Kenya Health Situation Analysis at Terre des hommes

1. Terre des hommes foundation

Terre des hommes (Tdh) is Switzerland’s largest children’s aid organization. For more than half a century, the Foundation has been working alongside children in distress. It struggles to enforce their rights, without political, racial or denominational concerns. In more than 30 countries, Tdh protects children against exploitation and violence, improves the health of children and their mothers, and provides psychological support and material assistance in times of humanitarian crisis.

Tdh has been present in Kenya since 2011 and is currently supporting access to basic services for populations affected by displacement, natural crises and poverty in Dadaab refugee camps, in Garissa County and in Korogocho slum in Nairobi.

The intervention in Dadaab refugee camps is focused on prevention and response to child protection issues while strengthening protection community-based mechanisms in the refugee operation and its host communities.

In Korogocho informal settlements, Tdh implements early child development activities and child protection activities coupled with an emergency intervention to mitigate the effects of COVID-19.

2. Justification of the Situation Analysis

Overall, Tdh Health Programme supports access to quality healthcare for new-borns, children under five and their mothers in remote areas by strengthening local capacities. To achieve this, Tdh works with the national authorities in three priority health topics: i) perinatal health – the period around birth – when most deaths take place; ii) digital health, to increase the impact of its work; iii) health system strengthening to ensure lasting change. In addition, it works towards improving water, sanitation and hygiene services as well as access to specialised care for all children.

As the Health Programme is now a priority for Tdh based on its 2021-2024 Strategy, Tdh s willing to explore health needs in current intervention areas.

Garissa County:

In Kenya from 2015 to 2020, Tdh implemented nutrition and health projects in collaboration with UNICEF covering the seven Garissa sub-counties. Tdh supported health system strengthening including access to quality facility and community-based nutrition services and strengthen nutrition information systems, coordination and emergency response systems. In addition, from August 2019 to February 2020, Tdh implemented an emergency project aiming to make available an early response to the drought emergency for nutrition. In Lagdera sub-county particularly, Tdh strengthened the system in addressing nutrition in the non-health sector linking malnourished children and families to national social protection sectors through the Department of Children Services.

Garissa is part of the larger North Eastern part of Kenya which is a semi-arid area with majority of the local residents being nomads. The majority of the local residents are of Somali ethnic group extraction and are predominantly Muslim. Compared to many other parts of Kenya, North Eastern Kenya is less endowed with social amenities such as schools, safe water, health facilities, and paved roads. Culturally, girls are married off at a relatively young age in line and female genital mutilation is common practice in this region. North Eastern Kenya continues to face insecurity due to communal tensions in the region and instability in neighbouring Somalia. This precarious environment limits humanitarian access and service delivery with the education and health sectors most affected.

Some of the barriers to healthcare access are rooted in the local cultural norms and practices. Medicalization of the birthing process that ignores social and traditional norms surrounding this family event is one of the reasons for home deliveries.

In terms of nutrition, children aged 54-59 months are the most malnourished while age 30-41 months are most severely malnourished. In Garissa, only 43% of children are exclusively breastfed during the first 6 months, and only 7.4% of 6-23 months are fed the minimum acceptable diet. 11.7% of all women of reproductive age and 9.9% of pregnant and lactating women are malnourished. Looking at women dietary diversity, the score has slightly deteriorated compared to 2019 data, as more women fall in the group of consuming less than 5 food groups (46.0% – 2019 to 57.4% – 2021). Only 45% households had acceptable food consumption score as compared to 93.4% reported in 2019.

Nairobi Informal Settlements:

Kenya is one of the fastest urbanizing countries in Sub-Saharan Africa and the majority of the population in its capital Nairobi reside in informal urban settlements and live under the national poverty line. Korogocho, the fourth largest slum in Nairobi and one of the most congested and poorest urban areas in Kenyan where an estimated population of 150,000 inhabitants (including 60,000 children) live in a mere 1.5 km2, coping with exceedingly cramped, unsanitary and unsafe housing conditions and high levels of poverty. High economic insecurity, violation of rights, endemic violence and lack of social protection services are undermining the capacity of the communities to enjoy their rights and develop opportunities in equality.

Malnutrition in urban locations can take a number of forms. These include stunting, wasting and micronutrient deficiency. In many instances, different types of malnutrition overlap. Stunting is the predominant form of malnutrition found in urban informal settlements. Stunting results from a child having a poor diet, either from too few calories, too little nutritious food, or both, for a number of years, or an infection leading to mal-absorption of nutrients. The high malnutrition rates are associated with inadequate dietary intake, morbidity, and unhygienic practices and microbiological quality of food and water. Wasting and underweight are prevalent. While severe and global acute malnutrition rates are lower than rural areas, the caseload is greater in the urban slums owing to the high population density. Limited but consistent evidence suggests higher infant and under-five years’ mortality for children residing in slums compared with non-slum areas. Children suffer from higher rates of diarrheal and respiratory illness, malnutrition and have lower vaccination rates.

Poor antenatal care (ANC) is a risk factor for adverse pregnancy outcomes for both the mother and the baby, including maternal mortality, perinatal mortality, premature delivery, low birth weight, preeclampsia and anemia, in many settings of the developing world. The frequency and timing of ANC are both important for timely identification and mitigation of potential pregnancy complications (Magadi, 2004). Apart from mere attendance of ANC, the quality of care received (in terms of the timing and frequency of visits and the content of antenatal care) does play a key role. ANC is important for the identification and management of maternal complications, as well as for providing essential services such as tetanus immunization, iron and/or vitamin supplementation, and nutrition education.

The lack of appropriate maternal health services and an almost near absence of public health facilities within the slums has led to the reliance on for profit health facilities. Most of the health facilities available in the slums face challenges like the lack of skilled personnel and necessary equipment to deal with maternal and child health emergencies. Transport costs and poverty are barriers to proper utilisation of maternal health care services in the slums leading to deaths of mothers during this critical period.

3. Objective of the situation analysis

This situation analysis on health in Nairobi informal settlements and Garissa County, will collect and analyse secondary and primary information to:

• Identify those geographical areas where populations are most at need and with limited (or absent) access to maternal, new-born, and child health care services.
• Understand the main vulnerabilities on health where Tdh could intervene to contribute to the decrease of maternal, neonatal, and child morbidity and mortality rates.
• Identify other actors on health already present in these countries and who could constitute potential partners for Tdh.
• Added value of Tdh’s intervention on health in the proposed geographical areas regarding the needs, needs coverage by other actors, Tdh’s capacities and risks associated to the context and the intervention itself.
• Explore the interest and willingness from local authorities for the use of new innovative technologies and digitalization of health services.

4. Methodology

This situation analysis will be mainly based on a desk review of secondary data from reference documents and on the collection and analysis of primary data from virtual interviews with key informants previously identified with the support from the head of programmes and other key staff from Tdh in Kenya.

The selected consultant will propose a detailed methodology that will aim at addressing the following information needs (for each country):
a. Context analysis :

• Health systems organization (including health information systems in place),
• Country health plans,
• Donor fund flow mechanism for INGOs,
• Health infrastructure at primary health care facilities especially WASH conditions
• Population access to services (availability, distance, social norms), security issues.

b. Stakeholder analysis:

• Affected population/potential beneficiaries (gender and age disaggregation),
• Community groups, community leaders, local and international NGOs present in the identified settings (and their areas of intervention),
• Local health authorities/actors, armed forces and groups, private/social sector organizations supporting health services (including digitalization).

c. Problem analysis:

This refers mainly to the health status of the targeted population and the quality of health services in the identified settings and that can be analysed by the collection of health indicators data, at national and district level:

• Maternal mortality ratio
• Under-five mortality rate
• Neonatal mortality rate
• Stillbirth rate
• Prevalence of children under 5 years diagnosed with severe acute malnutrition (SAM)
• Proportion of births assisted by skilled birth attendants
• Proportion of births attended in healthcare facilities
• Proportion of women who attended at least four antenatal visits during pregnancy by skilled personnel
• Proportion of new-borns and mothers who received postnatal care from a skilled provider within the first 48 hours after birth
• Proportion of infants under 6 months who are exclusively breastfed
• Proportion of primary health care facilities that collect and report statistics to district and national levels using modern communication and digital technology
• Proportion of health care facilities routinely monitoring performance through digital tools
• Proportion of outpatient consultations performed with the support of digital tools
• Proportion of healthcare workers trained and following the WHO protocol on Integrated Management of Childhood Illnesses (IMCI)
• Proportion of people with access to basic WASH services (clean water, sanitation, and hygiene services)
• Proportion of healthcare facilities having adequate WASH facilities
• Healthcare facilities following standardized protocols on Infection Prevention and Control (IPC)

d. Resource analysis:

• Internal resources (Tdh’s in-country presence and capacity),
• Tdh’s current health activities that could respond to identified needs,
• Potential donors supporting or willing to support interventions on health in the identified settings, potential alliances, and interagency coordination mechanisms.
• Mobile/Internet coverage(2G/3G/4G) and smartphone penetration,
• electricity availability in health care facilities, off-grid power solution availability.

e. Risk analysis:

Potential risks (with its mitigation strategies) of Tdh working on health in the identified setting and areas of intervention.

Additionally, it is expected that this situation analysis will also answer to the following questions:

• Are certain groups more affected/exposed to more health risk than others?
• How do different groups cope with their health situation?
• Is the population affected differently according to their geographical location?
• To what extend are existing health vulnerabilities exacerbated by the crises?
• Are certain groups more affected due to their origin, religion, or level of poverty?
• Are female and male populations in various age groups affected differently?

5. Organization and tentative Workplan

Publication of ToRs and recruitment process: January 10^th to 28^th, 2022

Starting date: February 14^th, 2022

Duration: 30 working days during a 6 to 8 weeks period.

Final report and oral presentation by April 8^th, 2022

Activities & working days

Initial desk review and submission of inception report with detailed methodology and data collection tool

(5 working days)

Data collection (15 working days)

Data processing, analysis and drafting of the final report (5 working days)

Presentation and debriefing of results (2 working days)

Review of final report incorporating feedback (2 working days)

Oral presentation (1 working day)

Total (30 working days)

6. Roles and Responsibilities

This situation analysis will be done by an external consultant/consultancy team and will be directly supervised by the Head of Programmes with the support from Country Representative, M&E Manager, Health Advisor at HQ.

The Heads of Delegations in the selected countries will facilitate access to data, contact with key informants, and identification of relevant stakeholders.

Individual Consultant or Consultancy Agency:

• The consultant will be the lead responsible for the situation analysis.
• The consultant/consultancy agency will be required to provide credentials (name and designation) of the study team.
• Conduct in-depth desk review.
• Develop, submit, and review the Inception Report: include work plans outlining the proposed methodology, study tools, process of data collection and analysis as well as final set of data-collection tools (Analysis Plan to be included in inception report).
• Develop data collection tools.
• Virtual interviews with key informants.
• Data entry, data analysis and development of draft report, ensuring protection of data.
• Provide final Report in English.

Tdh:

• Will provide access to key reference documents.
• Coordination with key informants to schedule and facilitate interviews.
• Provision of technical input, support review and feedback.
• Timely review and feedback on the inception reports, methodology and data collection tools.
• Validation on draft reports.

7. Intended users **

The final report of this situation analysis will be shared internally with Tdh with the aim to guide informed decision-making processes in terms of defining a health strategy for Kenya. The results of this situation analysis and its recommendations will be jointly analysed by the Health Programme and the Kenya management team.

8. Budget

The budget will be provided by the consultant as part of a financial proposal.

9. Deliverables

The key deliverables are:

1. Inception report (deadline on February 21^st):

This will be of maximum 10 pages describing the methodology, overall approach, data collection and analysis tools, risk and limitations, logistics details, analysis plan.

1. Draft final report (deadline on April 1^st) and final report (deadline on April 8^th):

This will be of maximum 25 pages, without annexes and should include:

• An executive summary (max. 2 pages)
• An automatic table of contents
• A list of annexes, abbreviations, tables, figures, pictures.
• An introduction
• The presentation of the methodology used for the situation analysis
• The presentation of the objective of the situation analysis (questions to be answered)
• The context analysis
• The problems analysis
• The stakeholders analysis
• The resources analysis
• The risks analysis (based on the problems, stakeholders, resources and risks analysis)
• The recommendations
• The operational conclusions
• Annexes
• References (sources of information)

The report shall be provided in Word format and the report pages numbered. The report shall be written and submitted in English.

10. Profile of the consultant (team): qualifications and experience

The individual Candidate or Consultancy Agency should have:

• Demonstrated professional experience and qualification in conducting health situation analysis studies focused on children and adolescents.
• Experience of conducting analysis on public health in resources limited settings.
• Sound knowledge of the geopolitical situation in Kenya will be a plus.
• Demonstrated previous experience conducting research for INGOs or government agencies in the selected countries.
• Public health background.
• Excellent communication skills and experience in appropriate techniques for collecting and analysing data.
• Excellent writing and synthesis skills in English.