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KENYAS CAPACITY TO MONITOR

CHILDRENS GOALS:
A MEDIUM-TERM ASSESSMENT

by

John Thinguri Mukui

Consultant Report Prepared for UNICEF, Kenya Country Office

14 July 1994
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS....................................................................................................................iii
ABBREVIATIONS AND ACRONYMS ............................................................................................... iv
INTRODUCTION .................................................................................................................................. 1
POVERTY .............................................................................................................................................. 3
INTRODUCTION ............................................................................................................................................. 3
MEASURES OF POVERTY .............................................................................................................................. 4
THE EXTENT, DEPTH AND SEVERITY OF RURAL POVERTY, 1992 ...................................................... 5
GROWTH IMPLICATIONS OF THE NATIONAL PROGRAM OF ACTION (NPA) GOALS .................... 6
COMMENTS ON THE NATIONAL HOUSEHOLD WELFARE MONITORING SURVEY, 1992 .............. 6
THE NATIONAL HOUSEHOLD WELFARE MONITORING AND EVALUATION SYSTEM ................... 7

NUTRITION......................................................................................................................................... 10
MALNUTRITION ........................................................................................................................................... 10
MICRONUTRIENT DEFICIENCIES ............................................................................................................. 13
BREASTFEEDING AND THE BABY-FRIENDLY HOSPITALS INITIATIVE ......................................... 14
CHILD GROWTH MONITORING ............................................................................................................... 16

HEALTH............................................................................................................................................... 19
INFANT AND UNDER-FIVE MORTALITY ................................................................................................ 19
MATERNAL MORTALITY ............................................................................................................................ 20
IMMUNIZATION COVERAGE .................................................................................................................... 21
CONTROL OF DIARRHOEAL MORBIDITY AND MORTALITY ............................................................. 27
GUINEA WORM DISEASE ........................................................................................................................... 31

EDUCATION ....................................................................................................................................... 33
EARLY CHILDHOOD EDUCATION ............................................................................................................ 33
PRIMARY SCHOOL ENROLMENT AND RETENTION ............................................................................. 35
LITERACY RATES ......................................................................................................................................... 39

WATER AND SANITATION.............................................................................................................. 42


ACCESS TO SAFE DRINKING WATER ....................................................................................................... 42
ACCESS TO SANITARY MEANS OF EXCRETA DISPOSAL ...................................................................... 43
ONGOING ACTIVITIES ON WATER AND SANITATION INDICATORS ............................................... 45

CHILD PROTECTION ........................................................................................................................ 47


INSTITUTIONS ENGAGED IN PRODUCING PERFORMANCE INDICATORS ........................... 49
CENTRAL BUREAU OF STATISTICS .......................................................................................................... 49
HEALTH INFORMATION SYSTEM ............................................................................................................. 53

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KENYA EXPANDED PROGRAMME ON IMMUNIZATION ..................................................................... 55

ANNEX 1: TERMS OF REFERENCE .................................................................................................. 58


ANNEX 2: POLICY MATRIX OF THE WORLD SUMMIT FOR CHILDREN GOALS .................. 60
ANNEX 3: STATISTICAL ANNEX ..................................................................................................... 65
ANNEX 4: REFERENCES .................................................................................................................... 80
ANNEX 5: LIST OF PERSONS INTERVIEWED ............................................................................... 87

TEXT TABLES
Text Table 1:
Text Table 2:
Text Table 3:
Text Table 4:
Text Table 5:
Text Table 6:
Text Table 7:

Provincial Status of Rural Poverty, 1992 (%)


Population Parameters in the KEPI CEIS Computer Program
Primary School Gross Enrolment Rates, 1992 (%)
Primary School Net Enrolment Rates, 1992 (%)
Primary School Age/Grade Mismatch, 1992 (%)
Literacy Rates by Region, 1992 (%)
Literacy Rates by Region, 1980/81, 1988 and 1989 (%)
STATISTICAL ANNEX TABLES

Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:
Table 7:
Table 8:
Table 9:
Table 10:
Table 11:
Table 12:
Table 13:
Table 14:
Table 15:
Table 16:
Table 17:
Table 18:
Table 19:

Nutritional Status by District, 1987


Nutritional Status by Demographic and Background Characteristics, 1993 (%)
Percentage of Living Children by Breastfeeding Status, 1993
Breastfeeding and Supplementation by Age, 1993 (%)
Median Duration and Frequency of Breastfeeding, 1993 (%)
Baby-Friendly Hospitals Initiative: Status as of June 1994
Infant and Under-Five Mortality Rates per 1,000 Live Births
Percentage of Children 12-23 Months Who Received Specified Vaccines, 1989
National Immunization Coverage for Children Aged 12-23 Months, 1992 (%)
Percentage of Children 12-23 Months Who Received Specified Vaccines, 1993
Prevalence of Diarrhoea and Knowledge and Ever Use of ORS, 1993 (%)
Treatment of Diarrhoea, 1993 (%)
Primary School Retention Rates for 1984, 1985 and 1986 Standard 1 Entrants (%)
Households by Main Source of Water in Wet Season, 1992 (%)
Households by Main Source of Water in Dry Season, 1992 (%)
Households by Type of Toilet, 1992 (%)
Households by Access to Water and Sanitary Facility, 1989 (%)
Households by Access to Water and Sanitary Facility, 1993 (%)
Households by Source of Water and Type of Excreta Disposal for Selected Districts

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ACKNOWLEDGEMENTS

I thank all the individuals in Government, international organizations and


nongovernmental organizations who were extremely helpful in providing ideas that
are reflected in this report. Generous support and encouragement was received
from Alfred Okinda (Monitoring and Evaluation Officer, UNICEF/Kenya Country
Office), Francis Kamondo (Chief, Integrated Community-Based Programmes,
UNICEF/Kenya Country Office), and Mahesh Patel (Monitoring and Evaluation
Officer, UNICEF/East and Southern Africa Regional Office). The excellent research
assistance provided by Rita Achieng Obura is much appreciated.

John Thinguri Mukui


Nairobi
14 July 1994

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ABBREVIATIONS AND ACRONYMS


AMREF
ANPPCAN
CBR
CBS
CDC
CDD
CEIS
CHANIS
CRC
DICECE
FEWS
GOK
HIS
HRSSD

African Medical and Research Foundation


African Network for the Prevention and Protection against Child Abuse and Neglect
Crude Birth Rate
Central Bureau of Statistics
U.S. Centers for Disease Control and Prevention
Programme for the Control of Diarrhoea Diseases
Computerized EPI Information System
Child Health and Nutrition Information System
Convention on the Rights of the Child
District Centre for Early Childhood Education
USAID Famine Early Warning System
Government of Kenya
Health Information System
Human Resources and Social Services Division, Ministry of Planning and National
Development
IDD
Iodine Deficiency Disorders
IGADD
Inter-Governmental Authority on Drought and Desertification
IMR
Infant Mortality Rate
KCPE
Kenya Certificate of Primary Examination
KDHS
Kenya Demographic and Health Survey
KEPI
Kenya Expanded Programme on Immunization
MIS
Management Information System
MMR
Maternal Mortality Ratio
MOH
Ministry of Health
MPND
Ministry of Planning and National Development
MTC
Medical Training Centre
NACECE
National Centre for Early Childhood Education
NASSEP
National Sample Survey and Evaluation Programme
NCHS
U.S. National Centre for Health Statistics
NCPD
National Council for Population and Development
NDVI
Normalized Difference Vegetation Index
NHWMES National Household Welfare Monitoring and Evaluation System
NPA
National Plan of Action
ODA
(British) Overseas Development Administration
ORS
Oral Rehydration Salts
ORT
Oral Rehydration Therapy
PEM
Protein-Energy Malnutrition
PHC
Primary Health Care
PPA
Participatory Poverty Assessment
PSRI
Population Studies and Research Institute, University of Nairobi
VAD
Vitamin A Deficiency
WHO
World Health Organization
WMS
Welfare Monitoring Survey

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CHAPTER ONE

INTRODUCTION
1.
The World Summit for Children goals covering the last decade of the twentieth century
were translated into the Kenya National Plan of Action (NPA) goals. Some of the Kenya NPA goals
were less ambitious than the World Summit goals e.g. on malnutrition, reduction in measles incidence
and mortality, primary school retention rate, infant and under-five mortality rates, access to antenatal
care, and reduction in acute respiratory infection mortality rates. Kenya also brought forward the
target date of achieving the mid-decade goals from 1995 to 1994, and intends to utilize 1995 to
consolidate the achievements. Kenyas mid-decade goals include (a) adoption of the Dakar consensus
based on the 1992 International Conference on Assistance to African Children convened by the
Organisation of African Unity, and (b) enhanced Dakar consensus e.g. Kenya NPA has a higher target
on measles immunization coverage (90%) than the Dakar consensus (80% coverage for the six antigens
of the Expanded Programme on Immunization). The GOK/UNICEF 1994-98 programme of operations
provides support to the World Summit for Children and mid-decade (1995) goals through advocacy
and direct support. The GOK/UNICEF goals on child survival and development had a profound impact
on the thrust and the contents of the National Development Plan 1994-96.
2.
The purpose of the activity as spelt out in the Terms of Reference is to carry out an
assessment of the current availability of relevant data relating to the Child Summit goals in general but
with special emphasis on the mid-decade goals. The Mission took its broad agenda to include:
(a)

Laying of baseline data on World Summit for Children goals as translated into Kenya
NPA goals;

(b)

Reliability of the indicators available together with recommendations on possible


improvements in definitions, data collection procedures, and analysis;

(c)

An evaluation of the institutional capacity to collect indicators on the World Summit


for Children goals, with special emphasis on mid-decade goals.

Two supporting World Summit goals under health were (a) give all couples access to family planning
information and services to enable them plan their families, and (b) give all pregnant women access to
antenatal care and to safe child birth. Due to time constraints, these two supporting goals were not
included in the assessment. The interim report was also supposed to be presented in a
UNICEF-sponsored sub-regional meeting involving three or four other countries in East and Southern
Africa region, but the meeting did not take place.
3.
The Mission did not take the issue of Kenyas ability to achieve the goals as its main
concern, but only the ability to monitor its achievements regardless of whether the achievements are
expected to exceed or fall short of the NPA goals. However, in some cases, the difference between
ability to monitor and ability to achieve a goal is pedagogical. For example, in the case of eradication of
the guinea worm disease, the worm is identified and extracted during an active case search, and
monitoring and achievement are basically a simultaneous process. In most cases, a program with a
high degree of accomplishment of its objectives gives incentives to the implementing personnel to
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leave footprints of their activities, thereby laying a better factual basis for analyzing the program. In
addition, program monitoring allows implementers to identify weaknesses and take remedial actions,
thus improving on both reporting and performance.
4.
The report is divided into three main sections. Section I (chapters 2 to 7) discusses each
indicator, its definitional issues, baseline data available or being collected, and recommendations on
improvements. The second section (chapter 8) analyzes institutional capacity of the main agencies
involved in collection of indicators pertaining or coincidental to the Kenya NPA goals (Central Bureau
of Statistics, Health Information System in the Ministry of Health, and the Kenya Expanded
Programme on Immunization) to ascertain their institutional strengths and weaknesses, and
recommendations on possible restructuring and financing arrangements to enable them to collect the
requisite indicators. The third section is the Statistical Annex showing the recent baseline data
available for each indicator.

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CHAPTER TWO

POVERTY
INTRODUCTION
5.
The World Summit for Children underscored the need to alleviate poverty and revitalize
economic growth as the foundation for achieving the goals on child survival and development. The
Kenya Governments National Plan of Action (NPA) operationalized the concept by specifying targets
to reduce the overall incidence of poverty by 50% of 1993 levels by the year 2000; and depth and
severity of poverty by one-third.
6.
The Central Bureau of Statistics undertook the National Household Welfare Monitoring
Survey in December 1992 and January 1993, funded by the World Bank under the Health
Rehabilitation Project (World Bank, 1991b), to fill the lacuna in poverty statistics in Kenya.
Consequently, the Government has produced (a) a basic report on the 1981-82 Rural Household
Budget Survey (Barasa and Wakanyora, 1994); (b) a basic report on the 1992 National Welfare
Monitoring Survey (Ayako, 1994); and (c) poverty profiles for rural 1981-82 and urban and rural
Kenya 1992 (Mukui, 1994). Chapter 3 of the Economic Survey 1994 gave a synopsis of the poverty
statistics derived using the 1992 National Household Welfare Monitoring Survey data. However, the
1982-83 Urban Household Budget Survey (UHBS) database could not be used since the data provided
was in aggregated form, and did not include key variables on household characteristics (e.g. household
members age and educational characteristics) and expenditure on key food items, mainly maize and
bread. The loss of the 1982-83 UHBS data underscores the need to refocus attention on the
development of appropriate data archival systems in the Central Bureau of Statistics.
7.
The Human Resources and Social Services Division (HRSSD) in the Ministry of Planning
and National Development (MPND) undertook a Participatory Poverty Assessment (PPA) during
February-April 1994. The purpose of the PPA was to understand poverty as seen by the poor in order
to complement quantitative studies of poverty. The study elicited rare donor coordination in an
exercise, as it was sponsored by the British Overseas Development Administration (ODA), the
principal technical coordinator was from the World Bank, and field coordination was undertaken by
the African Medical and Research Foundation (AMREF). The PPA covered communities in seven
poor rural districts (Bomet, Busia, Kisumu, Kitui, Kwale, Nyamira and Mandera) and Mathare Valley
in urban Nairobi. The activity in Kisumu and Mandera districts was sponsored by UNICEF/Kenya
Country Office. The analytical reports for each district and the report summarizing the main lessons
and conclusions from the entire PPA survey were ready by June 1994.
8.
The first National Welfare Monitoring Survey (WMS1) was a priority survey whose main
objectives were the identification of policy target groups and the production of key socioeconomic
indicators describing the wellbeing of different groups. The primary purpose of the Welfare
Monitoring Survey was to gauge the present and future net socioeconomic consequences of economic
management and structural adjustment in Kenya. The design of the survey was to draw on the
experience of the Kisumu Household Welfare Monitory and Evaluation Survey (Kenya, 1990d) as well
as the World Banks Social Dimensions of Adjustment Priority Survey (Grootaert and Marchant, 1991;
World Bank, 1991c).
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9.
WMS1 collected data in 44 districts, excluding Turkana, Marsabit and Samburu. Data for
North Eastern province was obtained from urban clusters only, and its results do not therefore
represent rural areas of the province. The questionnaires were intended to capture information on
household characteristics, household expenditures, household incomes, assets and amenities owned
and available to the households, and land utilization.
MEASURES OF POVERTY
10.
The degree of poverty depends on the incidence of poverty (numbers in the total
population below the poverty line), the intensity of poverty (the extent to which the incomes of the
poor lie below the poverty line), and the degree of inequality among the poor. In addition to reflecting
the three dimensions, a poverty index should also be decomposable among sectors and socioeconomic
groups. A summary measure which meets the four requirements is that of Foster, Greer and
Thorbecke (1984). If real expenditures or income are ranked as follows:
Y1 Y2 ... Yq < z < Yq+1 ... Yn
where z is the poverty line, n is the total population, and q is the number of poor, the FGT measure is:
P = (1/n)[(z - Yi)/z]; 0.
The poverty measure takes the proportional shortfall of income for each poor person [(z - Yi)/z], raises
it to a power () which reflects societies concern about the depth of poverty, takes the sum of these
over all poor households, and normalizes by the population size.
11.
The parameter is a policy parameter that reflects concern for the poor; as increases
greater weight is attached to the poverty gap of the poorest. The main measures in the poverty study
were (a) the head-count index (=0), which measures the prevalence of poverty and is insensitive to
how far below the poverty line each poor unit is; (b) the income-gap ratio (=1), the average of the
poverty gaps expressed as a fraction of the poverty line; and (c) =2, which gives the severity of
poverty. The head-count index (H) simply shows the proportion of people below the poverty line.
However, the income-gap ratio (HI) takes into account both the incidence of poverty (H) and its
intensity (I). The sum of the poverty gaps is the total income required to eliminate poverty.
12.
There is a conceptual problem in the definition of gender of household head that needs to
be highlighted in the measurement of poverty, since Governments NPA goals includes reduction in
poverty disparities between female-headed and male-headed households. As Clark (1985) points out,
conjugal structures in Kenya evades easy data collection and analysis due to biased identification of
households, heads of households and women heads of households. The standard definition of the
household assumes that (a) the physical boundaries of the household define units of social and
economic organization (thereby ignoring economic exchanges between households), and (b) the
household is a basic decision-making unit behaving according to the rule of household utility (thereby
ignoring intra-household inequality in resource allocation based on age and gender). It is assumed that
head of household and the primary breadwinner is a male, while women rather than men are
socially recognized as primary providers for their children through their efforts in subsistence
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agriculture. Frequently, woman-headed households are identified on the basis of the absence of a male
spouse in the household. There is need to break down woman-headed households into (a) de facto
female household heads defined by the temporary but long-term absence of a male spouse in the
household; and (b) de jure female household heads identified by lack of adult male/spouse in the
household. The aggregation of data into a single category of woman-headed households masks the
levels of poverty faced by de jure woman-headed households (single, separated, divorced).
THE EXTENT, DEPTH AND SEVERITY OF RURAL POVERTY, 1992
13.
The overall prevalence of rural absolute poverty was 46.3% by adult equivalents1 and
41.5% by households. The depth of poverty was 18.4%, while the overall severity of poverty was 9.8%.
The prevalence of poverty was highest in Western (54.8%), followed by Rift Valley (51.5%), Nyanza
(47.4%), Coast (43.5%), Eastern (42.2%) and Central (35.9%). Some of the districts with the lowest
prevalence of poverty were Kajiado/Narok (25.1%), Kiambu (32.7%), Meru/Tharaka (32.7%), Laikipia
(34.4%), Nyeri (35.4%), Nyandarua (36.7%) and Muranga (37.3%). The prevalence of poverty was
highest in Busia (67.7%), West Pokot (65.2%) and Kericho/Bomet (64.7%). The depth of poverty was
highest in West Pokot (35.4%) and Busia (33.3%).
Text Table 1: Provincial Status of Rural Poverty, 1992 (%)
All
Coast
Eastern
Central
Absolute Poverty Line
Prevalence (ad eq)
46.3
43.5
42.2
35.9
Prevalence (HHs)
41.5
37.9
38.1
31.2
Depth (ad eq)
18.4
15.4
14.9
12.1
Severity (ad eq)
9.8
7.6
7.4
5.4
Absolute Hard Core Poverty Line
Prevalence (ad eq)
37.4
32.8
32.2
28.1
Prevalence (HHs)
32.8
27.4
29.1
24.2
Depth (ad eq)
13.7
10.9
10.5
8.1
Severity (ad eq)
7.0
5.2
5.1
3.4
Prevalence of Absolute Poverty by Household Head (ad eq)
Total
46.3
Male
45.6
Female
48.4
Male-married
45.7
Male-other
44.3
Female-married
44.6
Female-other
52.9

Rift Valley

Nyanza

Western

51.5
44.5
22.3
12.7

47.4
43.4
19.7
10.6

54.8
53.5
23.0
12.6

42.9
36.2
17.4
9.5

39.1
34.8
15.1
7.6

45.4
42.9
17.6
9.2

Note: Ad eq means that the statistics are in adult equivalents, while HHs stands for households.
1 Equivalence scales are deflators used to convert household real expenditures into money metric utility
measures of individual welfare, mainly based on child costs and economies of scale in consumption (saving on
consumption by living together versus living apart). This procedure derives directly from Engels (1895)
pioneering work using a single good (food), although there is no reason why the model cannot be applied more
generally to other goods e.g. adult goods (tobacco, alcohol and adult clothes) see Prais and Houthakker, 1955;
Rothbarth, 1943; Working, 1943; Deaton, 1986; Deaton and Muellbauer, 1986; and Lewbel, 1989.

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14.
Some of the variables used to delineate socioeconomic groups were sex of household head,
education level of the head, household size, and age of household head. The sex of the head of the
household did not appear to be a significant factor in the determination of the incidence of rural
absolute poverty. However, female-married headed households had prevalence of poverty of 44.6%
at the absolute poverty line, compared with 52.9% for female-other. The depth and severity of
poverty were also lower in female-married compared with female-other households.
15.
Using education level of the household head, the lowest prevalence of absolute poverty was
among heads of households with secondary education (26.7%), compared with primary education
(45.5%) and no education (57.4%). Poverty consistently increases with household size. Poverty
measures using size of land holding did not portray any clear trend, probably because of different
agricultural potential of land holdings. Poverty increases with age of household head.
GROWTH IMPLICATIONS OF THE NATIONAL PROGRAM OF ACTION (NPA) GOALS
16.
The issue of whether WMS1 poverty statistics will be used as the baseline will probably be
settled when the next round of welfare monitoring survey data collected in June 1994 is analyzed. This
is because the Government used the lessons of the first survey to improve the design of the
questionnaire and enumerators reference manual for the second survey. However, given the overall
rural poverty indicators for 1992, the NPA targets imply that the overall incidence of poverty would
be 23.2% in the year 2000, while the overall depth would be 12.3%, and severity 6.5%. Since the
poverty statistics are insensitive to how far above the poverty line a non-poor household is, the
economic growth implications of the NPA targets are difficult to quantify. Based on the analysis of the
1992 WMS1 data, the targets imply that the national rural depth and severity of poverty in the year
2000 would be the same as those for Kiambu and Nyeri districts of Central province in 1992, while the
targeted incidence of poverty (23.2%) would be far much below those of the latter districts in 1992
(around 33%). The NPA targets for the poverty statistics are not feasible given the current economic
stagnation fuelled by bad weather, standoff with the donor community, and the quality of economic
management.
COMMENTS ON THE NATIONAL HOUSEHOLD WELFARE MONITORING SURVEY, 1992
17.
In general, the enumerators reference manual was brief, and it is difficult to know whether
the trainers clarified the issues to enumerators during training. There were also inadequacies in
definitions of, say, main economic status that could permit generation of meaningful socioeconomic
groups.
18.
In relation to crop income, the crops were not identified by name, and it was therefore not
possible to compute total household consumption of, say, maize and its products, since information on
maize purchases was available but itemized consumption of own-produce was not.
19.
The questionnaire put the analytical burden of the survey data on the respondents and
enumerators. The enumerator or the respondent was left to determine what is an export crop, while
export crops are also consumed locally, and the respondent may not know whether his/her cash crop is
ultimately exported.
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20.
The 1992 WMS1 was conducted only a few weeks prior to the Christmas festivities and the
first multiparty elections since Independence. Christmas is normally associated with above-average
expenditure on some items e.g. luxurious foods and items of clothing and footwear. The euphoria of
the elections would also affect the responses, but the direction of the bias is indeterminate.
21.
A survey design which involves consecutive visits to the same household is said to be bounded
if the recall is based on the period since my last visit. Under this definition, the reference periods
(last week, last month, last year) used in the 1992 WMS1 were not bounded, which can lead to serious
telescoping (mis-dating) errors. Telescoping errors are likely to increase with the length of the recall
period.
22.
A problematic issue is the comparability of data on food crop consumption from own
production with food purchases. The recall period for food crop own consumption was for long
season and short season, and both components were added up in the analysis to derive total food
crop consumption. The error from the unbounded recall periods described in terms of seasons is likely
to be higher than for calendar-defined recall periods e.g. last week or last month.
23.
The 1992 WMS1 survey period was characterized by unstable and rising commodity prices,
which implies that the prevailing prices last week and last month for the same commodity were
different. In addition, price variations by regions during the survey period were high and atypical,
mainly due to shortages of key commodities like sugar and maize. This factor complicates the
interpretation of shares in consumption of items collected under different recall periods.
24.
The changes in district boundaries and the number of districts have necessitated updating of
the national sample frame since districts are supposed to be treated as distinct strata. The creation of a
new district entails transfer of some households from a stratum. If a dry area within a predominantly
arable region was made an independent stratum, the original district might register a spurious
improvement in household welfare due to removal of the poorer households. The creation of new
districts will make district-specific inter-temporal poverty profiles less meaningful.
25.
Some of the data from the 1992 Welfare Monitoring Survey, especially on total income and by
its components, could not be meaningfully used in the preparation of poverty profiles and in
establishing socioeconomic groups. The survey was limited by the brevity of the enumerators
reference manual, which was not particularly useful in clarifying concepts. In terms of survey
organization, the initial steps of preparing an analysis plan for the survey, dummy tables of the most
important data from the survey, and a specification of data needs for development of poverty profiles,
do not appear to have been prepared before the survey was launched. The eventual authority on the
quality of survey data was difficult to identify.
THE NATIONAL HOUSEHOLD WELFARE MONITORING AND EVALUATION SYSTEM
26.
The National Household Welfare Monitoring and Evaluation System (NHWMES) is supported
by the World Bank under the Health Rehabilitation Project and is coordinated by the Human
Resources and Social Services Division in the Ministry of Planning and National Development. The
NHWMES also included a component of review of available CBS field staff, and the recruitment
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necessary so as to include North Eastern province in the national sample frame.


27.
One of the problems encountered in the implementation of the project has been the inability
to use the project funds due to the superimposition with Government procurement procedures. The
inaccessibility of donor funds has also been aggravated by Governments expenditure ceilings. Donors
and Government ought to explore ways of speeding up disbursement procedures, and for activities
(e.g. technical assistance for data analysis and report preparation) to be funded directly or through
trust funds deposited with nongovernmental organizations.
28.
The first round of the Welfare Monitoring Survey received comments from the analysts who
prepared the Basic Report (Ayako, 1994) and the Poverty Profiles (Mukui, 1994). The second round of
the Welfare Monitoring Survey strengthened the core questionnaire through clarification of concepts
in the enumerators reference manual and introduced more questions to make the interpretation of
data more meaningful.
29.
Some improvements in questionnaire design were the inclusion of proper definitions of types
of farmers, and itemization of food own-consumption expenditure. The survey also includes (a) an
anthropometry module; (b) fertility questions for all females aged 12 and above (including
immunization for Tetanus Toxoid), and use of family planning methods for females aged 12-49; (c)
child survival module (attendance in growth monitoring, immunization, breastfeeding, and the type
of personnel who assisted in child delivery); and (d) maternal mortality as related to pregnancy and
child birth. The anthropometry module will be the fifth rural nutrition survey and the first national
nutrition survey undertaken by the Central Bureau of Statistics since independence. The core
questionnaire and modules have common serial numbers of the household members, thereby making
it possible to interlink all the data collected in the second round of the Welfare Monitoring Survey.
30.
The survey will also fill data gaps in water and sanitation. Some of the improvements in water
and sanitation questions are (a) reliability of water source, and (b) time taken to fetch water so as to
ascertain the opportunity cost of not providing water close to homesteads and as a rough guide to the
corresponding female drudgery.
31.
The NHWMES will be the main source of poverty statistics. Given the number of modules
tagged on to the WMS2, it will be necessary to prepare a detailed analysis plan and coordination in
data processing. One of the constraints will be that some modules are not financed by the World Bank,
but by other agencies e.g. UNICEF. There will therefore be a tendency by the funding agencies to
exercise territorial rights to some modules at the initial stages.
32.
Steps taken to improve on WMS2, based on the lessons from WMS1, include (a) improved
questionnaire and enumerators reference manual, (b) stricter supervision of fieldwork, and (c)
preparation of data edit and consistency checks during data entry using a dedicated data-edit computer
package (Integrated Microcomputer Processing System, IMPS, developed by the U.S. Bureau of the
Census). Data entry and cleaning is expected to be done during July-August, 1994. The issue of
whether the baseline poverty statistics will be based on WMS1 or WMS2 need therefore to be
postponed until the WMS2 database is analyzed.
33.

Although CBS has sufficient number of computers for data entry, there is a shortage of
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computers for merging of data files after data entry is completed. CBS therefore needs at least two
high-memory, 486-capacity personal computers for data merge and analysis. Arrangements are under
way for UNICEF to provide two computers to CBS for that purpose. It will also be necessary for the
National Household Welfare Monitoring and Evaluation project to build CBS human resource
capacity through formal training and workshops, so as to provide them with new tools of analysis and
to enable them supervise consultants handling various aspects of the analysis more effectively.

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CHAPTER THREE

NUTRITION
MALNUTRITION
Introduction
34.
The mid-decade goal is to reduce the 1990 levels of severe and moderate malnutrition among
under five years of age by one-fifth (20 percent) or more. Kenya accepted that goal. However, before
evaluating Kenyas achievement on the goals, it is important to review the working definitions for
measuring the goal and the scope of existing data to provide baseline information on the requisite
goals.
The indicators of Protein-Energy Malnutrition (PEM) are underweight (moderate and severe),
underweight (severe), stunting (moderate and severe) and stunting (severe). Optional indicators are
wasting (moderate and severe) and wasting (severe). All the definitions are based on the U.S. National
35.

Centre for Health Statistics (NCHS) and accepted by the U.S. Centers for Disease Control and
Prevention (CDC), which uses Standard Deviation (SD) scores from the median of the reference
population. The recent sources of indicators of PEM malnutrition that will be discussed are the Fourth
Rural Child Nutrition Survey, 1987 (NS4), and Kenya Demographic and Health Survey, 1993.
36.
Underweight is measured by the proportion of children under five years of age falling below
minus 2 standard deviations from the median weight-for-age of the reference population (moderate
and severe) and below minus three standard deviations (severe). Stunting is measured by the
proportion of children under five years of age falling below minus 2 standard deviations from the
median height-for-age of the reference population (moderate and severe) and below minus three
standard deviations (severe). Wasting is measured by the proportion of children under five years of
age falling below minus 2 standard deviations from the median weight-for-height of the reference
population (moderate and severe) and below minus three standard deviations (severe).
37.
However, statistical treatment of anthropometric indicators of malnutrition can be based on
either Z-Scores or Percentages of the Reference Median. Z-scores are presented in terms of predefined
standard deviations below the median of the reference population, while percentage scores refer to the
proportion below a predefined percentage of the median score e.g. 80 percent of the median
weight-for-height of the reference population. The two measures do not generate identical indices of
malnutrition, even if the analyst adjusts the cutoff points.
Nutrition Surveys
38.
The NS4 was based on the national sample frame and covered all districts except North Eastern
province, and Isiolo, Marsabit, Samburu, Turkana, Lamu, Tana River and West Pokot districts. The
NS4 indicators were based on the growth reference curves of American children from the NCHS/CDC,
as studies have shown that children from well-to-do families in Kenya have growth patterns similar to
those of American children (Alnwick, 1980). In all, 6,909 children aged 6-60 months were included in
the analysis. The NS4 survey report cautions that (a) there was high non-response in some areas e.g.
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Kajiado and Narok districts due to nomadic nature of the population; and (b) supervision of
enumerators slackened in some districts, which may have affected the quality of nutritional indicators
particularly height-for-age index.
39.
The NS4 considered children with height-for-age median of less than 90 percent of the
reference population to be stunted, and children with weight-for-height of less than 80 percent as
wasted. District-level Z-scores are also presented for those below minus 2 standard deviations of the
height-for-age (moderate and severe stunting) and below minus 2 standard deviations of
weight-for-height (moderate and severe wasting). Analysis of anthropometric data to generate
indicators of underweight (weight-for-age) was not done in the last two nutrition surveys, and recent
national indicators of underweight based on the nutrition surveys do not therefore exist. Kenya
presently uses only stunting and wasting in their reporting on nutritional status. Underweight has
been recommended as the indicator for monitoring the World Summit goal for reduction in
malnutrition (de Graft-Johnson, 1991)
40.
Comparison of data from different nutrition surveys conducted in Kenya is limited by a
number of factors. First, the surveys covered different age groups. For example, the target population
for the 1977 rural nutrition survey was 1-4 years, 6-60 months for the 1978-79 survey, and 3-60
months for the 1982 survey. Second, all the surveys exclude North Eastern province and some districts
of Eastern and Rift Valley provinces, which may have higher percentages of malnourished children.
Third, the surveys do not cover a whole year and therefore do not allow for estimation of seasonal
factors on malnutrition. This factor is compounded by the fact that the surveys were carried out at
different times of the year and comparisons between them (especially on indicators of wasting since
wasting uses data on weight) is distorted by seasonal factors. Fourth, the first two surveys used the
Harvard growth curves, while the two latter surveys used the NCHS/CDC/WHO reference
population. Fifth, the results were analyzed using percentage rather than standard deviation (Z)
scores. The 1987 survey was analyzed using both methods although the text of the report is based on
percentage scores. In the case of the 1987 survey, the height-for-age cutoff point of 90 percent is
considered too high, as it includes children who may have been ill or temporarily malnourished but
who may have later caught up. A lower cutoff point of, say, 80 percent would only reflect children
who may suffer functional impairment due to malnutrition.
41.
The district-level indicators of nutritional indicators, namely, moderate and severe stunting
(below minus 2 standard deviations height-for-weight) and moderate and severe wasting (below
minus 2 standard deviations weight-for-height) are presented in Statistical Annex Table 1. The 1987
rural national moderate and severe stunting was estimated at 32.2 percent, with Kilifi (51.7 percent),
Kwale (56.1 percent) and Narok (59.7 percent) having over 50 percent stunted children. The 1987
rural national estimate of moderate and severe wasting was estimated at 4.5 percent, the highest rates
being in Siaya (11.7 percent), Kajiado (9.9 percent), Laikipia (8.2 percent) and South Nyanza (7.8
percent) among the surveyed districts. Provincial estimates of stunting and wasting based on Z-scores
were not published.
Kenya Demographic and Health Survey, 1993
42.
The 1989 Kenya Demographic and Health Survey did not contain an anthropometric module.
However, the 1993 KDHS obtained data on weight and height of all children born since January 1988
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(i.e. under five years of age since the survey was conducted during February-August 1993) and whose
mothers were interviewed in the KDHS. The anthropometric data, combined with a childs age, was
used to derive height-for-age (stunting), weight-for-height (wasting) and weight-for-age
(underweight) indicators for children of 1-60 months of age. The survey used the international
reference population defined by the U.S. NCHS/CDC and recommended by the World Health
Organization (WHO).
43.
Overall, 32.7 percent of Kenyan children were classified as stunted and 12.2 percent as
severely stunted. Stunting was highest among children of 12-23 months (40.3 percent). Stunting was
more prevalent among rural children (34.2 percent) than urban children (21.5 percent). The
proportion of stunted children was highest in Coast province (41.3 percent) and Eastern (39.4
percent), and lowest in Nairobi (24.2 percent). The 1993 KDHS states that the high levels of stunting at
the Coast have been observed in previous nutrition surveys, but the appearance of Eastern province in
the league of high stunting regions may be associated with the recent drought conditions.
44.
In 1987, the proportion of rural children who were reported as moderately and severely
stunted was 32.2 percent, which is roughly the same estimate for rural Kenya based on the 1993 KDHS
(34.2 percent). However, region-specific estimates are not comparable since the 1987 NS4 reported
Z-scores nutrition indicators by district while the 1993 KDHS reported by province. In comparing
1987 and 1993 estimates, it should be noted that (a) NS4 sample excluded Lamu, Tana River, and West
Pokot districts, which were included in the 1993 KDHS; and (b) the 1993 KDHS purposely
oversampled 15 districts so as to produce reliable estimates for the oversampled districts without
expanding the total sample to unmanageable levels. The 1987 indicators of stunting and wasting for
the districts oversampled in the 1993 KDHS were not uniformly below or above the national averages,
and the effect of oversampling on the national estimates of stunting and wasting in 1993 is therefore
indeterminate.
45.
An estimated 5.9 percent of the Kenyan children were wasted, and 1.2 percent severely
wasted. Variations in wasting by demographic characteristics show that it was highest for children of
12-23 months of age (10.0 percent). The highest prevalence of wasting was recorded in Coast province
(10.6 percent), followed by Rift Valley (7.9 percent) and Eastern (6.8 percent). The 1987 estimate of
moderate and severe wasting was 4.5 percent in rural Kenya, compared with 6.0 percent in rural 1993.
46.
The 1993 KDHS reported that 22.3 percent of the Kenyan children under-five years of age
were moderately and severely underweight for their age, and 5.7 percent severely underweight. As
with other anthropometric indicators, underweight was highest among children of 12-23 months
(31.6 percent), 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 percent) than urban areas (12.8 percent). Children in Coast (31.7 percent)
and Eastern (28.8 percent) are much more likely to be underweight than children from other
provinces. Prevalence of underweight was not reported in the 1987 NS4 Basic Report, and no
comparisons can therefore be made for reference periods 1987 and 1993. However, in interpreting
1989 and 1993 KDHS statistics on various indicators included in this report, it is important to keep in
mind that observations for urban centers, excluding Nairobi, are included in the respective provinces.
In addition, the 1993 KDHS included children aged 1-60 months while the 1987 NS4 covered 6-60
months, which affects comparability of the indicators based on the two surveys since children below
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six months are less likely to be stunted than older age cohorts.
Baseline Indicators of Nutritional Status
47.
Since the indicators in the 1987 NS4 do not meet the full reporting requirements of UNICEF
under the World Summit for Childrens goals, UNICEF could explore the possibility of requesting CBS
to provide tabulations for underweight using the Z-scores, and provincial estimates of stunting and
wasting. The 1993 KDHS probably presents the best baseline source of nutritional status for the 1990s.
However, UNICEF should request the National Council for Population and Development to provide
tabulations for 1993 district-level estimates of stunting, wasting and underweight, at least for the 15
districts which were purposely oversampled to produce reliable district-level estimates. Such request
could also include information on immunization, and other indicators of concern to UNICEF, but
which do not appear in the 1993 KDHS analytical report.
48.
The second round of the National Household Welfare Monitoring Survey (June 1994) contains
an anthropometry module financed by UNICEF. UNICEF therefore has proprietary access to the
anthropometric data immediately it is collected and keyed in. The initial efforts will, of course, be to
produce a basic report on anthropometric indicators to satisfy the immediate reporting needs under
the World Summit for Children goals. However, since all the modules in the Welfare Monitoring
Survey have common household identification information and household members serial numbers,
interrelationship between various household socioeconomic characteristics can be generated. UNICEF
should encourage coordinated analysis of the modules in the WMS2 database, to ensure that timely
analysis and dissemination of information is made possible.
MICRONUTRIENT DEFICIENCIES
49.
The World Summit goals in regard to micronutrient deficiencies are (a) to reduce iron
deficiency anemia 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 anemia, the Kenya NPA stated that, since the prevalence of
nutritional anemia among women in Kenya is unknown, the Government will undertake or
commission studies to determine the prevalence of nutritional anemia among women and children.
On IDD and VAD, the Government was to undertake nationwide surveys to determine their
prevalence.
50.
The Government has already taken a number of administrative and statutory steps with
respect to reduction of IDD. In 1988, the Government amended The Food, Drugs and Chemical
Substances Act (Cap. 254 of the Laws of Kenya) restricting the sale of table salt which does not contain
the required potassium iodate. Meetings have already been 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 salt manufacturing firms and on salt sold in the market. However,
the supervision needs to be strengthened by sensitizing 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.

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51.
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, partial loss of iodine occurs if the
salt is put too early during cooking, and kept in open containers or in damp places. A costless activity
would be to sensitize the mass 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 and/or features.
52.
The Food, Drugs and Chemical Substances Act states that table salt or salt for general
household use shall contain 168.5 mg. per kilogram of potassium iodate. However, the wording of the
legislation is vague since it is supposed to refer to 168.5 mg. of potassium iodate per kilogram of salt
rather than 168.5 mg. per kilogram of potassium iodate.
53.
The Nutrition section in the Division of Family Health, with financial support from UNICEF,
started a micronutrient survey in February 1994. The main objectives of the survey are to (a)
determine the prevalence of Vitamin A, iodine and iron deficiencies in Kenya, (b) determine the
possible causes of these deficiencies where they occur, (c) determine the geographical distribution of
these deficiencies, and (d) identify the groups at risk. The survey is being carried out in 49 districts in
the republic. The survey entails clinical assessments, and interviewing for food intake frequency and
available food resources. The survey results are expected to be ready by August 1994.
BREASTFEEDING AND THE BABY-FRIENDLY HOSPITALS INITIATIVE
Situation Analysis
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 infant feeding practices since they included the latest offsprings
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 percent 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 can not therefore be associated with any
specific time period.
54.

55.
In 1982, the Central Bureau of Statistics undertook a survey of Infant Feeding Practices on 980
low and 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, 1984a). 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 lactational amenorrhea, and increased child
morbidity. The correlation between breastfeeding and fertility was considered important because only
18 percent of the women surveyed reported using any form of birth control since the birth of the
index child.

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56.
The survey included questions on influences on feeding practices. While 77 percent of the
women surveyed had given birth in a health facility, only 14 percent recalled receiving any
information on infant feeding at that time, and half of this 14 percent reported being wrongly told that
exclusive infant formula feeding was best for the child.
57.
Other surveys which have collected household-based information on breastfeeding includes
the four nutrition surveys (1977, 1978-79, 1982 and 1987) and the 1989 and 1993 Kenya Demographic
and Health Surveys. The focus of our analysis will only be based on the Fourth Rural Child Nutrition
Survey 1987 and the 1989 and 1993 Kenya Demographic and Health Surveys.
58.
The fourth rural nutrition survey (1987) solicited responses on (a) whether the child was
breastfeeding at the time of the survey, (b) number of months breast-fed, and (c) whether the child
had breast-fed 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 districtand 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).
59.
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 of breastfeeding (not necessarily exclusively). The mean number
of months of any breastfeeding was 19.5 in the rural areas (compared with 16.1 months obtained from
the 1987 rural nutrition survey) and 18.8 months in urban areas. The Nairobi mean was 19.9 months
in 1993.
60.
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 rural areas. The mean length of exclusive breastfeeding was 0.5 months and
0.7 months for exclusive breastfeeding and plain water only.
61.
The 1993 KDHS asked mothers about breastfeeding status of all last-born children under five
and, if the child was being breast-fed, and whether various types of liquids or solid food had been
given to the child yesterday or last night. Children who are exclusively breast-fed receive breast
milk only, while those who are fully breast-fed include those who are exclusively breast-fed and those
who receive plain water in addition to breast-milk. The results are shown in Statistical Annex Tables
3, 4 and 5.
62.
In the first month of life, only 26.8 percent of the children were exclusively breast-fed during
the 1993 survey period, while an additional 17.7 percent breast-fed 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
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(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.
Assessment of Baby-Friendliness
63.
In the mid-decade goals, Kenyas aim is that by the end of 1994, all the circa 300 facilities
providing maternity services will be practicing the 14 steps of the National Policy on Infant Feeding
Practices. According to the Situation Analysis (1992), Kenyas Minister for Health officially launched
the Baby Friendly Hospitals Initiative in September 1991, making Kenya one of the first 12 countries
attempting to achieve Baby Friendliness by December 1992. By the end of 1994, it is anticipated that
all the estimated 300 maternity facilities will be declared Baby Friendly on a global rating.
64.
The Baby-Friendly Hospitals initiative aims to discourage the use of commercial baby foods; to
mobilize hospital personnel and health professionals (especially those involved in maternity hospitals
and wards) to support breastfeeding; and to create among women a demand for hospitals which are
optimally supportive of mothers wishing to breastfeed. By March 1992, two of Kenyas leading health
institutions, Kenyatta National Hospital and Pumwani Maternity Hospital, were formally declared
Baby Friendly on a global rating.
65.
The Division of Family Health in the Ministry of Health, with support of UNICEF, carries out
random checks on facilities providing maternity services. A detailed questionnaire is filled using
responses from the hospital administration, healthcare providers and mothers in the maternity wards.
The data is analyzed in the HIS section of the Ministry of Health using SPSS (Statistical Package for the
Social Sciences) software to ascertain the baby-friendliness of the maternity facility. As of June 1994,
17 maternity facilities had been declared baby-friendly by the Division of Family Health. Some health
institutions have not been reported as baby-friendly since they have not been inspected by the
Division of Family Health. An assessment of baby-friendliness of maternity facilities was being
conducted in July 1994. However, since the number of maternity cases per health facility is not
reported, the success of the baby-friendly hospitals initiative may be understated since the initial
impetus has been on health facilities with relatively higher than average number of child births. There
is therefore need to collect data on children born in each maternal facility for a common base year,
say, 1993, so as to measure the success of baby-friendliness by both the number of facilities and
maternity cases handled on average.
66.
The main risk in the continuous assessment of baby-friendliness is lack of funds to enable the
Division of Family Health to make frequent visits to the maternity facilities. There is therefore need to
focus on budgetary issues, both from the Government budget lines and donors, to prevent a relapse
due to infrequent supervision. In addition, although the promotion of breastfeeding is primarily the
responsibility of nurses, the doctors strike in Government hospitals may have led to a slight relapse in
the baby-friendly hospitals initiative, due to the increased responsibilities on the nurses.
CHILD GROWTH MONITORING
67.
The Health Information System (HIS) has until recently been processing data on child growth
monitoring through the Child Health and Nutrition Information System (CHANIS), but this
responsibility has now been transferred to the Division of Family Health. Health facilities fill daily
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tally sheets for all children-weighing, broken down by age (0-11, 12-35, 36-59 months) and whether
the child is normal weight or underweight based on the standard child growth reference curve.
Monthly facility totals are filled in Chanis 3 forms, which are forwarded to the districts. The districts
compile monthly district totals in Chanis 5 forms, which are then forwarded to the Division of
Family Health.
68.
The Chanis system has been affected by delayed reporting from health facilities. At the facility
level, the data captures child growth monitoring based on the US National Centre for Health Statistics
(NCHS) standard child growth reference curve. Those children whose weight-for-age fall below the
third percentile of the distribution of the standard reference population are classified as underweight
while those above the third percentile are classified as normal. However, the summary returns
capture only cross-sectional nutrition status rather than growth monitoring since the data is not by
individual child in the growth process. In addition, since the data does not distinguish between first
visit and revisits, the summarized data refer to children-weighing rather than children-weighed. Over
a period of, say, one year, different children will have been weighed different number of times. It is
therefore difficult to set up quantitative targets based on population parameters or to formulate
appropriate indicators of coverage of growth monitoring for the target age groups.
69.
Conventional child growth monitoring as an indicator of nutritional status is usually defended
on the grounds that, a childs revisit for reweighing is a fresh case since its weight is read against a
different age on the standard growth reference curve. However, severely malnourished cases are more
likely to be referred for reweighing; thereby leading to a downward bias in the reported overall
nutritional status derived using child growth monitoring data.
70.
The data from Chanis was reportedly used as a food deficit early warning system, and the
information is therefore shared with other ministries (e.g. agriculture) and the regional
Inter-Governmental Authority on Drought and Desertification (IGADD). IGADD also gives financial
and technical support to the Division of Family Healths child growth monitoring programme. Chanis
data is graphed with the Normalized Difference Vegetation Index (NDVI) to study the linkages
between the two datasets. The NDVI analyzes remote sensing measurements and assesses whether the
target being observed contains live green vegetation, and has been used to estimate crop yields, pasture
performance, and rangeland carrying capacities, among others. There was a proposal to link the
Chanis database with the USAID Famine Early Warning System project (FEWS) geographical
referencing system. No substantial progress was made by either USAID/FEWS or the Division of
Family Health due to (a) the fact that Chanis database was at district level rather than clinic-based
while NDVI are generated at more disaggregated levels; and (b) weight-for-age is more of an outcome
of poverty/food deficit rather than a food deficit early warning indicator. A link between the Chanis
database (on weight-for-age and the proposed sentinel-based weight-for-height indicators) and
USAID/FEWS geographical mapping system could be of great benefit to both the Division of Family
Health and USAID/FEWS.
71.
The Chanis information is used at health facilities to follow up on the progress of the
individual child especially for severely malnourished cases. Underweight (weight-for-age) as an
anthropometric indicator is affected more by seasonal factors e.g. harvests, food shortages and
temporary child sickness, compared with, say, stunting (height-for-age). However, data on incidence
of kwashiorkor and marasmus, which is submitted on the same Chanis facility and district returns, are
-17-

more commonly used since they reflect severe malnutrition that can lead to functional impairment of
the distressed child.
72.
Chanis has developed new forms to gather data on wasting (weight-for-height) in some pilot
districts, namely, Busia, Nyamira, Siaya, Kitui, Garissa, Laikipia, Kajiado, Turkana, Embu, Muranga,
Kilifi and Kwale districts. The data will be collected from four sentinel sites in each district, i.e. health
facilities with good reporting rates and a high turnover of children. However, there is a shortage of
equipment, especially wall charts and length boards. Data from such sentinel sites will be more easily
mapped against NDVI, compared with district-level summaries of nutritional status (weight-for-age)
currently entered in the Chanis information system.
73.
The Chanis was moved from HIS in the Ministry of Health headquarters to the Division of
Family Health in early 1994. The section has only one member of staff (a medical records officer) who
has previously received three-year training at the Medical Training Centre (MTC). The computing
facilities are one desktop PC, two laptop computers and an Epson dot-matrix printer, which are also
shared with secretaries for word processing. The desktop was an old computer which was not
functioning at the time of the Missions visit, and data entry was being done in one of the laptops. It is
necessary to provide a high-memory computer to handle data on child-growth monitoring and other
aspects of data analysis in the nutrition section in the Division of Family Health e.g. questionnaires on
baby-friendly hospitals initiative. The Chanis section did not have any data archival systems other
than diskettes. Loss of data in case of computer systems failure is therefore a real danger.

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CHAPTER FOUR

HEALTH
INFANT AND UNDER-FIVE MORTALITY
74.
Infant mortality is the probability of dying before the first birthday, and under-five mortality
is the probability of dying between birth and the fifth birthday. Both rates are expressed per 1,000 live
births. The World Summit Goal in respect of infant mortality is to reduce the rate by one third or to 50
per 1,000 live births, whichever is less; and to reduce under-five mortality by one third or to 70 per
1,000 live births, whichever is less. The Kenya NPA accepts the World Summit goals on infant and
under-five mortality, but cautions that achieving these reductions, however, could be adversely
affected by the additional mortalities due to AIDS.
75.
The sources of baseline information on the two indicators are the 1977 Kenya Fertility Survey,
the 1969 and 1979 Population Censuses, and the 1989 and 1993 Kenya Demographic and Health
Surveys. The estimates of under-five mortality rates derived from the 1979 population census are
based on mothers aged 15-49 years at the time of the census, and do not therefore reflect a defined
time period. The Central Bureau of Statistics has not completed analysis of infant and under-five
mortality rates based on the 1989 Population and Housing Census.
76.
The 1989 KDHS collected under-five mortality data based on retrospective birth history, in
which data was collected from respondents aged 15-49 years. The sources of data collection errors
would include underreporting of events, misreporting of age at death, and misreporting of date of
birth. The national infant mortality rate for the period 1979-89 was 58.6; 56.8 for urban areas and 58.9
for rural Kenya. Coast (107.3), Nyanza (94.2) and Western (74.6) had infant mortality rates above the
national average, while Rift Valley (34.6), Central (37.4), Eastern (43.1) and Nairobi (46.3) had lower
infant mortality rates than the national average.
77.
The regional under-five mortality differentials for the period 1979-89 based on the 1989
KDHS followed the same pattern as the infant mortality rates. The national under-five mortality rate
was estimated at 90.9, with Coast (156.0), Nyanza (148.5) and Western (132.8) being above, and
Central (47.0), Rift Valley (50.9), Eastern (64.3) and Nairobi (80.4) being below the national average.
This means that, for the reference period, almost 10 percent of live births did not live to see their fifth
birthday.
78.
The 1993 KDHS solicited information on under-five mortality. The results show an overall
increase in infant mortality rate from 58.6 for the period 1979-89 (based on the 1989 KDHS) to 62.5 for
1983-93 reference period (based on the 1993 KDHS). Although the reference periods that the
estimates refer to overlap, analysis for the 1988-93 reference period also depicts an increase in infant
mortality in Kenya. Infant mortality rates for Nyanza (127.9), Coast (68.3) and Western (63.5) were
above the national average, while Central (30.9), Nairobi (44.4), Rift Valley (44.8) and Eastern (47.4)
were below the national average.
79.
Under-five mortality rates for the reference period 1983-93 based on the 1993 KDHS also
depict similar regional differentials as infant mortality. While the national average under-five
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mortality rate for the reference period 1983-93 was 93.2, Nyanza (186.8), Western (109.6) and Coast
(108.7) were above the national average, while Central (41.3), Rift Valley (60.7), Eastern (65.9) and
Nairobi (82.1) were below the national average. The trend for Nyanza province is disturbing as it
shows that about 19 percent of live births do not live to see their fifth birthday, and the rate is almost
twice that of the second highest (Coast province, 10.9 percent) and four and a half times that of the
lowest rate (Central, 4.1 percent). The regional differentials of both infant and under-five mortality
followed the same pattern in both the 1989 and 1993 KDHS, with Coast, Nyanza and Western
provinces being above, and Eastern, Central, Rift Valley and Nairobi being below the respective
national averages.
MATERNAL MORTALITY
80.
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. Maternal deaths 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 (fertility). Maternal mortality ratio (MMR) is defined
as the number of maternal deaths in a population divided by the number of live births. The World
Summit goal is to reduce maternal mortality ratio by one half between 1990 and the year 2000. The
Kenya National Plan of Action states that, since no reliable estimates of maternal mortality are
currently available, the immediate plan was to determine the current rate of maternal mortality.
81.
There are only a few, facility-based, estimates of maternal mortality in Kenya (Boerma, 1987a;
Boerma, 1987b; Boerma and Baya, 1990; Boerma and Mati, 1989; Ewbank, Henin and Kekovole, 1986;
Makokha, 1980; Makokha, 1991; Ngoka and Bansal, 1987; Kenya and UNICEF, 1992a). A 1980 study of
maternal deaths at Kenyatta National Hospital yielded an MMR of 224 per 100,000 live births at that
hospital between 1972 and 1977 and 320 during 1978-1987 (Makokha, 1980; Makokha, 1991); while
MMR at Pumwani Maternity Hospital was much lower at 67.2 deaths per 100,000 live births over the
period 1975-84 (Ngoka and Bansal, 1987). A third study in Kwale district of coastal Kenya led to an
estimate of maternal mortality of 254 per 100,000 live births. The much higher MMR rate for Kenyatta
National Hospital compared with Pumwani Maternity Hospital may be due to the fact that Kenyatta
National Hospital is a referral hospital and would, on average, see more difficult cases.
82.
The Population Studies and Research Institute (PSRI), with financial support from UNICEF, is
conducting a Kenya Maternal Mortality Baseline Survey (KMMBS) during June-July 1994. The survey
covers all districts except seven -- the three districts in North Eastern Province and four other
northern districts (Isiolo and Marsabit in upper Eastern province and Samburu and Turkana in Rift
Valley province). The excluded areas account for only about 5 percent of Kenyas population. The
survey utilized the National Sample Survey and Evaluation Programme (NASSEP) master frame
maintained by the Central Bureau of Statistics. To obtain reliable district-level estimates, ten districts
were oversampled: Homa-Bay, Nyamira, Kisumu, Busia, Baringo, Nyeri, Embu, Kitui, Kwale and Taita
Taveta. The baseline survey has been designed to (a) collect information on maternal mortality, (b)
estimate levels of maternal mortality at the national level and for the ten oversampled districts, (c)
establish regional maternal mortality differentials, (d) determine socioeconomic, socio-cultural and
demographic factors that influence maternal mortality, and (e) determine the effect of maternal
-20-

mortality on child survival.


83.
The survey will consist of three modules. The estimation of maternal mortality will be
through the sisterhood method, i.e. asking questions about respondents sisters experience (whether
alive or dead at the time of the survey), such that each interviewee becomes a respondent for several
sisters. At the end of the survey, the survey organizers expect to have interviewed 40,000 respondents.
The information being collected includes mortality experience of all his/her sisters who ever reached
menarche (the time in a girls life when menstruation first begins), deaths due to pregnancy/child
birth, and survival and health status of the index child in case of maternal deaths.
84.
The second source of information is the study of maternal admissions in all the district
hospitals during the period January-December 1993, while the third source is selected participants for
Focus Group Discussions from local communities. For the Focus Group Discussions, a total of 5 groups,
consisting of medical personnel, local women of reproductive age, traditional birth attendants and
other community-based supervisors will be involved in each of the three districts: Homa Bay, Embu
and Kwale. The Focus Group Discussions will focus on socio-cultural beliefs and practices relating to
pregnancy/child birth, marriage and nutrition as they relate to maternal health/mortality.
85.
Although the survey is being conducted alongside the CBS National Household Welfare
Monitoring Survey, data collection is the responsibility of enumerators selected and supervised by
PSRI; and data entry, analysis and report writing will also be done by PSRI. This is probably the first
national survey using the CBS sample frame where data collection has been undertaken by a research
institute. The quality of data collected in the ongoing maternal mortality survey will therefore have
ramifications on the future distribution of responsibilities for national survey data collection activities
in Kenya. The report of the survey findings is expected to be ready by November 1994.
IMMUNIZATION COVERAGE
Kenyan Goals on Immunization Coverage
86.
The World Summit Goals relating to immunization include (a) eradication of polio by the year
2000; (b) elimination of neonatal tetanus by the year 1995; (c) reduction in measles deaths and measles
cases for children under five years of age by 95 percent and 90 percent, respectively, compared to
pre-immunization levels, by 1995; and (d) maintain at least 90 percent immunization coverage against
DPT (diphtheria, pertussis, tetanus), measles, polio and tuberculosis among under one year of age and
against neonatal tetanus.
87.
The Kenya NPA goals on immunization are: (a) achieve virtual eradication of polio by the year
2000, (b) elimination of neonatal tetanus by the late 1990s, and (c) achieve national immunization
coverage rate of 90 percent by the year 2000. The mid-decade goal expected to be achieved by the end
of 1994 is to raise immunization coverage against measles, polio, DPT and TB to 90 percent.
88.
The focus of analysis is on data sources for statistics on immunization coverage, mainly routine
records from immunization sites, and occasional surveys conducted by KEPI and the National Council
for Population Development/Macro International Inc (Kenya Demographic and Health Surveys).

-21-

KEPI Routine Reporting from Immunization Sites


89.
The information from the districts for the six antigens in the Expanded Programme on
Immunization (EPI) is entered in the Computerized EPI Information System (CEIS) program provided
by the World Health Organization (WHO). The KEPI Management Information System (MIS) moved
from Version 4 to Version 5 of the CEIS program in 1993. However, the system was not operating
properly for a number of reasons:
(a)
(b)

From the dates of the program files in the system, the Version 5 of the program was not
installed but copied on Version 4, thereby leaving some batch (*.bat) files of Version 4.
The specification of the minimum number of files in the CONFIG.SYS was far below the 55
required in the CEIS Version 5 manual.

90.
The program is installed in a 286, 104 Megabytes, IBM-compatible computer, whereas the
WHO recommends a minimum of a 386 computer. The program for printing graphs is Harvard
Graphics Version 2.3. There is therefore need to provide a 386 computer as required by the CEIS
programme developers, install Version 5 batch files in the program, and install a more up-to-date
version of Harvard Graphics. There is also no data archival system in KEPI other than floppy diskettes,
and the data in the computer is not available in software form outside of the room where the computer
is located.
91.
Information on immunization for the six antigens provides the numerators in the computation
of immunization coverage. The denominators are calculated from baseline information fed into the
computer on population by district for a baseline date, crude birth rate per 1,000 (CBR), population
growth rate, and infant mortality rate per 1,000 live births. The region-specific population parameters
are based on the 1979 Population Census, rather than the 1989 Population Census. However, the delay
to use the more recent census results was attributed to increase in the number of districts due to
subdivision of existing districts. Since the 1989 Population Census, the first group of districts created
was Machakos/Makueni, Kakamega/Vihiga, Homa-Bay/Migori, Kericho/Bomet, Kisii/Nyamira and
Meru/Tharaka-Nithi in 1992. The more recent divisions comprised Meru/Nyambene, Kitui/Mwingi,
Bungoma/Mt. Elgon and Migori/Kuria in 1993. This is a problem that has wreaked havoc to data
systems which assume population parameters (e.g. water and sanitation coverage) and morbidity and
mortality statistics from administrative records as percentage of total target population.
92.
Text Table 2 below shows the 1979 population, population growth rate, crude birth rate, and
infant mortality rate parameters fed into the CEIS program. Also included in Text Table 2 are the 1989
population projections based on the above population parameters, and data from the 1989 Population
Census. In the case of the 1979 baseline data, one problem with use of district-specific data is that the
total census figure of 15.327 million was adjusted to 16.141 million to compensate for
under-enumeration in Nyanza province, while the KEPI program uses the unadjusted Nyanza
province population. In addition, the assumption on the annual population growth rate was
unreasonably low for Turkana district (-0.20 percent), compared with an actual compound growth
rate of 2.56 percent for the period 1979-89 based on the 1979 and 1989 censuses.
93.
The use of inappropriate population denominators imply that the reported immunization
coverage is low if the population figure used is more than actual. In the case of the new districts,
-22-

population estimates of the mother districts have not been amended, while reporting on
immunization is per district. The mother district therefore shows lower immunization coverage than
actual, while the new district does not have population parameters and no immunization coverage
statistics are therefore computed. The Central Bureau of Statistics has not provided user ministries
with information on population for the new districts, probably because the new districts were hived
off after the 1989 Population Census. The Central Bureau of Statistics has also not published
information on crude birth rate and infant mortality rate by region based on the 1989 Population
Census.
94.
One of the factors behind Kenyas miracle in experiencing an accelerated demographic
transition may be the validity of the population adjustment in 1979 in respect of Nyanza province. For
example, the compound growth rate in Kenyas population during 1979-89 was 3.415 percent using
the unadjusted total population, compared with 2.881 percent using the adjusted total. The Central
Bureau of Statistics should clarify the baseline information that should be used in interpreting the
recent demographic transition, and in revising the data series for Nyanza province statistics on, say,
immunization coverage from administrative records. The published population data based on the 1989
Population Census also seem high for some districts, and could therefore cause a downward bias on
immunization coverage statistics for the respective districts. For example, the 1979-89 intercensal
population growth rates were over 5 percent for Isiolo (5.01 percent), Kajiado (5.67 percent), Narok
(6.61 percent) and Baringo (5.49 percent) districts. Since the abovementioned districts are not urban
settlements, such phenomenal growth in population is unlikely to have resulted from net
in-migration.
95.
The denominator problem has been aggravated by displacement of people in some parts of
the country, mainly Rift Valley province. Information on immunization coverage based on data from
immunization sites might give a false impression of deterioration in the areas where the people have
been displaced (due to reduction in the actual denominator), and an improvement in their
destination districts. Although this is likely to be a more serious source of error for data from
immunization sites, the data based on the NASSEP frame might also be biased since NASSEP is based
on the 1989 Population Census. The denominator problem will also be aggravated by the AIDS
scourge before the next population census is undertaken and analyzed.
96.
There may also be an inherent numerator problem in apportioning facility-based
immunization data by districts, as the data analysis is based on catchment area rather than
catchment population. An immunization facility in, say, Thika municipality may serve two
contiguous districts (Muranga and Kiambu) - the catchment population - while its immunization
coverage data is posted to Kiambu district - the official catchment area - since Thika municipality is
physically located in Kiambu district.

-23-

Text Table 2: Population Parameters in the KEPI CEIS Computer Program

Nairobi
Kiambu
Kirinyaga
Muranga
Nyandarua
Nyeri
Kilifi
Kwale
Lamu
Mombasa
Taita Taveta
Tana River
Embu
Isiolo
Kitui
Machakos
Marsabit
Meru
Garissa
Mandera
Wajir
Kisii
Kisumu
Siaya
South
Nyanza
Nyamira
Kajiado
Kericho
Laikipia
Nakuru
Narok
Trans Nzoia
Uasin Gishu
Baringo
E/Marakwet
Nandi
Samburu
Turkana
West Pokot
Bungoma
Busia
Kakamega
Total

KEPI PROGRAM
1979
Growth CBR IMR
population rate (%)
(mn)
0.828
5.17 34
92
0.686
4.00 56
92
0.291
3.65 56
92
0.648
4.05 56
92
0.233
3.55 56
92
0.486
3.65 56
92
0.431
3.92 41
92
0.288
3.94 41
92
0.042
5.15 41
92
0.341
3.86 41
92
0.148
3.67 41
92
0.092
5.07 41
92
0.263
4.18 56
92
0.043
3.98 56
92
0.464
3.76 56
92
1.023
4.11 56
92
0.096
5.20 56
92
0.830
3.91 56
92
0.129
5.73 40
92
0.106
2.51 40
92
0.139
4.88 40
92
0.870
3.63 56
92
0.482
3.28 56
92
0.475
3.42 56
92
0.818
3.41 56
92

0.149
0.633
0.135
0.523
0.210
0.260
0.301
0.204
0.149
0.299
0.077
0.143
0.159
0.504
0.298
1.031
15.327

5.06
3.74
5.55
5.18
4.94
5.67
4.65
3.47
0.86
4.19
2.50
-0.20
5.40
3.98
4.03
3.46

56
56
56
56
56
56
56
56
56
56
56
56
56
54
54
54

1989
population
projection
(mn)
1.370
1.016
0.417
0.964
0.331
0.696
0.633
0.424
0.070
0.498
0.212
0.152
0.396
0.064
0.672
1.530
0.160
1.218
0.225
0.135
0.224
1.242
0.666
0.664
1.143

92
92
92
92
92
92
92
92
92
92
92
92
92
92
92
92

0.244
0.914
0.231
0.866
0.341
0.450
0.474
0.287
0.162
0.451
0.098
0.140
0.268
0.745
0.442
1.449
22.684

-24-

1989
population
Actual (mn)

1989
projection/
actual (ratio)

Annual
growth rate
1979-89 (%)

1.325
0.914
0.392
0.858
0.345
0.607
0.592
0.383
0.057
0.462
0.207
0.128
0.370
0.070
0.653
1.402
0.129
1.145
0.125
0.124
0.123
1.137
0.664
0.639
1.067

1.03
1.11
1.07
1.12
0.96
1.15
1.07
1.11
1.23
1.08
1.02
1.18
1.07
0.91
1.03
1.09
1.24
1.06
1.80
1.09
1.82
1.09
1.00
1.04
1.07

4.81
2.92
3.01
2.85
4.02
2.25
3.22
2.89
3.06
3.08
3.43
3.39
3.48
5.01
3.47
3.20
3.02
3.27
-0.33
1.56
-1.23
2.71
3.26
3.02
2.69

0.259
0.901
0.219
0.849
0.398
0.394
0.446
0.348
0.216
0.434
0.109
0.184
0.225
0.679
0.402
1.464
21.444

0.94
1.01
1.06
1.02
0.86
1.14
1.06
0.82
0.75
1.04
0.90
0.76
1.19
1.10
1.10
0.99
1.06

5.67
3.59
4.95
4.97
6.61
4.24
4.00
5.49
3.81
3.79
3.53
2.56
3.55
3.03
3.03
3.57
3.42

Kenya Demographic and Health Survey, 1989


97.
The 1989 Kenya Demographic and Health Survey included questions on immunization
coverage for those children under-five years whose mothers were interviewed, and therefore
excluded children whose mothers had died or who were institutionalized. The omissions are likely to
be relatively small, and the results can therefore be generalized to children under five years of age at
the time of the survey. The immunization data was copied from health cards. For those who did not
have health cards, the mother was asked whether the child had ever received immunization, but no
information was obtained on specific vaccinations for these children, partly due to the long recall
period involved since information was collected for children of up to five years.
98.
Since the customary reporting of immunization coverage focuses on one-year olds, Statistical
Annex Table 8 shows the results for those children in the range 12-23 months who are expected to
have completed the recommended immunization schedule. The results show that 61.0 percent had
their health cards seen. An additional 35.1 percent did not have a health card available, but were
reported by their mothers to have been immunized. The information on specific immunizations was
based on health cards only. The data therefore measures dropout rates for those with health cards seen
rather than immunization coverage.
99.
It is noteworthy that there were more rural mothers (63.1 percent) than urban mothers (49.5
percent) with health cards to show the interviewers. Estimates of full immunization coverage for all
children range from (a) 72.8 percent, assuming that those with cards to show the interviewer and
those without had identical immunization profiles, to (b) 44.4 percent, assuming those without cards
had not been immunized at all, i.e. the product of the share of those with cards (61.0 percent) and
those with cards who had undergone the recommended immunization schedule (72.8 percent). The
true coverage was therefore between 44.4 percent and 72.8 percent.
KEPI National Immunization Coverage Survey, 1992
100.
In March 1987, an immunization coverage survey was conducted in ten randomly-selected
districts: Nairobi, Kiambu, Kilifi, Machakos, Kisii, Siaya, Kericho, Nakuru, Narok and Busia. This was
followed by the 1992 immunization coverage survey which used the national sample frame and was
conducted in all 41 districts. The newly-created districts were included in the mother districts. The
survey covered 8,966 children in the 12-23 months target age group, and collected information from
both health cards and mothers histories. A total of 9,055 mothers with children aged 0-11 months
were also interviewed on Tetanus Toxoid (TT) coverage.
Kenya Demographic and Health Survey, 1993
101.
The 1993 Kenya Demographic and Health Survey collected information on immunization
coverage for all children born in the five years preceding the survey. Unlike the 1989 KDHS,
information on immunization coverage was collected from both vaccination cards and mothers verbal
reports. Since polio doses and DPT are usually administered together, the number of polio doses
reported verbally was assumed to equal the number of DPT doses, although there were response errors
due to the recent introduction of polio0 vaccine.
-25-

102.
Statistical Annex Table 10 shows percentage of children 12-23 months who had received
specific vaccines (according to both vaccination cards and mothers reports). The results show that 96
percent had received BCG vaccination and the first doses of polio and DPT. The overall dropout rate
between the first and third DPT dose was 9.3 percent. Overall, 78.7 percent of children 12-23 months
were fully immunized, but with markedly lower achievements in Western (69.5 percent) and Nyanza
(69.7 percent) provinces. Urban-rural differences in immunization coverage were minimal. The
proportion of children who received all the recommended vaccines increases with the education level
of the mother; from 63.3 percent of children of mothers with no education to 88.5 percent of those
whose mothers had at least some secondary education.
103.
The 1993 Kenya Demographic and Health Survey report advances two ways of obtaining
trends in immunization coverage. First, although the 1989 KDHS did not solicit details on
immunization if the mother did not show a card to the interviewer, rough estimates can be obtained
using statistical techniques on the results based on those who had health cards. The suggested
technique gives an estimate of 63 percent for children 12-23 months who were fully immunized in
1989, which implies an improvement during the 1989-93 per period (78.7 percent in 1993). Secondly,
the 1993 KDHS uses different age cohorts, namely, 12-23 months old, 24-35 months (who were 12-23
months old one year before the survey), etc. Although reporting errors are expected to increase with
the length of the recall period, the results show an overall improvement in immunization coverage in
recent years.
104.
The 1989 and 1993 KDHS were both based on the national sample frame maintained by the
Central Bureau of Statistics. However, both surveys excluded North Eastern province (since it was not
in NASSEP) and four other northern districts (Isiolo and Marsabit in upper Eastern province and
Samburu and Turkana in Rift Valley province), which together accounted for only about five percent
of Kenyas population. In both surveys, fifteen selected districts were purposely oversampled in order
to produce more reliable estimates for certain variables at the district level. Due to purposeful
oversampling, the 1989 and 1993 KDHS samples were not self-weighting at the national level.
Baseline Information on Immunization Coverage in Kenya
105.
Information on immunization coverage from routine reporting from immunization sites has
suffered from low response rates and delays in publishing the results, the latest published results being
for reference year 1991. In addition, the summarized results are not fed back to the reporting districts
or immunization sites, which would provide an avenue for lowering non-response rates as districts
would not like to report low immunization coverage due to underreporting. Immunization coverage
from routine reporting can not therefore provide baseline information on immunization coverage in
Kenya.
106.
The Kenya Demographic and Health Survey, 1989 only collected immunization data based on
health cards (61.0 percent of the respondents), and did not include immunization information based
on mothers recall where the cards were not available (35.1 percent of respondents). The
immunization coverage data based on the Kenya Demographic and Health Survey, 1989 is therefore
only useful in studying dropout rates during the immunization schedule. The Kenya Demographic and
Health Survey, 1993 included immunization data based on mothers histories, but the accuracy of
-26-

reporting on the recently introduced polio0 vaccine (given at birth) is suspect.


107.
The Kenya Demographic and Health Survey, 1993 purposefully oversampled fifteen districts
in order to produce more reliable estimates at the district level. However, district-level estimates are
crucial in determining the focus districts in the immunization campaign so as to increase overall
immunization coverage, in addition to the high sampling errors for the districts which were
purposefully under-sampled. The KEPI National Immunization Survey, 1992 covered all districts, and
its national immunization coverage statistics therefore provide the best bet of the true coverage in
Kenya for both child immunization and Tetanus Toxoid.
108.
The second round of the National Welfare Monitoring Survey (June 1994) is collecting
information on immunization coverage for all children aged 0-60 months, based on both health cards
and mothers histories. Since household identification information and household members serial
numbers are common in the entire survey, the survey data can be used to relate immunization to a
host of other household-level socioeconomic characteristics. Since the survey sample is based on
NASSEP and is self-weighting at the national level (unlike the 1989 and 1993 KDHS) it will provide
valuable update to the KEPI National Immunization Coverage Survey, 1992.
CONTROL OF DIARRHOEAL MORBIDITY AND MORTALITY
Situation Analysis
109.
The World Summit goal is to reduce diarrhoea deaths and diarrhoea cases among under-fives
by 50 percent and 25 percent, respectively. However, the Kenya NPA stated that adequate data for
Kenya on diarrhoea mortality and incidence rates is not available to allow for setting up of a
quantitative goal at this moment in time. In the mid-decade goals, Kenya committed itself to control
diarrhoea under the umbrella of the Bamako initiative as the leading strategy for extending and
sustaining primary healthcare.
110.
The 1987 Fourth Rural Nutrition Survey included questions on child morbidity, mainly
focusing on diarrhoea, stomachache and fever/malaria. An estimated 21.1 percent were reported to
have suffered from diarrhoea in the two weeks prior to the survey. The diarrhoea incidence was
highest in Kiambu (50.5 percent), Elgeyo Marakwet (42.1 percent), Kericho (38.9 percent), Nakuru
(32.6 percent), Machakos (34.5 percent) and Embu district (30.3 percent). However, the data was not
tabulated by age of child, nor were the provincial diarrhoea morbidity statistics published in the basic
report. The survey basic report cautions that observed inter-district variations may be purely due to
regional-cum-seasonal differences in morbidity occurrences.
111.
The 1989 Kenya Demographic Survey solicited information on diarrhoea morbidity for
children under five. Almost seven percent were reported to have had diarrhoea in the 24 hours
preceding the survey and 12.7 percent in the two weeks preceding the survey. Diarrhoea incidence
was highest for those between 6 and 17 months (when weaning usually takes place), and lowest for
children of over 24 months, while child gender and mothers education differentials were
insignificant. In the two weeks preceding the survey, diarrhoea incidence was highest in Western
province (18.6 percent), followed by Nyanza (15.5 percent) and Eastern (15.1 percent). On the health
restoration actions following the onset of diarrhoea, 46.8 percent of those who had diarrhoea in the
-27-

previous two weeks consulted medical facilities, 21.1 percent used Oral Rehydration Salts (ORS), 48.9
percent used a home-made rehydration solution, and 83.7 percent used other treatment. Only 10.2
percent did nothing to control diarrhoea. The percentages on type of treatment, however, add up to
more than a 100 since children could receive treatment from more than one source. The 1989 KDHS
report cautions that, the majority of the interviews took place during the dry season, when the
number of cases of illness in question - diarrhoea, fever and respiratory problems - would be expected
to be somewhat lower than at other times of the year.
112.
The 1993 Kenya Demographic Survey solicited information on diarrhoea morbidity for
children under five. The national diarrhoea prevalence was recorded at 13.9 percent within two weeks
prior to the survey and 5.5 percent within 24 hours prior to the survey. Only 2.4 percent had bloody
diarrhoea (a sign of dysentery) in the two weeks prior to the survey. Diarrhoea prevalence was higher
among children aged 6-23 months than among older or younger children. In the two weeks preceding
the survey, prevalence was highest in Western (19.2 percent), Nyanza (17.7 percent) and Coast (15.0
percent) and lowest in Central province (9.4 percent). Diarrhoea incidence was higher among rural
(14.2 percent) than urban children (11.9 percent). It was lower among children whose mothers had at
least some secondary education (11.2 percent) than among those whose mothers had no education
(15.1 percent).
113.
The survey also included a question on the mothers knowledge of Oral Rehydration Salts, i.e.
whether they had ever heard of ORS. An estimated 79.7 percent knew about ORS packets and 58.2
percent had ever used them to treat diarrhoea. Knowledge and ever use were highest among
mothers in Coast province (86.8 percent and 69.3 percent, respectively), while knowledge of ORS was
lowest among mothers in Nyanza (76.3 percent) and ever use was lowest in Nairobi (47.3 percent).
114.
An estimated 40.9 percent of children with diarrhoea in the two weeks preceding the survey
were taken to a health facility (health post, health centre, hospital or private doctor) for consultation.
Of those with diarrhoea, 31.6 percent were treated with ORS packets, 49.7 percent received increased
fluids, and 36.0 percent were given home remedies or herbs. About one in six children were given
nothing to treat diarrhoea. Male children were more likely to be taken to a health facility (45.1
percent) than female children (36.5 percent). Urban children with diarrhoea were more likely to be
taken to a health facility (52.5 percent) than rural children (39.4 percent), and were also more likely to
receive ORS fluid, increased fluids of any kind, and antibiotics. Rural children are more likely to be
treated with home remedies or herbs (37.2 percent) than urban children (26.5 percent). The
proportion of diarrhoea cases taken to a health facility was highest in Coast province (55.5 percent)
and lowest in Nairobi (30.0 percent).
115.
The feeding practices during diarrhoea episode in the two weeks preceding the survey showed
that 59.3 percent of breast-fed children continued to breastfeed as usual and 21.7 percent were given
increased breastfeeding. A worrisome statistic, at least for the child health education programme, is
that, during the diarrhoea episode, 17.5 percent of breast-fed children had their number of
breastfeeding decreased or stopped altogether. In addition, about one in six mothers curtailed fluid
intake and/or reduced breastfeeding frequency when their children had diarrhoea.
116.
Other sources of diarrhoea incidence can be captured from the 1992 National Welfare
Monitoring Survey and the Health Information System (HIS) of the Ministry of Health. However, the
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1992 Household Welfare Monitoring Survey database has not been used to compute disease incidence
by age-cohorts, while the HIS system does not include information on the patients age in its routine
disease morbidity reporting system.
Programme Assessment
117.
The Programme for the Control of Diarrhoea Diseases (CDD) in the Division of Family Health
started in 1986. The programme objectives for the period 1994-98 are to reduce diarrhoea mortality
among children under five by 30 percent and morbidity by 20 percent by (a) providing 80 percent
access to correct case management in health facilities, and (b) increasing correct use of ORS at home
by 50 percent. However, the revised targets are to reduce diarrhoea mortality by 20 percent and
morbidity by 10 percent for children under five by the year 1997 in comparison with 1992 figures.
Monitoring the objectives therefore entails measurement of diarrhoea morbidity and mortality,
evaluation of access to case management through health facilities, and the proportion of diarrhoea
cases receiving Oral Rehydration Therapy (ORT) and feeding.
118.
The CDD activities were initially targeted at case management in Western and Nyanza
provinces, which were selected based on their high diarrhoea morbidity and mortality. To evaluate
programme effectiveness, the Ministry of Health carried out a CDD Case Management Survey in six
districts in January-February 1990. The survey covered Kakamega, Kisumu, Kisii districts (because
they had been identified as CDD pilot areas in communication activities and establishment of Oral
Rehydration Therapy centers), and Kwale, Nakuru and Kilifi (because future CDD programme
activities were scheduled to begin in the latter districts in 1990). The latter three districts were a
control group, in addition to the use of the data for planned CDD programme activities. The survey
was carried out using the standard WHO/CDD case management methodology, and interviewed
caretakers on child feeding and fluid consumption during diarrhoea for under-fives, type and amount
of fluids given, drugs or other treatment used, and the caretakers knowledge on when to refer a child
with diarrhoea.
119.
The Case Management Survey showed that the western districts where the CDD programme
had been more active had more satisfactory results than the coastal districts; breastfeeding was
continued during diarrhoea for practically all children on breast-milk; caretakers do not always give
more fluid than usual during diarrhoea; most caretakers do not mix ORS correctly; maize gruel (uji) is
commonly used for the prevention of dehydration during diarrhoea; and knowledge of when to bring
a child with diarrhoea to a health worker is poor. The study focused on the districts which were either
in the CDD programme then or were planned, and its conclusions were therefore a review of the
performance of CDD programme management in the respective areas. However, since there was no
baseline information on case management in areas covered in the survey, some of the regional
differentials did not necessarily reflect on the success of the program management.
120.
In 1992, the CDD programme undertook a focused programme review in two phases: Phase 1
identified the constraints facing CDD and ranked the constraints in order to identify priority issues,
while Phase 2 covered programme success at the case management level. Phase 1 of the review
concluded that (a) clinical management courses are delayed or ultimately cancelled, and (b)
supervisory visits do not always take place as planned. The major constraints were unavailability of
funds due to overreliance on donor funding, the failure to establish a CDD budget line in the
-29-

Government accounts, unavailability of transport, and inadequacy of skilled trainers to conduct


clinical management courses.
121.
Phase 2 of the review concluded that (a) diarrhoea home case management was poor, (b)
monitoring and supervision of district-level activities is irregular, (c) the system is over-reliant on
external donors, and (d) the quality of district-level training activities was probably inconsistent and
not monitored by the central staff.
122.
Due to decline in external funding to CDD, several planned activities for 1992 and 1993 were
postponed, except case management courses. In order to assess the impact of these training activities, a
CDD health facility survey was conducted in March 1994 in Coast, Nyanza, Rift Valley and Western
provinces. The survey covered 46 facilities: 13 Government hospitals, 20 Government health facilities
and 13 Mission hospitals.
123.
Although the health facility survey basic report is not published, provisional results based on
survey participants verbal testimony showed that (a) over 90 percent of the surveyed facilities had
established functional ORT centers, (b) cases correctly assessed were only 40 percent, (c) cases
correctly rehydrated were only 46 percent, (d) cases where the mother received proper advice on
home case management were only 40 percent, and (e) correct case management at health facilities was
low at only 27 percent. On personnel developmental issues, the survey showed that (a) health
workers knowledge on preparation and use of ORS was high at over 80 percent, (b) about 70 percent
of the facilities had at least two workers trained in CDD case management, (c) only a quarter of the
health workers had been supervised in the previous three months, (d) only a quarter of the supervisors
were trained, while (e) scores on caretakers who knew importance of continuing feeding during a
diarrhoea episode, the importance of increase fluids, and sufficient reasons to seek care, was about 60
percent in each case.
124.
The major constraint to CDD programme activities has been lack of sufficient funding. There
is no Government budget line for the CDD programme. One of CDDs earliest donors wound up its
activities in 1993, in order to concentrate on collaborative activities with nongovernmental
organizations. Due to unavailability of funds, the CDD staffs have even been unable to undertake
supervisory activities at the district level. In addition, donor attention appears to be shifting to an
integrated approach to child health, which has resulted in decline of funding for vertical activities e.g.
the CDD programme.
125.
ORT centers in health facilities fill diarrhoeal diseases monthly report forms containing
diarrhoeal cases by initial assessment (degree of dehydration, blood stool, other accompanying
illnesses), treatment given (at home, and antibiotics and ORS at health facilities), and outcome
(admission for inpatient treatment, mortality). The diarrhoeal cases are broken down by age: 0-6
months, 7-12 months, 13-24 months and 25-60 months. The facility-based reports are forwarded to
the districts to be used in compiling district totals. The district summaries are then sent to CDD
headquarters.
126.
The CDD MIS section currently has only one personnel of rank of statistical clerk. There is no
operating computer program to process the CDD returns from the districts. The staff of HIS in the
Ministry of Health developed data entry screens back in 1990, but did not prepare programs for
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analyzing the data and generating reports. The computer in the CDD MIS section is a 21-megabytes
IBM-compatible, has no antiviral software package, and breaks down often. Due to lack of computing
capability (weak, low memory computer) and a functioning software package, the CDD programme
has not been entering the district CDD returns since 1990. The forms are filed in box files, and are
therefore not used for management and policy purposes.
127.
The CDD MIS section requires (a) at least one high memory, powerful computer, (b)
accessories e.g. floppy diskettes and computer paper, and (c) development of a dedicated computer
package for data entry and reporting requirements under the CDD programme. The Division of
Family Health, which houses KEPI, CDD and Child Growth Monitoring (CGM) departments, has
statistical officers to handle their respective data needs. However, there is no senior computer
programmer to supervise, handle troubleshooting and update packages in line with changing
information needs. There is therefore need to post one senior computer programmer to the Division of
Family Health to oversee CDD, KEPI and CGM information processing activities. Training of the
existing MIS staff in the three departments on general computer housekeeping activities (formatting
diskettes, data archival systems, troubleshooting, antiviral utilities, etc.) also need to be undertaken as
a matter of priority.
128.
The departments of CDD, KEPI and CGM in the Division of Family Health do not have data
archival systems e.g. magnetic tapes and tape reader. The three departments could jointly acquire a
data archival system to be maintained by the senior programmer recommended in this report.
GUINEA WORM DISEASE
Guinea worm disease (dracunculiasis) is a crippling parasitic disease caused by dracunculus
medinensis, a long threadlike worm known as the Medina worm due to its prevalence around the
Arabian city of Medina. The waterborne disease is transmitted exclusively when people drink water
contaminated with tiny freshwater copepods carrying guinea worm larvae. It has been speculated that
an Old Testament description of fiery serpent (Numbers 21:6: Then the Lord sent fiery serpents
among the people, and they bit the people, so that many people of Israel died) may have been
referring to guinea worm (Kuchenmeister, 1857, page 391; Ward, 1905b; Cockburn, 1971). Guinea
worm disease derived its common name from its prevalence on the Gulf of Guinea (Daniell, 1849;
Tennent, 1861; Ward, 1905a). According to Tennent (1861), these pests in all probability received
their popular name of Guinea-worms, from the narrative of Bruno or Braun, a citizen or surgeon of
Basle, who about the year 1611 made several voyages to that part of the African coast, and on his
return published, amongst other things, an account of the local diseases.
129.

130.
In the Kenya NPA and mid-decade goals, Kenya accepted that it will be able to virtually
eliminate guinea worm disease. The 1992 Situation Analysis (GOK/UNICEF, 1992) stated that Kenya
has few or no cases of dracunculiasis, though there is always the possibility that cases will be imported
by visitors or refugees from neighboring countries. The GOK/UNICEF 1994-98 Programme Master
Plan of Operations states that dracunculiasis endemicity in Kenya is low. In November 1989, an
active case search in Turkana district detected six cases, while the disease was also detected in Kakuma
refugee camp (Turkana district) in March 1993. The Mission feels that the Government of Kenya may
have diminished attention to the guinea worm disease by underplaying its incidence.

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131.
In July 1993, a workshop held to map out strategies for guinea worm eradication noted that
Kenya is the only country in the region that has yet to begin a national case search, despite having
three suspected endemic areas (Samburu, Kitui and Turkana). The workshop recommended that (a)
dracunculiasis be made a notifiable disease as soon as possible; (b) establish a community-based
surveillance through such programs as Kenya Expanded Programme on Immunization (KEPI),
environmental sanitation and Primary Health Care (PHC); and (c) taskforces be formed in five
districts (Kitui, Samburu, Turkana, West Pokot and Trans Nzoia) to carry out and report any cases of
dracunculiasis.
132.
Guinea worm is largely an affliction of poor rural communities, and is contracted through
drinking contaminated water. The guinea worm disease has no known chemotherapeutic cure, occurs
in the most remote areas where there may be inadequate infrastructure, and its occurrence is therefore
unlikely to be captured in the routine morbidity reporting system maintained by the Health
Information System in the Ministry of Health. An active case search in 1994 in Turkana district and in
half of Trans Nzoia district detected 35 cases.
133.
The proposals for funding guinea worm disease active case search have been submitted to
UNICEF by individual district medical officers of health from the districts where guinea worm disease
might be endemic, rather than in a coordinated manner by the Ministry of Health headquarters.
Kenya is the only country in the region with a zero score in the indicators set by UNICEF and WHO
on eradication of guinea worm, i.e. villages with (1) monthly reporting, (2) trained village-based
health workers, (3) health education, (4) cloth filters, (5) water supply, (6) vector control, and (7) case
containment.
134.
The Mission recommends a less complacent approach to the eradication of the guinea worm
disease, and an active case search to ascertain the validity of the belief that guinea worm disease is an
imported phenomenon of low local incidence. Kenya shares common borders with the highly
endemic areas of Ethiopia, Uganda and Sudan, and Uganda is the second most endemic country in
Africa after Nigeria. In the absence of an active case search, Kenya can not be taken to have met the
target of eradicating guinea worm disease, either in 1994 or in the year 2000.

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CHAPTER FIVE

EDUCATION
EARLY CHILDHOOD EDUCATION
135.
The World Summit for Children goal is to expand early childhood development activities. The
Kenya NPA goal is to increase participation rates from the current levels of 30 percent to at least 50
percent by the year 2000.
136.
Early childhood education is coordinated by the National Centre for Early Childhood
Education (NACECE), based at the Kenya Institute of Education. The Centre was started in 1984 by
the Ministry of Education in collaboration with the Bernard van Leer Foundation, while the District
Centres for Early Childhood Education (DICECE) were established beginning 1985. The DICECE have
expanded to cover all districts in Kenya and some municipalities. The DICECE are classified into
fully-fledged and associate DICECE. The fully-fledged DICECE are those that have a residential
training component, and currently cover 18 districts. The associate DICECE are those that do not have
a residential training component, and therefore do not undertake residential training of teachers.
External supporters to the DICECE program include UNICEF, the Aga Khan Foundation and Bernard
van Leer Foundation.
137.
The Aga Khan Foundation (AKF) DICECE programme covering Garissa, Kilifi, Kericho and
Nyeri was evaluated in 1990. The AKF selected the districts for support for varied reasons. Garissa
district DICECE and its catchments districts (Garissa and Wajir) had very low preschool attendance
(3.3 percent) due to the nomadic nature of the population, and also because most of the population
profess the Islamic faith. The DICECE team was therefore required to design programmes which
would harmonize religious teaching and secular education. Just as in Garissa, the Kilifi DICECE was
supposed to harmonize religious teaching and secular education. In Kericho, the DICECE team was
required to undertake studies on the life patterns of preschool children that are born and brought up
in the tea estates. Nyeri district did not have exceptionally high preschool attendance compared with
other districts of similar economic potential, and the Nyeri DICECE was supposed to find out how the
district had managed to reduce child mortality despite low preschool enrolment (estimated at 20
percent then). The evaluation did not solicit information on early childhood education enrolment at
the district level for the four districts and their catchments areas.
138.
An evaluation of early childhood care and education on eleven UNICEF-supported districts
was conducted in 1992. The evaluation covered six fully-fledged DICECE (Baringo, Meru, Muranga,
Kakamega, Kisumu and Kwale) and UNICEF-supported area-based programme districts under the
UNICEFs Child Survival and Development (CSD) programme (Nairobi, Kitui, Baringo, Kisumu,
Embu, South Nyanza, Kwale and Mombasa districts). Statistics on preschool enrolment, number of
preschools, and number of trained and untrained teachers used in the evaluation report were gathered
in the regular data collection exercise but not during the evaluation.
139.
An evaluation of early childhood care and education of the Samburu District
Community-Based Early Childhood Care and Education Project (1990-1993) was undertaken in
December 1993, with professional and financial support of the Bernard van Leer Foundation. The
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evaluation covered a sample of facilities covered by the project and did not therefore provide
independent estimates of the districts preschool enrolment.
140.
To compile statistics on early childhood enrolment, the NACECE sends out forms to District
Education Officers in the respective districts, who in turn use zonal officers to collect enrolment data
from the schools e.g. nursery schools and kindergartens. A district only submits annual summary
figures for the districts early childhood education enrolment, broken down by sex of child. No
facility-based data is submitted from the districts, making it impossible to verify any queries due to the
nonexistence of primary data at the NACECE headquarters.
141.
The reported enrolment for 1993 based on the abovementioned reporting system was 924,094,
with male enrolment (472,024) being only marginally higher than that of female children (452,070). A
rough estimate based on enrolment and population by single years of age (3-6 years) gives a national
gross enrolment rate of about 35 percent.
142.
The response rate is not known as a district is assumed to base its summary statistics on a
complete count of all preschool centers. It should also be noted that the data collected does not include
age of children, and is not therefore limited to those children between 3 and six years of age attending
early childhood education centers. The estimates therefore refer to gross rather than net enrolment.
Due to the lack of primary data at the NACECE offices, it is not possible to compute response rates at
national and sub-national levels. This makes it difficult to put error limits on the estimates of gross
early childhood enrolment statistics released by the NACECE. In the case of primary and secondary
education, enrolment can be crudely taken as a measure of children-years since promotion to a higher
grade/class is conditional to having completed the immediate lower grade. Due to lack of fixed and
compulsory period of attendance in preschool education, an enrolment ratio from administrative data
is the lower bound of the true enrolment ratio based on children ever attended.
143.
The NACECE plans to undertake an annual survey of early childhood education centers and a
questionnaire is under preparation. The questionnaire will include teachers and their qualifications
and teaching experience, other members of staff and their duties, physical facilities, school feeding
programmes, child growth monitoring and promotion conducted in the school, and common illnesses
in the schools immediate environment. A different questionnaire will be used for the traditional
Islamic Early Childhood Education schools (madrassa).
144.
Currently, the NACECE does not have the necessary resources and technical manpower to
carry out an effective survey of early childhood education centers. Traditionally, employees of the
Kenya Institute of Education are trained in teaching and have previously held teaching jobs in
secondary schools and teacher training colleges. Their energies are therefore devoted to delivery of
requisite services rather than in keeping records of their own performance. The design of data
collection forms should therefore be done by the NACECE staff in conjunction with the Education
Statistics section in the Ministry of Education, but data collection can be coordinated by the NACECE.
Such a questionnaire should also not be overloaded if a high response rate is expected, especially from
private early childhood education centers.
145.
The NACECE and Education Statistics section could also consider using the CBS National
Household Welfare Monitoring Survey programme, which is based on the national sample frame, to
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obtain baseline information on preschool enrolment. This could involve development of definitions of
various types of preschool centers as a guide in data collection, so as to enable computation of
gender-specific net and gross preschool enrolment rates. It would not be possible to collect
information on preschool institutions (e.g. staffing and facilities) using such a survey module since the
CBS Welfare Monitoring Survey is a household-based rather than an establishment-based survey
programme.
PRIMARY SCHOOL ENROLMENT AND RETENTION
146.
The Kenya Government committed itself to the World Summit goals of (a) universal access to
basic education by the year 2000, and (b) completion of primary education by at least 80 percent of
primary school-age children by the year 2000. The mid-decade goal was to reduce the gap between
current primary school enrolment/retention rates and the year 2000 goal of universal access to basic
education by one-third.
147.
Education indicators usually employed are literacy, enrolment and dropout rates, and
age-grade mismatch. The literacy rate is defined as the proportion of the population above a specified
minimum age which can read or write. The gross primary school enrolment rate is the total number of
children regularly attending primary school in the current year divided by the total number of
children of primary school age (6-14 years). The net primary school enrolment rate is the total number
of children of primary age (6-14 years) currently attending primary school divided by the total
number of children of primary school age. The difference between primary school gross and net
enrolment rates shows the children in primary school who are not of primary school age divided by
the number of primary school age children. An important education indicator is the dropout rate at
various education levels and the reasons for dropping out. The dropout rate is normally defined as the
number of children who left school in the current year (excluding those who left due to completion of
the relevant education cycle) divided by the total number of children enrolled in the current year
(plus the dropouts).
148.
The Education Statistics section of the Ministry of Education traditionally receives annual
district figures on primary school enrolment broken down by sex of child. Such information is
aggregated to prepare totals by province and for the whole country. Since the age of children was not
reported, the statistics can only be used to compute gross rather than net enrolment. The statistics are
reproduced in the annual Economic Survey and Statistical Abstract.
However, beginning 1993, the Ministry of Educations Annual Questionnaire on Statistics of
Primary Schools was posted to school heads and information was solicited from individual schools.
The statistics collected include: whether school was private or public; enrolment by class, age and
gender; repeaters by sex and class; physical facilities; school milk and feeding programmes; teaching
staff by qualifications and teaching experience; data on KCPE examination results and admission to
secondary schools; information on itemized fees per student for each class; and information on school
wastage. The national enrolment figures for reference year 1993, broken down by sex, were published
in the CBS Economic Survey 1994. No other statistics from the 1993 census of primary schools have
been published.
149.

150.

The Ministry of Education does not normally compute gross enrolment rates for the primary
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school cycle. However, based on the 1989 population census, gross primary school enrolment rate is
estimated at 95 percent for 1989. The high rate is mainly due to the high repetition rates, which
overloads the primary school system with children who are above normal primary school age, i.e.
above 14 years. However, in the absence of population projections by single years of age, it would be
difficult to give a credible estimate of gross primary school enrolment rate for 1993. Although the data
for the Annual Questionnaire on Statistics of Primary Schools was supposed to refer to March of the
reference year, the Ministry of Education did not send out forms for 1994 due to lack of financial
resources for printing of questionnaires for over 15,000 primary schools in the republic.
The education Statistics section has revised the 1993 version of the Annual Questionnaire on
Statistics of Primary Schools based on comments from the field. However, the critical input to the
Education Statistics section (ESS) is the financial resources to print and distribute the questionnaires.
Funds should be identified for this activity, and the ESS should also continue the routine reporting
from the districts until a guaranteed budget line is available for facility-based data collection. In
addition, the expanded database from primary and secondary schools returns makes it imperative for
the ESS to acquire at least three more computers, each of a minimum memory size of 100 megabytes.
151.

152.
The 1992 Welfare Monitoring Survey database was used to compute primary school gross and
net enrolment rates for 1992. Text Table 3 shows that the rural 1992 primary school gross enrolment
rate was 95.39 percent, with the male enrolment rate (96.51 percent) being only slightly above that of
females (94.25 percent). The only rural regions with large gender disparities in primary gross
enrolment rates were Coast province, where the rate was 75.52 percent for boys and 66.66 percent for
girls; and Nyanza, with a rate of 109.16 percent for boys and 94.80 percent for girls. The gross
enrolment rate for urban areas was 82.03 percent on average, and the urban rates did not show a
significant gender bias.
Text Table 3: Primary School Gross Enrolment Rates, 1992 (%)
All

Male

Female

Coast
Eastern
Central
Rift Valley
Nyanza
Western
Total Rural

71.31
92.71
93.45
99.23
102.12
95.10
95.39

75.52
91.39
91.50
99.23
109.16
96.12
96.51

66.66
94.09
95.44
99.23
94.80
94.06
94.25

Nairobi
Mombasa
Total Urban

80.15
88.24
82.03

81.81
85.13
82.61

78.61
91.33
81.49

Source: Welfare Monitoring Survey, 1992 database.


153.
Text Table 4 shows the primary school net enrolment rates. The overall rural net enrolment
rate was 74.40 percent, compared with 71.71 percent for Nairobi and Mombasa combined. There was
no significant gender difference in primary school net enrolment rates in the rural provinces and
urban areas.
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Text Table 4: Primary School Net Enrolment Rates, 1992 (%)


All

Male

Female

Coast
Eastern
Central
Rift Valley
Nyanza
Western
Total Rural

57.64
73.22
74.30
77.19
77.92
73.35
74.40

59.77
73.04
73.33
75.48
80.16
73.00
74.24

55.41
73.40
75.21
79.00
75.59
73.72
74.58

Nairobi
Mombasa
Total Urban

73.13
67.03
71.71

76.65
63.96
73.62

69.86
70.10
69.92

Source: Welfare Monitoring Survey, 1992 database.


154.
In a flow model, students in a particular grade can either be promoted to the next grade, repeat
or drop out. Information on promotion, dropout and repetition rates in the primary school cycle is not
normally collected by the Education Statistics section in the Ministry of Education. The Government
policy is that pupils should not repeat but should be automatically promoted from one grade to the
next at the end of each year, a factor which may makes school heads reluctant to report on numbers of
repeaters and dropouts. To compute the progression rate in the eight-year primary school cycle, the
Ministry compares the student population in a class in the reference year, broken down by sex, to the
student population one class ahead in the following year. The difference is assumed to comprise
dropouts and repeaters. It is, however, difficult to separate the contributions of dropout and repeater
factors in total wastage computed in this way.
155.
Statistical Annex Table 13 shows total primary school wastage for the students who joined
Standard 1 in 1984, 1985 and 1986, using the gender-disaggregated enrolment statistics published in
the annual Economic Survey. For those who joined primary school in 1984, only 44.1 percent were
enrolled in Standard 8, the final year of the primary school cycle. The corresponding retention rates
for those who completed in 1992 and 1993 were 50.5 percent and 43.4 percent, respectively.
156.
From the statistics, the lowest progression rate is observed in Standard 7, where the student
enrolment as ratio of Standard 1 enrolment seven years before is about 70 percent, but declines sharply
to around 45 percent in Standard 8. The low progression rate is largely attributed to the thinning of
weak students before the Kenya Certificate of Primary Examination (KCPE) so as to uphold the
reputation of the respective school in KCPE performance. For this reason, many primary schools have
two or more streams at Standard 7, but usually only one or two streams at Standard 8. There is also a
low promotion rate of children going from Standard 1 to Standard 2. The difference in retention rates
by gender does not appear significant over the entire primary school cycle.
157.
The difference in enrolment between one year and the next is equal to the years dropouts plus
the years repeaters less repeaters to that class from higher classes or the same class in the previous
year. If repetition rates are maintained from one year to the next, dropouts would comprise the bigger
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share of the overall wastage rate of about 55 percent for the entire primary school cycle.
The revised Ministry of Educations Annual Questionnaire on Statistics of Primary schools,
1993 solicited information on school wastage and reasons for leaving school before completion of the
158.

primary school cycle. However, the questionnaire did not solicit information on wastage by last class
of dropout student. School heads were also to give information on (a) the number of children of school
age in their own area known not to have enrolled in school, and (b) known reasons why children have
not enrolled in school. The latter questions are more appropriate for a household-based survey, since
school heads would not be able to give proper estimates given that a schools catchment population is
difficult to define. The report on the dropout rates based on the 1993 primary school statistics has not
been released by the Ministry of Education.
159.
The age/grade mismatch shows the relation between age and school grade. If a child started
school older than is normally the case, dropped out of school or repeated some grades in the past, the
child will find himself/herself in a grade inappropriate for his/her age. A child with an age/grade
mismatch will observe a different educational experience, in addition to the fact such a child will have
additional, but undesirable, adult options compared with classmates e.g. pregnancy, marriage or work.
Other things being equal, age/grade mismatch is expected to be positively correlated with dropout
rates. This implies that an important policy variable is to encourage parents to send their children to
school early so that girl students would have achieved basic literacy and understanding of the destiny
bound to their biology before the onset of puberty.
160.
Text Table 5 shows the age/grade mismatch for children in primary schools in 1992. The
figures are the ratio of those above primary school age (i.e. greater than 14 years of age) to total
primary school enrolment. The overall rural primary age/grade mismatch was 21.40 percent,
compared with 10.08 percent in urban areas. Nairobi showed the lowest age/grade mismatch (5.75
percent) in the country. There were no striking differences in age/grade mismatch by gender. The
1994 Welfare Monitoring Survey being conducted by the Central Bureau of Statistics is also collecting
information on school dropouts, and it will therefore allow for estimation of dropout rates, reasons for
dropping out, and age/grade mismatch.
Text Table 5: Primary School Age/Grade Mismatch, 1992 (%)
All

Male

Female

Coast
Eastern
Central
Rift Valley
Nyanza
Western
Total Rural

18.40
20.81
20.00
21.83
22.73
21.85
21.40

20.41
19.85
19.54
23.40
25.67
23.32
22.53

15.68
21.79
20.53
20.16
19.21
20.32
20.21

Nairobi
Mombasa
Total Urban

5.75
23.07
10.08

4.31
23.36
9.01

7.14
22.81
11.11

Source: Welfare Monitoring Survey, 1992 database.

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LITERACY RATES
161.
Text Table 6 shows self-reporting literacy rates by region and sex of household member in
1992, based on the first round of the National Household Welfare Monitoring Survey. Provincial data
excludes urban clusters, while Nairobi and Mombasa were the only urban centers included in the
analysis. In rural 1992, literacy rate was highest in Central (84.76 percent), followed by Eastern (71.76
percent), Western (68.61 percent), Nyanza (66.88 percent), Rift Valley (66.31 percent) and Coast
(56.26 percent), compared with the rural national literacy rate of 70.34 percent. The overall literacy
rate for Nairobi and Mombasa combined was 91.52 percent, comprising Nairobi (93.24 percent) and
Mombasa (85.58 percent).
Text Table 6: Literacy Rates by Region, 1992 (%)
All

Male

Female

Coast
Eastern
Central
Rift Valley
Nyanza
Western
Total Rural

56.26
71.76
84.76
66.31
66.88
68.61
70.34

67.49
76.65
90.69
70.94
76.19
73.21
76.40

45.09
67.15
79.41
61.57
58.43
64.52
64.62

Nairobi
Mombasa
Total Urban

93.24
85.58
91.52

95.13
89.48
93.81

91.01
80.47
88.76

Source: National Welfare Monitoring Survey database, 1992


162.
In all rural and urban regions, literacy rates were higher for males compared with females,
with an overall rural male literacy rate of 76.40 percent compared with 64.62 percent for females.
Literacy rates in Coast province are surprisingly low, with 45.09 percent for females.
163.
The Central Bureau of Statistics (CBS) carried out its first National Rural Literacy Survey (RLS)
in 1976 as part of the Integrated Rural Surveys (IRS). The sample used for the survey was over 2,300
households in rural areas. The RLS was targeted on all persons in the age group 15+ years excluding
those undergoing fulltime schooling and the literacy data was collected on a self-reporting basis. The
RLS recorded a national literacy rate of about 46 percent, varying from 60 percent in Central province
to 25 percent in Coast province. However, the survey did not test respondents who claimed to be able
to read or write.
164.
The second rural literacy survey was carried out in 1980/81 within the national sample frame
and targeted household members aged 12+. The sample was made up of 10,650 households with a total
population of 56,248. The 1980/81 survey was based on objective tests of respondents ability to read
and write in either English, Kiswahili or mother tongue. The third rural literacy survey was carried
out in November 1988 on 8,069 households, and covered all household members aged 10+ (including
those attending school fulltime), and was also based on actual tests of a respondents ability to read or
write. The survey covered 30 districts and excluded Nairobi, Mombasa, Lamu, Tana River, Turkana,
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Samburu, Isiolo, Marsabit, Mandera, Wajir and Garissa districts. In comparing national and
sub-national literacy levels, it is important to note that (a) the 1976 survey excluded those attending
school fulltime and did not test the respondents ability to read and write, and (b) the target age
cohorts differ from survey to survey. Summary results of the literacy levels from the 1989 population
census and 1988 and 1980/81 literacy surveys are reproduced in Text Table 7.
165.
The results show similar pattern of literacy levels by province in both November 1988 and
August 1989. In the 1988 survey, the lowest literacy rate was recorded in Coast (42.7 percent) and the
highest in Central province (69.2 percent). The 1989 census results also recorded the lowest literacy
level in Coast (61.6 percent) and the highest in Central (85.1 percent), excluding North Eastern
province which reported a low 28.3 percent. The comparability of literacy levels from the two surveys
and the 1989 population census are limited by (a) census data was on self-reporting basis while the
1980/81 and 1988 RLS were based on objective testing; (b) the census data was based on complete
count rather than a sample; and (c) the census data refers to all household members aged six years and
above while the sample surveys were targeted at older age cohorts. The literacy levels computed from
the census data were higher than those from the 1988 rural literacy survey in all provinces, probably
due to (a) the 1989 census data was collected on self-reporting basis and should therefore be
considered as the upper bound of the actual levels of literacy in the country; and (b) the census data
include those aged six years and above and not in school but may eventually go to school. However,
the literacy rates derived from the 1992 Welfare Monitoring Survey (Text Table 6) and the 1989
Population Census (Text Table 7) are largely consistent since they were based on almost similar age
cohorts and were both on self-reporting basis.
Text Table 7: Literacy Rates by Region, 1980/81, 1988 and 1989 (%)

Coast
Eastern
Central
Rift Valley
Nyanza
Western
North-Eastern
Nairobi
Total

Male
72.6
77.2
89.9
73.1
78.5
75.8
41.2
94.2
78.36

1989
Female
50.4
65.5
80.5
60.9
63.6
64.6
14.4
89.2
65.46

Total
61.6
71.1
85.1
67.0
70.6
69.8
28.3
92.1
71.84

1988
Total
42.7
52.9
69.2
47.1
50.2
51.0
54.3

1980/81
Total
44.1
47.7
64.5
40.3
38.4
47.0
47.2

Source: Central Bureau of Statistics, Kenya Population Census, 1989, March 1994; Kenya Rural
Literacy Survey 1988: Basic Report; Social Perspectives, 7(1), December 1982.
Note: The 1989 census figures in the Table exclude cases of not stated, while percentages in the
published census report include not stated.
166.
The Kenya NPA stated that Kenya will be able to lower its illiteracy rate (at 40 percent) by half
(to 20 percent) by the year 2000. However, there are two comments about the baseline literacy rate
assumed in the Kenya NPA. First, the literacy rate of 60 percent in the Kenya NPA is below the
respondents self-reporting rate from the 1989 Population Census (71.8 percent) and exceeds the
objective test literacy rate of 54.3 percent obtained from the 1988 Kenya Rural Literacy Survey.
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Secondly, the Kenya NPA does not provide guidelines on (a) the target age cohorts in the indicator of
literacy rates, and (b) whether the indictors of the target literacy rates were to be based on
respondents self-reporting or objective literacy assessments.
167.
The Mission recommends that, since self-reporting literacy rates are expected to be higher
than those based on objective tests, the latter, based on the 1988 Kenya Rural Literacy Survey, ought to
be adopted as the baseline literacy indicators. However, the target needs to be region-specific given
that the 1988 literacy survey covered only 30 districts. CBS is taking steps to capture data from North
Eastern province, which is therefore likely to be included in the end-of-NPA indicators. Since literacy
levels in North Eastern province and other districts omitted in the 1988 Kenya Rural Literacy Survey
are expected to be lower than those of the rest of the country (see 1989 Population Census
respondents self-reporting estimates of literacy levels), the overall rural literacy level in 1988,
including North Eastern province, would have been slightly lower than indicated in the Kenya Rural
Literacy Survey.
168.
In the coastal area and North Eastern province, gender differences are embedded in Muslim
conventions such as the sanctions of the purdah that require special garments and limit womens
residential mobility, thus restricting their ability to participate in gainful economic activities (e.g.
wage employment and self-employment) and in local and national political life. This implies that the
girl-child might have cultural inhibitions to seek for remuneration that corresponds to her level of
education, thus diminishing the attractiveness of literacy and education in general. Given the short
span to the year 2000, measures ought to be taken to influence the cultural practices that diminish the
attractiveness of education to the Muslim girl-child if any meaningful literacy achievement is to be
expected from the Muslim areas.

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CHAPTER SIX

WATER AND SANITATION


ACCESS TO SAFE DRINKING WATER
169.
The World Summits target is universal access to safe drinking water. The Kenya NPA goal is
to provide clean and potable water at a source less than one kilometer in high potential areas and less
than five kilometers in low potential areas by the year 2000. The mid-decade goal is to increase access
to safe drinking water so as to narrow the gap between 1990 levels and universal access by the year
2000 by one-fourth. However, the division of the country into low and high potential areas is not
provided in the Situation Analysis on Children and Women in Kenya, 1992. The goal also implies that
district-level access would have to include the relevant distance to clean and potable water source in
its derivation, before a national access rate can be computed.
170.
Some of the more recent household-survey based sources of information on access to safe
drinking water are the 1987 Fourth Rural Nutrition Survey, the 1989 and 1993 Kenya Demographic
and Health Surveys, and the 1992 National Household Welfare Monitoring Survey. The
abovementioned references give estimates of access to safe drinking water based on numbers of
households rather than persons. The Fourth Rural Nutrition Survey, 1987 collected information on
households main source of drinking water in the wet and dry seasons. Taking clean water sources to
include only protected wells, boreholes, piped water and rainwater, an estimated 34.8 percent (wet
season) and 32.5 percent (dry season) of rural households had access to clean water sources in 1987.
171.
The Kenya Demographic and Health Survey, 1989, solicited information on the main sources
of water for drinking, hand-washing and cooking for most of the year, and the time it takes to fetch
water (return trip). The results are shown in Statistical Annex Table 17. The proportion of households
with access to safe water was 48.1 percent at the national level, 38.2 percent in the rural areas and 95.4
percent in urban areas. The lowest access rates were recorded in Rift Valley (33.2 percent), Western
(34.2 percent) and Nyanza (35.8 percent) provinces. The highest access was recorded in Coast province
(67.2 percent) due to the provinces high access to piped into residence (24.4 percent) and public
tap (32.7 percent), compared with the rural mean of 11.6 percent and 6.6 percent, respectively.
172.
The Kenya Demographic and Health Survey, 1993 used the same classification system of
sources of drinking water as the 1989 KDHS. The results show an overall rural access to safe drinking
water regardless of distance to water source of 47.6 percent, with a high 72.7 percent in Coast and a
low 28.7 percent in Nyanza province (see Statistical Annex Table 18). The access rate for urban areas
was 90.8 percent. The overall access for rural and urban areas combined was estimated at 55.9 percent.
173.
The first round of the National Household Welfare Monitoring Survey included questions on
main source of water, including distance to water source. The results show an overall rural access to
safe water in the wet season, regardless of distance to water source, of 45.12 percent in rural Kenya and
92.16 percent for Nairobi and Mombasa combined. The corresponding figures for dry season were
38.25 percent for rural areas and 94.06 percent for urban areas. The inclusion of urban clusters in the
provincial estimates based on the KDHS makes it difficult to compare the KDHS estimates with those
based on the 1992 Welfare Monitoring Survey.
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174.
The Ministry of Health, with the support of WHO, UNICEF and AMREF, has conducted
water and sanitation surveys in Kitui (1992), Kirinyaga (1992) and Migori and Kuria districts (1993).
The questionnaire includes main source of water, whether the water is adequate, distance to water
source, and the number of months in the year the water systems operate without drying up. The
district surveys take administrative areas as clusters for the purpose of sampling, and have a higher
district sample than would be covered in a national survey. The results for Kitui (1992) and
Migori/Kuria (1993) are shown in Statistical Annex Table 19.
175.
The second round of the Welfare Monitoring Survey (June 1994) uses a classification similar to
the first round, but includes information on reliability and time per day taken to fetch water.
However, information on the distance to water source will not be solicited, and time taken per day
cannot be a good proxy for distance since it is not based on a single trip but per household per day for
those household members responsible for the activity.
176.
The World Banks World Development Report 1994 reports a national access to safe water for
reference year 1990 as 49 percent, while UNDPs Human Development Report 1994 estimate is 50
percent. The Situation Analysis (1992) gives a national access to safe drinking water for reference year
1990 of 42 percent, which is in line with the 1989 KDHS estimate (48.1 percent), 1992 Welfare
Monitoring Survey (49.8 percent) and 1993 KDHS (55.9 percent). The GOK/UNICEF 1994-98 Master
Plan of Operations (1993) uses the Situation Analysis (1992) baseline estimates. However,
region-specific rates of access to safe drinking water in the Situation Analysis (1992) are not consistent
with other available sources, including the World Summit for Children National Plan of Action
(1992), the latter being based on the 1987 rural nutrition survey. For example, rural Coast (25 percent)
and Central province access (68 percent) in the Situation Analysis (1992) are not comparable with, say,
1992 National Welfare Monitoring Survey estimates of Coast (58.9 percent) and Central (44.5
percent). The baseline indicators on access to safe drinking water in the Situation Analysis (1992) and
GOK/UNICEF 1994-98 Master Plan of Operations need to be revisited and updated in light of their
inconsistency with household-based survey estimates.
ACCESS TO SANITARY MEANS OF EXCRETA DISPOSAL
177.
The World Summits target is universal access to sanitary means of excreta disposal, and the
Kenya NPA accepted that goal in totality. The mid-decade goal, presumably for end of 1994, is to
increase access to sanitary means of excreta disposal so as to narrow the gap between 1990 levels and
universal access by the year 2000 by one-tenth.
178.

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.
179.
Although many district-specific and nationwide surveys have collected household-level data
on types of excreta disposal, the focus of this report will be on surveys conducted in the last five years,
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namely the 1989 and 1993 Kenya Demographic and Health Surveys, and the 1992 National Household
Welfare Monitoring Survey. The sanitary means of excreta disposal include septic tank, ventilated
improved pit (VIP) latrine, alternating twin-pit VIP latrine, and pour flush; but excludes aqua privy,
bucket latrine systems and composting latrine.
180.
The Kenya Demographic and Health Survey, 1989 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 percent of the female respondents had sanitary means of excreta disposal (flush toilet
and pit latrine), comprising a high 94.4 percent in urban areas and 82.0 percent in rural areas. Within
rural areas, the lowest access was recorded for Coast province (63.1 percent) and the highest in Central
(97.7 percent). The results are shown in Statistical Annex Table 17.
181.
The Kenya Demographic and Health Survey, 1993 also 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 classification system was identical to the Kenya
Demographic and Health Survey, 1989, other than splitting the two categories of flush toilet and pit
latrine further. However, since the two major categories used in the 1989 survey are considered
sanitary, the results of the two surveys are comparable. The 1993 national access to sanitary means of
excreta disposal was recorded at 81.8 percent, with a high 94.1 percent for urban areas and a low 78.9
percent in rural areas. The results are shown in Statistical Annex Table 18.
182.
As noted earlier, the 1989 and 1993 KDHS excluded North Eastern province (since it was not
in NASSEP) and four other northern districts (Isiolo and Marsabit in upper Eastern province and
Samburu and Turkana in Rift Valley province), which together accounted for only about five percent
of Kenyas population. In both surveys, fifteen selected districts were purposely oversampled in order
to produce more reliable estimates for certain variables at the district level. Due to purposeful
oversampling, the 1989 and 1993 KDHS samples were not self-weighting at the national level. The
surveys cannot therefore be used to derive district-level estimates of access to sanitary means of
excreta disposal. However, in the enumerators reference manuals, the emphasis was on the type of
toilet that the household uses, and not the toilet they may have, thus putting a clear distinction
between ownership and use.
183.
The 1992 National Household Welfare Monitoring and Evaluation Survey had the following
allowed categories of responses on toilet facility: pit, VIP latrine, bucket, water closet, pour flush, and
none. The results show that the overall access to sanitary means of excreta disposal was 84.12 percent,
with an urban access rate of 96.80 percent and a rural rate of 80.85 percent. Coast province had the
lowest rate at 58.04 percent and Central the highest (99.49 percent). The Fourth Rural Child Nutrition
Survey, 1987 showed that households without sanitary toilet facilities were 20.8 percent in rural
Kenya, which is close to the estimates based on the 1989 KDHS (18.0 percent), the 1992 WMS1 (19.15
percent) and 1993 KDHS (11.1 percent). The 1994 National Household Welfare Monitoring and
Evaluation Survey, which started in June 1994, had the same classification scheme for types of toilet
facilities as the 1992 WMS1. The results of the survey will be available in the first quarter of 1995.
184.
The Ministry of Health, with the support of WHO, UNICEF and AMREF, has conducted
water and sanitation surveys in Kitui (1992), Kirinyaga (1992), and Migori and Kuria districts (1993).
The questionnaire for the district surveys lists the types of toilet facilities as: sewer, ordinary latrine,
-44-

VIP latrine, pour flush, aqua privy, bucket latrine, septic tank, communal latrine, and none. The
district surveys take administrative areas as clusters for the purpose of sampling, and have a higher
district sample than would be covered in a national survey. The results for Kitui (1992) and
Migori/Kuria (1993) are shown in Statistical Annex Table 19. However, Migori and Kuria were
separated in 1993, and can therefore be considered as one district. The district water and sanitation
surveys listed sewer and septic tank instead of flush toilet since sewers and septic tanks pose
different maintenance problems.
185.
The UNDPs Human Development Report 1994 estimate of Kenyas population with access to
sanitary means of excreta disposal is 43 percent. The estimate of Kenyas national access to sanitary
means of excreta disposal in both the Situation Analysis (1992) and GOK/UNICEF 1994-98 Master
Plan of Operations (1993) was 35 percent for reference year 1990. This is in contrast to the 1989 KDHS
estimate of 84.1 percent, 1992 Welfare Monitoring Survey (84.12 percent) and 1993 KDHS (81.8
percent). The Situation Analysis (1992) provincial estimates were 69 percent for Central and 26
percent for Eastern province, compared with 1993 KDHS estimates of 96.8 percent (Central) and 81.9
percent (Eastern province). The wide variations between the Situation Analysis (1992) and the
GOK/UNICEF 1994-98 Master Plan of Operations (1993) on one hand, and the 1992 Welfare
Monitoring Survey and the 1989 and 1993 KDHS on the other, justifies revisiting the baseline
indicators on access to sanitary means of excreta disposal.
ONGOING ACTIVITIES ON WATER AND SANITATION INDICATORS
186.
The 1989 Population and Housing Census contained questions on the households main source
of water and sewerage disposal. The choices for access to both water and sanitation facility allows for
easy classification into safe and unsafe access. The CBS has not published the results of the 1989
population census in respect of access to water and sanitation facilities. Analytical work is ongoing,
and will be available by the end of 1994. These estimates can be used as baseline indicators of access to
safe drinking water and sanitary means of excreta disposal, especially at the district level, since they
were based on a complete count rather than a sample. However, information on distance to water
source was not solicited in the 1989 Population and Housing Census, and distance is important in
defining access to water since every household has access to water but quantity, quality, reliability and
distance to water source may vary.
187.
In 1991, the Ministry of Health prepared a proposal to undertake a national water and
sanitation survey, excluding municipalities, to obtain information on households access to safe water
and supplies, and availability and condition of human waste disposal systems. The total sample size
was expected to be about 400,000 households, i.e. a tenth of the population. The total cost of the
survey was budgeted at Shs 27 million in 1991 prices. A detailed eleven-page questionnaire was
prepared for the national water and sanitation survey.
188.
However, due to lack of funds, the survey has so far only covered three districts (Kitui,
Kirinyaga, Migori/Kuria). A water and sanitation survey covering the previous Meru district (now
subdivided into Meru, Tharaka-Nithi and Nyambene districts) was conducted by the Ministry of
Health in May 1994, but the survey results have not been released. The district surveys have been
undertaken using a smaller questionnaire and were not for the same reference period. At the current
pace, a district-by-district survey will take over 30 years to cover the whole country, and the results
-45-

would not be comparable since they would not refer to the same reference period. The Ministry of
Health should consider financing a water and sanitation survey module under the CBS National
Household Welfare Monitoring Survey programme, using a detailed questionnaire and covering the
whole country including urban areas. However, due to the specificity of concepts used by the health
authorities (e.g. an almost full pit latrine is not counted as a latrine but a health hazard), the training of
enumerators and the actual data collection should be undertaken by trained health officers. Since the
Ministry of Healths water and sanitation survey methodology relies mostly on enumerators
observation and inspection rather than respondents self-reporting, such a module would not increase
the workload of respondents and CBS enumerators.

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CHAPTER SEVEN

CHILD PROTECTION
189.
The World Summit for Children formulated two major goals with respect to the protection of
the child in the 1990s:
(a)

The implementation of the Convention on the Rights of the Child; and

(b)

Increased protection of children in especially difficult circumstances.

190.
The Kenya National Plan of Action stated that, by the end of 1992, Kenya will have a
comprehensive Childrens Act. Kenyas optimism in domesticating the Convention on the Rights of
the Child was predicated on the fact that a lot of groundwork on child laws had already been
undertaken long before the tenth anniversary of the International Year of the Child in 1989, which
was also the year when the Convention on the Rights of the Child was adopted by the United Nations
General Assembly.
191.
During 1983-84 financial year, the Kenya Law Reform Commission commenced work on laws
relating to children with a view to reform, and held a two-day seminar with the aim of gathering ideas
on the topic. The seminar was funded by the Ford Foundation. The seminar, which was officially
opened by the then Attorney-General, Justice Matthew Guy Muli, received research papers on:
Definition of a Child; Custody, Maintenance and Inheritance Laws as they Affect Children: Statute
Law; Law of Custody, Maintenance and Inheritance with Specific Reference to Hindu Law; Adoption;
Childrens Services and Childrens Homes in Kenya; Child Labour and Juvenile Prostitution; The Law
for the Handicapped; Child Abuse Inside and Outside the Family with Specific Reference to
Psychological Aspects, Problems and Solutions; Juvenile Pregnancies; Criminal and Civil Liability of
Children; The Police and the Law as it Relates to Children; Consumer Protection for the Child; and
Protection of the Childs Health2.
192.
In May 1988, the African Network for the Prevention and Protection against Child Abuse and
Neglect (ANPPCAN), with support from UNICEF, organized a regional workshop in Nairobi on the
draft Convention on the Rights of the Child to deliberate on the Conventions relevance to Africa and
on national legal systems and their capacity to protect children3. During September 1988, a Kenyan
workshop on the Rights of the Kenyan Child, organized by the Kenya Chapter of ANPPCAN and
funded by UNICEF and the Ford Foundation, enhanced the national efforts in support of the draft
Convention. Following this Workshop, a study to review child laws in Kenya was initiated by
ANPPCAN, with support from UNICEF. The study was followed by another national workshop in
1989 to further review child laws in Kenya. In 1988, ANPPCAN and the Organization of African
Unity (OAU), with support from UNICEF and the Ford Foundation, organized an African experts
meeting in Nairobi to develop strategies for the adoption and implementation of the International
Convention and to consider a draft African Charter on the Rights and Welfare of the Child.
2 Kenya Law Reform Commission, Second Annual Report 1983-84, Government Printer, Nairobi
3 See ANPPCAN, 1989. The Rights of the Child: Selected Proceedings of a Workshop on the Draft Convention
on the Rights of the Child: An African Perspective, Nairobi, May 1988
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193.
After the OAU Council of Ministers and Heads of States Summit adopted the African Charter
on the Rights and Welfare of the Child in July 1990 as a common African support for the International
Convention, Kenyas Attorney-General directed the Kenya Law Reform Commission to review and
update the laws and regulations concerning the welfare of the child, with regard to the letter and the
spirit of the Convention. This was followed by the formation of a taskforce under the chairmanship of
Hon. Justice Effie Owuor in 1991. The first meeting of the taskforce was held in March 1991.
194.
In late May 1994, an experts meeting was held in Nairobi to review the draft report of the
taskforce and to discuss the draft Child Protection Law. In June 1994, the report of the taskforce which
included a draft Childrens Bill was presented to the Government. The bill is expected to be tabled in
Parliament by October 1994. The Bill will then become law after being discussed in, and passed by,
Parliament. Kenya is therefore likely to complete the process of domesticating the International
Convention into municipal law by December 1994.

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CHAPTER EIGHT

INSTITUTIONS ENGAGED IN PRODUCING PERFORMANCE INDICATORS


CENTRAL BUREAU OF STATISTICS
Introduction
195.
The decline of activities of CBS in the 1980s led to a process of self-reexamination that resulted
in two symposia, on household-based and establishment-based data collection activities. In September
1988, CBS organized a symposium on statistical censuses and surveys, mainly focusing on
household-based surveys undertaken using the national sample frame. In November 1990, CBS held
another symposium of producers and users of statistics to take stock of data collected and statistics
produced, and to prepare a forward action plan. The review of CBS activities in the 1990 symposium
covered nearly all regular data collection that feed into the annual Economic Survey and Statistical
Abstract.
196.
There were also two external reviews, carried out by Judith Heyer (1990) and K.W. Mwarania
(1991). Heyer (1990) evaluated the range of data available in Kenya on living conditions including
demography, food, poverty, education, communication, housing and amenities, and employment. The
review also included an assessment of censuses and household-based surveys undertaken within the
national sample survey programme. Heyer recommended that CBS reduce its data collection and
analysis in line with available resources, and make a major effort to solicit for funds and expertise to
expedite processing and analysis of survey data that had been collected but not analyzed. These
included the 1981-82 Rural Household Budget Survey and 1982-83 Urban Household Budget Survey.
Mwarania (1991) argued for strengthening of CBS capacity (personnel and financial resources) so as to
allow for generation of economic and social data disaggregated to the district level.
197.
As a logical follow-up to the 1990 Symposium of Users and Producers of Statistics, CBS
planned to host sectoral workshops so as to allow user ministries, private sector and donor agencies to
study the methodologies CBS uses in data collection, and to invite suggestions on technical and
programmatic issues so as to improve the quality of data collected. The first such workshop was held in
June 1991 in preparation for the 1993-95 Urban Household Budget Survey and covered technical and
conceptual issues related to the revision of the Consumer Price Index (CPI). The report of the
proceedings was completed in September 1991, but the report has not been released to a wider
audience4. Sectoral workshops need to be revived and supported so as to improve on data quality and
to help users interpret the statistics produced by CBS. CBS ought to release the report on the June 1991
CPI workshop.
During January-October 1992, the Central Bureau of Statistics undertook a National Statistical
Needs Assessment Project headed by Harris Mule, former Permanent Secretary in Kenyas Ministry of
Finance, and with financial support from the Netherlands Government. The report, which runs to 375
pages, identified some of the problems facing the Bureau as its outdated institutional structure; the
198.

4 Central Bureau of Statistics, Office of the Vice President and Ministry of Planning and National Development,
Proceedings of the Action Planning Meeting on Consumer Price Index and Urban Household Budget Survey,
Outspan Hotel, Nyeri, 4-8 June 1991

-49-

general resource constraint; inadequacy of professional personnel; methodological problems; statutory


problems; and problems of collaboration between producers and users of statistics. The statistical
needs assessment recommended the elevation of CBS into an autonomous institution, but attached to a
parent ministry. CBS should hasten the publication of the study so as to give the Government, users of
statistics, and the donor community a chance to discuss the findings.
199.
The Directorate of Personnel Management in the Office of the President in July 1992
completed the Report on the Organization, Operations and Staffing of the Central Bureau of Statistics.
The report recommended a reorganization of CBS, including expansion in staff and facilities; the
creation of a Finance and Administration section to handle all the finance, administrative and
personnel matters so as to relieve the professionals from these duties; creation of a Public Relations
section to handle clients queries and organize seminars/workshops; and redefine levels of
confidentiality of data so that users can access data for analysis in an effort to reduce CBS workload in
data processing and analysis. This report has not received wide circulation.
200.
In Kenya, there has been serious underfunding of Government institutions that generate
economic data. CBS household-based survey activities declined, partly because they fall under
development expenditure, which was compressed by a greater margin than recurrent expenditure in
the Governments Budget Rationalization Programme (BRP). In the short-term, the Government
ought to reduce the budget devoted to economic analysis in the Ministry of Planning and National
Development and transfer the resources (personnel and financial resources) to cater for the creation of
a reliable and timely database at the Central Bureau of Statistics. It is futile for the Ministrys staff to
spend time and resources in the construction of elegant economic models grounded on shaky
economic data. In addition, it is recommended that a closer link between CBS/Ministry of Planning
and local and foreign universities would reduce the analytical burden on the staff. One solution
towards long-term improvement of the economic database is to make the Central Bureau of Statistics a
semi-autonomous institution with authority-to-incur-expenditure, to source for funding directly from
donor agencies, and without being required to answer to the parent Ministry on a daily basis. If CBS
was semi-autonomous, its activities would not have been severely affected by the general decline in
donor funding which has characterized the early 1990s.
201.
The scenario being created here is that of an up-to-date database on macroeconomic and
household/production data, and a stream of local and external scholars using the data in writing
academic and policy-oriented papers, and thesis. It should be recalled that research papers written
using Governments economic database provided the intellectual foundation of economic planning in
the 1960s and 1970s. The link between Government planning machinery and scholars assisted the
Government in the planning process and was also an intellectual boost to the university scholars.
Data Collection in a Deregulated Economy
202.
Beginning 1993, the Government has made some far reaching policies aimed at reducing the
role of the state in production, enhancing efficiency, and reducing corruption. For example, the policy
reforms in foreign exchange allocation and in the banking sector have reduced future scope of
rent-seeking opportunities. Structural adjustment provides a market-based channel for reducing
monopolistic tendencies and rent-seeking opportunities, which is far more efficient and impartial
than anticorruption squads. Within a deregulated economic environment, the role of short-term
-50-

macroeconomic management has been elevated. In late 1993, the Government abolished maize
marketing controls. Since maize is a major staple, it will in future compete with Treasury bills and the
dollar as an alternative (financial) instrument that will react to changes in money supply, as well as a
means of payment in a futures contract. This implies that, if the monetary policies are relaxed, the
price of maize would increase, thereby making the survival of the poor more dependent and directly
linked to the quality of short-tem macroeconomic management than ever before.
203.
Economic liberalization should be accompanied by training of economic managers and
statisticians on economy-wide effects of changes in key variables (e.g. money supply) and new ways of
collecting economic data, e.g. valuation of imports and exports under a floating exchange rate regime
and collection of agricultural price and production data in a competitive market structure. The former
is probably the domain of the Central Bank of Kenya and the International Monetary Fund. On the
latter, the extensive marketing and privatization reforms have increased production and sales from
sources other than parastatals, companies and estates which have been the traditional sources of most
information. In future, such information would come from imputations of production per hectare for
individual crops and livestock products, from both smallholdings and large farms/estates. The CBS
staff need to be retrained in data collection in a deregulated environment, and more funds be allocated
in the recurrent account to carry out these activities if an accurate and up-to-date account of food
security is expected from CBS. This is also true of industrial production data which feeds into the
annual Economic Survey and Statistical Abstract.
Data Archival and Retrieval System
204.
While many authors have decried the inability of CBS to analyze survey data and release
survey results in time, this has probably been caused by lack of a clear policy on data archival system.
For example, the 1986/87 Agricultural Production Survey (APS) was combined with the fourth rural
child nutrition survey so as to provide interrelationships between nutritional indicators and food
security. However, some of the APS data was lost, and the original intentions of the survey planners
were never realized. The 1981-82 Rural Household Budget Survey data was recovered from the
Government Computer Services (GCS) mainframe computer through a laborious and expensive
process5. The 1982-83 Urban Household Budget Survey data tapes were found in 1993 to have been
overwritten with customs data.
205.
Although CBS has now moved from mainframe to personal computers, the risk of loss of data
still remain6. An urgent need is for CBS to undertake an assessment of its data archival system, transfer
data for previous surveys and censuses to more advanced and recent magnetic media, and explore the
possibilities of opening a safe custody account with the Central Bank of Kenya or a commercial bank
for storage of magnetic archives on publications (e.g. economic surveys) and survey data files.

5 See, Harvey Herr, Consultancy for Transfer of a Sub-set of the RHBS Data from Mainframe to Microcomputer
for use in Development of Poverty Profiles, Ministry of Planning and National Development, July 1992
6 The mainframe computer of the Government Computer Services is under the control of the Ministry of
Finance, and CBS therefore lacked computing autonomy as it had to compete for computer time with other data
processing tasks from the Ministry of Finance and other agencies.

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CBS Programme on Household-Based Surveys


206.
The preparation of the urban NASSEP frame was partly funded by USAID and was completed
in 1993, while the rural component was funded by the Government and was completed in June 1994.
During June-August 1994, CBS will add the non-NASSEP districts (Garissa, Wajir, Isiolo, Marsabit,
Samburu and Turkana districts and the whole of North Eastern province) to the NASSEP frame under
a consultancy funded by UNICEF. The entire NASSEP frame will also be updated in 1996.
207.
However, obtaining staff to maintain the NASSEP and data collection in the currently
non-NASSEP districts may initially face some difficulties due to (a) the ongoing civil service
retrenchment, and (b) identifying and employing at least six enumerators in every district who
understand the local dialect. District statistical officers can however be posted from the existing
personnel at CBS.
208.

The current household survey programme includes:


(a)
Fieldwork for the 1993-95 Urban Household Budget Survey is on stream;
(b)
The second round of the National Household Welfare Monitoring Survey started in
June 1994, and the third and the fourth rounds are planned for 1995 and 1996,
respectively;
(c)
A national nutrition survey module, funded by UNICEF, was tagged to the second
round of the Welfare Monitoring Survey, and another round is planned for 1996;
(d)
Rural and Urban Labour Force Surveys are planned for 1995, and CBS is already
negotiating with a donor agency for possible financial support;
(e)
Analytical work on fertility, mortality, migration and urbanization, labour force,
education, and access to housing and amenities, based on the 1989 Population and
Housing Census, will be funded by the UNFPA. This will be followed by preparation
of population projections for use by Government ministries and other users who
utilize population-based denominators. The basic report on the urban population
based on the 1989 population census is complete and is in press.

209.
CBS should undertake the following activities as a matter of priority. First, a technical report
on the NASSEP ought to be published once the inclusion of the currently non-NASSEP districts is
completed. There is also need to publish the National Statistical Needs Assessment Project report
completed in 1992 and the Directorate of Personnel Managements (Office of the President) Report on
the Organization, Operations and Staffing of the Central Bureau of Statistics (1992). This would help
to focus donor attention on CBS activities, and invite debate on the institutional developments
necessary to strengthen CBS capacity to undertake its role in a more demanding socio-political and
economic environment.
210.
CBS should organize a workshop to take stock of its achievements in the last few years, and to
lay an agenda for the coming four years. Such a workshop would assist (a) UNICEF, user ministries and
other donor agencies to fit their future data needs in the CBS establishment-based and
household-based survey programmes, and (b) user ministries and donor organizations to agree on
concepts to be used in the design of survey instruments (i.e. questionnaires and enumerators reference
manuals) to satisfy users specific needs.

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HEALTH INFORMATION SYSTEM


211.
The Ministry of Health established the Department of Health Information System (HIS) in
1980. HIS was commissioned to collect, process, analyze and archive health statistics collected from
Government health facilities. The data collected include outpatient morbidity, inpatient morbidity
and mortality, monthly workload by facility (attendance at general outpatient, casualty, and special
clinics; inpatient services; maternity services; operations; and other special services e.g. X-ray and
laboratory tests), and diarrhoea diseases monthly reports. Up to 1992, immunization data relating to
the activities of the Kenya Expanded Programme on Immunization was processed at the HIS, but has
since then moved to the KEPI offices in the Division of Family Health.
212.
The Health Information System relies on primary data generated in health facilities, and then
summarized into district, provincial and national estimates. Outpatient statistics are filled daily on
outpatient tally sheets (Form MOH 701), broken down by disease, and the daily totals transferred to
Daily Out-Patient Return of Morbidity - MOH 705 form. The monthly totals from each health
facility are forwarded to the district, which in turn prepare district totals in District Out-Patient
Morbidity Summary - MOH 719 form. The district summaries are forwarded to the HIS section in the
Ministry of Health, where they are used to compile monthly and annual totals by district, province
and for the whole country. The outpatient morbidity returns are not broken down by age, and
therefore do not provide information on disease incidence for the under-five years of age, who are the
main focus of the World Summit goals on health.
213.
Outpatient morbidity statistics are for a defined set of diseases, and all districts are supposed to
prepare monthly reports from all the facilities located within them. However, due to varied response
rates by district, the statistics do not allow for robust estimation of regional disparities in incidence of
and mortality from various diseases. However, the figures may provide more reliable estimates of
leading causes of disease in outpatient attendance at the district level. In addition, since not all diseases
are diagnosed through microscopy service, the outpatient statistics data may be viewed as estimates of
illness rather than disease. Disease is understood to be an objective phenomenon characterized
by altered abnormal functioning of the body as a biological organism, while illness is a subjective
phenomenon in which individuals perceive themselves as sick. Reporting errors from this source are
expected to be less when professional validation for a persons claim to the sick role is given by
trained health personnel (as in reporting based on health facilities), compared to a sick persons
provisional claim to the sick role (as in morbidity data collected through household-based surveys).
Within a health restoration model, lay persons only give provisional validation to the sick role, while
professional validation is only given by trained health personnel (Suchman, 1963; Mukui, 1994).
214.
The data on inpatient statistics include admissions and discharge, and inpatient morbidity and
mortality. Unlike outpatient returns, inpatient morbidity and mortality returns by disease are reported
by age of patient in years, namely, less than one year, 1-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64 and
65+ years. The returns are only from Government hospitals and may therefore be less representative in
urban areas where private health facilities are expected to provide a bigger share of curative health
services than in the rural areas.
215.
The health facilities also prepare separate returns for infectious diseases, which are forwarded
to the districts, and then district totals are forwarded to the Ministry of Healths HIS section on a
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weekly basis. The reporting on infectious diseases is made separately without distinguishing whether
they were inpatient or outpatient. The statistics on morbidity and mortality for those infectious
diseases under international surveillance are supposed to be sent to the World Health Organization
(WHO) on a routine basis. However, HIS rarely receives district reports on infectious diseases, and
does not therefore report to WHO as expected. The health facilities were not even instructed on
whether the reportable infectious diseases surveillance covers their patients or the community in the
health facilitys immediate vicinity. The list of reportable infectious diseases also needs to be updated
through an amendment to the Public Health Act (Cap. 242 of the Laws of Kenya).
216.
The health statistics may suffer from both qualitative and quantitative errors. Quantitative
errors arise from omissions and non-response arising from either negligence of the reporting
personnel and/or inability to send the reports to HIS due to postage expenses or poor road network.
The reporting personnel may not give sufficient attention to health reporting due to workload in
healthcare service delivery. Qualitative errors may arise from improper diagnosis of disease especially
in outpatient health services, e.g. the recent yellow fever outbreak which was initially reported as the
so-called highland malaria.
217.
HIS headquarters has 16 computers, six of which have broken down. Of the ten working
computers, only three have high computing speed (one 486 and two 386s). The total computer
memory and computing capacity are therefore low. There is currently no data archival system other
than floppy diskettes, and the data files which cannot fit in diskettes do not therefore have backups.
Some of the small data files are zipped so as to fit in the floppy diskettes. HIS needs to urgently acquire
(a) a few high memory, high speed, computers so as to increase computing capacity, and (b) a data
archival system (magnetic tapes, tape reader, etc.) and identification of a suitable safe custody for the
data archives. In the medium-term, HIS could also consider developing a local area network (LAN),
initially in the HIS computer section, and to gradually include other key personnel in the Ministry of
Healths headquarters.
218.
All the district health information offices operate manual systems. The chances of introducing
errors increase as the data moves from health facilities, to the district, and then to HIS headquarters. A
case in point is the recent misclassification of chicken pox cases in a district monthly report under
polio. There is need to consider supplying district offices with computers, so that health statistics can
be entered for each health facility separately, and for the districts to transmit data to HIS in floppy
diskettes for the preparation of national summaries. This would also assist districts to identify
non-responding health facilities.
219.
One of the constraints facing the Department of HIS is staff retention due to lack of a properly
defined scheme of service. The medical records technicians receive two years training at the Medical
Training Centre (MTC), and then join Civil Service Job Group F, and cannot be promoted beyond
Job Group G. The medical records technicians who collect data at the health facilities and process
data at the districts and the HIS offices - may not have the incentive to collect good quality data due to
the low pay scales and lack of upward progression. University graduates with postgraduate training in
computers join at Job Group J and cannot be promoted beyond Job Group K. HIS will therefore
find it difficult to retain staff within the existing scheme of service for operators, programmers and
analysts.

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220.
HIS is funded solely by the Government, although UNICEF occasionally gives financial
support in publishing statistical annual reports and bulletins. HIS has suffered from inadequate
funding and cash flow problems due to tight Governments budgetary ceilings and cumbersome
procurement procedures. Although HIS headquarters has a budget line in the Ministry of Health
budget, there are no separate budget lines for district and health facilities to support data collection
and its transmission to HIS headquarters. However, in the first quarter of 1994, US$ 1.6 million was
reprogrammed from World Banks Population III and Population IV projects to support the
enhancement of the Health Information System. The activities to be financed under the World Bank
funding were based on a HIS Assessment Report of March 1994, which was not made available to the
consultant. It is therefore not possible to comment on the adequacy of HIS future plans in developing a
health management information system for the public sector health services.
KENYA EXPANDED PROGRAMME ON IMMUNIZATION
221.
The Kenya Expanded Programme on Immunization (KEPI) was launched in 1980. The main
objective of its management information system is to collect, compile and analyze immunization data
in order to derive estimates of immunization coverage by districts. The summaries are supposed to be
fed back to the reporting districts so as to improve on reporting and to increase immunization
activities for the districts with low coverage. KEPI MIS is also supposed to collect and analyze data on
vaccine-preventable diseases, i.e. measles, polio, neonatal tetanus, tuberculosis, diphtheria and
whooping cough, in order to evaluate the impact of the expanded immunization campaign on the
occurrence of vaccine-preventable diseases.
222.
The facilities report once a month on their activities to the district, and the district records
officer in turn compiles the facility-based reports into a monthly district report. The district in turn
sends their returns to KEPI, with a copy to the Health Information System (HIS) based at the Ministry
of Health headquarters. The district reports contain immunization data for BCG, each of the three
DPT doses, each of the four polio vaccines, and measles, split between those administered to children
below one year and to those above one year. The reporting also includes district totals for doses of
Tetanus Toxoid administered to pregnant women.
223.
Monthly returns from the districts are expected to be received within one month after the end
of the reporting month. KEPI MIS section is then supposed to immediately follow up with the districts
on missing or inconsistent data from the district returns, and send monthly immunization summaries
to the districts within three months. This is supposed to increase incentive for complete and timely
reporting since districts would not want to be reported as having low coverage due to underreporting.
224.
All districts submit reports on immunization coverage for the immunization facilities within
their districts. However, some district reports are received late, while some districts do not report for
all months. Although there has been a marked increase in reporting, the response by months for all
districts was an estimated 77 percent in 1993. Response rate by immunization facilities is not currently
known since the survey of number of facilities was last done in 1990. Some old facilities could have
closed or new ones opened in the intervening four years. KEPI has not received sufficient support
from the districts in updating information on the current number of immunization sites or facilities.
225.

The KEPI MIS section has two members of staff: one medical records officer and one
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statistician. The monthly district immunization data is entered and managed in a program called
Computerized EPI Information System (CEIS) provided by the World Health Organization. Although
the CEIS computer program is supposed to cover immunization coverage, and morbidity and mortality
for vaccine-preventable diseases among other indicators, only data on immunization is currently
entered. Disease incidence on vaccine-preventable diseases is not presently entered due to very low
response from the districts. KEPI is therefore unable to report monthly to the WHO on incidence and
mortality of vaccine-preventable diseases.
226.
The CEIS program uses population parameters e.g. population, population growth rate, infant
mortality, and crude birth rate for each district. Population parameters are used to set district
immunization targets and as denominators in the computation of district and national immunization
coverage statistics. The population parameters are based on the 1979 population census. In addition,
due to subdivision of districts during 1992 and 1993, the population denominators for a district which
has been subdivided into two or more districts are entered against the original district, while the
immunization data is for each district separately. Immunization coverage statistics for the original
district have a higher than actual population denominator, while the new districts have no population
denominators at all.
227.
Version 5 of CEIS was installed in August 1993, but the program developed problems one
month later, thereby leading to a seven-month suspension of data entry until May 1994. It appears
that the program was not properly installed, or some batch files in the program require to be updated
by WHO CEIS program developers. The 1993 district and national immunization coverage summaries
are expected in July 1994.
228.
Urgent action is required in (a) reporting on immunization and morbidity and mortality from
vaccine-preventable diseases, (b) updating of the number of immunization facilities, and (c)
strengthening human and computing resources at the KEPI MIS section. Districts should respond on
immunization coverage and vaccine-preventable diseases surveillance for all months and in a timely
manner. KEPI should also follow up on delayed or inconsistent district returns, and endeavor to send
monthly district and national summaries back to the districts within three months of receipt of district
immunization data. Without feedback, districts may not cooperate if they do not feel that their returns
are of use for management at the district and national levels. The current number of immunization
facilities is not known, and no baseline estimates of immunization facilities exist for the districts
which have been subdivided since the last update of statistics on facilities in 1990.
229.
KEPI is undergoing financial strain due to the withdrawal of funding by a major external
donor in 1993. The KEPI MIS section has had constraints in sending the revised immunization
reporting forms to the districts, lapses in computing capacity, and manpower constraints to run the
CEIS program. Currently KEPI has only one computer, an IBM-compatible 286-capacity computer
and one EPSON dot-matrix printer. The computer is slow and is below the minimum standard
386-computer recommended by the WHO CEIS program developers. There is therefore need to
acquire (a) two 486-capacity computers to increase computing capacity and to allow for two officers to
do data entry at the same time, and (b) another computer printer.
230.
The MIS section was considering developing its own computer program, with the support of
HIS, due to problems in using the CEIS program. However, there seems to be insufficient
-56-

understanding of how the CEIS program operates by both the HIS and KEPI MIS staff. The WHO and
UNICEF should consider training the staff of HIS and KEPI MIS on the CEIS routine operations and
troubleshooting. The idea of developing its own computer program will hamper smooth reporting to
WHO in software form. A programmer should be trained on the technical aspects of the program, and
a programmers manual should be availed to KEPI MIS section.

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ANNEX 1: TERMS OF REFERENCE


MEASURING THE ACHIEVEMENT OF GOALS: WORLD SUMMIT FOR CHILDREN
PURPOSE AND SCOPE
In support of the UNSTAT (United Nations Statistics Division) project with UNICEF to assist countries
monitor the achievement of goals adopted at the World Summit for Children, the purpose of the
activity is to carry out an assessment of the current availability of relevant data relating to the Child
Summit goals in general but with a special emphasis on the mid-decade goals.
In particular the consultant will undertake the following tasks:
1) Collaborating with the National Plan of Action contact person, determine the degree to which
necessary data for the Child Summit goals as well as the Governments own priority indicators
are currently collected, and in which statistical programmes/series; ascertain the availability of
the data at both national and sub-national levels; compile the data for those indicators which
are available and appraise their quality (methodology, timeliness, disaggregation, frequency,
uses made);
2) Identify gaps in current data collection and availability of indicators and recommend the kinds
of structural changes in the statistical system and the type(s) of statistical programme(s) which
would be necessary to fill gaps, in terms of additional data collection and/or additional data
analysis; such recommendations would also include information on the periodicity of
collection and reporting of each targeted indicator as some may be required annually and
others less frequently;
3) Prepare an interim report for use in a sub-regional meeting (see below); this will include (a)
presentation of the data on the basis of the assessment detailed in (1) and (2) above, and (b) a
suggested plan of action with cost estimates for the country to obtain and maintain the
requisite indicators as an integral element of their various statistical operations;
4) Attend a UNICEF-sponsored 3-day sub-regional meeting involving three or four other
countries for purposes of discussing results of the investigation and developing the details of an
annual report.
ORGANIZATION
The national consultant will be guided somewhat on statistical aspects of the task by an international
consultant from the region who will meet with him/her and provide certain materials designed to seek
consistency across countries - for example, a statistical reporting format.
The most important contact for the national consultant will be the focal person in the Government
responsible for the National Plan of Action. Working together they will focus on the national
priorities with respect to indicators for Child Summit goals, but attention should also be given to the
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mid-decade goals. The national consultant will also establish important working contact with the focal
officer in UNICEF dealing with goal monitoring or evaluation.
In carrying out the tasks, the national consultant, perhaps together with the NPA focal person, will
contact all agencies likely to be involved in relevant data collection or analysis. These will include the
ministries in charge of planning, social services, labor, education, health and nutrition, womens
issues, and possibly housing, environment and agriculture. A key organization will be the national
statistical organization and that should be one of the first to be contacted. In addition, university and
research institutes may be included. It is emphasized that national data sources as opposed to
internationally-generated data are to be used.
Based on a consolidated list of NPA and mid-decade goal indicators, the consultant will ascertain:
(i)

Availability over the last 10 years;

(ii)

Source(s) of data (method of collection), noting multiple or duplicate sources;

(iii)

Coverage;

(iv)

Timeframe (date to which estimate pertains);

(v)

Evaluations of accuracy and reliability, noting down limitations;

(vi)

Levels of disaggregation:
(a)
Gender;
(b)
Other demographic (age, ethnic groups);
(c)
Geographical (urban-rural, regional, other);

(vii)

Availability of incomplete, indirect or partial indicators for provisional use when


dedicated indicators are unavailable.

An important feature of the work is to compile the actual data for those indicators which are available
including the relevant disaggregation. Gender disaggregation is especially important.
The consultant will submit a report within ten days of the completion of the work. As mentioned, a
sub-regional meeting will be convened by UNICEF later, to help countries develop the first annual
reports. This meeting will be conducted over a three-day period, probably in Nairobi.

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ANNEX 2: POLICY MATRIX OF THE WORLD SUMMIT FOR CHILDREN GOALS


POLICY
FOCUS
Poverty

Nutrition

WORLD SUMMIT GOALS

KENYA NPA GOALS

The World Summit for children (i)


Determine the current extent,
set two specific goals on poverty: distribution and severity of poverty in the
country.
(i)
To alleviate poverty (ii)
Reduce
household
poverty
and revitalize economic growth. incidence by 50% of 1993 levels by the
(ii)
To
disseminate year 2000.
knowledge and supporting iii)
Reduce the depth and severity of
services in order to increase food poverty by one third of 1993 levels by the
production
and
ensure year 2000.
household food security.
(iv)
Reduce
poverty
disparities
between female-headed households and
No indicators were specified for male-headed ones
monitoring these goals
The World Summit set one (i)
Reduce moderate malnutrition
major goal and seven supporting by 30% [as opposed to 50%] of its 1992
goals in the field of nutrition
level.
(ii)
Give special attention to the
Major Goal
nutrition of the female child.
(iii)
Give special attention to the
(i)
To reduce severe and needs of pregnant and lactating mothers
moderate malnutrition among by encouraging attendance at antenatal
children under five years of age and postnatal clinics and by reducing the
by 50% over the 1990-2000 drudgery characterizing the lives of these
period.
women.
(iv)
Continue to encourage the
Supporting/sectoral Goals
incorporation of traditional methods of
pregnancy management that have proven
(i)
To
give
special useful
into
mainstream
health
attention to the nutrition of the management systems.
female child and pregnant and (v)
Design
and
implement
lactating mothers.
programmes
aimed
at
increasing
(ii)
To reduce low birth household food security and reducing
weights (i.e. 2.5 kg) to less than womens workload.
10%.
(vi)
Institute mechanisms to generate
(iii)
To
reduce
iron the appropriate data so that quantitative
deficiency anemia in women by measures of Low Birth Weight (LBW) can
one third of the 1990 levels.
be made.
(iv)
To virtually eliminate (vii)
Undertake or commission studies
iodine deficiency disorders.
to determine the prevalence rates of
v)
To virtually eliminate nutritional anemia among women and
Vitamin A deficiency and its children.
consequences,
including (viii)
By the year 2000 Iodine
blindness.
Deficiency Disorder (IDD) will have been
(vi)
To
empower
all virtually eliminated. Meanwhile, a
women to breastfeed their nationwide survey will be carried out to
children exclusively for four to determine the prevalence of IDD.
six months and to continue (ix)
The Government believes that it
breastfeeding,
with will be possible to attain the summit goal
complementary food, well into on Vitamin A deficiency. In the
the second year.
short-term, a nationwide survey will be
(vii)
To
institutionalize carried out to determine the prevalence of

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MID-DECADE GOALS
(1995)

(i)
Provide
universal
access to iodized salt.
(ii)
Virtually
eliminate
vitamin A deficiency.
(iii)
Make all hospitals and
maternity
centers
baby
friendly by ending free and
low-cost supplies of infant
formula and breast milk
substitutes and following the
Ten Steps recommended by
UNICEF and WHO.
(iv)
Reduce 1990 levels of
severe
and
moderate
malnutrition by one-fifth or
more

POLICY
FOCUS

Health

WORLD SUMMIT GOALS

KENYA NPA GOALS

growth promotion and its Vitamin A deficiency.


regular monitoring by the end of (x)
More and more mothers will be
the 1990s.
encouraged to, where possible, exclusively
breastfeed their babies for the first four
months. Mothers and employers will be
encouraged to consider longer maternity
leaves and where possible to establish
crches at places of work.
(xi)
Ensure
that
all
mothers
breastfeed their babies (with food
complements) well into the second year of
life.
(xii)
Continue putting more emphasis
on the need for child growth promotion
and monitoring and will avail the
necessary resources for this purpose.
However, as these resources are likely to
be limited, community-based strategies
such as the Bamako Initiative will be
encouraged and supported.
The World Summit set three (i)
Aim
at
achieving
Infant
major goals and nine supporting Mortality Rate (IMR) and Under-Five
goals in the field of health. Mortality Rate (U5MR) of 70 per 1,000 live
These goals area:
births and 90 per 1,000 live births,
respectively. Achieving these reductions,
Major Goals
however, could be adversely affected by
the additional mortalities due to AIDS.
(i)
Between 1990 and (ii)
Determine the national and
2000 reduce the infant mortality district rates of maternal mortality.
rate by one third or to 50 per (iii)
Disparities in access to health
1,000 live births, whichever is between boys and girls will be removed.
less.
Practices, cultural and otherwise, that
(ii)
Between 1990 and discriminate against the female child will
2000 reduce the under-five be discouraged.
mortality rate by one third or to (iv)
By the year 2000, the
70 per 1,000 live births, Government aims to give all couples and
whichever is less.
individuals access to information and
(iii)
Between 1990 and the services to prevent pregnancies that are
year 2000 reduce maternal too early, too closely spaced, too late or too
mortality rate by one half.
many.
(v)
Deliveries attended by trained
Supporting/sectoral Goals
health professionals: achieve 100% access
in urban areas and about 60% in rural
(i)
Give special attention areas. The quality of personnel attending
to the health of the female child to childbirth will be further improved
and to pregnant and lactating through training of traditional birth
mothers.
attendants.
(ii)
Give all couples access (vi)
About 71.2% of under-fives did
to family planning information attend postnatal clinics in 1990. The
and services to enable them plan Government will take measures to increase
their families.
the level to at least 90% by year 2000.
(iii)
Give all pregnant (vii)
Kenya expects that it will be able
women access to antenatal care to achieve virtual eradication of polio by
and to safe child birth.
the year 2000.
(iv)
Eradicate polio by the (viii)
Kenyas goal is to eliminate

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MID-DECADE GOALS
(1995)

(i)
Ensure 90% measles
immunization for the majority
of children under five years old.
(ii)
Raise immunization
coverage against diphtheria,
pertussis, polio, tetanus and
tuberculosis from 75% to 80%.
(iii)
Eliminate
neonatal
tetanus.
(iv)
Eliminate
measles
mortality by 95 percent and
measles morbidity by 90
percent
compared
with
pre-immunization levels.
(v)
Achieve 80% access to
oral rehydration therapy.
(vi)
Virtually
eliminate
dracunculiasis (guinea worm
disease).

POLICY
FOCUS

Education

WORLD SUMMIT GOALS

KENYA NPA GOALS

year 2000.
(v)
Eliminate
neonatal
tetanus by the year 1995.
(vi)
Reduce measles deaths
and measles cases among
under-fives by 95% and 90%,
respectively,
compared
to
pre-immunization levels, by
1995.
(vii)
Reduce
diarrhoea
deaths and diarrhoea cases
among under-fives by 50% and
25%, respectively.
(viii)
Reduce deaths due to
acute respiratory infections
among under-fives by one third.
(ix)
Maintain at least 90%
immunization coverage against
diphtheria, pertussis, tetanus,
measles,
poliomyelitis
and
tuberculosis among under-ones
and against tetanus for women
of child-bearing age.

neonatal tetanus by the late 1990s.


(ix)
World Summit goal of reducing
measles mortality by 95% and incidence
rates by 90% too ambitious for Kenya. The
Government set modest but achievable
goals of 80% (mortality) and 75%
(incidence).
(x)
Adequate data for Kenya on
diarrhoea mortality and incidence rates is
not available to allow for setting up of a
quantitative goal at this moment in time.
(xi)
Reduce
Acute
Respiratory
Infections (ARI) mortality rates by 10% [as
opposed to one-third] of their 1993 levels
by year 2000.
(xi)
Raise immunization coverage
from 71% to 80%. Between 1996 and 2000,
the country hopes to further increase the
national average coverage from 80% to
90%.
(xii)
Although full eradication of
malaria is not possible, the government
will intensify the use of the third strategy
[vector control measures] to reduce both
malaria mortality and incidence rates in
the 1990s. A National Malaria Control
Programme will be set up. (The three
strategies suggested by WHO for dealing
with malaria are: chemotherapy for cases
to reduce morbidity and mortality;
chemotherapy
with
additional
chemoprophylaxis for pregnant women
and children with anemia and poor
nutrition; and vector control measures).
(xiii)
Create maximum awareness
among the people of the dangers of getting
this preventable but currently incurable
disease i.e. AIDS. A secondary goal will be
to design humane conditions for caring for
those who are unfortunate to acquire it.
(i)
Between 1990 and 2000, the
Government would like to see early
childhood education (3-6 years of age)
participation rates increased from the
current level of 30% to at least 50%.
(ii)
The goal of universal access to
primary school education by the year 2000
is achievable.
(iii)
Achieve an average national
primary school completion rate of about
70%.
(iv)
Study the causes of high dropout
rates for girls, under the auspices of the
Education Sector Adjustment Programme.
(v)
The country will be able to lower

The World Summit set three


major goals and four supporting
goals in the field of education.
These goals are:

Major Goals
(i)
Universal access to
basic education by the year
2000.
(ii)
Completion of primary
education by at least 80% of
primary school-age children by
the year 2000.
(iii)
Reduction of adult

-62-

MID-DECADE GOALS
(1995)

(i)
Reduce by one-third
of the gap between current
primary
school
enrolment/retention rate and
the year 2000 goal of reaching
universal access to basic
education.
(ii)
Achievement
of
primary education by at least 80
percent of school-age children.
(iii)
Reduce the gender
gap in primary education in
1990 by a third.

POLICY
FOCUS

WORLD SUMMIT GOALS

KENYA NPA GOALS

illiteracy to at least half of its its illiteracy rate (at 40%) by half (to 20%)
1990 level, with emphasis on by the year 2000. While this national
female literacy.
average is achievable, the disparities,
especially regional ones, will still be
Supporting/sectoral Goals
significant. A secondary goal for Kenya,
therefore, will be to reduce these
(i)
Special emphasis on disparities.
basic education of the female
child to remove existing
disparities between girls and
boys.
(ii)
Accelerated literacy
programmes for women.
(iii)
Expansion of early
childhood
development
activities, including appropriate
low-cost
familyand
community-based
interventions.
(iv)
Increased acquisition
by individuals and families of
the knowledge, skills and values
required for better living.
Environment The World Summit restricted its (i)
Provide clean and potable water
discussion of environmental at a source less than one kilometer in high
concerns to the micro and meso potential areas and less than five
levels and even then only to safe kilometers in low potential areas by the
drinking water and sanitary year 2000.
means of excreta disposal. Two (ii)
It is possible to achieve the
major goals and one supporting Summit goal of universal access to sanitary
goal were set in this area:
means of excreta disposal, and the
Government therefore adopts that goal.
Major Goals
(iii)
Improve the ventilation and
standard of hygiene in traditional houses.
(i)
Universal access to safe (iv)
Review and revise urban
drinking water.
development policy, planning regulations
(ii)
Universal access to and building codes, taking into
sanitary means of excreta consideration affordable intermediate
disposal.
standards so as to enable the provision of
shelter, services and infrastructure for low
Supporting/sectoral Goal
income people in urban areas.
(v)
Take action to reduce the extent
(i)
Elimination of guinea of environmental pollution. Such action
worm disease (dracunculiasis) will include environmental screening of
by the year 2000.
proposed industrial projects and more
active vigilance on existing factories.
(vi)
Reforestation will be continued
and intensified so that the tree cover lost
over the last 30 years is restored by 80% by
the year 2000.
Equity
The World Summit limited itself (i)
The disparity between rural and
to
considerations
of urban areas will be reduced by designing
gender-related equity issues. In more rural-friendly programmes and by
particular the Summit set the devoting more resources to the
following goals:
development of rural areas under the

-63-

MID-DECADE GOALS
(1995)

(i)
Increase access to
safe-drinking water so as to
narrow the gap between 1990
levels and universal access by
the year 2000 by one-fourth.
(ii)
Increase access to
sanitary means of excreta
disposal so as to narrow the gap
between 1990 levels and
universal access by the year
2000 by one-tenth

POLICY
FOCUS

WORLD SUMMIT GOALS

(i)
The disparity between
unequal access to educational
opportunities and completion
rates between boys and girls
should be closed by giving
special
attention
to
the
education of the female child.
(ii)
In view of the fact that
the female child is a potential
future mother, special attention
should be given to her health
and nutrition.
(iii)
The disparities existing
in adult literacy between males
and females should be closed by
developing accelerated literacy
programmes for women.

Protection

The Summit formulated three


major goals for the protection of
children in the 1990s:
(i)
Ratify the Convention
on the Rights of the Child where
it had not already been ratified.
(ii)
The implementation of
the Convention on the Rights of
the Child.
(iii)
Provide
improved
protection of children in
especially
difficult
circumstances, and tackle the
root causes leading to such
situations.

KENYA NPA GOALS


District Focus Strategy.
(ii)
The Government will increase
equality in political participation by
allowing the formation of many political
parties. This system will also introduce
checks and balances, accountability and
transparency which are vital in the
management of public affairs.
(iii)
The Government will endeavor
to close the disparities between men and
women by designing development
programmes that are more gender
sensitive and which recognize the role of
women in both production and
reproduction.
(iv)
The Government will set up
special programmes to increase the
participation of the female child in
education so that by the year 2000 parity is
achieved between boys and girls.
(v)
The Government will intensify
programmes aimed at increasing the
income-earning potential of low income
households so as to reduce the gap
between high income and low income
groups.
(vi)
The Government will promote
programmes
aimed
at
increasing
employment opportunities.
(i)
It is expected that by the end of
1992 Kenya will have a comprehensive
Childrens Act.
(ii)
In the 1990s the Government
will study both the Convention and
Charter on the Rights of the Child to see
which areas of these two international
legal instruments are currently not
provided for in the Laws of Kenya. Where
such omissions are discovered, appropriate
legislation will be drafted.
(iii)
In the 1990s the Government
will set up appropriate institutions to
effectively implement the law on children.
(iv)
In 1990s the Government will
strive to improve the welfare of children in
especially difficult circumstances.

-64-

MID-DECADE GOALS
(1995)

ANNEX 3: STATISTICAL ANNEX


Table 1: Nutritional Status by District, 1987

National
Kilifi
Kwale
Taita Taveta
Machakos
Kitui
Meru
Embu
Nyeri
Muranga
Kirinyaga
Kiambu
Nyandarua
Laikipia
Nakuru
Nandi
Narok
Kajiado
Kericho
Uasin Gishu
Trans Nzoia
Baringo
Elgeyo Marakwet
South Nyanza
Kisii
Kisumu
Siaya
Kakamega
Bungoma
Busia

Height-for-age
Mean Z
-2SD (%)
(1.4)
32.2
(2.0)
51.7
(2.5)
56.1
(1.8)
41.2
(1.8)
45.9
(1.6)
37.8
(1.4)
38.0
(1.4)
30.1
(1.5)
32.6
(1.2)
24.9
(1.2)
15.3
(1.2)
17.9
(1.5)
37.0
(1.1)
25.7
(1.8)
37.3
(1.2)
22.8
(2.7)
59.7
(1.0)
24.7
(1.8)
45.8
(0.8)
7.9
(0.7)
11.5
(1.0)
24.9
(1.1)
15.0
(1.6)
44.8
(1.8)
44.4
(1.2)
38.2
(1.5)
33.7
(0.9)
18.4
(1.3)
22.8
(1.0)
27.0

Weight-for-height
Mean Z
-2SD (%)
(0.04)
4.5
(0.21)
4.5
0.11
6.7
(0.09)
4.6
0.09
2.1
(0.11)
4.7
(0.12)
3.9
(0.28)
5.4
0.08
2.7
(0.42)
5.3
(0.27)
2.7
(0.07)
1.1
(0.11)
1.1
(0.18)
8.2
0.04
3.7
0.03
2.6
0.84
6.4
(0.44)
9.9
0.17
1.8
(0.26)
5.8
(0.26)
5.0
(0.09)
5.9
(0.32)
2.9
0.60
7.8
0.59
3.4
(0.18)
6.3
(0.10)
11.7
0.10
2.8
(0.10)
1.7
(0.13)
6.4

Note: Negative numbers are put in brackets.


Source: Central Bureau of Statistics, Fourth Rural Child Nutrition Survey, 1987

-65-

Table 2: Nutritional Status by Demographic and Background Characteristics, 1993 (%)


Height-for-age
Below -3SD Below -2SD
Age (months)
<6 months
6-11
12-23
24-35
36-47
48-59
Sex
Male
Female
Birth order
1
2-3
4-5
6+
Residence
Urban
Rural
Province
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
Education
No education
Primary incomplete
Primary complete
Secondary+
Total

Weight-for-height
Below -3SD Below -2SD

Weight-for-age
Below -3SD Below -2SD

1.2
4.3
14.3
15.1
14.9
13.5

7.5
18.1
40.3
37.7
37.3
34.5

0.2
1.1
2.3
0.7
1.4
0.7

4.3
4.8
10.0
5.4
4.7
4.7

0.6
4.2
8.5
7.1
5.4
4.5

3.5
16.1
31.6
26.2
22.0
20.4

12.9
11.5

35.5
30.0

1.4
1.0

6.4
5.4

5.9
5.5

24.4
20.2

8.9
11.9
13.2
13.9

28.7
32.5
34.3
34.6

1.3
0.8
1.2
1.6

3.8
5.3
6.5
7.7

4.3
4.6
7.0
6.8

17.0
22.1
23.8
25.0

5.1
13.1

21.5
34.2

1.4
1.2

5.2
6.0

2.6
6.1

12.8
23.5

4.2
11.1
17.5
14.7
12.5
11.3
9.9

24.2
30.7
41.3
39.4
32.1
28.5
30.0

0.0
0.3
3.4
1.2
1.1
1.6
0.6

0.8
4.0
10.6
6.8
4.7
7.9
3.9

0.8
4.0
9.5
6.7
5.3
5.7
5.2

9.2
17.1
31.7
28.8
20.3
23.5
17.0

15.3
16.3
10.2
6.5
12.2

36.7
39.7
32.0
21.3
32.7

1.8
1.1
1.0
1.1
1.2

9.3
6.1
5.2
3.9
5.9

8.1
7.8
4.2
2.8
5.7

28.4
26.8
19.5
15.0
22.3

Note: Below-2SD (moderate and severe) includes children who are below -3SD (severe).
Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1993

-66-

Table 3: Percentage of Living Children by Breastfeeding Status, 1993


Age in months

Not breastfeeding

0-1
2-3
4-5
6-7
8-9
10-11
12-13
14-15
16-17
18-19
20-21
22-23
24-25
26-27
28-29
30-31
32-33
34-35

Exclusively breast-fed

1.5
2.8
0.5
0.2
1.2
1.6
6.8
12.9
22.0
29.5
45.2
47.8
71.7
76.7
85.9
91.7
94.3
91.9

Breastfeeding and:
Plain water only
Supplements
17.7
54.0
5.8
82.1
2.6
94.8
2.7
96.6
0.7
96.9
1.6
95.7
1.0
91.8
0.0
86.7
0.0
77.2
0.9
69.0
0.0
54.8
0.0
50.8
0.7
27.6
0.0
23.3
0.0
14.1
0.0
8.3
0.0
5.7
0.0
8.1

26.8
9.4
2.0
0.5
1.2
1.0
0.4
0.4
0.8
0.6
0.0
1.4
0.0
0.0
0.0
0.0
0.0
0.0

Total
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0

Note: Breastfeeding status refers to preceding 24 hours. Children classified as breastfeeding and plain
water only receive no supplements.
Table 4: Breastfeeding and Supplementation by Age, 1993 (%)
Age in months
0-1
2-3
4-5
6-7
8-9
10-11
12-13
14-15
16-17
18-19
20-21
22-23
24-25

Infant formula
2.0
4.3
1.1
3.2
3.7
6.5
4.5
5.3
5.3
3.7
3.4
3.1
0.6

Receiving supplement
Other milk Other liquid
15.9
48.8
44.6
48.0
67.0
47.6
66.5
44.2
68.0
45.0
57.6
56.2
72.4
55.2
61.0
47.3
74.9
63.8
59.5
48.0
68.1
47.7
54.1
52.5
42.9
49.6

Using a bottle with a nipple


Solid/mushy
5.0
49.4
80.2
91.2
90.3
93.9
96.9
98.5
98.7
96.2
100.0
95.8
97.5

10.3
21.1
15.1
13.2
8.9
7.5
13.1
6.0
5.8
5.6
2.3
4.2
4.7

Note: Breastfeeding status refers to preceding 24 hours. Percentage by type of supplement among
breastfeeding children may sum up to more than 100, as children may have received more than one
type of supplement.
Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1993
-67-

Table 5: Median Duration and Frequency of Breastfeeding, 1993 (%)


Median duration in months
Any
Exclusive
Full
breastfeeding
breastfeeding
breastfeeding
Residence
Urban
Rural
Province
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
Education
No Education
Primary
incomplete
Primary complete
Secondary +
Assistance
at
delivery
Medically trained
Traditional
midwife
Other or none
Sex of child
Male
Female
Total

Children under 6 months


Breastfed 6+ times in
preceding 24 hours

19.6
21.5

(0.5)
0.5

0.5
0.7

76.9
86.9

(19.5)
20.3
21.1
24.8
21.2
19.5
23.0

*
(0.5)
0.4
0.5
0.5
0.5
0.7

0.4
1.4
0.6
0.6
0.6
0.6
1.0

83.3
81.9
90.1
79.8
84.1
88.9
89.6

23.4
21.0

0.6
0.5

1.0
0.6

91.1
81.3

20.8
20.1

0.5
0.5

0.6
0.6

87.7
84.1

20.8
22.0

0.5
0.5

0.6
0.6

82.6
90.5

21.0

0.5

0.7

86.1

22.0
20.4
21.1

0.5
0.5
0.5

0.6
0.7
0.7

83.7
87.3
85.7

Note: An asterisk (*) means the rate is based on fewer than 25 women and has been suppressed. Rates
in parentheses are based on 25-49 women. Full breastfeeding is either exclusive breastfeeding or
breastfeeding and plain water only.
Source: National Council for Population and Development, Kenya Demographic and Health Survey,
1993.

-68-

Table 6: Baby-Friendly Hospitals Initiative: Status as of June 1994


1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47

HOSPITAL
Narok District Hospital
Eldoret District Hospital
Chogoria Mission Hospital
Aga Khan Hospital- Kisumu
Nyahururu District Hospital
Nyeri Provincial General Hospital
Isiolo General Hospital
Chuka Hospital
St. Elizabeth - Mukumu
Kajiado District Hospital
Nanyuki District Hospital
Mathari Hospital
Meru District Hospital
Makueni District Hospital
Bungoma District Hospital
Embu District Hospital
Mater Hospital- Nairobi
Kisumu General Hospital
Kenyatta National Hospital
Pumwani Maternity Hospital
Kiambu District Hospital
Kitui District Hospital
Machakos District Hospital
Thika District Hospital
Coast Provincial General Hospital
Homa Bay District Hospital
Nkubu District Hospital
Moi - Voi Hospital
Muranga District Hospital
Kapenguria District Hospital
Kisii District Hospital
Wesu District Hospital
Garissa District Hospital
Kilifi District Hospital
Malindi District Hospital
Naivasha Hospital
Msambweni Hospital
Lodwar District Hospital
Kinangop Hospital
Siaya Medical Centre
Kijabe Mission Hospital
Aga Khan Hospital- Nairobi
Taita Taveta Hospital
Mombasa District Hospital
Kakamega Provincial General Hospital
Nyanza Provincial General Hospital
Kerugoya District Hospital

% SCORE
88
85
85
85
85
82
82
79
76
76
76
74
74
71
71
71
71
68
68
68
65
65
65
62
62
62
62
62
62
62
62
59
59
56
56
56
56
56
53
53
53
53
50
50
50
47
47

-69-

NO. OF STEPS
14
14
13
13
13
13
13
14
12
12
12
13
12
13
12
11
10
12
11
10
12
10
10
12
11
11
11
10
10
10
8
10
9
11
9
9
9
8
10
9
9
8
9
9
8
10
9

REMARKS
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared

48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

HOSPITAL
M.P. Shah Hospital- Nairobi
Rift Valley Provincial General Hospital
Kabarnet District Hospital
Nyamira District Hospital
Iten District Hospital
Kericho District Hospital
Kwale District Hospital
Kapsabet Hospital
Pandya Hospital
Kitale District Hospital
Uasin Gishu Memorial
Tumu Tumu Hospital
Aga Khan Hospital - Mombasa
St Marys - Mumias
Busia District Hospital
War Memorial Hospital
Vihiga District Hospital
Siaya District Hospital
Nairobi Hospital
Kijabe Mission Hospital
Machakos Nursing Home
Bethany Hospital- Machakos

% SCORE
47
47
47
44
44
41
41
41
41
41
38
32
32
32
32
32
20
6

NO. OF STEPS
9
9
6
9
6
9
8
7
7
6
6
6
5
5
5
2
4
1

REMARKS
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Declared
Not Evaluated
Not Evaluated
Not Evaluated
Not Evaluated

Table 7: Infant and Under-Five Mortality Rates per 1,000 Live Births
Kenya Fertility
Survey (1967-76)
Infant mortality
Coast
Eastern
Central
Rift
Valley
Nyanza
Western
Nairobi
North
Eastern

1979 Census
Under-five
mortality

129
77
56
64

206
128
85
132

128
109
75

220
187
104
160

KDHS 1989 (1979-89)

KDHS 1993 (1983-93)

Infant
mortality
107.3
43.1
37.4
34.6

Under-five
mortality
156.0
64.3
47.0
50.9

Infant
mortality
68.3
47.4
30.9
44.8

Under-five
mortality
108.7
65.9
41.3
60.7

94.2
74.6
46.3

148.5
132.8
80.4

127.9
63.5
44.4

186.8
109.6
82.1

Rural
Urban

92
82

58.9
56.8

91.2
89.0

64.9
45.5

95.6
75.4

Male child
Female
child
Total

96
85

63.0
54.3

96.1
85.7

66.6
58.6

97.1
89.3

58.6

90.9

62.5

93.2

91

150

-70-

Table 8: Percentage of Children 12-23 Months Who Received Specified Vaccines, 1989

Sex
Male
Female
Residence
Urban
Rural
Province
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
Education
None
Some
primary
Primary
complete
Secondary+
Total

With
health
cards
seen

Some
immun.
on card

Immun
reported
by
mother

BCG

DPT1

DPT2

DPT3+

OPV1

OPV2

OPV3+

Measles

All

63.4
58.7

63.2
58.4

32.7
37.5

96.9
96.5

98.7
99.1

96.6
95.4

90.3
91.0

99.4
99.2

96.2
95.3

92.6
92.1

75.8
80.3

70.0
75.9

49.5
63.1

48.9
62.9

46.9
33.0

96.7
96.7

98.7
98.9

98.7
95.7

94.7
90.1

98.7
99.4

98.0
95.5

94.7
92.0

86.1
76.8

82.1
71.5

47.9
61.0
66.2
73.1
55.0
62.3
55.5

46.5
61.0
65.7
73.1
55.0
62.3
54.6

47.9
36.7
32.0
24.1
39.7
33.9
38.4

92.8
95.6
96.4
97.4
97.8
97.8
95.5

97.1
100.0
99.3
100.0
98.6
97.8
98.3

97.1
99.4
97.1
98.6
95.2
94.4
90.8

94.2
98.2
85.6
92.4
91.7
89.5
80.6

97.1
100.0
99.3
100.0
99.3
99.8
97.4

95.7
100.0
97.1
98.6
96.6
94.6
86.5

94.2
97.9
93.6
96.8
93.3
90.8
78.7

85.5
93.6
71.6
82.0
67.4
77.2
66.2

79.7
87.7
68.7
79.4
64.8
70.7
56.5

53.0
65.3

52.9
64.7

38.1
30.8

96.3
94.7

98.8
98.8

91.6
96.3

77.8
91.2

98.7
99.4

92.7
95.5

86.9
91.8

58.4
76.8

55.1
70.5

66.5

66.5

32.5

98.0

100.0

98.8

96.0

99.8

97.8

95.0

84.7

79.4

56.7
61.0

56.5
60.8

41.2
35.1

98.6
96.7

97.4
98.9

96.3
96.1

95.4
90.7

99.0
99.3

96.3
95.8

95.2
92.4

90.7
78.0

85.8
72.8

Note: The immunization data is according to immunization cards only and exclude mothers histories.
All refers to those who had received BCG, at least three doses of DPT and polio, and measles.
Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1989
Table 9: National Immunization Coverage for Children Aged 12-23 Months, 1992 (%)

Nairobi
Central
Kiambu
Kirinyaga
Muranga
Nyandarua
Nyeri
Coast
Kilifi
Kwale
Lamu
Mombasa
T/Taveta
T/River
Eastern

% with cards
81.8

BCG
99.2

OPV0
96.3

OPV1
98.5

OPV2
97.8

OPV3
95.4

DPT1
98.7

DPT2
97.8

DPT3
96.6

Measles
91.2

Fully Imm.
89.6

82.2
94.0
82.2
89.9
75.2

99.1
98.9
99.6
98.9
99.3

91.1
95.1
88.0
91.1
96.1

98.3
99.5
98.8
97.8
98.6

96.3
99.5
98.8
97.2
97.9

94.8
98.9
97.3
96.1
97.9

98.3
99.5
99.6
98.3
98.6

96.8
99.5
99.2
97.8
98.2

94.3
98.9
98.8
96.1
97.2

91.4
93.4
93.0
92.2
93.6

87.1
93.4
90.7
92.2
90.1

82.2
83.1
91.6
82.6
83.1
66.7

96.8
95.5
99.2
98.3
98.9
82.2

76.7
82.0
91.6
89.2
91.0
48.1

96.0
94.4
99.2
97.3
98.9
80.7

91.7
92.7
97.5
95.1
98.4
77.0

87.0
89.9
94.1
93.1
96.8
75.6

95.3
94.9
99.2
97.1
98.9
80.7

92.1
92.7
97.5
95.3
98.4
77.0

88.5
91.0
96.6
93.1
97.9
75.6

82.6
83.7
90.8
86.2
94.7
68.1

76.3
81.5
87.4
83.8
94.2
65.2

-71-

Embu
Kitui
Machakos
Meru
Isiolo
Marsabit
N/Eastern
Wajir
Garissa
Mandera
Nyanza
Kisii
Nyamira
Kisumu
Siaya
S. Nyanza
Rift Valley
Baringo
Kericho
Nakuru
Nandi
Narok
T/Nzoia
U/Gishu
W/Pokot
Turkana
Kajiado
Samburu
E. Marakwet
Laikipia
Western
Busia
Bungoma
Kakamega
Total Rural
Total Urban
National

% with cards
92.9
85.7
81.3
86.6
95.9
89.3

BCG
100.0
99.2
86.5
98.6
100.0
93.6

OPV0
98.5
84.2
87.0
94.1
67.3
38.6

OPV1
100.0
98.5
96.5
97.6
98.0
92.9

OPV2
99.5
95.5
96.5
95.5
94.9
82.9

OPV3
98.5
91.7
93.0
92.4
89.8
73.6

DPT1
100.0
98.5
97.2
97.9
95.9
92.9

DPT2
100.0
95.5
96.5
95.9
95.9
82.9

DPT3
99.0
95.1
94.0
92.4
90.8
74.3

Measles
94.9
87.6
90.8
84.1
90.8
77.1

Fully Imm.
93.9
84.6
88.6
83.8
78.6
65.0

63.4
26.9
55.5

75.3
43.4
46.7

19.4
13.2
22.6

71.0
30.2
45.3

51.6
16.5
37.2

35.5
14.3
32.1

71.0
28.6
45.3

54.8
16.5
38.0

35.5
14.3
32.1

69.9
46.2
62.8

31.2
12.6
27.7

91.7
90.6
73.8
77.0
83.3

99.2
98.8
94.9
94.7
94.6

83.5
86.5
76.1
84.2
78.3

97.2
98.8
93.3
91.9
90.0

95.7
94.1
86.7
87.1
80.6

89.8
85.3
78.1
76.1
71.0

97.6
98.2
93.5
90.0
90.1

96.1
96.5
86.7
88.0
81.4

90.6
88.2
77.9
78.0
71.8

83.9
77.1
66.3
60.3
61.1

81.1
73.5
63.6
56.9
55.8

82.0
86.6
79.0
87.9
78.9
87.9
85.3
80.9
77.4
83.8
81.3
83.9
83.0

98.2
98.5
99.2
95.5
94.6
98.3
98.7
93.6
96.1
99.5
91.1
92.5
98.2

96.4
92.7
90.4
75.0
62.7
86.1
93.3
78.6
86.5
85.8
63.4
87.4
93.3

97.6
97.7
97.8
95.1
90.4
96.5
96.6
89.6
94.2
93.4
89.3
90.2
97.6

94.6
95.4
96.7
94.3
85.5
93.1
95.8
79.2
88.4
88.3
82.1
86.8
97.0

92.8
93.1
94.8
91.7
79.5
89.6
94.1
69.9
78.7
79.7
80.4
78.7
95.2

98.2
98.1
98.1
95.1
89.8
96.5
96.2
90.8
96.1
95.9
89.3
90.8
97.6

95.2
96.2
97.8
94.3
83.7
91.9
94.5
79.2
89.7
92.4
82.1
86.8
97.6

92.8
94.7
96.4
92.0
79.5
89.6
93.3
71.7
80.6
82.7
80.4
78.7
94.5

85.6
88.5
84.2
81.4
69.9
75.1
87.0
73.4
77.4
80.2
72.3
65.5
89.1

85.0
86.3
82.2
81.1
65.7
73.4
83.6
64.2
68.4
60.9
70.5
64.4
87.9

93.6
74.5
81.3

97.3
95.8
94.9

89.3
74.5
83.8

97.3
90.2
91.7

92.5
88.9
87.6

83.4
84.6
81.9

96.3
92.2
93.0

92.5
88.6
88.9

85.6
83.7
83.5

78.1
69.9
76.2

75.9
68.0
71.7

82.7
82.5
79.7

95.4
99.0
93.0

79.5
93.9
77.8

93.5
98.5
91.4

90.5
97.4
88.6

86.7
94.7
85.0

93.9
98.4
91.6

91.1
97.2
89.0

87.5
95.0
85.8

81.4
88.5
81.2

77.7
86.6
76.7

Note: The data is according to immunization cards and mothers histories.


Source: Kenya Expanded Programme on Immunization (KEPI), National Immunization Coverage
Survey, 1992.

-72-

Table 10: Percentage of Children 12-23 Months Who Received Specified Vaccines, 1993

Sex
Male
Female
Birth order
1
2-3
4-5
6+
Residence
Urban
Rural
Province
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
Mothers
education
No education
Primary
incomplete
Primary
complete
Secondary+
All children

BCG

DPT1

DPT2

DPT3

OPV0

OPV1

OPV2

0PV3

Measles

All

None

% with
cards

96.6
95.9

96.1
95.5

92.8
92.4

87.0
86.7

60.8
62.4

96.5
95.5

93.1
92.2

87.1
86.3

83.2
84.4

78.4
79.0

3.1
3.5

68.3
70.1

96.1
97.6
99.0
92.0

96.5
97.2
98.1
91.2

93.3
94.2
96.4
86.3

89.6
90.1
88.8
77.9

66.4
63.5
63.8
52.7

96.5
97.5
98.1
91.6

93.0
94.2
96.4
86.8

89.5
90.6
88.7
76.9

89.9
89.6
83.3
70.5

85.2
84.8
78.2
64.8

3.5
1.9
0.8
7.3

70.1
65.4
78.9
64.9

98.9
95.8

98.6
95.3

93.7
92.4

92.5
85.8

62.3
61.5

98.6
95.6

93.7
92.5

92.5
85.6

84.0
83.7

80.9
78.3

1.1
3.7

58.7
71.1

100.0
97.4
94.8
99.0
93.6
97.0
93.1

100.0
97.4
95.0
97.8
91.9
97.1
93.1

100.0
95.2
91.1
96.1
88.6
92.9
88.1

100.0
94.4
85.6
90.8
79.6
84.8
82.3

57.8
65.2
72.7
72.4
56.4
56.1
55.8

100.0
97.4
95.0
98.4
91.9
97.1
93.9

100.0
95.2
91.1
96.1
88.6
92.7
88.8

100.0
94.4
85.6
90.7
79.9
85.1
80.9

86.7
94.2
88.0
90.0
76.1
83.3
73.8

86.7
92.6
81.1
85.0
69.7
75.9
69.5

0.0
2.6
4.1
1.0
6.1
2.1
6.1

53.3
65.4
74.5
76.6
60.8
68.8
75.3

89.1
96.9

87.6
96.3

83.2
91.4

74.0
85.8

49.5
60.0

88.1
96.7

83.2
91.8

73.8
85.8

68.9
78.4

63.3
74.5

10.6
2.4

58.7
73.8

98.2

97.9

96.3

89.9

67.1

97.9

96.1

90.1

89.4

83.6

1.7

72.6

98.0

98.4

96.1

93.3

65.2

98.4

96.1

92.5

93.7

88.5

1.3

66.6

96.3

95.8

92.6

86.9

61.6

96.0

92.7

86.7

83.8

78.7

3.3

69.2

Note: The data is according to immunization cards and mothers histories.


Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1993

-73-

Table 11: Prevalence of Diarrhoea and Knowledge and Ever Use of ORS, 1993 (%)

Diarrhoea incidence
Previous 2
Previous 24 hrs
weeks
Age (months)
<6 months
6-11
12-23
24-35
36-47
48-59
Sex
Male
Female
Residence
Urban
Rural
Province
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
Mothers Education
No education
Primary
incomplete
Primary complete
Secondary+
All children

Knowledge and Ever Use ORS


Know about
Have ever
ORS
used

15.0
23.8
24.4
13.0
8.0
4.7

7.8
10.6
10.2
4.1
2.4
1.6

14.3
13.6

5.5
5.5

11.9
14.2

5.1
5.6

83.7
79.0

58.0
58.2

10.8
9.4
15.0
12.2
17.7
11.8
19.2

5.4
2.3
6.1
4.8
7.0
4.3
8.7

78.4
81.4
86.8
77.6
76.3
79.4
81.0

47.3
51.1
69.3
62.1
53.2
60.1
58.4

15.1
15.3

6.7
5.9

73.4
78.5

55.8
58.8

13.9
11.2

5.7
3.6

79.1
86.9

56.3
61.4

13.9

5.5

79.7

58.2

Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1993

-74-

Table 12: Treatment of Diarrhoea, 1993 (%)

Age
(months)
<6 months
6-11
12-23
24-35
36-47
48-59
Sex
Male
Female
Residence
Urban
Rural
Province
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
Mothers
Education
No
education
Primary
incomplete
Primary
complete
Secondary+
All
children

Taken
to
health
facility

Treatment
with ORS
packets

Increased
fluids

Neither
ORS/increased
fluids

Antibiotics

Treatment
Injection
Home
remedy/herbs

42.1
41.3
42.0
38.1
45.3
31.4

17.7
31.3
34.6
32.9
35.4
23.8

42.1
52.6
49.0
50.5
49.7
53.1

50.2
36.7
37.7
37.8
36.1
38.8

14.5
9.8
20.4
12.9
22.1
19.3

7.9
9.5
6.6
4.2
6.7
6.5

35.0
37.2
36.4
33.6
37.9
36.1

26.8
17.5
16.6
16.3
14.5
15.2

45.1
36.5

33.2
29.9

48.1
51.4

38.7
38.4

17.5
15.9

6.7
6.9

37.0
35.0

16.1
18.5

52.5
39.4

40.4
30.5

58.5
48.6

30.3
39.6

29.0
15.2

4.5
7.1

26.5
37.2

12.5
17.9

30.0
39.7
55.5
34.2
41.9
44.6
38.1

10.0
21.6
52.2
27.0
30.1
42.5
25.4

55.0
66.0
36.8
61.2
42.3
48.9
46.3

45.0
30.0
30.8
30.8
45.9
38.3
44.0

20.0
4.2
7.6
18.8
24.9
6.7
24.3

5.0
3.1
5.9
1.7
6.9
4.5
14.9

35.0
46.3
40.3
37.8
35.3
24.5
39.6

15.0
10.0
14.3
11.7
19.4
22.4
19.9

37.9

39.5

51.6

31.8

10.4

4.2

33.8

13.7

35.9

26.3

47.4

42.1

17.9

8.0

34.7

24.0

43.8

31.0

48.8

39.6

10.9

7.9

42.3

12.3

49.1

33.2

53.2

37.9

30.7

5.8

31.5

16.7

40.9

31.6

49.7

38.5

16.7

6.8

36.0

17.3

No
treatment

Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1993

-75-

Table 13: Primary School Retention Rates for 1984, 1985 and 1986 Standard 1 Entrants (%)

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total

100.00
100.00
100.00
81.21
81.00
81.11
75.49
76.24
75.85
73.35
75.10
74.19
65.86
69.59
67.66
64.98
68.46
66.66
70.07
73.17
71.56
46.36
41.61
44.07

100.00
100.00
100.00
85.40
84.07
84.75
80.50
79.32
79.93
75.90
77.49
76.67
71.70
74.12
72.88
66.92
69.53
68.19
75.01
75.16
75.08
52.57
48.25
50.47

100.00
100.00
100.00
84.61
85.12
84.85
75.77
76.88
76.30
74.27
76.08
75.14
66.29
69.50
67.83
63.98
68.83
66.32
65.36
68.95
67.09
44.48
42.21
43.39

Source of basic data: Ministry of Education; and Central Bureau of Statistics, Economic Survey 1994

-76-

Table 14: Households by Main Source of Water in Wet season, 1992 (%)
Others
River
Lake/Pond/Dam
Roof Catchment
Protected Spring
Unprotected
Spring
Protected Well
Unprotected
Well
Borehole
Piped water
Safe water

Coast
Rural
1.22
21.38
18.90
4.13
0.31
4.20

Eastern
Rural
2.14
32.50
6.60
16.29
3.25
9.42

Central
Rural
1.47
26.43
1.64
24.48
1.24
4.04

Rift/V
Rural
1.22
37.72
4.73
11.71
3.57
12.50

Nyanza
Rural
3.77
31.82
15.76
8.12
8.50
16.48

Western
Rural
0.38
11.79
1.13
3.17
14.01
24.59

Nairobi
Urban
7.14
1.61
0.22
0.04
0.00
0.00

Mombasa
Urban
0.00
0.99
0.00
0.00
0.00
0.00

Other
Urban
1.38
5.37
0.41
1.13
0.34
0.45

8.44
4.49

1.88
5.91

2.48
2.77

7.00
4.57

5.55
3.14

7.03
8.02

0.00
0.00

0.26
0.00

10.43
26.51
49.81

0.67
21.34
43.42

5.46
30.00
63.65

2.66
14.34
39.27

3.85
2.99
29.02

19.03
10.86
54.11

0.04
90.95
91.03

0.32
98.43
99.01

Total
2.29
23.59
5.67
10.08
4.27
9.86

Total
Rural
1.84
28.93
7.07
12.57
5.35
12.38

Total
Urban
4.01
3.04
0.27
0.47
0.14
0.18

3.27
0.87

4.26
3.76

5.02
4.65

1.34
0.35

5.15
81.63
91.52

5.02
31.20
54.83

5.77
16.41
45.12

2.12
88.10
92.16

Total

Total
Urban
1.31
3.49
0.35
0.00
0.14
0.44

Source: Welfare Monitoring Survey, 1992


Table 15: Households by Main Source of Water in Dry season, 1992 (%)
Others
River
Lake/Pond/Dam
Roof Catchment
Protected Spring
Unprotected
Spring
Protected Well
Unprotected
Well
Borehole
Piped water
Safe water

Coast
Rural
0.15
20.18
9.61
0.34
0.31
5.22

Eastern
Rural
2.24
41.03
3.75
3.12
4.57
9.07

Central
Rural
0.27
42.28
3.35
2.39
1.58
3.80

Rift/V
Rural
0.87
44.43
6.21
0.60
3.96
12.77

Nyanza
Rural
2.45
37.07
15.27
0.77
10.20
16.32

Western
Rural
0.16
11.79
0.93
0.00
15.56
26.46

Nairobi
Urban
1.34
1.53
0.00
0.00
0.00
0.00

Mombasa
Urban
0.00
0.89
0.00
0.00
0.00
0.00

Other
Urban
1.65
6.63
0.88
0.00
0.34
1.09

1.22
29.29
5.28
1.05
5.03
10.10

Total
Rural
1.19
36.00
6.56
1.33
6.31
12.62

9.59
5.95

2.78
6.89

2.72
5.76

6.52
4.71

5.56
2.84

7.28
7.52

0.00
0.00

0.26
0.00

3.47
0.87

4.43
4.34

5.21
5.38

1.42
0.35

13.44
35.22
58.89

2.30
24.26
37.02

7.47
30.37
44.54

4.49
15.45
31.02

6.05
3.45
26.04

19.87
10.42
53.14

0.08
97.05
97.13

1.48
97.37
99.11

6.01
79.05
88.87

6.58
32.67
49.77

7.61
17.79
38.25

2.61
89.89
94.06

Western
Rural
91.99
0.26
0.42
1.04
0.64
5.65
93.93

Nairobi
Urban
50.20
1.48
4.34
20.69
23.29
0.00
95.66

Mombasa
Urban
75.06
6.25
0.00
11.44
3.83
3.42
96.58

Other
Urban
64.68
3.94
0.69
8.94
20.70
1.06
98.25

Total

Total
Rural
78.00
1.52
0.13
0.84
0.49
19.02
80.85

Total
Urban
58.87
3.02
2.38
14.92
20.00
0.82
96.80

Source: Welfare Monitoring Survey, 1992

Table 16: Households by Type of Toilet, 1992 (%)


Pit
VIP Latrine
Bucket
Water Closet
Pour Flash
None
Sanitary means

Coast
Rural
56.26
0.46
0.00
1.01
0.31
41.96
58.04

Eastern
Rural
76.78
2.17
0.09
0.10
0.18
20.68
79.23

Central
Rural
95.89
1.65
0.00
1.12
0.83
0.51
99.49

Rift/V
Rural
70.32
2.31
0.17
0.81
0.73
25.66
74.17

Nyanza
Rural
68.03
1.10
0.08
1.07
0.13
29.59
70.33

74.07
1.83
0.59
3.73
4.50
15.28
84.12

Source: Welfare Monitoring Survey, 1992


Note: Safe water includes roof catchment, protected spring, protected well, borehole and piped water;
while sanitary means of excreta disposal includes pit latrine, VIP latrine, water closet and pour flush.

-77-

Table 17: Households by Access to Water and Sanitary Facility, 1989 (%)
Urban

Rural

Nairobi

Central

Coast

Eastern

Nyanza

Rift/V

Western

Total

Source of drinking water


Piped into residence
Public tap
Well with hand pump
Well without hand pump
Lake
River
Pond
Rainwater
Other
Safe water

56.1
34.7
2.1
2.3
0.2
3.0
1.0
0.2
0.4
95.4

11.6
6.6
5.9
12.5
1.9
43.9
7.4
1.6
8.6
38.2

57.7
38.1
0.8
1.3
0.0
1.7
0.0
0.2
0.1
98.1

34.0
3.9
6.3
7.6
0.0
38.8
2.7
4.9
1.8
56.7

24.4
32.7
4.0
6.1
0.1
15.7
15.7
0.0
1.2
67.2

15.6
8.8
3.9
22.5
0.1
38.0
3.6
1.0
6.5
51.8

7.6
9.2
6.5
12.1
8.8
27.1
3.4
0.4
25.0
35.8

9.0
5.9
7.0
10.2
0.2
51.9
9.2
1.1
5.6
33.2

13.7
8.8
4.9
5.8
0.2
52.5
11.5
1.0
1.5
34.2

19.3
11.4
5.3
10.7
1.6
36.8
6.3
1.4
7.2
48.1

Sanitation facility
Flush toilet
Pit latrine
Other
No facility/bush/field
Sanitary Means

44.3
50.1
2.5
3.1
94.4

1.5
80.5
1.3
16.8
82.0

46.6
47.1
4.0
2.2
93.7

7.7
90.0
1.9
0.4
97.7

14.5
48.6
0.5
36.4
63.1

0.8
83.8
0.2
15.2
84.6

4.9
77.6
0.5
17.0
82.5

5.0
70.4
1.2
23.4
75.4

7.4
81.1
3.2
8.3
88.5

8.9
75.2
1.4
14.5
84.1

Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1989

Table 18: Households by Access to Water and Sanitary Facility, 1993 (%)
Urban

Rural

Nairobi

Central

Coast

Eastern

Nyanza

Rift/V

Western

Total

55.8
31.4
0.9
2.1
0.1
1.6
0.6
6.6
0.8
90.8

10.7
8.9
10.8
14.6
8.7
41.2
2.6
1.9
0.5
47.6

65.0
27.3
0.0
0.2
0.0
0.0
0.0
6.8
0.8
92.5

27.4
10.7
5.5
13.6
1.9
33.2
5.2
1.5
1.0
62.4

15.8
37.4
13.6
5.4
9.4
12.1
0.5
5.4
0.4
72.7

14.8
11.6
3.3
13.5
7.1
45.8
2.5
1.3
0.2
45.7

3.5
8.4
8.2
7.3
21.8
43.7
1.3
5.0
0.9
28.7

15.9
9.8
5.0
15.2
4.6
44.0
2.8
2.1
0.8
48.7

14.4
5.3
31.2
21.7
2.5
23.2
1.1
0.7
0.0
73.7

19.4
13.2
8.9
12.2
7.1
33.6
2.2
2.8
0.6
55.9

23.5
21.4
42.3
6.9
2.1
3.0
0.9
94.1

1.1
0.5
71.4
5.9
20.3
0.3
0.5
78.9

19.3
34.0
36.5
3.3
3.1
3.1
0.8
93.1

2.0
1.2
83.3
10.3
0.8
1.2
1.3
96.8

5.9
3.8
58.1
7.9
23.7
0.1
0.5
75.7

2.1
1.0
73.4
5.4
17.8
0.0
0.4
81.9

1.5
1.6
61.7
4.3
29.9
0.2
0.8
69.1

6.9
3.5
55.6
6.2
26.0
1.5
0.3
72.2

7.2
0.7
80.2
4.1
7.6
0.0
0.3
92.2

5.4
4.5
65.8
6.1
16.8
0.8
0.6
81.8

Source of drinking water


Piped into residence
Public tap
Well with hand pump
Well without hand pump
Lake/pond
River/stream
Rainwater
Other
Missing/Dont know
Safe water
Sanitation facility
Own flush toilet
Shared flush toilet
Traditional pit toilet
Ventilated improved pit latrine
No facility/bush/field
Other
Missing/Dont Know
Sanitary Means

Source: National Council for Population and Development, Kenya Demographic and Health Survey,

1993

-78-

Table 19: Households by Source of Water and Type of Excreta Disposal for Selected Districts (%)
KITUI (MAY 1992)
Rural
Urban
Total

Rural

MIGORI (1993)
Urban
Total

Rural

KURIA (1993)
Urban

Total

Sources of Water
River
Lake
Piped water
Protected spring
Unprotected spring
Open well
Protected well
Roof catchment
Dams
Borehole
Rock catchment
Kiosk

67.47
0.00
6.30
0.13
3.37
7.37
0.33
1.73
7.90
0.23
5.17
0.00

67.22
0.00
15.55
0.55
0.00
0.00
0.00
1.11
0.00
15.55
0.00
0.00

67.45
0.00
6.82
0.15
3.17
6.94
0.31
1.69
7.45
1.10
4.87
0.00

29.00
12.90
0.50
7.80
27.10
7.30
10.90
0.00
4.30
0.20
0.00
0.10

6.00
0.00
12.00
26.00
25.00
16.00
14.00
1.00
0.00
0.00
0.00
0.00

27.50
12.00
1.20
9.00
27.00
7.90
11.40
0.10
4.00
0.20
0.00
0.10

17.20
0.00
0.20
7.40
67.60
7.30
0.20
0.20
0.00
0.00
0.00
0.00

0.00
0.00
0.00
58.00
0.00
32.00
8.00
2.00
0.00
0.00
0.00
0.00

15.90
0.00
0.20
11.00
62.80
9.00
0.80
0.30
0.00
0.00
0.00
0.00

Reliability
Safe water

64.97
8.72

38.33
32.76

63.46
10.07

86.40
19.40

94.00
53.00

86.90
21.90

90.60
8.00

100.00
68.00

91.30
12.30

Type of Excreta Disposal


Ordinary pit latrine
VIP latrine
Bucket latrine
Septic tank
Communal latrine
Pour flush
None
Sanitary means

34.00
2.47
0.00
0.13
3.13
0.00
60.27
39.73

57.22
20.56
0.00
0.00
0.00
11.11
11.11
88.89

35.31
3.49
0.00
0.13
2.96
0.63
57.48
42.52

0.30

3.00

0.50

0.50

7.00

0.90

0.30
32.40

0.30
85.60

0.30
35.80

0.50
42.70

0.00
83.00

0.40
45.60

67.00
33.00

11.00
88.90

63.40
36.60

56.30
43.70

11.00
90.00

53.00
46.90

Source: Ministry of Health, Division of Environmental Health, Water and Sanitation Survey: Kitui
District (May 1992), and Rapid Assessment of Water Supply and Sanitation Coverage in Migori and
Kuria Districts (November 1993).

-79-

ANNEX 4: REFERENCES
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ANNEX 5: LIST OF PERSONS INTERVIEWED


MINISTRY OF HEALTH
Division of Family Health
Dr. K.L. Chebet
Manager, Kenya Expanded Programme on Immunization
Dr. C. Osir
Deputy Manager, Kenya Expanded Programme on Immunization
Mrs. M. Mwangi
Training Officer, Kenya Expanded Programme on Immunization
Mrs. B.R.A. Shako
Deputy Chief Nutritionist
Miss Ruth Wamatuba Nutrition Officer, in-charge-of Micronutrient Programme
Dr. J.M. Makhulo
Manager, Control of Diarrhoeal Diseases (CDD)
Mrs. Joy Opumbi
Training Officer, Control of Diarrhoeal Diseases (CDD)
Mr. Charles Kinuthia
Medical Records Officer, Kenya Expanded Programme on Immunization
Miss Elizabeth Akinyi Statistical Clerk, Control of Diarrhoeal Diseases (CDD)
Mrs M.A. Okoth
Nutritionist, Growth Monitoring Programme
Mrs Edith Pam Malebe Nutritionist/National Coordinator, Breast-Feeding Programme
Health Information System
Dr. C.K. Sigei
Head, Health Information System
Mr. G. Kimani
Economist/Statistician
Mr. A.M. Runyago
Economist/Statistician
Mr. D. Mutua
Head of Computer Section, Health Information System
Division of Environmental Health
Mr. K.A. Ajode
Deputy Chief Public Health Officer
Mr. J.G. Kariuki
Public Health Officer
Mr. J.M. Waithaka
Senior Public Health Officer

Mr. G.A.N. Lusweti


Mrs. M.W. Njoroge
Mr. B.N. Gachanja
Mr. T.M. Katembu
J.M. Oduor
Mrs. Margaret Kabiru
Mr. Kimani Gichia

Mrs. V.M. Nyaga

MINISTRY OF EDUCATION
Deputy Director of Education, in-charge-of Pre-Primary, Primary, Special
Education and Field Services
Assistant Director of Education, in-charge-of Pre-Primary Education
Assistant Director of Education, in-charge-of Primary Education
Economist/Statistician, in-charge-of Education Statistics Section
Statistical Officer, Education Statistics Section
Principal Coordinator, National Centre for Early Childhood Education
Senior Lecturer, in-charge-of Research and Evaluation, National Centre for
Early Childhood Education

MINISTRY OF ENVIRONMENT AND NATURAL RESOURCES


Deputy Coordinator, National Environmental Action Plan

Mrs. Vicky Kattambo

KENYA LAW REFORM COMMISSION


Senior Principal State Counsel

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MINISTRY OF PLANNING AND NATIONAL DEVELOPMENT


Mr. E.S. Osundwa
Chief Economist, and National Coordinator, National Programme of Action
(NPA) for World Summit for Children Goals
Mr. W.O. Okello
Economist/Statistician, Food and Nutrition Planning Unit, HRSS
Mr. J.O. Owuor
Economist/Statistician, Food and Nutrition Planning Unit, HRSS

Mr. P.P. Kallaa


Mr F. Z. Omoro
Mr. J.B. Kirimi

CENTRAL BUREAU OF STATISTICS


Director, Central Bureau of Statistics
Deputy Director, Central Bureau of Statistics
Principal Economist/Statistician

UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT


Ms. Millie Howard
Family Planning Services and Support (FPSS), Office of Population and
Health
NATIONAL COUNCIL FOR POPULATION AND DEVELOPMENT
Mr. P.W. Thumbi
Assistant Director, NCPD

Dr. M. Patel
Ms. J. Mpungu
Ms. M. Murage
Dr. I. J. Uhaa

UNICEF, East and Southern Africa Regional Office


Monitoring and Evaluation Officer
Consultant, Monitoring and Evaluation Office
Consultant, Convention on the Rights of the Child (CRC)
Senior Project Officer, Dracunculiasis Eradication Programme

Mr. A. Okinda
Mr. F. Kamondo
Mr. B. Makotsi
Dr. G. Ho-Sang
Dr. J. Ojiambo
Ms. J. Mambo
Mrs. G. Syongoh
Mr. S. Makondiege
B.O.N. Oirere

UNICEF, Kenya Country Office


Project Officer, Monitoring and Evaluation
Chief, Integrated Community-Based Programmes
Economist
Chief, Health and Nutrition Section
Project Officer, Expanded Programme on Immunization (EPI)
Project Officer, Nutrition
Project Officer, Education
Project Officer, Water and Sanitation
Project Officer, Primary Health Care (CDD, ARI) programmes

POPULATION STUDIES AND RESEARCH INSTITUTE


Professor John Oucho Director, PSRI

Mrs. Grace Maina

MINISTRY OF CULTURE AND SOCIAL SERVICES


Family Life Training Programme

Mr. Lee Muthoga

MUTHOGA GATURU & CO ADVOCATES


Advocate

Mr. C. Mullei

INTERNATIONAL COMMISSION OF JURISTS (KENYA CHAPTER)


Programme Secretary
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