Ndalo Knowledge for Life

Malnutrition remains a major health challenge in Kenya. It is estimated that twenty-six percent of children under 5 years are stunted, 4 percent are wasted whereas 11 percent are underweight[1]. In addition to this nine percent of women age 15-49 are thin or undernourished (BMI <18.5kg/m2). The maternal nutrition status is further compounded by micronutrient deficiency due to inadequate intake of iron supplementation, with only 8% women taking iron tablets for more that 90 days during their pregnancy. Kakamega County is the 4thmost populous county in Kenya with a total population of 1,867,579[2]. It is also one of the counties that contribute significantly to poor nutritional indicators nationally. In Kakamega28% children under five are stunted, 1.8%are wasted and 10% are underweight compared to national averages of 26%, 4% and 11% respectively whereas maternal undernutrition stands at 7.7% in KakamegaCounty1. Much as the county has a relatively vast geographical coverage with diverse climatic conditions, it generally receives adequate amounts of rainfall ranging between 1280.1mm and 2214.1mm annually and has relatively fertile land[3]. The poor nutrition indicators are therefore not expected in such context thus underscores the need for behaviour change interventions at the community level to improve the nutrition indicators. Agricultural practices in some parts of the county, especially the lower middle ecological zone, could be a contributing factors with most land engaged in sugarcane farming. The land that could be used for food production is often held for 18 months or more by sugarcane. This has been compounded by the underperformance of the sugar sector in Kenya hence the residents. Poor health seeking behaviour in Kakamega County has contributed to several missed opportunities to implement nutrition interventions for mothers and their infants. According to the KDHS 2014, only 19.7% of pregnant women in the western region of Kenya begin antenatal clinic (ANC) visit before 4 months of pregnancy with only 51.3% achieving the recommended four or more ANC visits. Further missed opportunity to offer nutrition interventions occur during delivery since only 47% of mothers in Kakamega County deliver at a health facility.

References 

[1]Kenya Demographic and Health Survey 2014

[2]Kenya National Bureau of Statistics.2019 Kenya Population and Housing cencus. Volume 1

[3]Kakamega County Integrated Development Plan 2018-2022

The Goal of the project is: To improve the health and nutrition among women and children, with a focus on outcomes within the 1,000-day window from pregnancy to child’s second birthday.

The project will engage existing community health volunteers (CHVs) to implement community based interventions that will increase demand for nutritional services. Two hundred CHVs will be trained on community nutrition so as to have capacity to conduct nutritional assessment of mothers and infants as well as offer baby friendly community initiative (BFCI) interventions. The CHVs will identify a cohort of 1000 pregnant mothers at the community and conduct escorted referral to the primary healthcare facilities for confirmation of pregnancy and enrolment into antenatal clinic (ANC). The mother will receive services both at the community and the facility with bidirectional referral maintained. The CHVs will follow up the pregnant mother to ensure they attend 4-6 ANC visits and deliver at a health facility under skilled attendance. At the community level, mothers will be organized into support groups (meeting monthly) that will provide peer to peer support to each other on nutrition. The CHVs will conduct monthly home visits to monitor the nutrition practices and provide any relevant interventions. They will also attend community action and dialogue days to address nutrition issues. At the ANCs, mothers will receive comprehensive nutrition package as per the IYCF guidelines as well as nutritional education including plans for feeding of the newborns. In addition, they shall be enrolled into a bulk messaging platform where they will receive regular reminders for ANC attendance and nutritional education appropriate for gestation period. 

Health facilities will maintain contact information of the mothers attending ANC and child welfare clinic (CWC). Using bulk messaging, nutrition related messages will be shared regularly with the mothers. The facilities will maintain a clinic appointment system that will send timely SMS reminders for mothers. Currently, the bulk messaging system with nutrition information does not exist in the health facilities as such it will be an innovation of OGRA Foundation. The messages will be developed by the county nutrition technical working group (TWG) where OGRA will be represented by the Nutrition Advisor. The roll out will be disseminated by the county and subcounty health records and information officers (HRIOs) and nutrition officers. Examples of messages to mothers will include a reminder on ANC appointment dates and the foods and food groups for the gestation period of pregnancy as well as complementary feeding practices. It is expected that most mothers will have access to phones in the households. However, in the event that some mothers lack phones, messages will be sent through an alternative phone number of their choice or physical follow-up done by the CHVs. 

The solution will serve pregnant mothers from rural poor families and children below five years of age (first 1000 days of life), community health volunteers, healthcare workers and general community. 

The first 1000 days from pregnancy to the child’s second birthday is a critical period for achieving adequate nutrition. Maternal nutrition during pregnancy is important in achieving favorable birth outcomes for the mother and the baby. Immediately after birth, the practice of exclusive breastfeeding for the first 6 months has been shown to confer benefits to the baby and the mother. Continuation of breastfeeding through age 2 years while adequate complimentary feeds are introduced is recommended after that[1]. According to the KDHS 2014 however, 9% of women of reproductive age are thin or undernourished nationally. Exclusive breastfeeding rates have improved considerably from 32% (KDHS 2008-09) to 61% (KDHS 2014). However, complementary feeding was largely inadequate. Only 41 percent of children between ages 6-23 months had an adequately diverse diet, 51 percent had been fed the minimum number of times appropriate for their age and only 22 percent of children age 6-23months met the minimum standards with respect to all three IYCF practices that relate to appropriate complimentary feeding[2]. Maternal malnutrition is mainly caused by poor feeding practices. There is need to utilize locally available foods to achieve balanced diet for mothers. Agricultural practices need to be improved to reduce vulnerability to the changing climatic conditions and focus on food production.

In Kakamega county 7.7% of women of reproductive age (WRA) are thin or undernourished, translating to a total of 38,817 WRA in 2020. This leads to poor nutritional status of their infants whom 1 in every 4 is stunted. The poor nutritional indicators are mainly contributed by inadequate feeding practices, poor health seeking behavior and other socio-cultural factors. Kakamega County therefore needs interventions that foster demand creation for nutritional services and behavior change at community level. The late ANC attendance, failure to achieve 4 or more ANC visits and the low rates of health facility delivery in Kakamega leads to missed opportunities for nutritional interventions for mothers and infants. The services at the health facilities especially the primary healthcare level also needs improvement to be responsive to the needs of the mothers and their infants. According to KDHS (2014), of the mothers who attended ANC in western Kenya, only 62% were informed of pregnancy complications, 95% were weighed whereas only 32.5% had their height taken. In terms of information dissemination, only 72.8% of mothers attending ANC in western Kenya were given information on breastfeeding while 66.8% were educated on iron and folate supplementation. This underscores the fact that at the health facility, nutrition services are not at their optimum level hence the need to strengthen their capacity.  

References 

[1]Ministry of Health, Kenya. National Maternal, Infant and Young Child Nutrition Policy Guidelines, 2013

[2]Kenya Demographic and Health Survey 2014

Ndalo Heritage is comprised of a diversified multi-disciplinary team with a cumulative experience of over 100 years that have the zeal to steer the organization towards a sustainable future by adopting sound, ethical, and legal governance aimed at operationalizing the United Nations Sustainable Development Goals 2 (zero hunger), 3 (health and wellness), 13 (climate action) and 17 (partnerships for the goals). The board of management (BOM) consists of the Founder and Executive Director (Chair to the board and principal responsible person), A Policy/advisory Manager, a Managing Director, an accountant/administrator, head of training/facilitation and a head of curriculum development. In addition, the BOM is supported by highly experienced consultants in Business Development (Dr.Barbara van Heeden – 38 years’ cumulative experience), as well as Occupational therapy and disability inclusive micro development (Prof. Madie Duncan, 45 years’ experience).The Founder and Executive Director is trained in pediatrics nutrition, biotechnology and food security. He offers additional expertise in project management, resource mobilization besides strengthening leadership, collaboration and partnerships with stakeholders. Some of the recent projects implemented include: The (1) Udongo Kwa Maisha program involved training over 500 mothers, care-givers, households and community members in rural Kisumu in accessing more nutritious food that improves the dietary requirements of a child’s first 1000 days of life. Further (2) Ndalo’s Maarifa Kwa Maisha project operationalized SDG 3 and WHO (2018) Nurturing Care Framework by giving over 200 young children and their caregivers opportunities for early learning, through interactions that are developmentally responsive and emotionally supportive. 

The project will be overseen by the Project Director who is also the Founder of Ndalo Heitage Trust (NHT). There will be a fully dedicated Nutrition Advisor, Project Manager (Charchils Ayodo), Finance Manager (Kennedy Oyoo) and an Occupational Therapist (to be employed at 100% level of effort) who will be responsible for the day-to-day coordination of project activities and technical support to the project sites and staff. The Nutrition Advisor will be assisted by a Project Officer who will be responsible for the field level implementation and coordination. There will be a fully dedicated M&E Officer who reports to the MER manager as well as a fully dedicated Project Accountant reporting to the Finance Manager. The Finance Manager will oversee all finance and procurement functions. The Project Director (Odwour Midigo) is a nutritionist with extensive experience in public health programming. He has worked in collaboration with ministry of health and county governments, collaborating in implementation of various projects hence will be able to adequately support the project team. The Finance Manager (Kennedy Oyoo) has over 7 years’ experience managing grants of different sizes and has relevant trainings on accounting requirements as well as the relevant academic qualifications. The Project Director, M&E Manager and Human Resource Manager will be working part time on the project. This will be monitored through elaborate time sheets that will be reviewed by the relevant supervisors and by ensuring that specific deliverables are achieved based on the level of effort. 

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My name is Erich Midigo, Founder and Executive Director- Ndalo Heritage Trust (http://www.ndaloheritage.co.ke/). Ndalo is a community based non-profit organization geared towards implementing projects in UN SDG 3 (health and wellness) of children and their mothers as well as SDG 2 (Zero hunger) campaign in underprivileged communities in Kenya. I am aware that Solve has been supporting meaningful change in building the capacity of their members to a problem-solving attitude and creating a better world through strengthening existing transformative projects. Solve membership will establish my organization as a leader in grassroot health systems strengthening and improve our capacity for innovations that serve Africa’s most marginalized populations. I am looking forward to partnerships with over 200 tech-based entrepreneurs that will enable us drive impact on SDG 3 (health and wellness) campaigns. Here, I am specifically interested in learning about how technology can be used to serve pregnant and lactating mothers with clinic date reminders for attendance of ANC. I hope to build lasting relationships by connecting with leading minds and organizations such as the Bill and Melinda Foundation that are keen on promoting health and nutrition outcomes for marginalized communities. Ndalo Heritage is a young organization (registered in Jan 2020) with a mission to partner with communities, local and international stakeholders in undertaking nutrition sensitive and specific activities for alleviation of hunger, poverty and human suffering. Here, I am leading a diverse team that is keen on developing knowledge and analytical tools for the design, monitoring and evaluation of our two pilot projects (Maarifa Kwa Maisha and Udong Kwa Maisha). I am motivated to be part of the transformative Solve competition and training because my main intention is to venture into creating opportunities for youth and rural communities that have devastating levels of disease, malnutrition poverty and human suffering.

Having devastating health challenges at the family level and losing a loved one from malnutrition, I felt that I have a unique perspective and voice to bring passion to programs and work that target maternal and child and health programs to Africa's most marginalized communities. However, I have limited experience in project monitoring and evaluation as well as monitoring and evaluation. Presently, I am really in the process of expanding the organization’s capacity in terms of developing our logical framework in line with models such as the WHO (2018) nurturing care and the human scale development/human poverties framework. It is my aspiration to enhance my teams understanding of the key project evaluation criteria to improve our sustainability and effectiveness. Soon thereafter, I will be sharing this crucial knowledge with my colleagues as we advance into early development screening and longitudinal follow-ups, parental training focusing on child (disability) learning and play and support of mothers with postpartum depression.

I hope the selection committee will consider my application to strengthen skills that will enable me harvest skills in Project Monitoring, Evaluation and Learning (PMEL) and to more accurately use evidence to improve Ndalo’s contribution in grassroot policy translations. 

Nutrition and health interventions need a multi-sectoral approach for comprehensive and sustainable model. The project will facilitate the county health department to conduct mapping and profiling of nutrition stakeholders and partners. The county will be supported to conduct quarterly nutrition stakeholder forums that shall bring together various ministries/ departments as well as partners to have a comprehensive approach to nutritional challenges including allocation of resources for nutrition. In addition, there shall be established and operationalized the county nutritional technical working group (TWG) to develop the nutrition agenda, provide technical guidance to the county government as well as review progress regularly. The TWG, the county health management team (CHMT) and the sub-county health management teams (SCHMT) will be supported to conduct quarterly supportive supervision in health facilities implementing the nutrition project.

The collaboration will also ensure that the program aligns to the Ministry of Health (MOH) ongoing efforts, mobilize resources as well as review and develop support materials towards achieving shared project goals. Our strategic approach focuses on a positive deviance at the grassroots level-using existing community systems as the platform for the overall Social Behavior Change (SBC) interventions. For instance, the project will use existing community systems and local channels to hold discussions with influencers on the pros and cons of identified barriers to health seeking behaviors. The strategy will also promote dialogue targeting small doable actions that may increase uptake and acceptance of prioritized behaviors. Messages will focus on learning through peers while capacity strengthening will focus on cordial client/customer relationships. It is envisaged that the present approach will generate social support at the grassroots level and help decision makers to slowly address changing the harmful social-cultural and religious norms noted as one of the key barriers to change.  

Impact Goal 1: To increase the uptake of health and nutritional services among mothers and young children in Kakamega County

Expected Outcomes/result

·         Reduced by 30% children <24 months with malnutrition (stunting, wasting, underweight and obesity)

• Reduced by 30% underweight among WRA.
• Increased early ANC attendance (<4 months gestation) from 19.7%  to 40>
• Increased attendance of 4+ ANC visits from 51.3% to 70>
• Increased percentage of hospital delivery from 47%  to 70>

·   Nutrition behavior change among the population. 

Activities 

• Train and engage 200 CHVs on community nutrition and BFCI
• Identify and enroll 1000 pregnant mothers at community and link them to ANC.
• Conduct monthly community based support group meetings for pregnant and lactating women
• Conduct health education sessions for pregnant and lactating mothers on IYCF practices at health facility
• Conduct home visits for community based nutritional interventions for 1000 pregnant mothers and infants
• Conduct community outreaches for sensitization on nutrition for mother and infants – action and dialogue days
• Facilitate health facilities to provide SMS messaging to mothers on MIYCN and ANC/CWC clinic reminders

Impact Goal 2: To improve the availability and quality of nutritional services for mothers and young children at primary healthcare facilities and the community units in Kakamega County.

Expected Outcomes/result

·         100 health care workers have adequate knowledge and skills for provision of nutritional care to mothers and children.

·         50 primary healthcare facilities certified as mother and baby friendly

Activities 

• Conduct mapping of nutrition capacity of primary healthcare facilities in Kakamega County.
• Engage 50 health facilities in provision of quality nutritional services
• Conduct Nutrition training for 100 HCWs.
• Support procurement and distribution of nutrition commodities.

Impact Goal 3: To strengthen sectoral, multi-sectoral coordination, leadership, governance and partnership among nutrition stakeholders in Kakamega county.

Expected Outcomes/result

·         Increased resource allocation to nutrition in Kakamega County by 40%.

·         Nutrition stakeholder forum technical working group active and meeting quarterly.

Activities 

• Hold Quarterly County Nutrition Stakeholders forum.
• Baseline survey to map nutrition stakeholders and partners
• Support quarterly county nutrition technical working group (TWG) meeting. 

Ndalo Heritage has a robust monitoring and evaluation system with clear standard operation procedures and guidelines that ensure programs are supported to attain the highest level of impact on all interventions. The system is integrated with the online cloud where data is stored for maximum security with access to limited and designated persons. At the top of the M&E structure we have the M&E manager who is responsible for ensuring continuous documentation on all programs/projects, sharing of key lessons for purposes of continuous improvement. Every project being implemented by Ndalo Heritage has a designated M&E person who supports the day to day implementation of the and linking with the wider organizations dash board that provides progress across all implementation fronts and update to the strategic plan. All programs have well defined indicators, established baselines, milestones tracked and updated on a quarterly basis. The program risks are also monitored and updated. The organization has reporting capacities right from the community level that are trained to effectively support the delivery of the projects. 

 The project will conduct monthly report collection to monitor the following indicators:

• Number of pregnant mothers identified and enrolled into the project and linked to ANC.
• Number of pregnant and lactating mothers receiving health education sessions on IYCF practices
• Number of home visits conducted for nutritional assessment of pregnant mothers and infants
• Number of people reached through community outreaches for sensitization on nutrition for mother and infants

• Number of CHVs trained on MIYCN and Baby Friendly Community Initiative (BFCI)
• Number of healthcare workers trained on MIYCN and Baby Friendly Hospital Initiative (BFHI)
• Number of pregnant and lactating mothers reached through bulk SMS.
• Number of mother and infants receiving nutrition commodities.
• Number of County Nutrition Stakeholders forums held.

• Number of county nutrition technical working group (TWG) meetings held.

Data will be accessed through the CHV reports, facility reports as well as project activity reports. Facility reports will be accessed via the DHIS which Ndalo Heritage has access rights. Data will be collected on real time basis during activity implementation and will be collated monthly for analysis. The data will then be summarized on a dashboard where indicators will be monitored monthly. The dashboard will have colour codes based on targets so that corrective action can be taken where targets are not on course to be met. Information will be disseminated in the various county and national forums such as nutrition stakeholder forums as well as annual reports. The M&E function will be coordinated by the Monitoring, Evaluation & Research Manager who coordinates all M&E activities at Ndalo Heritage. He will be assisted by a dedicated M&E Officer for the project. They will work in collaboration with County and sub-County Health Records and Information Officers (HRIOs) to manage the collection, analysis and dissemination of data.

Our theory of change borrows from the ecological model showing how the anticipated impact and program interventions would lead to the desire outcomes. The theory considers needed changes at stakeholders’ level, service delivery level, individual level, and households’ level. The strategy shows the specific pathways for change targeting different audience groups for sustainable nutrition and health outcomes. The assumptions in this theory are that strengthening the capacity at the community and health system level (i.e Mothers, CHVs, HCWs and TBAs), health communication for SBC and advocacy through stakeholder forums will result in opportunities to address the barriers identified in the formative assessment. The framework is refined along the overall Ndalo Heritage project objectives hence proposes three areas for change interventions namely: (1) community-based approach (demand and awareness creation); (2) enhancing quality of health services and; (3) strengthening multi-sectoral engagement/advocacy around the mutual goals. In the end, these changes will lead to increased care seeking and reduced malnutrition rates in the project implementation areas. 

We facilitate primary health facilities to provide SMS messaging to mothers on MIYCN and ANC/Child Welfare Clinics (CWC) reminders

Health facilities are supported to maintain contact information of the mothers attending ANC and child welfare clinic (CWC). Using bulk messaging, nutrition and health related messages will be shared regularly with the mothers. The facilities will maintain a clinic appointment system that will send timely SMS reminders for mothers. Currently, the bulk messaging system with nutrition information does not exist in the health facilities as such it will be an innovation of OGRA Foundation. The messages will be developed by the county nutrition technical working group (TWG) where Ndalo Heritage is represented by the Nutrition Advisor. The roll out will be disseminated by the county and subcounty health records and information officers (HRIOs) and nutrition officers. Examples of messages to mothers will include a reminder on ANC appointment dates and the foods and food groups for the gestation period of pregnancy as well as complementary feeding practices. It is expected that most mothers will have access to phones in the households. However, in the event that some mothers lack phones, messages will be sent through an alternative phone number of their choice or physical follow-up done by the CHVs. The messaging system will use an existing platform that is commercially available where the project will pay hosting fees and airtime for sending of messages. The system will be managed by the County Health Records and Information Officer (HRIO) and will use unique identifiers that will ensure patient particulars are kept confidential.