including the number of meals per day. A typical meal pattern would be breakfast (black tea, cassava or leftover ugali) and lunch/supper (ugali or cassava with fish or additional vegetable made with coconut milk). 8.43. In general, every member of the family in Mwingi is involved in agricultural activities. However, there is segmentation of labor, with men involved in activities requiring effort (such as ploughing and opening up bushes) while women and children take part in activities that are time-intensive (planting,

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sowing seeds, weeding, harvesting). The postharvest management of food is by women. During August and September, boys may be withdrawn from school to scare birds from the sorghum and millet crops. The annual farm calendar in one community shows that men, women and children are responsible for preparing shambas, planting, weeding, guarding the crop from birds and wild animals, and harvesting; men construct silos and clear bushes; while women cut and transport thatching grass for silos. 8.44. During times of food stress, Kibera people said that the women and children may eat less or go hungry for the men to eat. One of the coping strategies is to reduce the rations eaten. When they get some money, they use all of it as if there is no tomorrow. They do not normally keep stocks for a rainy day. The children said that almost all children have no plan of what to during holidays and weekends. A very large number, especially boys, have nobody to guide them on what to do. However, girls have no time to play due to heavy demands of household chores which takes them until evening. Most parents and guardians leave their houses very early in the morning (5 am) and leave the responsibility of all household chores to their daughters.

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CHAPTER NINE

COORDINATION OF NUTRITION ACTIVITIES INDIVIDUAL LEVEL

9.1. The human rights approach to programming entails analyzing coordination of activities right from the individual and household levels to national and international levels. The most extreme case cited was the need for international cooperation in ensuring local food security (fishing in Bondo) by defining territorial rights in the lake as the fishermen reported cases of harassment by a neighboring country while fishing. At the individual level, there were cases where the instinct of self-preservation was not evident. This was most evident in the case of HIV/AIDS where it was reported that there was high awareness in all districts, but little by way of behavior change. The members of Akorino and Kavonokia religious sects do not take their children for immunization.

HOUSEHOLD LEVEL
9.2. At the family or household level, there was coordination in some cases, but in other cases the household was at war with itself. This was most evident in the intra-household allocation of labor (gender and age divide) and food (mainly gender divide), lack of improved diet for pregnant and postpartum mothers, and lack of change in workload during pregnancy. For example, one of the reasons cited for low agricultural production in Bondo was that the youth do not want to soil their hands (leaving farming to elderly men and women). In most communities, one of the short-term coping strategies cited was maternal buffering, defined as the practice of a mother deliberately limiting her own intake in order to ensure that children usually recently-weaned toddlers get enough to eat (Maxwell, 1996). 9.3. A district departmental head in Kilifi reported that almost all children start working at an early age, but as boys grow older, they reduce their involvement in farming activities to imitate their fathers. There is child labor e.g. girls working as housemaids and in some cases their salaries are paid directly to their mothers. However, in Bogarash, both men and women work together in the farms, though there is a tendency for women to spend more hours in farm activities than men do. The children also assist in the evenings (after school) and during weekends and school holidays. 9.4. In Mwingi, there is segmentation of labor with men involved in activities requiring effort (such as ploughing and opening up bushes) while women and children take part in activities that are time-intensive (planting, sowing seeds, weeding, harvesting). 9.5. Children in a community in Kibera said that most of them, especially boys, do nothing other than play ballgames near the river. However, girls have no time to play due to heavy demands of household chores which takes them until evening. Most parents and guardians leave their homes very early (5 am) and leave the responsibility of all household chores to their daughters. 9.6. In times of stress, one of the sources of livelihoods in Maranda division, Bondo, is remittances from family members working elsewhere. In Mwingi, a community reported that remittances formed an important source of income. In most cases, the recipients were mainly spouses. It was not a common practice for grownup children to remit money to their parents. However, in Thika, there is some neglect of parents and the old. For most old people, their children live far away and visit them once a month, if at all. Unlike men, women can visit and stay with their grownup offspring for short or long periods, leaving their elderly husbands unattended.

COMMUNITY LEVEL
9.7. The moral economy of the peasant was evident in the type of sharecropping reported in Maranda division of Bondo district. The land holdings are in most cases fragmented a family can own two or three parcels in different places. Some people lease out some of their land due to poverty or if they are unable to till all their land. The common arrangement is for the lessee to plough the whole parcel of land, and then the parcel is equally split between the lessor and the lessee. Thereafter, each one of them sows, weeds and

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harvests own produce for the season, after which the land reverts to the owner. This process can be repeated over many seasons. 9.8. The youth at Uhanya beach in Bondo did not have any registered organized group, and those formed in the past had collapsed. The youth argued that the groups were poorly organized due to lack of training and exposure. Some of the members did not understand the benefits they could derive from organized groups and associations. 9.9 The youth in Kibera reported that they are neglected because they are poor and the community has no trust in them. The youth has initiated groups in the community for entertainment, but are not paid when they perform. The chief appoints the village elder directly, who is taken to work in another village where he is not familiar with the local issues. Consequently, the youth find it difficult to raise their specific problems with the village elders. The NGOs tend to misuse funds in the name of developing the community and hence do not complete all planned projects. In addition, the NGOs do not deal with the youth groups directly. 9.10. The youth believe that the elders (wazee) are in charge of sanitation because they lack trust in the youth. The CBOs and youth groups involved in sanitary work in the village provide the community with polythene bags to dispose garbage but instead people dump waste in open spaces and the rivers. The male youth drain stagnant water in the paths in an attempt to control mosquito breeding. 9.11. The role of TBAs featured in every district in their advice to mothers during antenatal care, referral of pregnancy complications to hospital, and assistance during delivery. For example, in Garissa, it was reported that the majority of deliveries occur at home with assistance of trained TBAs because of long distances to health facilities. 9.12. Most deliveries in the Nairobi slums take place at home sometimes with the help of TBAs, mainly because the mothers cannot afford the requisite maternity fees. Pregnant mothers do not encounter many problems since any condition that may pose a problem (e.g. high blood pressure) is detected early enough and referred to hospitals by the TBAs. However, there may be capacity gaps in the training of TBAs. For example, in a Nairobi slum, TBAs talked of advising the mothers to introduce fruits as early as a month or two after birth. 9.13. Governance at the local level was also cited as one of the constraints to development in Thika district, namely, the mismanagement of cooperative societies that has led to a decline in crop and livestock production.

GOVERNMENT DEPARTMENTS
9.14. Beyond the household are government departments, civil society organizations (e.g. NGOs and CBOs) and churches. The coordination between individuals and households on one hand, and the rest of the system on the other, was mixed. Office of the President 9.15. There has been coordination between the National Aids Control Council (NACC) and CBOs in support of community-based programs on HIV/AIDS, especially home-based care. This was cited by local communities in Baringo, Bondo, Mwingi and Thika. The community-based programmes have also solicited support from other agencies e.g. unspecified Germans (in Baringo), Futures Group (in Bondo), churches (in Mwingi and Nairobi), and churches and private companies (in Thika). The organized groups deal with home-based care of patients and orphans, and solicit for cash supported by written proposals, or in kind (e.g. private companies in Ruiru). It was difficult to classify ACTIONAID activities in Baringo, since its programme is implemented entirely through the umbrella CBOs in the programme area. Normally, the infected are encouraged to stay within their families and the orphaned children to stay with relatives.

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9.16. In case of nutrition and HIV, very few community members in Thika know that there are drugs to reduce the chance of mother-to-child transmission during birth. In addition, nutritionists are not invited by medical personnel to advice the HIV-positive people on nutrition. 9.17. According to communities in Baringo, Garissa, Kilifi and Mwingi, there are community-based food relief committees, which are involved in the identification of beneficiaries and the actual distribution of food. In Mwingi, for example, coordination has improved through identification of lead agency to coordinate all relief efforts in the district, introduction of food-for-work (mainly on improvement of infrastructure and soil conservation), and community involvement in targeting and food distribution. Department of Agriculture 9.18. The relationship between home economists (in the department of agriculture) and the communities was generally positive. For example, in Baringo, the CHWs and nutritionists provide information on nutritious diet for those infected with HIV/AIDS. In Mwingi, there are programmes aimed at minimizing food insecurity and improving nutritional status through public education on food management and energy saving. The two most notable programs are (a) promoting consumption of sorghum and millet using simple innovative products, and (b) promoting the use of cowpea leaves through preservation. The target groups have been women groups who are trained in these methodologies so that they can train their group members. These programs have been very successful since farmers have readily accepted these messages and are practicing them. 9.19. It was reported that, in Baringo, there is no regular assistance in food production, but in 2001, seed for sorghum, cowpeas, beans and maize were given in response to the 2000 drought. During community consultations, it was recommended that there should be more emphasis on environmental conservation (soil and water) for sustained food supply; fruits trees be planted in school compounds (for learning and to supplement the micronutrient requirements of the children); and introduce 10 am snacks for preschools, nursery, and up to primary Standard 3. 9.20. The communities reported that the quality and availability of agricultural extension services were inadequate. In Garissa, some causes of food insecurity were cited as limited extension coverage due to the vastness of the district, nomadic lifestyle that makes it difficult for continuity of dissemination of extension messages, and low funding of agricultural activities. In Kilifi, contributory factors to low productivity were cited as inadequate extension services; and lack of technology transfer within households as men are trained but do not pass the knowledge acquired to the women. 9.21. The veterinary department (in the ministry of agriculture) inspects animals slaughtered in Thika town, while the ministry of health is in charge in the rest of the district. The veterinary department only inspects meat at the slaughterhouses while health staffs follow up to the retail level. There is room for jurisdictional disputes since the Public Health Act vests power of meat inspection on health staff. Department of Health 9.22. In most study areas, the community members indicated that they do not receive any information on nutrition (apart from mothers through MCH clinics). However, in a community in Kibera, they reported that the main health center does not have a nutritionist and therefore the nurses only try to give basic information on nutrition. The community is therefore able to differentiate between a nurse and a nutritionist. In order to respond to the above concerns, the district departmental heads in Nairobi recommended that the nutrition units in the Organization of Government be reorganized, harmonized and given specific guidelines; intensify and expand nutrition programmes; and equip doctors and nurses with nutrition knowledge (and how to incorporate the knowledge in their activities). 9.23. In some cases, there are lapses in coordination between various sections in the ministry of health. For example, in Bondo, the public health office rarely undertakes testing of water quality since the Government chemist charges a lot of money for testing water. Apart from coordination, there were issues of capacities of nutritionists to undertake the assigned activities (e.g. inadequate training and exposure for both the district nutritionist and the community health workers), difficulties in implementation of activities

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(e.g. lack of funds for rehabilitation of critically malnourished children and for demonstration of best practices), and understaffing. At the district level nutrition issues are not seen as priority even in the allocation of cost-sharing funds. Department of Social Services 9.24. The department of social services in Thika undertakes community mobilization for group formation on behalf of other agencies. They coordinate or request other departments (e.g. home economics) to visit the groups, say, on soya production, as this increases the economic viability of the groups. The department acts as the midwife of most community-based programs, although the host government departments and NGOs do not normally involve the department of social services after the programs take off. 9.25. The DANIDA-funded community based nutrition programme is implemented in Baringo and Bondo. It is coordinated by the department of social services, and works with the relevant government departments (e.g. water, education, planning, and agriculture) and civil society organizations. Apart from community initiative funds (grants to community activities), the programmes main achievement is to build relationships between government departments, some of which should already be there if the government departments were empowered (through provision of resources for operations and maintenance) and coordinates their activities at the local level. The program also assists to build relationships between the government departments and the communities, and facilitates community-based government programs on nutrition and related development issues. Department of Education 9.26. Most districts reported that the nutritional value of various foods and the importance of balanced diet are taught in school as part of the curriculum e.g. in Bondo. In Garissa, pupils are introduced to the concept of balanced diet and the main food groups at Standard 3-4, and HIV/AIDS has been integrated in the school curriculum (where pupils are taught on the basic facts and coping strategies). In Mwingi, nutrition is taught at secondary school level through the Form 2 home science syllabus. The aspects included in the syllabus include food nutrients, nutritional deficit disorders, and food fortification. Coordination between Government Departments 9.27. In Thika, the maternal child health nutritionist goes for outreach clinics in areas where there are no nutritionists or where the health center is far to give talks on nutrition, and trains mothers in kitchen gardens as a form of community-based nutrition rehabilitation. The topic of nutrition is included in all training of community health workers in the district. The cooperation between the departments of agriculture and health is evident in the kitchen gardens established in Kirwara health center and Mitumbiri dispensary for demonstrations. 9.28. The nutritionists assisted in training preschool teachers on nutrition and public health issues, but were not involved in follow-up and supervision after training. The training on all health and nutrition issues took only two days, and the nutrition section was not consulted on what they should train on. Such training normally takes a week, with follow-ups after three months. 9.29. The nutrition section cooperates with the home economics staff of the ministry of agriculture to train women groups on home economics and nutrition. However, it appears that there is no open relationship between the NGOs and government departments in Thika, since the government departmental heads found it difficult to explain in detail the operations of the local NGOs. They were only able to explain the link between government departments and the NGOs, especially in cases where government staffs are used as trainers. 9.30. In Nairobi, one of the major constraints to improvement of nutrition is lack of knowledge and failure of the relevant authorities to attach sufficient importance to nutrition issues. A significant proportion of government officers do not visualize the importance of nutrition in the health of an individual, and the need to teach people about food production, preparation, storage and consumption.

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Consequently, funding and facilitation for such programmes are scarce. Secondly, there is shortage of personnel, especially at the Nairobi City Council health centers. This does not allow for proper dissemination of health and nutrition information. Thirdly, nutrition is not incorporated in the national HIV/AIDS programme. 9.31. The recommendations from district consultations in Bondo included the need to sensitize district heads on the role of nutrition in development, involve the district nutritionist in distribution of relief food, train more CHWs so that they can offload some activities from the district nutritionist, and emphasize growing nutritious foods rather than relying on manufactured supplements. 9.32. The NGOs operating in Garissa cited constraints to food and nutrition to include limited collaboration among stakeholders, lack of knowledge on food utilization, low coverage by government departments, socio-cultural beliefs (e.g. mothers are not involved in key decision-making), poor access to health facilities and water, inadequate support of nutrition activities, and poor feeding habits at the household level. They identified the necessary strategies to include empowering women through income generating activities, collaboration by relevant actors and coordination of their activities at the local level, deployment of more nutritionists, allocation of adequate funds to support nutrition activities, harmonization of activities of home economists and nutritionists, facilitating training on nutrition at community level, and including nutrition in the training curriculum for nurses. 9.33. Some of the recommendations from Baringo include the need to use women groups in the implementation of development programmes, improve production of indigenous crops, put more emphasis on environmental conservation (soil and water) for sustainable food supply, encourage food preservation especially among pastoral communities, plant fruits trees in schools for learning and feeding children, and introduce chicken and rabbits. In Bondo, there was a further recommendation to sensitize men to be more directly involved in food production.

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ANNEX ONE: CHECKLIST OF SOME ISSUES COVERED IN THE COMMUNITY CONSULTATIONS

GENERAL POVERTY SITUATION Main Economic activities Available resources Definition of poverty Causes of poverty Intra-household elements of poverty Attributes of wealth groups Stratification of the community (% in each wealth group) - optional Changes in the poverty situation of each wealth group Causes of changes in the poverty situation Coping strategies to the poverty situation (in order of importance) separate traditional and non-traditional (e.g. Government and civil society) Allocation of labor by age and gender Land sizes FOOD SECURITY Seasonal and long-term weather changes Main crops grown in the area (food and cash crops) Main types of livestock kept in the area (including small stock) Seasonality of food production Seasonality of production of livestock products (e.g. milk, eggs, slaughter of small stock) What is the labor allocation in the household with respect to food and livestock production, by age and sex of household members? Does child labor in the family parcels affect their education? What are the main expenditure categories at the household level? What proportion does each expenditure category take? Do expenditures on health affect food security? Do expenditures on education have major bearing on food security? Are food sales used to fund education and health? Do food purchases lead to shortages elsewhere (e.g. health and nutrition), or conversely food sales used to finance health and education? Meals by each individual per day (men, women, children)

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Quantity and quality consumed by each individual (breakfast, lunch, supper) The contents of each meal (quality and quantity) Methods of food preparation (for each type of meal) Are there times of food stress (shortage)? Which groups are most affected? (Include intra-household elements) How do households cope with food shortage? (Long-term and short-term) Change in access to food in the last 10 years (production, sales, purchases, consumption) What does the community understand by a nutritious diet (by specific age and gender groups)? Roughly, what proportion of families in the community affords a nutritious diet? Where does food come from? How much is from own production and how much from food purchases (specify the main types of foods along the seasonal calendar)? If food relief is regular, it should be captured. Have there been changes in types of foodstuffs consumed? How have the changes affected peoples lives (e.g. health)? What proportion of food consumed do they produce themselves? (By type of food crop) Is it possible to produce more (explain)? Do people receive assistance to increase food production (e.g. extension services, provision of seeds)? Is the community able to market any surplus? (When and why) If food is sold, what is the money realized from the sales mainly spent on? Are there seasonal variations in purchased food and prices? Do community members who work elsewhere make remittances to their families? If yes, who remits and who are normally the recipients? What are the remittances mainly spent on? FOOD AND NUTRITION Feeding of pregnant mothers include traditional beliefs and practices Proportion of pregnant women who attend antenatal clinics, and why others do not attend Iron supplementation of pregnant mothers Maternal health and nutrition advice during pregnancy, and who provides the advice (include feeding, malaria prevention and treatment, anemia) Child health and nutrition advice during antenatal and postnatal clinics (include malaria prevention and treatment, breastfeeding, complementary feeding and weaning, causes of diarrhea and its management, deworming) Womens workload during pregnancy and lactation Proportion of children born at home

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What is the proportion of low birth weight children (less than 2,500 g)? Are there many children who die in the first month after birth (and causes)? Feeding of postpartum mothers (after birth) Hours to first breastfeeding (include colostrum) including mothers knowledge and beliefs Months exclusively breastfed and reasons (knowledge, attitudes and practices) Months children breastfeed (separate boys and girls) Immunization schedule (knowledge, extent followed, reasons) Complementary feeding (age introduced, types, quantity and quality) Weaning foods (age introduced, types, quantity and quality) Major childhood diseases and how managed (include traditional and modern methods and the sequence of health seeking behavior) How do mothers identify malnourished children? What actions do they take, and at what point are the actions taken? Do mothers take children for growth monitoring and promotion? If yes, what proportion of children is malnourished? What advice and support is provided to prevent malnutrition? Do mothers follow the advice? Feeding patterns of children 1-5 years Feeding of primary school-age children (6-13 years) Feeding of adolescents (13-19) Feeding of young women Feeding of young men Feeding of older women Feeding of older men Does the community receive any nutrition information? Who provides the nutrition information, and what types of nutrition information are provided? In addition, where and how? Major adulthood diseases by gender, their management and impact on household and community What are the main sources of water? What type of water is available? Do animals and humans use the same water sources? Are the water sources polluted? What can be done to prevent pollution of water sources? Do the communities understand about safe water? Who delivered messages about safe water? Are the messages followed? What are the main problems related to water and sanitation (include type of toilets and families with access to safe sanitation)?

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Do members of the household boil water before drinking? Personal hygiene practices (e.g. bathing, cleaning clothes), washing hands (e.g. after visiting toilet, before meals), and food hygiene (washing fruits and vegetables, cleaning utensils for food preparation and service, covering food, food storage) NUTRITION AND HIV/AIDS What does the community know about HIV/AIDS? What are the most vulnerable groups in the community? Prevalence of HIV/AIDS by age-sex groups Has the community noticed an increase in the incidence of HIV/AIDS? If yes, how are they dealing with this? Does the community receive information on HIV/AIDS and from whom? Does the community understand the messages being delivered? Has there been change in behavior as a result of the messages? Knowledge of methods of transmission and prevention, especially the use of male condom What family and community care exists for the infected? Are there community or civil society organizations involved in their care? Community beliefs about causes of HIV/AIDS Community beliefs about routes of transmission of HIV/AIDS and how it affects interactions between the infected and those who are not Effect of infection on the immediate family; how does it impact on the welfare of the household? What kind of nutrition information is provided specific for HIV/AIDS patients and by whom? Feeding practices of the infected (knowledge, actual practice, and reasons for any discrepancy) How can the transmission of HIV from mother-to-child be minimized? (Knowledge, actual practice in the area) Are children of infected mothers breastfed? (Including local beliefs, knowledge, practice) NUTRITION AND EMERGENCIES Has the community received relief food in last 5 years? Year, type of food, how much, frequency, providers, type of relief (food-for-work, other) Did this relief food meet nutritional requirements? Who received the food? Was it targeted? Who was responsible for targeting? Has the availability of relief food led to dependency in any way? Is there an operational community relief committee? How was the committee formed? How has the committee performed? What is the gender composition of the committee? How often does the committee meet? Is there a school feeding programme? If yes, types of food, quantity and quality per child, whether for early childhood or primary education?

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ANNEX TWO: THE PARTICIPATORY TOOLS USED DURING COMMUNITY CONSULTATIONS

SEMI-STRUCTURED INTERVIEWS Focus group discussions (FGD) are aimed at discussing specified topics in detail with a small group of concerned people. This tool is particularly useful when applied to mothers in relation to, say, their nutritional knowledge (for self and child). Key informant interview is for specific individuals with specialized information e.g. extension workers, schoolteachers, midwives and nurses. Their perspectives may complement or differ from that of the community. TOOLS USED The village resource map (the resources in the community) shows the location of various resources in the village in relation to local infrastructure e.g. roads, resources (such as water), land utilization (say between cash and food crops, and other forms of land use), and amenities (such as churches and government offices). If a village has a large number of households, it may be necessary to cluster the individual dwellings. A village map can also be used to countercheck information from the wealth-ranking (wellbeing) matrix. The village resource map exercise should be carried out with the whole community before splitting it into smaller FGD groups of, say, youth, men and women. The service map shows the distances of various institutions from the center of the community. The service map shows the distances from the center of the community to the service institution/facility. This should be discussed with the whole community. The Venn (chapatti) diagram shows the services they receive at the community level, the service providers, and the significance of each service to improving community welfare. The relative sizes of the different circles represent the importance of the institution to them while the position of the circle (close or distant) shows how often the community has contact with the mentioned institution. A wealth ranking matrix shows how different groups perceive their social and economic status. The first step is to ask the community about the criteria for assessing the wellbeing in the community, and then define the wealth groups in the community e.g. poor, middle and upper. This is followed by drawing a matrix with criteria on one axis and the wealth groups on the other axis. This is followed by asking the community to give an indicative number of households for each of the categories using, say, stones. The wealth ranking exercise should be carried out with the whole community before splitting it into smaller groups of, say, men and women. The problem ranking helps the community to prioritize their problems and needs. The community first lists their problems in a problem bag, and then the community ranks them either through stones (as votes for the problems) or the community does it through pair-wise ranking. The problem ranking will be conducted at the general community level. The problem analysis diagram interrelate various issues specific to food and nutrition. It starts by showing a selected main problem at the center of the diagram, draws links to the different causes of the problem below it, and its possible effects above it. This is followed by asking the potential solutions to each problem and what is necessary to achieve each of the mentioned solutions. A transect walk can be used to verify the information given by the community. It involves taking a walk through the community with a few community members, discussing with community members what is seen, and finally drawing a transect diagram. There might be no need for the transect walk if the village resource map and service map have been prepared in an exhaustive and inclusive way.

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Timelines assist to trace the root causes of the problems they are encountering, and includes short-term (seasonal within a one-year timeframe) and long-term or historical calendars. The long-term (historical) calendar shows historical profiles and trend analysis and is used to discuss changes in availability of resources, changes in access to services, and major political or economic changes over time. The seasonal calendars will be used to show changes over one year, say, in food availability. There are also daily calendars (24-hour activity profiles) for women, for men, for youth, etc. Each sub-group should draw its daily calendar. The visioning matrix shows the situation ten years ago, the present, where they expect to be ten years from now under the present circumstances, and where they would desire to be ten years from now. This should also include the reasons for the change, and the interventions necessary to move to the preferred future. The visioning matrix will include environment (including weather patterns), food/livestock production systems, food/livestock production (including sales, purchases and consumption), food taboos specific to age and gender groups, allocation of labor in the household, food intake in terms of quantity/value and diversity, food preparation methods, fuel, water, sanitation, prevalence of diseases, childcare and support (breastfeeding, complementary feeding, weaning, food habits), and feeding habits (including intrahousehold elements). THE INTERVIEW SCHEDULE The interview schedule could begin with a session on introduction and village resource map, a session on community service map, a session on Venn diagrams and visioning matrix, a separate section on visioning matrix discussion, session on problem bag and wealth ranking, focus group discussions with men and women separately, and a final session on feedback session with the community. It is expected that key informant interviews will be conducted with, say, chief or his assistant, agricultural extension staff, primary school inspector or a head teacher, nurse, etc.

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BARINGO DISTRICT 1.
1.1

DISTRICT CONSULTATIONS
Introduction

Baringo district is located in the northern part of Rift Valley Province. It has an area of 8,655 km2. The district borders Turkana district to the north, Samburu and Laikipia districts to the east, Koibatek district to the south, and Keiyo, Marakwet and West Pokot districts to the west. In terms of length (North-South) and breadth (East-West), the district is about 210 and 100 km, respectively. Administratively, Baringo district is divided into 14 divisions, namely, Kabarnet, Marigat, Mochongoi, Mukutan, Selawa, Sacho, Tenges, Bartabwa, Barwessa, Kabartonjo, Kipsaraman, Kolowa, Nginyang and Tangulbei. The district had an estimated population of 286,643 people in 2001. The district is divided into 3 agro-ecological zones, namely, the highlands (Tugen hills), the midlands and the lowlands. The land tenure is individual ownership in the highlands, both individual and communal ownership in the midlands, and purely communal in the lowlands. The average farm sizes are 2-3 acres in the highlands. The average annual rainfall is 1,200 mm. Drought is a common occurrence in the district (severe ones occurred in 1994 and 2000). The highlands are conducive to crop and dairy farming because of the fertile volcanic soils and good rains; the midlands are inhabited by agro-pastoralists as rainfall is not adequate for crop farming; and the lowlands are mainly conducive for livestock rearing. 1.2 Main Economic Activities

The main economic activities are: Livestock production (pastoralism in the lowlands, dairy in the highlands and midlands, and beekeeping in the lowlands with about 60,000 beehives) Crop production (highlands, and irrigation schemes in the lowlands) Cash crop production coffee, pyrethrum and groundnuts in Tugen hills; cotton in Kerio Valley and horticulture (rain-fed in the highlands and under irrigation in the lowlands) Tourism (Marigat division Kampi ya Samaki, Lake Baringo and Lake Bogoria) The main food crops in the area are maize, beans and vegetables (kales, cabbages, tomatoes) in the highlands; maize, beans, sorghum, millet, cowpeas, green grams, cassava, sweet potatoes, weeds and onions in the lowlands; and finger millet in the transitional zone. About half of the food consumed is produced locally. The main cash crops are coffee, pyrethrum, groundnuts in the highlands (Tugen); cotton in Kerio valley; papaws, watermelons, mangoes in the lowlands under irrigation; and citrus, bananas, mangoes, guavas, and passion in the highlands under rain-fed farming. The main types of livestock are local breed of cattle (250,000), goats (900,000), sheep (250,000), camels (6,000), chicken, bees (60,000 beehives) and rabbits. The main planting season is March-April, and harvest in August. Thus, food is available in AugustDecember while food stress is mainly during January-May. In a household, men are served first, followed by children and women last. When there is food stress, women are the most affected. Men are well fed and at times sell livestock to take care of themselves at the market centres. Milk is mainly given to young children.

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1.3

Food Security

Poverty is generally defined in terms of food insecurity, and an estimated 80% of the population is food poor. Livestock is kept as a symbol of status, not for sale or slaughter. The number of wives and children is considered a symbol of status and wealth. The causes of poverty are: Unreliable rainfall, Recurrent drought and floods, Destruction of water catchments resulting to drying up of water ponds, The rough terrain, Lack of entrepreneurship and thus limited involvement in income generating activities, Insecurity, Communal land tenure (e.g. in the lowlands and part of the midlands), Poor marketing strategies for honey and horticultural products, and High rates of unemployment The poverty situation is getting worse due to increase in population (causing strain on the land and other resources), poor economic growth, diminishing water resources, and soils are becoming poorer. The coping strategies include: Moving livestock to other grazing grounds Migration to trading centres to wait for food relief Casual labor Reduce number of meals Change diet e.g. porridge instead of ugali (as porridge uses less flour) and honey in place of vegetables to eat together with ugali Look for wild roots and fruits Children sent to school if there is a school feeding programme Slaughter of small stock for home consumption, and may also consume dead livestock During dry spells, they slaughter small stock, mainly goats and to a lesser extent sheep. Some animals die during droughts and floods. Cattle-rustling is rampant during September-December when the initiates are released after one-month confinement. This is the period when most initiates get married and therefore raid cattle for dowry. The main household expenditures are food, health and education. Expenditures on health affect food security because it is shared between the two. Primary education is free, and most schools have school feeding programs which reduce the familys burden on food. There is no surplus food for sale. They sell livestock to fund other activities, especially food purchases and health. During food stress, prices of food are high. A reported 50% of the food is own-produced and the rest purchased. It is possible to produce more if water availability is improved. Food produced is mainly maize and beans, with no surplus for sale. There has been no change in the types of foodstuffs consumed in the last decade. There is no regular assistance in food production, but in 2001 seed for sorghum, cowpeas, beans and maize were given due to the 2000 drought. The quantity and quality of food consumed is not adequate. It is not nutritious as it is mostly maize and beans and little vegetables and fruits. During food stress, women are the most hit, especially elderly women. 1.4 Allocation of Labor by Age and Gender

Women and children take care of livestock when grazing around the homes. However, when there is drought, men take livestock to where there is pasture. In crop farming, both men and women are involved although it is mainly women. Household chores are the sole responsibility of women and the girl child. Child labor does not affect their education because families have small parcels of land to work on.

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1.5

Health and Nutrition

At the health centres, pregnant women are advised to improve diet by increasing intake of calories, proteins, and iron and vitamin A-rich foods. They are advised that foods rich in these nutrients are eggs, liver, meat, green leafy vegetables, fruits (with yellow, orange, red color) and milk. Iron supplementation is given to women at health facilities. However, actual consumption of all these foods depends on availability and access at home. Traditionally, pregnant women are advised not to overfeed, and specifically not to eat eggs because the unborn baby will be too big. They also continue with their daily activities, with no reduction in workload. This sometimes leads to premature births. However, women are fed well after delivery. The proportion of pregnant women who attend antenatal clinics was reported as 80%. Some do not attend because they are busy tilling the land; school dropouts do not attend because they do not want to be known that they are pregnant; and ignorance. Most deliveries (80%) take place at home because of long distances to health facilities, high cost of healthcare, TBAs are easily available within the community, and fear of harassment (unkind treatment) by nurses. It was reported that very few children die before the age of two and that most child deaths occur from two years onwards. Breastfeeding of newborns starts immediately for those born in health centres, but after two or three days for those born at home because they first start with herbal feeding to clean/clear the babys stomach. It was reported that the health of children who first receive herbal feeding was better than for those who were breastfed immediately after birth. The period of exclusive breastfeeding is short because they are very busy with economic activities. Women have knowledge on immunization, and follow the immunization schedule up to the end. Growth monitoring stops after the last immunization unless the child is sick. Complementary foods introduced after 3 months are uji, potatoes, and ugali softened with milk. The major childhood diseases are diarrhea, malaria, pneumonia and kala-azar; while major adulthood diseases are malaria, kala-azar and URTI. Kala-azar (visceral leishmaniasis or dumdum fever) is transmitted to man by sand flies, and invades the cells of the lymphatic system, spleen and bone marrow. Some of the local management of diseases include destroying anthills, smearing houses smoothly to cover all cracks, and sleeping on beds high above the ground (for kala-azar); and outdoor and indoor spraying, clearing bushes and using mosquito nets (for malaria). Mothers identify malnourished children by observing their body size, whether child is eating well or not, frequency of sickness, and by tying a string around the waist and wrist. If they realize that the child is malnourished they take it to a health facility. At the health facility, the nutritionist gives mothers nutrition information on how to feed their children and families. However, most mothers do not follow the advice because they may not afford the recommended food, lack of time to prepare the food, and reckless behavior e.g. drunkenness by the mother. 1.6 Water

Surface water sources provide 90% of the water needs and the underground sources the remaining 10%. The surface water sources are normally fresh while the underground sources are salty. The main sources of surface water (mainly in the highlands) are rivers, pans, dams and lakes. The underground sources (mainly in the lowlands) are mainly boreholes; animals and humans use the same sources and the water is polluted to a small degree. However, efforts are being made to prevent pollution through stopping encroachment of

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the rivers upstream. The implementation of the National Environmental Management Act will assist in managing settlements in the catchments areas. The communities have knowledge on safe drinking water and the need to boil water before drinking. The information has been received from health workers, but in practice they do not boil it. The main problems related to water and sanitation is shortage of water and that the water sources are polluted. There is also knowledge on personal hygiene practices but it is not followed. 1.7 School Feeding Programme

Out of the 357 primary schools, 355 are covered by the school-feeding programme, and the remaining two volunteered not to. The preschools attached to the primary schools benefit from the school-feeding programme. The rest of the preschools depend on their own arrangements. The types and amounts of food given are maize 150g/day/child, beans 40g/day/child and oil 5g/day/child. Due to the free primary education, more pupils have enrolled leading to food shortage. Such food shortages affect school attendance negatively and sometimes schools close down when there are delays in food delivery as the children do not come to school. The feeding programme improves enrolment and general performance of pupils. 1.8 Nutrition and Emergencies

The community has been receiving relief food for sometime now. Initially the method of distribution was according to World Food Programme guidelines where everyone received some food. From the year 2000, the target has been free rations for the most needy and food-for-work for the able-bodied. The method is working well and is reducing dependency. The relief food is not nutritionally adequate as it is only maize and beans. 1.9 Nutrition and HIV/AIDS

The communities know that HIV/AIDS is a killer disease. The vulnerable groups are youth in the urban areas and drunkards in the rural areas. However, the most affected group is adult men. Although there is high level of awareness due to activities of many agencies (e.g. NGOs and health workers) there has been minimal behavior change. The infected and orphans are supported by CBOs, NGOs and other organizations through food, drugs and education. They are encouraged to stay within their family set-ups and the orphaned children to stay with relatives. The disease has had a big effect in increasing household expenditures. The pastoralists in Baringo still believe that HIV/AIDS is caused by witchcraft. The CHWs and nutritionists provide information on nutritious diet for those infected with HIV/AIDS, but practice of the same depends on availability and access to food. A health nurse said that mother-to-child transmission of HIV/AIDS can be minimized through drugs administered to a mother just before birth, and exclusive breastfeeding without any complementary foods. 1.10 Christian Childrens Fund (CCF) in Kiture area

The programme started in the district in 1981 with setting up an agriculture demonstration farm, and rehabilitating mothers with malnourished children (1981-87). At any given time, there were on average 12 mothers with malnourished children who spent a period of 3 weeks at the rehabilitation centre. During their stay, they were trained on good nutrition, food security, health and hygiene, and safe drinking water. After 1987, CCF decided to start approaching the problem of malnutrition from the community level. They would identify the poorest households and enroll a needy child to benefit from the programme. Individual sponsors are then identified for each child who would remit to CCF a minimum of $12 per month for school fees.

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The households where the needy children came from benefited from other CCF projects such as passing the gift heifer project (in which a heifer is loaned to a member who passes it on to another member of the group after it gives a calf), supply of orange seedlings, micro-enterprise development, and food security. The programme so far has been successful because the communities have been empowered, children who have benefited have succeeded in life, and the incidence of poverty is reducing. The main challenges are high population growth, HIV/AIDS, drunkenness, and illiteracy. 1.11 World Vision Area Development Programme (ADP)

This programme is in three divisions, namely, Kabarnet, Sacho and Salawa. They mainly sponsor children to a maximum of 14 years in education each receiving $10/year, but sometimes they engage in other community development projects like construction of health facilities, classrooms, boreholes and spring protection. The areas of emphasis are education, heath and sanitation, food security, and emergency relief and disaster management. In 2003, they are introducing HIV/AIDS as a sector. Education is the main activity and they use schools as the focal points of development. Volunteer teachers follow up with the sponsored children. They have six clusters of between 16 and 32 schools each. The programme is set to wind up in 2007, and they have trained a CBO for each cluster to manage takeover in preparation for the phase-out. 1.12 Kabarnet Community Development Programme (KACODEP)

The NGO was started in 2001 to assist orphans and those living with HIV/AIDS. Funds started flowing in from February 2002 from the National Aids Control Council and some German friend. They mainly provide food (like finger millet, eggs, beans, green grams and milk), drugs and herbs. They also pay fees for the orphans, and so far have supported 78 orphans and 29 infected adults. The chairperson of KACODEP observed that people are getting de-stigmatized and are volunteering to be tested for HIV/AIDS. 1.13 Community Based Nutrition Programme (CBNP)

This is a DANIDA-sponsored programme under the department of culture and social services. The department of social services coordinates the other government departments (such as water, education, planning, agriculture, and information) and NGOs (e.g. CCF). The program is in three divisions. The main role of the programme is to mobilize communities to use their own resources in implementing their priority projects. In community projects, CBNP provides the expertise and contribute 50% resources while the community provides the remainder, although the officers on the ground feel that the community should provide between 25% and 30%. The communities are trained to solve their problems through participatory learning approach. They guide the communities to take activities they can implement on their own. The impact realized include starting shops to stock food, posho mills, dry farming (using water harvesting techniques), laying water pipes (CBNP bought pipes and community fixed them), increasing food production, and CHWs were trained on nutrition and to do growth monitoring. 1.14 ACTIONAID

This is an NGO operating in two locations from 2001, Kabutiei and Lawan of Barwessa division. Their main activities are within five thematic areas, namely, income-generating activities, health, education, food security, and water. ACTIONAID works with the umbrella CBOs in the programme area who identify the appropriate groups to be supported on activities related to the thematic areas.

2.

COMMUNITY CONSULTATIONS

The study team visited a community comprising of two sub-locations, Barwessa and Konoo of Lawan location, Barwessa division. They are mainly Tugen. There were three main criteria used to select the community. First, there are two main economic activities in Baringo district: crop farming and livestock

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farming. The community in Barwessa and Konoo sub-locations involve themselves in both activities. Secondly, there was no recent study carried out in this community, hence no risk of community fatigue. Third, since it was during the rainy season, the study team had to go to an area where the roads were passable. However, the study team encountered several problems during the community consultations. Since it was during the rainy and planting season, farmers were busy on the farms and were only available in the afternoon. On the second day, the consultations started much later because the agricultural extension officer was talking to farmers on planting and planting materials. The discussions with the women were cut short by the rains, and the study team had to wait until the rains subsided before it could hold discussions with the youth in their pool game room. Finally, the time was not enough to apply all the tools exhaustively especially the visioning matrix. 2.1 The Main Economic Activities

Their main economic activities are crop and livestock production, although they have been relying on relief food because of the weather conditions. The main crops grown are beans, finger millet, cowpeas, green grams, sorghum, cassava, sweet potatoes and groundnuts. The main livestock are indigenous cattle (zebu), sheep, goats and poultry. A part of the community land has been designated as a game reserve, which the community feels is in the most fertile area. There are quite a number of primary schools, secondary schools and churches, but only one dispensary with one clinical officer. The main problem is water and soil erosion. Most of the dams are proposed and the few operational ones are far from the area where the community consultations were undertaken. Though the schools are evenly spread, there are still children who travel far to school. Some services which the community feels are important but are not available are cooperative societies (for credit and marketing of cotton and cowpeas), while boreholes and irrigation schemes are inadequate. The community problems in order of priority are food; water; diseases, drugs for snake and dog bites; low incomes/poverty; communication (roads, public transport, electricity); secondary school fees; no free health services, no ambulance, only one health facility; low prices for cotton; soil erosion; and not enough teachers. Seasonal Calendar
Activity/Month Rainfall Land preparation Ploughing and planting Weeding Harvesting Animal diseases Human diseases Labor outside Ceremonies Pasture and water for livestock J F M A M J J A S O N D

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Daily Calendar
TIME 5.00 am 5.30 am 6.00 am 6.30 am 7.00 am 7.15 am 8.00 am 9.00 am 9.30 am 10.00 am 11.00 am 1.00 pm 2.00 pm 4.00 pm 5.00 pm 6.00 pm 7.00 pm 7.30 pm 8.00 pm 8.30 pm 9.00 pm 9.30 pm 10.00 pm 10.15 pm 10.30 pm 11.00 Lunch and rest Go to the farm Socialize Socialize Socialize Socialize Socialize Socialize Socialize Socialize Arrive home Take bath Take supper Take tea Wake up Wash face Take tea Delegate duties Farming/herding/leadership MEN WOMEN Wake up Light fire Warm water for utensils Sweep the house Prepare porridge Prepare tea for husband Wake up children and wash their face Children take porridge Bathe children and dress up Wake up husband Children off to school Warm water for husband to wash face Take tea with husband Milk cows Boil milk Wash utensils Start preparing lunch Set livestock free for grazing Go to fetch water Grazing cattle Lunch break Go to the farm Children go to graze Fetch vegetables/firewood Mother bathe Go to posho mill Bring livestock back home Cook vegetables/ugali Children do homework Children bathe Supper Songs and prayers Prepare for children to sleep Warm water for utensils Husband take bath Wash utensils Husband eat Prepare tea for husband Husband takes tea Go to bed Mother go to bed

Daily Calendar for Male Youth 6 am Wake up 8 am Go to the farm 1 pm Lunch break 2 pm Go to the farm 4 pm Leisure, pool, visiting, cards, darts, reading, bathing 6 pm Back home 8 pm Supper 9.30 pm Bed

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2.2 2.2.1

FOCUS GROUP DISCUSSIONS Women Group

The team met with a group of 21 women and discussed various issues including the daily calendar, quantity and quality of the food consumed, and general nutritional knowledge including traditional beliefs and practices. Some of the issues that came up are: Mothers start attending antenatal clinics from four months of pregnancy They receive iron supplements at the clinics The workload is not reduced until delivery Their diet does not change from that of other family members even during pregnancy However due to traditional beliefs, pregnant mothers are barred from eating the following: Dead goats whose lungs appear infected child will develop the same symptoms Livestock with infected ears - will affect hearing of child Livestock with skin disorders - skin diseases on the child Milk from snake-bitten cow or goat - bad luck Meat or milk of goats saved from the jaws of a leopard - may be bad luck Most mothers deliver at home. After delivery their diet improves as they take milk, ugali, wimbi porridge, honey, water, and slaughter a goat if can afford. The mother rests for one month. After delivery the baby is given water first then breastfed after several hours. After one month the baby is given cows milk, and at 4 months start taking porridge mixed with milk. Immunization schedule is followed, but there is no growth monitoring after completion of the immunization schedule. At 6 months other foods are introduced like ugali, and at 1 years start eating adult food. In vegetable (kale) preparation, they first wash, cut, and then fry for 5 minutes. Traditionally the mothers used to know malnourished children through: skin feels loose on pinching; child appears miserable; child takes long to start sitting, crawling, walking; no normal development; or lift the child and feel the weight. The main childhood diseases are pneumonia, malaria, diarrhea, colds and flu. The main adult disease is kala-azar. The largest proportion of expenditure is on food followed by health, then education. 2.2.2 Youth Group

A group of 33 youth (mainly boys) were met. It had just rained heavily and most of the girls had dispersed to their homes. The boys were interviewed in their poolroom where they were playing. The meeting discussed the daily calendar, daily feeding pattern, and HIV/AIDS. The youth have nutritional knowledge on the kinds of food that should be eaten but the foods are not available. The youth are idle most of the time, and would prefer to be busy doing something. They have knowledge on HIV/AIDS e.g. it is a killer disease, and its modes of transmission and prevention. They said that they need more training on HIV/AIDS, especially as trainers to teach their fellow youth and parents/adults in the interior. They should also be facilitated with teaching aids, posters, videos, condoms, and other information, education and communication materials. December is a very idle month for the youth. 2.2.3 Issues for a National Nutrition Policy

During discussion with various groups, there were some recommendations which could be included in the national nutrition policy:

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Use women groups in the implementation of development programmes, as they seem to be more active Boost funding to nutrition and HIV/AIDS, especially to home-based care Researchers should improve production of indigenous crops due their nutritional value There should be market for agricultural produce to increase farmers incomes Put more emphasis on environmental conservation (soil and water) for sustainable food supply Encourage food preservation especially among pastoral communities, and if possible should have powdered milk on the shelves Reintroduce the school milk programme for preschool to Class eight to improve performance Fruits trees be planted in school compounds both for learning and to supplement the micronutrient requirements of the children; also introduce chicken and rabbits A product called supro which used to be in the school feeding programme be brought back De-worming tablets and vitamin A supplements be provided for preschool and primary school children There should be 10 am snacks for preschools, nursery, and up to primary Standard 3 In the dry areas of the country, a lot of support is required for irrigation, check dams, boreholes and springs for micro-irrigation

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BONDO DISTRICT 1.
1.1

DISTRICT CONSULTATIONS
Background

The introductory remarks by the study team emphasized three main aspects about the study. First, there is a cascading process through consultations at the national, district and community levels to generate the important elements of a nutrition action plan and to understand the role of each level in its implementation. Secondly, the background study by the research team covers nutrition throughout the lifecycle (from intrauterine feeding to old age) and special circumstances within the lifecycle (e.g. nutrition and HIV/AIDS, and nutrition and emergencies). The study includes nutrition and HIV/AIDS since the infected are normally dependent, the disease affects absorption of nutrients, and well-fed people may be less susceptible to AIDS. Other sub-topics include nutrition and maternal child health, and intrauterine feeding (as low birth weight can even determine life expectancy). Thirdly, the study takes a human rights approach in design and implementation of policies. At the elementary level, the human rights approach tries to understand what people know (and therefore their gaps in knowledge), and what they practice (and its corresponding gaps). At each level, there is a claimant or rights-holder (e.g. child in case of breastfeeding) and duty bearers, with corresponding responsibilities of other agents to support the immediate duty bearer. 1.2 Socioeconomic Profile of the District

Bondo is one of the 12 districts that make up Nyanza province. The district was carved out of the original Siaya district in May 1998. The total area of Bondo is 1,972 km2 of which 972 km2 is land surface and 1,000 km2 is covered with the waters of Lake Victoria. It borders Siaya and Busia districts to the northwest, Kisumu district to the east, and Rachuonyo, Homa Bay and Suba districts across the lake on the southeast and south. To the west lies the Republic of Uganda. The district has five administrative divisions, namely, Rarieda division which lies to the north of Uyoma peninsula, Madiany division which lies entirely in Uyoma peninsula, Nyangoma division in the north, Maranda division in the north and central part of Bondo, and Usigu which is the smallest lies to the west. The district has 19 locations and 49 sub-locations. The district heads of departments emphasized that Bondo district suffers severe food shortages, and most food consumed comes from other places. A big proportion of the population depends on fishing, as agriculture does not do well. Poverty levels are high, the potential for irrigation has not been exploited, and the residents have a problem accessing clean water. There was a motion passed by parliament in July 2002 to include Bondo and other contiguous districts as arid and semi-arid areas, probably to make them eligible for food relief. When there are no rains, there is general lack of vegetables, and fish (mainly omena) has to be eaten in all meals (from breakfast to supper). The economic base of the district is fisheries, agriculture and retail trading. The district suffers high poverty levels (estimated at 52%), high HIV/AIDS prevalence (estimated at 29.4%), and is exposed to severe food shortages. Although the area has adequate rains that can make the community sufficient in local food needs, only about 25% of the arable land is utilized. The public health facilities are 1 district hospital, 1 subdistrict hospital, 4 health centers and 16 dispensaries. The district has two health centers run by the Catholic Church and six private dispensaries. Much of the water consumed is unsafe. Some of the food consumed is imported from adjoining districts and neighboring countries. It is estimated that about KSh 1.8 billion is spent annually to buy food, which is made possible by income from fisheries, agriculture and remittances. A large proportion of the population depends on fishing for their livelihoods. Although agriculture does not perform well due to drought, other sources of livelihoods include peasant farming, local trading and remittances from relatives working in large towns.

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The most common foods consumed include fish (tilapia, Nile perch, omena), vegetables (especially kale), nyama, dengu/beans and ugali. Most of the kale and maize is imported from Kericho, Nandi Hills and Bungoma. Madiany and Rarieda divisions produce relatively more maize and sorghum than the other divisions. The consumption of sorghum has declined due to change in tastes towards substitutes such as rice. It is felt that sorghum is less tasty compared to the substitutes. Most of the beef consumed is produced locally. There are little imports of beef from Rift Valley and Tanzania (via South Nyanza, Migori). There are a number of programmes in the district e.g. FAO Bondo Food Security Programme and the National Aids Control Council (NACC), which work at the grassroots through support to communitybased organizations. The community imports only basic foodstuffs (e.g. maize), which implies that there is nutrition deficiency and lack of variety, especially during the dry season. The study is therefore important as nutrition deficiencies are expected to lead to lower productivity. The government has well-established structures (with sub-DDC up to the sub-location level), and churches and CBOs are very active in the area. Bondo has been selected as a pilot district by a number of agencies e.g. UNIFEM (on female empowerment) and FAO (on food security). They reiterated that Bondo could produce enough food. However, the morbidity rates in the district are very high, the youth do not want to soil their hands (leaving farming to elderly men and women), and the Lake Basin Development Authority (LBDA) did not have much impact despite massive funding from the government of Netherlands. There is a proposal to give Dominion Group of Companies a 45-year lease of Yala swamp after which the land will revert to the people. 1.3 Food and Nutrition

The district produces animal products (meat, milk), cereals (maize, sorghum, cassava, potatoes and finger millet), pulses (cowpeas and beans) and oil crops (groundnuts and simsim). However, local production falls short of domestic food requirements. There is a critical deficit of cereals (maize and sorghum). The production of oil crops is low and most farmers face a marketing problem arising from poor prices. Usually, agricultural production fluctuates with season, with relatively more production during the long rains than at other times of the year. Although most families hardly harvest enough to last a year, the produce is usually sold at throwaway prices (especially immediately after harvest) only to purchase food more expensively later. Some of the causes of low yields include inadequate rains, expensive inputs, low quality seed varieties, and problems related to land preparation. Tractors are not available and most of the local cattle suffer from tick-borne diseases. With the onset of HIV/AIDS, the productive population has been reduced and this has increased stress on incomes. The National Agriculture and Livestock Extension Programme (NALEP) in the district has placed emphasis on drought-resistant crops and broad issues of production, consumption and utilization of agricultural produce. The programme has been decentralized to the division and location levels. Under the program, field schools are convened where farmers come together for specific lessons. The lessons are demand-driven and have been supported by NGOs and CBOs. Farmers have been anxious to receive training. They have been responsive to the training offered as well as the extension services provided. However, the main handicap has been financial constraints at the household level. The main types of food are fish (Nile perch and omena), vegetables (e.g. kale along the lake), meat (mainly local, but also animals imported from other areas like Rift Valley and South Nyanza Migori), dengu (which is actually wairimu beans which they call dengu) and ugali. Maize is imported from Bungoma and Kitale, while kale is from Rift Valley (e.g. Kericho and Nandi Hills). In most areas, the maize grown lasts for a maximum of 5 months; but Rarieda and Madiany grow relatively more maize and sorghum. Sorghum is mainly mixed with maize or dried cassava before taking it to the millers. The learned people focus more on maize than sorghum consumption.

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The main type of cooking fuel in the rural areas is firewood, and charcoal in urban areas. It is easy to get fuel in Maranda and Nyangoma divisions since they have a larger proportion of bush cover. In comparison, it is not easy to get firewood in Rarieda and Madiany divisions. Iodine fortification is covered in cap 242 of the Laws of Kenya. However, its monitoring is not easy. Since the health department has no test kits, it only monitors through the labels of salts in the shelves (e.g. whether iodized and expiry date). They also rarely undertake testing of water quality since the Government chemist charges them a lot of money for testing water. Food quality depends on the Kenya Bureau of Standards (KEBS), but public health officials deal with hygiene when they visit public eating places. Most families cook fresh fish from the lake. 1.4 Maternal Child Health

During antenatal care, mothers get anti-malaria drugs. They are advised to take food containing iron, proteins and starch. They are advised to eat omena, beans, sorghum, and (if can afford) liver. They are also advised to supplement with an egg. However, few follow the advice, as food available has to take care of the whole family. They are advised to initiate breastfeeding immediately on delivery. They even breastfeed for two years unless the mother gets pregnant. There are no iron deficiencies as mothers eat a lot of fish (fish has a lot of iron). There is however some demand for iron supplements due to malaria (anemia may cause iron deficiency); while HIV may also cause anemia since it lowers immunity. There is no iron deficiency in a normal healthy mother in the area. Malaria can cause miscarriage. A childs complementary feeding normally starts with porridge, cows milk and fruits. From six months, other types of food are added e.g. mashed potatoes, bananas and vegetable soup. Some introduce ugali at the early age of 6 months. If weaning is not done properly, a child may get marasmus or kwashiorkor. Other problems may include otitis media (inflammation of the middle ear), malaria, anemia, pneumonia and gastritis, especially if weaning is followed by immediate stoppage of breastfeeding. In most families, mothers have enough time to breastfeed. Only a small minority (e.g. teachers) are working class and therefore breastfeed at night and during weekends. Most women are peasants, and time for breastfeeding is therefore not a problem. The district has 21 static immunization centers and 5 mobile facilities. The immunization coverage for year 2002 was 57%. Measles campaign was conducted and managed to cover 107% of the targeted population. The health facilities are Bondo district hospital, Bondo sub-district hospital (Madiang), 4 health centers (one in each division except in Maranda where the district hospital is located) and 16 dispensaries. There are 49 nurses and clinical officers in the government health facilities, 20 in the district hospital and 29 in the rest of the health facilities. When a child falls sick, some parents start with herbal medicine since health facilities are about 5 km apart. Herbal medicine works for diarrhea, and the neem tree (mwarubaine) that grows in the area is used to treat malaria. If children are properly weaned and immunized on schedule, they are ready to go to school at the age of five. Under-five mortality is mainly accounted for by malaria. 1.5 Water and Sanitation

The vast area of the district does not get clean water, and even Bondo town water treatment plant constructed during the colonial era broke down. In the whole of Bondo, wholesome water coverage is around 41% - which include hand-dug wells (e.g. in Bondo division) and treated community water supply (e.g. in Uyoma). The majority of the population depends on untreated water from dams, ponds, rainwater and the lake. A large proportion of the population depends on pit latrines and bushes for disposal of human waste. Generally, less than 20% of the households have pit latrines. However, this varies with season since many pit latrines collapse during the rainy season (because of the types of soils and flooding). For example, latrine coverage in Madiany division is low because of types of soil, and some parts are rocky. In the areas near the

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beaches, the water table is very high. Given the variations in latrine coverage, the onset of rains determines the seasonal calendar of waterborne diseases, which are mainly experienced at the beginning of the dry season (around September) and beginning of the wet season (April-May). Cholera is endemic in both periods, while malaria is common. 1.6 Incidence of Diseases

The management of diarrhea depends on the level of education. The majority in the interior (especially the illiterate) starts with traditional healers, then to shopkeepers, and normally reaches the health facilities when they are already serious clinical cases. Diarrhea in children is mainly caused by types of complementary feeding, weaning foods and childcare. Parents with the right knowledge use oral rehydration therapy in the management of diarrhea. Diarrhea management generally depends on poverty and lack of knowledge. Other factors are distance to health facilities and roads e.g. in Madiany the roads are bad because of types of soils and poor maintenance. Diarrhea can be controlled by local fluids e.g. porridge. Most gainfully employed males are in fish harvesting and trade, and management of children is left entirely in the hands of mothers. General childcare can therefore be determined by ignorance, poverty, and the profession (e.g. fishing). Malaria is endemic, with heaps of incidences during short and long rains because of pools of water and sprouting of bushes. Most patients visit shopkeeper as their first doctor, mainly to purchase cheap chloroquine-based rather than sulphur-based drugs. The district is a pilot in the rollback malaria where the training includes shopkeepers (who are in turn supposed to train their customers) and community health workers (who also run the Bamako Initiative sites). There are also malaria days, which are used for training and raising awareness. The messages have not reached deep in the grassroots, and there is no effective traditional treatment and management of malaria. Some of the efforts to encourage the use of treated nets include social marketing through supanet groups by Population Services International (PSI), which has led to considerable purchase of affordable nets. The programs include nets and tabs for treating the nets. Support has also been received from UNICEF and even CDC covering only Rarieda - (though the main interest of the latter was research). The ministry of health does not spray malaria-breeding grounds, and only undertakes health education on the need to drain stagnant water. Since the initial supply of nets is free, most people are unable to meet the cost of retreatment of the nets and replacement of worn-out or torn nets. People know about personal hygiene but practice is very low. The messages are mainly through health education programs in schools. There are no testing labs for water. The public health department depends on labels and KEBS marks. This has an effect on the quality of food. Although salt has to be fortified (iodized) there are cases where noniodized salt is sold. 1.7 Nutrition and HIV/IDS

The HIV/AIDS infection rate was reported at 49.9% - which is probably an overstatement since it based on hospital records rather than sentinel sites while bed coverage for HIV/AIDS and related causes is around 50%. There are public health officials dealing with HIV/AIDS up to the grassroots. Infection rates are estimated from hospital admissions, as there are no antenatal sentinel sites. The Voluntary Counseling and Testing (VCT) services were recently introduced, where mothers are counseled and then tested in the VCT clinics, and if positive provided with drugs to prevent mother-to-child transmission. There is high concentration of HIV/AIDS incidence along the beaches due to the high densities of population. Most widows and old men relocate to the beaches with the hope of earning a living. Once on the beaches, the widows befriend the relatively younger men who run fishing businesses. There are also higher incidences in towns such as Bondo.

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There are drugs in all health facilities for treatment of sexually transmitted diseases and opportunistic illnesses (e.g. TB). TB cases are treated free of charge. Community-based organizations have been active in mobilizing resources for their projects. One of the most common areas of interest among CBOs is homebased care for AIDS patients. CBOs dealing with HIV/AIDS make their proposals to the constituency AIDS committees, which are then forwarded to district and finally provincial AIDS committee (for funding), but are supervised at the district level. One of the common items in the proposals is home-based care. Although the communities are being trained on home-based care (HBC), the feeding of the infected normally depends on the familys income. The groups most at risk of infection are normally the breadwinners, and the rest of the family cannot therefore afford a proper diet. Those engaged in homebased care have a hard time telling people to eat what they cannot afford. Probably only 1% affords the requisite meals. Since food increases immunity, some people die faster, and some cannot even afford hospital bed. Vertical transmission (also known as mother-to-child transmission) is high but the actual rate is not known. HIV mothers are advised not to breastfeed, but some mothers do not follow the advice because they do not have the means to buy breast-milk substitutes. It is only possible if you separate the child from the mother. 1.8 Coordination of Nutrition Activities in the District

The district nutrition section in the ministry of health is involved in a number of activities. First, growth monitoring and promotion is conducted monthly at the static health facilities and at the community level (at the latter by trained CHWs). The data is forwarded to the statistics section for onward transmission to the MOH headquarters, which is then inputted into the CHANIS (Child Health and Nutrition Information System). Second, the nutrition section is involved in rehabilitating severely malnourished children in the hospital. Third is awareness creation to promote good nutrition, with the support of CHWs. The section is also involved in micronutrient supplementation (iron, vitamin A) at the static facility level. Some of the key constraints include inadequate training for both the nutritionist and the community health workers, and high child malnutrition levels in the district (with an average of 30% undernourished). There is capacity and logistical difficulties in implementation of activities e.g. lack of fuel to undertake community level activities, inadequate funds to train CHWs and for refresher courses for staff, lack of funds for rehabilitation of critically malnourished children and for demonstration of best practices, occasional shortage of tally sheets and monitoring forms for CHANIS data, and understaffing. At the community level, there is poor dietary diversity and overreliance on fish and ugali as the main food types. Traditional foods that were rich in nutrients and were drought-resistant and disease-resistant have been neglected. At the district level nutrition issues are not seen as priority even in the allocation of costsharing funds. The gender role is of major concern, mainly because the district has acute shortage of surface water and women have to travel long distances to fetch water, leaving inadequate time for food preparation. It was recommended that: Findings from this study be sent back to the districts for appropriate action Build district-level capacity to train CHWs, and undertake regular monitoring, adequate rehabilitation of the malnourished children, and regular awareness and sensitization campaigns District heads should be sensitized on the role of nutrition both for personal and economic development (micro and macro levels) The district nutritionist should be involved in relief food because often the food does not provide adequate nutrition and there may be need for supplementation More CHWs should be trained so as to offload some activities from the district nutritionist Safe water coverage should be improved especially by tapping on underground water Malnutrition clinics should be started at community and static facility levels

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 1.9

There should be emphasis on promotion of food-based supplements and growing of nutrition-rich traditional foods rather than relying on manufactured supplements. Community Based Nutrition Programme

The department of social services implements nutrition activities through the DANIDA-supported Community Based Nutrition Program. The progarmme mainly undertakes the following: data gathering (normally to provide baseline information of a particular community for problem identification), training the communities on simple project management skills, and assist in the preparation of Community Action Plans (CAPs). The program assists the community to design their own action plans on possible areas of intervention to reduce the incidence of malnutrition. The program is already operating in Rarieda, Maranda and Usigu divisions. Based on the findings of the baseline survey, the program prioritized water, health and agriculture as entry points. Based on the subsequent CAPs, the program is supporting the following interventions: Feeding and rehabilitation centers and follow-up activities Training communities on how to be self-sufficient in food Promotion of income-generating activities Training on food preparation especially weaning foods Awareness campaigns Training on the Participatory Approach to Nutrition Security (PANS)

The key challenges facing the program include: Most community members are not willing to undertake communal activities The community suffer from immediate benefits syndrome Prolonged drought and poor soils Retrogressive cultural practices

The DSDO and his team made the following recommendations: To augment their incomes, communities should be further encouraged and empowered to undertake income-generating activities Sensitization of men to be more directly involved in food production The community members should be supported with farm implements and inputs More ground and underground water should be tapped More emphasis should be placed on the use of CHWs in interventions

2.
2.1

COMMUNITY CONSULTATIONS AT UHANYA FISH LANDING BAY

The Process

The acting chief of Usenge location assembled the community, and proceeded to tell the community the purpose of the visit and the need for their cooperation and active participation to make the meeting a success. This was followed by an address to the community by the study team on the specific purpose of visiting the area. Before actual data collection could begin, some community members said they would first like to ask a few questions. The first community member to stand asked whether our only concern was food, and if not, whether we deal with finance that can support organized groups. The second question related to their main source of livelihoods (fishing) where they described their farm as the lake. They wanted to know how the study team can assist them in, say, life jackets (in case of accidents), and whether those who rely on farming can be assisted with water pumps. The community members were told by the study team that the Ministry of Planning and National Development is in charge of formulating development policies and programs,

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and therefore the outcome of such a study will be the basis upon which other Government departments, international development partners and nongovernmental organizations will support the community. The final question was on whether the outcome of the study on their beach would be used to assist the beach or whether it will also support operators in other beaches. The answer was, of course, affirmative. During community consultations, resource mapping and seasonal calendar (for production and food stress) were done, but were not drawn, and the process therefore failed in attracting participation. The problem bag was carried out with a residue of the community members in attendance (as the women group had already been set aside for another focus group discussion). There is need to do resource mapping on the ground to invite attention and keep the community members focused. 2.2 Resources in the Community Lake/beach (fish landing bay) Land (small-scale peasant farming) Small-scale businesses (in general) Fish landing store Roads and boda boda Boats Fish transport vehicles (owned by outsiders) Out-board engines (for transport) Nets and fishing gear Shops and rental buildings Fishermen Livestock and poultry at home Trees (charcoal) Omena fishing gear (different from other gears) Churches Schools Rabogi primary school Hospitals Usigu dispensary and a private clinic Drinking water (there are no rivers, the piped water system is not working, and currently rely only on the lake)

The main problems encountered are preservation of fish, fluctuations in prices, unaffordable fishing gears, security and safety of fishermen, insecurity, hospitals are very far, communication, poor road network, and territorial rights in the lake. 2.3 Sources of Livelihoods

The main sources of livelihoods were reported as fishing, peasant farming, business and livestock. In order of importance, fish harvested locally are Nile perch, tilapia and omena. The high harvest season for Nile perch is from April-September, tilapia May-August, and omena January-April. The low harvest season for all fish varieties is September-December. Nile perch is harvested entirely for sale in major towns (Kisumu, Nairobi and Mombasa) and some exported overseas after further processing. The local consumption for tilapia and omena is 20% and 60%, respectively. Local consumption of omena is high due to affordability at the household level. Farm produce includes maize, potatoes, cassava, beans (wairimu), green vegetables and tomatoes. Maize is planted in April-May and harvested between July and August. An average family harvests two to three bags of maize, which lasts about 3-4 months. Beans (wairimu) are inter-cropped with maize. An average family harvests one bag of beans that lasts about three months. Potatoes and cassava are available throughout the year. Each family harvests about four bags of finger millet per year, which normally lasts 4 months. Green vegetables (kale, tomatoes and onions) are grown throughout the year.

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The main periods of food stress are March-August and January-February. During food stress (MarchAugust), they buy maize from Kitale and Uganda, rice from Tanzania through the lake, and cassava, yams and bananas from Uganda. During January-February, they mainly consume fish with purchased unga. The income used to buy unga is mainly from fish and other businesses. The main types of business are fish buyers (mongers), fish hawkers, hotels and bars, general shops, and food sellers from Uganda (who sell up to the retail level to individual consumers). The daily woman calendar (as given by women) is as follows: 5 am: 6 am: 9-10 am: 10 am-1 pm: 1 pm: 6 pm: 9-10: Sweep house, clean dishes, draw water from lake, and prepare breakfast To shamba Leave shamba Prepare own tea, look for lunch foods (e.g. at the beach) and then prepare lunch Wash/bathe, look for food, drawing water for household, hawking omena Prepare supper Sleep

The daily man calendar (as given by women) 3-4 am: Wake up 4 am: Go fishing 4 pm: Wash, take tea and ugali, then take a nap 5-8 pm: Walk around the beach area 8 pm: Go home, take supper 9 pm: Sleep One elderly man who owns a boat said that the male daily calendar begins at 4-5 am when one prepares to go fishing. They carry soda and bread, and some carry milk for lunch. They come back around 2-5 pm (they do not eat lunch); are in fish trade during 5-7 pm; go home to eat at around 7 pm; and sleep around 8 pm so that one is able to wake up early. There is little emphasis on farming in the community. Young women are involved in small-scale businesses e.g. selling tomatoes and frying fish for sale. Young men are in fishing as employees; old women are only involved in farming; and old men are in fishing and burning charcoal. There are no jobs for the youth, even those who have completed 12 years of schooling (meaning end of secondary school cycle). The people who look after livestock are paid workers since children go to school. Mothers are in charge of farming, and are sometimes assisted with paid labor using ox-plough. The youth (boys) go to look for jobs. They do not assist their mothers in farming when young, but may assist after completing school. One member of the study team held discussions with two men. The men identified the main problems in the area as (a) lack of capital (e.g. to buy boat engine), (b) low productivity in farming (rainfall is unpredictable and there are no resources to plough), (c) no government health facility other than a private clinic, and (d) the nearest primary school has no nursery school and young children cannot reach the school that has nursery facilities. There are no resources for tractor farming and people are already used to oxdriven ploughs. Twenty years ago, there was more income; so people ate what they wanted e.g. could not take a week without eating chicken, eggs or meat. However, these foods are currently almost nonexistent. Fishing thrives but there is very little farming. Kiboko (hippopotamus) destroys farms e.g. vegetables. People used to keep a lot of cows and goats but no more due to diseases, especially foot and mouth disease. Many people are dying from AIDS where children lose both parents. The diseases in the area include diarrhea, malaria, chest (TB) and AIDS. HIV/AIDS has gone down; it is high among the youth but old men do not have the power. The types of food and methods of food preparation are probably reducing

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male strength (virility) e.g. too much fat, and reduction in time used to cook omena (it used to be cooked for 4 hours but currently only for a few minutes). 2.4 Maternal Child Health

Child spacing is around 2 years. The majority of the children are born at home due to emergency conditions, long distance to hospital, and delivery services are only available at Bondo (which is 30 km away and KSh 50 one way). However, the local delivery systems through TBAs (nyamrerwa) are safe. Food availability affects everybody and is not specific to children or mothers. The women group said that, in feeding of the unborn baby (intrauterine feeding), the ideal diet would be tea, milk, oranges (imported from other districts), porridge (sorghum), ugali, rice, avocados (bought), vegetables (grown here) and mangoes (from outside). The actual situation is that the feeding of pregnant mothers is ugali (flour from the local maize miller), porridge (maize), fish and vegetables. Their workload is supposed to be low, but is high for some. The antenatal nutrition advice corresponds with the ideal situation above. They reported that the proportion of low birth weight children is likely to be very small. There are very few cases of neonatal deaths. The mothers initiate breastfeeding within five minutes and exclusively breastfeed for 3 months. In the third month, cows milk is introduced, and at 5 months porridge mixed with milk, mashed bananas plus avocado, potatoes. At around 3-6 months, the common diseases are diarrhea and vomiting, and stomachache. The traditional treatment is mtama (sorghum) porridge and herbal medicine. Currently, there is combination of traditional and modern methods, where medicine is obtained from the clinic and the mothers still provide boiled water with salt. At around 6 months, they add other foods e.g. eggs, ugali, soup and fish steak. They take children for immunization on schedule up to measles (angiew). Malaria cases are taken to hospital for treatment. Shops also stock anti-malaria drugs, mainly malaria-tab while others keep fansidar. The majority of the population does not have mosquito nets (due to poverty) and there is hardly any treatment of nets. 2.5 Food and Nutrition

Twenty years ago, the diets consisted of fish, ugali, sorghum porridge, potatoes, cassava and cow milk. There also used to be nyoyo (githeri) maize and beans but not anymore since maize and beans are very expensive, require a lot of cooking fuel, and require much maize per cooking. Currently, it is the same dish, less quantity, and there is no nyoyo. The main type of cooking fuel is firewood. They also buy charcoal from Uganda (delivered directly to the fishing town by boat). There is currently a tendency of semi-cooking foods e.g. omena. The normal breakfast is tea (with ugali, nyoyo or boiled potatoes) and uji (porridge). Lunch and supper consists of mainly fish, ugali and vegetables. The first plate is given to mzee (the household head), followed by boys, while girls eat with the mother in the kitchen. The mzee gets the highest ration. This feeding arrangement lasts to old age. There is no special feeding of pregnant mothers. Water for domestic use is obtained from the lake. Some people do not boil drinking water, but the majority does, and even a small percentage uses chlorine. They said that unboiled water from the lake causes typhoid, diarrhea and vomiting. The majority has toilets, and the majority uses them. The ones who do not use is because they refuse to share e.g. with wifes mother or if a toilet is too near the boys simba (hut) the parents cannot use it. Toilets cannot be made on swampy and sandy areas e.g. as in Kayomo area.

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2.6

Nutrition and HIV/AIDS

The prevalence of HIV/AIDS has gone down. The community believes the disease travels by road and lake (boats from Uganda that brings in maize, cassava, beans, etc). They said that sex for fish is hardly there any more. They understand that the infected like chicken and fried meat. The infected are only given special diet when available, as an improved diet is not sustainable on a regular basis. They believe that an HIV-infected pregnant mother will always give birth to an infected child. However, they know the mothers should not breastfeed, but they still breastfeed. 2.7 Victoria Women Group

AIDS has slightly reduced. For example, at the fish-landing bay, there were 10 deaths in 2001, 5 in 2002, and none so far this year. The fish banda is the center of the economic and social activity of the beach. AIDS awareness has worked; today you see a young man buying a girl soda and then leave her to go home. The group undertakes home-based care for the infected, and for orphans. They have established an orphans center which has now reached primary Class 2 and will be a feeder school with up to Class 4. In the school, they take breakfast, lunch, plus 3 pm uji. They make the uji there and it consists of cassava, beans, njugu, maize, sorghum and soya beans. They add folic acid tablets and Vitamin B complex, plus sugar and lime to add to taste. The porridge is given to both the infected and orphans and assists to also boost immunity. They currently support 110 orphans. They have 67 clients (infected or with AIDS-related infections). Some are in a state of denial although have all symptoms as may relate symptoms with customs and beliefs e.g. home built in the wrong position. The group had originally identified 165 for care and support, but 65 have died which left them with 100. However, 55 have migrated, and have added more to reach the current figure of 67. They replace those who die. They operate in three villages (Uhanya beach and village, Misori Nyenye beach and village, and Kanyibok village). Some people in the community still follow the custom that the father has to plant first. If he does not, his grownup children in the homestead do not plant. The culture has therefore become a food security issue, and is one of the factors that have led to a lot of idle land in the area. The community around the study site follows these traditions e.g. after father plants, he is followed by first born and so on. Others taboos are a second born marrying before the first-born and first-born house not at the right hand side of the home. The women group was being supported by Futures Group (which has phased out) and gave KSh 100,000 every 6 months since September 2001. NACC has started supporting the group with KSh 400,000 given two weeks before our visit. UNDP has taken the group as a pilot in poverty reduction in the district, with an allocation of KSh 296,000 mainly for training in management, entrepreneurship, and savings and credit. A small part of the money (KSh 40,000) will be seed capital for clients. The ICROSS supports the group with beddings, mosquito nets, drugs for opportunistic infections (antibiotics, painkillers), gloves, and cotton wool. ICROSS has its head office in Nairobi and field offices in Bondo and in Siaya, and works closely with MOH. Ten years from now, we have to understand that the main cause of poverty is AIDS. The fish catch is low, and this will therefore be a changed community looking beyond fish e.g. small-scale businesses. Currently, most businessmen come from far, and even some boat owners come from outside this place. We are also having changes in agriculture e.g. cassava was not doing well due to pests but now a resistant type is being introduced. Previously, boys and girls were not after education, but now parents are taking more children to school. 2.8 Focus Group Discussion (Uhanya Beach Youth)

The youth identified some of the problems they faced as lack of facilities, dirty environment and the reluctance of local authorities to clean the environment, inadequate rains, and lack of some critical skills

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(e.g. in the area of beekeeping). They believe the area should be provided with better quality seeds, and for irrigation to be done every 200m from the lake. Currently the youth did not have any registered organized group. Many were formed in the past but collapsed. An example of a youth group that collapsed is Uranda Youth Group. Other unregistered youth groups include Extra Sibuor and Mobile International. The latter two are involved in brokerage of fish. The other unregistered group is Ayombe. The youth argued that the groups were poorly organized due to lack of training and exposure. Some of the members did not understand the benefits they could derive from organized groups and associations. 2.9 Nutrition Program in Schools

Two key informants (primary school teachers) said that the nutritional value of various foods and the importance of balanced diet are taught in school as part of the curriculum. In one of the programs of food growing in the schools, FAO donate seeds and the communities provide the other inputs. There are also demonstration farms in schools. They recommended that every school should have a demonstration farm, micronutrient supplements should be made available in schools accompanied by the requisite training for the concerned staff, growth monitoring should be done in every school, there should be provision of safe drinking water in all schools, and nutrition education for parents and teachers should be promoted.

3.
3.1

FOOD AND NUTRITION ISSUES IN MARANDA DIVISION

The Cultural Foundations of Economic Activity

The main resource in the community is land, most of which is under bush. The main economic activity is subsistence farming. Milk and poultry are strictly for home consumption. In most families, land tillage is by hoes. A few ox-ploughs are shared among families, with a family providing either the oxen or the plough. The family that provides the plough is allowed to plough first, followed by the family that provides the oxen. In some cases, families with both plough and oxen do not have the expertise in ploughing, mainly because those who can afford a plough are middle class families whose younger members are away from home. To overcome this problem, labor is hired where payment is in kind through tilling the laborers farm with the same plough. The land is demarcated, just as in the rest of Bondo district, and the title deeds are normally in the names of heads of families. As the family unit grows in age and size, the cultural practice is for the eldest son to leave the parents compound to put his own home. He is followed by the second in age, and so on. The setting up of homes cannot be done by two sons in one calendar year. According to tradition, if a son is still in his fathers compound, he (or his wife and children) cannot initiate any farming process (e.g. tilling, weeding and harvesting). At all stages, the process is initiated by his parents. In the event that both parents are dead, the eldest son within the parents compound (or his wife) initiates the process. This process is a hindrance to freedom of choice in farming, and leads to low yields in crop production as some people may plant late or not plant at all. 3.2 Food Security

The land holdings are around 3-6 hectares and are in most cases fragmented. One family can own two or three parcels in different places. Some people lease out some of their land due to poverty or if they are unable to till all their land. The common arrangement is for the lessee to plough the whole parcel of land, and then the parcel is equally split between the lessor and the lessee. Thereafter, each one of them sows, weeds and harvests own produce for the season, after which the land reverts to the owner. This process can be repeated over many seasons. The community plants crops in both rainy seasons - the long and the short rains. The main crops grown are maize, sorghum, beans and cassava. The crops are grown for subsistence. The harvest only lasts about

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3-4 months. There is negligible application of fertilizer. There are no rivers or any water source for irrigation. Due to erratic rainfall, it is possible to lose all food planted in a season. The area is bushy and there are many pests and wild animals competing to annihilate the crops. The squirrels attack the seeds immediately they are planted. Whatever escapes the squirrel is at the mercy of the common weeds in the area. The weeds are followed by monkeys, which are so fierce they even attack the residents. Then comes birds singing, dancing and pecking. The result is very little harvest. After harvest, the farmer tends to sell a part of the produce to finance other household expenditures, which is a further drain on food security. Some homesteads keep a few cattle, goats, and sheep (to a small extent). There is a small dairy in Bondo town that buys milk from farmers. Most families rely on purchased pasteurized milk. After land demarcation in the seventies, most families reduced their stock of cattle, goats and sheep due to scarcity of grazing land. Indigenous breeds of chicken are kept for home consumption. A chicken is slaughtered for a visitor, when a member of the family comes back home, or during a festive season (e.g. Christmas). Very little attention is paid to disease prevention; and when a disease epidemic strikes entire stocks are lost. Restocking is a long, unsteady process. Cattle are sold to raise funds for major expenditures e.g. school fees, hospital bills and funeral expenses. Cattle are also used to pay dowry. The slaughter of cattle and goats is a main feature of all funerals. Consumption of dead carcasses is widely practiced, as the community trusts their methods of treating and preserving carcasses of dead animals to prevent transmission of diseases. Eggs are rarely eaten, and are normally allowed to hatch, as chicken is a favored delicacy. Food shortages are a common feature, as the food produced cannot sustain the community for a season. Food stress is most acute during the long rains planting season, which makes it necessary to import cereals from other parts of the country. However, the period is characterized by plenty of vegetables (e.g. kale and cowpea leaves kunde) and wild local vegetables. During food stress, the main meal is ugali and omena. The ugali consists of maize and sorghum flour, as this is preferred to maize flour alone. The maize and sorghum ugali is heavy, and a small portion can feed more household members than plain maize meal. Cassava is also dried and mixed with sorghum to prepare ugali. Dagaa (omena) is a favorite dish at this period because it is cheap and easily available. Dagaa is used to prepare a wide variety of dishes, and the time taken to cook the fish depends on whether it is fried or boiled. In times of stress, the main sources of livelihoods are remittances from family members working elsewhere, and earnings from casual jobs e.g. bush clearing, charcoal burning and selling firewood. 3.3 Food and Nutrition

The lack of adequate food almost throughout the year has led to child malnutrition, while lack of food diversity means poor nutrition for the whole community. There is high dependence on fish (tilapia and omena) for protein, but a general lack of vegetables. There is very little vegetable production except traditional varieties like osuga, mrenda and others which grow wild. During drought, vegetable prices are very high. The catch of Nile perch is high but it is mainly exported because the community has less preference for it compared to other types of fish. Pregnant mothers do not get any preference and eat the same foods as the rest of the household members. However, they eat a lot of soil, which they pick from anthills and demolished mud houses, and those who can afford buy special stones to chew. If a man dies and the wife has not been inherited, she cannot cook for her older children (say, those over 15 years) but she can cook for the younger ones. In a family where there are grown up children, older children still under the care of such mother would feed in the homes of their married offspring. Women do not eat the tail or gizzard of a chicken; these parts are reserved for the household head or the eldest son if the household head is not in. However, women can eat the said chicken parts in the absence of any man in the household.

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3.4

Water and Sanitation

The main source of water is dams. The dams contain stagnant water, and the dangers of waterborne diseases are real. Livestock (cattle, goats and sheep) use the same water sources, which makes the water dirty and brown in color. The few households who have roofed their houses with corrugated iron sheets harvest rainwater for drinking. The nearest piped water facility is at Bondo Teachers College where 20 litres of water costs two shillings. Although most people are aware of the need for boiling drinking water, very few do so. They argue that boiled water loses taste. Most households keep drinking water in traditional pots for cooling. The households are aware of the need for clean sanitation and have toilets. The tradition is that parents and grownup siblings (especially married sons and their families) should have separate toilet facilities. 3.5 Nutrition and HIV/AIDS

The community is well aware of HIV/AIDS, although they are reluctant to relate or associate any death with HIV/AIDS. Deaths due to illnesses with symptoms of AIDS are normally attributed to violation of taboos.

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GARISSA DISTRICT 1.
1.1

DISTRICT CONSULTATIONS
Methodology

The consultations were done at two levels: district level where the team held discussions with the District Commissioner, government departments (agriculture, health and education), CARE-Kenya and the Arid Lands Resource Management Project; and the community level where the team held discussions with the Balambala community represented by one enumeration area (Bulla Gun). The tools used for the community consultations included resource and social mapping, Venn diagram, seasonal calendar, timelines, wealth ranking, role pattern analysis, problem ranking, problem analysis and visioning matrix. There were only two days for community consultations, and the community was only available for 2 hours in the morning and 1 hours in the afternoon. However, due to the limited time, language barrier, absence of male community members in the consultations, and fear of fatigue within the community (a similar exercise was undertaken in the area five months before), the team did not cover resource mapping and Venn diagram. The rest of the tools were used in the consultations with the community, which consisted of only women, with the sub-chief as overseer. 1.2 Background

Garissa district is one of the four districts of Northeastern province, the others being Wajir and Mandera to the north, and the newly created Ijara district to the south. The district is vast with an area of 33,620 km2. The district is flat with no hills or mountains. The only notable physical features are seasonal laghas and the Tana River basin in the western side of the district. The soils can be classified into alluvial and white and red sandy soils. The white and red sand soils occur in Balambala division where the terrain is relatively uneven and is well drained. The district is semi-arid receiving an average of about 34 mm of rainfall in a good year. However, there are occasional droughts that recur almost after every two years such that the district is always either preparing for drought or is in a drought-related emergency e.g. food relief. The district has a projected population of 368,593 in 2002 (including refugees based around Daadab market) of which 69% is youthful (0-24 years). Major towns attract large populations especially Garissa town which accounts for 20% of the districts population. The welfare indicators are very low e.g. school enrolment, access to health services and water (quantity, quality and reliability), and other measures of socioeconomic status of households. For example, a survey conducted by CARE-Kenya in 1999 reported an overall literacy rate of 13% (4% for females and 23% for males). The major activity in the district is pastoralism. The lifestyle is nomadic, whereby a section of the population move in search of water and sometimes settle around small market centers where water is available. Agro-pastoralism is practiced mainly along River Tana. Most people have lost their livestock, which is the mainstay of the population. The frequent droughts often deplete the family stock, forcing people to migrate to towns in search of relief food. The population living below the poverty line is estimated at 68%. The district therefore has a poor base for food security and nutrition. There is need for stepping up efforts in livestock and crop development especially irrigation activities since the district is deficient in rain-fed agriculture.

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1.3

Food Production

Table 1: Food Production in the district (2002)

Crop Bananas Tomatoes Mangoes Papaws Maize Sorghum Rice Cowpeas Melons Onions Brinjals Kales Area (hectares) 205 220 110 40 260 120 130 80 75 70 7 7 Yield (tons) 4,940 2,420 1,800 600 100 90 120 39 780 500 13 22

Source: Garissa District Agriculture and Livestock Development The main types of food grown in the district and production (area and yield) for year 2002 are shown in Table 1. Tomatoes do best during the cool season (June-September) although it is grown throughout the year; bananas are grown throughout the year; water and sweet melons perform well during the dry season (May-October); mangoes have two seasons (May-August while peak season is September-December); and onions are grown throughout the year. Most produce of sweet melons is sold to other parts of the country. The major pests are American bollworm in tomatoes, thrips in onions, and leaf miner, nematodes and weevils in bananas. The major diseases in crops include mosaic virus in tomatoes, early and late blights in tomatoes, decline disease in bananas, and fusarium wilt in bananas. Table 2: Livestock Production in 2002
Type livestock Cattle Goat Sheep Camel of No. of animals 279,536 238,315 44,262 74,137 Livestock sales (export plus slaughter) 138,052 21,628 4,412 No. of animals sold outside the district 137,845 17,106 1,786 Milk production (kg) 1,872,000

Most of the milk produced is consumed at the household level. There is also a lot of waste due to lack of milk preservation technologies in the area. Peak production is during long rains season. The major livestock diseases are helminthasis (very prevalent), rinderpest, injuries/wounds (endemic), contagious bovine pleuro-pneumonia - CBPP for cattle - and contagious caprine pleuro-pneumonia - CCPD for goats (endemic), and lumpy skin disease (LSD) for cattle. Currently, sources of livelihoods in the district include pastoralism, agriculture, and various other income generating activities such as trading, charcoal and firewood sale, selling of non-food items, employment, selling miraa (khat), and casual labor. According to CARE-Kenya Livelihood Security Assessment Report (2000), the households can be split into seven discrete livelihood categories: pastoralism (32.0%), pastoralism and other (33.5%), agro-pastoralism (13.0%), agro-pastoralism and others (10.6%), agriculture (0.7%), agriculture and other (2.5%), and other (7.7%). The causes of food insecurity include: Poverty, Frequent crop failure due to prolonged droughts, Poor yields,

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Lack of access to farm inputs (no established stockists for farm inputs forcing farmers to use uncertified seeds), Limited extension coverage due to the vastness of the district (farmers are unable to get updated agronomic practices in good time), Production of cereals and pulses is poor (emphasis is on horticulture, which has good returns/gross margins), High postharvest losses due to lack of transport of produce to the markets, Flooding in case of irrigated agriculture, High rates of illiteracy, Nomadic lifestyle that makes it difficult for continuity of dissemination of extension messages, and Low funding of agricultural activities

According to the District Agriculture and Livestock Extension Officer (DALEO), the strategies to reduce food insecurity include: Adequate funding of agricultural extension, Targeting production to the available market demand, Encouraging marketing of produce to the local markets (to create demand at the local level), Address marketing problems, including knowledge of possible markets for produce, Have project that specifically targets agricultural production, Discourage distribution of famine relief for free to avoid dependency syndrome, Special nutrition programmes aimed at changing the eating habits, and Issue relief food that consists of balanced diet Other constraints identified by CARE-Kenya include: Limited collaboration among stakeholders, Lack of knowledge on food utilization, Low coverage by government departments, Socio-cultural beliefs: mothers are not involved in key decision-making, Poor access to health and education facilities, and water, Limited capacity in data analysis and interpretation among government departments, and Lack of regular meetings by the District Health and Nutrition Sub-committee CARE-Kenya identified necessary strategies to include: Empower women through increased control of finances by initiating income-generating activities, Nutrition education, and Use integrated approach to nutrition (collaboration by relevant actors and coordination of their activities at the local level) 1.4 Food Habits

The traditional foods consist of meat and milk, sorghum (either fried or pounded), and maize pounded into grits (also known as ambula) with milk. Tea is a very popular beverage taken on average four times a day and with high concentration of sugar. There is a high incidence of anemia. Malnutrition is common because of underutilization of nutritious foods particularly vegetables due to cultural beliefs and taboos. Some of the food taboos include: women do not eat eggs; girls are forbidden from taking tea (it is believed that tea will make them fat); all types of birds (e.g. chicken), rabbits and fish are rarely eaten by any community members; and green leafy vegetables are for livestock. Birds (e.g. chicken) are not considered as livestock (and may leave them behind when migrating), eggs are eaten by children, and vegetables are rarely eaten. The head of household (the man) and other male members are served first, followed by children, and lastly the mother. In fact, the best and sweet foods are for the father. The famous nyirinyiri is a delicacy but is only reserved for men. This practice is so inbuilt that even children are aware that they are not supposed to

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eat such foodstuffs. A husband is never aware that her wife has missed a meal and is a taboo for the woman to reveal that she has missed a meal. This only becomes evident when, for instance, she falls sick and it is diagnosed that she is anemic and need blood transfusion. The populations in Central and Sankuri divisions have adopted urban feeding habits, eating three balanced meals per day. There has been limited progress in diet diversification among the rural community. In Dadaab and Liboi, vegetables are consumed because of the influence of refugees and outsiders residing there. Meat is prepared through frying, boiling and smoking (popular with the pastoralists) or preserved through salting, sun-drying, and frying to make a product known as nyirinyiri. The process of preparing nyirinyiri (prepared specifically for husbands) is first to cut the steak portion of the meat into strips, salt it and sundry it for one day, cut the strips into very small pieces and shallow-fry, cool and put into a special container and fill up with ghee, and then add herbs and preserve in a special container made from camels skin. The preserved meat can last for up to one year. Milk is drunk fresh or fermented e.g. kalba (fermented cow milk) and susa (fermented camel milk). Maize is pounded and prepared with milk (ambula) or boiled together with beans to make githeri. Sorghum is pounded into flour, or fried. 1.5 Health

The district has the following health facilities: 23 dispensaries, 4 health centers, 1 sub-district hospital and 1 Provincial General Hospital (PGH). The facilities have adequate drugs but do not have enough personnel. Dispensaries are manned by unqualified personnel mainly community health workers (CHW) or traditional birth attendants (TBA). The facilities are at a distance ranging between 25 and 100 km. Common illnesses and traditional treatment include: malaria (neem tree), URTI, skin infections, worm infestation, anemia (iron-rich foods such as liver and kales, milk is also given), diarrhea (neem tree, honey) and fever. The traditional treatment of fevers includes neem tree pounded and boiled and solution taken; hagar bark and leaves is used for heat rash; black caraway (habba sowda) for headaches and nose bleeding; honey; and malmal (gum-like substance applied on skin abscess. Majority of deliveries occur at home with assistance of TBAs who have been trained on safe delivery, including prevention of transmission of HIV. Nutrition lectures are given to mothers who attend antenatal and postnatal clinics. In case of anemic mothers, iron supplements are administered and weekly follow-ups are carried out. They are also given nutrition advice. Growth monitoring is done for children under 5 years of age. Immunization coverage is low estimated at 65% for measles because majority of births occur at home and children are not presented for immunization unless they are sick. It is believed that colostrum is unclean and therefore not suitable for babies. Its consumption is associated to delay of commencement of talking. There is also a cultural belief that breast-milk is only available 2 to 3 days after birth (i.e. until the umbilical cord falls off). The initiation of breastfeeding therefore takes place 23 days after birth, and children are in the meantime given water and cows milk. Nutrition education is only given at PGH family planning clinic and the pediatrics unit. The prevalence of malnutrition is high and is linked to poverty and lack of education. There has been an increase in bottlefeeding because of influence of refugees, which is suspected to be one of the contributory factors to child malnutrition. The percentage of persons with HIV/AIDS was reported as very low in the district, and that the majority of population is aware of the disease. Currently, there are no home-based care programmes or home visits targeting people living with HIV/AIDS. However, nutritional counseling is given to those seeking treatment at PGH. Some people believe that camel products (meat, milk and urine) and herbs (such as

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neem tree) can cure HIV. Other interventions believed to cure HIV include eating a lot of boiled meat and prayers. Some of the constraints to improvement of health and nutrition include: Lack of clean and safe drinking water, Dependency on famine relief, Inadequate support of nutrition activities, Lack of nutrition knowledge, Access to health facilities is limited, causing low immunization coverage, MOH not involved in relief food to advice on quality of ration, Maize given as relief food is not suitable for children under 5 years of age, Children do not attend clinics regularly, Poor management of environment and sanitation, Lack of designated garbage disposal sites, Lack of proper latrines particularly in the rural areas, The strategies include: Deployment of more nutritionists in the district, Allocation of adequate funds to support nutrition activities, Harmonization of activities carried out by home economics branch in the MOALD and those of nutrition section of MOH, Promotion of income-generating activities at household level, Provision of safe drinking water, Support research on traditional methods of treatment, Facilitate training on nutrition at community level, Include nutrition in the training curriculum for nurses so that they can double up as nutritionists, Revive family health educators, Promote polythene paper recycling into mats and ropes, Conduct training on proper hygiene and sanitation 1.6 School Feeding Programme

The school feeding programme was started more than 20 years ago with the aim of cushioning schoolgoing children from long distances to and from school to obtain lunch from their homes. It is supported by WFP in collaboration with the government. The local community provides water, firewood, salt and other ingredients in addition to facilitating the cooking. The food consists of a midday meal for both preprimary and primary schools. Each child is entitled to 150g maize, 40g beans or pulses and 5 g oil per day, which are deemed adequate. The benefits of SFP include increased school enrollment, enhanced learning and retention, and improved school performance. Other nutrition-related activities include integration of nutrition and better health in the primary school curriculum. At Standard three to four, pupils are introduced to the concept of balanced diet and the main food groups. HIV/AIDS has also been integrated in the school curriculum where pupils are taught on the basic facts and coping strategies. 1.7 CARE-Kenya

CARE is a secondary distributor of WFP-funded food aid during droughts and other emergencies such as the El Nino rains. In addition, it runs local community programmes with the overall goal of reducing poverty at household and community levels through activities such as drought recovery, capacity building, rehabilitation and sinking of boreholes, and mobilization and coordination of pastoralist groups.

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The WFP ration scale is used. The ration consists of cereals, pulses and vegetable oil. Occasionally high energy density biscuits are given to severe cases of malnutrition. The community is involved right from identification of beneficiaries to actual distribution, while CARE-Kenya monitors the process. The programme has been successful since rural-to-urban migration - because of death of livestock - has been controlled. In event of prolonged drought that lead to loss of the only source of livelihood (livestock), the pastoralists would migrate to peri-urban and urban centers in search of food. Such pastoralist dropouts are among the poorest people in the district. 1.8 Arid Lands Resource Management Project (ALRMP)

ALRMP has established drought early warning system in both Garissa and Ijara districts, where they administer a total of 420 questionnaires per month in 14 selected areas to monitor the following indicators: environmental conditions (rainfall and pasture situation), rural economy (livestock and crop production), and human welfare (milk consumption, nutritional status of children under 5, monitoring of relief food, and supplementary feeding). The key determinant of food security in the district is livestock. Therefore, the most vulnerable group to food insecurity is the peri-urban poor. These people lost their livestock during El Nino and severe drought and have settled around urban and peri-urban centers. Their coping strategies include farming, casual labor and petty trade. Camel owners are considered to be food secure. The community is fully involved in the process of food aid, right from beneficiary identification to the distribution. After the identification of the vulnerable households, each family (average size of 6 members) receives the following amount of food per month: 18 kg of cereals, four kg beans or pulses, and 0.5 kg vegetable oil. The Arid Lands Resource Management Project identified food insecurity coping mechanisms as: Social support systems (able households give support to vulnerable ones in terms of food or cash), Migration, Herd separation: the herd is separated into milking herd, and strong and weak herds where the strong ones go to far distances in search of pasture and water, and Preservation of meat and milk

The coping strategies should include (a) special programmes to address poverty (e.g. restocking households who have lost their livestock), (b) capacity building in farming, (c) provision of irrigation kits, and (d) support to income-generating activities.

2.
2.1

COMMUNITY CONSULTATIONS
Historical Profile/Timeline

Traditionally, the community led a pastoralist way of life, migrating from place to place in search of pasture and water. Their livelihood depended solely on livestock. They looked for other ways of survival after they lost their livestock to successive droughts. For example, in 1984, there was a severe drought, which wiped out their livestock and subsequently they settled in Balambala where they were assisted with food relief by the government. During 1990-1996, the community had good farm plots, which were swept away during El Nino rains. The Tana River tributary passing through Balambala changed its course making them abandon farming. In 1992, there were tribal clashes during which their livestock were stolen and some people lost their lives, leaving families widowed and children orphaned. This was followed by a disease outbreak in 1995 (cholera and measles in humans and foot and mouth disease in livestock). There was another disease outbreak in 1997 (measles, malaria and diarrhea in humans and Rift valley fever in livestock). After migrating to Balambala, the community adopted coping strategies characteristic of sedentary communities, e.g. petty trade, casual labor and farming. About 40% of the households were engaged in

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farming between 1990 and 1996, and consumed about of the total produce (mainly vegetables and fruits) and sold the remainder. Seasonal Calendar According to Balambala community, there are four seasons:
Season Jilal (Dry) Gu (wet) Haga (6 months dry) Period January-March April May-October Characteristics of Season Low milk production Water shortage High temperatures Improved milk production Surplus milk which they sell Windy and cool Receive relief food Migrate in search of pasture and water Collect firewood for sale as a coping mechanism Low milk production Eating habits change to strong tea and dry ugali while children take uji with no milk Food purchases through credit system Increased milk production Good market for their livestock and products High calving rate Have surplus milk to sell

Deyr/dayr (rainy season 2 months)

NovemberDecember

2.2
Category Rich

Wealth Ranking
No. of Animals Camels more than 40 Cattle more than 100 Goats more than 200 Also have property such as shops Camels about 10 Cattle about 20 Goats 80 to 100 Camels None Cattle 1 to 5 Goats - 2 to 5 Collect firewood and sell to the rich to generate income Proportion of Households (%) 10

To assess the social status of households, the community uses the number of livestock as an indicator.

Middle income Poor

50 40

2.3

Sources of Income

The main sources of income were identified as sale of livestock, sale of milk, petty trade, sale of water, remittances from relatives, firewood and charcoal business, brokerage in livestock trade, sale of local herbs, TBA fee, circumcision fee, divorce compensation, and assistance from NGOs. Leakages/Expenditure Patterns
Expenditure item Purchase of food Health Payment of wages (casual labor, herders etc) Education (including duksi - Quran study) Clothing Community assistance funds Taxes Purchase of livestock Savings Others (transport, debts, marriages, etc) Percent Allocated 70 7 6 5 3 3 2 1 1 2

The community ranked the main problems as poverty, poor diet, malnutrition, childhood diseases, lack of exclusive breastfeeding, and drought.

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2.4

Food and Nutrition

The types of food purchased are maize, beans, sugar, milk, oil, meat, potatoes, spices, fruits (such as bananas, mangoes and papaw), and occasionally kales. The community perceives nutritious foods to include meat, beans and vegetables, although vegetables are rarely eaten due to cultural beliefs. For children the food includes milk, uji and eggs. About 25% of the community is capable of eating a nutritious diet. The traditional diet comprised of meat prepared mainly in two ways: boiling or frying. The meat could also be preserved and stored in a special gourd. The diet included milk taken fresh or fermented. The current diet consists of maize and milk. Many households cannot afford three meals per day. Breakfast consists of tea with sugar for adults; and uji made from maize flour enriched with milk for children. Lunch is mainly maize and milk, while supper is beans and rice. Many families cannot afford supper. In many cases, children eat the same meals as adults. The women complained of husbands leaving home without leaving any provisions for food for the children. The causes of malnutrition were reported as: Lack of adequate food e.g. vitamins (children resort to eating soil - mchanga), Poor diet e.g. taking strong black tea with ugali, Poverty, Illness The likely solutions to malnutrition were reported as: Seeking treatment: This can be clinical (syrups and nutritional advice) where those who can afford the prescribed diet and drugs follow the advice and severe cases are referred to the district hospital; or traditional e.g. tying a root from special herb around the neck, applying herbal solution on the body, taking a mixture of ghee and milk Eating highly nutritious foods such as eggs and liver Long term solutions include assisting the vulnerable households with food and cash or restocking their herds Starting income generating activities Seeking assistance from GoK and NGOs in the following areas: repair of the existing water pump, avail tractors to clear their farming plots, grants to purchase livestock, and provide farm inputs. 2.5 Maternal Child Health

Infants are introduced to breast-milk three days after birth. The community believes that breast-milk production only starts once the umbilical cord has fallen off. During this period, the infant is fed on milk and water. It is also a cultural belief that the first milk (colostrum) is unclean and that if fed; the child will take long before it can talk. The community does not practice exclusive breastfeeding since cow milk is given to the infant alongside breast-milk in the first 5 months. Complementary feeding is introduced after 5 months and consists of potatoes and uji. Children are weaned off breast-milk at the age of 2 to 3 years. Special diet is recommended for lactating mothers and consists of porridge, milk, liver and beans. Few women attend antenatal and postnatal clinics. Majority of deliveries takes place at home with the assistance of TBAs. This is mainly due to lack of knowledge on the importance of the MCH clinics. However, majority of children are taken for immunization. The women reported low infant mortality (in the first year of life). The major childhood diseases are malaria and diarrhea. The traditional treatment of malaria includes covering the patient with fresh goatskin smeared with fresh goats blood. It is believed that this enhances sweating thus treating the malaria. Diarrhea is treated at home using traditional herbs. The community

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believes that if a healthy child inhales the fumes of herbs used to treat diarrhea, the child will start to diarrhea and subsequently become malnourished. Malnutrition is common during the dry seasons of Jilal and Haga. It was reported that about 40% of children under five years of age are malnourished. Mothers said that child malnutrition is manifested through loss of appetite, stunting, mental retardation, skin disease, weak joints, enlarged stomach, changes in hair color, diarrhea, and increased vulnerability to diseases. The consequence is death. 2.6 Nutrition and Emergencies

The community has benefited from relief food during the following periods of prolonged drought: 1984, 1992, 1996, and 2000/2001. Each family (with an average of 10 to 12 members) receives the following food ration per month: sack of maize, 2 kg beans or available pulses, and 1-3 litres vegetable oil. Families prepare the food ration in form of githeri or pound it into flour. Malnourished children are given supplementary feeding in form of porridge flour (3 kg per child per fortnight). Children with low weight-for-height (severely malnourished) are given nutritious biscuits and vitamin A capsules. The community also benefits from the School Feeding Programme. However, the community did not know the quantity of food the school-going children receive per day but they suspect that it is not adequate since occasionally some children report allegedly missing their ration. The food ration is given at lunchtime and consists of ugali and beans or pulses. 2.7 Actions Recommended by the Community

The current sources of information on nutrition were identified as CBOs, Balambala AIDS Awareness Group, Ministry of Agriculture and Livestock Development, media (radio), Parents Teachers Association (PTA), and barazas. 2.8 Current Partnership Analysis
RESPONSIBILITY Provide famine relief food Provide famine relief food Provide famine relief food Restored the original course of river Construct toilets; Provided mosquito nets and mattresses to hospitals and schools; Provided rakes, spades, brooms and wheelbarrows for sanitation improvement Road construction Feed the vulnerable groups with biscuits and vegetable oil Assist the poor with funds every month Has assisted in constructing the local primary school; Provides food; Pays school fees for the less fortunate PARTNER CARE Red Cross Young Muslims Association ALRMP UNICEF

Ministry of Housing SIMAHO M. K. Roble Ali Korane

Public

Works

and

The community identified the key partners in the requisite interventions to include: Ministry of Agriculture and Livestock Development (provide farm inputs such as seeds and fertilizers, and extension services) Arid Lands Resource Management Project (provide tractors, repair the water pump engine) UNICEF (to provide farming tools) Community (to provide funds for casual labor, and to contribute 15% of funds to repair the water pump engine)

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2.9
Problem Poverty

Action Plan
Action Farming Responsible Organizations MOALD ALRMP Community UNICEF ALRMP Veterinary department MOALD Community As for poverty Both parents Health personnel Mothers Elders

Restocking Poor diet Malnutrition Childhood diseases Lack of exclusive breastfeeding Farming As for poverty Provide nutritious foods, Seek treatment, Overcome poverty. Provide nutrition education, Nutritional counseling at the hospital, Good cultural practices from the elders

They identified the expected benefits as (a) cultivation of highly nutritious foods such as vegetables and fruits, (b) increased livestock production more milk, and (c) higher farm incomes to pay for education and health expenses. REFERENCES Kenya, Ministry of Finance and Planning, Garissa District PRSP Consultation Report for the period 20012004, 2001 Kenya, Ministry of Finance and Planning, Garissa District Development Plan 2002-2008, 2002 Kenya and UNICEF, UNICEF/KCO/ GoK Learning Communities Baseline Survey 2002: Final Draft Report, January 2003 CARE-Kenya, Garissa District Livelihood Security Assessment Report, December 2000

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KILIFI DISTRICT 1.
1.1

DISTRICT CONSULTATIONS
Introduction

Kilifi district is one of the seven districts in Coast Province. It lies between 3o 16 south and 4o south and 39o 05 east and 40o east. The shore is 144 km from Mtwapa Creek and Mida Greek. The district borders Taita Taveta district to the West, Malindi district to the northwest and Mombasa and Kwale districts to the south. The district covers an area of 4,779.2 km2 including the Arabuko Sokoke Forest with 189 km2. Table 1.1 Area and Administrative Units by Division
Division Bahari Kikambala Chonyi Kaloleni Bamba Ganze Vitengeni Arabuko Sokoke Forest Total Area km2 227.0 299.7 202.2 909.2 1,743.5 481.9 676.9 189.0 4,779.2 Locations 5 3 4 11 4 5 4 36 Sub-locations 14 11 9 33 13 13 14 107

Kilifi district is divided into seven administrative divisions, namely, Kaloleni, Bahari, Chonyi, Kikambala, Ganze, Vitengeni and Bamba. It has 36 locations and 107 sub-locations. Bamba division is the largest with an area of 1,743.5 km2 subdivided into four locations and thirteen sub-locations followed by Kaloleni division with an area of 909 km2, while Chonyi division is the smallest with area of 202.2 km2 with four locations and nine sub-locations as indicated in Table 1.1. Politically the district is divided into three constituencies, namely, Kaloleni comprising of Kaloleni division; Ganze comprising of Ganze, Vitengeni and Bamba divisions; and Bahari comprising of Bahari, Kikambala and Chonyi divisions. The district is divided into three local authorities, namely, County Council of Kilifi with 26 electoral wards, Kilifi Town Council with 8 electoral wards, and Town Council of Mariakani with 7 electoral wards. 1.2 Physiographical and Natural Conditions

Kilifi district has four major topographical features. The first one is a narrow belt, which forms the costal plains and varies in width of 3 km to 20 km. The coastal plain lies below 30m above sea level with a few prominent peaks on the western boundary including hills like Mwembetungu. Across this plain run several creeks resulting in excellent marine swamps. These swamps are endowed with mangrove forests and presents potential for marine culture. This zone is composed of marine sediments, including coral, limestone, marble, clay stones and alluvial deposits that support agriculture. To the west of the coastal plain lies the foot plateau that is characterized by slightly undulating terrain. The plateau falls between 60m and 135m altitude and slopes towards the sea. The surface is traversed by a number of dry watercourses with underlying Jurassic sediments consisting of shells, sandstones and clays. In this zone, grassland and stunted vegetation prevails. The coastal range falls beyond the foot plateau and has distinct low range of sandstone hills of about 150m to 450m high. These hills include Simba, Kiwava, Jubana, Mazeras and Mangea. Occupying the lower lying ground along the western side is the Nyika Plateau, which occupies about two thirds of the district. The plateau is sparsely populated and is covered by thin vegetation, shallow depressions and gently undulating terrain. This is an arid and semi arid zone, which is suitable for livestock farming. The drainage pattern in Kilifi district is formed by seasonal rivers, which drain into Sabaki River and Indian Ocean. The rivers and streams are Kambeni, Nzovuni, Goshi and Wimbi. The average annual rainfall ranges from 400mm in the hinterland to 1,200mm at the coastal belt. The coastal belt receives an average

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annual rainfall of about 900mm to 1,100mm with marked decrease in intensity to the north and to the hinterland. Kilifi district can be divided into 5 agro-ecological zones (AEZ) in terms of areas that have similar characteristics such as annual mean temperatures, vegetation and humidity. Coconut-Cassava Zone (CL3): This is the zone with the highest potential for crops in the district spreading along the coastal uplands and low-level coastal plains. Major farming activities include tree cropping (mango, citrus, cashew nuts, coconuts) vegetables (chilli, brinjals, okra, etc), food crops (maize, bananas, cowpeas, green grams, etc) and upland rice. Dairy farming is doing well in this zone. It has an average precipitation of 1,300mm per annum and mean annual temperature of 24 degrees centigrade. Cashew nut-Cassava Zone (CL4): This stretches northwards along the coastal plain up to Sokoke Forests. It has an average precipitation of 900mm and mean annual temperature of 24 degrees centigrade. It has agricultural potential with the same crops as in CL3 zone, but with less production. Livestock-Millet Zones (CL5): The zone is of lower potential with a precipitation of 700-900mm. The area is suitable for dry land farming and livestock ranching. Lower Ranching (CL6): It varies in altitude of 90-300mm with mean annual temperature of 27 degrees centigrade and annual precipitation of 35-700mm. Major activities include ranching and wildlife. Coconut Cashew nut-Cassava (CL3-CL4): This zone is mainly found in Bahari division and is the smallest of all the zones. It varies in altitude of 300-310m above sea level with mean temperature of 27 degrees centigrade and annual precipitation of 900mm per annum. The area has potential for the crops grown in CL3 and CL4. 1.3 Settlement Patterns

The district settlement patterns are influenced by infrastructure network and climate, which determine various agricultural potential zones. High population densities are found in Bahari, Kikambala and Kaloleni divisions along the tarmac roads from Mombasa-Malindi and Mombasa-Nairobi up to Mariakani town. These areas are well supplied with piped water and electricity. High population clusters are also found in Chonyi division and some parts of Kaloleni division where there is high potential for agricultural production. Sparsely populated divisions are Ganze, Vitengeni, Bamba and some parts of Kaloleni division. These areas are rangelands and less productive agriculturally. The larger towns in the district (Kilifi, Mariakani, Mtwapa, Kaloleni, Majengo and Bamba) have a total population of 127,656 (1999), which represents 32% of the total districts population. Population Densities by Division (population per km2)
Division Bahari Chonyi Kikambala Ganze Bamba Vitengeni Kaloleni District Total 1999 325 233 327 69 21 64 217 114 2002 356 255 358 276 23 70 238 125

Sources: District Planning Unit Kilifi 1.4 Crop Production

The major food crops are cassava, maize, cowpeas, green grams, rice, beans (little), sweet potatoes, and horticulture (e.g. tomatoes). The tree crops are coconut, cashew nuts, mangoes, oranges and citrus trees, while cotton is being introduced (purchased by Malindi ginneries). Farmers have a problem in timing the planting of beans because rains normally destroy them when they are flowering. The farmers prefer cowpeas because they eat both the leaves and the beans.

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There are two main rain seasons: long rains (May-July) and short rains (October-November). The main food crop planted in the long rains is maize, and the short rains are more reliable than the long rains in the dry areas of the district. The maize yield per hectare is low (5 bags per hectare), while agriculture staff says it is possible to harvest 15-20 bags with right seeds and the right crop husbandry. The food harvest lasts the family for only 3-4 months (around September-December), when they afford two to three meals a day. For the rest of the year, they normally eat about one meal a day. They use cassava to make ugali, and can be boiled or roasted. The growing of millet and sorghum is not popular. All children start working at an early age, but as boys grow older, they reduce their involvement in farming activities to imitate their fathers. There is child labor e.g. girls working as housemaids and in some cases their salaries are paid directly to their mothers. Boys normally work in the shopping centers selling small items e.g. groundnuts. 1.5 Livestock Production

Livestock include cattle, goats, sheep, poultry and donkeys. Dairy cattle include exotic breeds (e.g. Friesian, Jersey and Brown Swiss), while indigenous breeds are zebu and sahiwal. Dairy industry is picking rapidly. There are about 130,000 beef cattle, about 240,000 goats (of predominantly indigenous variety), and about 28,000 sheep (the fat-tailed type). There are about 500,000 poultry (layers, broilers) e.g. chicken, ducks, guinea fowls, and are kept for commercial and household purposes. The keeping of rabbits and pigs is minimal because most of the residents are Muslim. Beekeeping is also encouraged, and there are currently about 1,809 KTBH, 20 langstroth and 600 log hives. It is rare for the birds (poultry) and livestock to be slaughtered for family consumption, as they are seen as a source of income. An estimated 66% of the population live below the poverty line, and consequently sell some animals to buy veterinary drugs for the rest of the stock. During January-February (dry months), prices of livestock are very low because people have no money and most people want to sell, while during the long rains the prices go up because the livestock is healthy. 1.6 The General Poverty Situation

Wealth was defined in terms of land size, number of livestock, and family size (wives, children). According to this classification, the very poor include squatters in Bahari division. In general, poverty manifests itself in the inability by the majority of the people to access basic needs. An estimated 66% of the population in Kilifi lives below the poverty line. KDDP has added the very poor as a poverty class distinct from the poor using the ability to have a meal per day as the criteria. From their findings, there are households who eat one meal in two days. The causes of poverty are lack of rains, lack of money to buy farm implements, lack of access to extension services, low levels of education, and heavy workload on women including tilling the land. They expect extension services to deteriorate because the government is not recruiting new extension staff. Women spend more time on the farm, in addition to childcare and other household chores. The drinking of illicit brew was cited as a major problem. In addition, it is men who attend agricultural training, but is never translated practically because it is women who are mostly in farming and men do not pass the knowledge to their wives. In the communities, wealth is defined in terms of land, livestock, and number of women and children. The main sources of employment along the coastline are fishing, tourism and trade. In the hinterland, the sources of livelihoods include hunting, charcoal burning, selling of palm wine (mnazi), and selling makuti. There are also people specialized in climbing the palm trees, and do it for a fee.

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The average land holding is about 6 acres, but there are many squatters along the coastline. Men mainly spend their income on mnazi, while women spend their income on food, education and health. Most families have one meal per day. The coping strategies in times of stress include eating less, looking for manual jobs, girls work as house helps during January-February (but return home during planting and harvest periods). Other coping mechanisms include charcoal burning, casual jobs (e.g. petty trade), selling local brew, hunting, and selling makuti. Many people have resorted to farming, unlike before when they depended mostly on animals. They said people prefer to plant local maize because hybrid maize is more affected by pests during storage, and pounding of hybrid maize produces smaller pellets. Some of the contributory factors to poverty (via low yields) are: Low acreage under cultivation Traditional farming methods e.g. use of uncertified seeds Inadequate extension services Most of the households are poor and cannot afford farm inputs like fertilizers Poor storage facilities Women provide the largest labor in agriculture alongside other household chores Lack of technology transfer as the men are trained but do not pass the knowledge acquired to the women 1.7 Food and Nutrition

In food preparation, the main process is to boil (whether it is maize, cassava or other foods), and then add tomatoes and local vegetables (e.g. managu, mchicha, mnavu, mchunga). Children are most affected during times of food stress because they eat the same meals as adults and consequently experience shortage of essential foods like milk. Livestock does not appear to feature in the diet and is mostly for commercial use. 1.8 Water and Sanitation

The main sources of water are pans, dams, rivers and shallow wells. The water sources are unprotected and open to contamination. An estimated 24% of the district population has access to safe water. The communities have been sensitized on the need to boil water before drinking, but most community members believe that boiled water loses taste. In some places, e.g. in Bamba and Ganze, there is virtually no water in the dry season. In most of the district, sanitation coverage is high, but very low in Bamba and Ganze (hence the common reference to kajembe mkononi hoe at hand). Plan International has undertaken training and awareness on sanitation in some areas of the district. The district health personnel said that the incidence of diseases in Kilifi is lower than other districts in the province (e.g. Kwale). The health seeking behavior shows that 20% attend hospitals, 19% go to other health facilities, and 1% goes to Mission hospitals, while the remainder is treated at home by traditional healers. However, the health restoration action may depend on the type of illness e.g. those suffering from malaria tend to first purchase drugs from shopkeepers. The government and other agencies have been undertaking training of shopkeepers in dispensing of malaria drugs. 1.9 Maternal Child Health

Only a small proportion (about a ) of pregnant mothers attends antenatal clinics. The factors mentioned were ignorance (lack of knowledge), and the consent of husbands is normally required before attending antenatal and postnatal clinics. In the antenatal and postnatal clinics, women are given advice on diet, hygiene, HIV/AIDS, and other aspects of maternal child health (including feeding of both normal and malnourished children). However, pregnant mothers take the same diets as the rest of family members. Although health workers advice mothers to reduce their workload during pregnancy, the women continue with their normal duties, as they do not have much choice.

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There are very few newborns who are either overweight or underweight. The causes of neonatal deaths were reported as anemia and tetanus (due to low immunization rate of pregnant mothers). Postpartum mothers take the same diets as the rest of the family. Exclusive breastfeeding takes about 3 months, after which children are introduced to water and complementary foods like porridge. A mother knows whether the child is malnourished by feeling the weight with her hands. Some mothers do not follow and some resent - the child nutrition advice given at the clinics, as some feel that they are doing the best they can for their children. According to the MOH, malnutrition is the number one cause of child deaths in the district. The common diseases are diarrhea, convulsions and malaria. The first health restoration action is to visit witchdoctors and other traditional healers. They only seek medical help at health facilities when there is no improvement. The common meals are black tea, cassava and ugali leftovers for breakfast; ugali, fish (e.g. omena) and fruits (e.g. papaw) for lunch; while dinner is same as lunch but may add traditional vegetables (e.g. mchicha). 1.10 Nutrition and Emergencies

Food relief is mainly given in Ganze, Vitengeni and Bamba divisions. The food relief consists of maize, beans and cooking fat. The quantities are not enough and the provisions are erratic e.g. receive 2-5 kg of maize and 1 kg of beans occasionally. They said that the relief food therefore has no impact on nutrition. There are food relief committees that assist in identifying needy households in the distribution of food. The school-feeding programme is in 38 primary schools in the dry areas of the district, namely, Ganze, Bamba and Vitengeni divisions. The rations contain yellow maize, beans, dengu (green grams), yellow split peas and cooking oil. The daily ration for a child is 150 g maize, 40 g peas or beans, and 5 g of cooking oil. The dropout rates in the district are high, especially in areas where there is no school feeding programme. The 38 schools with school feeding programmes are normally among the top in KCPE in the district. 1.11 Nutrition and HIV/AIDS

The HIV prevalence in the sentinel sites (antenatal clinics) in Bamba and Kilifi district hospitals shows a declining trend. For example, in 1997 Bamba had a prevalence of 9%, which dropped to 6% in 2002 while Kilifi district hospital dropped from 10% to 7% during the same period. Awareness of the existence, modes of transmission and consequences of infection is high. Death through AIDS has had a very significant impact on the peoples awareness. It is suspected that the rate of transmission increases during traditional ceremonies e.g. funerals and weddings. HIV was reported as closely related with polygamy and single women. The ministry of health is the lead agency in creation of awareness, with the support of other government departments (e.g. education, agriculture, social services, provincial administration), AIDS control units in other government ministries, and nongovernmental organizations in the area (e.g. Plan International and KDDP). There is still a strong belief within the communities that any illness is a result of witchcraft and kijicho (evil eye). HIV infection results in: Loss of income due to lower productivity If the infected is the breadwinner, the family sinks deeper in poverty due to loss of income The little household income is diverted towards medical care Sale of property to meet medical expenses The added problem of leaving children as orphans Health workers advise HIV patients to eat balanced diet, but this rarely happens due to the food situation at the household level. The HIV status of most lactating mothers is not known, and they therefore continue to breastfeed. The health personnel advise HIV-positive lactating mothers not to breastfeed.

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2.
2.1 2.1.1

BRIEF DESCRIPTION OF THE COMMUNITIES VISITED

BOGARASH VILLAGE Rationale for the Selection of the Community

Bogarash was chosen because it was a prototype community. It is not rich or too poor and was therefore representative. The community has undergone the participatory integrated development (PID) process and is therefore familiar with participatory learning approaches. 2.1.2 Community Response to the Team

The community was receptive and persevered for seven hours and actively participated in the following: community resource map, service map, Venn (chapatti) diagram, focus group discussion (FGD), and problem ranking. In his closing remarks, the Chairman of Village Development Committee expressed appreciation that their community was chosen for this exercise. They also took this opportunity to make a follow up of their HIV/AIDS proposal with the District Development Officer (DDO) who had accompanied the team. They look forward to government response and follow-up on the exercise. Those in attendance included 10 women and 13 men. 2.1.3 Main Economic Activities

Bogarash village is in Mikiriani sub-location, Kaloleni division, Kilifi district. Bogarash village has undergone the participatory integrated development (PID) process since 1999, by Kilifi District Development Programme (KDDP). KDDP is a GTZ programme. The PID process identified insufficient food production (hunger) as the number one problem in the community due to poor farming methods e.g. lack of farm inputs (certified seeds, fertilizers, farm implements) and lack of extension services. The other problems in decreasing order of priority were education, health, biashara (non-farm income opportunities), poor roads, lack of industries, and lack of clean water. Their priority was therefore to improve food security by availing farm implements/inputs at community level. In 1999, a demonstration farm was started. The plot has a shop which stocks farm implements, seeds, fertilizer and veterinary drugs. The plot has crops like maize, fruit trees, and traditional vegetables (mchicha, etc). The members later set up an accumulating savings and credit scheme of their own to enable them to purchase the agricultural inputs and implements. The savings and credit scheme has 170 members consisting of over 90 women. The Coast Development Authority assisted the members to introduce fruit trees (e.g. oranges, lemons and tangerines). The community members have been trained in the use of the veterinary drugs. The crops they grow on the plot and in the surrounding area are traditional Giriama crops, and have not diversified to crops grown in other parts of the province or country. The community has an active village development committee (VDC) through which they managed to secure funds from the Poverty Eradication Commission (PEC). This fund has been utilized in stocking an agrovet shop, farm input implements and a savings and credit scheme. The main crops are maize, cassava and fruits (oranges, passion, pineapples, papaws), while the main types of livestock are cattle, sheep, goats, donkeys and poultry (chicken and ducks - mbata). During the dry season, there is shortage of livestock products (meat and milk). The main expenditure categories in descending order are food, clothing, health, education, farming, ceremonies, entertainment (including alcohol), lighting fuel, laundry (e.g. soap), savings, and shelter. Both men and women work together in the farms, although there is a tendency for women to spend more hours in farm activities than men. The children also assist in the evenings (after school), and during weekends and school holidays.

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2.1.4

Food and Nutrition

The community believes that a nutritious diet (lishe bora) is food that has a variety and gives you good health. This includes starch (cassava, maize and potatoes), proteins (beans), and vitamins from vegetables (e.g. mchicha) and fruits. Very few can afford the recommended diet. In addition, they emphasized that the communities that had not undergone the PID process did not have the right information on food and nutrition. The food eaten is the same for all family members including the number of meals per day. A typical meal pattern would be breakfast (black tea, cassava or left over ugali) and lunch/supper (ugali or cassava with fish or additional vegetable made with coconut milk). The community has never received any relief food since 1996 although they do not grow enough food to meet local needs. In some years, rain is unreliable and crops are destroyed by either extreme cold weather or insufficient rain. They do not sell food since they do not even produce enough. 2.1.5 Maternal Child Health

The nearest health facilities are at Kaloleni and Rabai. The mothers said that there is almost no training on the proper feeding of pregnant mothers. There is no special feeding for pregnant mothers the normal diet is uji (millet/maize and with milk and sugar for those who can afford); ugali, mchicha, managu and coconut juice for lunch; and the same for supper. There is no reduction in a womans workload during pregnancy, unless the husband has the financial ability to recruit casual labor in the farm and house when needed. An estimated half of births take place in health facilities while the balance is taken care by TBAs who are not trained. The proportion of low birth weight babies was reported as high. The cause of deaths in the first month was mainly due to tetanus (pepopunda). The feeding of postpartum mothers includes chicken and ugali. Some newborns are first given a solution of water and sugar before initiation of breastfeeding. Some mothers take up to three days before initiation of breastfeeding as the mothers attend to some traditional ceremonies before initiation of breastfeeding. There is exclusive breastfeeding for about a month, after which they start introducing porridge (mainly maize porridge with salt/sugar). The child is occasionally given water mixed with salt and sugar to prevent constipation and ease the bowels. Children are introduced to adult foods at the tender age of 9 months, but might dilute the food (e.g. ugali) to avoid choking. Most mothers below 35 years know the benefits of immunization and follow the immunization schedule. The major childhood diseases are malaria, diarrhea and vomiting, fever, coughs and flu, and worm infections. The sick children are taken to hospital although some first take them to traditional healers. They identify malnourished children just by feeling the weight. The community believes that those children who get sick because of the evil eye (kijicho) do not recover because there is no treatment. In the clinics, the mothers are advised to feed their children with milk, eggs, beans, bananas, mchicha (and other traditional vegetables), but most are unable to provide because they cannot afford. The adult education officer in the area also gives them advice on nutrition. 2.1.6 Water and Sanitation

The area has clean piped water. Very few boil water before drinking because they assume the piped water is already safe. Only about half of the homesteads have pit latrines. The mothers make sure that they wash their children regularly. The main adult diseases in the area are malaria, HIV, typhoid and gonorrhea. There is very little knowledge on prevention of the diseases.

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DERA VILLAGE

The second community visited was in Dera village, 9 km from Kilifi town along the Kilifi-Bamba road. It is located in Tezo location of Bahari division in Kilifi district. It has an estimated population of about 800 people. Villages bordering Dera are Mdzongoloni to the North, Mikingirini to the East, Kabarani to the south and Mjibu to the west. Dera village was chosen because it had undergone the PANS process under the Community Based Nutrition Programme (CBNP) since 2002. The community at the time prioritized their problems as follows: Health Education Agriculture Technical training Security Lack of markets Posho mill The first four problems were ranked as most critical to development of the area. A village development committee was started with 15 villagers being trained on a wide range of developmental issues, including health issues that led to the starting of a Bamako initiative in February 2003. The Bamako started with six types of drugs but had increased to twenty by mid-April. During growth monitoring for children, it was found out that lack of nutritious diets was the main cause of underweight in children, and therefore started food demonstration (types of food and food preparation methods) at the Bamako site. Before the Bamako site was started, the community used to buy medicine from the shops, go to herbalists, or travel to Kilifi district hospital as a last resort. They started a nursery school in March 2002, with 12 children (5 girls, 7 boys), but had increased to 79 (46 boys, 33 girls) by April 2003. The parents pay the two nursery school teachers (KSh 2,000 per teacher per month) out of the fees collected (KSh 60 per child per month). Some eligible children are not enrolled in the nursery school because their parents are unable to pay the school fees. There is child feeding in the nursery school. They are putting up toilets in the nursery school. The vision is for the nursery school to finally become a primary school, as there is no primary school nearby. 2.2.1 Community Response to the Team

The community was very receptive and felt privileged to have been chosen although by the time the team arrived at the meeting place some villagers were busy planting as it had rained. They suspended planting and participated actively in drawing chapatti diagram, major diseases chart, and problem ranking. They had previously drawn a village resource map and there was therefore no reason to take them through the same process again. The social services officer in charge of the CBNP was extremely cooperative and helpful in all the activities the team undertook in Dera. 2.2.2 Agricultural Production

The farmers in the area have begun to embrace new technologies in food production. There is an active extension officer who visits them, and this boosts their morale mainly because he makes return visits to check on progress. CBNP has trained the communities on savings and credit (and the community has already started one group), and given the community 3 bicycles to ease transport to Kilifi on community activities. Agricultural extension officers train selected community members in farming and nutrition, who are in turn expected to train the rest of the community. With the use of new farming methods (certified maize seeds, planting in good time, use of fertilizer, good crop husbandry) an acre can produce 15-17 bags per acre. The food lasts 2-5 months depending on the number of people in the household, but the average is 3 months.

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Children normally eat three meals and adults 2 meals. However, during times of severe food stress, food consumption declines and is mostly cassava for all the meals. The types of livestock kept are cows, goats, poultry (chicken, turkey), and rabbits, although they also hunt squirrels for consumption. In majority of cases, they only slaughter chicken and turkey for visitors; and eggs are rarely eaten and are either sold or kept for hatching. The main method of cooking is boiling using firewood. The main types of food are ugali and omena (dagaa), coconut milk, mabuyu (baobab seeds, fruits), mangoes and mandafu (coconut juice). 2.2.3 Maternal Child Health

Majority of the mothers do not attend antenatal clinics due to traditional beliefs and long distances (over 10 km) to the nearest health facilities. Pregnant mothers eat the same foods as the rest of the family. Those who visit antenatal clinics are screened for anemia, given iron and folic supplements, malaria treatment and advised on feeding. There is no reduction in the workload of pregnant mothers. Most women deliver at home. The cause of child deaths in the first month of life was mainly due to tetanus (pepopunda). There is no special diet for postpartum mothers. Before breastfeeding the baby for the first time, a solution of salt, sugar and water is given to the child. The child is breastfed exclusively for 2-3 months regardless of whether it is a boy or a girl. Thereafter, children are given porridge (mainly maize porridge with salt/sugar) twice a day, which is increased to three times as the child grows older. The major childhood diseases are malaria, coughing, diarrhea, heat rash and dysentery (kuhara damu). The main women diseases were back pains, leg pains, waist pains and teeth problems. The whole community had problems with coughing, earache (njika), and eye problems (matongo). They described them as diseases of the poor since it is difficult to find the same problems among the rich. 2.2.4 Water and Sanitation

Some of the areas have access to piped water where the community members pay KSh 5 per 20-litres of water. During dry spells, those without access to piped water travel up to 6 km to get water. Walking long distances in search of water drains the energy levels of women. At the time of the visit, the community was expecting some experts from the ministry of water to come to advise them on protecting a well. Most community members do not boil water before drinking despite the awareness created through community resource persons e.g. CHWs. Only an estimated 1% of the households have access to a toilet. 2.2.5 Training and Entertainment through Theatre

There is a theatre group, which was started as an awareness tool since the community had problems accepting new ideas. Some of the issues covered in the theatre include behavior change in HIV/AIDS, and benefits of new technologies in farming.

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MWINGI DISTRICT 1.
1.1

DISTRICT CONSULTATIONS
Agricultural Production

The main crops grown in the district include cereals (maize, sorghum and millet), legumes (beans, cowpeas, green grams, delichos labalab njahi, and pigeon peas), cash crops (cotton, sunflower and coffee), fruits (mangoes, papaws, oranges) and vegetables (kales, tomatoes, onions). The vegetables are mainly grown under irrigation. The staple food consists of maize, sorghum and millet. The main types of livestock are local breeds of cattle, goats, sheep, donkeys and poultry. Dairy and poultry production of improved breed is practiced on very low scale. Sahiwal bulls are reared to improve the quality of local breeds. The district is able to produce enough food for local consumption during good years (when there is enough rain). However, even in years when the harvest is good, crop produce and livestock are sold to meet domestic expenditure requirements. Usually, the food produced can last for only 2-3 months due to heavy sales soon after harvest. Apart from maize received as part of relief food, most of the maize purchased is produced within the district. The grain traders purchase and store food for resale during periods of scarcity. During seasons of food deficit, food prices tend to rise while the prices fall during surplus period. Maize is planted twice a year, at the onset of the March/April rains (less reliable) and the October/November rains (more reliable and is the main season for maize). The main varieties of maize grown are Katumani, Makueni and drought-tolerant hybrid varieties supplied by the Kenya Agricultural Research Institute (KARI) such as DH01, DH02 and H511. The main varieties of sorghum supplied by KARI include Serena, Serondo and KARI Mtama I. At a general level, every member of the family is involved in agricultural activities. However, there is segmentation of labor, with men involved in activities requiring effort (such as ploughing and opening up bushes) while women and children take part in activities that are time-intensive (planting, sowing seeds, weeding, harvesting). Some of the common fruits grown (and the season) include mangoes (December to February), grafted citrus fruits (October to late November), non-grafted citrus fruits (September to October) and guavas (January to March). Grafted citrus fruits are adapted to local climate, and therefore ripen during the dry season, while guavas include both local and improved varieties. A large proportion of fruits produced are consumed locally and the balance sold outside the district. Apart from domestically produced fruits, there are also wild fruits that supplement local production. The most common include baobab (kiamba/ mwamba) tree fruit or mugiyo in Kikuyu, mkwaju fruit (tamarind), and mkomoa/ kikomoa/ kiluilui. The baobab fruit is common during the dry season when there is general scarcity of fruits. The tree is not affected by drought. When the fruit is mature, the seeds dry up. The seeds are colored and sold or consumed. The fruit contains some flour-like substance. This substance is mixed with milk to make porridge. Mkwaju (tarmindus indica) fruit is usually in season during August to October. The fruit is mostly exported to Mombasa. After the fruit is crushed, the testa/hardcover of the seeds is removed. The seeds are soaked in water, and the mixture is sieved and used to add flavor to porridge. At other times, children suck the juice from the unprocessed fruit. When the juice comes into contact with teeth, it makes them sensitive/numb. The common types of food in the district include githeri, muthokoi, rice, green grams, beans, meat, kinaa (a cake made of a mixture of sorghum/millet and milk) and millet/sorghum porridge.

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Food and Nutrition Programmes

The programmes in the district aimed at minimizing food insecurity and improving nutritional status include public education on food management and energy saving. The two most notable programs are (a) promoting consumption of sorghum and millet using simple innovative products, and (b) promoting the use of cowpea leaves through preservation. There are also special programs to boost the production of sunflower and cotton to ease financial stress at the household level. Since sorghum and millet (though nutritious) are labor intensive, most farmers were abandoning growing these crops. Public education has been used to popularize innovative products from these crops e.g. sorghum pillau, sorghum chapatti and sorghum/millet pancakes. The target has been women group members who are trained in these methodologies so that they can train their group members. There have been efforts to disseminate these technologies through schools (targeting primary Standards 7 and 8 children who may be involved in cooking at home), and by organizing field days for communities. Such training sessions are done at least once per month. Although there is good supply of cowpea leaves during the wet season, there is a serious shortage of vegetables during the dry season (June to October). In an effort to smooth out supply, the dried cowpea leaves technology was developed. The technology is simple and is based on drying the leaves through dehydration. First, water is boiled, and then the fresh leaves are blanched (immersed in the hot water for a short period). They are removed and spread on gunny/polythene bags under a shade to dry. Drying usually takes any time from a few hours to one and half days. When dry, the leaves are packed in black polythene bags for storage. The leaves should not come into direct contact with sunlight during drying and storage since it is believed that the nutrient content is adversely affected. The dry leaves can be cooked by immersing in cold water for about 10 minutes before boiling. Once boiled, they can be fried in the same way fresh leaves are handled. Once fried, they maintain the same taste and texture. In fact, it has been noted the leaves taste better than the fresh ones. Dry cowpea leaves have been sold to GTZ under the food-for-work program. These programs have been very successful since farmers have readily accepted these messages and are practicing them. More people are now planting sorghum and finger millet and storing cowpea leaves. However, large sections of farmers have not yet been trained due to time and financial limitations. Nutrition is taught at secondary school level through the Form 2 home science syllabus. The aspects that are included in the syllabus include food nutrients, nutritional deficit disorders and food fortification. 1.3 Maternal Child Health

Pregnant mothers are provided with nutrition information during visits to clinics under the micro-health education programme through lessons that take about 20 minutes. However, pregnant mothers are not followed at home to establish whether they practice the knowledge. Even though nutrition advice is provided during clinic visits, there are pregnant women who do not attend clinics and women who visit the clinics but avoid taking the health education lessons. The health personnel felt that mothers should be exposed to programmes that impart health education long before pregnancy. In addition, information, education and communication materials would be critical in passing on messages to mothers at prenatal, antenatal and postpartum stages. The coverage of antenatal clinics in the district is still low. Some of the reasons for poor attendance include long distances to the nearest health facility, lack of money for transport, and poor transport network. A significant proportion of women deliver at home. There has been no specific programme on the feeding of postpartum mothers. However, a programme was introduced a month ago (March/April 2003), which provides mothers with information when they are at the maternity wards. After delivery, they are given appointments to return later, but many of them rarely honor the appointments. The main problem has been that there is no proper feeding after delivery.

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During 2002 measles campaign, the district achieved the target of 95%. Immunization is carried out regularly in all government facilities. It has been the practice that mothers bring children for immunization up to 9 months. However, thereafter, participation has been very low. Since a lot of information is given during immunization visits, most mothers miss vital health information. The main childhood diseases include malaria, diarrhea, respiratory tract infections (RTI) and intestinal worms. Insecticide-treated nets are provided to mothers free in the district hospital after delivery. In addition, efforts have been taken to spray and clean mosquito breeding places. De-worming programmes have been initiated as well as public education campaigns to improve the management of RTI and diarrhea at the household level. The main adulthood diseases include malaria, diarrhea, RTI, intestinal worms, HIV/AIDS, accidents and TB. However, there has been a rise in the number of cases of hypertension and diabetes especially among elderly people (60+ years). For adults, health education programmes place emphasis on enhancing the capacity of people to identify the problems early enough. 1.4 Environmental Conservation

The district does not run any community environment programmes. However, due to the problem of land scarcity, communities have been encouraged to develop viable woodlots, fruit orchards, beekeeping and so on. Woodlots are small plots within the farm for agro-forestry or otherwise. Farmers are encouraged to have fruit orchards as an income generating activity as well as for consumption at the household level. The Belgium Government (through the Department of Forestry) supports most of these programmes. The main types of cooking fuel include firewood, charcoal, kerosene, and gas (to a small extent, in urban areas). Firewood and charcoal are available locally, and some is sold to neighboring districts/towns. Government policy in the district has been to encourage the harvesting of dry wood. Commercial charcoal production is discouraged due to concerns of environmental conservation. It is therefore recommended that charcoal should be produced from deadwood. In Mumoni Division (areas near Tana River district), there has been serious forest depletion by commercial charcoal dealers. Although all the divisions in the district have adequate supply of firewood, high potential areas (e.g. Migwani and Central divisions) are facing pressure on wood. In fact, charcoal burning is being discouraged. 1.5 Water, Sanitation and Personal Hygiene

The district suffers extreme water shortage during drought spells. The last drought was experienced in 2001. Since drought is experienced in three out of every 10 years, water shortage is a perennial problem. The main sources of water include dry riverbeds, shallow wells, River Tana, boreholes (piped), piped water (from Kiambere Water Project), roof catchments, springs, and rock catchments (to a small extent). Dry riverbeds accumulate water immediately after rains, and the quantity available reduces with time as the dry conditions set in. Largely, the water consumed in the district has high microbial content. Domestic animals and wildlife share the same water sources with humans. The main water sources in the district are unprotected. The water is contaminated, which explains the high incidence of diarrheal diseases. Sanitation coverage is not high. Although people are aware about the need to drink safe water, disposal of waste and promotion of personal hygiene, the practice has been poor. This has been explained by the extreme water scarcity, which makes water availability more critical than the question of its safety/quality. 1.6 1.6.1 Nutrition and Emergencies Food Relief

During drought years when there is serious food stress, the district relies on relief food. The main sources of relief food have been the Government, World Food Programme, GTZ, Catholic Diocese of Kitui, and ACTIONAID. The WFP also supports the School Feeding Programme in the district. A few years ago, the

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GoK provided rations of 2 kg of maize per family per month. The WFP was very active in the area of relief particularly during the 2000-2001 period. Under the WFP programme, the monthly food ration included 6 kg of maize, 2 kg of beans and 200 mls of vegetable cooking oil per person. During the period 1999 to early 2002, GTZ introduced the food-for-work programme. Most of the projects under the food-for-work program have been in the areas of infrastructure and environmental conservation. The GoK relief food was provided through the provincial administration. At the community level, the chief was the sole decision maker regarding the beneficiaries and the logistics. The district would receive about 6,000 bags of maize per year. The program was poorly organized and faced problems of transport, logistics and corruption. It was more of a political tool than a humanitarian intervention. Under the WFP, communities were involved through local-level committees who provide critical local information. The committees were charged with the responsibility of targeting the neediest households. Households were ranked based on need and relief food distributed starting with households that were ranked as most needy. About 10% of the available food supplies were reserved for special groups such as the aged, disabled, etc. Initially, food relief in the district was used as a political tool. During these periods, there would be a lot of food during election years particularly in the lower divisions of the district. This encouraged dependency. However, lately, coordination has improved. A lead agency is identified to coordinate all relief efforts in the district. GTZ has been instrumental in initiating the food-for-work programme. Through the food-forwork programme, the communities receive multiple benefits through improved food supply, better infrastructure, and soil conservation. Unlike in the past when food was used as a political tool, food-forwork and community-based approaches of targeting the poor have reduced dependency since people are aware that they can be independent by growing more food. 1.6.2 School Feeding Programme

The WFP-supported School Feeding Programme has been operational in the district since 1980. It targets primary schools. The WFP provides food to schools directly through the District Education Office. The main objectives of the SFP are to increase enrolments, improve attendance, reduce dropout rates and enhance educational performance. The SFP operates under two sub-programmes, namely, the regular (continuous) school feeding and the expanded (emergency) school feeding. The regular school feeding is the one implemented during normal years on a continuous basis. However, the expanded programme is implemented during periods of drought and extreme food stress. The district has 353 schools. Currently, there are 96 schools under regular school feeding while 103 schools have been placed under the expanded programme. About 154 schools are not covered under any of the programmes. All schools under the SFP receive maize, beans and cooking oil to make lunch for all students in the school. In addition, all schools under the expanded programme receive corn soya milk to make porridge for students at 10 am break. The communities contribute to the programme by supplying firewood and water, as none of the primary schools in the district has piped water in the compound. The communities also supply beans during periods of good harvest. The main role of government is administering the programme and handling logistics. There are no NGOs and churches supporting the programme. One of the most important achievements of the SFP has been the significant increase in primary school enrolments. For example, in 2000 when the current programmes were resumed, primary school enrolment was 54,164 (27,177 boys and 26,987 girls). After one year (2001), enrolment during Term I was 58,303 (27,419 boys and 30,884 girls), Term II 62,550 (30,816 boys, 31,734 girls) and Term III 65,385 (32,328 boys, 33,057 girls).

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Some of the constraints the programme has faced include long delays in delivery of food from WFP to the district stores, poor roads that make food be dropped several kilometers from schools, and use of commercial transport (at considerable expense to the district education office). To ensure the sustainability of the SFP, schools have been encouraged to initiate income generating activities like school farms, beekeeping, etc. The problem has been that some schools do not have shambas. 1.7 Nutrition and HIV/AIDS

The HIV/AIDS prevalence in the district stands at 7.6% but this has been falling over the past 5-7 years. The high level of awareness (estimated at 99%) has failed to trigger a change in behavior. Although VCT centers are important in influencing behavior change, there is no such center in the district. There are several home-based care programmes initiated by the Catholic Church and several CBOs. Community based organizations have been very active in providing food, clothing, school fees (for orphans), and through guardian-orphan support. The National Aids Control Council has funded organized groups to implement AIDS-related activities. Mothers who are infected with HIV/AIDS are advised to stop breastfeeding. It is recommended that babies of infected mothers be given breast-milk substitutes. However, most of the mothers are not able to afford the alternative foods. At the district hospital, there are no drugs to prevent mother-to-child transmission. 1.8 Community Organization

The district does not have any community groups specifically dealing with nutrition. Apart from school feeding, there are no programs for promotion of adult feeding. Although the approach at the district-level has been to use public education during special days (such as Malaria Day), such efforts make very little impact since such days are traditionally marked by celebrations and entertainment. Therefore, there is minimal focus on health education issues. At the household level, there is labor specialization in farming. The breaking of the land is done by men alone using ox-ploughs while men and women do planting. At the planting stage, men open the furrows with ox-plough while women sow seeds and apply fertilizer. Weeding is mostly carried out by men and harvesting by women and children. The postharvest management of food is by women. During August and September, boys may be withdrawn from school to scare birds from the sorghum and millet crops. During years of good harvest, most families do not store food for long due to storage problems. Locally, the great grain borer (locally known as Osama) attacks the crop in the farm and destroys the crop during storage. The farmers have been completely vulnerable since there are currently no control measures for this pest. Although food supply in the district has improved over the last 5 years, local food production does not meet the local food demand. As such, food stress cycles are regular. During periods of food stress, the most vulnerable are women and children. Some men migrate to towns in search of jobs. Most families cope by relying on food relief and intra-district food supply. A small proportion (20-30%) of the population in the district can afford a nutritious diet. The popularity of ugali has been improving over time. In the past, ugali was not a popular dish. The popularity of muthokoi is confined to the rural areas. Muthokoi is time demanding in terms of cooking, and is therefore accorded least preference in urban areas. 1.9 Migwani Child and Family Programme

The Migwani Child and Family Programme is sponsored by the Christian Childrens Fund (CCF) and was started in 1979. It covers 75% of Migwani Division. The programme is non-denominational and runs five sub-programmes, namely, Early Childhood Development, Small and Micro Enterprise Development, Basic

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Education, Health, and Sanitation and Nutrition. Although the programme had been providing food supplementation since 1993, the nutrition sub-programme was initiated in 2002. The objective of the nutrition programme is to monitor the nutrition status of enrolled children and provide supplementation where necessary. Those are children who were earlier identified with symptoms of malnutrition and were enrolled in the nutrition programme. The programme also supports school feeding for under-fives. Under the nutrition programme, growth-monitoring clinics have been established within Migwani Division. These clinics apply a holistic approach by monitoring the growth of both enrolled and non-enrolled children. A trained nutritionist conducts growth monitoring using normal anthropometrics standards, and uses data on age and height to classify children as normal, moderately malnourished, and severely malnourished. At intervals of three months, visits are made to the growth monitoring centers. All children with moderate and severe degrees of malnutrition are invited to the programme offices to establish the exact causes of malnutrition. When a child is presented as a severely or moderately malnourished case, the child is enrolled into the programme and provided with appropriate food and vitamin tablets. The food is given to the mothers on behalf of their children. Since the food could end up being consumed by older members in the family, social workers carry out regular visits to establish whether the supplementary food that is provided benefits the malnourished child. During the month of April 2003, 740 children (400 boys, 340 girls) were monitored. Three hundred and ninety nine (or 54%) were of normal status, 173 (or 23.4%) had mild malnutrition, 141 (19.1%) had moderate malnutrition and 27 (or 3.6%) had severe malnutrition. In 2002, malnutrition status was high with 842 families suffering from the condition. In order to raise awareness on the problem of malnutrition in the division, the programme has mounted public education sessions for community health workers who are expected to pass on the same knowledge to untrained parents. Although this has been the case, it has been noted that parents still have a problem in identifying cases of moderate malnutrition. However, parents have been able to identify severely malnourished children. Parents have been encouraged to get involved in farming activities that improve the capacity of the household to provide nutritious foods especially to the children who were formerly enrolled in the food supplementation programme. Some of the approaches encouraged include kitchen gardening, provision of drip-kits (for irrigation) and container gardening. The programme has been hampered by a number of problems. First, due to high poverty levels (estimated at 60-65% in the district), most households lack the capacity to sustain proper feeding for their children once support from the programme is withdrawn. Secondly, high poverty levels have also meant that the number of malnourished children has exceeded the capacity of the programme. Therefore, not all children suffering from malnutrition are put on supplementary feeding. In most cases, preference is given to cases of severe malnutrition. Thirdly, is the inability of parents to identify malnutrition at an early stage. It was also noted that the programme lacked growth-monitoring cards. The programme management recommended that the mandatory age for growth monitoring should be reviewed. The Ministry of Health recommends growth monitoring for only the under-fives. After five years, parents are not compelled to take their children for monitoring even when the children suffer from malnutrition. It was also recommended that nutrition education should be taken up in the school curriculum right from the primary level to secondary school. The programme has collaborated with similar programmes in the region. Three years ago, the programme provided maize flour to the Catholic Diocese of Kitui, which has been running nutrition-based activities in the area. The Migwani programme has also been taking part during health education days that have been organized by the Catholic Diocese of Kitui and Jeshi la Wokovu.

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COMMUNITY CONSULTATIONS

Community consultations were carried out in Thonoa sub-location, Waita Location, Central Division. There were fifty members of the Mitukii ya Iveti Women Group. This group draws its membership from men, women, boys and girls. 2.1 Resources

Some of the main resources identified in the community include schools (5 Primary and one Secondary school), rivers and dry riverbeds, roads, and churches (8). The sub-location has no established market place, no cattle dip, and no dispensary. Piped water is 15 km away. The water in the streams is unsafe for human consumption and lasts for only 2-3 months after the onset of rains. 2.2 Month January Annual Farm Calendar Activity Weeding Guarding the crop from birds and wild animals Construction of silos Cutting and transporting thatching grass for silos Harvesting Preparing shambas Planting (late march)* Planting* Weeding* Weeding Guarding crop from monkeys Harvesting Harvesting Bush clearing Bush clearing Preparation of shambas Planting Weeding Guarding against wild animals By whom Men, women, children Men, women, children Men Women All All All All All All Women All All Men Men All All All Women

February March April May June July August September October November December

Note * the exact timing for these activities depends on the onset of the rains 2.3 Food and Nutrition

Major food crops include millet, maize, sorghum, green grams, cowpeas, beans, pigeon peas and cucumber. The capacity to produce own food varies by season. During the dry season, the households are able to supply 25% of own consumption while purchases account for 75%. During the wet season, own production accounts for 75% of the household food requirements while the rest is accounted for by purchases. It was felt that with adequate irrigation programs, drilling of boreholes and supply of droughttolerant seeds, farmers would be able to produce more food. The community experiences food stress. The most affected during such periods are women and children. Men migrate to towns. However, households cope with such stress by borrowing from neighbors (to repay back later in kind), selling livestock, selling land, sale of family labor, and relief food. During the past 10 years, access to food has worsened, which has even led to breakup of families. Most of the losses at farmlevel and during storage were attributed to the great grain borer (locally known as Osama). Most of the community members did not understand what was meant by a nutritious diet. Instead, they indicated that they eat food to fill the stomach. They indicated that even if they understood the concept of good nutrition, they do not have the capacity to provide such to their families. They indicated that out of

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those present during the community consultations, none of them could afford a nutritious diet. They argued that it would be foolhardy to strive to obtain a nutritious diet when they could hardly afford a basic provision of three meals a day. The members noted that there had been a change in the popularity of some meals over time, although the change has been minimal. For instance, most families have shifted consumption from millet porridge (for breakfast) towards white tea (with milk). The community felt that the change in eating habits has been detrimental to their health since the food eaten in the past made people strong but now people are relatively weaker. The community did not receive any assistance to promote food production. The only programme by the Ministry of Agriculture sells seeds to the farmers. Since the seeds were not free, most of the community members could not afford to purchase them. The community members noted that the sale of food (not necessarily surplus food) is common. However, immediately after harvest, prices fall to very low levels. For maize, the price would fall to as low as KSh 5 per kilogram while millet would sell for KSh 2 per kilogram. The money realized from sales is used to purchase school uniforms, pay school fees, purchase clothing, meet health expenses (especially drugs and treatment), and domestic use. Remittances formed an important source of income. In most cases, the recipients were mainly spouses. It is not a common practice for grownup children to remit money to their parents. Most of such remittances were spent on purchase of livestock and seeds and to meet health expenses. 2.4 Maternal Child Health

Majority of the mothers attend antenatal clinics. However, some mothers never attend such clinics due to ignorance. At times when patients go for treatment without money, they are treated on credit with a promise to pay later. Some of them who incurred debts at the clinics feared to go there for MCH care. Mothers who attend clinics are given information on proper feeding and childcare. Apart from providing maternal and childcare services, such clinics usually provide other health services. However, many ended up with poor feeding since they could not afford the recommended diet. Although most mothers attended antenatal care clinics and were aware of the consequences of delivery at home, most of them delivered at home. Despite this, they noted that the number of children who died in the first month after delivery was low. Mothers indicated that the majority of children took between 2 to 3 hours before the first breastfeeding. However, there were cases of babies breastfeeding immediately after delivery. Complementary feeding was introduced at any time between 3 to 6 months, while the child is breastfed in the first 2 years. Childhood diseases include measles, pneumonia, smallpox, intestinal infections and malaria. For most of these diseases, the first line of action is to take the child to hospital. However, for teething, some parents consult traditional specialists. Major adulthood diseases include malaria, TB, typhoid, HIV/AIDS and amoeba. Mothers indicated that they were able to identify malnourished children by observing the hair and frequency of illness. When the hair turned brown and the child fell sick frequently, it was likely that the child was malnourished. Such children were taken to hospital or were given nutritious food. Most mothers indicated that they took their children for growth monitoring.

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At the household level, the frequency of feeding differed across the various age and gender groups as shown below: Age (years) 1-5 6-13 13-19 Young women Young men Old women Old men Frequency 4 to 5 times a day 2 to 3 times a day depending on the distance from school Twice per day Three times a day Once or twice per day Twice per day Twice per day

The community members indicated that they did not receive any information on nutrition (apart from mothers through MCH clinics). Nutrition information used to be provided in the past on visits to major hospitals but this was no longer the case. When nutrition information was provided, food was also supplied. The members complained that the water consumed in the community was polluted. Humans shared the water sources with animals. Most families have toilets (about ) while the rest use bush. Although most of the members understood that unsafe water should be boiled, they did not boil water as they felt the process was tedious and time consuming. They indicated that they always washed vegetables before cooking, washed hands before handling food, and washed fruits before eating.

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NAIROBI PROVINCE 1.
1.1

DISTRICT CONSULTATIONS
Background

The district consultations were carried out through interviews with the following departments: agriculture and livestock, health (central government and Nairobi City Council), city education office, and Nairobi Breastfeeding Information Group (an NGO). Nairobi Province is located in the central part of Kenya on longitude 36o 52 east and 1o 15 south. It borders Kajiado district to the south, Machakos district to the east, Thika district to the north and Kiambu district to the west. It covers an area of 696.1 km2. The province is divided into 8 divisions, 49 locations, 110 sub-locations, and 8 constituencies whose borders are the same as the divisional boundaries. The table below shows the population of Nairobi by divisions, total area, number of households, and density of population as per the 1999 population census. Population by Division - 1999
Division Central Makadara Kasarani Embakasi Pumwani Westlands Dagoretti Kibera Total Male 129,464 108,773 183,320 227,098 109,809 111,209 125,072 159,083 1,153,828 Female 105,478 88,661 155,605 207,786 92,402 96,401 115,437 127,286 989,426 Total 234,942 197,434 338,925 434,884 202,211 207,610 240,509 286,739 2,143,254 Hhs 69,958 58,032 109,149 133,472 54,801 61,258 73,670 89,086 649,426 Area km2 10.5 20.1 85.7 208.3 11.7 97.6 38.7 223.4 696.1 Density 22,164 9,823 3,955 2,088 17,283 2,127 6,215 1,284 3,079

Population of Survey Area - 1999

Location/Sub-location Kibera location Kibera sub-location Makina sub-location Silanga sub-location Lindi sub-location Male 48,492 9,328 17,821 10,360 10,983 Female 35,195 6,762 15,103 6,158 7,172 Total 83,687 16,090 32,924 16,518 18,155 No. of Hhs 28,701 5,226 10,589 6,281 6,605 Area km2 1.7 0.3 0.9 0.2 0.3 Density 49,228 53,633 36,582 82,590 60,517

1.2

Poverty

In Nairobi, poverty is defined in terms of inadequacy of income, lack of basic needs and lack of access to productive assets as well as to social infrastructure. Urban poverty in Kenya is increasing at a rapid rate. An estimated 27% of the population is below the poverty line. The majority of the poor lives in informal settlements, which account for an estimated 55% of its population and occupy 5% of total residential area. Most men are engaged in wage or salaried employment and women undertake all household chores with the assistance of children. There are various manifestations of poverty, depending on the specific social structure of the population. These include food poverty (food consumption below a normative minimum level), income poverty (lack of adequate income or expenditure to meet basic needs), extreme destitution (inability to satisfy even minimum food needs), and environmental poverty (overcrowding, sanitation, drainage, water supply and access to health services). The main causes of poverty in Nairobi can be attributed to economic, environmental health, and social factors. The major economic factors are lack of employment opportunities, high cost of living, poor governance, slow growth in the industrial sector, landlessness (lack of secure land tenure), lack of access to credit, and poor access to basic infrastructure and urban services. The social factors include difficulties faced by vulnerable groups (including female-headed households, street children, disabled, the elderly and AIDS orphans); social breakdown within the family structures; insecurity; and high population growth due

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to rural-urban migration. Environmental health factors include lack of proper liquid waste management, lack of solid waste collection and disposal, lack of supply of potable water, and lack of affordable and accessible healthcare services. 1.3 Food and Nutrition

Since Nairobi is an urban area, most food consumed comes from outside, leading to food availability at all times. Food produced in Nairobi urban agriculture is insufficient to meet consumption needs. The crops grown are mainly vegetables (e.g. kale, spinach and tomatoes), with the area estimated at 42 hectares. There are also some livestock production activities mainly involving poultry, dairy cows, and goats and sheep. At the national level, the ministry of agriculture and livestock development (MOALD) promotes food security through the following: Promotion of indigenous and underutilized foods such as soya, cassava, sorghum, millet and traditional vegetables; Promotion of food processing e.g. sorghum processing which promotes digestibility; Teaching on recipes through cookery programmes in the media; Promotion of appropriate technology that saves time and energy i.e. energy-saving jikos; Promoting the diversification of eating habits. People tend to eat ugali and kale all the time, but are encouraged to eat other types of food such as the Asian vegetables, mushrooms, power porridge, etc; Promotion of kitchen gardening and keeping small animals. The multi-storage bag farming and backyard farming are encouraged; Promotion of healthy eating habits from local foodstuffs such as garlic, carrots, etc; Gender sensitization programmes, of which the farming bag is encouraged as a friendly technology for the man. The main types of food produced in Nairobi are horticulture (mostly produced in Westlands, Dagoretti and Langata), poultry (scattered all over), small livestock (in the outskirts), wastewater irrigation (in Ruai and Kibera) and river irrigation (along Nairobi River which is likewise polluted). One issue of concern is the use of contaminated (sewage) water for irrigation, as the vegetables become contaminated during handling and accumulate heavy metals during growth, which are harmful to health. The crops grown along the roadsides also pick up lead from vehicle fumes. There are a number of constraints to urban agriculture. First, there are no proper programmes to reach as many urban farmers as required, and there is no mass media programme for that purpose. Secondly, the farmers are normally squatters, and there are therefore no incentives for proper land utilization as the farms can be repossessed anytime. Thirdly, there is theft of mature produce before harvest. There is need for proper and full utilization of the Agriculture Information Center (Westlands) as it has all the necessary information on methods of food production, food preparation, and preservation and storage. One of the coping strategies include looking for some little land on the outskirts, along the roads, railway line, etc to do some urban farming. People also tend to reduce the number of meals and the quantity consumed, and in the process become malnourished. The food allocation is biased towards the man who is served first and gets the biggest ration. The children and mother eat last. The promotion of consumption of indigenous food is picking up, although most people still eat ugali, sukumawiki, meat or fish. Most people do not prepare the food in the right way. Some people buy ready chopped vegetables where nutrients are lost while washing, and normally tend to overcook vegetables. In addition, the common use of paraffin for cooking is a source of air pollution in poorly ventilated houses, and the fumes also get into the food. Finally, there is a shift to fast-cooking foods due to cost of fuel and the short time available for cooking, thereby avoiding cooking foodstuffs like maize and beans.

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1.4

Maternal Child Health

Most women attend antenatal clinics in health centers operated by Nairobi City Council, although mothers start attending clinic late despite the services being free. This could be due to competing demands for time or lack of awareness on the importance of attending the clinic early. There are many cases of anemia. Those who attend antenatal clinics are given the usual attention and advice, and given iron supplements. Some cases of nutrition deficiencies among pregnant mothers are attributed to some cultural beliefs such as not eating eggs - especially for women from Western province to avoid the unborn child growing too big (for safe delivery). There is normally no change in workload during pregnancy. Most deliveries in the slums take place at home sometimes with the help of the TBAs, mainly because they cannot afford the requisite maternity fees. Malnutrition is evident especially in the slum areas. In Langata city council clinic, for example, they receive up to 30 malnourished children per month. Health staffs give nutrition advice at the clinics, at the community level and during seminars. The health staffs advice on complementary feeding and weaning foods, although most mothers give mashed potatoes and bananas and very little protein and fruits. Some of the women give complementary foods as early as one to two months. 1.5 Constraints to Improvement of Nutrition

One of the major constraints to improvement of nutrition is lack of knowledge and failure of the relevant authorities to attach sufficient importance to nutrition issues. A significant proportion of government officers do not visualize the importance of nutrition in the health of an individual, and the need to teach people about food production, preparation, storage and consumption. Consequently, funding and facilitation for such programmes are scarce. Secondly, there is shortage of personnel, especially at the City Council health centers. This does not allow for proper dissemination of health and nutrition information. Thirdly, nutrition is not incorporated in the national HIV/AIDS programme. The component of nutrition is not recognized or internalized. Finally, growth monitoring at the clinics is not regularly carried out due to lack of weighing equipment and child health cards. In order to respond to the above concerns, it is necessary to: Reorganize and harmonize the nutrition units in the organization of government, and give them specific guidelines; Intensify and expand nutrition programmes; Equip doctors and nurses with nutrition knowledge, and how to incorporate the knowledge in their activities; Boost economic growth and household incomes, as people are becoming increasingly informed about nutrition but their economic status does not allow them to have proper diets. 1.6 Sources of Water

The sources of water in Nairobi include: Treated water from the piped Nairobi Urban Water Supply (Sasumua, Ruiru, Ondiri and Ndakaini); About 1,300 boreholes mainly for institutions, industrial use, and some domestic use. The water has too much fluorine; Roof catchments in peri-urban areas for domestic and livestock use; Water vendors especially in slum areas where there are few water connections. This water may be contaminated during handling; River water for drinking (e.g. the upper parts of Nairobi River before it becomes polluted) and polluted river water (for washing and bathing). The polluted water contributes to a range of skin ailments;

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Mineral water for drinking in affluent households

An estimated 52% of the Nairobi water supply is unaccounted for as it is tapped through illegal connections (for irrigation, car wash, domestic and industrial use). This has forced residents to go without clean water, and distorted the price of piped water in the city. There is therefore need for sensitization on preservation and storage of water, modernization of management of water, effective handling of surface water, surveillance of the piped water system, and studies on sewage irrigation. Some of the policy recommendations include: Dissemination of information on nutrition policy to communities and relevant organizations and government departments; Irrigation should be done within the appropriate health and quality standards; Bacterial/mineral quality of water for irrigation should follow applicable standards; Pollution control; Reactivation of checks for bottled water 1.7 School Feeding Programmes

There is no policy on feeding in primary schools, other than midday meals in Mukuru and Kariobangi slums in a bid to improve enrolment, enhance retention, and reduce dropout and repetition rates. The City Council has 21 day nursery schools which are a small number for the citys population. The nursery schools were once under the public health department but are now managed by the City Education Department. There was a feeding programme where the Council was responsible for the feeding with parents paying only a nominal fee. In preschool and primary school, child feeding largely depends on initiative of parents and school management. In some schools, feeding is mainly undertaken by NGOs and churches as part of the effort to retain children in school or other humanitarian or sectarian interests. NGO efforts are confined to schools with catchments in informal settlements. The number of schools with feeding programmes is: Kibera division (3), Dagoretti division (3), Embakasi division (6), Makadara division (9), Starehe division (6), Westlands division (5), Kamukunji division (2) and Kasarani division (2). 1.8 Emerging Issues There is no overall policy on school feeding; Where there is a feeding programme it is a matter between school, parents and NGO/church; Many feeding programmes are the voluntary or pay-as-you-eat variety; The menu depends on the provider and its affordability; Many schools have kiosks that sell commercial beverages and confectionery. Unfortunately, these are the foods children normally go for instead of the more nutritious varieties. Junk foods (snacks) are expensive and lack vital nutrients, and thus affect childrens health negatively; Some children carry packed lunch consisting mainly of starch-based foods. This is usually an unnecessary baggage and lack vital nutrients; Many schools go for days without tap or clean drinking water, which is a hazard to health; Without proper feeding programmes, it often becomes necessary to de-worm children who might eat contaminated food; Lack of feeding can translate into low rate of learning because of discomforts resulting from hunger; Because of lack of feeding programmes, neighboring communities get opportunity to sell food to children often in unhygienic conditions; The lack of overall policy has been a constant source of conflict among teachers and school committees

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2.

COMMUNITY CONSULTATIONS

Community consultations were conducted with a community in Kianda location of Kibera division for men, women, youth and children. Apart from the central Government and the Nairobi City Council, there are a number of agencies in the study areas. These include UNICEF (building of toilets, water tanks), UMMK (sanitation), Catholic Church (feeding orphans, medical services, preschool and primary education), Rye Sports Association (body building for the youth, training in tailoring, salon), Kibera Girls Center (tailoring, informal education, feeding programme), Salvation Army (training teenagers on tailoring and carpentry, preprimary education, sponsorship of destitute and orphans to informal schools), UNEP (drainage and sanitation), Ushirika Health Centre (antenatal service, family planning and curative services), ACTIONAID (training of ECD teachers, empowering the community in sanitation knowledge), and the Methodist Church (microfinance for women, health services, and feeding programmes for HIV/AIDS orphans). 2.1 Food Security

Most individual take three meals per day, but is small in quantity and low in quality. Men and male youth take a larger share, and hence women are most affected during food stress. There are problems with food preparation methods. For example, sukumawiki is cut then washed, thus washing away most of the nutrients. Due to the high cost of cooking fuel (charcoal and kerosene), households prefer foods that cook fast, which has led to reduction in traditional foods such as githeri and beans. The food eaten comprises of kale and ugali and in rare cases githeri. The githeri is boiled and salted ready for eating and very few fry it. The sukumawiki is either fried or boiled. Most people tend to buy ready-cut sukumawiki, wash it with cold or hot water, and then cook it. This is preferred because it is an easy meal to prepare. Some people even go to the extent of boiling the sukumawiki for about 5 minutes (and throw away the water) so that the color is washed off to remove the green color. Others fry it for over 20 minutes ndio iive mzuri (overcooking). The community does not have proper knowledge of what is a nutritious diet. They eat to fill their stomachs. In the dry season food prices go up. The main household expenditure categories (excluding transport) in descending order are food, rent, school fees, medical, clothing, household items, and entertainment. Expenditures on education and health affect food security as they lead to lower food expenditure, but in case of extreme food stress other expenditures are foregone to first cater for food. Expenditures on education take precedence especially in the month of January, when many go without food to cater for school expenses. During April-June, there is adequate supply of vegetables, but in August there is a general shortage of vegetables. During the months of June-July, the prices of beans are favorable. During times of food stress, women and children may eat less or go hungry for the men to eat. One of the coping strategies is to reduce the rations eaten. When they get some money, they use all of it as if there is no tomorrow. They do not normally keep stocks for a rainy day. Most people do not have knowledge on nutrition. Very few could explain what a nutritious diet is. All they said was that they eat sukumawiki (kales), maharagwe (beans), and occasionally fish and fruits. They estimated that only about 2% of the people can access a nutritious diet. Fruits are a dream to many. They were nostalgic about the Kenyatta era when people could afford proper food, compared to the present when prices are too high for their meager earnings. The food taboos depend on the rural home (meaning ethnic group) of the family or household. For example, among the Dholuo, a woman may not eat the tongue of livestock (e.g. cattle and goats). Among the Dholuo, Luhya and Gusii, the gizzard and back (tail) of chicken is reserved for men, while wings, neck, leg, liver and intestines are for women and children. Among the Luhya, children may not be fed on eggs, lest they become dumb; and women do not eat fish soon after delivery. Among the Gusii, old women do

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not eat chicken and eggs. Among the Kikuyu, the foods given to women after delivery include soup and njahi. 2.2 Maternal Child Health

The attendance to antenatal clinics is quite low, and only about 50% of those who attend continue regularly until delivery. Those who attend clinics are given advice on the foods to eat, and undergo blood tests. However, the main health center (Ushirika) does not have a nutritionist and therefore the nurses only try to give basic information on nutrition. Pregnant women do not reduce their normal workload. They continue with the normal work because there is no one else to do it for them. The majority delivers at home with the help of TBAs. They reported that there are many cases of stillbirths. Some children die during childbirth due to fetal distress and premature births, especially those born at home. There are many cases of STDs and other infections due to poor sanitary conditions that lead to child infections and some child deaths. The women said that lactating mothers try to eat some special foodstuffs such as chapatti, nyama, mboga, kienyeji, beans, carrots, soup, and drinking chocolate or cocoa. The special feeding lasts a period of 2 to 3 months after birth, although it depends on household finances. Most women breastfeed immediately after birth, within half an hour or so. Exclusive breastfeeding takes 3 to 4 months, although the TBAs talked of advising the mothers to introduce fruits as early as a month or two. However, the child is breastfed for up to 2 years unless the woman gets pregnant. The manifestations of malnutrition were cited as the child becoming thin, having no appetite, and eventually developing a big stomach. The sickly child is taken to hospital, but the nutrition advice given may not be strictly followed due to lack of finances. The normal feeding of the under-fives is tea at breakfast, uji at 10 am, lunch with the rest of the family, uji at 4 pm and finally the same supper with the rest of the family. In some families, the children eat the same foods and at the same time with adults. They drink treated tap water, but do not boil before drinking. They attend seminars on cleanliness and sanitation but many do not practice it. 2.3 Nutrition and HIV/AIDS

The community has knowledge of HIV/AIDS, how it is transmitted, and ways of prevention. There is high awareness of HIV/AIDS but little behavior change. The majority has not accepted the use of the male condom. The most vulnerable groups are youth (because of idleness) and adults (because of drunkenness). The infection rate is highest among those under 35 years of age. Their perspective of the spread of the disease is that somebody infected with STDs tends to have more urge for sex, thereby engaging in promiscuity. The common routes for creating awareness include community programmes through seminars, churches, and the grapevine (normal discussions among neighbors and friends). The TBAs advise mothers not to breastfeed their children if they know they are HIV-positive, and to give their children infant formula or fresh milk. Due to the low economic status of most households, it is difficult to give a balanced diet to People Living With AIDS (PLWA). Interactions between the infected and the uninfected are normal and friendly, due to the level of awareness created by community-based organizations e.g. Kituka Community Development Programme (KICOSHEP) and USHIRIKA. 2.4 Nutrition and Emergencies

The community has never received any major food relief from the government. Those affected during the clashes sparked by rent riots received some food. There are, however, some programmes such as the Catholic Relief Services that target certain groups, e.g. elderly, orphans and sickly.

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2.5 2.5.1

Issues Raised by the Youth HIV/AIDS

All the youth said they learnt about AIDS through seminars, neighbors, radios, TV and magazines. Despite the high level of awareness, the rate at which youths are engaging in unprotected sex is increasing. The youth do not use condoms, and have adopted an attitude that catching HIV/AIDS is an accident or bad luck. They said that condoms ni kama kula sweet na karatasi yake (using a condom is like eating a sweet with its wrapper). Close relatives hide the infected because they have brought shame to the family. Children orphaned by AIDS are under the care of immediate relatives. Girls are not interested in discussing AIDS matters. 2.5.2 Water and Sanitation

There is not enough water from taps. During shortages, the youth buy water from far areas and sell to residents at a higher price. The price of water from project tanks is cheaper (1/= per 20-litre jerrican). They do not boil water since they assume it is safe. There is usually an outbreak of waterborne diseases e.g. cholera and typhoid due to dirty water from rivers and contaminated pipe water (in case of burst pipe thereby water mixing with sewage). Some of the water points were constructed by various NGOs. There are water vendors who sell water at cheaper prices. There are also illegal connections with fake meters, which are quickly disconnected when City Council officials pass by. The water points are not sufficient to serve the whole community. The community fails to get enough water because of illegal connections and bursting of water pipes. The pipes are narrow (thus do not supply enough water) and rusty. When there is a serious shortage of water, some students fail to go to school so as to assist their parents to search for water. In schools, water is not sufficient and students bring it from home. In informal schools, kids carry water to school almost every day. They do not boil drinking water, which leads to diseases like cholera, typhoid and dysentery especially among children. They consider it expensive to boil water. They proposed that the government should treat piped water properly to avoid the need to boil it. The youth lag behind because they are not involved in selling water, which would have earned them some income. The youths are neglected because they do not have enough incomes and the community has no trust in them. The NGOs tend to misuse funds in the name of developing the community and hence do not complete all planned projects. The youth has initiated groups in the community for entertainment, but are not paid when they perform thus losing their morale. They said that the government should support the youth groups. The chief appoints the village elder directly, who is taken to work in another village where he is not familiar with the local issues. Consequently, the youth find it difficult to raise their specific problems with the village elders. In addition, the NGOs do not deal with the youth groups directly. The disposal of human waste is through pit latrines. The toilets are not regularly emptied (exhausted) when they get full. The pit latrines are within the settlement, which leads to poor sanitation. They also have flying toilets, where the waste flows on the surface when it rains. There is poor drainage. The youth are not given materials to dig or maintain the drainage system. The youth believe that the elders (wazee) are in charge of sanitation because they lack trust in the youth. The CBOs and youth groups involved in sanitary work in the village provide the community with polythene bags to dispose garbage but instead people dump the waste in open spaces and the rivers. The male youth drain stagnant water in the paths in an attempt to control mosquito breeding.

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Other issues of concern to the youth were: There is child labor of school-age children who are also underpaid; Children are sexually abused by older people in exchange for chips and little money; Video shows and immoral movies on TV have drained morals from children as they try to do what they watch; There are a few cases of rape of young girls by their fathers and community members; The mode of dressing, character and influence of grownup girls has brought immorality among younger girls 2.6 Issues Raised By Children

The interviews/discussions were undertaken with a cross-section of children aged 3-18 (boys and girls both school-going and out-of-school). 2.6.1 Health and Nutrition

The most common childhood diseases were colds and flu (caused by dust and exposure to cold conditions), scabies (caused by dirty conditions, especially not bathing for up to one week), headaches (caused by hunger, too much thinking), eye infections (too much dust), diarrhea (caused by eating unclean food), leg pains (walking for long distances), chest pains, ringworms, ear infection, measles, rickets, kwashiorkor and polio. The children know the causes of most of the diseases, especially malaria, but they say their families cannot afford mosquito nets. In one school only one out of the 8 children uses a net at home. The children were able to explain the way cholera comes about. Very few are taken to a doctor when they are unwell. Most of them are given aspirin or mothers boil herbs gathered from the river. Others use traditional medicine purchased from the Maasai, who dispense the medicine after you explain your sickness at KSh 20 a glass. Others wait for a cold to cure by itself, while a few others take the child to the nearby mission clinics. The children said that they do not get enough food, which is usually mchele (rice), maharagwe (beans), ugali, waru (potatoes) and a few fruits. Most of the children have only one meal a day, and milk is rarely in their diet. Almost all of them do not take breakfast and lunch. The foods are mainly carbohydrates (ugali, rice, porridge and githeri). When they cannot get food at home, they go to the market to scavenge what people have thrown away, and at times steal when the seller is not seeing them. 2.6.2 Water and Sanitation

The main source of water in the area is tap. Most people do not boil water before drinking, although the children said they know the importance of boiling water before drinking. Some children said that their parents could not allow them to boil water because of lack of cooking fuel (kerosene). The schools have no water at all, and children complained of lacking drinking water while at school. The most prevalent problem is lack of toilets and poor sanitation, and the stench of faeces in the air can tell a lot. Due to lack of toilets, the children explained that people use paper for toilets, especially at night and throw them away in the morning on the road or on rooftops (flying toilets). During the day, some relieve themselves in the open fields. 2.6.3 HIV/AIDS

The children know about AIDS. They hear about it from other people, on television, on videos at the DOs offices, and videos in schools. They said that dawa yake ni kifo (its medicine is death). It is spread through unprotected sex, having sex with more than one partner, and through contaminated needles and open wounds. People should abstain (from sex), keep one partner, or use condoms if you really must do it.

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2.6.4

Daily Activity Profile

Almost all the children do not have a plan of what to do during holidays and weekends. A very large number, especially boys, have nobody to guide them on what to do. They do nothing, other than play ballgames near the river. However, girls have no time to play due to heavy demands of household chores which takes them until evening. Most parents and guardians leave their houses very early in the morning (5 am) and leave the responsibility of all household chores to their daughters. 2.6.5 Child Abuse

The children narrated stories of how children in the neighborhoods are mistreated. They are beaten and thrown out of the home on many occasions, and this is how they end up in the streets. The area has street children but some of them have their parents within the community, but do not want to go back home due to harassment by parents. They said that they have not seen prostitution among children but it is there among adults due to poverty. The girls are looking for money for survival. 2.7 2.7.1 Issues Raised By Women Health and Nutrition

TBAs provide antenatal care to majority of the women. The TBAs are trained mainly by the Nairobi City Council health workers. Some mothers go for antenatal services at the clinics (e.g. Kujitolea and Langata clinics) and Pumwani Maternity Hospital. The mothers normal workload does not change during pregnancy. Most of them deliver at home. In most cases, pregnant and postpartum mothers eat the normal family diet of sukumawiki and ugali. Consequently, the mothers are not well fed, and most are anemic and underweight. The malnourished mothers are referred to hospitals by health workers. The Langata NCC clinic has a programme for feeding children and mothers. In addition, the Methodist Church has a feeding programme for children, mothers, the aged, and HIV/AIDS patients which run once a week. Pregnant mothers do not encounter many problems since any condition that may pose a problem (e.g. high blood pressure) is detected early enough and referred to hospitals by the TBAs. The TBAs are paid a small fee but sometimes do it free. In the past, the common diseases among children were diarrhea and skin diseases. However, the initiation of afya (health) groups has brought down the infections. Currently, skin diseases, malnutrition and worm infections are common. The coping strategies include taking children to hospital; home management of ringworms; UMMK (a CBO) supplies mothers with oral rehydration salts (ORS) for treating diarrhea; eye infections are referred to hospital; some children go to feeding centers for food; and the Catholic brothers have a rehabilitation center for children. Breastfeeding begins immediately after birth, maybe after 30 minutes. All mothers in Kianda breastfeed their children. Mothers breastfeed for up to 2-3 years. TBAs advice mothers to breastfeed. Some mothers do not have breast-milk, which they believe to be due to lack of proper food and psychological problems. The under-fives eat the same food with the rest of the family, but may get a meal between the main meals (e.g. porridge and fruits). Some children are given porridge as complimentary food as early as 2 weeks. 2.7.2 Water Availability

Piped water was installed in the area in 1971 after a cholera outbreak. In the seventies, the City Council extended piped water to some areas which was mainly used for drinking, while the community used water from two springs (Kwa Mbugua and Thuo) for washing and bathing. During the eighties, the Council availed water to interested consumers, who sold water to their neighbors at a profit.

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In the recent past, the water available is adequate but the price is too high (2/= per 20-litre jerrican). The water is sold by landlords and water-point owners. There are no storage facilities e.g. tanks. Some external agencies, e.g. UNICEF and KWAHO, donated tanks and NCC supplied piped water. The tanks donated by KWAHO have worn out because they were metal tanks. Every village received a tank, but the KWAHO project failed because the pipes were stolen and there was no community involvement in the project. In the dry seasons, water is sold at 5/= and may go for as high as 20/= per jerrican. In addition, the water is not clean, and causes typhoid, skin rashes, diarrhea and cholera. The community does not know the source of that water. Sometimes the water they buy is salty. 2.7.3 Health

In the past, there were few diseases, and the most prevalent was bilharzia. Malaria was rare by then. Mothers attended antenatal clinics and delivered at Pumwani Maternity Hospital. There was sufficient food available in normal years and government relief in the dry years. Breastfeeding took long (beyond two years). The feeding of children and adults was on demand, and children were given traditional foods. During the last decades, antenatal care has been provided by both trained and untrained TBAs. Poverty has encouraged abortion among girls. Breastfeeding practices have changed e.g. by reducing the period of exclusive breastfeeding. Children are introduced to adult foods (e.g. sukumawiki and ugali) at very early age. The most common food in the community is sukumawiki and ugali. Most diseases found in children are diarrhea, typhoid and malaria. Most of the young girls who give birth do not normally take their children for immunization, but the TBAs and the parents encourage them to take the babies for clinic. Most of the girls leave the babies under the care of the childs grandmothers, while others take care of their own babies. The women raised concern about two disturbing issues, namely, the common and careless disposal of used condoms, and that most men spend almost all their income on alcohol at the end of the month. 2.8 Seasonal Calendar Generated By a Women Group in Kianda

January-March Planning for various activities start in January Children go back to school Preparation of small plots for subsistence farming Green vegetables are expensive, cereals are cheap Food budget low due to school fees Families stressed by lack of money Diet is poor Family quarrels due to high demands for family expenditure Some children sent home due to outstanding fees Some savings for April holidays food budget High rate of STI infection due to mothers engaging in commercial sex to settle the high bills April-June This is usually a rainy season Floods wash down structures along the valley People drown and property destroyed Children close school in April, hence high expenditure on food Settling of debts Tendency of parents transferring children to other schools to avoid accumulated fee arrears High incidence of thuggery, as any alarm raised cannot be heard by neighbors due to the heavy rains Increased incidence of diarrhea and vomiting, typhoid because of draining garbage and sewage into peoples compounds and use by some families of rainwater for drinking and cooking High incidence of pneumonia and coughs Some fishing by young boys along the drains

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High conception rates due to cold weather and limited movement/activities July-September During this period, business is stable There is plenty of food at affordable prices, especially greens but cereals are a bit expensive Schools are closed for August holidays; there is high expenditure on food and nutrition Parents save for the new term High rates of abortion (those conceived in the second quarter) Common diseases are malaria, diarrhea and vomiting October-December Parents save for school fees, especially those with examination candidates in the New Year Save for Christmas festivities (e.g. travelling, food, clothing and leisure) High rate of STI infections among the youth due to promiscuity Stress within the family due to unaffordable Christmas expenses

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THIKA DISTRICT 1.
1.1

DISTRICT CONSULTATIONS
Administrative organization of the district

Thika district is one of the seven districts that form Central province. It was carved out of the larger Kiambu and Muranga districts in 1995. It borders Nairobi to the south, Kiambu district to the west, Maragwa district to the north, and Machakos district to the east. The district is divided into six administrative divisions, namely, Thika municipality, Kakuzi, Gatanga, Kamwangi (Gatundu north), Gatundu south, and Ruiru. The district has an area of 1,960.2 km2. 1.2 Demography and Settlement Patterns

As per 1999 Population and Housing Census, Thika district had a population of 645,713 persons with an estimated annual growth rate of 2.8%. This population is projected to increase to 701,664 in 2002 and 828,531 in 2008, assuming that constant fertility rate and the same growth rate prevail. The district is densely populated but with diverse population densities. Gatundu, Thika municipality and Gatanga divisions are the most densely populated, with Gatundu division having the highest density. The lower parts of Ruiru and Kakuzi divisions have the least density. The latter regions normally receive low rainfall, ranging from 116mm to 965mm, and are beneficiaries of relief food especially during drought periods. 1.3 Physiographic and Natural Conditions

The district has a diverse topography ranging from 1060m to 3550m above sea level. The highlands to the west form water catchments and watersheds of most of the rivers, which flows towards the lowlands of southeast parts of the district. All these rivers flow from the Aberdare ranges to the west and towards southeast to form part of the Tana and Athi river drainage systems. The eastern parts of the district are lowlands, which cover Ruiru, Thika municipality and Kakuzi divisions. The district has a bimodal rainfall pattern with long rains occurring in the months of March to May and short rains in the months of October and November. Rainfall ranges from 965mm to 2130mm, with least rainfall experienced in the eastern parts of Thika highway, Samuru, Mitumbiri, Juja, Gatuanyaga and Ithanga areas. The eastern part is a semi-arid region and receives low rainfall ranging from 116mm to 965mm. The flat topography characterized by low rainfall and well-drained soils makes it suitable for plantation farming, mainly coffee and pineapples. Cut flowers are also an upcoming economic activity. Agricultural activities and types of crops grown are heavily determined by rainfall patterns. Tea, coffee and dairy farming are the dominant economic activities in the northern and western parts of the district which receive 1,500mm minimum annual rainfall. In the semi-arid areas to the east with low and unreliable rainfall, cattle rearing and production of drought-resistant crops are the main preoccupation of farmers. The district produces about 80 million kg of green tea leaf annually, while coffee production averages 20,000 metric tones of clean coffee annually. 1.4 Poverty

The prevalence of absolute poverty is estimated at 48.4%, with 51% in rural areas and 39% in urban areas. The areas most hit by poverty are semi-arid areas of Ruiru division, Gatuanyaga, Munyu and Ngoriba in Municipality division, and most parts of lower Kakuzi division. All these areas are characterized by low and inadequate rainfall. Other pockets of poverty are slum areas in Thika, Ruiru and Juja towns. During the district PRSP consultation process, some of the causes of poverty were identified as insufficient extension services, high cost of agricultural inputs, and mismanagement of cooperative societies that have led to a decline in crop and livestock production. Other factors are the poor quality of the road network and high incidence of HIV/AIDS.

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1.5

Nutrition Profile of the District

Thika district is divided into Gatanga, Ruiru, Gatundu, Kamwangi and Thika divisions. The upper Gatanga (e.g. Gatura) near the Aberdare mountain ranges is a tea zone and grows food crops (maize, beans, avocados, potatoes and some bananas). There may be few cases of malnutrition because people work for long hours, and may not have enough time for their children. Malaria and pneumonia are common, and there are cases of diarrhea especially due to HIV. The main food eaten is githeri (a mixture of maize and beans), carrots and potatoes. Ugali is also becoming popular and is normally eaten with vegetables and beans. The increasing popularity of ugali is because it is faster to cook in terms of time and fuel consumption since firewood is becoming scarce. In food preparation, they normally overcook vegetables. They also consume more cabbages than dark green vegetables and therefore lack some vitamins. Cabbage loses vitamin C after 24 hours, and cabbage does not have carotene. This also leads to shortage of iron, and the lack of vitamins lead to frequent illnesses. In the Gatanga lower zone, there are more cases of malnutrition since most people do not own land, they depend on purchased food, and earn about KSh 80 per day in the flower farms and coffee plantations. The food crops grown are mainly maize, beans, potatoes (sweet and Irish) and fruits (avocadoes and papaws). During the dry season, food is expensive, hence the few cases of marasmus and kwashiorkor. Most parents spend time working in the farms and have little time for their children, which include stopping breastfeeding very early. The food eaten is mainly rice, ugali, potatoes, githeri, cabbages, beans and avocados. In Gatundu, malnutrition is low, although hospital records may show some cases due to diseases (e.g. malaria and diarrhea). Thika division used to register more cases of malnutrition than other areas due to lack of information on feeding of children, but currently only a few cases are reported. In Gatuanyaga, there is some farming e.g. of maize and beans. They are settlers, and therefore have relatively bigger farms. The land is not very productive because it used to be a sisal farm, but the people are still able to feed well. The area gets support from Plan International e.g. in training, growth monitoring, and school feeding programme (now stopped). The areas of the division bordering Machakos (e.g. Ngoriba) are dry, and there are few cases of malnutrition especially during the dry season. There is a nutrition program by Sustainable Agriculture Community Development Programmes (SACDEP). Kakuzi is a very dry area, and they hardly grow enough vegetables, in addition to general shortage of other foods. They grow pigeon peas and a little maize which only lasts a few months after harvest. They depend on food from other parts of Thika, and some food relief. Kakuzi and Del Monte plantations occupy most of the land, and the residents therefore import food from the upper zones. There are nutrition problems as most people work in the plantations and in the private coffee farms. The area has a lot of fruits, and at times people use papaw to eat ugali (from relief maize). Children lack adequate attention from parents and are not well fed because the families are poor. Even for the employed mothers, the quality of child feeding is poor, and is mainly uji especially when mothers are working in the plantations. Ruiru has shifted from ranching to residential area due to subdivision of land. There are mushrooming slums occupied mainly by people working in the factories, and drunkenness is a major problem in the slums. In Juja Farm, rains are not adequate and they do not irrigate although Athi River passes by. Generally, Thika town has access to cheap grain legumes e.g. dengu (from Uganda) and there are many grain millers in the town. Kamwangi is hilly and people plant tea and pineapples. They sell pineapples to buy food. Consumption of illicit brews is a problem in some areas of Kamwangi. Food relief in the district is distributed to every administrative division regardless of need. The most hit area is Kakuzi, but generally there is no place in the district where people are dying of hunger.

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1.6

Coordination of Nutrition Activities in the District

The district has a small pool of trained nutritionists, namely, nutrition field workers (trained nurses with a further six months training in nutrition) and community nutrition technicians (with two-year certificate course in nutrition). The nutrition section is headed by a district nutrition officer who holds a degree in home economics. The district nutrition officer coordinates all nutrition activities in the district. She is based in the districts health department, but coordinates with other agencies e.g. government departments (social services, agriculture, education, finance and planning) and nongovernmental organizations. She supervises the nutrition assistants and mobilizes resources for them. Nutrition is normally included in the training of community resource persons e.g. TBAs and CHWs. Within the precincts of the hospital, there are four nutrition assistants: in maternal child health, kitchen, office, and in the wards. In addition, there are nine nutritionists outside Thika hospital, two at Gatundu sub-district hospital and seven in the health centers. Under the MCH, children are weighed, data collected, and mothers advised on nutrition (especially in relation to underweight in children). The serious cases identified become the focus of follow-up, including home visits. The MCH nutritionist also goes for outreach clinics in areas where there are no nutritionists or where the health center is far. The kitchen nutrition assistant supervises the preparation of all special diets in the hospital. There is a cateress for all general cooking. The kitchen nutritionist is the link between the ward and the kitchen. The office nutrition assistant controls the stores where supplements, beans and dengu are kept. She also manages the office when the district nutritionist is away. Adult outpatients are also referred here for counseling. The ward nutritionist accompanies the doctor during ward visits, advises on diet after identifying special cases (e.g. diabetes), and then communicates with the kitchen. She also prepares special milk for the patients who are not able to chew by adding custard powder (source of energy), oils (e.g. Elianto), eggs and sugar so that it is rich in both energy and protein. Some patients may receive multivitamins. Patients with nutrition problems are counseled before discharge. In the pediatric ward, there is a cubicle for malnourished children, and the ward nutritionist makes sure that the children are fed as per requirements. The community encounters problems in following nutrition advice due to resource constraints, which sometimes make it necessary to give the mothers some food on discharge. They also train the mothers in kitchen gardens as a form of community-based nutritional rehabilitation. The ministry of health vote caters for feeding of patients at health centers. However, most health centers admit only maternity cases, which are also few because mothers prefer hospitals. There are consequently some savings in the budget earmarked for food in the health centers, which is given to the malnourished. The district nutrition section also receives some support from the nutrition section in the ministry of health headquarters (equivalent to three bags of beans every three months). There are cases of abandoned children who are brought here before they are admitted to childrens homes. Some cases of malnutrition are brought from Nairobi (e.g. Githurai), Machakos (Manyatta) and Maragua. UNICEF gives vitamin A through the ministry headquarters. Plan International is engaged in growth monitoring at community level, which assists in identifying malnourished cases for the children who have received all vaccines. The medical officer of health assists the nutrition section to undertake activities in the field e.g. growth monitoring, training on nutrition, and identification of groups (especially where there are NGOs). The topic of nutrition is included in all training of community health workers in the district. In 2002, there were cookery demonstrations in areas such as Kakuzi and Gatanga through women groups. Kitchen gardens

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have been established in Kirwara health center and Mitumbiri dispensary for demonstrations and the communities have responded well in getting the idea into their homes. The nutritionists assisted in training preschool teachers on nutrition and public health issues under the early childhood education project, but were not involved in supervising them after training. They trained for only two days on all health and nutrition issues. In Gatundu, for example, they had 120 students at a go. In addition, the nutrition section was not consulted on what they should train on. Such training normally takes a week, with follow-ups after three months. The preschool teachers were trained as community health workers to use the knowledge directly in the ECD centers. This is an important approach because there is a nursery school in every village, and preschool teachers are a potential source of information compared with village leaders (who may have received similar training) but may not pass on the information to other community members. The nutrition section participates in the World Food Day organized by the ministry of agriculture, and in agriculture shows (although the one for central province has virtually collapsed). They also cooperate with the home economics staff of the ministry of agriculture to train women groups on home economics and nutrition. For example, training by home economists includes food storage, preparation of soya, fireless cookers (on how to conserve energy), home keeping, and kitchen gardens. In such training, the nutritionists assist in training on the importance of soya in the diet and various ways of preparing it, and the technical aspects of kitchen gardening. The nutrition section would have had more linkages with the department of social services if the CBNP project included Thika district. However, social services assist in community mobilization, while the groups formed by the nutrition section are also registered by the department of social services. 1.7 Community Organization

The department of social services undertakes community mobilization for group formation on behalf of other agencies. When the staff of social services identifies malnourished children, they refer them directly to hospitals (mainly its nutrition unit). They coordinate or request other departments (e.g. home economics) to visit the groups, say, on soya production, as this increases the economic viability of the groups. Some of the groups are engaged in agriculture (trained on sustainable agriculture) and making flour (unga). The latter groups mix many ingredients e.g. pumpkins (marenge), soya, cassava, bananas, sorghum and millet. Fifteen such groups have a factory in Gatanga division, which sell flour even to the supermarkets. Other groups keep poultry layers. The department provides linkage with government departments, Plan International, World Vision, SACDEP, CCF and AMREF. Plan International is in Gatuanyaga, Juja Farm and Ruiru and is involved in community development, food security, water, health, and child sponsorship. World Vision operates only in Kakuzi in the same sectors as Plan International. SACDEP is involved in sustainable agriculture. CCF is involved in child sponsorship and nutrition education in only one sublocation (Mitumbiri around Kabati area). After mobilization and training on management and conflict resolution, the department of social services hands over the groups to the relevant departments e.g. health, water, and agriculture. The department acts as the midwife of most community-based programs, although the host government departments and nongovernmental organizations do not involve the department of social services after the programs take off. 1.8 Nutrition and Public Health

The roles of public health officers in nutrition include educating people on proper diet and all aspects of health, and food hygiene all the way from planting to storage. In the case of planting, chemicals can accumulate in food systems and finally eaten e.g. fertilizer hence the campaign for organic fertilizers. The farmers are supposed to use recommended sprays (not DDT) as traces of the chemicals can appear in the food. Food develops aflatoxins if harvested as immature stock or if stored in a humid environment. Food must be stored in a good rat-proof granary without moisture. A simple rat-proof granary is normally

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raised above the ground and has a strip of protruding iron sheet around the base to prevent rats from reaching the food. The department is quick to condemn foods that are not stored under recommended conditions. They sensitize people on need to avoid overcooking, while undercooking may be dangerous in case of meat as parasitic worms (e.g. liver flukes and tapeworm) may survive. Overcooking of vegetables destroy vitamin A, while overcooking meat denature (destroy) proteins. Food may also be prepared under unhygienic conditions e.g. cutting of vegetables may cause typhoid if not cleaned or if washed with polluted water. Public health officers are in charge of inspection of meat and all types of food. They are also involved in disposal of human waste e.g. proper sanitation (latrines) and sewerage systems. Waste management also influence incidence of diseases which have impact on nutrition e.g. malaria (which may lead to anemia) and cholera. People with diseases (e.g. worms) are vulnerable to malnutrition. Over and above the issues of sanitation, the department is concerned with water supply systems because of its wide impact on health e.g. waterborne diseases (due to poor sanitation), water-washed diseases (lack of enough water), water-related diseases (due to amoeba as intermediate hosts in water) and vector-borne water-related diseases (e.g. mosquitoes and sleeping sickness). The department enforces caps 242 (Public Health Act), 254 (Food, Drugs and Chemical Substances Act), and the Malaria Control Act. Cap 242 also covers storage and premises, while cap 254 vests them with authority to withdraw contaminated food. Under general disease control, they are involved in management of all disease outbreaks. The office also deals with occupational health and safety related with working places e.g. industries and the chemicals used or produced by the industries. The veterinary department (in the ministry of agriculture) inspects animals slaughtered in Thika town, while the ministry of health is in charge in the rest of the district. The veterinary department only inspects meat at the slaughterhouse while health staffs follow up to the retail level (butcheries are still under health). There is room for conflict because health staffs can condemn inspected meat at the butchery level. The Public Health Act vests power in health staff to prosecute offenders in a court of law, but the veterinarian has no such powers. The department inspects food in the factories and follows up to wholesale, retail and even service level (consumer level). Manufactured food is required to have a manufacturers label that indicates area where it was produced, ingredients and the expiry date. If the information is missing, the health staff has authority to withdraw the products from the commercial chain. They are also on the lookout for expired commodities. They do periodic sampling (taken to Government chemist and public health laboratories), but the process is not regular because of scarcity of resources as the department pays for the services. The department covers specific diseases in disease surveillance e.g. polio, measles (directly related to nutrition as a sick child lacks appetite), malaria (anemia) and parasitic worms. The main diseases are respiratory tract infections, malaria (which has begun to penetrate the highlands), skin infections (scabies, fungi, athletes foot), intestinal worms, diarrhea, pneumonia, accidents, urinary tract infections (UTI), eye diseases, anemia, and rheumatism and joint pains. Adult malnutrition is low, as the staple food is githeri. In public hospitals, there are diabetic cases that are not obese. In the public hospitals, health staff run the risk of advising some diabetics to eat less fat, which could make them go off fat completely if they currently eat meat rarely, say, once a month. If pancreas fails to produce insulin, diabetes sets in. However, private doctors observe a different diabetic population where obesity might come in. 1.9 Food and Nutrition

The ministry of agriculture advices people on food crops to grow e.g. maize, beans, bananas, sorghum, millet, root crops (arrowroots, potatoes, cassava), fruits and vegetables (mainly cabbage, kale and carrots). The department is putting special emphasis on traditional vegetables (e.g. cassava leaves) and fruits (avocados, pineapples, papaws, guava and oranges), and intends to promote gooseberry. The farmers are

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advised on how to grow the crops and optimal mix of various crops grown. They hold demonstrations for farmers on growing various crops. They are promoting soya beans since meat has become very expensive, while soya has double the meat protein. Some farmers harvest enough to take them to the following season. The seasonal price fluctuations are too high, e.g. farmers sold beans at KSh 16 per kg soon after harvest which they are now buying at KSh 35. The government therefore encourages preservation of fruits and vegetables (e.g. kales and pumpkins) through drying, but the adoption rate is low. The department trains on value-adding preservation of fruits and vegetables that can last three years using chemicals used in food-processing factories. Most of the mangoes for February-March season went to waste, but could have been used to make sauce e.g. chutney (East Indian condiment, generally made with mangoes, peppers and spices) which can be sold to the supermarkets and other sales outlets. The ministry of agriculture assists in environmental conservation through energy-saving jikos. This encourages mothers to cook foods they were not cooking before (e.g. githeri) by reducing cost of fuel. The fireless cooker can release womens labor since it needs no attention. There is less denaturing of food when you use the fireless cooker, and thus better preservation of nutrients. Some households have taken the production of fireless cookers as a business. There is over 60% adoption of energy-saving jikos in the district. The agriculture extension staff advises on water tanks for roof catchments. The district is characterized by high water seepage, cultivation up to the rivers, destruction of catchments, and high soil erosion. Rivers have become streams. The department promotes kitchen gardens. The home gardens include small livestock, fruit trees, and all kinds of vegetables including traditional vegetables. The department is promoting small stock e.g. rabbits, poultry and dairy goats. The rabbit campaign is succeeding. The farmers are facilitated to buy rabbits from Ngong Farmers Training Center at KSh 200 each. Local rabbits are small, but the ones bought at Ngong FTC are heavier (about 5 kg). Rabbit is white meat. In the case of poultry, efforts are being made to improve the local birds by keeping hybrid cockerels to get heavier birds that also lay more eggs. Fruits include tomatoes, papaws, bananas, passion fruit, pineapple, avocado, mangoes, oranges, lemons, guava and watermelons. The major types of vegetables grown in the kitchen gardens are kales, amaranth, spinach, tomatoes, cowpeas, pumpkins, onions and nightshade (managu). They also encourage drip irrigation where even a bucket can irrigate a large piece of land. Home gardens improve nutrition of the household as people eat fresh vegetables handled under hygienic conditions, saves income, can eat as much as you can, is environment-friendly (can use waste for compost), and is convenient (can even harvest at night). In case of purchased vegetables you are never sure when they were harvested. The home economics staff hold cooking demonstrations e.g. on soya production and utilization. This involves preparation of different recipes e.g. soya githeri, soya porridge, soya cake and soya mandazi (incorporating soya in all the dishes). The home economics staff also incorporates activities in home management (e.g. sanitation, management of family resources human and non-human, personal hygiene), and family life education (e.g. HIV/IDS awareness, and childcare and development) in their regular activities. Traditional vegetables have higher nutritive value than cabbages. Some traditional vegetables also require very little care e.g. amaranths (terere) scattered on the ground grow naturally. Traditional vegetables are high in calcium (deficit leads to weak bones, teeth) and iron (anemia). Others have iodine whose deficiency is linked to goiter. In the last 8 years, weather has been very poor, and most people have therefore been feeding mainly on githeri and ugali. In the river valleys where arrowroots used to grow, the farmers currently grow crops which can fetch money (e.g. snow peas, kales, French beans). People have changed feeding habits e.g. away from arrowroots as arrowroots are very expensive. People used to mash food with bananas, but now

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consumption of bananas is low, as most people grow them for sale or ripening. They have replaced bananas with Irish potatoes. Food has also become expensive and has less protein e.g. kale and ugali diet. They normally overcook vegetables when they should do it for only 10 minutes. They are supposed to wash vegetables before cutting (not the other way round) otherwise vitamin C goes with the air. In the urban areas, there is a habit of shredding vegetables before selling them, and are cleaned again when the buyer reaches home. There is an increase in obesity and diabetes because people have become more sedentary (less exercise). There is malnutrition especially in the flower farms and coffee estates among the children of the workers. Some of the elderly men (wazee) of over 50 years are sick (diabetes and hypertension) probably because they no longer get the indigenous foods. For most old people, their children live far away from home (e.g. in towns) and visit them once a month, if at all. Unlike men, women can visit and stay with their grownup offspring for short or long periods, leaving their elderly husbands unattended. Many widows live alone after they lost their husbands either during the Emergency or after. 1.10 The Burden of Disease

According to the ministry of health vital statistics data, the crude birth rate in Thika is 2.2%, crude death rate of 0.7%, fertility rate is 91 births per 1,000 women aged 15-49, an infant mortality rate of 40 deaths per 1,000 live births, and maternal mortality of 3 deaths per 1,000 live births. The top ten causes of outpatient morbidity in 2002 were diseases of the respiratory system (29.5%), malaria (28.2%), skin diseases including ulcers (7.4%), intestinal worms (6.9%), diarrheal diseases (4.8%), accidents including burns (3.1%), pneumonia (2.7%), urinary tract infections (2.2%), eye infections (1.8%) and anemia (1.4%). The top ten diseases contributed to 88% of the total disease morbidity. The top ten causes of mortality in Thika district hospital, in descending order, are broncho-pneumonia, AIDS, malaria, pulmonary tuberculosis (PTB), diarrhea, anemia, dehydration, meningitis, diabetes and congestive heart failure. 1.11 Maternal Child Health

The ministry of health trains TBAs on safe delivery and other aspects of maternal child health. The mothers also have traditional knowledge on safe delivery practices, especially in non-complicated cases. Neonatal tetanus is very rare in the district. The hospitals only get umbilical cord infections, which are treatable with antibiotics. During antenatal services, there is counseling of mothers (e.g. on nutrition, prevention of diseases, and need for early health-seeking to restore health) and treatment of malaria. They are given ferrous sulphate and folic acid supplementation, treated for worms (though not regular because worm infestation is not common in the district) and advised on the need for a balanced diet (e.g. protective foods like fruits and vegetables). Pregnant mothers are given malaria treatment during 16-24 weeks from conception and again during 24-36 weeks regardless of whether they have malaria. There is also family planning (education and provision of services) that includes STI treatment and education. Mothers breastfeed their children but the problem is late initiation of breastfeeding and early introduction of complementary foods. Even a mother who delivers in hospital may be separated from the newborn, and may not immediately demand the baby especially after caesarian section. In private hospitals, babies and mothers normally sleep on separate beds, and breastfeeding on demand does not therefore take place. The private hospitals are generally not baby-friendly, although this may also be true of government hospitals especially with respect to late initiation of breastfeeding. The mothers have no problem with giving the children colostrum, and they understand it is nutritious. Colostrum gives protection and has vitamins to protect the baby for some time. Exclusive breastfeeding is minimal, as they start giving water mixed with glucose, other types of milk, and papaws and bananas as early as two weeks. According to the health staff, there is a serious knowledge gap among mothers (what they know is not right). Mothers say they give children food at such early age to

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prevent crying. They continue breastfeeding and giving other types of foods and by three months, breastfeeding is normally down to only morning and evening. At three months, they give the child uji (wimbi, soya, maize, etc), cow milk, mashed potatoes, mashed bananas and papaw. The children get constipation and other unnecessary infections. The child is left with other caregivers, especially in towns. The mental development of the child is therefore not adequate. The children get off the breasts after 18-24 months, while some stop as early as 12 months especially for working mothers. Very few mothers breastfeed beyond one month (even the trained MOH staff, especially if the staff start maternity leave one month before delivery), and do not even express milk. Surprisingly, mothers in the district like fruit juices and papaws as complementary feeding, and uji. The health staff said that they doubt whether any babies in the district exclusively breastfeed for 6 months. In a clinic, only a negligible number of children (say one in a month) will be reported as malnourished, while in the hospital wards you see few cases of anemia, marasmus and kwashiorkor. The malnourished children in the wards will normally show about two immunization visits in the health cards, and thus irregular attendance to clinics and incomplete immunization schedule. By the end of year 2002, the district had 74 established immunizing health facilities (40 Government, 15 missionaries and 19 private). In addition to immunization, disease surveillance on EPI target diseases of polio (acute flaccid paralysis/AFP), measles and neonatal and maternal tetanus are carried out. During 2002, 6 cases of AFP were notified, investigated and a 60-day follow-up done. One case died before followup. There were 864 cases of measles reported and investigated, most of which occurred in Kakuzi, Gatanga and Thika divisions. Immunization figures from administrative records are dropping e.g. 2002 were lower than for 2001. Vitamin A is supposed to be supplemented every 6 months up to five years, but they do not come back after measles immunization. The Akorino and Kavonokia religious sects do not take their children for immunization. There are cases of epilepsy, and epileptic cases that become convulsive because of cerebral palsy. The latter might be due to birth asphyxia (suffocation, lack of oxygen) and injuries during childbirth. This is true for both home and hospital deliveries. Most child deaths in the hospital nursery in the first 28 days are due to asphyxia or infection. In the hospital child clinic, they get few cases of kwashiorkor and marasmus (e.g. one in 2 months) and most of these children will be underweight (low weight-for-age) related with sickness e.g. coughing and diarrhea. The hospital gets about one case per month of spina bifida, because of inadequate development of the central nervous systems (encephally). The most severe cases are due to nutrition problems of the mother e.g. lack of folic acid and possibly vitamins. Giving folic acid and other supplements during pregnancy may not eliminate this problem, and ideally, remedial actions should be taken before conception. Some of such cases die at home while some live long but are deformed. Accumulation of fluid in the head is one of the extreme cases of this. In such instances, nutrition issues have to come before conception. About 95% of births are without event. It is the 5% which receive a lot of attention, the cases you keep seeing and remembering. About 40% deliver outside hospitals. The health personnel said that TBAs have become too brave, as they wait for too long before seeking professional help, which can lead to cerebral palsy. Some TBAs have tried to deliver twins and even try delivering breech presentation (legs and buttocks first) while doctors normally go for caesarian for the latter. 1.12 Nutrition and HIV/AIDS

There are 10 VCT centers in the district, where pregnant mothers are advised to go for tests. If mothers have HIV, Thika and Gatundu hospitals have programs to minimize mother-to-child transmission. Those who are HIV-positive are told to make informed choices, have proper feeding during pregnancy, and booked for delivery in any of the two hospitals. A HIV-positive mother is given antiretroviral (nevilapine) once she gets into labor and the newborn given nevilapine syrup. This reduces chance of transmission during labor and delivery by 30-50%. Very few community members know about this, as training is focused on hospital staff (maternity, nurses) and not the field staff.

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The HIV-positive mothers are advised not to breastfeed. Those who accept the advice are given Nan-1, a breast-milk substitute. The mothers who have ability to provide Nan and cows milk are able to avoid breastfeeding the child. It is possible for a child to have antibodies at birth without being infected. The antibodies disappear later if the child was not infected. In case of HIV adults, there is a gap in nutrition advice. After visiting a VCT, a nutritionist should come in so as to delay the onset of sickness. If infected and feed well, one is not likely to get opportunistic infections. TB is also a disease of environment as it is most common in the crowded settlements e.g. Kiandutu slums. The HIV-positive adults are advised to eat a balanced diet and food rich in vitamins e.g. indigenous vegetables (terere, managu, pumpkin leaves, thoroko/cowpeas) and all types of fruits. Cabbage is low in vitamin A, while vitamin C only lasts for one day after harvesting. Those who can afford the recommended diet do buy. If the patient puts food in the same rank as drugs, he will purchase the requisite food. However, drugs are expensive and the patients may value drugs more than food in the management of HIV. It also requires positive living otherwise the patient will die of stress. From the sentinel sites, HIV prevalence had declined from around 34% in 1999 to 18% in 2002. It takes long for well-fed, HIV-positive people to be suspected of being sick as they appear healthy, and may therefore spread the disease. 1.13 Families, Orphans and Children Under Stress (FORCUS) Self-Help Group

The group started in late 1999, and registered in 2000 by department of social services as an awareness group on HIV situation in Ruiru division, mainly focusing on dangers of infection. People are aware about means of HIV transmission e.g. unprotected sex with an infected partner, infected blood if there is an opening, and mother-to-child transmission (perinatal and breastfeeding). However, the group members believe that people do not use the knowledge, e.g. when they take local brew they forget about protected sex. The group therefore works on behavior change. For example, they are working with PSI on theatre on condom efficacy, where they discount myths surrounding the condom e.g. lubrication has a virus, condoms break, virus can penetrate the pores, and reduces pleasure. Home-based care was introduced after group members were trained by Pathfinder International as community health workers. The group has CHWs in Murera, Githurai, Gitambaya and Gatongora, where they identify patients, and train caregivers (e.g. friends, family members of the infected person) to take care of the patients. In October 2002, the group opened a daycare center for the orphans and the vulnerable (whose parents are in the advanced stages of AIDS). The orphans and vulnerable children in the center are not infected. The center was also involved in informal education of the children, as education was not free then. In 2003, the group sent some to primary school since primary education became free and retained only younger ones at the center for preschool education. In the morning, the children at the center go through some education. At 10 am they take porridge (mixed flours), and get lunch and 4 pm tea before they go home. They have 21 children, eight of whom are in primary. For those in the nearby primary school, the group members deliver porridge to them at 10 am, the children go to the center for lunch, and come for porridge at 4 pm after school. The National Aids Control Council gave the group KSh 350,000, KSh 60,000 of which was for the daycare center. The group solicits for support from companies, churches and well-wishers in the area. A company in Ruiru gave them material support in the form of beans, maize and rice, and has promised to continue with the support at regular intervals. Other companies have donated fruit juice, blankets and some cash. The center is rented at KSh 5,000 per month. They get water from a deep well in the compound. They boil water before drinking. Children wash hands before eating, and all fruits are washed. For their own personal survival, members perform verses and drama on behavior change. The group has an environment program where they collect compost from garbage sites and sell as organic fertilizer, with support from EMI Technologies. The group has 25 members (12 ladies and 13 men) of age 19-30 years. They are all volunteers and each contributes KSh 240 per year.

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The population groups most vulnerable to infection are 24-35 year old women, and youth of 15-24. In the coffee estates, women have no bargaining power in relation to sex. Poverty has made women powerless, especially in negotiating safe sex. The high-risk groups include workers in industries, coffee estates, flower farms, General Service Unit (GSU) camp, Prisons Staff Training College, the military barracks (Kahawa), and the effects of the Thika highway especially on commercial sex trade. The group has moved beyond awareness creation to behavior change. They facilitate church youth groups and colleges. Most other groups in the area are in awareness, not behavior change. Home-based care includes counseling, and they also refer them to trained counselors. HIV/AIDS has devastated families e.g. use a lot of money for drugs, the infected was probably the breadwinner, children drop out of school, adolescent girls get married early or go looking for jobs, is an emotional drain on grandparents (have a case of one taking care of 12 grandchildren), and increased child labor. The group members advise pregnant mothers not to breastfeed, as child can get infected, and on the availability of antiretroviral drugs. The district nutritionist advised them that such knowledge should be in general awareness, and not only among pregnant women. The group works hand in hand with Ruiru health center, and the nurse visits them when they organize with her. She examines the children and gives free drugs, and de-worms them. It is the teams view that the group should make de-worming and Vitamin A supplementation routine. The common diseases are malaria, typhoid, amoebiasis, fungal infection on the head locally known as mashilingi (prevented through de-worming), diarrhea (not very common) and common cold. Although there is piped water in the area, typhoid is still common because most people use borehole water, as they cannot afford piped water. 1.14 Plan International

Plan International is a child-centered NGO. In Thika, it covers Juja location, Gatuanyaga location, Ruiru East (Murera), Municipality, and is partly in Machakos (Cheleni division). The programs include health (growing up healthy), learning (support to schools, train teachers, provide learning materials, classroom infrastructure), livelihoods (vocational training, food security, IGAs), and community-basic services (habitat) e.g. water and roads. They also build community relationships e.g. train CBOs on management, leadership skills, and conflict resolution in groups. Since the main source of funding is child sponsorship, they encourage relationships between children and sponsors. The main activities in health are reproductive health, STI/HIV-AIDS, ECD and child survival. They train TBAs on safe motherhood practices and support them with kits since health facilities are far. They also train them on family planning, and train CHWs on primary healthcare (PHC). The STI/HIV program uses the so-called HICDAM approach (Hearing the information, Internalizing, Conceptualizing, Deciding, Action, and Maintaining). People have information but are not ready for behavior change, and HICDAM is therefore designed to bring about behavior change. The control of HIV starts with knowing ones status. They support some orphans with school fees (for those in secondary school), others in vocational training, and a few cases with food and food supplements at their homes. They do not have centers, and do not even encourage daycare centers. In the case of ECD, they build capacity of nursery school teachers, provide chairs, and learning and play materials for early stimulation, and work with DICECE. In child survival, they train CHWs on PHC, identification of children in need of help (referred to assessment centers e.g. near Joy Town), and then place such children in various centers (e.g. Munyu, Jacaranda and Joy town).

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The food security program includes training farmers groups on proper farming methods, in cooperation with ministry of agriculture, SACDEP and sometimes with KARI. They sometimes support farmers with certified seeds. There are two groups doing horticulture through a CBO. One group was loaned a water pump, and KARI has supported another group. The IGAs engaged in business are trained through Business Initiatives and Management Assistance Services (BIMAS), a national NGO resulting from the spin-off of a credit program of Plan International. Plan International is not in food relief. Their partners are WEM Integrated Health Services (WEHMIS), SACDEP, BIMAS, KARI, most Government departments, and the municipal council (e.g. in funding a health center in Gatuanyaga) as the council has funds for community development.

2.

LIVELIHOODS IN GATUANYAGA LOCATION

According to a village chairman in Rurii sub-location (Gatuanyaga location), the area grows maize, beans (not eaten by wild animals), while sweet potatoes and cassava are eaten by porcupines (njeege). However, along the riverbed, theeru (type of a small monkey) disturb maize and beans, while hippo (nguu) destroys everything (including maize and beans). The Kenya Wildlife Service (KWS) brought in dwarf hippo from India, which are very destructive. Giraffe also messes up pigeon peas (njugu cia Gikuyu). The sources of income in the area are general shops, but the problem is that the cost of business license is the same as in the municipality. There are limited employment opportunities, and if you are a carpenter, you only work for about 6 days per month. The main types of food are maize and beans, and other types if climate allows. The area has cotton soil which dries fast, and cannot therefore sustain crops like carrots. Potatoes are not common as they do better in red soil, require a lot of rain and fertilizer (or manure), and generally need cool and wet conditions. One of the common diseases is typhoid because human waste is washed to the river, where people draw water for drinking and cooking. Some people treat the river water with some chemical bought in Thika town to make it look clear (and then boil it), but only few afford to do this anyway. The nearest health facility is Munyu health center (a bit far) but a dispensary is being built in the area by Plan International (Gathanji dispensary). AIDS is common, partly because of old men moving with young prostitutes or marrying a young wife who is likely to stray. Condom use has increased promiscuity. An infected young man can deliberately remove a condom to pass on the infection to a partner. In the case of malaria, the poor cannot afford mosquito nets.

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SITUATION ANALYSIS AND COMMUNITY CONSULTATIONS IN THE NUTRITION SECTOR IN KENYA

VOLUME III: CONCEPT PAPER ON NATIONAL NUTRITION POLICY

April 2004
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VOLUME III: CONCEPT PAPER ON NATIONAL NUTRITION POLICY

1. BACKGROUND

The Governments Economic Recovery Strategy for Wealth and Employment Creation 2003-2007 (ERS) emphasized the role of human capital development as an important input to development, as well as a desirable outcome of development. In particular, it put special emphasis on food and nutrition, as the achievement of food security and good nutritional status is critical in enhancing human development and overall productivity in Kenya. The Government policy on food and nutrition is based on the Sessional Paper No. 2 of 1994 on National Food Policy and the 1994 National Plan of Action for Nutrition. The overall objectives of food policy were to maintain a position of broad self-sufficiency in the main foodstuffs, achieve a calculated degree of security of food supply for each area of the country, and ensure that these foodstuffs are distributed in such a manner that every member of the population has a nutritionally adequate diet. The International Conference on Nutrition (ICN) of 1992 adopted the World Declaration and Plan of Action for Nutrition, which provided a framework and guidelines for countries to develop and strengthen their national plans of action to promote the nutritional wellbeing of their populations. The Kenya country position paper to the 1992 ICN evolved into a National Plan of Action on Nutrition (NPAN) in 1994. The aim of the NPAN was to develop three main types of actions: The incorporation of nutrition objectives and actions into national, sectoral and integrated development plans, and the allocation of the necessary human and financial resources for achieving these objectives; The development of specific nutritional interventions directed at particular problems or groups; and The generation of information from community-based actions for the nutritional assessment of problems and implementation of appropriate intervention measures.

However, the implementation of the NPAN has not been encouraging because most of the activities in the Plan were generic, the themes and subsequent activities were not prioritized, most activities were implemented on an ad hoc basis, there has been inadequate funding for nutrition-related activities, and lack of a continuous process through which nutrition concerns find their way to the national planning processes. Other policy documents (e.g. the PRSP and the Development Plans) also take a limited view of nutrition as an output rather than an input to development. The nutrition situation in Kenya for the last twenty years has either stagnated or deteriorated, as measured by nutritional indicators of children under 5 years, national micronutrient surveys, under-nutrition of mothers of childbearing age, and the prevalence of low birth weight (less than 2.5 kg) babies. Despite the unfavorable trend in nutritional indicators, nutrition has continued to be given low priority in government policies due to inadequate awareness among policy makers on matters pertaining to nutrition. In addition, most of the development policies and programs formulated are macro-based and there is limited link between macro and micro-level policy formulation and implementation. The few community-based programs have not demonstrated measurable impact in terms of change in nutrition outcomes and the good lessons learned have not been scaled up to the national level. Nutrition policy is currently embedded in food policy developed by the Ministry of Agriculture. Within the health sector, there are nutrition interventions included in maternal and child health programs. Various national institutions also provide training and capacity building in nutrition to achieve selected national goals and objectives. A nutrition policy embedded in food policy is likely to overemphasize household food security issues and provide inadequate linkages between nutrition, health and care. It is also not based on a lifecycle approach that examines nutrition status and interventions over the lifecycle of a human being. The Inter-ministerial Coordinating Committee on Food and Nutrition (ICCFN), coordinated by the Food and Nutrition Planning Unit (FNPU) of the Ministry of Planning and National Development, has identified

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the need for a policy specific on nutrition. A nutrition policy that is independent from a food policy will allow for conceptual and practical linkages between nutrition and other aspects of development e.g. human rights, health, education, gender, agriculture, poverty, environment, crises, population (demography), behavioral practices, and politics. To jumpstart the process, ICCFN has undertaken a number of preparatory activities to lay the grounds for the development of a national nutrition policy. The preparatory activities have included a national nutrition policy workshop (October 2002) and commissioning a report that included community and district views on nutrition (July 2003). Stemming from the above steps, the consensus is that the nutrition policy will contain a set of principles, objectives and priorities which will form an integral part of the national development planning. The emphasis will be on providing an enabling environment for the improvement of nutritional status of all population groups, while keeping a special focus on vulnerable groups (e.g. children and women of childbearing age) and specific concerns (e.g. nutrition and HIV/AIDS, and nutrition in emergencies). The policy will propose a common institutional framework under which nutrition activities are coordinated. The purpose of this concept paper is to highlight the importance of nutrition in human capital development, the current nutritional situation in Kenya, and the link between nutrition and other aspects of development. The main nutrition activities undertaken by government departments and other key players will be described, as will be the current institutional arrangements in nutrition activities. In line with the Governments Economic Recovery Strategy, the paper will present a case for the urgent need to develop a holistic national nutrition policy. 2. 2.1 THE IMPORTANCE OF NUTRITION DEFINITION OF NUTRITION

Nutrition is the study of how essential nutrients from various types of food are utilized by the body and how deficiencies arising from failure to consume essential nutrients cause malfunctions, malformations and deficiency diseases. Malnutrition is a pathological condition brought about by the inadequacy, overconsumption or imbalance of one or more essential nutrients necessary for survival, growth, development, reproduction and work productivity. There are various forms of malnutrition. Under-nutrition is caused by inadequate intake of needed nutrients due to inadequate food intake, malabsorption, and loss of nutrients because of illnesses (e.g. diarrhea, vomiting or hemorrhage) or excessive sweating, or addiction to drugs. Persons who are undernourished often lack energy, protein and other nutrients and develop protein-energy malnutrition. Micronutrient deficiencies refer to lack of one micronutrient in sufficient quantities for the body to function effectively. Specific deficiencies in vitamin A, iron, iodine and zinc are common although in particular situations, such as refugee populations where diets are inadequate and variety poor, others such as vitamin C or niacin deficiency may occur. There are also conditions of over-nutrition, which result from overeating and regular consumption of the wrong types of food and insufficient exercise, leading to obesity, cardiovascular disease, diabetes and hypertension. In Sub-Saharan Africa one is generally concerned with under-nutrition and its consequences. The term malnutrition will refer to protein-energy malnutrition and micronutrient deficiencies. The prevalence of malnutrition is a powerful indicator of a societys development state as well as its progress on the fulfillment of human rights. 2.2 THE IMPORTANCE OF NUTRITION THROUGHOUT THE LIFECYCLE

Nutritional challenges vary as we progress through the lifecycle. Adequate nutrition for pregnant women is essential for growth and healthy physical and mental development of the child and minimizes the risk of birth defects. Apart from having an increased risk of mortality, children with Low Birth Weight have impaired immune functions that contribute to increased risks of morbidity from diarrhea and Acute

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Respiratory Tract Infections. Breastfeeding affords many benefits to the infant, including optimal nutrition, reduced incidence and severity of gastrointestinal diseases, and improves mental, cognitive and visual development. Generally, human milk is the only food an infant needs until 6 months, except for HIVpositive mothers who choose not to breastfeed to minimize the risk of mother-to-child transmission (World Health Organization, 1998)14. During infancy through childhood, good nutrition plays a critical role in promoting growth and development, strengthening the immune system, and enhancing social and cognitive ability. Young adults require adequate nutrition to cope with their high activity levels, and demands of pregnancy and adulthood. In late adulthood, the challenge is to avoid premature death or disability from diet-related chronic diseases and to progress into fit and healthy old age. The effect of poor nutrition starts in utero and extends throughout the lifecycle, particularly in girls and women (ACC/SCN, 1999). This amplifies the risks to the individuals health but also increases the likelihood of damage to future generations, through further fetal growth retardation and a limited ability to cope with stresses within the family and in the provision of childcare. Good nutrition in early life beginning with the fetal stage - pays dividends in childhood and in later life. Undernourished girls who survive may grow up to be stunted women who in turn produce low birth weight babies who may have a lower chance of survival than normal-weight babies. These undernourished children fall ill recurrently and fail to develop optimally - both physically and mentally. Optimal nutrition is therefore vital at all stages of the lifecycle, namely, prenatal, infancy, young child, adolescence, adulthood and old age. 2.3 DETERMINANTS OF NUTRITIONAL STATUS

According to UNICEFs conceptual framework (UNICEF, 1990; UNICEF, 1997), the basic causes of malnutrition in society are the way potential resources interact with economic and political superstructure, as well as formal and informal institutions that arbitrate in production and distribution. This gives rise to underlying causes e.g. inadequate access to food, inadequate care for mothers and children, and insufficient services (e.g. healthcare) and unhealthy environment (including sanitation). In this framework, the underlying causes have profound influence on the immediate causes of malnutrition outcomes, namely, inadequate dietary intake and disease. The trends in malnutrition are normally correlated with changes in the underlying causes of malnutrition e.g. access to safe water and sanitation, food intake, access to health services, intra-household control of resources, and education of women and girls. Kenya has recorded poor economic growth in the 1990s, which was matched by stagnation in nutrition status as shown by indicators of child nutrition. The incidence of poverty has increased considerably and it is currently estimated that over half of the population lives below the poverty line. At the macro level, Kenya has been a net importer of food, especially coarse grains. Among the basic causes of malnutrition has been minimal resource allocation to nutrition activities and limited understanding of the key importance of nutrition in development. Even where there may be enough food in the household and the family lives in a healthy environment, the quality of child and maternal care may be inadequate. Care practices relate to feeding, protecting childrens health, support and stimulation for children, and care for mothers. For example, only 16% of infants are exclusively breastfed for the first three months (MICS, 2000). The weaning foods given are very inadequate in terms of nutrient content and suitability for certain age groups. Only 59.2% of children under two years are fully immunized, and half of children between 6-23 months are affected by malaria (KDHS, 2003). There is a vicious cycle between malnutrition and infection. Malnutrition weakens the bodys resistance to infections by undermining the immune-response functions. Infections cause loss of appetite, malabsorption and behavioral changes, which in turn increase the bodys requirements for nutrients. Among
Infant feeding policy is made with the best interests of the mother and baby as a pair. The elements include: (a) to prevent HIV infection in women of childbearing age, (b) develop and promote voluntary and confidential counseling and HIV testing services which are committed to informed consent and protection of confidentiality, (c) strengthen antenatal care services and encourage attendance, (d) implement interventions to prevent MTCT, (f) strengthen family planning services, (g) protect, promote and support breastfeeding as the best infant feeding choice of uninfected women and women whose HIV status is not known, and (h) prevent commercial pressures for artificial feeding.
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children under-five, the burden of disease is high, the biggest killers being malaria, acute respiratory infections (ARI) and diarrheal diseases. The distribution of available health services is skewed with disparities in access and affordability across the country. The rural areas and North Eastern province are particularly disadvantaged. A large proportion of households in Kenya do not have adequate access to health and nutrition services, safe water and sanitation. The 2003 KDHS showed a national HIV/AIDS prevalence rate of 6.7%, with 8.7% among women and 4.5% among men. The highest prevalence among females was in the age group 25-39 years, and the highest among males was in the age group 25-44 years. HIV/AIDS significantly impacts on individuals and households. At the individual level, it accelerates the vicious cycle of inadequate dietary intake and disease through raising nutrient requirements and eroding the immune system. At the household level, HIV/AIDS has taken a heavy toll on productivity of both the infected and affected, diverted household resources from essential needs (e.g. nutrition, education and health), and has contributed significantly to the level of poverty. It is safe to assume that HIV/AIDS has led to decline in household food security and consequently to the observed worsening of the nutrition situation in certain parts of the country. 3. LINK BETWEEN NUTRITION AND OTHER ASPECTS OF DEVELOPMENT 15

It has long been recognized that there are many pathways to under-nutrition, and the baby that fails to grow properly has been let down by a potentially large set of actors and sectors. Nutrition contributes to development in many sectors, and actions in many sectors also have an impact on nutrition. For example, investing in girls nutrition can help advance the status of women and increase the incentives for smaller desired family sizes; nutrition is an important first step in developing human capital and reducing poverty; nutrition programming can develop participatory processes that promote human rights and facilitate successful decentralization; and better nutrition status can help prevent noncommunicable diseases such as diabetes. 3.1 NUTRITION AND HUMAN RIGHTS

The right to food is enshrined in Article 25 of the Universal Declaration of Human Rights of 1948. It is further spelled out in the International Covenant on Economic, Social and Cultural Rights adopted by the United Nations General Assembly in 1966, and reiterated with a view to its more qualitative nutritional aspects in the Convention on the Rights of the Child (CRC) adopted in 1989. The Childrens Act, 2001, domesticated the CRC into municipal law, and includes adequate diet for a child among the specified parental responsibilities. A human rights approach starts from the ethical position that all people are entitled to a certain standard in terms of physical, mental, spiritual and economic wellbeing. A human rights approach thus removes the charitable dimension and emphasizes rights and responsibilities. It recognizes beneficiaries as active subjects and claimholders and establishes duties or obligations for those against whom a claim can be held (duty-bearers). The concept of claimholders and duty-bearers introduces an important element of accountability. The most fundamental principle of the international human rights system is that of non-discrimination. Nutritional surveillance is a potent measure of biological outcomes of discriminatory practices between men and women, across the age profile of the population, and between ethnic groups. An understanding of the immediate and underlying causes of differences in nutritional outcomes can be invaluable tools for resource allocation and public education. Participation and community empowerment in program design and implementation are sound both as values and as tools for sustainable human development. Community-based nutrition programming provides a useful basis and test case for human rights-based approach to development.
This section is mainly based on twelve policy briefs prepared under the auspices of the United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition (ACC/SCN) titled Nutrition: A Foundation for Development (see references).
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Nutrition as a human right requires two qualifications. First, nutrition advocacy begins with the moral and legal imperative of the right to food, centered on human dignity, while the contribution of good nutrition to efficiency and outcomes in other sectors should be viewed as a premium. Secondly, the main role of the state is not charity but to provide households and individuals with the environment to realize their rights and prevent infractions by third parties in realizing their rights. Nutrition has a link with politics, both at local, national and international levels. For example, provision of micronutrients and food fortification or campaigns to promote breastfeeding may not have as much political capital as food aid. Political considerations therefore favor efforts at general malnutrition at the expense of micronutrient malnutrition, both at national and international levels. 3.2 NUTRITION AND HEALTH

The synergy between nutrition and infection is demonstrated by the fact that those suffering from infections can become malnourished and those who are malnourished progressively succumb to infection much faster and may have more severe illness than those whose nutritional status is optimal. Undernutrition affects both the bodys immunological and non-immunological defenses. It increases the incidence, severity and duration of common childhood diseases such as diarrhea, acute respiratory infections and measles. There is also a relationship between certain types of under-nutrition and morbidity and mortality. An improvement in Vitamin A status of vulnerable populations reduces under-five mortality and save many children from irreversible blindness. Iron deficiency is a contributing factor in anemia and maternal deaths. Iodine deficiency is the most common form of preventable mental retardation and brain damage. Obesity and poor diet is a major factor in the development of chronic diseases. Evidence is also emerging that malnutrition suffered in the womb may lead to predisposition to hypertension, coronary heart disease and diabetes later in life. 3.3 NUTRITION AND BEHAVIORAL PRACTICES

In Kenya, the underlying causes of malnutrition go beyond lack of food to include intra-household food discrimination and deep-rooted traditional habits particularly in the feeding of pregnant women and small children. Discrimination against women in access to food takes various forms. The most common are food taboos, especially in the feeding of pregnant women and young children, which is a cultural and political expression of the underlying relations on gender and seniority. The coping strategies (fallback mechanisms) to deal with short-term insufficiency of food do not affect all household members equally (Maxwell, 1996) e.g. through maternal buffering (the practice of a mother deliberately limiting her own intake in order to ensure that children usually recently-weaned toddlers get enough to eat). Food insufficiency has the potential for sex and age bias in food intake, especially in promale cultures. Discrimination in the sharing of food directed specifically at children varies from community to community, and its impact on nutritional outcomes therefore varies. For example, some communities believe colostrum is unclean milk and do not therefore breastfeed immediately after birth. In other communities, the choice of weaning foods may be particularly harmful to childs health and nutrition. Some communities attribute symptoms of malnutrition (e.g. kwashiorkor and marasmus) to witchcraft, curse, or violation of a taboo by the childs parents. When malnutrition is not associated with food intake, food is unlikely to be used as a remedy for such a malnutrition disorder. 3.4 NUTRITION AND EDUCATION

Nutrition is important for intellectual and educational advancement. Low birth weight and growth retardation among children (low height-for-age) is associated with a substantial reduction in mental capacity and adverse school performance; and poor nutrition in school-going children reduces their levels of concentration and ultimately their education performance. Iodine deficiency in school children leads to reduced cognitive function while deficiency during fetal life can have profound and irreversible effects on a

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childs mental capacity. Iron deficiency anemia in school-age-children leads to reduced cognitive abilities and low school performance. 3.5 NUTRITION AND GENDER

Gender differentiation interacts with biological roles to affect nutritional status of the whole family and of each gender. Women are particularly vulnerable to deficiencies in diet due to the cyclical loss of iron and childbearing. Furthermore, the nutrition status of women before, during and after pregnancy affects the nutrition status of newborns and infants. Their triple burden of productive, reproductive and social roles make women have less time to attend to their own needs. Poor female nutrition early in life increases reproductive and maternal health risks, and lowers their productivity. Inequalities in access to assets and income have severe consequences for womens ability to provide food, care, health and sanitation services to themselves, their husbands and children. Maternal malnutrition increases the risk of low birth weight, which in turn affects child morbidity and mortality. Nutrition education is also passed during prenatal and antenatal clinics, and the ability of women to internalize and apply the knowledge is dictated by their levels of education and control over household resources. 3.6 NUTRITION AND DEMOGRAPHIC CHANGE

Nutrition is intimately linked to demographic change. Nutrition is a major factor in fertility and mortality rates. Maternal nutritional status affects fertility, and famines are normally associated with a drop in birth rates. Good nutrition reduces maternal, neonatal and child mortality, while improved child survival slows population growth by increasing birth intervals and reducing the demand for large families. Fewer pregnancies in turn reduce the risk of maternal death. The prevention of stunting among girls helps reduce the risk of obstetrical complications and low birth weight, while infants that receive good nutrition face better chances of survival. Breastfeeding, especially when exclusive for about six months after birth, is important for child nutrition and for reducing fertility through lengthening the lactation amenorrhea (the period to the return of the menses). Population and demographic change also have an influence on nutritional status. Rising population threatens food availability, and rapid population growth also goes hand in hand with increased urbanization. In poor and congested urban areas, diarrheal diseases and under-nutrition are frequent because of poor food hygiene, inadequate water supplies and waste disposal, poor housing, and decline in prevalence and duration of breastfeeding and a corresponding increase in bottle-feeding. Poor clothing, housing, and worm infestation makes it imperative to consume a higher food ration to compensate for heat loss and gut parasites. Urbanization is also accompanied by consumption of higher share of processed foods, which are linked to obesity and cardiovascular diseases. 3.7 NUTRITION AND AGRICULTURE

The three main pillars of good nutrition are food security, good care practices (for mothers and children), and good healthcare. Agriculture affects nutrition through household food security, and improved nutrition in turn supports the agricultural sector by enhancing peoples ability to undertake strenuous farming activities. Besides its impact on food output, agriculture also has impact on incomes. However, the pattern of agricultural production has profound effects on nutrition e.g. between cash crops and food crops and the production mix of food crops. In cash crop economies, higher agricultural production may not be correlated with improved nutrition due to reduction in land allocated to food production, while changes in production systems from food to cash crops are normally accompanied by shift in control of household resources in favor of males. 3.8 NUTRITION AND POVERTY

The case for public action to eliminate malnutrition is both a moral and economic imperative. Food and nutrition are human rights enshrined in various international conventions. Governments therefore have a duty to ensure that these dimensions of wellbeing are realized. On the economic front, private markets for

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health, education, sanitation and other determinants of good nutrition are often beyond the reach of the very poor, and ability to access the available services is normally differentiated by income and gender. The inadequacy in sharing resources for infrastructure development, e.g. roads, comes to sharp focus when it becomes impossible to market local food production or deliver food to food-deficit areas. In the Kenya case, the road infrastructure is mainly geared to connecting the various levels of the provincial administration, rather than connecting areas of food surplus and food deficits. Poor nutrition undermines intellectual capacity and labor productivity in a most savage way. In addition, good nutrition in the first two years of life reduces private and public health expenditure throughout ones lifetime. The intergenerational cycle of poverty can be broken when there is good nutrition right from an early age. Diet-related diseases impose a heavy burden due to costs of healthcare, lost work due to illness and early death. However, rapid improvement in nutrition will not necessarily be a direct result of economic growth. Nutrition may not even respond to improved income. Countries with similar Gross National Products (GNP) have very different rates of preschool underweight, for example. If income distribution is very unequal or if economic growth mostly reflects increases in production from agribusiness or large-scale industry, the benefits may not reach the undernourished. Nutrition in such cases may stagnate or even deteriorate. In Kenya, for example, the regional prevalence of poverty tends to increase in the same direction with indicators of malnutrition (e.g. body mass index), but the relationship between regional indicators of poverty and child nutrition varies probably due to differences in breastfeeding and weaning practices. The process through which malnutrition is reduced can also be used to empower communities. Most nutrition programs are community-based, and participatory approaches used in community-based nutrition programs are normally used for other types of poverty-reduction interventions and in building social capital (broadly interpreted as a shared set of values and norms). Other developmental activities can also be grafted on the community-based food and nutrition programs e.g. local growth monitoring and promotion. Communities empowered through a well conceived decentralization process are able to enforce accountability of local and national agents, respond to crises at the local level, engage in mutual support, and reduce the cost of implementing national programs at the local level. 3.9 NUTRITION AND ENVIRONMENT

Unless human populations meet their basic survival they cannot afford to conserve the environment, and unless local communities protect the environments around them, they have limited scope to thrive beyond the short-term. Nutrition is the most fundamental of human needs, and is therefore a useful perspective from which to address this paradox. Environmental degradation and consequent reduction in access and intake of bio-resources may lead to protein-energy malnutrition and micronutrient deficiencies. Increasingly, the rural poor live in areas of high ecological vulnerability and relatively low levels of biological or resource productivity such as dry lands or steep mountain slopes. The narrow consumption base in urban populations is associated with diabetes and coronary heart disease, and the interaction between nutritional and environmental factors largely explains the prevalence of tuberculosis, gastrointestinal diseases, measles and respiratory diseases. Environmental contamination from industrial and agricultural chemicals may compromise nutritional status either directly by making food unfit for human consumption, or through changes in diet as a result of changes in traditional food systems. 3.10 NUTRITION AND CRISES

Empirical research has shown that good nutrition relieves the social unrest underlying violent conflict, decreases human vulnerability that transforms systemic shocks into humanitarian disasters, and promotes timely return to equitable and durable development in the aftermath of crises. The infant mortality rate, as the most efficient indicator of the quality of material life, has been shown to be the most powerful predictor of future conflict (Marchione, 2002), and infant mortality is in turn dependent on some pillars of good nutrition, namely, food availability and access, safe environment, education and healthcare.

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The violations of human rights in the context of lack of basic needs and faulty economic systems that do not distribute resources equitably form the core causes of conflict and malnutrition. The competition for scarce, depleted, and poorly distributed resources such as land and water has been observed to lead to ethnic conflicts in Kenya and elsewhere. The predatory nature of political and economic elites in the competition for resources has also been observed to lead to crises. During a humanitarian crisis, nutrition surveillance is used as part of the early warning system on vulnerability to crisis and for targeting humanitarian assistance. Inadequate or inequitable provision of relief can also have adverse political and economic effects, and thus prolong the crisis. 4. 4.1 TRENDS IN NUTRITION STATUS MEASURES OF NUTRITIONAL STATUS

In the measurement of nutritional status, the term under-nutrition refers to conditions of inadequate nutrition, namely, fetal growth retardation, stunting, underweight, wasting, and low body mass index (BMI). The term malnutrition refers to both under-nutrition and over-nutrition, or excess. The table below summarizes the commonly collected indicators of under-nutrition. Table 1: Commonly collected Anthropometric Indicators
Anthropometrics Age Profile Children 6-59 months Indicator Underweight Stunting Wasting Adults Body Index Low Weight Body Index Mass Birth Mass What it measures Low weight for age either due to wasting or stunting or a combination of both Shortness (low height for age) as a result of chronic malnutrition Thinness (low weight for height) as a result of acute malnutrition Thinness (low weight for height) as a result of acute malnutrition Associated with poor nutrition in mothers Thinness (low weight for height) as a result of acute malnutrition Contexts where mainly used Commonly collected through growth monitoring systems Associated with poverty and usually assessed in stable situations Most commonly assessed in rapidly changing situations through surveys in emergencies Adult nutritional status for all situations Measures changes in maternal nutrition over time

Elderly Micronutrient Deficiency Iron Deficiency Anemia Vitamin A Deficiency Iodine Deficiency Vitamin C deficiency

Indicators Clinical signs; Hemoglobin levels Clinical signs; Blood assays Clinical signs; Urinary assays Clinical signs

Context where used Mainly women of childbearing age, school children and children under 5 Children under 5 Endemic areas normally Often monitored in emergencies

Source: Busili, Frize and Shoham (2004) The main nutrition information systems in Kenya include Child Health and Nutrition Information System (CHANIS) in the Ministry of Health, and national level periodic surveys by the Central Bureau of Statistics. The CHANIS system was adopted as an appropriate primary healthcare strategy following the Alma Ata conference in 1978. It was established in Kenya in 1985 with the objectives of preventing malnutrition from occurring, and to maintain and promote good growth among 0-5 years age group attending monthly weighing sessions at health facilities. CHANIS is supposed to cover all MOH and private health facilities and community-based nutrition programmes in the country, but the coverage is low and only the data generated at MOH health facilities is further analyzed at district and national levels.

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The national nutrition surveys include nutrition assessments for under-fives conducted either independently or as modules of the welfare monitoring surveys, and the Kenya Demographic and Health Surveys (1989, 1993, 1998 and 2003). There has also been two multiple indicator cluster surveys (MICS) in 1996 and 2000, conducted by CBS with support from UNICEF. Other nutrition information include nutrition data incorporated into early warning systems (e.g. Arid Lands Resource Management Programme, Famine Early Warning System network and Vulnerability Assessment Mapping/World Food Programme), and localized studies and surveys by research and academic institutions, school and preschool feeding programmes, and ad hoc health facility based data on noncommunicable nutrition-related diseases (e.g. obesity). Since 2000, UNICEF and other development partners have undertaken several emergency nutrition and health surveys in the arid and semi-arid areas. The main nutrition problems in Kenya are related to under-nutrition. They include protein energy malnutrition, iodine deficiency disorders, iron deficiency anaemia and vitamin A deficiency. Kenya is increasingly facing the emergence of diet-related noncommunicable diseases that are mainly caused by change in diets associated with urbanization, consumption of processed foods, and decreasing levels of physical activity. Ideally, nutritional assessments should cover all stages of the lifecycle. There is, however, no nationally representative information on the prevalence of diet-related noncommunicable diseases and malnutrition among school-age children, as most of the nutrition information is focused on children under 5 years. 4.2 PROTEIN-ENERGY MALNUTRITION

The overall prevalence of low birth weight (LBW) in children was reported at 9.3% in the 2000 Multiple Indicator Cluster Survey. This figure varies by provinces with the highest proportion of infants with LBW recorded in Eastern province (8.6%). There were no significant variations in LBW between rural and urban areas. The nutritional situation in Kenya as measured by the growth deficit among young children has not shown improvement over the last two decades. As shown in the 2003 KDHS, the prevalence of stunting is now at 31%, much higher than the 23% thirty years ago. In 2000, the prevalence of chronic malnutrition among children was estimated at 35%, a level about 17 times higher than what is expected in a healthy wellnourished population. The 2003 KDHS show that the highest levels of stunting were recorded in Coast (35.6%) and the lowest in Central province (26.7%). Children in rural areas are notably more undernourished than their urban counterparts, at 32.2% and 23.3%, respectively. The prevalence of wasting has deteriorated from 4.5% in 1982 to 5.7% in 2003. Wasting (and stunting) has been correlated not only with higher morbidity but also increased risk of mortality in children. It should be noted that wasting is usually as a result of recent morbidity or inadequate dietary intake resulting from loss of appetite or food shortage.

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Table 2: National estimates of the population affected by under-nutrition

Type of Deficiency Protein Energy Malnutrition (under 5s) * Stunting Wasted Underweight Chronic Energy Deficiency (women)** Anemia*** Children Adult Males Adult Females Iodine Deficiency Disorders Total Goitre Rate Vitamin A Deficiency*** Preschool children Women % Affected 30.7 5.7 20.2 11.5 54.2 26.2 28.0 16.0 88.0 51.0

Sources:

* ** ***

Kenya Demographic and Health Survey 2003 Kenya Demographic and Health Survey 1998 Micronutrient Survey 1999

The 2003 KDHS shows that 20.2% of children were underweight, with 4.3% classified as severely underweight. Coast presents higher rate of malnutrition at 25.9% followed by Rift Valley at about 24.4% and Eastern at 21.7%. In Kenya, malnutrition sets in early. As shown by the 2003 KDHS, wasting is most common in the 10-23 months age group, a phenomenon most possibly linked to improper and inadequate weaning practices as well as higher incidences of diarrheal diseases in this age group. Early introduction of complementary foods in an infants diet exposes the child to disease-causing pathogens before the child has developed immunity. Table 3: Nutritional stunting: Trends and child population affected
Province Nairobi Central Coast Eastern North Eastern (Urban) Nyanza Rift Valley Western KENYA 1982 -33.6 48.6 39.0 -43.1 31.4 40.5 37.1 1993 (KDHS) 24.2 30.7 41.3 39.4 -32.1 28.5 30.0 32.7 % annual change -- 0.26 - 0.66 + 0.04 --1.00 - 0.96 - 3.41 - 0.40 1993 (KDHS) 24.2 30.7 41.3 39.4 -32.1 28.5 30.0 32.7 2000 (MICS) 29.6 27.4 33.4 42.8 34.4 35.9 36.8 38.1 35.3 % annual change + 0.78 -0.47 -1.13 + 0.49 -+ 0.54 + 1.18 + 1.16 + 0.40 Number stunted (2000) 98,417 160,648 155,329 357,109 59,766 295,336 509,807 267,107 1,871,264

Primary school-age children (6-13 years) constitute 22% of the countrys population, but limited information is available about their nutritional condition and the functional effects of chronic undernutrition on ill health and school performance. Little is also known about nutritional status of the adolescents in Kenya. Growth retardation in adolescent girls is of particular concern and constitutes major impediment to safe motherhood. The Body Mass Index is used to assess the nutritional status of adults. While on average, the mean BMI for women in Kenya is within the normal global range (18.5-25) at 21.9, the incidence of malnutrition among women in Kenya is on the rise. Whereas 9% of women were considered malnourished in 1993, 12% were considered malnourished in 1998. There were notable regional variations with 5% of the women in Nairobi having low BMI compared to 15-16% in Coast, Eastern and Rift Valley provinces (KDHS, 1998). The 1999

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national survey on iron, vitamin A and zinc also assessed maternal malnutrition, where 17.7% were found to be malnourished. Maternal malnutrition may be intergenerational, related to inadequate access to food, poor care practices and knowledge, as well as cultural and social taboos and traditions that prevent women from partaking sufficient amounts of nutritious foods. 4.3 MICRONUTRIENT MALNUTRITION

Micronutrient deficiency or hidden hunger has profound effects on the health and wellbeing of individuals and consequently on their productivity. Deficiencies of Vitamin A, iron, iodine and zinc are widely prevalent in Kenya. 4.3.1 Iron Deficiency Anemia (IDA)

Iron deficiency and the resultant anemia is a global nutrition problem affecting primarily young children and women of childbearing age. Iron deficiency is a common nutritional deficiency and is the second most important after protein-energy malnutrition. Iron deficiency anemia during pregnancy increases perinatal risks for mothers and neonates and the overall infant mortality. The detrimental effects of anemia include impaired cognitive performance, reduced growth and lowered immunity to infections. The 1999 Kenya national survey on micronutrients revealed a very high prevalence of anemia among children below five years of age (73%) and among women in reproductive age group (55%). The highest levels of IDA were in the Lake Basin and the Western highlands. Young children were the most affected with those below 30 months of age having a prevalence of 76.5%. The main factors associated with iron deficiency were vitamin A deficiency, zinc deficiency, malaria and hookworm infections. Low BMI was seen to be an important risk factor for maternal anemia. The current guidelines on the control of iron deficiency anemia have a facility-based strategy, which includes providing iron and folate tablets to pregnant mothers from the first trimester. However, it is important to note that only 46.3% of the responding women in the 2003 KDHS had received iron supplementation during the most recent birth in the 5-year period preceding the survey. 4.3.2 Vitamin A Deficiency (VAD)

Vitamin A is required for proper vision, proper immune function and reproduction. Some diseases increase the risk of vitamin A deficiency because of poor appetite, reduced absorption of vitamin A (diarrhea and worm infestations) and increase in vitamin A needs (e.g. in diarrhea and measles). In addition, studies have shown a relationship between a childs nutritional status and VAD. The findings of the 1999 survey indicated that both stunting and wasting were strongly associated with vitamin A status. VAD leads to decreased absorption of iron, therefore predisposing individuals to iron deficiency anemia. Fats and oils help in the absorption of vitamin A. Colostrum and early breast-milk are concentrated sources of vitamin A. However, in many cultural settings, colostrum and early breast-milk are considered unclean and thus not given to infants. Vitamin A deficiency worsens the severity of illness in children, especially persistent diarrhea, measles, malaria and dysentery. Vitamin A deficiency affects large numbers of preschool children and women of childbearing age. About 24% and 61.2% of preschoolers suffer from acute and moderate Vitamin A deficiency, respectively. The prevalence of acute and moderate VAD among mothers on the other hand was 9.1% and 29.6%, respectively. In mothers, VAD in combination with zinc deficiency contributes to intra-uterine malnutrition leading to low birth weight and stillbirth. The most sustainable way to prevent VAD is through the consumption of foods that are rich in vitamin A such as green leafy vegetables, fruits, red palm oil and liver. Although dietary sources are important, the poor biological availability of vitamin A from plant sources suggests the need to examine other strategies for the prevention and control of VAD e.g. supplementation and fortification. The 2000 Multiple Indicator Cluster Survey indicated that through routine coverage only 42% of children below five years of age

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received one dose of vitamin A supplement. The MICS 2000 report showed that only 23% of the women who had given birth within the previous 12 months had received the required vitamin A dose. 4.3.3 Iodine Deficiency Disorders (IDD)

Iodine deficiency disorders (IDD) include goiter and a wide spectrum of mental and intellectual defects of varying degrees of severity, including cretinism, paralysis and deaf-mutism. These disorders can also lead to stunted growth and development, miscarriages, stillbirths and high infant mortality. Iodine deficiency is the worlds single most significant cause of preventable brain damage and mental retardation. A 1994 evaluation of iodine deficiency disorders in Kenya showed a prevalence of total goiter rates of 16%. Of the 45 study districts, only three did not have IDD, 28 were classified as mild prevalence areas, moderate prevalence occurred in 8 districts and 6 districts had high prevalence of IDD. Moderate prevalence (20-29.9%) was reported in Nyandarua, Nyamira, Nandi, Migori, Bomet, Mt Elgon, Bungoma and Narok; while severe prevalence (more than 30%) was reported in Isiolo, Lamu, Garissa, Elgeyo Marakwet and Turkana. Globally, the most cost-effective strategy to combat the problem is universal salt iodination, which was adopted in Kenya in the 1970s. Presently, it is estimated that over 95% of households consume adequately iodized salt. 4.3.4 Zinc Deficiency

Zinc plays a central role in cellular growth, differentiation and metabolism. Zinc is particularly important in determining pregnancy outcomes, susceptibility to infection (especially diarrhea and acute infections of the lower respiratory tract), physical growth and neuro-behavioral development. There is also strong evidence of a relationship between zinc deficiency and stunting. The 1999 National Micronutrient Survey (Kenya, 2000) showed that zinc deficiency in the Kenyan population was a high 84%. Zinc deficiency was significantly associated with fever, malaria, diarrhoea and hookworm. The causes of zinc deficiency include inadequate intake and/or poor bioavailability due to presence of dietary inhibitors. Fish, crustaceans, fowl and meat are the richest sources of zinc; eggs and dairy have slightly lower zinc content; and while most cereals and legumes have an intermediate level of zinc, their phytate content reduces the amount of zinc that is available for the body to absorb. There has not been any dedicated effort to tackle zinc deficiency in the country. 4.4 NUTRITION-RELATED NONCOMMUNICABLE DISEASES

Developing countries are increasingly suffering from high levels of public health problems related to chronic diseases. Although HIV/AIDS, malaria and tuberculosis, along with other infectious diseases, still predominate in sub-Saharan Africa, 79% of all deaths worldwide that are attributable to chronic diseases are already occurring in developing countries (WHO/FAO, 2003). It is clear that the earlier labeling of chronic diseases as diseases of affluence is increasingly a misnomer, as they emerge both in poorer countries and in the poorer population groups in richer countries. This rapid shift in the pattern of diseases is creating a major public healthy threat, which demands immediate and effective action. It has been projected that, by 2020, chronic diseases will account for almost three-quarters of all deaths worldwide, and that 71% of deaths due to ischemic heart disease, 75% of deaths due to stroke, and 70% of deaths due to diabetes will occur in developing countries (WHO/FAO, 2003). The number of people in the developing world with diabetes will increase by more than 2.5-fold, from 84 million in 1995 to 228 million in 2025 (WHO/FAO, 2003). On a global basis, 60% of the burden of chronic disease will occur in developing countries. 4.4.1 Diabetes Mellitus

Diabetes Mellitus (DM) is one of the most common noncommunicable diseases worldwide. DM is the fourth leading cause of death in most developed countries and there is substantial evidence that it is epidemic in many developing countries. In Kenya, an estimated 209,400 people suffered from diabetes in the year 2000. The prevalence rate is estimated at 5-10% in the total population but these are conservative

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rates since most people are not aware of its symptoms and thus do not seek medical attention promptly. The incidence is higher among males than females, in urban than rural populations, and the most affected are those over 40 years. The incidence of DM is on the rise as evidenced by the rising attendance in various health facilities in the country. The rise in the cases of DM is attributable to sedentary lifestyles especially by those living in urban areas. In addition, there is change in the diets of many Kenyans, mainly a shift from traditional diets to foods that are highly refined and that contain high levels of sugar. Nutrition serves as the cornerstone for successful management of DM. In view of the rising incidence of DM, there is need for sensitisation on the dangers, symptoms and signs and the need for its early detection, and capacity building on its nutrition management with special emphasis on dietary habits and lifestyles that reduce its incidence. 4.4.2 Obesity/Overweight

Given the rapidity with which traditional diets and lifestyles are changing in many developing countries, it is not surprising that food insecurity and under-nutrition persist in the same countries where chronic diseases are emerging as a major epidemic. The epidemic of obesity, with its attendant co-morbidities (heart disease, hypertension, stroke and diabetes) is not limited to industrialized countries. The increasing prevalence of obesity in developing countries also indicates that physical inactivity is increasing as well. Studies on current prevalence of obesity in Kenya are limited, but facility-based data suggests that obesity exists and its prevalence is increasing. 5. MAIN AGENCIES IN PROMOTION OF NUTRITION

The current food and nutrition activities fall under three major themes, which have their own distinct history and independence in the implementation process. The first historical thread in policy development is the growth of nutrition and nutrition-related activities in the functions of the ministries of health, agriculture and education. The municipalities where health and primary education functions have been delegated by the central government may be involved in nutrition in the preschools and in rehabilitation of malnourished children in the health centers. Secondly, is the community-based nutrition program, which grew out of the nutrition rehabilitation centers opened in the fifties, and is funded by donors and coordinated by the department of social services. The third strand of nutrition-related activities are the developments emanating from the 1974 FAO World Food Conference that set in motion the setting of food and nutrition policies in member countries. This finally led to the formation of the Food and Nutrition Planning Unit in the Ministry of Planning and National Development in 1979. The policy received further stimulus from the 1990 World Summit for Children and the 1992 International Conference on Nutrition. This is the same policy link within which the GoK/UNICEF national plan of action has been implemented. The Ministry of Planning and National Development is in charge of coordination of nutrition activities, monitoring of nutritional status through occasional nutritional surveys (conducted by the Central Bureau of Statistics), and is the convener of the GoK/UNICEF Program of Cooperation in Kenya. The Kenya Bureau of Standards (KEBS) has many important activities, including spearheading legislation on food quality and safety standards, and enforcing the established standards. In recent years, there has been an attempt to bring together the government departments, donor agencies, and civil society organizations on food and nutrition under the auspices of the Inter-Ministerial Coordinating Committee on Food and Nutrition. A perusal of the Governments printed estimates showed that the resources allocated to nutrition activities are minimal. The only direct reference to nutrition was the activities of the nutrition unit in the Ministry of Health and the DANIDA-supported Community-Based Nutrition Programme. However, the Home Economics Branch of the Ministry of Agriculture has nutrition-related activities undertaken as part of the regular agricultural extension program. UNICEF is the key agency in support to nutrition activities in Kenya, including technical and financial support in undertaking nutrition surveys.

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5.1

MINISTRY OF HEALTH

The elements of the program are mainly infant and young child feeding, micronutrients, growth monitoring and promotion, integrated early childhood development (IECD), nutrition and HIV, and dietetics. The Division of Primary Health Care advocates for production, consumption and preservation of micronutrient-rich foods, and activities that promote appropriate weaning foods and community diagnosis of malnourished children. The Division is responsible for vitamin A and iron supplementation through static and mobile health facilities countrywide. Vitamin A supplementation covers lactating non-pregnant mothers (once at birth or within 4 weeks after birth), infants 9-11 months (once during measles vaccination or any other contact) and children 1-5 years (every 3-6 months). The Ministry of Health monitors compliance as outlined in the enabling legislation on iodination of salt, mainly through the National Public Health Laboratories in collaboration with the Kenya Bureau of Standards. The nutrition unit in the Ministry of Health receives support primarily from UNICEF and WHO to address issues of infant and young child feeding, micronutrients, and nutrition and HIV/AIDS. The ministry collaborates with the ministry of agriculture in creating awareness on the need to fortify foods and the necessary food diversification to achieve the necessary iron intake. The ministry is also in the process of developing guidelines for fortification of foods to make them rich in vitamin A, and to identify the necessary food vehicle for vitamin-A fortification. The department trains on growth monitoring and promotion (GMP), conducts GMP activities, analyzes the data collected, undertakes nutrition education, and gives nutrient supplementation to the malnourished children. Remedial actions on malnourished children may include breastfeeding practices, supplementary and weaning foods, and treatment if the malnourishment is accompanied by pathological symptoms of disease. The GMP data from the health facilities is entered into a national database called Child Health and Nutrition Information System (CHANIS). Early childhood development programs in Kenya cater for children from birth to 8 years and for women of reproductive age. The program emphasizes holistic growth and development of the child that integrate health, nutrition, socialization, emotional, motor skills and cognitive development. However, the formal center-based ECD program does not cater for 0-3 years and reaches less than half of the eligible preschoolers. The integrated program has been developed to also cover children outside mainstream ECD services through sustainable community-based interventions and programs. The main objectives of the program are to strengthen the knowledge and capacities of parents and other caregivers to better care for their young children; improve the status of health and nutrition of children 0-8 years; raise enrolment and improve quality of education in preschools; enlist the support of other government departments and organizations not usually involved in ECD activities; and raise the level of awareness about ECD within communities. The dietetics function involves the development of guidelines on hospital feeding diets for both regular diet and diets specific to the health condition of a patient. The special diets include pediatric nutrition, soft or liquid diet for those who cannot tolerate solid foods, diet for the management of acute gastrointestinal disorders, diets for nutrition-related noncommunicable diseases (e.g. obesity, hypertension and diabetes mellitus), and dietary management in HIV/AIDS. 5.2 MINISTRY OF AGRICULTURE

The national food policy, as outlined in Sessional Paper No. 2 of 1994, recognizes the fact that national food security does not necessarily ensure household or individual food security. The policy paper therefore outlined strategies to improving household food security e.g. incentives to farmers for improved agricultural production, improved extension services, improved health and nutrition education, provision of emergency food relief, and food-for-work programs for the rural poor. The nutrition component of the food policy is aimed at increasing the production and consumption of more nutritious foods, improving distribution of purchasing power, implementing specific market interventions, and collection and analysis of information on the nutritional status of the population.

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The nutrition activities are implemented by the Home Economics Branch (HEB), alongside other extension activities. The main objective of HEB is to improve the nutritional status and household food security of farm families in the country. The activities are divided into three general themes, namely, food and nutrition, appropriate technologies, and population education and HIV/AIDS. Food and nutrition activities include dietary diversification through promotion of kitchen gardening and rearing of small livestock, promotion of consumption of indigenous and underutilized foods, food preparation, food preservation, food processing, and nutrition education. The appropriate technologies include energy-efficient and timesaving technologies and practices, incomegenerating technologies, improvement of household incomes through promotion of income-generating activities, and home management (health and sanitation technologies, and home improvement technologies). Population education is geared to planning families in relation to available household resources, developing coping mechanisms to address the needs of families affected and infected by HIV/AIDS, and offering enriched and integrated HIV messages e.g. how to manage the infection with appropriate diet. The HEB utilizes group approach to disseminate information. To create change in food-related behavior, HEB conducts training sessions on nutrition. Nutrition education is aimed at increasing the nutritional knowledge and awareness, promoting desirable food behavior and nutritional practices, and increasing diversity and quantity of family food supplies. The energy-saving stoves save on cost of cooking fuel, reduce women workload, and make it economical to prepare foods whose consumption has declined due to high energy costs (e.g. githeri). The strategy also involves measures to reduce the margin between individual consumption and absorption (e.g. combinations of vitamins and minerals), storage (e.g. sunlight and infestation damage), processing, and cooking. There are other programs that have a direct bearing on nutrition and food security. The Central Kenya Dry Areas Project (supported by IFAD) that covers five districts Thika, Maragwa, Nyandarua, Nyeri and Kirinyaga has home economics as one of its components. There is also a project on promotion of horticultural and traditional food crops in Eastern province, a nationwide special program on food security (supported by FAO), and the National Agriculture and Livestock Extension Programme in five provinces (Rift Valley, Central, Eastern, Western and Nyanza). 5.3 MINISTRY OF EDUCATION

To address the health and nutrition needs of school children, the ministry of education has put in place three main programs: early childhood development program (ECD), school feeding program (SFP), and school health and nutrition program (SHN). The Ministry of Education is in charge of the school-feeding program, which involves feeding of school children in the arid and semi-arid lands (ASAL), de-worming of school children in the ASAL areas in collaboration with the ministry of health, and planting of fruit trees. The SFP provides midday meals to preschool and primary school children in targeted ASAL districts and selected urban slums in Nairobi (Mukuru and Kariobangi slums) in a bid to improve enrolment, enhance retention, and reduce dropout and repetition rates. The SFP began in Turkana and West Pokot in 1980, and was later expanded to cover 26 other ASAL districts. Due to decline in resources, many districts were phased out in 1996. The SFP is a joint effort between the Government and the World Food Program. The school health and nutrition program is a continuous program for promotion of nutrition and health in all schools and colleges in Kenya. Its activities include in-service training of teachers on health and nutrition issues (including HIV/AIDS); developing messages that promote hygiene, nutrition and health standards in schools and communities; organizing health education and disease management programs in collaboration with health facilities; and monitoring school sanitation and maintenance of clean and safe school environments. The health and nutrition component of the ECD program is implemented in eight districts, namely, Makueni, Mwingi, Samburu, Isiolo, Turkana, Baringo, Thika and Kiambu plantations. Some of the activities undertaken at the ECD centers include supplementary feeding, growth monitoring and promotion, and vitamin A supplementation and de-worming.

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5.4

THE COMMUNITY-BASED NUTRITION PROGRAM

During the struggle for independence, the Kenya Red Cross began to gather children under five years in village health centers and similar places, where they gave them milk from skimmed milk powder. Later, the Kenya Red Cross felt that setting up Nutrition Rehabilitation Centers would assist the poorest mothers because they would also be given clothing and other help depending on their needs. The programs activities targeted affected children and mothers through a network of nutrition centers that fed and taught worst-case victims of malnutrition. In the early seventies, the program changed its name from Nutrition Rehabilitation Centers to Family Life Training Program under the department of social services. The main aims of the program were to assist individual families by training mothers in key areas of family welfare, prevent malnutrition and poor health among children by giving mothers instruction on preventive health measures, and treat malnourished children by providing a high protein-calorie diet. However, during the period of the mothers absence from home with the malnourished child, other activities at home were affected (e.g. care of other children, fetching water and firewood, and economic activities), and they returned to the same environment of low food intake (despite having better knowledge on nutrition). In addition, the coverage of the program was low as a Center normally covered a community within a radius of about 25 km. It was therefore found necessary to rehabilitate the children within their own environment through a community-based nutrition program and enhancement of the home economics extension services normally provided by the ministry of agriculture. The Community Based Nutrition Program (CBNP) is an evolution of the Family Life Training Program, which was initiated by the Government in 1974 when it took over the responsibility of running Family Life Training Centers. Since 1979, the Danish government has supported the program. The 1994-98 phase of the program piloted a community-based approach to nutrition security where emphasis was put on improving nutrition knowledge and practices through participatory approaches, strengthening inter-sectoral collaboration, and establishing a system of technical support and management. The program is implemented in 13 districts, namely, Kilifi, Kwale, Makueni, Kirinyaga, Maragua, Kiambu, Baringo, West Pokot, Bungoma, Busia, Bondo, Nyando and Mbeere. The program aims to enhance the capacity of communities to initiate, plan, implement, and monitor activities that promote the health and general development of children. There is, however, a small community initiative fund set aside for financial support to the communities for the implementation of their action plans. 6. THE CASE FOR A NATIONAL NUTRITION POLICY

Although nutrition affects many sectors, nutrition activities are normally coordinated by one line ministry, commonly the ministry of health, which end up favoring one pillar of good nutrition at the expense of others. This is also reinforced by external funding agencies whose mandate or projects often mirror the departments of government. The mono-disciplinary approach is fixed in place by conceptual frameworks that normally equate food production with food security or equate nutrition with food security rather than emphasizing the interaction of the three pillars food, health and care practices. Food and nutrition councils that bring together line ministries, such as agriculture, health, social services, planning and finance, have been successful in a number of instances. However, flaws in their conceptual frameworks that tend to equate food security with nutrition sometimes hamper their coordination and finance mechanisms. They also normally exclude private sector and civil society organizations that have profound impact on nutrition e.g. food processors and producer organizations. In addition, they normally lack vertical relationships with communities both in their design and implementation. The current nutrition strategy does not provide the essential framework that caters for all population subgroups in their diversity of nutrient requirements, its nexus with poverty and other vulnerabilities, and the critical role of nutrition in human capital development. There is therefore need for policy guidelines that

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encompass a more inclusive conceptual framework, shares out roles and responsibilities among various actors including the regulatory development (e.g. food standards, legislation and quality guidelines), and outlines the operational framework for accountabilities and resource allocation. The new political dispensation in Kenya currently stresses the need for community participation as evident in the preparation of the Poverty Reduction Strategy Paper (PRSP) and the writing of the new constitution. Community consultations as a process will ensure that voices from community groups are inbuilt in the new policy. Decentralization in allocation of responsibilities and public resources is currently in vogue as it reduces costs, ensures sustainability, and brings about accountability closer to the beneficiary communities. It also facilitates complementation of national resources by the beneficiary communities. Finally, the government is a signatory to major international conventions on development and governance, some of which have specific mention of nutrition outcomes. These include the Millennium Development Goals and Convention on the Rights of the Child (CRC). The first millennium development goal aims to eradicate extreme poverty and hunger, while article 24 of the CRC requires States to combat disease and malnutrition through, inter alia, the provision of adequate nutritious food and clean drinking water. The preparation and implementation of a comprehensive and inclusive nutrition policy will go a long way in meeting nutrition targets specified in these international instruments, and other targets which affect or are affected by nutrition.

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