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ADDRESSING DETERMINANTS OF HEALTH THROUGH INTERSECTORAL COLLABORATION: FISH FARMING PROJECT IN SOUTH IMENTI CONSTITUENCY IN MERU COUNTY, KENYA

CONTENTS1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.1 Study setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.2 Data collection methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.3 Methodological limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3 General Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.1 Kenya context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.2 Meru County context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.3 Fish farming in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

4 Initiation of the economic stimulus programme and . . . . . . . . . . . . . 6 governance structures

4.1 Process of intersectoral actions . . . . . . . . . . . . . . . . . . . . . . . . . . . 75. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

5.1 Socio-demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . 85.2 Fish farming as a source of food security and nutrition intake 95.3 Importanceoffishfarmingasaneconomicactivity . . . . . . . . . . 95.4 Technicalskills-fishmanagement,handling,storage . . . . . . . 10

and preparation skills5.5 The host’s community cultural practices that . . . . . . . . . . . . . . 11

influencefishfarming6. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

6.1 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.2 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Kenya intersectoral case study

WHO/AFRO Library Cataloguing – in – Publication

Addressing determinants of health through intersectoral collaboration: fish farming project in South Imenti constituency in Meru County, Kenya

1. Fishes 2. Fish Products – economics – supply and distribution3. Food Supply4. Social determinants of health5. Socioeconomic factors6. Cooperative behavior7. Food Industry - organization and administration

I. World Health Organization. Regional Office for Africa

ISBN: 978-929023271-1(NLM Classification: WA 703)

© WHO Regional Office for Africa, 2013

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro.who.int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specif ic companies or of cer tain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use.

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1. IntroductioneGlobally,thefisheriesindustryplaysanimportantroleineconomicandsocialdevelopment.InKenya,thisindustrycontributestolocalincomes,subsistenceandnutrition,whichareallimportantdeterminants of health. Food and livelihood security can accelerate the Millennium Development Goals (MDGs) in Kenya. These and other determinants of health have positive consequences for population healthoutcomesandyieldgreaterandsustainablereturns.Forexample,thefisheriesindustrysupportsoveronemillionpeopleandprovideslivelihoodstomanyotherKenyans.Theexportoffishandfisheryproducts earns the country an average of USD 70m (KES 5.3 billion) annually and could increase if aquacultureorfishfarmingpotentialwerewelltapped.Thefisheryindustrypresentlycontributesabout5% to the National GDP and has the potential to rise to 8% by 2015.

The Government of Kenya in its governance role is committed to the policy of sustainable development asdemonstratedinthePovertyReductionStrategies(PSR),theEconomicRecoveryStrategy(ERS)forWealthandEmploymentCreation,aswellasthesocialpillaroftheKenyaVision2030andtheEconomicStimulusProgramme.Inparticular,theintersectoralEconomicStimulusProgramme(ESP)waslaunched to address food insecurity and mitigate the effects of the 2007 post-elections violence and the globaleconomicandfinancialcrisis.TheESPwasintroducedthroughthe2009/2010budget,entitled‘Overcoming Today’s Challenges for a Better Kenya Tomorrow’(Government of Kenya 2009). The ESP wasallocatedKES22billion,whichwascommittedtonumerousprojectsforeachconstituency.EachconstituencyreceivedoverKES100millionfunding,aimedatsupportingintersectorallocaldevelopmentprojects.AccordingtotheMOF,intersectoralcollaborationandstakeholderparticipationinidentifyingandimplementingprojectsallowsprioritizationofsocialanddevelopmentneedsanddesignofhome-

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grown interventions to address their respective challenges (Government of Kenya 2011). The sectors thatbenefitedfromtheESPfundsallocatedwereeducation,healthandsanitation,environment,localgovernment,industrialization,foodproductionandfisheries.Theprojectsinthesesectorswereintendedtocreateemployment,provideessentialservices,jobsandbusinessopportunities,includingensuring enough food at the constituency level (Government of Kenya 2009).

Amongthenumerousintersectoralprogrammesintroducedwasthefisheriesdevelopmentprogramme.Theprogrammeconsistedofconstructionoffishpondsin140constituenciesinKenyaandstockingthemwithfingerlings.Themainaimofintroducingfishfarmingwastoimprovenutritionandcreateover120000employmentandincomeopportunities.ImentiSouthconstituencywasoneofthebeneficiariesoftheGovernmentESPfishfarmingoraquacultureinitiative.Culturally,Merucommunitiesarenotknowntopractisefishfarmingorconsumefish.Therefore,thepurposeofthiscasestudywastoexploretheextenttowhichfishfarminginImentiSouthhadimprovedfoodnutritionofhouseholdmembers and impacted on household employment and income – the underlying determinants of health. Thecasestudycoversaperiodofthreeyears(2010-2013),soastocapturetheperiodbetweentheprojectimplementationphaseandfirstwaveofenterprisedevelopment.

2. MethodologyThestudyisdescriptiveinnatureanditadoptedamultiple-methodsdesign,combiningbothqualitativeand quantitative data collection approaches to explore the questions of interest.

2.1 Study design and setting

DatawerecollectedintheImentiSouthconstituency,locatedintheEasternpartofKenyaandspecificallyinMeruCounty.Theconstituencywaschosenbecausehistoricallyitdidnotengageinfishfarming. Imenti South has around 197 604 people and their dependants. Coffee and tea are the main cash crops and sources of income in the district. Data were collected from four purposefully selected divisionsoutofthesix(Mitunguu,IgojiEast,IgojiWest,AbogetaEast,AbogetaWestandNkuene)intheconstituency.Fisheriesofficersandcommunityleaderswereconsultedabouttheirviewsontheselectedsites,toensurethattherewasabuy-inforthestudy,tomaximizeparticipationandensurecooperation with research staff.

2.2 Data collection methods

DatapresentedinthispaperaimstoexploretheextenttowhichfishfarminginImentiSouth,hadanimpactonnutrition,employmentandincomeofhouseholdmembers,hencereducinginequitiesassociated with these important determinants of health in Kenya. Quantitative data was collated using aquestionnairetoexplorethevariablesofinterest.Atotalof132fishfarmersweresampledoutofthe200benefitingfromtheinitialGOKProgramme.Qualitativedatainvolvedsixin-depthinterviews(n=six)conductedwithkeyinformants(consistingoftwofisheriesofficers,twocommunityleadersandtwocommunityhealthofficers).ImentiSouthconstituencywaspurposefullyselectedfortworeasons:1)theconstituencywasoneofthebeneficiariesoftheGOKfishfarmingESP;and2)traditionallyitwasnotknowntoengageinfishfarminguntiltheintroductionoftheESP.Theselectionofparticipantswas undertaken in consultation with the Kenya Ministry of Fisheries and Imenti South constituency keystakeholders.All200householdsengaginginfishfarmingintheselecteddivisionsweremappedandgivenauniqueidentificationnumber.Atotalof33householdsperdivisionwerethenrandomlyselected from a complete list of 200 households. All selected households were contacted with the help offisheriesofficersandconsentedtoparticipateinthestudy.Thequestionnairewasthenadministeredbytworesearcherswithinaperiodofthreeweeks.Keythemesincludedinthequestionnairewere:householdfishconsumption(impactonnutrition),salesoffish(livelihoodsecurity),creationofemploymentduetofishfarming,fishpondsmanagementtraining,knowledgeoffishfarmingandbehaviour change.

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In-depthinterviewswereconductedseparatelyandwereaudio-recordedandfieldnotestaken.Quantitative data was analysed using Microsoft Excel and qualitative data was transcribed and typed into Microsoft Word and transferred to Nvivo 8 for analysis. Data were analysed using the thematic framework approach.

2.3 Methodological limitations

Duetotimeconstraint,theresearcherswerenotabletoincludealargersamplesize.ItwasalsonotfeasibletoexploretheextenttowhichfishfarmingandconsumptionmighthavecontributedtonarrowingmorbidityandmortalityamongbeneficiariesoftheGOKprogrammeinImentiSouthconstituency.Amoredetailedstudywouldberecommendedtoinvestigatetheextenttowhichfishfarminghashadanimpactonpopulationhealthoutcomes,hencereducinghealthinequities.

3. General Background3.1 Kenya Context

The republic of Kenya lies astride the equator on the Eastern seaboard of Africa and has an estimated38.7millionpopulation(KNBS2010),withaprojectedannualgrowthrateof2.9percent.Administratively,Kenyaisdividedinto47countiesaccordingtothenewConstitution(NationalCouncilofLaw2010).Incommonwithmanydevelopingcountries,thepopulationstructureisyoung,withabout60%undertheageof20.Lifeexpectancy,whichhasbeenonthedecline,isestimatedtobe54.2years(Table1.0)andisexpectedtofallfurtherduetotherisingincidenceofHIV(GovernmentofKenya2009;UNDP&WHO2009)andpovertylevels.EventhoughpovertyinKenyadeclinedfrom56%ofthepopulationin2000to47.2%in2009,extensivedifferencesstillremainacrossthedifferentregions of the country. The areas that are less fortunate economically are also those underserved by health resources. The criteria used previously for allocating resources did not explicitly correct to favour underservedareas,andtendedtoleavethoseinpoorareaswithverylimitedprotection.Thishasresulted in persisting historic inequities in health outcomes between different population groups.AsdemonstratedinTable1,only32%ofthepopulationhadsustainableaccesstoimprovedsanitationand 59% had access to improved drinking water sources in 2008. Infant mortality rates (IMRs) were 57 IMRsper1,000livebirthsfortherichestquintilecomparedto66inthepoorestquintile.Theunder-fivemortalityrate(U-5MR)amongtherichestquintilewas13per1,000livebirthscomparedto34reportedin the poorest quintile (KNBS and ICF Macro 2010).

Table 1: CounTry eConomiC and healTh indiCaTors

Source: World Bank, 2008; Food and Agriculture Organization, 2007; World Health Organization, 2008

Economic Indicators

Total population (million) - 2008 38.8

Population growth rate – 2008 2%

GNI per capita, $ PPP - 2008 1560

Population below 1$ PPP per day - 2005 19%

Rural population - 2008 78%

Agriculture, value added (% of GDP) - 2008 26%

Food Consumption

Undernourished population - 2005/2007 31%

Cereal share in total dietary energy consumption - 2007 49%

Health Indicators

Pop. with sustainable access to improved sanitation - 2008 32%

Life expectancy at birth (years) both sexes - 2008 54

Pop. with access to improved drinking water sources - 2008 59%

Prevalence of HIV among adults aged >= 15 years - 2005 6%

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Access to affordable healthcare is a challenge for many Kenyans due to poverty. According to the HouseholdandHealthExpenditureReport2007,44%ofKenyanswhofellsickdidnotseekhealthcareservicesduetolackoffinances.ThestudyonWell-BeinginKenyaalsoindicatedthatover40%ofthepoorpopulationundertookself-diagnosiswhensick(KNBS2007a),duelargelytoinaccessibilityandaffordabilityofhealthservices.InKenya,inequitiesinhealthsectorfinancingpersist.Forexample,government health expenditures as a percentage of total government expenditures declined from eightpercentin2001/02to4.6percentin2009/10(GovernmentofKenya2010;KNBS2010)despitegovernment commitment to increase the health budget to 15% (WHO 2010).

ThehealthsectorinKenyacontinuestobepredominantlyfinancedbyprivatesectorsources,mainlyhouseholds’out-of-pocketspending,whichiswell-recognizedasaninequitableandinefficientmeansoffundinghealthcare(WHO2005;WHO2010).Althoughthepoorspendlessinabsolutetermsthanthebetter-off,alargershareoftheirhouseholdexpenditureisdevotedtomeetingtheirhealthcareneeds.Currently,theGovernmentofKenyahasmadeacommitmenttoprioritizehealthintheVision2030(GovernmentofKenya2010)andEconomicRecoveryStrategy(GovernmentofKenya2003).Inaddition,KenyamadeacommitmenttotheAbujaDeclaration2001,toincreasehealthallocationsto15percentoftotalgovernmentexpenditureonhealth(WHO2005).Withpoliticalwillingness,thisincreasecanbeachievedthroughincreasedfiscalspaceforhealth,giventhatKenyaisoneofthefewcountriesinAfrica that has recorded tremendous improvement in tax revenue. It did this by strengthening the tax administrativesystem,whentherewasachangeingovernmentin2002(KRA2010).

Asaresultofgrowthinrevenueinthelast10years,theKenyangovernmenthasachievedkeymilestones,includingrevivaloftrade,tourismandagriculturesectors,whicharealldeterminantsofhealth.Inparticular,thegovernmentadoptedastrategytoexpeditecommercialfishfarming(aquaculture)growththroughacollaborativeandparticipatoryapproach,involvingbothpublicandprivatesectors under Public-Private Partnership (PPPs). This intersectoral collaboration strengthened the total quantityoffishproducedinthecountryto149.0thousandtonnesfrom140.8thousandtonnesin2010,a5.8percentincrease.Thequantityoffreshwaterfishproducedincreasedby6.2percentto140.5thousandtonnesfrom132.3thousandtonnesin2010.Productionfromfishfarmingincreasedsignificantlyfrom12.2metrictonnesin2010to19.3metrictonnesin2011.Thiswasattributedtoanincreaseinareaoffarmedfishasaresultofthegovernment-fundedfishfarmingthroughtheEconomicStimulusPackage(ESP).Undertheprogramme,27392fishpondswereconstructedin140constituenciesandstockedwithover23.5millionfingerlings,therebyincreasingtheareaunderaquacultureto14076hectaresin2011(GovernmentofKenya2009;KNBS2010).Theaimoftheprojectwastoaddressthebroaderdeterminantsofhealthrelatedtonutrition,improvingfoodsecurity,creatingemployment and increasing household income generating activities. One of the constituencies to benefitfromtheintersectoralgovernmentESPprogrammewasImentiSouth,MeruCounty.

3.2 Meru County Context

MeruCountyislocatedinEasternKenyaborderingIsioloCountytotheNorthandNorthEast,TharakaCountytotheSouth,NyeriCountytotheSouthWest,andLaikipiaCountytotheWest.Itcoversanarea of about 6936 km2. In 2009 the population was estimated at around 1 356 301 million with a density of 196 people per square kilometre (Government of Kenya 2009). Imenti South constituency populationstructureisyoung,withabout40%undertheageof15comparabletothenationallevel.Theproportion of the population aged 65 years and above is about 4.4%. The sex distribution is slightly in favouroffemales(50.6%).Intermsofahealthindicator,infantmortalityrates(IMRs)are39per1,000live births (KNBS and ICF Macro 2010). According to the Kenya Integrated Household Budget Survey (KIHBS)2008,thepovertyratewasestimatedat28.3%comparedto47.2%fornationallevel(KIHBS2008).

Administratively,MeruCountyisdividedintoseven(ImentiNorth,ImentiCentral,TaganiaWest,Tagania

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East,IgembeNorth,IgembeSouthandImentiSouth)constituencies,eachofwhichissub-dividedintoanumberofwardsordivisions.ThemaineconomicactivitiesinMeruareMiraatrade,tobacco,teaandcoffeefarmingandfishfarming.ThiscasestudyfocusesonfishfarminginImentiSouthConstituencyandexplorestheextenttowhichfishfarminghashadanimpactonnutrition,improvedfoodsecurity,created employment and increased household income.

3.3 Fish Farming in Kenya

FishfarminginKenyabeganin1920anduntilthemid-1990s,theactivityfollowedapatternsimilartothatobservedinmanyAfricancountries,characterizedbysmallponds,subsistence-levelmanagement,andverylowlevelsofproduction(NgugiC,BowmanJ.Retal.2007;MwangiM.H.2008).In1960,thegovernmenthelpedincreasethepopularityofaquaculturethroughthe“eatmorefish”healthpromotioncampaign.Asaresult,Tilapiafishfarmingexpandedrapidlywiththeconstructionofmanysmallponds.Nonetheless,theinitiativefailedinthe1970’sduetoinadequatefishfarmingservices,lackofqualityfingerlingsandinsufficienttrainingoffishfarmingworkers.Bythe1990’sthereemergedsmall-scalefishfarming(aquaculture)atdifferentlevelsinKenyaforsubsistence(GitongaandAchoki2003).Sincethen,aquacultureinKenyahastakenmanydifferentforms,rangingfromthesmallhand-dug‘kitchenponds’,tolargeearthpondsof1000m2.Damsandotherimpoundmentsusedforstoringwaterareoftenstockedwithfishandthemostcommonspeciesfarmedaretilapia,catfish,troutandgoldfish.ThedifferentaquaculturesystemsusedinKenyavaryconsiderably,accordingtotechnologicaladvancementand the level of investment and management. AccordingtoFAO(2004)aquaculturewasabletomakeanimportantcontributiontopovertyalleviation,foodsecurity,andsocialwell-being,i.e.asasourceofincome(FAO2004).Aquaculture,thefarmingofaquaticorganisms,includingfishisoftencitedasanefficientmechanismforincreasingfoodproduction.Fish provides a good source of protein and essential micronutrients and thus plays an important role in thepreventionofmanyhumandiseases(WilliamsM.J.andPoh-SzeC.2003;FAO2008).Fishfarmingalsoreducesfishingpressureonouroceans,lakesandrivers(FAO2009).

Overall,thegovernmentofKenyarecognizedthatdevelopmentofaquaculturecouldplayaleadingroleinacceleratingtheMillenniumDevelopmentGoals,particularlyinpovertyreductionandasasourceofalternativefish,insteadofrelyingonthenaturalecosystem,whichisindecline(Gitongaand Achoki 2003). Fish farming improves human well-being in a number of ways that support the Millennium Development Goals (MDGs) and tackle the social and economic determinants of health. Thedirectbenefitsassociatedwithfishfarminginclude:greaterfoodsecurity,improvednutrition,supplementalincome,andlivelihoodoptions.Theapproachcanbringsignificantindirectbenefitsaswell,bycontributingtoeconomicgrowth,easingpressureonincreasinglyscarcestocksoffishinthewild,improvinghealthandempoweringmarginalizedpopulationgroups,particularlythoseresidinginruralareas.Currently,the“eatmorefish”healthpromotioncampaignhasbeenrenewedthroughmultisectoralcollaboration,involvingtheMinistryofHealth,MinistryofAgriculture,LivestockandFisheries,MinistryofPlanning,MinistryofFinanceandprivatestakeholdersinKenya.Thenextsectiondescribes the ESP policy initiation and governance structures put in place to ensure accountability and monitoring and evaluation of the intersection programme

4. The Intersectoral Economic Stimulus Programme initiation and governance structuress

TheEconomicStimulusProgramme(ESP)wasintroducedbytheGovernmentofKenya,MinistryofFinanceastheleadsector.ESPwasintendedtobeashort-tomedium-term,high-intensityandimpactprogramme,whichwasmeanttojump-starttheeconomytowardslong-termgrowthanddevelopment,by securing the livelihood of Kenyans and addressing the challenges of regional and inter-generational

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inequity. The programme was intersectoral and focused on sectors that will generate maximum benefit,restoreconfidenceandhelpthebusinesscommunitytoweatherthestorm,whileprotectingthelivelihoodofpoorpopulationsandcreatingjobsfortheyouth(GovernmentofKenya2009).SomeoftheactivitiescoveredunderESPincluded:expansionofirrigation-basedagriculture,constructionofwholesaleandfreshproducemarketsandfishponds.

KeyobjectivesofESPincluded:boostingthecountry’seconomicrecoveryandreturningittotheenvisionedmedium-termgrowthplan,investinginlong-termsolutionstothechallengesoffoodsecurity,expandingeconomicopportunitiesinruralareasforemploymentcreation,andpromotingregionaldevelopmentofequityandsocialstability.Theseobjectivesweretobeachievedthroughintersectoralcollaborationconsistingofpublic-privatepartnerships.Inparticular,aquaculturewasimplemented collaboratively and the intervention was intended to improve nutrition and create employmentandincomeopportunities.Over200fishpondswereconstructedineachconstituencyat an estimated cost of KES 12 million per constituency including Imenti South. In each constituency potentialfishfarmerswereallocatedaseedfundingofaboutKES40000thousandtoconstructapondandwereprovidedforfreewithonethousandfingerlingsandfishfeed.Thefarmerswerealsoempoweredwiththerelevanttechnicalinformationandeducatedonwhichfishspecieswerebestsuitedtotheirsitesandhowtocareforthefingerlingstoensurefishfarmingwasasustainableventureintheregion.Theyreceivedcontinuoussupportrelatingtofishmarketingchannels,improvementofinfrastructure,andinformationprovision.Thenextsectiondepictstheprocessofintersectoralactionsby the GOK through the economic stimulus programme.

4.1 Process of intersectoral actions

Differentgovernmentsectors(health,housing,employment,economicdevelopment,tradeandindustrialization,finance,environmentandsustainability,socialsecurity,education,urbanplanning,genderandagriculture)influencehealth(CSDH2008).TheGOKacknowledgesthatproblemsofpoverty,hunger,poorhealth,lackofeducation,socialandeconomicinequalitiesandenvironmentarecommonly interconnected and an intersectoral approach in healthy public policy formulation would be necessary to ensure sustainable improvements to the health and well-being of the disadvantaged population(GovernmentofKenya2010).Forexample,theGOKEconomicStimulusProgrammewasacomprehensive,mutually-supportivepolicy,designedtoachieveagreedgoalsthroughanintersectoralapproach and stakeholder participation. Involvement of different sectors in implementing public policies advances the broader determinants of health and acknowledges that good health is instrumental for achieving social and economic development goals. The failure of public policies to involve relevant sectorsandcitizensinwiderdevelopmentstrategiesmaycauseunderdevelopment.Inparticular,publicpolicies that aim to improve population health ought to be integrated with transformative economic and social development policies that can be more effective in addressing health determinants (Leppo K.,OllilaE.etal.2013).Thefisheriesprojectadoptedastrategytoexpeditecommercialfishfarminggrowththroughacollaborativeandparticipatoryapproach,involvingbothpublicandprivatesectorsunder Public-Private Partnership (PPPs).

The overall ESP was implemented with an aim of tackling underlying determinants of health and membersofthepublichadaresponsibilitytomonitorpublicdevelopmentprojectstoevaluatehowwellpublicresourceswerebeingusedandhowtoimproveperformance.Inparticular,theESPensuredmaximumintersectoralstakeholderandcommunityparticipationtoensuretransparentidentificationandimplementationoftheprojects,thatfundsweremanagedaccountably,andprojectswerecompletedandgovernedeffectivelytobenefitthetargetedcommunities(GovernmentofKenya2011).

Governance and leadership of the intersectoral ESP was provided by the Ministry of Finance (MOF) and Ministry of Fisheries. This was done to ensure accountability and community participation in theintersectoralESPprojectsweremanagedattheconstituencylevelbytheDistrictInfrastructure

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andtheStimulusProjectManagementCommittee(SPMC),whoseresponsibilityitwastoidentifytheappropriateprojectlocation,makepaymentsrecommendationsinconsultationwithrelevantandtechnicalministriesandmonitorimplementationofESPprojects.TheintersectoralSPMCteamconsistedofaMemberofParliamentasthepatron,theDistrictCommissioner,DistrictDevelopmentOfficer,DistrictPublicWorksOfficer,CommunityDevelopmentFundCommittee(CDFC)Chairperson,SecretaryandTreasurer,DistrictAccountant,headsofalldepartments,non-governmentalandreligiousorganizationsrepresentatives,twomenandwomenrepresentativesfromtheconstituency,twoyouthrepresentatives,theCDFCFundAccountManagerandConstituencyProjectsTechnicalCommittee(CPTC)andtheKenyaPrivateSectorAlliance(GovernmentofKenya2010;RepublicofKenya2010).TheroleoftheMinistryofHealth(MOH),incollaborationwithotherstakeholders,wasfirstandforemosttopromotefishconsumptionbenefitsthroughlocalhealthfacilitiesandoutreachactivitiesparticularlyduringmarketdays.ToensureeffectiveimplementationandmonitoringoftheESPprogramme,intersectoral and stakeholders meetings were held twice a month at the national (coordination and monitoring) and constituency (implementation) level.

AccordingtotheMOF,intersectoralandstakeholders’participationintheproject’sidentificationandimplementationallowedprioritizationofsocialanddevelopmentneedsandthedesignofhome-grown interventions to address their respective challenges (Republic of Kenya 2011) mainly health determinants.ThisstudyaimedtoinvestigatetheextenttowhichintersectoralESPfishfarmingprojects,identifiedasoneofthekeyactivitiesthatcouldcontributetofoodandlivelihoodsecurityandpovertyalleviationinruralKenya,hadachievedtheirobjectives.Thenextsectionpresentsthestudyfindings.

5. Results5.1 Socio-demographic characteristics

Table 1 presents an overview of the socio-demographic and economic characteristics of the respondents interviewed. A total of 132 households participated in the cross-section survey with 66% sampled from each of the four divisions. In each household a single individual was interviewed. The majority(72.7%)offishfarmersweremen,withonly27.3%women.Themajorityoftherespondentsweremaleswhorepresented72%ofthetotalsampletaken,whilewomencomprised27%.Thismaybe an indicator of who controls the units of ownership and family income. Most people were aged over 30years(70.1%).About56.1%offishfarmershadprimaryleveleducation,34.1%hadsecondaryleveleducation,and11%hadbeeneducatedtopolytechniclevel.Only2%ofthefishfarmershaduniversityleveleducation.Among33.3%offishfarmersinterviewed,themainsourceofincomewasfishfarming,while11.4%wascattleand55.3%fromothersources(e.g.employment,coffee,tea).Themostpopularmethodoffishingadoptedbyfarmerswaspond(80.3%).

Table 2: soCio-demographiC and eConomiC CharaCTerisTiCs of households

Variable Number (%)

four division households interviewed in imenti south

Mitunguu

Igoji East

Abogeta West

Nkuene

33 (66%)

33 (66%)

33 (66%)

33 (66%)

Total 132 (66%)

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5.2 Fish farming as a source of food security and nutrition intake

Allfarmersparticipatinginthesurveyreportedthatfishisafoodofhighnutritionalvalueandsourceofqualityprotein,vitaminsandminerals.Basedontheirexperiences,thoughfishfarmingwasnothistoricallydoneinImentiSouthconstituency,sincetheinceptionoftheGovernmentofKenya’sESPinitiative,ithasbeenwidelypracticedthereand42.4%thoughtthattheactivityhadincreasedfoodsecurity(foodavailability).Ontheotherhand,57.6%wereoftheopinionthattheintroductionoffishinthe households’ diet had an impact in family nutrition intake by introducing a different source of protein tomanyhouseholdsinImentiSouthconstituency(seeTable3).Priortocommencingfishfarming,farmers relied on beef as the main source of protein but that practice changed due to the accessibility of fish.

Table 3: fish farming inCreased food seCuriTy and nuTriTion in household

5.3 Importance of fish farming as an economic activity

ThefisheriessectorinKenyaconsistsofthreemajorsub-sectors,namelyinlandfisheries,marinefisheriesandaquaculture.Aquaculturehasremainedatsubsistencelevelsinceindependencein1963,butwasrecentlyboostedwhenthegovernmentlistedfishfarmingasoneofthekeyactivitiesintheESP(Aloo-Obudho2010).However,notmanyfarmerswereinitiallyinterestedindiversifyingtheirfarmactivitiesduetonegativeperceptionsaboutfishfarming.Accordingtofisheriesofficers,somehouseholdsallegedthatfishpondswouldbeabreedinggroundformosquitoes,buttheseviewschangedafterthefirstpilotprojectwascompleted.Therefore,participantsinterviewed,indicatedthat

Variable Frequency Percentage

Fish farming increased availability of food 56 42.4%

Fish farming source of nutritional intake (protein) 76 57.6%

Total 132 100%

gender distribution of fish farmers

Male

Female

96 (72.7)

36 (27.3)

Total 132 (100)

highest education level among fish farmers

Primary school

Secondary school

Polytechnic

University

74 (56.1%)

45 (34.1%)

11 (8.3%)

2 (1.5%)

Total 132 (100%)

main source of income of fish farmers

Fish farming

Cattle

Other (Coffee, Tea etc)

44 (33.3%)

15 (11.4%)

73 (55.3%)

Total 132 (100%)

fishing method adopted by fish farmers

Cage

Pond

Tanks

24 (18.2%)

106 (80.3%)

2 (1.5%)

Total 132(100%)

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theESPfishfarmingprojectcreatedemployment(56.1%)andboostedhouseholdincome(43.9%)(seeTable4).Farmersexplainedthatduetoalackofstorageunitsfortheharvestedfish,fishingdidnotturnedouttobeashighanincomeearnerasexpected.However,theofficersconfirmedthattheGOK,throughPublic-PrivatePartnerships,wasintheprocessofconstructingastoragefacilityintheconstituency,whichwouldbenefitfarmersandensuretheirproducewasappropriatelypreservedforsale.

Table 4: fish farming sourCe of employmenT and livelihood seCuriTy in The household

5.4 Farmers’ technical skills - fish management, handling, storage and preparation skills

TheFisheriesOfficersattheImentiSouthconstituencyreportedthatmostparticipants(78.5%)wereadequatelyequippedwithtechnicalskillsrequiredforfishmanagement,handlingandstorage.TrainingandrefreshertrainingwasundertakenincollaborationwiththeMinistryofEducation(MOE),whiletheMOHatlocallevelfacilitatedfishpreparationandconsumptionlessons,confirmingthatintersectoralpartnershipscontributedtothesuccessfulimplementationoftheprojectinImentiSouth.Amajorityofparticipants(66%)alsofeltthatfieldvisitsbytheextensionfisheriesofficerprovidedcontinuoustechnicalknow-howtofarmers.Intotal78.9%ofthefarmersattendedrefreshertrainingonfishfarminganddiseaseprevention.However,only56.4%weretrainedonmarketingskills,whichwasasignificantdeterminantoffishsales(seeTable5).Knowledgeandtechnicalskillswereessentialtoensuregoodpondmanagementandsustainabilityoffishfarmingactivityintheconstituency.

Table 5: fish farming knowledge

TheFigure1belowillustratesanextensionfisheryofficerconductingonsitetrainingtoguaranteefarmers were well equipped with the necessary knowledge and skills required to successfully manage fishfarming.

figure 1: exTension offiCer Training farmers on pond managemenT skills

Variable Frequency Percentage

Fish farming source of employment 74 56.1%

Fish farming income-generating activity 58 43.9%

Total 132 100%

Variable Percentage

Fish farmers technical knowledge 78.5%

Farmers receiving adequate refresher training 78.9%

Fish marketing skills 56.4%

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5.5 The host’s community cultural practices that influence fish farming

Fish farming in Imenti South constituency was a new concept that required communities to change behaviourintermsoffishconsumption.AccordingtoFAO(2004),oneofthemostimportantconditionsforreliableconsumerdemandforfishproductswasawell-establishedcultureoffishconsumptioninregionswherefishwereproduced(FAO2004).Surprisingly,developmentagencies,NGOsandnationalagriculturalresearchorganizationsinmanycountriesinsub-SaharanAfricahavetriedtointroduceaquaculturetoregionswherethereisnotraditionoffishconsumption,forexample,thefishfarmingprojectinitiatedundertheGovernmentofKenyaEconomicStimulusProgramme(ESP).InKenya,manyethniccommunitiesdidnotconsumefishuntilasrecentlyas1980,butfishhasnowbecomepartofhouseholddietinalmostallpartsofthecountry(NgugiC.CandManyalaJ.O.2009).

Thefisheriesofficersinterviewedobservedthat,inhouseholdswithmostlymales,itwasachallengetoinfluencethemtoincludefishintheirtraditionaldietssinceallharvestedfishwouldbesoldtogenerateincome. This was also to do with men not wanting to change their behaviour from what they had always eatentofish.However,mostcommunitieshavesincechangedbehaviourandacceptedfishaspartofthe household diet.

“since we began the fish farming project in Imenti South, we have had to conduct “eat more fish focusing on health benefits” awareness campaigns to ensure communities adopted fish in their traditional diets, because this would create demand for fish in the constituency…one of the challenges faced involved men who were unwilling to support change in the household diet, preferring fish to ultimately be a source of income. But with intensive sensitization in collaboration with health centres, most families are consuming fish and appreciate the health benefits.” Extension officer1

Other challenges involved cultural practices and eating habits. Some households were of the opinion thatpreparingfishmealsandeatingthemwasalengthyprocedure,hencepreferringothermeats.Thestrongfishodourwasalsoaconcernforsomehouseholds.Thesesentimentswereexpressedparticularly by the pastoralist communities and those who practised mixed farming.

“Fish farmers initially complained that cooking and eating fish takes a long time…the smell of fish was viewed as unpleasant… so it took us sometime to convince women particularly, on the many health benefits of eating fish for them and their children…we also taught them the most effective way of cooking fish and use of lemons to mask the strong smells and with time, they acquired the taste and started to experience the benefits…” Extension officer2

Accordingtohealthworkersinterviewed,theESPfishfarminginitiativehascontributedtoremarkableimprovement in health mostly among mothers and children. Although the Ministry of Health has not conductedastudytoassesstheeffectsoffishconsumptiononhealth,healthworkersinImentiSouthconstituencythoughtthatthenumberofmalnutritioncaseshaddecreasedsignificantly.

“…we have seen health improvements as a result of fish being introduced in the family foods and the diet… the number of children suffering from malnutrition has gone down…we don’t get as many cases as before…although we cannot say for sure it’s because of fish farming…I believe fish is one of the contributing factors…I would like our Ministry of Health to conduct a detailed study in this region to find out whether the population’s health has improved as a result of eating fish …”Health workers.

6. Discussion Thisstudysetouttoexploretheextenttowhichtheintersectoralfishfarmingproject,identifiedasoneofthekeyactivitiesthatcouldcontributetoimprovednutritionintake,foodandlivelihoodsecurityand

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povertyalleviationinruralKenya,wasachieved.Inthissection,wediscussthemainfindingsofthisstudy and their implications on the Kenyan government’s efforts to transform the economy through home-grown interventions.

Thefindingshavedemonstratedthattherewassignificantimprovementinfoodsecurityandnutritionasresultofhouseholdsengaginginfishfarming.42.4%studyparticipantswereoftheopinionthatfoodavailabilityhadincreased,while57.6%reportedenhancednutritionintake.Foodsecurityandnutritionalstatusarekeydeterminantsofhealthandatthenationallevel,meansthatadequatesuppliesoffoodare available through domestic or imports to meet the consumption needs of everyone in a country. Foodandlivelihoodsecurityareknowntocontributetoeconomicgrowthindevelopingcountries,aswell as sustaining progress on the poverty reduction target. The United Nation’s Food and Agricultural Organization(FAO)statesthat,foodsecurityexists‘whenallpeople,atalltimes,haveaccesstosufficient,safeandnutritiousfoodtomeettheirdietaryneedsforanactiveandhealthylife’(FAO1996).Foodsecurityisafunctionoffoodavailability(dependentonnaturalandhumanresources),foodaccessibility(dependentonpurchasingpoweroraccesstofertileland)andfoodutilization(nutritionaluptake)(EricksenP.2008).TheESPfishfarmingprojecthastosomeextentaddressedfoodavailability,accessibilityandutilizationinImentiSouthconstituency.Asaresult,manyparticipantswereawarethatfishfarmingaddressedhouseholdfoodinsecurityandnutritionrequirements.Participantsalsounderstoodthatgoodnutritionwasimportanttoreachthehealth,educationandeconomicgoalstheGovernmentofKenyawaspursuing.Thenutritionimprovementfishfarmingprogrammehasanessential role in tackling health determinants and health equity. It does this through protecting and promotingcommunityandanindividual’shealth,includingreducingmortality,especiallyamongmothersandchildren,andencouragesandenableschildrentoattendandbenefitfromschool.

Overall,advancingfoodsecurityandnutritionisfundamentaltoachievingtheMillenniumDevelopmentGoals(MDGs)andforpromotingasustainabledevelopmentagenda.DuringtheG8andG20,worldleadersacknowledgedthesignificanceofaddressingfoodinsecurityandnutritioninanefforttoachievedevelopmentgoals(DFID2013).Furthermore,ahealthydietisanimportantmeansforpreventingandcontrollingnon-communicablediseases(NCDs),asstatedintheHigh-levelPoliticalDeclarationonthepreventionandcontrolofNCDs(UnitedNations2011).TheFoodandAgriculturalOrganizationalsoemphasizestheimportanceofpromotingnutritionawarenessamongwomen,especiallyinruralareasand that ensuring greater household food security can all contribute to better maternal health (FAO 2009).

Regardingemploymentcreationandincomegeneration,itwasclearthatparticipantsbenefitedfromthefishfarmingprogramme.Despiteinitialnegativeperceptionsaboutfishfarming,householdsparticipatinginthegovernmentprojectprofited.Forexample,56.1%ofparticipantscreatedemploymentwithintheirhouseholdsandexternallyand43.9%deemedfishfarmingasaprofitableincome-generatingactivity.AccordingtoMwangi(2008),fishfarmingwasanimportantsourceofincomeandcontributedsignificantlytothenationaleconomythroughemploymentcreation,foreignexchangeearnings,povertyreductionandsocialwell-being,particularlyforruralcommunitiesinKenya(Mwangi M.H. 2008). This implies that improvements in the productivity of agriculture and related sectors directly increased farm and rural incomes and household food security as demonstrated by the GovernmentofKenyaESPfishfarminginitiative.Growthinagriculturefocusedonsmallfarmers(likethecaseoffishfarminginImentiSouth)promotedoverallruralandnon-farmemploymentandhadastrong poverty-reducing effect. It also contributed to tackling determinants of health and narrowing of healthinequities.Indeed,thefishfarmingpublicpolicyisanotableexampleofhowsuchpoliciescanhave long-lasting effects on health determinants.

Addressing key determinants of health through intersectoral collaboration and promotion of healthy publicpolicyleadstopositivepopulationhealthoutcomes.Asdemonstratedbythisstudy,advancing

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healthypublicpolicies,oneofthefiveactionareasoftheOttawaCharter(WHO1986)impliesthathealthisshapedbysocial,economic,physicalandenvironmentalfactorsthatareoutsidethecontrolofthehealthsector,suchashousing,transport,environment,education,agriculture,tradeetc.,an outcome resulting from changes to the natural and built environments and to social and work environments(CSDH2008;GOSA2011).Hence,theGovernmentofKenyathroughtheVision2030,acknowledges that for a healthier and happier Kenya it is necessary for all sectors to work towards a shared goal of addressing health determinants and inequities (Government of Kenya 2010). This means thatpolicymakersandresearcherscanseizetheopportunitiespresentedbysuchpoliciestoadvocatehealthy public policies1(WHO1986)andaHealthinAllPoliciesapproach,whichisfoundedonhealth-relatedrightsandobligations(LeppoK.,OllilaE.etal.2013).

6.1 Conclusions

Basedonthefindingsofthestudy,theintersectoralESPfishfarmingprojectinImentiSouthconstituencyhashadsignificantimpactonfoodsecurity,householdnutrition,employmentandincomegeneration,whichthusaddressedkeydeterminantsofhealth.Fromthefindings,itwasevidentthatparticipantsbenefitedfromfishmanagementtrainingandnutritionalknowledgeandawareness.Clearly,effective nutrition education contributed to behaviour and attitude changes and nutrition awareness madesignificantcontributionstoreducinghungerandmalnutritionevenwithimprovementsinfoodsuppliesandincomes.Thestudyconcludesthatincreasedpoliticalwillingness,asillustratedbytheintersectoralEconomicStimulusProgramme,contributedtothesuccessfulimplementationofthefishfarmingprojectthusbenefitingtheparticipantsintermsofincreasedfoodproductionandimprovedsourceofproteinandessentialmicronutrients,whichareallimportantforpreventingmanyhumandiseases.Thefindingshavealsodepictedtheextenttowhichintersectoralcollaborationinvolvingdifferent actors was strengthened.

6.2 Recommendations

1. There is need to promote healthy public policies in Kenya through intersectoral collaboration in ordertoachieveaHealthinAllPoliciesagendaandaddressthebroaderdeterminantsofhealth,usinglessonslearnedfromtheGovernmentEconomicStimulusProgrammeingeneral,andthefishfarmingprojectinparticular.

2. There is a need for government to support intersectoral collaboration in developing a new health promotionstrategyinKenya,whichfocusesonallsectorsthatimpactonpopulationhealthtopromotecitizens’well-being.

3. Thereisneedforincreasedfundingtotheagricultureandfisheriesindustriesconsideringthemultiplerolesofagriculture.Themostimportantaspectofagriculturedevelopmentisthatitexpands,enhancesandsustainspeople’sabilitytoacquireandutilizetheamountandvarietyoffoodtheyneedto be active and healthy.

4. Itisimportantthatinterventionsutilizeparticipatoryandcommunity-basedapproachestoimprovethenutrition and food security of the poorest and most vulnerable population groups within the context of securing sustainable livelihoods.

5. Thereisaneedforgovernmenttoconstructmorefishstoragefacilitiesclosertothefarmerstoreducewastageoffishharvested.

6. Thereisaneedtopromotefisheatinghabitstocommunitiesandschools,whicharenotyetinvolved,takingintoaccountthenutritionalbenefits.

7. There is a need for policymakers and researchers to document evidence of direct and indirect healthy publicpoliciesbeingimplementedinKenya,tosupportthewayforwardforaHealthinAllPoliciesagenda.

1 Promotionofhealthypublicpolicieswouldfacilitateequitythrough,enablingsupportiveenvironmentstolive,workandplayin,improvingstandardsofliving,accesstohealthservicesandaddressingthebroaderdeterminantsofhealththroughmultisectoralcollaborationandpartnerships.

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Areas of Further researchBasedonthefindingsofthisstudy,thefollowingissuesneedtobeinvestigatedfurther:

1. The impact of the Economic Stimulus Programme on broader determinants of health and health equity,includingenvironmentalandhealthimpactofdiggingfishpondsinhomesteadsandthesocialimpactonthecommunityasaresultoffishfarminginthearea.

2. Adetailedinvestigationtoexploretheextenttowhichfishfarminghashadanimpactonreducingmortality and morbidity in Imenti South constituency.

AcknowledgmentsThis document was prepared with the support of the Rockefeller Foundation (grant no. 2012 THS 317) as part of the RockefellerTransformingHealthSystemsInitiative,Supporting the Development of Regional Positions on Health in All Policies and Identifying Lessons and Opportunities for Implementation (for the sake of brevity: Supporting Regional Positions on Health in All Policies).Thegrant,receivedbytheDepartmentofEthicsandSocialDeterminantsofHealthoftheWorldHealthOrganization(WHO),aimedtosupportevidence-informeddecisionsonhowgovernmentscanenhanceintersectoralapproachestoimprovehealthandhealthequitythroughimplementingaHealthinAllPoliciesapproachinthreeWHOregions:Africa(AFR),South-EastAsia(SEAR)andtheWesternPacific(WPR),withaparticularemphasisoncontributingtoevidenceanddialogueinrelationtotheWHO8thGlobalConferenceonHealthPromotionin2013.Theprojectteam,coordinatedbyMsNicoleValentine(principalinvestigator)oftheDepartmentofEthicsandSocialDeterminantsofHealth,included,forWHOheadquarters,MrTomasAllen(librarian),XeniadeGraaf(intern)andDrOrielleSolar;fortheregions:DrTigestKetsela(WHOAfrica),DrDavisonMunodawafa(WHOAfrica),andMrPeterPhori(WHOAfrica),DrSuvajeeGood(WHOSEAR),DrShilpaModiPandav,ProfessorKRNayar,MsAnjanaBhushan(WHOWPR),andMsBrittaBaer(WHOWPR),ProfessorSharonFriel,MrPatrickHarrisandMsSarahSimpson.ThecasestudywasdevelopedandwrittenbyDrDorisKirigia,PopulationHealthConcernsNairobi,Kenya.

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AcronymsCPTC ConstituencyProjectsTenderCommittee

CDFC Constituency Development Fund Committees

CPTC ConstituencyProjectsTenderCommittee

ESP Economic Stimulus Programme

ERS Economic Recovery for Wealth and Employment Creation Strategy

FFE&PP Fish Farming Enterprise Productivity Programme

GDP Gross Domestic Product

GoK Government of Kenya

HIV/AIDS AcquiredImmunedeficiencySyndrome

PIU ProjectImplementationUnits

PPP Public Private Partnership

MoE Ministry of Education

MoF Ministry of Finance

MoH Ministry of Health

MDGs Millennium Development Goals

MED Monitoring&EvaluationDirectorate

MGC Ministerial Gender Committee

M&E Monitoring and Evaluation

MPER Ministerial Public Expenditure Reports

MTEF Medium Term Expenditure Framework

MTP Medium Term Plan

MOPND MinistryofStateforPlanningNationalDevelopmentandVision2030

NGO Non-GovernmentalOrganization

NCDs Non-Communicable Diseases

SPMC StimulusProjectManagementCommittee

Definition of significant termsfish farming or aquaculture:areusedinterchangeablytorefertothegrowingoffishandotheraquaticorganismsincontrolledenvironments,suchasinartificialponds.

economic stimulus programme:Itisashort-tomedium-term,high-intensityandimpactprogrammeaimedatjump-startingtheeconomytowardslong-termgrowthanddevelopment,securingthelivelihoodofKenyansthroughprojects,suchasfishfarming.ThegovernmentinjectedKenyashillings(KES)1.12billion into the programme.

eating habits (or food habits):referstowhyandhowpeopleeatfish,aswellasthewayspeopleobtain,store,useanddiscardfish.

food security:Situationwheresufficient,safeandnutritiousfoodisavailableatalltimes.

health in all policies: is an approach to public policies across sectors that systematically takes into accountthehealthandhealthsystemsimplicationsofdecisions,seekssynergiesandavoidsharmfulhealthimpacts,inordertoimprovepopulationhealthandhealthequity.