Kenyan Strategy on Infant and Young Child Feeding

HOW DID THE KENYAN STRATEGY ON INFANT AND YOUNG CHILD FEEDING COME TO BE?A CRITICAL ANALYSIS.

*Commonly used Acronyms

EBF-Exclusive Breastfeeding

IYCF/N-Infant and Young Child Feeding/Nutrition

BFHI/CI-Baby Friendly Hospital Initiative/Community Initiative.

MOPHS-Ministry Of Public Health and Sanitation

The first 1000 days of life are crucial stages for a child’s growth and development. Damages accrued from nutritional deficiencies during this time are likely to lead to poor cognitive development which results into compromised educational achievement and hence low economic productivity.(Murage et.al,2013;Bhutta et.al,2013).Poor nutrition results from inappropriate feeding practices with poor timing, poor quality and inadequate quantity of food.(M.O.P.H.S,2010).

Optimal breastfeeding and complimentary feeding practices are essential in meeting the nutritional needs of children in the first years of life.The Lancet (2003),indicates that exclusive breastfeeding(EBF) for the first 6 months, followed by continued breastfeeding from 6-11 months in addition to complementary feeding and a continued breastfeeding up-to 2 years of age help reduce child mortality rates by 19%.This would not only be in line with The Kenyan National Health Sector Strategic Plan II but also significantly contribute towards attainment of Millennium Development Goal 4(Huffman et.al,2001), and The Kenyan Vision 2030.(M.O.H,2000).

Several worldwide efforts intended to address child malnutrition emerged in the 1990’s,championing to promote Infant and Young Child Feeding by providing appropriate breastfeeding environment.(M.O.P.H.S,2007/10).These included; The Innocenti Declaration(1990),World Summit For Children(1990),Earth Summit, International Conferences on Nutrition and on Population Development(1992),World Alliance for Breastfeeding Action(WABA) and the Baby Friendly Hospital Initiative.

The 2003 Kenya Demographic Health Survey(KDHS) results showed only 2.6% of exclusive breastfeeding( EBF) rates in the country.Additionally, the rates of malnutrition were 30% for stunting,20% underweight and 6% severe malnutrition. Between 2008-2009,Kenya was listed among the top 20 countries with the highest under-nutrition rates.26.9% stunting and 20.3% underweight rates for ages 6-59 months(KDHS 2008/09;KNBS,2008).The HIV pandemic and the attendant risk of Mother To Child Transmission continued to pose a threat to exclusive breastfeeding even to the non-affected families.A study revealed the increased fear by both mothers and peer counsellors on the risk of HIV transmission through breastfeeding(Koricho et.al,2010).The peer counsellors were more comfortable if HIV positive mothers would abstain from EBF and rather opt for replacement feeding which mostly did not meet the WHO guideline of AFASS(Acceptable, feasible, affordable, sustainable, safe).This led to an increase in infant mortality rates and malnutrition(Creek et.al,2006).

Over 30 countries have developed National IYCF(Infant Young Child Feeding) Strategies based on WHO/UNICEF guidelines..(Sagoe et.al,2012;WHO,2006).Kenya was also a signatory to all global conventions meant to improve IYCF practices.(M.O.P.H.S,2007/10).

This essay aims to critically analyse the Kenyan Strategy on Infant and Young Child Feeding practices (IYCF), developed between 2007-2010. The strategy was intended to provide a strong mechanism, through which the government and various sectors could in a comprehensive and coordinated manner influence accelerated action to improve IYCF practices in Kenya.(M.O.P.H.S,2007/1O).I will draw upon the Walt and Gilson approach of the health policy triangle(1994,cited by Buse et.al,2012) to critically analyse and discuss how the Strategy came into place, what were the key driving factors and the stakeholders involved in the policy making process. I will combine the health policy triangle for analysis and John Kingdon’s Policy Windows and 3streams approach to agenda setting. The Health Policy Triangle comes in as a more suitable approach, as it acknowledges the importance of looking at content and process of policy making; besides exploring the role of power by the state, national and international organisations and its influence on policy making.(Buse et.al,2012).Kenya is a low income country hence hence a policy making process would involve an interaction among various different stakeholders.

Buse et.al(2012) defines policy as the decisions made by those with responsibility for a given area; and a health policy as that which covers courses of action or inaction that affects the set of institutions, organisations, services and funding arrangements of both private and public healthcare systems.The health policy triangle is divided into four constituent parts, both interrelated and interconnected and which are suitable for describing and understanding the Kenyan IYCF Strategy. These include the context, content, process and actors.

Context entails the political, social, economic, cultural, both national and international which may have an effect on health policy(Buse et.al,2012).Further classified into situational, structural, cultural and international/exogenous factors by Leichter (1979),cited by Buse et.al,(2012).Some of the situational factors that stimulated the development of The Kenyan Strategy on IYCF include the issue of HIV and its great influence on exclusive breastfeeding and the increased rates of malnutrition combined with decline in the key indicators of IYCF(M.O.P.H.S,2007/10).A rapid assessment study (Chopra et.al,2009)indicated widespread mis- information on the Mother To Child Transmission(MTCT) of HIV as a major factor influencing breastfeeding patterns in Kenya.IYCF practices that differ from the commonly seen ones in the community would result in unwanted disclosure of HIV status.(Onono et.al,2014).This had a great influence on the duration of breastfeeding and the method of infant feeding used by the mother.

Increased malnutrition rates caused by declined exclusive breastfeeding rates from 3.5%(KDHS 1998)to 2.6%(KDHS 2003) was the other factor(M.O.P.H.S,2007/10).Structural factors included inadequate capacity building on healthcare workers on IYCF ,HIV and breastfeeding leading to decline in promotion of Baby Friendly Hospital Initiative(BFHI) and breastfeeding promotion through healthcare facilities(Kimani et.al,2015;MOPHS,2007/10).Buse et.al,2012 describes capacity as the ability of the government to make and implement policies.Kenya recorded a decline in BFHI from 600 in 1996 to less than 6 in 2003(M.O.P.H.S,2007/10;Chopra et.al,2009).

On the other hand, contextual cultural factors would entail issues such as, the fact that 60-80% of Kenyan women were involved in labour and agricultural practices with minimal male involvement in childcare, leading to poor child caring practices(MOPHS,2007/10).Other beliefs and practices in Kenyan families e.g the belief that breast milk alone is not sufficient for a child also played a great role in influencing the strategy(MOPHS,2007/10;Matsuyama et.al,2013;Murage et.al,2013).To most African countries, exclusive breastfeeding(EBF) is alien(Magoni et.al 2005,cited by Onono et.al,2014).Mixed feeding(breastfeeding along with other liquids or fluids) is the most common method of infant feeding globally and is often continued up to 2 years of age.The strategy was developed to mirror the WHO/UNICEF global strategy for IYCF that was developed to improve global IYCF practices.(Murage,2015).Kenya’s aim was to actualize this through the BFHI, along with other interventions such as adopting and implementing the WHO Code Of Marketing of Breastmilk Substitutes(MOPHS,2007/10)meant to regulate the marketing of breast milk substitutes.A reflection of the influence of international factors to the development of this strategy.

Content of a policy refers to substance of a particular policy which details its constituent parts.The aim of the strategy was to contribute to improved health, nutritional status development and survival of infants and young children in Kenya.(MOPHS,2007/2010).Some of the component parts and targets of the strategy between 2008-2010 included: strengthening national structures on IYCF to facilitate planning, coordination and advocacy for implementation of the strategy; updating the existent IYCF policy guidelines and the National policies in the context of HIV, to be in line with WHO consensus and statement on HIV and IYCF(WHO,2006) ,and disseminating it by 2008;Enactment of Kenyan National Law for regulation of foods eaten by children aged below 3years and putting up a monitoring system by 2009;revitalization of the Kenyan BFHI to ensure 75% of mothers who deliver in healthcare facilities are initiated on exclusive breastfeeding and providing support and necessary information to help them continue up to 6 months of age; ensuring support for breastfeeding mothers by employees through the Employment Act and attendance of IYCF Inter-grated Course by 60% health workers, and 80% PMTCT service providers.The nine main strategic components deemed crucial for the attainment of the strategy goals included; policies and legislation on IYCF, practices in IYCF and IYCF in difficult circumstances, HIV and infant feeding, capacity building on IYCF, communication and advocacy, research on IYCF, partnerships and coordination and finally monitoring and evaluation in IYCF.(MOPHS,2007/10).

The process of policy making refers to the way in which policies are initiated,developed,formulated,negotiated,communicated,implemented and evaluated.(Buse et.al,2012).The Kenyan strategy on IYCF can be broken down into the four different theoretical stages of policy process named by Sabatier & Smith,(1993) cited by Buse et.al,(2012).These are, problem identification, policy formulation, policy implementation and evaluation.Kenya had recorded a decline on key indicators on IYCF during the two decades prior to the formation of this strategy.Exclusive breastfeeding rates were at 3% with virtually no BFHI facilities(MOH,2007-2010).Additionally, only about 52% of mothers would initiate breastfeeding within one hour.Complementary feeds were introduced way too early for the babies.These issues were closely linked to poor IYCF programming at that time(Lancet 2003;MOPHS,2007/2010).

On formulation, The Strategy was developed as a measure that sought to build on past initiatives and improvements to promote IYCF in Kenya(Murage et.al.2013).It was derived from The Global Strategy on IYCF, the Kenyan Policy Guidelines on IYCF, The National Assessment of IYCF policies, programmes and practices and National Food and Nutrition Policy (was still being reviewed in parliament).(MOPHS,2007/10).The rationale for the strategy accrued from among other issues, the increased evidence on interventions to promote exclusive breastfeeding and complimentary feeding practices being able to prevent about a fifth of under-five mortality rates in developing countries(Lancet,2003;MOPHS,2007/10).

Nutrition is universally recognized as a child’s right to enjoyment of the highest attainable standard of health(UNICEF,2012).Based on the global strategy, an assessment of IYCF policies, programmes and practices was conducted in 2004.(Sagoe et.al,2012).Weaknesses were identified, hence leading to a suggestion of the need for a national programme focusing on IYCF, with high levels of advocacy if mothers and children were to practice exclusive breast and complementary feeding.This strategy evolved as a response to that assessment.

The strategy would be mainly implemented through BFHI which promotes breastfeeding around the maternity ward during the time of delivery (Murage et.al,2013).It would call for increased political will, public investment and heightened awareness of the critical importance of IYCF amongst health workers, other professionals and community based care providers.(MOH,2007/10).Additionally, involvement of the government, families, communities and community based organisations(CBOs)in collaboration with international organisations and other concerned parties would ensure that necessary action is taken(MOH,2007).

The monitoring and evaluation(M&E) process would be achieved through: reviewing, developing and harmonizing monitoring and evaluation tools for IYCF; developing and installing software for IYCF at district level; all level monitoring of the National Communication Strategy on IYCF; developing and maintaining a data bank for the persons trained on IYCF/BFHI/code; developing M&E tools for IYCF in difficult situations including HIV and Infant Feeding; regular review of IYCF strategy implementation, among many other evaluation strategies such as M&E of the implementation of the communication strategy at all levels.(MOPHS,2007).

Actors in a policy refers to individuals, organizations the state and their actions that affect policy(Buse.et.al,2012).They may try to influence policy at local, regional, national and international levels.Buse et.al(2012) further classifies the actors into: interest/pressure groups which refers to a type of civil society group that attempts to influence the policy to achieve specific goals; or civil society groups which refers to group or organization which is outside the government and beyond the family group.The actors who played different roles towards the formation of this strategy and were to be actively involved in the implementation included: the government; the non-governmental organisations and community based support groups; international organisations; industries and enterprises; professional associations, ministries, mass media and other groups and communities which includes parents and caregivers directly responsible for feeding children.(MOPHS,2007/10).These can be classified as either interest/pressure groups or the civil society groups.

The power of international bodies and their influence on the development of this strategy is clearly depicted.Power as defined by Buse et.al,(2012) is the ability to influence and to control resources or the ability to achieve a desired outcome.Being a member of the WHO, Kenya had to comply to the guide it provided on IYCF by creating a National strategy, just like all the other member countries(Jones et.al,2013;Sagoe et.al,2012)),especially within the Sub-Saharan Africa, Asia and the Caribbean.The strategy also adopts the BFHI which was originally launched by WHO/UNICEF(1991) following the Innocenti Declaration, meant to promote exclusive breastfeeding (WHO/UNICEF,2009).A demonstration of the power emanating from WHO as a decision making process.(Dahl,1961 cited by Buse et.al,2012).

Development of the strategy would involve using WHO/LINKAGES assessment tool to assess the policies and practices in the country, after which they would be rated after review by national stakeholders and the results used to create a interventions meant to address the gaps(Sagoe et.al,2012).

A mixed scanning method of decision making was applied in the formation of the strategy.Mixed scanning would involve a sweep of the problem as a whole followed by a detailed analysis of the component parts(Etzoni,1967 cited by Buse et.al,2012).The Ministry Of Health ,at the national level was involved in assessments intended to quantify the levels of different IYCF practices.Whereas the Ministry Of Public Health And Sanitation(MOPHS)went further ahead to come up with different approaches towards addressing the issue e.g revitalizing BFHI, training all health officials on PMTCT(Prevention of Mother to child transfer);and renewing commitments to create an environment that enabled Kenyan women to practice optimal IYCF.Additionally,it would collaborate with other ministries and international stakeholders and NGOs towards fulfilment of the objectives of the strategy.Therefore working as a policy community.

A Policy community is a recognizable subdivision of public policy making in which there is sustained interaction between participants through a web of formal and informal relationships(Buse.et.al,2012).It was demonstrated through participation and consultation among different key IYCF stakeholders; including the government, international bodies, non-governmental organisations and communities, steered by a technical working group under the auspices of National Infant Feeding Steering Committee(MOPHS,2007/10).

A legislative framework that would help support and promote breastfeeding had to be set up in the formation of the strategy.The legislature refers to a body that enacts the laws that govern a country and oversees the executive.(Buse et.al,2012).Its roles would include, legislation to give effect to the aims and principles of the International Code Of Breast Milk Substitutes.Additionally,it would legislate towards protecting and supporting breastfeeding among working mothers.(MOPHS,2007/2010).

Getting onto the agenda setting aspect of the IYCF strategy; Kingdon’s(1984) theoretical model of agenda setting(cited by Buse et.al,2012), would be much suitable in explaining how the Kenyan Strategy on IYCF became a major focus of government. Agenda setting is the process by which issues come into the policy agenda from the much larger number of issues potentially worthy of attention by policy makers.(Buse et.al,2012).Policy making is therefore viewed in agenda setting as responding to daily problems that need solutions.(Thomas and Grindle,1991 cited by Buse et.al,2012).The approach focuses on the role of policy entrepreneurs within and outside the government who utilize policy windows(agenda setting opportunities)to move issues onto the governments formal agenda.It is explained using 3 streams ;problem, policy and politics streams and the policy windows.Policy entrepreneurs promote their ideas into many different fora and invest time to ensure they are put onto the agenda.(Kingdon,1995).

Problem stream is defined as public matters that requires attention(Gulbrandson and Fossum,2009). With an emphasis that it only becomes a problem if identified by the decision makers besides other lists of problems presented.Chopra et.al 2009 acknowledges the existence of a huge gap in the level of political support that nutrition and infant feeding was able to achieve compared to other components of the Prevention of Mother To Child Transfer(PMTCT) programme.An explanation to the delay in implementation of the then, already existing IYCF policy and the pending approval of other existent nutritional programmes that would promote IYCF.The Ministry Of Public Health and Sanitation(MOPHS) was majorly involved in advocacy besides other nongovernmental organizations.The overwhelming evidence on malnutrition recorded by KDHS and Kenya Bureau of Statistics e.g 29.% stunting and 20.3% underweight children, data on huge reduction in EBF and decrease in BFHI by 70% (KDHS 2003;Lancet,2003) were the key indicators that evidenced the magnitude of the issue and the need for prompt government action.

Implementing this strategy was Kenya’s way of renewing its commitment to WHO, by adopting its 2006 consensus statements on HIV and infant feeding.It was also a major stakeholder and a potential source of funding.The policy stream consists of ongoing problem analysis, and their proposed solutions together with debates surrounding the problems.(Buse et.al,2012).The solutions should be easily available and promptly reachable by decisionmakers.(Guldbrandson and Fossum,2009). The strategy was drawn from national assessments of IYCF policies ,programmes and practices in the country(2004)and from consultative meetings with stakeholders.In addition to being harmonized with the National Food and Nutrition policy that was pending in the government at that time; it was intended as a guide of action based on accumulated evidence on importance of infant and child nutrition during their early months and years of life and for growth and development.(MOPHS,2007;Murage et.al,2013).

The Kenyan Public Health & Sanitation ministry then also had the expertise, technical and programme knowledge to rapidly improve Infant and Young Child Feeding indicators and to save lives.(MOPHS,2007/2010).

Politics stream is defined as being composed of such events as national mood swings, government changes and campaigns by interest groups.(Buse et.al 2012;Guldbrandson and Fusson,2009).The year of 2007 was an elections and campaign year in Kenya.The then existing government had a strong intention to go for a second term.Cairney and Jones,(2015) describe this as an existence of both motive an opportunity in politics stream.Implementing the IYCF strategy during this period would be one of the moves to entice the public by showing attention to their problems.The strategy would provide a strong framework through which the government and other important stakeholders could contribute towards improvement of Kenyan children’s nutritional status through IYCF practices.(MOPHS,2007/10).

The existence of an attention lurching problem(problem stream),with readily proposed solutions(policy stream) and a conducive and positive political environment that accepted and supported the strategy(politics stream) led to development of a policy window.An opportunity to develop the strategy in parliament and eventually its implementation.

The Kenyan Ministry of Public Health and Sanitation(MOPHS-Kenya)would support this strategy by renewing its commitment to create an enabling environment for optimal IYCF(MOPHS,2007/10).It would also improve child survival by strengthening focus on IYCF through various ways like: advocating for enforcement and implementation of Maternity protection Provision in the Employment Act 2007 in all sectors; working with the attorney general and the Minister Of Justice and Constitutional Affairs to ensure enactment of a law that protects optimal IYCF; develop clear, consistent policies and guidelines; build the entire capacity of the public and private healthcare system to implement them, among many other key supportive tasks.(MOPHS,2007).

Development of the IYCF strategy was a huge and commendable step in Kenya.Different factors are clearly outlined as having contributed towards its formation.Improvement infant and young child feeding practices, and maternal health being the core driving factors, besides adherence to WHO Global Strategy on IYCF.(MOPHS,2007/10).By 2012,Kenya was in its final stages of enacting the strategy.(Sagoe et.al,2012).

The successive process of the strategy formation can be attributed to, the involvement of WHO/UNICEF, the intense collaboration between the Ministry of Health(MOH) and the MOPHS-Kenya together with other major national and international NGO’s such as APHIA II Partners, World Vision Kenya among many others.(MOPHS,2007/10)

Several significant achievements accrued from the implementation of this strategy include the 61% increase in EBF rates(KDHS,2014).Making Kenya among the handful of countries that have managed to achieve the WHA target of 50% EBF rates by 2025.Enactment of the Code of Marketing for breastmilk substitutes(Sagoe et.al,2012)and the development of various models like the BFHI and the Breast Feeding Community initiative(APHRC,2014) have greatly contributed towards achieving high EBF rates.

A critical analysis of the strategy implementation process and the challenges pertaining to its implementation, an aspect my essay did not focus on; would be a clear and concise way of depicting the achievements of the strategy and the barriers faced on rolling out and implementation of its plans.

TOTAL WORD COUNT-3,265.