Table 6.

BFCI: Successes and challenges by national and subnational level

National level			County level
Successes	Challenges	Resolutions	Successes	Challenges	Resolutions
• BFCI implementation by a large number of partners (NGOs and UNICEF) implementing MIYCN in Kenya • Brought attention to the need to revitalize BFHI—as mothers can also be referred from the BFCI communities to the hospitals for delivery • Built on existing community structures (i.e. community units) as a platform for BFCI implementation	Insufficient links between community level efforts on breastfeeding (BFCI) and facility level (hospital‐ BFHI) due to inadequate implementation, knowledge gap and follow up	• There are efforts to revitalize BFHI once the new global guidelines are in place. In areas where BFCI is implemented, the link health facilities that qualify for BFHI also benefit in the additional support. Hospitals will also need to implement BFHI to ensure that regardless of the facility that the mother visits (in cases of referral), it is baby‐friendly	• Identification of BFCI champions in community units	Lack of community units[Link]: Establishing and training community units in semiarid and arid areas, where no community structures exist, can be expensive (need to budget for additional 5‐day training for CHVs on the community module then budget for another 6 days for the BFCI training) since a 5‐day training has to be done for the CHVs on the basic CU module before training on BFCI	When BFCI is implemented where there are no CUs, the first criteria are forming and training the CU on the basic CHV module. This would add to costs of BFCI implementation. Therefore, BFCI training started among CUs that were already established, trained, and functional apart from the arid and semiarid areas where mapping had first to be done.
Development of national guidance and materials: • Development of national policies, strategies and guidelines which support BFCI – National nutrition action plan, MIYCN strategy, MIYCN policy •Development and roll‐out of a national MOH BFCI implementation package, inclusive of guidelines for implementation, advocacy tools, training modules and protocol for external assessment and certification of communities as “baby friendly,” with support from MCSP and UNICEF and partners • Development and roll‐out of MIYCN counselling cards for use by health workers and CHVs which included guidance for counselling for both nutrition specific and sensitive interventions, including WASH, kitchen garden and child stimulation) for first 1,000 days and up to 5 years of age	No national MOH BFCI training curriculum tailored for community‐based providers (CHVs)	• A BFCI training manual for CHVs is under development and will be finalized by 2018. A simplified training package based on the 8‐point plan is being piloted, the results of which will inform on the training package for CHVs. MIYCN counselling card have been used to date, for the training of CHVs, while the package is under development.	• Support for BFCI by political administration and politicians at county level who mobilized the community for implementation	Lack of allocation of funds for BFCI in county government health budget hindered sustainability of BFCI.	Advocacy is ongoing to have budget allocated to the nutrition department. There has been political commitment in some community units at county level with the local administration and members of county assembly. This would result in allocation of budget for nutrition and specifically BFCI
Integration with other sectors • ECD: Linkages with Ministry of Education ‐ECD section enabled incorporation of child stimulation • Agriculture: Linkages with agriculture offered an opportunity to improve complementary feeding practices, through increasing variety through establishment of demonstration gardens and development of recipes for complementary feeding • Income generation: The M2MSGs identified income generating activities on their own that increased cohesiveness and improved their livelihoods and variety of food	Insufficient number of BFCI master trainers to meet the demand from counties for BFCI roll out, due to funding challenges	• The MOH with support from implementing partners will continue to build capacity in all 47 counties to build a pool of trainers. Prioritization in funding for training and follow‐up to ensure implementation and offer support need to be considered.	• Continued implementation through training, mentorship, supportive supervision and follow up with documentation and reporting of BFCI activities	Lack of motivation of CHVs, who are unpaid workers within the ministry of health	• Advocacy with the county government to provide monthly stipends supported by implementing partners and the health management teams at county level. Kitui is one of the counties where the advocacy efforts have borne fruit and the CHVs are paid monthly stipend by the county government. Others have committed but yet to start,e.g., Migori • CHVs supported by MCSP to register with the Ministry of Social Services, which is needed to be legally recognized as a group, to apply for and have access to loans and grants. Income‐generating activities are important for CHVs since they do not have any formal salary as volunteers.
Community ownership was critical to implementation to ensure that the community took lead in the process and would also ensure sustainability	Inadequate BFCI coverage for entire country	Both MOH and partners are scaling up implementation of BFCI.	• Improvement in infant and young child feeding indicators through monitoring of five key BFCI indicators • Real‐time documentation is now available at community level for complementary feeding since CHVs capture data on the individual infant child and growth monitoring form, previously it was only available via survey data	Insufficient number of MOH MIYCN counselling cards or counselling during M2MSG meetings and household visits by CHVs	The available MIYCN cards were distributed among the CHVs based on the proximity of their households to allow ease of sharing of counselling materials.
Engagement and use of community own resource personsb	—	—	• Utilized BFCI as platform encouraging early and frequent ANC attendance and hospital deliveries.	Government transfer of BFCI‐trained facility‐based health workers to other health facilities following training, which led to a gap in provider capacity to implement BFCI in a few facilities. Transfers continued throughout the course of implementation leading to a gap in BFCI capacity in some subcounties.	The newly replaced staff were mentored by subcounty teams to build their capacity on BFCI.
A mechanism to improve and monitor IYCF at community level	—	—	• Engagement of adolescent mothers through BFCI to improve EBF. The adolescents were recruited when pregnant and reached in their homes. They were supported to attend ANC through to the postpartum period. Their mothers were also reached to teach them on how to support their adolescents who were now mothers. They supported them to practice exclusive breastfeeding and would give the expressed breastmilk to the child when the adolescent was still in school and she would then continue with breastfeeding in the evening.	Integration of agriculture with BFCI. Inadequate physical space around some health facilities for setting up “kitchen gardens.” A number of health facilities had kitchen gardens within the health facility while those without space identified and set up kitchen gardens in the community. Virtually each community unit had a demonstration garden while mothers had gardens in the community and individual gardens at home.	The CHVs identified spaces within the community and started demonstration gardens that were used to teach mothers.
—	—	—	• Mothers enrolled in the M2MSGs were supported to start IGAs the IGAs improved attendance of the mothers during their meetings and also ensured sustainability of the groups	Difficulty in follow‐up of mothers in M2MSGs/home visits due to, migration of mothers, residing in urban informal settlements and in arid/semiarid areas	Some of the mothers ended up joining other BFCI groups in the areas where they had migrated to (if the areas were implementing BFCI). However, others were lost to follow up if they moved to non‐BFCI implementing areas
—	—	—	—	IGA groups are not linked to other support systems (i.e. government organizations that support start‐up of small businesses and gives funds to women groups. The only funds accessible is what is contributed by group members, which may be a small amount	The M2MSGs were encouraged to formally register with the Ministry of Social services ‐ to be recognized by the government so these M2MSGs would be able to write and apply for loans and grants to support start‐up of the IGA. Group members therefore set amounts that they would be contributing on a monthly basis. IGAs enhance cohesiveness and sustainability
—	—	—	—	Health workers strikes (*affected almost half the implementation year). Community activities proceeded without effect, yet public sector health facility activities were affected as health talks on the various BFCI scheduled topics could not be done, staff offering services at the health facility could not be assessed in terms of progress on BFCI, BFCI trainings in various counties were halted until after the strike	Continued mentoring and coaching of CHVs and referral of mothers to deliver in the private and faith‐based health facilities that were operational during the strike were conducted, as a temporary measure
—	—	—	—	Political unrest and instability affected attendance to community support group and mother to mother support group meetings, due to restriction in movement.	Meetings and activities continued in remote/rural areas which were little affected and follow up and meetings resumed in all other areas once stability was restored.

The “community unit” as defined in this context comprises approximately 1,000 households or 5,000 people who live in the same geographical area, sharing resources and challenges. In most rural areas, such a unit would be a sublocation, the lowest administrative unit. The number of households in a community unit will determine the number of community health workers to be selected, so that 1 CHW serves approximately 20 household (MOH, 2007).

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