Usaid Kenya and East Africa/Afya Jijini Program Fy2019 Q1 Progress Report

/ USAIDUSAID KENYA KENYA AND AND EAST EAST AFRICA/AFRICA/AFYAAFYA JIJINI PROGRAMJIJINI QUARTERPROGRAM 1 PROGRESS REPORT – YEAR 4 (FY 2019)

FY2017 Q4 PROGRESS REPORT & FY2016 ANNUAL PERFORMANCE REPORT

1 JULY 2017 – 30 SEPTEMBER 2017 (Quarterly Report) 1 SEPTEMBER 2016 – 30 SEPTEMBER 2017 (Annual Performance Report)

Award No.: AID-615-C-15-00002

Prepared for Dr. Teresa Simiyu, COR USAID/Kenya and East Africa c/o American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya

Prepared by: JANUARYIMA World Health2019 1730 M Street N.W., Suite 1100 ThisWashington, publication DC was20036 produced for review by the United States Agency for International Development. It was prepared by IMA World Health.

January 30, 2019

USAID KENYA AND EAST AFRICA/AFYA JIJINI PROGRAM FY2019 Q1 PROGRESS REPORT

1 OCTOBER 2018 – 30 DECEMBER 2018 (Quarterly Report)

Award No.: AID-615-C-15-00002

Prepared for Dr. Teresa Simiyu, COR USAID/Kenya and East Africa C/o American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya

Prepared by: IMA World Health 1730 M Street N.W., Suite 1100 Washington, DC 20036

January 30, 2019

DISCLAIMER The authors’ views expressed in this report do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

TABLE OF CONTENTS TABLE OF FIGURES ...... 2 LIST OF TABLES ...... 2 ACRONYMS AND ABBREVIATIONS ...... 3 I. USAID/KENYA AND EAST AFRICA AFYA JIJINI EXECUTIVE SUMMARY: FY2019/Q1 PERFORMANCE REPORT ...... 8

QUALITATIVE IMPACT ...... 8 Sub-Purpose 1: Increased Access and Utilization of Quality HIV Services...... 8 Sub-Purpose 2: Increased Access and Utilization of Focused Maternal, Newborn, and Child Health (MNCH), FP, Water, Sanitation, and Hygiene (WASH), and Nutrition Services...... 9 Sub-Purpose 3: Strengthened and Functional County Health Systems ...... 9 CONSTRAINTS AND OPPORTUNITIES: ...... 10 II. FY 2019: Q1 (OCTOBER – DECEMBER 2018) ...... 11

A. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 11 Sub-Purpose 1: Increased Access/Utilization of Quality HIV Services ...... 11 Output 1.1: Elimination of Mother-to-Child eMTCT ...... 11 Output 1.2 and 1.3: HIV Care, Support, and Treatment Service ...... 2 Output 1.4: HIV Prevention, HIV Testing and Counseling (HTC), Voluntary Medical Male Circumcision (VMMC), Gender-Sensitive HIV Prevention, and DREAMS ...... 5 VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC): ...... 8 HIV PREVENTION: GENDER BASED VIOLENCE ...... 9 DREAMS ...... 10 Output 1.5: TB/HIV Co-Infection Services...... 15 Sub-Purpose 2: Increased Access and Utilization of Focused MNH, CH, FP, WASH, and Nutrition Services ...... 17 Output 2.1: MNH Services ...... 18 Output 2.2: Child Health Services ...... 23 Output 2.3: FP Services ...... 25 Output 2.4 WASH Services Year 4 Quarter 1 Report ...... 27 WASH GRANT UNDER CONTRACT ...... 31 Sub-Purpose 3: Strengthened and Functional County Health Systems ...... 36 Output 3.1: Partnerships for Governance and Strategic Planning ...... 36 Output 3.2: HRH ...... 37 Output 3.3: Health Products and Technologies (HPT) ...... 37 Output 3.4: Strategic M&E Systems ...... 42 Output 3.5: QI Systems ...... 45 B. CONSTRAINTS AND OPPORTUNITIES ...... 47 C. PERFORMANCE MONITORING ...... 48 D. PROGRESS ON GENDER STRATEGY ...... 48 E. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 48 F. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 49 G. PROGRESS ON LINKS WITH GOK AGENCIES ...... 49 H. PROGRESS ON USAID FORWARD ...... 49 I. SUSTAINABILITY AND EXIT STRATEGY ...... 50 J. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE) ...... 50 K. SUBSEQUENT QUARTER’S ACTIVITIES ...... 50 L. FINANCIAL INFORMATION ...... 50 M. ACTIVITY ADMINISTRATION ...... 50 III. ACTIVITY PROGRESS OF Q1 FY 2019 PROGRESS REPORT AGAINST FY TARGETS ...... 50

IV. ANNUAL SUPPLEMENT TO QUARTERLY REPORT ...... 50 V. GPS INFORMATION ...... 50 VI. SUCCESS STORY ...... 50 ANNEX 1: SCHEDULE OF FUTURE EVENTS ...... 52

TABLE OF FIGURES FIGURE 1: 12 MONTH HEI OUTCOMES 1 FIGURE 2: 24 MONTH HEI OUTCOMES 1 FIGURE 3: AFYA JIJINI TEST AND TREAT TRENDS QUARTER 1 3 FIGURE 4: TB HIV CASCADE 16 FIGURE 5: AFYA JIJINI YEAR 4 QUARTER 1 PERFORMANCE: 4+ ANC 18 FIGURE 6: ADOLESCENTS PRESENTING WITH PREGNANCY (Y4 Q1) 18 FIGURE 7: AFYA JIJINI NCC Q1 PPH CASES AND RESPONSES 20 FIGURE 8: Q1 PERINATAL MORTALITY 21 FIGURE 9: MAKADARA HEALTH CENTRE QUARTERLY TOTAL DELIVERIES - 2018 21 FIGURE 10: AFYA JIJINI Q1 PERFORMANCE: PNC 23 FIGURE 11: Q1 DPT3, MEASLES PERFORMANCE AND FIC PERFORMANCE 24 FIGURE 12: Q1 CYP PERFORMANCE 26 FIGURE 13: Q1 FP UPTAKE AMONG ADOLESCENTS 26 FIGURE 14: UNDER FIVE TREATED WITH DIARRHEA TREATED WITH ZINC AND ORS: Q1 29 FIGURE 15: PREGNANT WOMEN REACHED BY NUTRITION-SPECIFIC INTERVENTIONS: Q1 33 FIGURE 16: UNDER FIVE RECEIVED VITAMIN A 34 FIGURE 17: ARVS REPORTING RATE 40 FIGURE 18: FP REPORTING RATE 40 FIGURE 19: FACILITY CONTRACEPTIVES CONSUMPTION REPORT AND REQUEST FORM – JULY 2015-DEC 2018 43 FIGURE 20: AVERAGE OUTPUT ANALYSIS FOR 15 FACILITIES CONSISTENTLY USING EMR 44 FIGURE 21: IMPROVING CATEGORIZATION OF PATIENT FOR DCM 47

LIST OF TABLES TABLE 1: EMTCT IMPLEMENTATION BY PRONG (FY19/Q1) 11 TABLE 2: EMTCT AT 1ST ANC IN Q1 11 TABLE 3: PSYCHOSOCIAL SUPPORT GROUPS AND THEIR REACH 4 TABLE 4: OUTCOMES OF DEFAULTER TRACING Y3/Q1 4 TABLE 5: HIV TEST YIELDS BY TESTING POINTS (FY19/Q1) 6 TABLE 6: PNS SUMMARY 7 TABLE 7: HIGH-LEVEL RESULTS FROM AUDIT 7 TABLE 8: VMMC MINIMUM PACKAGE QUARTER 1 REACH 9 TABLE 9: AFYA JIJINI Y4 Q1 CUMULATIVE DREAMS ACHIEVEMENTS 10 TABLE 10: CONTRACEPTIVE METHODS 11 TABLE 11: HTS 12 TABLE 12: OUTCOMES OF THE CHARACTERIZATION ACTIVITIES 13 TABLE 13: YR4 Q1 CASH TRANSFER GIVEN 13 TABLE 14: COURSES UNDERTAKEN FOR VOCATIONAL TRAINING 14 TABLE 15: DISTRIBUTION OF BENEFICIARIES 30 TABLE 16: ACTIVE CASE FINDINGS THROUGH MUAC SCREENING 34

ACRONYMS AND ABBREVIATIONS ACF Active Case Finding ACT Accelerating Children’s HIV/AIDS Treatment Initiative AGYW Adolescents Girls and Young Women ALHIV Adolescent Living with HIV AMSTL Active Management of the Third Stage of Labor ANC Antenatal Care AoC Ambassador of Change APHIAplus AIDS, Population, and Health Integrated Assistance Plus APOC Adolescent Package of Care APR Annual Performance Report ART Antiretroviral Therapy AVD Assisted Vaginal Delivery AWP Annual Work Plan AYRSH Adolescent and Youth Sexual and Reproductive Health BCC Behavior Change Communications BemONC Basic Emergency Obstetric and Newborn Care BHESP Bar Hostess Empowerment and Support Program BMI Body Mass Index CASCO County HIV/AIDS and STI Coordinator CBD Community-Based Distribution CBHIS Community-based Health Information System CCC Comprehensive Care Center CHA Community Health Assistant CHAI Clinton Health Access Initiative CHISP Nairobi City County Health Sector Strategic and Investment Plan CHMT County Health Management Team CHV Community Health Volunteer CLTS Community-Led Total Sanitation CME Continuing Medical Education CMLT County Medical Laboratory Technician CNAP County Nutrition Action Plan CNTF County Nutrition Technical Forum COC Continuum of Care COP Country Operational Plan COP Chief of Party CTLC County TB/Leprosy Coordinator CWC Child Welfare Clinic CYP Couple-Years Protection DAC DREAMS Advisory Committee DBS Dried Blood Spot DCM Differentiated Care Model DCOP Deputy Chief of Party DHIS2 District Health Information System 2 DICE Drop-In Center DMPA Depot-Medroxyprogesterone Acetate (also known as Depo-Provera) DOT Directly-Observed Therapy DQA Data Quality Assurance DREAMS Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe Women Initiative EBF Exclusive Breastfeeding Feeding

EBI Evidence-Based Intervention ECD Early Childhood Development EID Early Infant Diagnosis EMMP Environmental Monitoring and Mitigation Plan EmONC Emergency Obstetric and Newborn Care EMR Electronic Medical Record eMTCT Elimination of Mother-to-Child Transmission EPI Expanded Program on Immunization FANC Focused Antenatal Care FBO Faith-Based Organization FGD Focus Group Discussion FHOK Family Health Options Kenya FMP Family Matters Program FP Family Planning FSB Fresh Stillbirth FSW Female Sex Worker GBV Gender-Based Violence GoK Government of Kenya HCSM Health Commodity and Supply Management HCA HIV Cohort Analysis HCBF Healthy Choices for a Better Future HCMP Healthcare Management Plan HCW Healthcare Worker HCWM Health Care Waste Management HEI HIV-Exposed Infant HINI High-impact Nutrition Intervention HOYMAS Health Options for Young Men on HIV/AIDS/STIs HRIO Health Records and Information Officer HPT Health Products and Technologies HR Human Resources HRH Human Resources for Health HRM Human Resources Management HSS Health Systems Strengthening HTS HIV Testing Services HWWK Hope Worldwide Kenya HWMP Healthcare Waste Management Plan ICF Intensified Case Finding ICT Information Communication Technology IEC Information, Education, and Communication IEE Initial Environmental Examination IFAS Iron and Folic Acid Supplementation IMAM Integrated Management of Malnutrition IMCI Integrated Management of Childhood Illness INH Isoniazid IPC Infection Prevention and Control IPD Inpatient Department IPT Isoniazid Preventative Therapy IUCD Intrauterine Contraceptive Device KEMSA Kenya Medical Supplies Agency KEPI Kenya Expanded Program on Immunization

KHQIF Kenya HIV Quality Improvement Framework KII Key Informant Interview KMC Kangaroo Mother Care KMTC Kenya Medical Training College KP Key Population KQMH Kenya Quality Model for Health KSG Kenya School of Government L&D Labor and Delivery LARC Long-Acting Reversible Contraception LDP+ Leadership Development Program Plus LGBT Lesbian, Gay, Bisexual, and Transgender LMIS Logistic Management Information Systems LMS Leadership Management and Sustainability project LTFU Lost-to-Follow-Up M&E Monitoring and Evaluation MAM Moderate-Acute Malnutrition MAP Men as Equal Partners MCH Maternal and Child Health MDR-TB Multi-Drug Resistant TB MDSR Maternal Death and Surveillance Response MDTs Multi-Disciplinary Teams MEC Medical Eligibility Criteria MHMC My Health, My Choice MIYCN Maternal Infant and Young Child Nutrition MLKH Mama Lucy Kibaki Hospital MMR Measles, Mumps, Rubella MNCH Maternal, Newborn, and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Review, Surveillance, and Response MSW Male Sex Workers MTC Medicine Therapeutic Committee MUAC Mid-Upper Arm Circumference NACC National AIDS Control Council NACS Nutritional Assessment Counseling and Support NASCOP National AIDS and STI Control Program NCC Nairobi City County NHIF National Health Insurance Fund NHRL National HIV Reference Laboratory NPA Nasopharyngeal Aspirates NPA/NG Nasogastic and Nasopharyngeal Aspirate NTLDP National Tuberculosis, Leprosy, and Lung Disease Program ODF Open Defecation-Free OI Opportunistic Infection OJT On-the-Job Training OPD Outpatient Department ORS Oral Rehydration Solution ORT Oral Rehydration Therapy OTP Outpatient Therapy OVC Orphans and Vulnerable Children

PAC Post-Abortion Care PCR Polymerase Chain Reaction (test) PEP Post-Exposure Prophylaxis PHDP Positive Health Dignity and Prevention PHO Public Health Officer PITC Provider-Initiated Testing and Counseling PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission PNC Post-Natal Care POC Point-of-Care POU Point-of-Use PPFP Post-Partum Family Planning PrEP Pre-Exposure Prophylaxis PSM Patient Self-Management PSS Psychosocial Support PSSG Psychosocial Support Group PT Proficiency Testing QA Quality Assurance QA/QI Quality Assurance/Quality Improvement QI Quality Improvement QIT Quality Improvement Team RDQA Routine Data Quality Assessment RED Reach Every District RH Reproductive Health RMNCH Reproductive, Maternal, Newborn, and Child Health RRI Rapid Results Initiative RTK Rapid Test Kit RUSF Ready-to-Use Supplementary Food RUTF Ready-to-Use Therapeutic Food SAB Social Asset Building SAM Severe Acute Malnutrition SBA Skilled Birth Attendants SCASCO Sub-County HIV/AIDS and STI Coordinator SCHMT Sub-County Health Management Teams SCMLT Sub-County Medical Laboratory Technician SCNTF Sub-County Nutrition Technical Forums SCPHN Sub-County Primary Health Care Nurse SCTLC Sub-County TB/Leprosy Coordinator SGBV Sexual- and Gender-Based Violence SIA Supplemental Immunization Activities SOPs Standard Operating Procedures SMLT Sub-County Medical and Laboratory Technologist SRH Sexual and Reproductive Health STI Sexually-Transmitted Infection STLC Sub-County Tuberculosis and Lung Disease Coordinator TA Technical Assistance TB Tuberculosis TIBU EMR for TB patient data TOR Terms of Reference TOT Training of Trainers

TPA Treatment preparation and Adherence TWG Technical Working Group UCLTS Urban Community-Led Total Sanitation UCT Unconditional Cash Transfer UHAI Team An IMA innovation of technical support teams VAS Vitamin A Supplementation VL Viral Load VMMC Voluntary Medical Male Circumcision WASH Water, Sanitation, and Hygiene WCD World Contraception Day WITs Work Improvement Teams WRA Women of Reproductive Age YFS Youth-Friendly Services

I. USAID/KENYA AND EAST AFRICA AFYA JIJINI EXECUTIVE SUMMARY: FY2019/Q1 PERFORMANCE REPORT

Afya Jijini is implementing the first option year on the contract, continuing the mission to strengthen Nairobi City County (NCC)-level institutional and management capacity to deliver quality healthcare services. Specifically, the project aims to improve access to and uptake of quality health services in NCC for the most pressing health issues, with a focus in the informal settlements. In Year 4 (Y4) (FY2018/19), Afya Jijini provided technical assistance (TA) to 42 Comprehensive Care Clinics (CCCs), 43 elimination of mother-to- child transmission (eMTCT) sites, 47 HIV testing services (HTS) sites, 67 maternities, 189 integrated management of acute malnutrition (IMAM) sites, and 247 family planning (FP) service sites in NCC. The program continued to utilize the lessons learned from its base three years to guide activities. Throughout, Afya Jijini collaborated closely with NCC, sub-counties, USAID, USAID-funded projects, and other implementers. This report presents achievements, specifically in Quarter 1 (Q1), in relation to annual targets provided by USAID. In particular, the project’s first quarter focused on helping the County effectively respond to the ongoing optimization strategies where stable patients were being transitioned to the more efficacious Tenofovir Lamivudine Dolutegravir (TLD) regimen.

Qualitative Impact Sub-Purpose 1: Increased Access and Utilization of Quality HIV Services. In Q1, Afya Jijini supported HIV testing for 12,315 of 12,382 (99.5% of the Q1 target) pregnant women attending their first ANC appointment, identifying 295 new HIV-positive pregnant women, a yield of 2.4%, and 282 known positives. Of the 295 new HIV positives, 274 (92.8%) were started on ART. Early infant diagnosis (EID) activities yielded a positivity rate of 3.4% for infants who received a PCR test while aged under 12 months. As a result of the ongoing PNS interventions, 1,698 index clients were screened and 1,384 contacts identified. Of these, 549 were tested, 70 (12.8%) were found positive, and 69 (98.5%) linked to treatment, indicating a strong strategy for identifying HIV-positive clients. In addition, 1,305 HIV self-test kits were distributed at supported facilities. Afya Jijini-supported sites tested 4,962 adolescent girls and young women (AGYW) within ANC, with 1.8% prevalence measured. Fifty-nine (59) AGYW were known positives and all were initiated on ART. Overall, Afya Jijini tested 85,698 clients during Q1, identifying 1,867 HIV infected clients. This is an overall positivity rate of 2.2%. The project enrolled 1,441 newly-diagnosed patients on antiretroviral therapy (ART), representing a 77% linkage to treatment. By the end of Q1, Afya Jijini had rolled out a Differentiated Care Model (DCM) for HIV treatment in 26 facilities, with 14,617 stable patient’s line listed and 5,863 enrolled. During Q1, 1,217 tuberculosis (TB) patients knew their HIV status, among whom 346 (227 known positives and 119 new) tested positive for HIV, and 331 (96%) of those who tested positive were initiated on ART.

Afya Jijini implemented DREAMS activities in Mukuru Kwa Njenga Ward in Embakasi East Sub-County and Kangemi in Westlands Sub-County. In Q1, Afya Jijini conducted a Rapid Results Initiative (RRI) to increase enrolment of AGYWs at safe spaces, resulting in 192 new AGYWs being enrolled. This brings a total of 11,987 AGYWs accessing various services through Afya Jijini support.

Y4, Q1: Working toward the first 95, Afya Jijini confirmed the status of 12,315 pregnant women during Q1 (19% of target). From this cohort, 50.9% (295) of women were identified as new HIV-positive cases and a further 282 were known positives. The project helped initiate 95% (549/577) on ART in pursuit of the second 95.

The project also initiated 1,441 new clients on treatment, representing 20% of the program’s annual target. Furthermore, the project focused on high-yield strategies ultimately testing 85,698 clients (39% of APR target), with a yield of 1,867 (2.2%) stemming from the high-yield strategies. The project linked 77% of HIV-positive clients to treatment in pursuit of the second 95. Retention of ART clients at 12 months was at 76%. Afya Jijini supported 32,610 to access and receive valid VL results, with 88.8% (28,631) virally suppressed contributing towards the third 95.

In prevention, the project-trained Voluntary Medical Male Circumcision (VMMC) teams reached 3, 765 clients (60% of APR target).

Sub-Purpose 2: Increased Access and Utilization of Focused Maternal, Newborn, and Child Health (MNCH), FP, Water, Sanitation, and Hygiene (WASH), and Nutrition Services. In Q1, the program continued its facility technical support as per MOH guidelines by providing mentorship sessions, OJTs, and CMEs aimed at improving the quality of child health care. Afya Jijini officers, working closely with the Sub-County EPI coordinators, mentored HCWs on the documentation in the daily activity registers in Child Welfare Clinics. The project continued working with 48 CHVs engaged by AJ and 125 engaged by HRI in five informal settlements of Nairobi (Embakasi East and West, Makadara, Ruaraka, Kasarani) reaching a total 6,690 mothers with immunization messages. The program continued to distribute FP guidelines, community family planning manual, Tiarht charts, SOPs, counselling cards, minimum eligible criteria (MEC) wheels, and job aids which offer quick check lists for the HCWs to use during counselling as well as guidance on what to do when providing the services. The project also supported KEMSA to distribute 13 vasectomy sets to the County. The program reached 94,367 women of reproductive age (WRA) with FP services translating to a CYP of 84,764 in the quarter, with long acting and reversible contraceptives (LARC) contributing to 60% of the total CYP.

Furthermore, the project supported WASH activities at county level by supporting Global Hand Washing Day (GHWD) which was undertaken on October 15, 2018 at Gitwamba Primary School in Kasarani Sub-County where over 3,500 children and 500 adults participated and were reached with hygiene messages during the event, which the project supported with IEC materials (300 t-shirts and two event banners) and technical assistance through participation in planning for the event. In collaboration with the County, the project continued Implementing UCLTS, with the aim of decreasing the number of informal settlement populations practicing open defecation (OD), scaling-up sanitation and to enable communities and households to provide sanitation facilities to defecate hygienically. This saw two additional triggered villages increasing the total to 35 triggered villages in Nairobi.

To improve nutrition in informal settlements, the project supported supportive supervision visits across the ten sub-counties. A total of 120 sites were assessed and HCWs mentored on proper documentation and roles assigned to ensure compliance to MOH standards. To increase knowledge and update the healthcare workers on the new MIYCN guidelines, 28 HCWS were trained on the Baby Friendly Hospital Initiative (BFHI) for three days. The staff participants were drawn from Pumwani hospital and other selected facilities that have the potential of implementing BFCI including Mama Lucy and faith-based Neema Uhai hospitals.

Sub-Purpose 3: Strengthened and Functional County Health Systems. Afya Jijini has continued to collaborate with the Nairobi City County Government Health Services sector to strengthen the capacity of the health system across all levels of service delivery to improve access to and quality of service delivery. The project continued to support implementation of the activities in the County’s Annual Work Plan and aligned the work plan activities to Afya Jijini’s objectives in health systems strengthening. The County has demonstrated overall growth and maturity in taking a lead role and ownership of strengthening the

health sector; particularly in stakeholder coordination, strategic planning and health care financing. In HRH, the project has continued to collaborate with the County and HRH Kenya Mechanism to coordinate HRH activities. In the quarter under review, the project supported the HR team to hold its quarterly HRM/IHRIS TWG in addition to participating in HR conversations at the County level to include health worker transition discussions with the interim leadership, staff establishment (rationalization of staffing needs for the County which considered job promotions, salary scale, funded positions, vacancies against filled positions) and the County health leadership structure. At the hospital level, the project held HRH discussions with the Pumwani Maternity Hospital leadership particularly on leadership structure development and departmental role and function delineation. This was a key focus for consideration and discussion during workshop 1 of the hospitals’ strategy plan development process.

Stakeholder coordination fora have continued to improve with the County taking a lead role in planning and coordinating partners and stakeholder fora both at the County and Sub-County levels. In addition, the support for this meeting has been put on a rotational basis where other partners have stepped in to support the meetings.

In the quarter under review, Afya Jijini continued to collaborate with the County and Sub-County pharmacy leadership and staff to strengthen commodity and supply chain and laboratory systems. This involved stakeholder coordination; capacity building of pharmacy staff in pharmacovigilance and commodity management; security, quantification and allocation of Rapid HIV Test Kits (RTKs); forecasting and quantification of GeneXpert commodities; capacity building for viral load and EID remote logging; and real time test results access. Finally, Afya Jijini continued to provide technical support to the coordination and implementation of QA/QI activities at all levels of service delivery. Through coaching, mentorship and support supervision activities, it was noted that health facilities are adopting QA/QI approaches for improved service delivery.

Constraints and Opportunities: Afya Jijini experienced and addressed several constraints during the quarter that impacted project implementation. Some PEPFAR reporting requirements do not match with the current national reporting tools which challenges efforts to strengthen the Kenyan national reporting system. To meet PEPFAR’s reporting requirements, the project develops separate templates to collect the required data from supported sites. Staff shortages within the County health system remain a challenge especially in provision of quality services in the CCCs, maternal and child health (MCH) departments, and IMAM departments as well as at the community level. The project has engaged health care staff to work at the facility level in response to facility staffing shortages. At various times during Y3, the County experienced stock-outs of FP commodities and the project has support redistribution where possible. Infection prevention and control (IPC) was not fully addressed as the County has been working on the health care waste referral schedule which will also require fuel to be made available to transport and burn the waste, and this is not always possible.

At the same time, the project recognized and capitalized on key opportunities in Q1 to improve outcomes. The Project will work closely with the HTS counselors in all high-volume facilities (HVFs) to scale up identification through PNS in order to maximize yield. The rollout of dual testing in ANC and maternity departments provides an opportunity for early identification and cost reduction for STI screening that will increase access to care for pregnant women. Collaboration with different actors and the input from sub grantees under the small grant awards (SGA) has given the project a wider reach and provided synergies in the implementation of reproductive, maternal, newborn, and child health (RMNCH) and WASH activities for (reproductive, maternal, neonatal, child and adolescent health). Good will from the county and sub-county level also gave support to increased activities especially for the UHAI teams (an IMA innovation for technical support).

II. FY 2019: Q1 (OCTOBER – DECEMBER 2018) A. KEY ACHIEVEMENTS (Qualitative Impact)

Sub-Purpose 1: Increased Access/Utilization of Quality HIV Services In Option year 1 Afya Jijini continued to support 43 eMTCT sites, 29 high-volume care and treatment CCCs, and 36 sites with TB/HIV services. The project assisted the county to work toward 95-95-95 targets: • The First 95%: Using facility and community-based strategies Afya Jijini provided HTS to 85,698 clients, achieving 39% of its quarterly target. Of these, 1,867 tested positive (27%) of target), an overall positivity yield of 2.2% (with higher yields among certain sub-populations). • The Second 95%: The program continued implementing the Test and Treat strategy across all the supported care and treatment facilities in line with NASCOP guidelines. Out of the 1,867 patients who tested positive for HIV, 63% were linked and initiated on ART on the same day; 9% were initiated within the first two weeks of testing positive, 5%, were linked after two weeks. • The Third 95: Through file audits and outreach, the project rapidly increased VL coverage, reaching 89% of all patients on ART by the end of Y3. VL suppression stands at 88.8% (adults and children) in patients with documented results

Output 1.1: Elimination of Mother-to-Child eMTCT Afya Jijini’s eMTCT approach utilizes the global four-pronged approach to Prevention of Mother-to-Child Transmission (PMTCT). In Q1, the program addressed each prong through multiple activities, as detailed in Table 1 below.

Table 1: eMTCT Implementation by Prong (FY19/Q1) Prong Activity implementation Prong 1 Activities 1.1.1 and 1.1.9 provided patient education, HIV testing services (HTS), condom distribution in service areas, and use of PrEP and ART in discordant couples as part of prevention activities. Prong 2 Activities 1.1.1, 1.1.2, and 1.1.9 provided access to family planning (FP) services through integration of reproductive health (RH) services in CCC and client referrals. Prong 3 Activity 1.1.3 links and initiates all HIV positive pregnant and breastfeeding mothers on ART and monitors for viral suppression and retention, and through Activity 1.1.4 tracks HIV Exposed Infants (HEI) cohorts for eMTCT outcomes and impact. Prong 4 Activities 1.1.3, 1.15, 1.1.7, and 1.1.8 provide lifelong support to the mother and child, as well as using the mother as the index client to reach out to other family members for HTS and linkages.

Afya Jijini’s focus for this quarter were to ensure that PMTCT services provided are of quality and that this is sustainable throughout Year 4. Afya Jijini also focused on working with HCWs to ensure that the recommendations given for care of PMTCT clients and their children in the new ART guidelines were implemented. Further, Afya Jijini worked towards strengthening reporting for PMTCT and possible transition from paper-based to electronic medical records (EMR) for three PMTCT sites.

Table 2: eMTCT at 1st ANC in Q1 Client Status 10-14 15-19 20-24 25-49 Total Newly-tested positive 0 13 77 205 295 Negative 4 853 4,015 6,866 11,738 Sub-total (1st ANC Tested) 4 866 4,092 7,071 12,033 Not tested 0 1 20 46 67

Known positive (not tested) 0 6 53 223 282 Total (1st ANC) 4 873 4,165 7,340 12,382

Activity 1.1.1: Identify 3,059 HIV-positive pregnant women through HIV testing and re-testing In Q1 Y4, Afya Jijini supported facilities offered HIV testing and services to 12,315 women out of 12, 382 who attended 1st ANC services translating to 19% achievement of the annual PMTCT STAT target. 282 women already knew their HIV positive status and were not tested. 577 were identified as HIV positive achieving 19% of the annual target for identification of HIV positive pregnant women. Afya Jijini’s focus during the quarter was to ensure that all first ANC clients with unknown HIV status received HIV testing services through the integrated system for HIV testing implemented across the facilities. Mentorship activities were provided for HCWs on HIV testing throughout the quarter through Afya Jijini’s UHAI teams.

Afya Jijini also trained 120 HCWs on the use of the dual HIV/Syphilis test kits in Kasarani, Embakasi West, Westlands and Langata Sub Counties. This training is aimed at increasing access to syphilis testing for pregnant women to improve the diagnosis and treatment of syphilis as part of the elimination of HIV and syphilis agenda. As of this writing, 10,436 1st ANC mothers were screened for syphilis, 30 tested positive and received treatment

Activity 1.1.2: Improve eMTCT-Maternal, Newborn, and Child Health (MNCH) integration Afya Jijini continued to work with 36 facilities to ensure that integration of eMTCT and MCH services is maintained. Twenty program-supported PMTCT nurses who have been trained on eMTCT service delivery continued to support service integration in high volume facilities throughout the quarter. Afya Jijini has also focused on client flow systems through the Maternal Child Health clinic to ensure that service integration does not interfere with the quality of services and/or create long waiting times.

Activity 1.1.3: Enroll 2,914 HIV-positive pregnant women on ART and achieve 95% VL suppression. In Q1, 295 women were newly identified as HIV positive at their first ANC visit through HIV testing. In addition, 282 women who attended ANC had a known HIV positive status. Of the 577 women identified as HIV positive, 95% (549/577) were initiated on HAART and 30 clients declined treatment. Mentor mothers and nurses continue to follow up with the patients who declined treatment this quarter for possible initiation of ART.

From the Maternal Cohort analysis, 1,085 eMTCT clients were eligible for a viral load test, with 985 samples taken for viral load testing (uptake of 90.7 %). Of those tested, 888 (90.2%) were virally suppressed, and 94%, 90% and 79% of clients were retained in care at 6, 12 and 24 months respectively. Afya Jijini continued to support sub county CMEs, facility-based CMEs and on-the-job mentorship to build the capacity of nurses and clinical officers to monitor viral suppression and retention of mothers in the program. This was done in compliance with the national ART and PMTCT guidelines and through mentorship after doing client chart reviews. Furthermore, Afya Jijini’s UHAI teams worked with facilities to initiate enhanced follow up for clients who were not virally suppressed.

Activity 1.1.4: Support and track HIV-exposed infants (HEI) Afya Jijini continued to support HCWs to conduct the HEI cohort analysis throughout the year. In Q1, 497 HIV exposed infants born during the reporting months of the 2017 cohort were enrolled for follow-up and 497 HIV exposed infants of the 2016 cohort reporting months were enrolled into follow up. In the first review (2017 cohort), 11 (2.2%) infants were reported as HIV-positive and (100%) of them were linked to care, while 12 (2.4%) infants from the 2016 cohort were identified as HIV-positive, with all initiated on ART. 81.9% of infants enrolled were active in follow up at 12 months which is an improvement from last quarter 73%, while 66.4% of infants were active in follow up by 24 months an improvement from 58% reported last quarter. Facility-based and community-based mentors continued to support retention, identification, tracking of defaulters and leading psychosocial support group activities both at the facility and community levels.

Figure 1: 12 Month HEI Outcomes

Figure 2: 24 Month HEI Outcomes

Activity 1.1.5: Increase mother-baby retention in the eMTCT cascade In Y4, Q1, Afya Jijini continued partnering with a sub grantee, St John’s Community Center (SJCC) whose focus is to improve retention of the mother-baby pair in 19 facilities that contributed to the highest rates of loss to follow up in Afya Jijini-supported facilities. SJCC works with 51 facility-based mentor mothers and 28 community-based mentor mothers to provide peer education and psychosocial support. In Q1, the mentor mothers provided referrals and linkages to clients for various services. Supervision and mentorship activities for mentor mothers continued during the quarter through the Afya Jijini UHAI teams and the SJCC program officers.

Mentor mothers in collaboration with HCWs coordinated a total of 186 psychosocial support groups (PSSGs), with 2,366 clients attending sessions. Mothers were educated on safe motherhood, infant feeding (with an emphasis on exclusive breastfeeding [EBF]), adherence, family planning (FP), family testing, and disclosure. In addition, mentor mothers continued receiving mentorship and OJT on documentation in the mother-baby pair longitudinal registers (updated to include the new guidelines) to support follow-up of the mother-baby pair along the continuum of care and to facilitate documentation of processes and services provided.

Activity 1.1.6: Boost eMTCT focused stakeholder collaboration Afya Jijini continued to support collaborative activities with the county and sub-county health teams. During the quarter, various stakeholder meetings were held and the issue of poor PMTCT reporting was highlighted and discussed.

Afya Jijini also participated in the PMTCT TWG. Various issues were discussed at the TWGs including low HIV testing rates in the country amongst pregnant women, low identification of HIV infected pregnant women, low EID testing for babies under two months, and the upcoming PMTCT Rapid Results Initiative.

Activity 1.1.7: Strengthen ART linkages for HIV-positive infants In Q1, the program collected and networked 1,121 dried blood spots for PCR testing at the Kenya Medical Research Institute (KEMRI), with 26 reported as HIV-positive. 385 initial EID tests were collected under the age of 2 months and 66 were between 2-12 months, out of these a total of 16 were reported as HIV positive. Afya Jijini continued to emphasize on timely initiation of ART for all HIV positive infants through mentorship of HCWs. Mentorship activities also focused on updating the treatment status of the HIV positive infants on the NASCOP EID data base.

Activity 1.1.8: Strengthen family-centered HIV testing and care Mentor mothers continued carrying out chart abstraction for index clients (HIV-positive pregnant and breastfeeding mothers) to establish the family testing status throughout this year. During the quarter, 286 index clients were provided with family testing services, a total of 414 contacts were positively identified and underwent testing for HIV, 40 of 205 (19.5%) were diagnosed with HIV infection while 45 of the contacts were already HIV infected and on HAART. Afya Jijini UHAI teams continued to provide mentorship and training focused on Partner Notification Services (PNS). Activity 1.1.9: Increase adolescent-friendly ANC services In Q1 Y4 the program, worked with high volume facilities to implement focused psychosocial support for pregnant adolescents and young mothers (Operation Tipple Zero Plus) in Mama Lucy Kibaki Hospital, Mbagathi Referral Hospital, St Mary’s Hospital & Bahati Health Centre. Going forward Afya Jijini will establish structures in each of these facilities to ensure continuous enrolment and follow up of young mothers for improved management.

Output 1.2 and 1.3: HIV Care, Support, and Treatment Service Activity 1.2.1: Initiate 7,174 new clients on ART. In Q1, 1,441 newly-diagnosed clients (1,396 adults, and 45 children) were enrolled on treatment, representing a 77% linkage to treatment. The program continued implementing the Test and Treat strategy across all the supported care and treatment facilities in line with NASCOP guidelines. Out of the 1,867 patients who tested positive for HIV, 63% were linked and initiated on ART on the same day; 9% were

initiated within the first two weeks of testing positive, 5%, were linked after two weeks as summarized in Figure 3 below.

Figure 3: Afya Jijini Test and Treat Trends Quarter 1

In Q1, a total of 1,441 new clients were initiated on treatment, representing 20% of the annual target. Following the line listing and data reconstruction exercise, at the end of Q1, 99.3% (36,811/37,068) of patients in care were on treatment, with a further 257 patients needing to be transitioned to ART. The patients who were not ready to be initiated on ART were taken through ART preparation sessions by the Treatment Preparation and Adherence (TPA) Counselors, peer educators, and clinicians.

Activity 1.2.2: Boost HIV treatment adherence support. The 50 peer educators at the 31 supported sites and 27 adherence counselors at the 22 sites continued holding daily morning PSSGs and patient self- management (PSM) sessions reaching out to 20,634 clients. The project supported pediatric PSSGs (11 facilities), adolescent PSSGs (15 sites), caregiver (11 facilities), new client (22 sites), non-suppressed (21 sites), and routine daily morning PSSGs (31 facilities).

Table 3: Psychosocial Support Groups and Their Reach PSSG Type Facilities Number Reached Pediatric 11 366 Adolescent 15 807 Caregiver 11 366 Non-Suppressed 21 1190 New Clients 22 1,395 Daily Morning 31 20,634 Total 111 24,758

Activity 1.2.3: Sensitize HCWs on new ART guidelines. Following the launch of the 2018 National ART guidelines, Afya Jijini supported 300 HCWs to be trained on the new guidelines. In addition, Afya Jijini continued supporting facility-based Continuing Medical Education (CMEs).

Activity 1.2.4: Scale-up and support pediatric and adolescent ART. As of end of Q1, Afya Jijini supported 1,235 children (0-14yrs) and 2,831 adolescents (15-24 years) to access treatment services. Afya Jijini supported adolescent and youth days/PSSGs during school holidays in 22 facilities 405 (211 male & 194 female), mainly targeting youth with non-suppressed VLs, reaching 38 (16 male & 22 female) youth and adolescents. In partnership with NEPHAK, the program continued implementing Operation Triple Zero (OTZ) in 22 high-volume facilities and supported 30 adolescent living with HIV (ALHIV) to act as advocates and ambassadors to their peers. By the end of Q1, a total of 287 adolescents had been reached out to, 11 PSSGs formed and 8 meetings held during the school holidays. From the 1,235 pediatrics enrolled, 1,022 had viral load done with a 81% suppression rate, while 2,831 adolescents enrolled in the program, 2,467 had their viral load done, 87% adhered to clinic appointments and to ART and 84% had a non-detectable viral load.

Activity 1.2.5: Strengthen HIV defaulter tracing. Afya Jijini continues to conduct defaulter tracking and tracing efforts for patients who miss clinical appointments through peer educators. The table below identifies the outcomes of defaulter tracing for Y3 Q1.

Table 4: Outcomes of Defaulter Tracing Y3/Q1 Contacted Brought Transfer Not with Total Identified Back to Dead LTFU Out Reached Follow-Up Contacted Care in Q2 8,218 5,477 65 305 2,146 685 595 5,936

During the quarter, Afya Jijini continued working with WOFAK, a sub grantee, to improve defaulter tracing efforts through chart abstraction and line listing of all active clients and defaulters. Peer educators (50) were used to call all defaulters with phone contacts and the outcome documented in the defaulter tracing register. The project also ensured that the necessary tools such as appointment diaries and defaulter registers were printed and available at all the project facilities. Daily line listing of clients who missed their appointments was conducted, and they were followed up through phone calls. This will continue in the coming quarter.

Activity 1.2.6: Increase VL uptake and suppression. VL uptake: The program supported VL testing for 32,610 clients representing 89% coverage of all eligible clients. The program implemented high viremia clinics in 29 facilities. Facilities with low viral load uptake were identified and eligible clients were line listed and contacted by the TPAs to fast track their VL review and clinic appointments. Daily bleeding was conducted by the laboratory technicians, and joint supportive supervision conducted by the sub- County AIDS/STI Coordinator (SCASCOs).

VL suppression and review: Clinicians and Lab Technologists were mentored on VL register use and review. In addition, the TB/HIV advisor conducted a CME on implementation of the viremia clinic at the Nairobi County TWG. The program sites identified 532 patients with two or more non-suppressed VLs during Q1. 369 had a repeat viral load, after undergoing satisfactory enhanced adherence sessions. Of these, 110 were switched to second-line therapy.

Activity 1.2.7: Implementation of DCM. At the end of Q1, Afya Jijini intensified support for DCM in 26 facilities, with 14,617 stable patient’s line listed and 5,863 enrolled. 1,045 patients had been on fast track for more than 12months, out of whom, 634 had their viral loads done. A total of these, 614 (97%), were virally suppressed.

Activity 1.2.8: Improve HIV treatment stakeholder collaboration. Afya Jijini provided technical support toward the formation of a regional clinical TWG for the County for HIV treatment. The TWG is a collaborative effort of NCC, University of Nairobi, UMB, and other implementing partners (IPs) in the county. It has been tasked with providing clinical support to facilities in Nairobi, including reviewing patients failing second line and those with complicated cases, providing mentorship to HCWs, and supporting. The Extension for Community Health Outcomes (ECHO) tele-mentoring platform at the STC Casino clinic was continuously supported with airtime. Furthermore, two monthly meetings were supported with snacks.

Activity 1.2.9 Roll out of early morning Clinics targeting male clients: During Q1, the program team held a CME on the implementation of male only clinics to reach out especially to working-class men who preferred attending clinics early in the mornings. This initiative was rolled out at Mbagathi Hospital and Gertrude’s Hospital. During the period, a total of 320 men attended the early morning clinics and through the support of the TPAs and the clinicians, formed PSSGs. Through support with snacks and health education, the PSSG members are held once per month to discuss unique challenges facing men who are HIV infected. In addition, screening for hypertension and diabetes was done, reaching 50 of clients with these services. This initiative will further be intensified in Q2 with scale up to 3 more sites.

Output 1.4: HIV Prevention, HIV Testing and Counseling (HTC), Voluntary Medical Male Circumcision (VMMC), Gender-Sensitive HIV Prevention, and DREAMS

Activity 1.4.4: Provide strategic HTS. Increased access to targeted HIV testing at facility level. The program continued to support targeted, cost- effective and high-yield testing approaches such as assisted Partner Notification Services (aPNS) at the facility- and community-level. In this quarter, the project continued to work with Partnership for an HIV Free Generation (HFG), a sub grantee mandated with the task of supporting HTS in 10 project facilities. The HTS providers in project supported facilities received mentorship and OJT to ensure optimization of the high yielding testing strategies. HIV self-testing also continued being implemented in project supported facilities mainly in the MCH as a way of reaching out to male sexual partners of clients attending the MCH, and also in the OPD, CCC and PMTCT clinics. A total of 1,305 (745 males and 560 females) clients were reached, with 8 (males) coming back for confirmation of their positive status and subsequent enrollment to care. In Q1, the program reached 85,752 clients with testing services, with 1,865 new positives identified (a yield of 2.2%). This translates to 39% of the annual testing target and 27 of the annual positivity target respectively. The PNS approach helped reach out to 1,350 partners of index clients, out of which 545 were tested for HIV and 70 tested positive, translating to a yield of 12.8%.

Table 5: HIV Test Yields by Testing Points (FY19/Q1) Testing Point Tested Positive Yield Inpatient Services 2,516 89 3.5% PITC Emergency clinic 68 3 4.4% PITC TB Clinics 990 119 11.9% STI clinic 362 5 1.4% PITC PMTCT (ANC1 Only) Clinics 12,032 294 2.5% PITC PMTCT Post ANC1 8,033 34 0.4% VMMC Services 1,606 0 0.0% Other PITC 34,737 683 2.0% VCT 24,313 561 2.3% Index Testing 1,041 79 7.6% TOTAL 85,698 1,867 2.2%

Increased targeted HIV testing at community level. Afya Jijini continued to provide support for targeted outreaches during the reporting period as follows:

• The program worked with the county to provide testing for pre-World AIDs Day activities in Kasarani, Embakasi East and Dagoretti Sub counties. The theme for the WAD activities was on identification of HIV status, with a focus on reaching men. A total of 936 (811 males and 125 females) were reached with 6 (1 male and 5 females) being diagnosed as HIV positive. These 6 were subsequently linked to care and treatment in project supported sites.

• The program worked with Kenyatta University to conduct an integrated outreach targeting its students during the pre-World AIDS day activities. A total of 1,020 clients (526 female and 494 male) were reached. Among the tested, 816 (430 females and 386 males) which translates to 80% of those tested, were first time testers. Out of the total number tested, 1 male was HIV positive who has been linked to care at KU CCC. There were young women’s session and the young men’s session in which reproductive health services namely family planning and cervical cancer screening were offered. HIV sensitization to staff over 25 years old was done in which willingness of staff to take up HIV services was noted, with 5 being tested during the activity. A total of 8400 condoms were distributed during the activity.

• The program worked with HFG to conduct outreach events in the identified hotspots within Westlands, Starehe, Embakasi West and Kasarani Sub-counties. This was done as a way of increasing access to men. A total of 350 clients (25 females, 325 males) were reached with testing out of which four were identified as positive and were subsequently enrolled to care and treatment. • The program worked with United States International University (USIU) during the pre-World AIDS Day activities to conduct a testing activity targeting the student attending the institution. A total of 200 (81 females and 119 males) clients were reached with 2 (1 male and 1 female) being diagnosed as positive. These two were subsequently linked to care. Assisted Partner Notification Services: In Q1, the project continued to support implementation of aPNS in supported facilities. Mentorship on documentation and line listing of contacts continued, with emphasis being placed on ensuring generated reports are correct and accurate. Working with LVCT and the County/Sub-county teams, the project conducted joint aPNS post training mentorship for the HTS providers in seven facilities, namely Kayole 2, Mama Lucy, Ngaira HC, STC Casino, Mathare North, Lunga Lunga and Dandora 2. The project continued to sensitize HCWs at the supported facilities on PNS, through CMEs conducted in the facilities and in-charges meetings. A total of 4 facility-based CMEs were conducted in Quarter 1, reaching 53 health care workers. The facilities continued receiving airtime as a way of improving contact tracing and escorted referrals.

Table 6: PNS Summary Male Female Index clients screened 595 1,103 Contacts identified 838 546 Known Positive 159 115 Eligible 670 432 Tested 311 238 Positive 43 27 Linked 42 27

Newly-diagnosed clients enrolled into care: In Q1, Afya Jijini worked to link 1,441 of the 1,867 positives identified to care and treatment in project-supported facilities, and a further 92 clients to care outside facilities, giving a total linkage of 82%. Mentorship was done for the HTS providers with emphasis being placed on proper follow up and correct documentation on the linkage registers. An audit of all positives identified in the quarter that were not initiated on treatment was done as shown in the table below:

Table 7: High-level Results from Audit New Positives Number Percentage Linked to a Tx facility 1,533 82% On follow up 178 9% Linked later to CCC 11 1% Referred out linkage not confirmed 43 2% Unreachable 15 1% Adherence Counseling for clients not ready to start Tx 19 1% Declined enrollment 22 1% Dead 12 1% Admitted 23 1% Awaiting confirmation of partners status 10 1%

During the quarter, the program continued to support testing and linkage through the HTS/TPA counselors to ensure linkage to care and treatment for all newly diagnosed clients. The HTS/TPA counsellors work to ensure that newly-diagnosed patients are escorted to CCCs for enrollment. Upon identification of a HIV positive client, the TPA counsellors conduct the first adherence session before enrollment. Clients opting to be enrolled in other facilities are referred to the facility of choice using the County facility directory and referral forms. Follow up of those linked to outside facilities is done through phone calls by the HTS counselors on a weekly basis and documented in the linkage register. To support these activities aimed at improving linkage and retention, the project continued working with AMURT (a local sub grantee) to support 27 TPAs at 22 high volume facilities. Internal HTS quality assurance (QA) strengthened. During the quarter, Afya Jijini continued to work with the Sub-County and supported facilities to provide quality assurance of HTS services within the supported facilities. In conjunction with the SCASCOs, the program supported counselor supportive supervision sessions in three sub-counties, namely Embakasi East, Kasarani and Langatta Sub-counties. Working jointly with the team at HFG, the program was able to provide facility-based supervision sessions at six facilities. This support will continue in the coming quarter. Observed practice was also emphasized in the quarter, with the HTS providers being encouraged to participate and have documentation of the outcome of the session. Afya Jijini worked with the sub county teams to provide observed practice sessions to HTS providers in 5 facilities namely Mama Lucy, Westlands, Kangemi, Mbagathi and St. Mary’s.

External HTS QA measures improved. During the reporting period, Afya Jijini continued to work with the sub- counties to provide corrective action for those with unsatisfactory results during Proficiency testing (PT) round 18. Out of 487 enrolled testers under Afya Jijini, 25 had unsatisfactory results requiring a PT Corrective and preventive action (CAPA) session before enrollment to PT Round 19. The project worked with the sub-county health teams to provide a facility level PT (CAPA) session with the 25 testers with unsatisfactory results. Afya Jijini also continued to work with NHRL to ensure health care workers enrolled in PT round 18 received results after constitution of the panels. Enrollment for PT round 19 was also done in the quarter with Afya Jijini supporting enrollment of testers in 47 project facilities. Scale up of PrEP services: During the reporting period, Afya Jijini continued to provide PrEP to AGYWs through the DREAMS project, and in project supported facilities catering to the general population and discordant couples. A total of 252 (111 DREAMS girls and 141 Discordant couples) have been newly provided with PrEP in the quarter. This brings the total number of clients currently on PrEP to 1,522 (117 DREAMS girls and 1,405 discordant couples) by the end of Q1. Afya Jijini continued working with the sub- county teams to ensure adequate PrEP commodities in the supported facilities. This will continue in the coming quarter. Scale-up of condom promotion and contraception use: The project continued to do mentorship and OJT on contraceptive use in a bid to improve FP integration in the provision of HIV testing services. Afya Jijini supported distribution of male condoms from NASCOP to the sub-county depots, from which the condoms were then distributed to the project-supported facilities. Job aids on contraception including TIART charts were also distributed to the project-supported facilities as needed in the quarter. This will continue in the coming quarter. Support HIV stigma reduction efforts: Afya Jijini continued working in ten facilities to reduce stigma. Working with AMURT (a sub grantee), the program reached 265 health care workers with messages on maintaining a positive attitude. This was done in a bid to create awareness among the HCWs on attitude and its effects on stigma reduction and mitigation during service delivery. Job aids on patient rights, stigma reduction and patient responsibilities were also provided to the facilities and the staff sensitized on them. This will continue in the coming quarter.

VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC):

In the first quarter, building on the gains from Year 3, i.e. training of health care workers on Dorsal slit technique for VMMC, Afya Jijini supported integration of VMMC into facility service provision in seven more GOK facilities (Korogocho H/C, Kayole 2 Sub-county Hospital, Kahawa West H/C, Mathare North H/C, STC casino, Waithaka H/C and Jericho H/C) in additional to the 3 (Biafra, Mbagathi and RTI) already existing. This ensured VMMC service delivery in low socio-economic community set ups in Mathare slums, Ngomongo slums in Korogocho, Kabiria slums in Waithaka and Soweto slum in Kahawa West. The facilities were able to provide extended hours services that included early mornings and late evenings including community outreaches to reach more clients and minimize missed opportunities.

During this reporting period, the program was able to collaborate/partner with faith-based community organizations during the October to December holidays to support community outreach events led by GOK facilities to reach clients seeking VMMC services and demystify VMMC as well as addressing myths and misconceptions through health talks and distribution of IEC materials to the community. Total of 1,880 clients were reached during the community outreaches. Key Results: During the quarter, the project reached 3,765 clients with VMMC minimum package of care, which accounted for 60% of the annual target. Integration of VMMC services into routine service delivery particularly in Korogocho Health Center (reached 783 clients), Mathare North Health Center (reached 122 clients) and Kayole 2 Sub County Hospital (reached 54 clients) has resulted in a tremendous increase in VMMC service uptake and the acceptability of the intervention by non- circumcising communities.

A total of 5,120 clients were reached with information, education and communication through health talks in community settings i.e. during church services and facility-based health talks facilitated by trained

health care providers. This has improved the reach to older males specifically those 15 years plus in age (accounted for 38 % reached in the reporting period) and the change by community in seeking VMMC services during the school holiday only.

Table 8: VMMC Minimum Package Quarter 1 Reach Age Groups 10-14 15-19 20-24 25-29 30-49 >50 Number circumcised 2,318 1,120 203 79 41 4 Number tested for HIV 457 901 157 52 35 4 Number tested positive 0 0 0 0 0 0

HIV PREVENTION: GENDER BASED VIOLENCE

Strengthen Community gender norms: Working with the County’s Sub-county Gender Based Violence and Psychosocial Coordinators as well as community defenders, Afya Jijini reached all nine sub-counties with HIV prevention-focused on community gender norms in Y4 Q1. Through this intervention the project reached 456 community members with GBV discussions. Afya Jijini contributed to the 16 days of gender activism which ran from the 25th November to 10th December with the theme “Orange the World #Hearmetoo”. The campaign was designed to champion accelerated efforts across the county to bring the legal/justice services closer to the community and educate the community on the importance of maintaining a clean and secure chain of custody (The process of coordinating medical legal justice, forensic evidence of the survivor statement) and their role in preventing and responding to cases of GBV.

Work with the County and sub-counties to Strengthen comprehensive Post-Rape Care (PRC) chain of custody by improving the networking: Working with the County Gender Coordinator in Y4 Q1, Afya Jijini enhanced psychosocial support services through coordination of GBV staff debriefing sessions for 12 Sub-county Defenders and 33 Community Defenders. The project further trained 26 GBV Case Managers and Defenders from Nairobi City County School health promotion department in a five-day workshop on identifying and linking school-going GBV survivors to services and psycho-trauma counselling. These participants will provide feedback to the respective sub county schools while ensuring we minimize unreported defilement and abuse. Afya Jijini’s focus of averting new infections and unintended pregnancies will be prioritized throughout Y4.

Conduct CMEs and OJTs on SGBV screening and management for HCW In Y3 Q4, Afya Jijini coordinated a series of trainings to improve linkages to care and treatment and basic management of GBV survivors. In Y4 Q1, it was imperative that the trained teams demonstrate improved skills in case management. This began with feedback sharing forums and CME sessions in health facilities (Pumwani, Kasarani, Dandora II, Embakasi Health Centre and Mukuru Health Centre) where 123 Health Care Workers (82 F and 41 M) were sensitized, and in DREAMS safe spaces-10 in Mukuru and 6 in Kangemi reaching the program implementation team and beneficiaries.

Strengthen County & sub-county GBV TWGs: Afya Jijini assisted the County to facilitate two sub-county GBV TWGs in Embakasi East and Westlands during Y4 Q1. These TWGs coordinate GBV services across partners and advocate for survivor services and GBV integration at health facilities with a variety of GBV stakeholders, who include the CHMT and SCHMT members’, community defenders, the Administrative Police-Gender Desk Coordinators, MSF France, Africa Youth Trust, Wangu Kanja Foundation, Women Empowerment Link, and other implementing partners. The TWGs provide a forum where participants comprehensively map GBV stakeholders across sectors, review GBV terms of reference (TORs), the County GBV Framework, and build responder capacity in SGBV case management including how to report SGBV cases. Participants were advised that witnesses are supposed to be refunded transport costs during SGBV court cases which requires coordination with the courts.

Operationalize GBV Clinics: During Y4 Q1, the project supported the County and sub-county to operationalize five GBV clinics which have high referrals out of the sub-county. These facilities are

Pumwani Hospital, Mukuru Health Center, Embakasi Health Centre, Dandora II and Kasarani Health Center. This was prompted by the understanding that to provide basic management at all points of care does require the provision of the essential package of services, which are generally available in all health center facilities. Subsequent to the training, five clinicians from Mukuru and Embakasi were mentored through a benchmarking experience at Makadara–Tumaini Clinic.

Strengthen utilization of SGBV guidelines GBV reporting tools. In Y3, the project provided Referral Pathways for Sexual Violence and Algorithms for Sexual Violence and distributed them to Afya Jijini assisted sites. In Y4 Q1, Afya Jijini followed up select health facilities where a referral tool had been distributed to assess the utilization of the tool. The project, with the County GBV TWG, reviewed the reporting trends from the reporting tools, namely, MOH 705, MOH 364 (A & B) and the SGBV Monthly Summary to address strengthen areas in need of improvement and document learning as evident in the improved reporting from 540 cases to 960 cases in Y3 Q4 and 1,597 during Y4 Q1 within the cohort summary in DHIS 2 data.

DREAMS Table 9: Afya Jijini Y4 Q1 Cumulative DREAMS Achievements DREAMS Indicators by Target 10-14 15-19 yrs. 20-24 yrs. Total % age yrs. Gender GBV 9,658 139 121 228 408 4.2% Community 7,726 496 903 1,399 18.1% mobilization/norms change HTS 4,042 20 255 255 530 13.1% Priority population HIV 1,145 260 269 6 535 46.7% prevention SAB interventions 5,053 220 730 575 1,525 30.2% Family Matters Program 1,732 88 185 10 283 16.3% (FMP) Education subsidies 3,416 - 12 - 12 0.4% Cash transfers 957 31 61 4 96 10.0% Financial Capability 5,053 61 153 210 424 8.4% Condom education and 4,042 - 239 258 497 12.3% promotion Contraceptive method mix 3,234 - 178 139 317 9.8% PrEP 187 - 19 91 110 58%

Support Strong Community Engagement and Leadership Support for DREAMS Success In Y4 Q1, Afya Jijini DREAMS harnessed further engagement with health facilities, SCHMTs, Nilinde- OVC, Partners for an HIV Free Generation (HFG) and targeted communities, for a more enhanced AGYW cohort saturation of service layering in Mukuru Kwa Njenga and Pipeline wards, as well as new AGYW enrollment and saturation of Westlands wards, attaining a cumulative enrollment of 11,987 AGYW (2,239 10-14yrs, 4,546 15-19yrs, 4, 29 and 20-24yrs 911 25 plus). Out of this 11,987, 0.52% AGYW (10-14 years: 18, 15-19 years: 24 and 20-24 years: 19,) were co-enrolled with Nilinde OVC partner. Activity 1.4.3.1: Empower AGYW (Core Area 1):

In Y4 Q1, Afya Jijini prioritized the flagging of AGYW benefiting from less than four services in the Kenya service layering table, to accelerate service uptake. By the end of Y4 Q1, an additional 192 new people attended activities at safe spaces as a result of this refocus.

Condom promotion and distribution: As was done in Y3 Q4, the program continued to ride on community platforms like (chiefs Barazas, Women groups, youth group meetings), SASA! Advocacy sessions, to deliver condom efficacy education in hot spots as well as health facility referrals, providing both condom education and condom distribution. In Mukuru kwa Njenga, the project partnered with Pathfinder International through the Female Condom Education and Promotion Africa (FCEPA) to offer a sensitization session to the mentors on the new female condom FC-2 model. A total of 317 (12.2 %) AGYW were reached with condom education and a total of 32,654 condoms (M= 31,819; F= 835) were distributed. Evidence-based behavioral interventions (EBI’s): In Y4 Q1, the DREAMS partner HFG trained 25 facilitators1 for school-based HIV/GBV prevention on EBIs. The facilitators were thereafter supported to provide routine school-based EBIs for AGYWs. AGYW aged 10-14 years (n=310) were reached with Healthy Choices for a Better Future (HCBF) and those aged 13-17 years were supported with My Health My Choice (MHMC) (n=223). Two additional girls were reached with other behavioral interventions bringing the total reached to 535 AGYW. Table 10: Contraceptive Methods

Contraceptive Method 15-19 yrs. 20-24 yrs. > 24 yrs. Total Oral contraceptives 0 4 1 5 Injectable 4 14 4 22 IUD and Implant 0 2 1 3 Condoms 87 106 14 207

Contraceptive method mix: During this reporting period, the program continued with empowerment of 317 AGYW aged 15-24 years through provision of information about sexual reproductive health and rights (SRHR) at the various safe spaces. 40 mentors were given a refresher orientation on contraceptive methods including the new FC2 so that they are better equipped to provide AGYW with correct information on contraceptive methods. In quarter one, a total of 333 AGYW (aged 15-19 years were 178 and 139, 20-24yrs and 16, girls above 25 years) were reached with information on contraceptive method mix. Additionally, in this quarter, Afya Jijini strategically prioritized the development of more precise targeting of Male Sexual Partners (MSPs) of AGYW to provide effective behavioral and biomedical interventions including contraceptive options and to further engage these MSPs to participate in safe contraceptive options for their partners. The table above describes the family planning methods accessed by new AGYW aged 15-24 years during the reporting period. Pre-Exposure prophylaxis (PrEP): In this quarter, Afya Jijini continued to intensify mobilization efforts to increase PrEP uptake among vulnerable AGYW in the program. PrEP information was given to 321 AGYW (15-19 years: 160, 20-24 years: 138, 25 years plus: 23) within their safe spaces in both Kangemi and Mukuru implementation areas. As a result, 111 (15-19 years: 19, 20-14 years: 77, 25 years plus: 15) new AGYW were able to access PrEP. Retention of AGYWs on PrEP still remains an old challenge, by end of December 2018, 117 out of 635 active AGYW received PrEP. Post-violence care, gender-based violence (GBV): In Y4 Q1, Afya Jijini made AGYW aware of trauma counseling services and made the services available to AGYW who were physically and emotionally violated. Subsequently, AGYW received trauma counselling and enrollment in psychosocial support groups where

1 Majority of the facilitators they trained were drawn from the Afya Jijini trained mentors and financial capability/ entrepreneurship pool and this was to enhance their retention which has been previously a challenge in Mukuru.

they could share their experiences and learn how to best resolve household conflicts. During the quarter, working closely with HIV Free Generation (HFG), local administration and technical working groups in both Mukuru and Kangemi, Afya Jijini sensitized the community on GBV. The project also intensified GBV sensitization and information giving for 408 (4.2%) AGYW (10-14yrs: 139, 15-19yrs: 121; 20-24yrs: 199; 25 Plus: 29). Two (2) AGYW who had reported experiencing SGBV earlier received up to four sessions of trauma counselling and another 46 AGYW (aged 15-19 years) and 173 AGYW (aged 20-24 years) were enrolled into psychosocial support groups. Mentorship: In Y4 Q1, Afya Jijini continued to provide mentorship at 18 safe spaces (10 Mukuru and Pipeline; and 8 Westlands SC). Subsequently, a total of 1,525 AGYW (10-14yrs: 220; 15-19yrs: 730; 20- 24yrs: 575) were reached with social assets building (SAB) sessions. The information provided to AGYWs by mentors covered various topics to ensure that AGYW are empowered to make healthy choices and sound decisions and build resilience so they stay safe and HIV free. Beyond curricula guided and structured sessions, fun activities suggested by AGYWs and facilitated by role models to cover topics like cookery, dancing sessions team building activities and visiting children homes as a way of giving back to the community were supported at the safe spaces. Twenty (20) mentors at Mukuru were trained on female condoms efficacy by Pathfinder at the Salvation Army hall. The main objective of this training was to increase awareness of and to eradicate myths and misconception around female condoms. HTS: In Y4 Q1, the project continued to saturate Mukuru with HTS services as well as reach first time or new testers in Kangemi through line listing of AGYW aged 15-24 years who may have missed HTS and to prioritize them with testing services. The project also provided HTS to AGYW aged 10-14 years who had risk exposure. Subsequently, 530 AGYW (10-14 years: 20; 15-19 years: 253; 20-24 years: 218; and 25 plus years: 28) were tested for HIV and two were identified positive and were linked to nearby facilities for care and treatment services. The two identified positive were aged 20-24 years. Table 11: HTS Age group (years) Tested for HIV Negative New Positive Known positive

10-14 20 20 0 0 15-19 253 253 0 0 20-24 218 216 2 0 25 + 28 28 0 0 Total 530 528 2 0

Activity 1.4.3.2: Interventions to reduce risk of/among AGYW sex partners During this quarter, AJ strategically conducted activities to characterize the Male Sexual Partners (MSP) of the AGYW from Kangemi safe spaces in order to determine their social, sexual and behavioral characteristics and inform the targeting of MSP and AGYW with effective behavioral and biomedical interventions. The AGYW were segmented into groups of eight to ten participants according to age, schooling status, and marital status enabling a conducive environment for close and candid discussion. The focus group discussions are facilitated mentors who also act as their confidants thus contributing to active participation among the AGYW during characterization of MSP Activities in the safe spaces. Plans are now underway to reach out to the profiled MSP with targeted behavioral and biomedical interventions which include HTS, condom promotion and distribution, post violence care sessions and PrEP with the aim of reducing risk for contracting and/ transmission of HIV. Referrals and linkages will also be considered for other services such as VMMC, ART and SASA for the MSP. Indicated in the table below is a summary of the outcomes of the characterization activities described above:

Table 12: Outcomes of the Characterization Activities AGYW Age and No. of AGYW Profile Ranking of MSP Who Engage in Sex With Segmentation Reached through AGYW From Most to Least FGDs FGD 15-19 yrs-In School 57 Classmates, Collage students, Teachers, School Coach 15-19 yrs-Out of School 78 Sponsors, Boda boda riders, Plot caretaker 20-24 yrs-Single/Married 96 Sponsors, Boda boda riders, Plot caretaker, Water Vendor

Activity 1.4.3.3: Strengthening families Parent and caregiver program: This quarter Afya Jijini greatly improved the provision of the Families Matters Program 1 and II (FMP I & II) a six to seven weeks curriculum-based EBI to parents/care givers of the AGYW. This program seeks to empower the parents/care givers of AGYW 10-19yrs with positive parenting skills to enable evidence informed engagement with their teenage daughters with the aim of enhancing healthy sexual relationships through delayed sex. The project trained 103 parents of girls aged 10-14 years with the FMP I program and 180 parents for girls aged 15-19 years with the FMP II intervention in Westlands. In Mukuru, 637 parents of AGYW aged 10-14 years and 699 parents of AGYW aged 15-19 years were reached during Q1. Unconditional cash transfer (UCT) program: During Y4 Q1, Afya Jijini provided six batches of cash transfers to 158 AGYW with three batches receiving at least six cycles within the quarter. By the end of Y3, seven batches totaling to 638 AGYW had received at least one cycle of cash transfer. Table 13: YR4 Q1 Cash Transfer Given Batch Number Batch Cycle # AGYW Given Cash Transfer BATCH 4 CYCLE 6 62 BATCH 7 CYCLE 1 96 Total 158

Education subsidies program: In Y4 Q1, Afya Jijini slowed the provision of education subsidies to AGYW because the second round of disbursements were put on hold pending completion of the procurement of dignity kits, which was initiated during the reporting period. The project is on the process of receiving shoes from Tom-shoes Company to distribute to the school going AGYWs in the subsequent quarter.

Combined socio-economic approaches: During Q1, Afya Jijini continued providing routine financial capability sessions in safe spaces, where a total of 424 AGYWs were reached. A total of 424 AGYW completed all financial capability sessions and 84 graduated to entrepreneurship training. Afya Jijini facilitated local partnership linkages with various institutions providing employability skills training, with 25 AGYW in Mukuru reached with sensitization on online marketing skills using mobile technology by Jumia Kenya, while an additional 130 were sensitized on NHIF as a means to social protection, facilitated through a public private partnership (PPP) initiative by the MoH, AMREF Africa and Pharm Access. Subsequently, 29 AGYW took up M-Tiba coverage for their families. In Kangemi, Jumia trained 72 AGYW on sales and marketing skills and engaged 42 who demonstrated interest and initiative. The 42 have been earning Kenya shillings (Ksh) 2000 per week plus commission based on how many clients they take to Jumia. Fifteen (15) AGYW have been consistently earning at least an income of KES 3500 per month since the training was completed. During the quarter, 140 AGYWs attended various training from three colleges within Mukuru informal settlements (St. Teresa College, Hi-Tech Hope college and Impala Driving school). 86 AGYW completed hair dressing and beauty therapy courses; 27 completed catering and pastry-making courses; 11 completed tailoring and dressmaking; and16 studied driving at Impala driving school.

Table 14: Courses Undertaken for Vocational Training Course Undertaken College No. AGYW Completing Course Hair Dressing and Beauty Therapy Hi-Tech Hope College 46 St. Teresa’s college 41 Catering -Pastry St. Teresa’s 27 Tailoring and Dress-making Hi-Tech Hope College 10 St. Teresa’s college 0 Driving Impala Driving School 16

Activity 1.4.3.4: Interventions to mobilize communities for change. SASA! Intervention: In Q4, HFG embarked on systems set up for implementation of SASA! in Kangemi ward. Entry and introductory meetings were held with MOH partners at the sub-county level to introduce Partners for HIV Free Generation (HFG) as the new sub grantee on board to implement EBIs in Westlands DREAMS wards. They attended the GBV TWG meeting, in charges meetings and one sub-county health management team (SCHMT) meeting where they made a presentation of their role in the implementation of Adolescents and Youth Empowerment Project (AYEP). During this quarter, HFG trained 24 SASA! Advocates drawn from the pool of community gender defenders and other active CHVs as well village elders. In Mukuru, the trained gender advocates continue to work with community members to report cases of GBV to the volunteer children’s officers, the law enforcement office, the chief for Mukuru and Wangu Kanja Foundation. In Westland’s, implementation of SASA! Activities will kick off in Q2 Y4 after HFG completes entry and training processes in this reporting quarter. Cross-Cutting DREAMS Activities Conduct stakeholder engagement: During this quarter, Afya Jijini DREAMS and the Nilinde teams co-hosted guests from Office of the Global Aids Coordination (OGAC) who visited to better understand how DREAMS has been able to integrate with OVC activities for better service outcomes for AGYW families and particularly for co-enrolled girls. The visit took place at Mukuru Kwa Njenga Mililani safe space. During the reporting period, Afya Jijini DREAMS participated in the DREAMS IP meeting held at Silver Springs Hotel in Nairobi where key highlights were presentation of draft SOPs for AGYWs exit from the program and the new MER indicator definition for the minimum package of services for each category of AGYW cohorts. Performance comparison with the COP18 targets was done and Afya Jijini joined other IPs to come up with targeted approaches to close implementation target gaps for interventions like Social Assets Building trainings (SABs), financial capability trainings, education subsidies, and PrEP. DREAMS also participated by making presentations at two other PEPFAR USAID and FBO partners meetings held at Safari Park Hotel (7th -9th November) and at the Queen of Apostles’ Conference Center in Kasarani, Desmond Tutu’s Conference Center in Westlands and St. Mary’s Hospital in Nairobi (6th and 7th December). Partnership with sub- county: Within this reporting period, AJ DREAMS participated in sub-county meetings with in-charges for Westland and the Westlands SCHMT meeting. AJ also met with the SCMOH to introduce Partners for an HIV Free Generation as the new entrant to conduct SASA! and school-based HIV/GBV prevention activities in four wards of the sub-county. In Mukuru, AJ participated in the Mashujaa Day celebration organized by the sub-county administration and highlighted DREAMS as one of the social and health programs that have positively impacted the community with invitation by the area Chief. In the spirit of partnership and leveraging resources for better services to the AGYW, DREAMS participated in the legal clinic held in Mukuru facilitated by Africa Youth Trust, one of the partners in Chaminade. AGYW and their partners, parents, care givers, mentors, and field assistants took part in this empowerment meeting. Data review: During this quarter, the team held one data review meeting for both Kangemi, Mukuru and Pipeline implementation sites. During the forum, the teams were able to share their challenges, best practices and success stories for others to consider bench marking especially around retention, PrEP, HTS

and post violence care and reporting. Over this period, regular field meetings were held with the operations teams to strengthen quality of services and to re-evaluate interventions that seemed to not be working. It is noteworthy that FMP 1 and 2 have gained momentum after these forums in terms of parents participating in the training. Sub granting: Two meetings were held with sub grantees to assess progress and find areas of more targeted support to improve target achievement. Partners for an HIV Free Generation is on course with all their DREAMS activities and their grant is due for renewal in mid-January. Private, Private Partnerships (PPP): The team also worked hard to identify external sources of strength and income opportunities for the AGYW with the merchandise they are making in Mukuru. Such ventures have resulted in 100 AGYW aged 18-24 years accessing services where they were contributing 50% of the required premium or monthly medical coverage subscription with the rest covered by M-Tiba. This program is still on-going and more and more girls will be engaged to access this social protection path. The girls were linked with Jumia sales platform and they conducted a two-day training reaching over 60 girls from both Mukuru and Kangemi. They were being trained on quality improvement of products they produce and strategies to attract online marketing platform. These strategies will be applied in Q2 to improve marketability of their products. AGYW were also trained on how to use Jiko-koa to reduce pollution in their houses in the informal settlements and how to sell the jiko (traditional stoves) and make profits from it. Quality Improvement: In this quarter, the teams implemented quality improvement projects based on the indicators where the project has not been performing to expected standards in the safe spaces. These included but were not limited to work environment improvement, filing and arrangement of the safe spaces, and clear documentation for paper-based tools for better synchronization with the online data base. Performance against these indicators will be evaluated and posted on the talking walls in the next quarter. Output 1.5: TB/HIV Co-Infection Services. Activity 1.5.1: Strengthen County TB Coordination This quarter Afya Jijini supported Sub-county TB and Leprosy Coordinators (STLCs) to conduct data review and target setting meetings at Embakasi, Starehe, Westlands, Ruaraka and Roysambu sub- counties. Key in review were Year 3 achievements, challenges, and strategies for focusing on all of the TB indicators. The facilities shared their best practices, performed Year 4 target setting and discussed strategies for improving their achievement against poorly performed indicators. Afya Jijini further collaborated with the TBARC (accelerated response care) project and County TB and Leprosy Coordinator (CTLC) to conduct the annual stakeholders’ forum, where the best performing facilities, sub-counties and SCTLs (based on data) were recognized and awarded certificates, trophies and shopping vouchers. This was to motivate the STLCs to strive to achieve targets and devise strategies to win in Year 4. CTLC and Afya Jijini also collaborated with the TB Accelerated Response Care Project (TB ARC) and conducted data driven supportive supervision at Mbagathi Hospital, Kasarani HC, Githogoro Clinic, Kayole HC, Makadara HC and Dandora II HC. They offered mentorship on IPC as well as training on the utilization of new tools and talking walls.

Activity 1.5.2: Strategically Scale the “Mirror Mirror” Model for Active Case Finding (ACF) This quarter the project’s focus was on facilities where low case finding was reported in Year 3, i.e., Melchizedek, Kivuli, Diwopa and Jamaa. CME on ACF was conducted at the facilities, focusing on the selection of ACF focal person or team leads who ensure daily TB case identification activities at all service delivery points. A total of 58 HCWs from four private facilities were orientated on the utilization of presumptive TB registers and GeneXpert testing. Afya Jijini also supported STLCs in Westlands (Keroka Gichagi, Deep Sea) and Dagoretti (Nairobi University and Riruta Israel) to conduct ACF following high positivity incidences being reported within these locations. A total of 2,897 (1,189 men and 1,708 women) people were screened for TB, with 89 suspicious cases reviewed of whom seven men and five women were found to have TB. All positive TB cases were over 15 years of age and have started on treatment. This quarter a total of 492 presumptive cases were bacteriologically confirmed through AAFB and GeneXpert.

Activity 1.5.3: Strengthen Community TB Treatment Monitoring and Defaulter Tracing

Sub-county TB and Leprosy Coordinators were supported to conduct sensitization sessions at Gichagi and Deep Sea health facilities on TB awareness and self-screening. They reached a total of 36 CHVs and 16 community elders with updates on TB and provided IEC materials on TB. At Dagoretti and Embakasi, the sub-counties with the highest number of DRTB cases, a total of 18 patients are being followed up by CHVs/ cough monitors on drug adherence and appointment keeping. Afya Jijini supported STLCs to sensitize the CHVs on early signs of adverse events and how to conduct DOTs so as to enable them to educate and follow up patients. OJT was conducted for 63 CHVs and cough monitors on the utilization of defaulter tracing registers and correct documentation of outcomes. A total of 24 treatment interrupters (all male with a history of alcohol abuse) were reported with 21 traced back and three lost to follow up.

Activity 1.5.4: Improve Isoniazid Preventive Therapy (IPT) The project supported County TB and Leprosy Coordinators (CTLC) to conduct sensitization on IPT for 41 CCC clinicians from private sites that have been affected by high staff turnover. They were therefore educated on management of latent TB and provision of information to CCC clients on the importance of INH. OJT for clinicians on correct documentation in IPT registers was given during the quarterly Work Improvement Team (WIT) meeting held at CCCs. At Ruben Center, IPT initiation increased to 92% from 73% in Y3 Q3 and can be attributed to consistency in WIT meetings conducted at the facility in collaboration of Afya Jijini cluster teams. This quarter a total of 1,520 were newly initiated on IPT and 1,467 have completed therapy, there was no shortage of INH this the quarter under reporting.

Activity 1.5.5: Strengthen TB Infection and Prevention Control (IPC) The project continued to mentor facilities to form IPC committees, which was a noticeable gap in year 3 at some facilities. During the quarter, IPC committees met in seven facilities (Westlands HC, Melchizedek, Kivuli, Ruben, MMM, Mukuru HC and Mbagathi hospital) following last quarter’s IPC assessment. The committees identified gaps such as a lack of cough areas, poor client flow at outpatient departments (OPDs) and CCCs that increased risk of cross infection. STLC collaborated with Afya Jijini to ensure that the facilities addressed gaps by developing and distributing signage for cough areas. At Melchizedek and Kivuli, the clinicians gave separate appointment days for TB/HIV co-infected clients to reduce the risk of cross infection.

Activity 1.5.6: Boost TB-HIV Integration and Provision of Immediate ART for TB Clients Afya Jijini continues to support HTS counselors who ensure 100% testing or no missed opportunities for testing at all 42 supported facilities. At Melchizedek a total of 23 HCWs were sensitized on TB screening and TB management. This quarter a total of 35,982 were screened for TB at CCCs by AJ-supported cough monitors and clinicians. A total of 1,217 (95%) knew their HIV status across all TB facilities.

Figure 4: TB HIV cascade

Activity 1.5.7: Strengthen Pediatric TB Diagnosis and Treatment Afya Jijini collaborated with STLCs to mentor clinicians on pediatric case finding at facilities. At Embakasi sub-county, contact tracing among smear positive clients (who are considered highly infectious) was noted to be low since the recommendation by NLTB is that every adult with a positive smear test, at least one child should be screened for TB. Afya Jijini found that among 106 smear positive adults, only 21 children were screened for TB. Also, there was minimal documentation in the newly introduced contact registers. These gaps were identified through the quarterly data feedback review meeting during a round table discussion conducted with 30 clinicians. A target was set for all facilities to ensure contact tracing was being conducted and 5 cough monitors sent out invitations for contact tracing at facilities. At Mbagathi and St Mary’s (level 4 hospitals), HTS counselors were mentored on TB screening at pediatric in-patient departments to strengthen HTS and TB screening among children. This quarter a total of 87 children were diagnosed with TB, 6 were co-infected and started on HAART.

Activity 1.5.8: Multi-Drug Resistant (MDR-TB) The project continues to support monthly DRTB clinical meetings at the ten sub-counties to review patients on second line treatment. This month a total of 13 patients were reviewed with their laboratory results and four were discharged from treatment. To empower the SCHMT and include them in clinical discussions, a total of 16 sub-county members were sensitized on DRTB patient management at Westlands sub-county for ongoing mentorship and ownership. The Westlands SCHMT was awarded for best team in Programmatic management of drug resistance TB in Nairobi County.

Sub-Purpose 2: Increased Access and Utilization of Focused MNH, CH, FP, WASH, and Nutrition Services In Y4 Q1, the project continued service delivery and capacity strengthening by addressing needs such as emergency obstetric and newborn care (EmONC) especially in private health facilities, re-distribution of FP commodities, poor documentation and inadequate data reporting tools at the facility level. The project worked with 66 maternities, 243 ANC sites and 183 facilities offering modern FP services. Afya Jijini continued to build the capacity of HCWs on targeted MNCH topics through training 40, CMEs 163, OJTs and mentorship reaching a total of 63 HCWs. During the quarter the project had 20,952 pregnant women attend four or more ANC visits; 24,817 (27% of annual target) women had skilled birth attendants present during childbirth. On immunization, a total of 23, 923 babies were reached with DPT 3, and 23,731 with the measles vaccine. In the same period, 22,176 children were fully immunized (FIC). In addition, a total of 6,266 pneumonia cases were diagnosed and treated among children under the age of five. The project also focused on PNC to newborns within two days of delivery, a key intervention in improving early neonatal outcomes. This resulted to 10 041 babies receiving PNC within two days in Q1.

Maternal and perinatal deaths review was also strengthened in the health facilities through regular meetings and addressing action points established in the review meetings. In Q1, 7 maternal deaths occurred and all were audited, with 422 of the total 941 perinatal deaths (562 FSBs, 229 MSBs, 150 neonatal deaths) being audited.

To improve reporting of maternal and perinatal deaths at community level, a total of 83 community MPDSR committees were formed, with verbal autopsy tools distributed to the committees. CHVs continued with their community services reaching 8,211 mothers with ANC messages, 5,825 with FP messages, and 13 with PNC messages. The CHVs also referred 861 women for ANC services, 511 women for delivery services, 10525 were issued condom as family planning services and 1343 babies’ were referred for immunization services.

During the quarter, the project achieved CYP of 84,764, with Long Acting Reversible Contraceptives (LARC) at 50,217 contributing a 60% of the total CYP.

Output 2.1: MNH Services

Activity 2.1.1: Strengthen County and sub-county MNH service quality and coordination. During Y4Q1, the project provided logistical support to the County towards World Prematurity Day build- up activities to help create awareness on Kangaroo Mother Care (KMC) for preterm and low birth weight babies, and supported stakeholders’ fora in nine Sub Counties. The fora provided an opportunity for partners to share their achievements and areas of collaboration such as supportive supervision. During the stakeholders’ fora, it was realized that most partner/ donor funding was on decline and thus the Sub County were advised to improve on self-reliance and efficiency in resource management so as to sustain gains made in MNH. Activity 2.1.2: Boost ANC attendance (uptake and completion of 4+ ANC visits). The program reached 20,540 mothers with 4+ANC visits against a quarterly target of 20,952 (19% of annual target) in Q1. Building on achievements of Y3, during Q1, the project continued coaching and mentoring Afya Jijini supported CHVs to strengthen community-facility linkages by conducting health talks at the facilities and home visits at the community level. In response to mothers attending 1st ANC within the first trimester, the project supported and facilitated in CMEs for HCWs and CHVs and Binti Shujaas to educate mothers and pregnant adolescents on importance of FANC and continued to encourage women to seek urgent ANC services as soon as they miss their monthly periods. Facility level sensitizations for HCWs on importance of screening for pregnancy for all WRA seeking services in respective health facilities at all service delivery points also continued. At the community, a total of 8,211 pregnant women were reached with ANC messages and 861 referred for ANC services to their nearest facility. Through OJT, documentation of ANC services has also improved at Pumwani maternity hospital and Kangemi HC. The project also embarked on following up on action points that were developed during the FANC training in Y3Q4, with project teams doing onsite mentorship for gaps identified. The 26 PMTCT nurses deployed in high volume facilities, continued supporting ANC service delivery especially RH-HIV integration in the MCH department.

Figure 5: Afya Jijini Year 4 Quarter 1 Performance: 4+ ANC

Figure 6: Adolescents presenting with Pregnancy (Y4 Q1)

Activity 2.1.3: Increase safe deliveries within NCC. In Q1, the program continued working with the Sub County Public Health Nurses and Sub County Mentors in providing hands-on technical support, mentorship, OJTs and CME. A total of ten CMEs were done on various topics including Respectful Maternity Care (RMC), Partograph use, maternal complications such as pre-eclampsia/eclampsia, PPH, retained placenta, asphyxia and newborn resuscitation, and reached 134 HCWs. The CMEs were informed by the gaps identified during facility assessments, mentorship and maternal and perinatal death surveillance and response (MPDSR) meetings. Building on Y3 gains of scheduled OJT and mentorship informed by MPDSR and WITs findings, St. Mary’s Mission Hospital has consistently decreased number of perinatal deaths at the facility over the period. Maternal deaths across all facilities decreased over Q1 compared to the quarterly reports in Y3. Mentorship on documentation in the maternity files and maternity register continued at the facilities. To sustain Leadership Development Program (LDP) gains for skilled deliveries at Bahati, Ngara, Waithaka, and Dandora 2 health centers, the program through HSS arm, continued with coaching sessions to the teams to improve and sustain achievements. A key challenge during the quarter was the implementation of the decongestion plan for Mbagathi Hospital that was undertaken by the County following the condemnation of the maternity wing in Y3. The facility was referring mothers in labor back to health centers (i.e., Kibera South and Lang’ata) due to the limited space in the makeshift maternity ward. The current maternity ward has four beds for ANC admissions, three beds in the labor ward, eight beds in the PNC ward, seven incubators, and six cots. Community mobilization activities are now re-directing mothers to deliver in the surrounding health centers. This has resulted in a decrease in skilled deliveries at the facility. The program is continuously engaging the County leadership through advocacy to make the necessary structural adjustments of the maternity wing so that services can resume to normalcy. Printing and distribution of IEC materials, job aids, SOPs to facilities continued over the quarter. Among the materials distributed included patients’ rights and responsibilities, management of puerperal sepsis, and management of neonatal sepsis. 2,904 maternity files were distributed to 16 maternities for improved monitoring of mothers in labor and documentation of patient information. During Q1, the project conducted an EmONC assessment at 14 facilities out of the 66 supported high- volume maternities. A total of 24,061 deliveries were reported. 89% of total deliveries received uterotonics in the third stage of labor. There was no reported stock-out of oxytocin in the maternities over the quarter. During the project’s early assessment, failure to document an uterotonic administered was the main gap

that was also being strengthened through maternity WIT activities and onsite OJT by the project technical officer. Maternal and Perinatal Death Surveillance and Response (MPDSR) activities: In Q1, 776 maternal complications were reported in the 67 maternities contributing to occurrence of 7 maternal deaths which were all audited. The causes of maternal deaths included pulmonary embolism (3), thromboembolism in Sickle cell crisis (1), PPH (1), complication of abortion (1) and unanticipated complications of management (1). Perinatal deaths reported in the period were 941. Out of this, 422 were audited. The project reported a maternal mortality ratio of 38 deaths per 100,000 live births and perinatal mortality ratio of 52 deaths per 1000 live births.

To strengthen MPDSR, the program continued with printing and distribution of maternal and perinatal death notification and review forms to improve MPDSR reporting for all the 66 supported maternities and verbal autopsy forms for the community reviews. The program offered technical support to 14 monthly MPDSR meetings were held as scheduled in most maternities with Afya Jijini offering direct technical support to 14 meetings held at nine health facilities (MLKH, PMH, Mbagathi, St. Mary’s, St. Francis, Mathare North, Makadara, Mukuru Reuben and Mukuru HC) and AJ supported most of the responses as indicated during the review such PPH prevention/management and pre-eclampsia (PET/E) management OJT and mentorship. The two complications were also the main contributors of maternal deaths in the Y3. As response to some of the action points, three CMEs on PPH prevention and management and two CMEs on PET/E management reaching 52 and 31 HCWs respectively. The CMEs and follow-on mentorship were conducted by Sub County EmONC mentors who received logistical support from the program. The program also oriented HCWs on use of fetal dopplers at St. Mary’s to support in fetal monitoring during labor, as a result of MPDSR action point.

In the same period, Lang’ata Sub County MPDSR meeting was held. Reporting of maternal events and auditing was at 100%. The gap established was uploading of audited reports in the DHIS-2. This was strengthened during the meeting.

Community MPDSR: Following the training of CHAs on MPDSR in Y3, a total of 83 verbal autopsy committees were formed in Y4 Q1. Sensitization meeting on verbal autopsy was also provided for the 48 volunteers. 3 perinatal deaths were reported from the community and all were audited the causes were; pneumonia, asphyxia and Prematurity. The deaths were then audited at the link facilities with appropriate action points taken up by the CHAs and CHVs on community health education and early referral

Figure 7: Afya Jijini NCC Q1 PPH Cases and Responses

Figure 8: Q1 Perinatal Mortality

Quality Improvement in maternities. In Q1, the program continued sustaining the WIT activities in the health facilities. Pumwani continued with their WIT projects: 1) correct and accurate use of the partograph, and 2) correct and complete documentation of the patient admission information. During the quarter, Pumwani began a project of reducing time during Caesarian Section (C/S) in theatre in order to reduce maternal and neonatal morbidity and mortality that could result from delayed C/S interventions.

MLKH, Bahati HC, Huruma Nursing Home and St. Mary’s also continued working on improving monitoring of labor using the partograph. The facilities recorded improved accurate documentation on the partograph with MLKH at 60% from a baseline of 20%, Bahati HC at 67% from a baseline of 33%, Huruma Nursing Home at 40% from a baseline of 4% and St. Mary’s maintaining at 80% from a baseline of 0% in their last review in the quarter. Kangemi HC successfully completed their project on partograph use in the period.

Activity 2.1.4 Improving HCW attitude through training and coaching To increase patient confidence and utilization of health services, the project, through sub-grantee Health Right International, trained 38 HCWs (6M, 32F) from five HVFs, two health centers and training institutions on RMC. The training also incorporated the respectful newborn care (RNC) package, an innovation to improve care given to newborn babies while in the health facilities. RMC messages that include patient rights, patient obligations designed as IEC materials were also distributed to the facilities. Following the training, CME on RMC was done at MLKH reaching 24 HCWs in maternity department. This was aimed at increasing positive attitudes of HCWs as they serve mothers and their babies in the department. WIT activities continued to be avenues of attitude change for HCWs as they worked towards improvement of service delivery in the maternities. Following continued engagement with facility leadership since Y3 on staff attitude change, community engagement through 25 CHVs supported by the program, support for maternity open day and maternity tours for pregnant women during first ANC, Makadara HC skilled births increased tremendously over Q1. Figure 9: Makadara Health Centre Quarterly Total Deliveries - 2018

Activity 2.1.5 Improve uptake and provision of PNC at target health facilities. Building on training done in Y3 Q4, Afya Jijini technical officers continued to strengthen PNC within two days to both mothers and babies through mentorship in 10 maternities that had poor documentation of the PNC register. Through the 21 project monitoring and evaluation assistants, improved documentation of the PNC register, and reporting of postnatal care information in all health facilities was also strengthened. HCWs were mentored on PNC as a continuum of care that begins immediately after third stage of labor and importance of reporting on the PNC services provided. The package of PNC within two days including exclusive breastfeeding, assessment and treatment/referral of newborn conditions, cord care using chlorhexidine, thermal care, PMTCT for those born to HIV positive mothers were emphasized during PNC mentorship. The project also convened a meeting with the County and all the Sub County Health Records Information Officers (SCHRIOs) aimed at improving PNC reporting across all facilities. During in-charges meeting for Emabakasi East Sub County, a CME on targeted postnatal care guidelines was done where 40 in-charges were in attendance. This was aimed at strengthening postnatal care reporting since PNC this is among the high impact interventions.

The project also distributed 2018 National PNC guidelines to 5 maternities during Q1. In the same period, the project provided logistical support for World Prematurity Day build-up activities in four high volume facilities (i.e., Mbagathi, MLKH, Pumwani, St. Mary’s) and surrounding health centers (Lang’ata, Kibera South, Eastleigh, Kayole 2) was provided.

The project also provided an additional 228 KMC Tharis to be used by mothers during and after their stay in KMC room at Pumwani hospital. At community level in Q1, 268 CHVs continued to provide information to clients on the importance of PNC and accompanied those who had home deliveries to the nearest facility within the first 48 hours.

During the quarter, 10,041 newborns (23% of the annual target 44,280) were documented to have received PNC within 48 hours after birth. This contributed to (44 %) of total live births within the reporting period, translating to 9% of the annual target. The major challenge on PNC performance was documentation in the primary tools which the project has been working on for improvement as highlighted above.

Figure 10: Afya Jijini Q1 Performance: PNC

Activity 2.1.7: Scale-up gender-sensitive approaches to MNH. In Q1, the project worked with 258 CHVs (56 males, 202 females) in the informal settlements of Nairobi. 125 CHVs are working under sub grantee Health Right International (HRI), while 48 CHVs work directly under Afya Jijini. The CHVs continued to provide health messaging at both community and link facilities on the importance of MNCH services. In Q1, a total of 206 men were reached to support their partners in accessing MNH services (26 ANC, 10 SBA, 13 family planning, CWC 43, 13 PNC, and seven other services) were seen in eight (Makadara HC, Mama Lucy, Embakasi Health Center, Kayole 1 and 2 Health centers, Dandora 2, Kahawa west health center and Korogocho Health Center) facilities with ‘We Men Care’ service desks served by male champions. Output 2.2: Child Health Services In Q1, the program supported the County to hold a review meeting for the concluded Polio SIA Round 4. The County reached 976,748 (111% of the target of 883,792) under-five children with the monovalent oral polio vaccine sub-type 2 (m-OPV2). The program also supported the County to immunize 24,536 babies under-one year of age (24% of annual target) with diphtheria-tetanus-pertussis 3 (DTP3), 22,806 (23% of annual target) with measles vaccines, and reached 22, 176 (22% of annual target) with FIC in Q1. This was achieved through working with 243 facilities. 107 facilities of the 243 contributed to 85% of immunized children as per the catchment areas of informal settlement. Over the quarter, 6,266 cases of pneumonia among under-5 children were diagnosed and treated with antibiotics. The key challenge over the period were the inadequate supply of amoxicillin DT in the MOH facilities which meant caregivers were to purchase the medicines. The program has continued to advocate to the County to stock adequate amounts of amoxicillin DT.

Figure 11: Q1 DPT3, Measles Performance and FIC performance

Activity 2.2.1: Strengthen County and sub-county planning/supportive supervision for child health. During the quarter, the program provided technical and logistical support to the County enabling their staff to carry out child health activities as planned by the County.

The project also supported the World Prematurity Day build-up activities in partnership with other implementing partners in Nairobi City County. Afya Jijini supported 25 HCWs drawn from MLKH, Pumwani, St. Mary’s and Mbagathi Hospitals while other IPs supported CHVs and radio messaging during build-up to the celebration. The build-up activities were aimed at increasing awareness of the impact of low-cost but high impact KMC for preterm and low birth weight babies. The celebrations were held at Kenyatta National Hospital on 16th November 2017, a day earlier than the internationally recognized day of 17th November 2018.

Activity 2.2.2: Improve facility child health service provision. In Q1, the program continued its facility technical support as per MOH guidelines by providing mentorship sessions, OJTs, and CMEs aimed at improving the quality of child health care. Afya Jijini officers, working closely with the Sub County EPI coordinators, mentored HCWs on the documentation in the daily activity registers in Child Welfare Clinics.

Following the mentorship activities, defaulter tracing mechanisms such as defaulter tracing registers, intensified CHV tracing at all immunizing facilities. Makadara, MLKH, and Bahati HC facilities began working on improvements of FIC through their WIT project. A gradual monthly improvement on fully immunized child (FIC) was being witnessed at Bahati HC across the quarter compared to the previous quarters. The main challenge in the indicator was the dynamic mobility of the population. In the same period, distribution of job aids, and immunization guidelines was also done while development of SOPs to support the services went on through the quarter. Through advocacy to the Sub County, the project also supported Ngaira Dispensary get a vaccine fridge from Remand prison. Their fridge broke down in 2017 and the facility had been unable to perform immunizations for more than a year. The facility is now able to provide immunization services to its catchment population. The program has also continued mentorship on improved documentation in the MLKH newborn unit through WIT and has improved documentation on the feeding chart for the sick neonates from a baseline of 0% in October to 40%.

The program also distributed MNCH job aids and Integrated Management of Newborn and childhood illness (IMNCI) guidelines aimed at both standardizing client care and providing HCWs a quick reference source. Activity 2.2.3: Strengthen knowledge and uptake of infant and child health services at the household- and community-level. In Q1, the project continued working with 48 CHVs engaged by AJ and 125 engaged by HRI in five informal settlements of Nairobi (Embakasi East and West, Makadara, Ruaraka, Kasarani) attached to 12 facilities (Embakasi and Mukuru Health Centers and Mukuru Reuben in Embakasi East; Kayole I, Kayole II Health Centers, and MLKH Hospital in Embakasi West; Mathare North, Kahawa West, and Korogocho HCs in Ruaraka; Dandora II HC in Kasarani; and Makadara and Bahati HCs in Makadara). In the same period, CHVs reached a total 6,690 mothers with immunization messages, 1,343 mothers were referred for immunization, and 354 defaulters were traced for immunization services. Another 6365 mothers were reached with messages on diarrhea management, and 6,618 with messages of other illnesses e.g. TB, fever, HIV and all cases referred for specific treatment when need arose. Following the ICCM training of community Health assistant in Y3, on job training was conducted to volunteers who were able to reach under-five and offered services in informal settlement and reached the following number of children with various services (i.e., Makadara, Ruaraka, Kasarani, and Embakasi West and East): 16 cases of pneumonia were referred for treatment, 106 cases of diarrhea were treated with ORS and Zinc. Output 2.3: FP Services

During the reporting period, the program continued to distribute FP guidelines, Community family planning manual, Tiarht charts, SOPs, counselling cards, minimum eligible criteria (MEC) wheels, and job aids which offer quick check lists for the HCWs to use during counselling as well as guidance on what to do when providing the services. The project also supported KEMSA to distribute 13 vasectomy sets to the County.

The program reached 94,367 women of reproductive age (WRA) with FP services translating to a CYP of 84,764 in the quarter, with long acting and reversible contraceptives (LARC) contributing to a 60% of CYP in Q1.

In Q1, the project worked with 183 sites and 258 CHVs to provide FP services to clients in need. The volunteers were able to referred 1,148 WRA for implants and IUCDS in the following facilities (Kayole I Health Centre, Kayole II Sub-District Hospital, Mama Lucy Kibaki Hospital, Embakasi Health Centre, Dandora II Health Centre, Bahati Health Centre, Makadara Health Centre, Korogocho Health Centre, and Kahawa West Health Centre).

Activity 2.3.1: Strengthen County and sub-county FP coordination and service delivery. Afya Jijini worked with the county and sub counties to strengthen planning, delivery, and monitoring of FP services. The program worked very closely with sub counties to re-distribute FP commodities with the County FP TWG in response to the inadequate stocks of progestin only pills (POPs) and Jadelle in some Sub-counties. The project also printed and distributed 200 SC FCCRR tools, and 200 cervical cancer screening forms to Makadara SC facilities (i.e., Pumwani, Mbagathi, and MLKH). Activity 2.3.2 Improve access and quality of facility-based FP services. During Q1, the program supported health facilities to offer quality FP services through the distribution of IEC materials and reporting tools (i.e., FCCRR). The project also distributed/re-distributed 5 FP demonstration kits for use during health education and counselling in postnatal ward, CCC and PMTCT rooms of MLKH, CCC and PMTCT rooms at Makadara HC and PMTCT room at Bahati HC. The project also continued with FP OJT reaching a total of 21 HCWs from 9 facilities.

Figure 12: Q1 CYP performance

During Q1, there were relatively stable stocks of commodities, which contributed to an increase in CYP from the previous quarter in Y3. However, towards the end of the quarter, some key commodities were running out of stock at Sub County stores; key among them being POPs and two-rod implants (Jadelle).

FP Uptake among adolescents and youth: A total of 3,231 adolescent girls received FP services across the program facilities. In Q2, the program will focus on immediate PPFP for adolescent and young mothers giving birth in health facilities to improve FP uptake utilizing maternities as a key entry point. During Q1, the Binti Shujaa Model is implemented to reach 400 adolescent girls through 20 trained peer mentors linking to three facilities Bahati HC, Makadara HC and Dandora 2 HC. So far, the Binti Shujaa mentors have consistently retained 383 adolescent girls for referral on MNCH within the last three months. During a review meeting held in the quarter the team re-emphasized on advantages of complete referral of MNH/FP services among adolescents and young mothers as well as reporting. Figure 13: Q1 FP uptake among adolescents

Activity 2.3.3: Strengthen household and community access to FP messaging and commodities. In Q1, the program supported 258 CHVs to offer FP information at the household level and during dialogue days conducted at 511 CUs. The program also distributed 500 copies of MOH 100, and 710 family planning guides were distributed to CHVs in the ten Sub Counties. The MOH 100 tools and family planning referral guides were aimed at improving community referral and standardizing CHVs messaging on as per the MOH guidelines’ requirements respectively. A total of 4,373 households were visited over Q1, reaching 5,187 women of reproductive age (WRA) with messages on FP. Seven hundred twenty-four (724) WRA were referred for LARC services and 7,209 condoms were distributed by CHVs at the community level.

Activity 2.3.4: Offer gender-sensitive FP approaches. During Q1, the program continued working with two male champions to support the We Men Care model to reach men with FP information. A total of 23 men were reached with FP information, 23 with other RMNCH services and 11 with HIV testing services.

Integration of RH/HIV services: The program continued to strengthen the RH/HIV integration services in high volume care and treatment facilities through mentorship and OJT of HCWs at CCC. As a result, during Q1, 40% of HIV positive WRA were reached with FP services during the quarter. The UHAI team are working on introducing pregnancy intention assessment services to increase FP uptake and improve pre-conception care in high volume facilities. A case study of MLKH also had a WIT project towards improvement of FP integration and had achieved 95% (from a baseline of 20%) as at the end of Y4 Q1.

Photo 1: A case of Mama Lucy Kibaki Project on FP integration

Output 2.4 WASH Services Year 4 Quarter 1 Report

Activity 2.4.1: County-level WASH support.

Improving collaboration and networking:

To build the capacity of the County and strengthen networking and collaboration, the project participated in consultation meetings, planning meetings, fora and stakeholder meetings held in the County and all Sub- counties attended by the County staff and other WASH partners. These afforded the project opportunities to pursue and discuss areas of collaboration, learning and experience sharing. The project was also able to provide support to the development of the County essential package for WASH which will be utilized in health education for children and other WASH stakeholders in informal settlements. As reported previously, the County embarked on the development of the County Environmental and Sanitation Bill, through adoption of the prototype bill developed by the national government, and the Kenya Environmental Sanitation and Hygiene Policy to Nairobi City. During the reporting period, the project supported this process and the co-convenors and secretariat of the Urban Sanitation Technical Working Group (TWG). Several consultative meetings and one workshop were held during the reporting period resulting in a draft bill, and development of a roadmap which will culminate in presentation of the bill to the County Assembly. Strengthening awareness and promoting WASH through global awareness days: Afya Jijini supported and participated in promotion of hygiene and sanitation awareness through two global awareness days. The project supported celebration of Global Handwashing Day (GHWD) which was undertaken on October 15, 2018 at Gitwamba Primary School in Kasarani Sub County. Global Handwashing Day is a global advocacy day dedicated to increasing awareness and understanding about the importance of handwashing with soap as an effective and affordable way to prevent diseases. The theme of the event this year was “Clean hands – a recipe for health”, focusing on the link between handwashing and food, including food hygiene and nutrition. Activities undertaken during the event included edutainment by Natural Leaders (NLs) from triggered villages and school children from the Sub-county on hygiene and demonstrations on handwashing. Over 3,500 children and 500 adults participated and were reached with hygiene messages during the event, which the project supported with IEC materials (300 t-shirts and two event banners) and technical assistance through participation in planning for the event.

Prior to the GHWD, Afya Jijini supported two sub-counties to conduct hand washing promotion in schools and ECD centers. These were Kasarani and Kamukunji sub counties. At Kamukunji, 144 children in ECDs were reached with education on handwashing, with the majority of the children being less than eight years of age. Thirty-five (35) adults who manage the institutions were also reached during the event. At Kasarani Sub-county, 549 children from five ECD centers were reached with WASH and handwashing messages. Chlorine tablets were also distributed to the five ECD centers for treatment of water. The project supported the County and participated in celebrating World Toilet Day on the 19th November 2018 at the Child Survival grounds, Kamukunji Sub-county. This is a national day which is set to raise awareness on sanitation and the theme for this year was “When Nature Calls”. The event was undertaken in one of the villages in which the project has been supporting promotion of sanitation through the Urban Community-Led Total Sanitation (UCLTS) approach. Activities undertaken during the celebrations were a procession from to the venue, launch of a latrine which had been constructed with support from another implementing partner after Afya Jijini supported triggering of the village, cleaning of public latrines, edutainment by different groups, and speeches by different government officers and partners. Afya Jijini participated in planning the event and provided IEC for distribution on the event day.

Activity 2.4.2: Sub-county and facility-level WASH support.

Improving WASH in health facilities and supportive supervision: To promote improvement of provision of WASH services and hand washing in health facilities, the project procured and distributed 260 posters in health facilities to improve knowledge on hand-washing. These posters had messages on critical hand washing times and proper handwashing procedures.

To promote infection preevention in health facilities, the project funded one CME in Mama Lucy Kibaki Hospital, where 32 participants were sensitized on healthcare waste management, personal protection for IPC, and handwashing. In addition, to promote IPC and facilitate waste management in health facilities, the project procured and distributed 300 waste bins.

Support functional Oral Rehydration Therapy (ORT) Corners at supported facilities: The project continued to provide technical support to health facilities in management of diarrhea. Project-supported volunteers (WASH Champions) assisted with diarrheal disease management and with the functioning of ORT corners in 28 health facilities. The WASH Champions linked patients to their communities for continuous provision of services and promotion of diarrhea prevention at community and household level. Capacity gaps in ORT corners were noted and addressed through the health facility in-charges and the Sub-county Management teams. Action plans developed to address the issues. In terms of results, 20,328 (25% of annual target) children were attended in ORT corners, and over 5,000 caregivers benefited from counselling on management of diarrhea in children. Figure 14: Under Five Treated with Diarrhea Treated with Zinc and ORS: Q1

Activity 2.4.3: Implement and scale UCLTS in Nairobi’s informal settlements

Pre-triggering and triggering activities: The project collaborated with the County to continue implementing UCLTS, with the aim of decreasing the number of informal settlement populations practicing open defecation (OD), scaling-up sanitation and to enable communities and households to provide sanitation facilities to defecate hygienically. During the quarter, the project invested in sanitation efforts by engaging communities to initiate sanitation improvement through the UCLTS approach. The project supported pre- triggering activities and triggering of two villages during the quarter. The two triggered villages were Tassia 1 Kijiji in Embakasi East Sub County and Ribakia in Embakasi West Sub County. This increased the number of villages triggered with support of the project from 33 as at end of Y3 to 35. As a result, 1,781 households with population of 5,180 in these two villages have access to sanitation.

Post triggering monitoring and follow up: To support triggered villages and ensure progress in facilitating villages to be open defaecation free, the project facilitated 28 post-triggering monitoring and follow-up field visits in triggered villages. In addition, after the triggering and post triggering activities, several villages have been observed connecting households and plots with sewer lines; a good indication of movement towards open defecation free status.

Capacity building for Sub-counties in UCLTS: The project continued providing OJT to Sub-county WASH Focal Persons, Natural Leaders, Public Health Officers (PHOs), Community Health Assistants (CHAs) and other health workers in all 10 sub-counties to strengthen UCLTS implementation. The sessions undertaken covered reporting of community UCLTS progress and outcomes after triggering; providing post-triggering motivation and support; building capacity of Natural Leaders (NLs) and sanitation champions; and scaling-

up sanitation activities. The OJT contributed to improved knowledge, skills and quality of facilitation during triggering and post-triggering monitoring and follow-ups.

Activity 2.4.4: Additional community-based WASH support activities.

Promoting WASH-Friendly ECDs, day-care centers, and schools through the community outreach model: To improve health seeking behavior of children related to hygiene and sanitation, their caregivers (teachers and parents) and community in informal settlements, the project supported implementation of the ECD and Small Doable Approach (SDA) models. During the review period, the project supported 60 CHVs to promote WASH-friendly learning institutions and day-care centers in informal settlements in four Sub- counties (Kasarani, Westlands, Langata and Dagoretti). Using the model, ECD Centers and day-care centers are reached with messages on hygiene, maintenance of drinking water quality, and safe disposal of excreta (all aimed at preventing diarrhoea in children under five). CHVs also distributed IEC materials (posters) on handwashing. The table below shows the distribution of beneficiaries (children) of this intervention: Table 15: Distribution of Beneficiaries SUB COUNTY OCT NOVEMBER DECEMBER KASARANI 13,774 14353 1249 LANGATA 0 0 0 DAGORETTI 8695 6709 1024 WESTLANDS 3700 4110 1310 TOTALS 26169 25172 3583

Promoting environmental sanitation through clean-ups: During the quarter, the project supported seven Sub- counties2 to undertake 23 clean-up and sanitation action days, where 1,197 (339 male and 858 female) participated, reaching over 20,000 people with WASH messages. These sessions were conducted in informal settlements, including the triggered villages. The communities developed plans to improve waste management in their locations. The clean ups were also used as an opportunity to undertake advocacy on environmental sanitation. Other achievements were unblocking of sewers, collection and proper disposal of solid waste dumped in the villages, engagement of community members especially youth in the clean ups and sanitation dialogues driven by the slogan “our garbage our responsibility”.

Diarrhoea prevention and control: During the quarter, the County experienced an increase in reported cases of diarrhea and suspected cholera cases. There were suspected and confirmed cases in Starehe, Embakasi East, Kasarani, Langata and Makadara Sub Counties, with a death in Embakasi East, according to the County records. As part of prevention and to build community capacity in WASH, and working in partnership with the County, the program supported various interventions in response to the increased number of diarrhea diseases and the suspected cholera cases in the two affected Sub-counties (i.e., Makadara and Embakasi East).

The project supported sensitization of communities in Embakasi East Sub-county, targeting informal settlements in Embakasi East and Makadara Sub-county. The activity involved health education for targeted communities on matters related to domestic water treatment, sanitation, personal hygiene and disease prevention. During the exercise, treatment of water in public water sources was undertaken as well as disinfection of filled latrines and septic tanks. As a result of this activity, 32,998 households were visited and health education undertaken with those household members. A total of 93,667 people were reached with key health messages on WASH, 18 ECDS and schools visited, over 10,000 children were reached with

2 Embakasi East, Westlands, Makadara, Embakasi West, Kasarani, Ruaraka and Kamukunji

health messages on handwashing and ensuring water quality. 21,190 chlorine tablets were distributed for treatment of water for drinking. A total of 138 food premises were also reached with hygiene messages for prevention of cholera in Embakasi East. 155 health talks were also undertaken in Embakasi East Sub County in 13 villages.

Supporting safe water and household water treatment technologies: Most households in informal settlement get water from illegal water connections, water vendors and other sources which are unsafe, easily damaged and contaminated. This necessitates the need to treat drinking water at the point of consumption. To facilitate practicing correct use of water treatment technologies and promotion of safe water in the informal settlements, the project supported distribution of 236,350 chlorine tablets (AquatabsTm) for Point- of-Use (POU) water treatment of 4,727,000 liters of drinking water. These products were distributed at household level during household visits, in ECD and day care centers, and in schools.

To promote water quality and access to safe water, the project partnered and supported sub-counties to undertake water sampling and testing in informal settlements. During the reporting period, 29 water samples were taken from boreholes, tanks in schools and other public places, and piped water taps in public places. The samples were used for bacteriological analysis and testing of residual chlorine using rapid test kits which the project provided for the County. A total of 146 residual chlorine tests were undertaken. The sampling and testing of water informed the actions and interventions to be undertaken during the remainder of this year.

WASH GRANT UNDER CONTRACT

Kumea, the Afya Jijini grantee for WASH activities, supported a training session for 175 community leaders and community health volunteers on water, sanitation and hygiene in Embakasi East, Starehe and Makadara Sub-counties. The participants were drawn from informal settlements where the grant project is supporting WASH activities. The aim of the training was to build the capacity of the participants in terms of WASH and UCLTS so that they may act as champions and resources in health for their communities and facilitate implementation of the WASH grant.

The grant project supported point of use water treatment where 8,300 chlorine tablets (Aquatabs) were distributed in 150 households and 150 ECD and day care centre. As a result, 166,000 litres of water were treated. To promote hygiene and sanitation among children, the grant project engaged 45 CHVs to undertake promotion of WASH in 150 ECD and day care centre in three sub-counties, reaching approximately 15,000 children during the quarter. To promote sanitation in informal settlements in the three sub-counties, the grant project supported triggering of eight villages using the UCLTS approach.

Activity 2.5 Nutrition Services

Activity 2.5.1: County-level nutrition support Afya Jijini supported one county nutrition forum (CNTF) in October 2018. The forum brought together stakeholders including the CHMT and SCHMT members directly linked to nutrition and child survival activities as well as representatives from different line ministries like Ministry of Agriculture and education as well as nutrition implementing partners within in all the 10 sub counties. The core issue discussed during this forum was the need for other partners to outline their areas of support in each sub counties since most of the partners are new. One such partner is the Kenya Red Cross which plans to roll out IMAM Surge approaches in selected IMAM sites supported by Afya Jijini. The two projects formed an agreement to closely collaborate on strengthening the follow up of the clients to reduce defaulter rates in IMAM-OTP programs. Some of the highlighted support by AJ during the first quarter included logistic support for commodities, technical support on proper documentation and use of anthropometric tools, ACF, supportive supervision and community conversations.

Sub county support: In Y4 Q1, all 10 sub-counties were supported to conduct a five-day nutrition oriented supportive supervision visit by a team of five SCHMT members from every SC under the supervision of two CHMT members who provided mentorship during the supervision exercise. A total of 120 sites/facilities were assessed. Nutrition weeks: Planning meetings were also conducted within the county and sub counties to plan for Malezi bora activities to be done during November 2018, the main theme was ‘Afya kwa Jamii ustawi wa Nchi’ (The health of people is strength of a nation) of Other activities supported included supportive supervision and ACF for de-worming and vitamin A supplementation treatment, which were conducted in the ten SCs as well as community conversations in Langata and Embakasi East SC. CHVs and county and sub county health management team members were provided logistic support to conduct these activities, and mothers in the targeted communities were provided with bread and milk during the community conversation. Activity 2.5.2: Facility-based nutrition strengthening activities. Ensuring the Growth Monitoring and Nutrition Assessments: During the reporting period, the project conducted facility checks to assess use of anthropometric tools and categorization of clients according to their nutritional status. This was also supported by the county and sub county health management team during the supportive supervision of 120 sites described above. The project also assessed facilities to ensure proper functionality and availability of anthropometric tools by sourcing from facilities that had extra tools. The project sourced weighing scale and height boards from Makadara and gave them to Kaloleni and Jerusalem sites. The project also provided photocopies of MOH 713 for nutrition data collection and reporting, which was lacking in most of the facilities within the sub-counties. In addition, in coordination with the county and sub county health teams, the project sourced reporting tools from nutrition division and all the 10 sub counties got the new MOH 713 and other nutrition reporting tools, which included MOH 409, MOH 511 and the IFAS policy. These tools were provided to over 40 facilities which were identified in the supportive supervision report. Encourage quarterly nutrition supportive supervision and improve reporting: Using the nutrition supportive supervision tool developed by the county, the project supported a nutrition oriented supportive supervision visit in all the 10 SCs. Findings from the supervisions outlined the lack or inadequacy of storage space for nutrition commodities in over 40% of facilities and a shortage of staff in high volume CCCs. These shortfalls mean nutrition services for patients with HIV and TB are not being implemented well and some facilities require updated tools (especially MOH 511), which is a reporting tools for nutrition indicators in order to have uniformity in reporting. Some facilities also lack some IEC materials, which, in coordination with the sub county nutritionist, are going to be sourced and others photocopied by Afya Jijini. It was also noted that HCWs from the assessed facilities reported being trained on NACs, VAS, MIYCN and IMAM, but needed refresher trainings on nutrition in HIV to improve on proper integration of nutrition in HIV (NACS). A total of 120 sites were assessed and HCWs mentored on proper documentation and roles assigned to ensure the right thing is done in line with MOH standards.

Capacity building: To increase knowledge and update the healthcare workers on the new MIYCN guidelines, 28 HCWS were trained on the Baby Friendly Hospital Initiative (BFHI) for three days. The staff participants were drawn from Pumwani hospital and other selected facilities that have the potential of implementing BFCI including Mama Lucy and faith-based Neema Uhai hospitals Strengthening Nutrition Assessment and Counseling (NACS) services: During the reporting period, the project continued to provide technical support at the CCCs and PMTCT units in high volume facilities within the county. At least 20 of those sites were provided with proper documentation including green cards and HEI cards. The project also provided BMI wheels and adult MUAC tape. In response to a gap identified during the joint supportive supervision visits, AJ provided guidance on nutrition notes to be attached in the patient files so as to document nutrition interventions done at CCCs. To dates, this guidance has been implemented in 25 sites following NACs training done during the last quarter. Further strengthening facility HINI provision: The project has continued to support facilities to ensure there are no stock outs of IFAS so mothers are able to access them. Nutrition education and counselling has been conducted every day at facilities on such topics as EBF, complementary feeding, and maternal nutrition.

Furthermore, community conversations for mothers have also to teach mothers about these cost-effective nutrition interventions. Two community conversations were conducted during the quarter and were held at PCEA pipeline and Beyond Zero Clinic. Two CMEs were held during the quarter on HINI in Mathare North and Kasarani H/C on EBF/ complementary feeding and on significance of IFAS to pregnant mothers and documentation of the same. Strengthen Integrated Management of Malnutrition (IMAM) at priority health facilities: Afya Jijini provided technical support and mentorship on proper documentation on reporting tools and proper use of anthropometric tools in Kasarani, Kangemi, Kariobangi North, Njiru, Kaloleni Riruta, Waithaka, Soweto PHC, Kayole 11, Bahati, Dandora 1 and 11, Njiru, Kangemi H/C, Mukuru H/C. The projects also continued to support the redistribution of nutrition commodities (FBF, RUTF, and RUSF) and multivitamins to facilities whose supplies were short on those supplies, which included moving them from Kaloleni to Makadara H/Jericho Ofafa, Jerusalem, and Njiru and from Njiru to Dandora 1 and 11 to ensure smooth running of OTP sites. In addition, 120 sites were assessed by the project with the SCHMT to assess progress on filling gaps at the OTP sites. Also, facility staff were mentored on proper documentation and proper use of anthropometric tools. Improving maternal nutrition: One CME was held on IFAS and maternal nutrition at Njiru H/C and a total of 30 HCWs were reached. The project also supported redistribution of 30 copies of the IFAS policies per SC and 300 copies were distributed and disseminated to MNCH sites. Fifty IFAS counselling cards were distributed to five facilities per sub-county to guide the HCWs on key information to give the mothers on when, how and why they should take the IFAS. A total of 29,364 mothers received IFAS at their first ANC visits in our coverage facilities.

Figure 15: Pregnant Women Reached by Nutrition-specific Interventions: Q1

Support and scale up Baby friendly hospital initiative (BFHI) approaches: To strengthen certification of Pumwani and Mama Lucy to be baby friendly facilities, the project supported 28 HCWs mainly nurses from new borne units and maternity wing in general to undertake a BFHI training from Pumwani Maternity and Mama Lucy Hospitals. The training will be followed up to see if steps of BFHI are strengthened during the subsequent support supervision.

Activity 2.5.3: Community-based nutrition support activities.

Deploy trained CHVs for improved community-based nutrition:

Active case finding (ACF): Afya Jijini supported ACF by deploying CHVs trained by the project, to accelerate case finding of under-nutrition in under 5 populations and referring identified cases to health facilities for management of acute malnutrition. The project supported ACF in all the 10 sub counties through MUAC screening which was integrated with de-worming and vitamin A distribution. Vitamin A supplementation (VAS): The County carried out community-level VAS distribution during the quarter integrating VAS with ACF activities in all the informal settlement in Nairobi’s ten SCs. The VAS campaign reached 3906 children aged 6-11 months and 110,617 aged 12-59 months in age. Altogether, 154,849 children were reached with VAS during the quarter.

Figure 16: Under Five Received Vitamin A

De-worming: During the Malezi bora weeks, the county carried out a de-worming campaign that reached 15,200 children aged 12-59 months through the outreach activities. There were no stock out of de- worming medications during the quarter. During this reporting period, a total of 67,732 children aged 12- 59 months were de-wormed in Nairobi City County.

Table 16: Active Case Findings through MUAC Screening

SUB <115mm 115-125mm 125-135mm >135mm OEDEMA TOTAL COUNTY

M F M F M F M F M F M F

Makadara 1 3 4 7 25 38 2895 3850 0 0 2925 3898

Starehe 3 5 39 66 1123 1244 6553 6576 0 0 7718 7891

Kamukunji 6 11 22 52 461 609 1658 1792 0 0 2147 2464

Ruaraka 0 1 14 22 1348 1461 15648 16587 0 0 17012 18071

Westlands 1 1 9 26 1986 1672 2152 3575 0 0 4184 5274 Embakasi 2 0 3 4 1189 1065 7765 8479 0 0 8959 9548 East

Embakasi 0 2 198 214 629 649 3472 2746 0 1 4299 3612 West Dagoreti 2 1 2 5 24 44 3797 4054 0 1 3825 4104

Kasarani 3 3 14 17 940 1115 4059 4258 0 0 5016 5393

Langata 0 0 1 1 1 5 2699 3109 0 0 2701 3115

Total 18 27 306 414 7726 7902 50698 55026 0 2 58786 63370

Community conversation: To promote behavior change on maternal nutrition and young child feeding, the project supported two community conversations in Langata’s Raila Village and for Embakasi East at Penta Costol East Africa church (pipeline) for pregnant and lactating mothers. The community conversations were integrated with child health community outreach activities. The services offered included immunization, family planning, vitamin A supplementation, growth monitoring and promotion, deworming, IFAS, MNPs and education on optimal infant feeding practices. In Embakasi East, a total of 191 under 5 children were screened; 270 were given vitamin A supplementation; 233 children were dewormed; and 210 mothers were reached with nutrition information on EBF, complementary feeding, and maternal nutrition talks. The majority of the mothers initiated breastfeeding one hour after delivery with only a minority having the knowledge of why early initiation of breastfeeding was important. The mothers knew that babies should be exclusively breastfed for the first six months, but the majority initiated complementary feeding earlier than the recommended age. The discussions demonstrated the existence of a lot of myths and misconception surrounding breastfeeding such as mothers do not have enough milk and that mothers’ milk alone is not enough for the baby. Afya Jijini will carry out more community conversation sessions with other partners like Concern Worldwide and the Red Cross. In Langata, a team of ten volunteers were assigned to mobilize 200 women from the community including pregnant women, lactating women, and those with children under five years of age. Other participants comprised of CHVs, village elders, nurses working in the community unit, clinicians and nutritionists.

During the community conversation, a total of 70 under five children were reached with Growth Monitoring and Promotion and found six underweight and 1 severely underweight. Eighteen children were given VAS, 16 were de-wormed, and 50 given MNPS.

Community-based Nutrition – The ECD Model: Afya Jijini During the quarter, ECD growth monitoring and promotion were conducted in four SC: Westlands, Kasarani, Dagoretti and Langata SC. Sixty CHVs were engaged to conduct monthly growth monitoring, and Community Health Assistants and nutritionists followed up with the CHVs in the community to compile the data. A total of 90,743 children were screened, which resulted in the identification of 18 SAM cases and 208 MAM cases. 54,953 children were also reached with hand-washing information and a hand washing demonstration.

Photos 2 and 3: Nutritionist giving a talk on MIYCN to mothers during community conversation. Demonstration table used during CC at Pipeline area

Sub-Purpose 3: Strengthened and Functional County Health Systems

Output 3.1: Partnerships for Governance and Strategic Planning Activity 3.1.1 Strengthen County and Sub-County Level Leadership and Governance.

Stakeholder Coordination: During this review period, the project supported the Sub-counties through the County Partnerships Coordinator office to conduct eight Sub-county stakeholder coordination forums for Starehe, Kamukunji, Embakasi East, Dagoretti, Langata, Westlands, Ruaraka, and Kasarani Sub-counties. The meetings were well attended especially by Sub-county health development partners, who shared program support activities with the representatives from the Sub-counties as well as lessons learned and challenges faced during the implementation period.

County Integrated support supervision: During Y4 Q1, the project supported the County to conduct quarterly supportive supervision visits in all Sub-counties. The County, with the support of AfyaKit, uploaded the supportive supervision tool in an online platform. The CHMT were oriented on the use of the online tool which was accessible through mobile phones. There were reported challenges on the login at site in the first two day of the four-day exercise. The report will be ready in the next reporting period. This is a clear demonstration that the County is embracing technology to make processes effective and efficient.

Leadership Management Training: In the period under review, the project supported ten health leaders drawn from the Sub County and hospitals to train in the Senior Management Course at the Kenya School of Government. This course contributes to capacity enhancement in health leadership teams.

Medium Term Expenditure Framework (MTEF): Afya Jijini was nominated as a technical member to the 2017/2018 MTEF reporting committee/TWG and development of the MTEF framework for the 2019- 2022 period. The project was mandated to draft three chapters namely: cross sector linkages, emerging issues, and conclusions and recommendations. The draft document is ready for validation by the senior health management team prior to its submission.

Program Based Budgeting: In the quarter under review, the project collaborated with the County Health department to bring together all facility in charges in Level 2 and 3 facilities to introduce performance-

‘’I am glad this happened. I have been requesting the County to orient in charges through the budgeting processes among other management practices since I took office, but nothing was happening’’. ‘’Although I will still need further coaching and mentorship following this training, I am leaving here confident that I can cost a budget out of the facility AWP, implement and monitor with ease!’’-In Charge

based budgeting approaches. This came in the wake of the County disbursing funds to the newly appointed facility in-charges for the first time in nearly five years since devolution [2013/2014-2016/2017]. This included orientation of the AWP planning process and linking the AWP to other county planning tools such as the procurement plan. Further emphasis during this session was on budget monitoring implementation, reporting and tracking/monitoring budgets, and evaluation using the Authority to Incur Expenditure (AIE) tool. The team was also taken through procurement planning processes and tools. The sessions were practical and hands on. The participants were provided with scenarios and put in teams to allocate and report on fund utilization using tools provided. In the next reporting period, the CHMT responsible for health care financing will conduct supportive supervision at health facilities to gather and share experiences in budget planning, implementation and monitoring following the training. One participant/in charge in a health center had this to say at the end of the two-day session:

Activity 3.1.2 Strengthened facility level leadership and governance

Strategic planning for County Referral facilities: In November 2018, the project engaged the interim Pumwani Maternity Hospital health management team to kick off the process of developing the Hospitals’ Strategic Plan. In December 2018, the health management team met to conduct the hospitals strengths, weaknesses, opportunities and threats (SWOT) analysis. This exercise was also an opportunity for the health management team to bring out issues that affect optimal performance of the hospital. In the next review period, the technical team will come together to work on the strategic objectives and priority actions that will inform implementation of the plan. Output 3.2: HRH Activity 3.2.1 County-level HRH strengthening. County HR TWG: In November 2018, the project supported the quarterly HRH Management and IHRIS meeting. The meeting was well attended. Key in this meeting was presentations from the sub-counties on HRH dashboards at the facility and sub county levels. Much progress has been made at the sub-county level in terms of data updates into the IHRIS system. The next area of focus will be utilization of this data for decision making and the update of the Sub County Medical Officers of Health (SCMOH) on the IHRIS system and its uses in workforce planning and management.

Leadership Development Program: Following the LDP training in Y3 of the project, Afya Jijini has embarked on post-training follow up of trained teams through coaching on new improvement projects. A key observation made during the coaching sessions was that eight of the ten health facilities supported have already started working on the improve projects last year.

Human Resources for Health Advisory Committee Training: The project, in collaboration with the County, selected 10 health management leaders from both the County and Sub County who are members of the Advisory Committees members to attend HR advisory management training. The training was offered at the Kenya School of Government. It is expected that trained members will be champions and will take a lead role in ensuring that advisory committees are active at their duty stations.

Output 3.3: Health Products and Technologies (HPT) Activity 3.3.1: County and Sub-county level HPT strengthening: Quarterly Sub County Pharmacists work planning meeting. This meeting reviewed the achievements attained in Y3 and the planned activities for Y4. The following activities had been carried out to satisfaction of the County and Afya Jijini: 1) the county commodity TWGs review meetings held in Y3 Q1 and Q2, 2) the Sub-county commodity TWG-supported commodity management training done in Embakasi East, 3) supportive supervision and commodity redistribution done in eight sub-counties, 4) the training workshop on management of TB, 5) installation of the IQCare pharmacy module in Westlands Health Centre, St. Mary’s and Mbagathi Hospitals, 6) the pharmacovigilance training conducted in three sub counties, and 7) the review of the Mbagathi Formulary. Activities planned for Y4 were discussed and agreed upon. They included the following: development of commodity management SOPs for hospitals and health centers, pharmacovigilance CMEs in all supported sites, supportive supervision visits by sub-county teams, commodity security technical working group meetings at the county and sub-county levels, pharmacy staff

forums at the sub-county level, assessment of storage capacity at hospitals, and support for DHIS2 training and reporting.

Targeted Support Supervision. In the quarter under review, the Westlands Sub-county Pharmacist and three other officers carried out supportive supervision for five hospitals (i.e., Kangemi HC, Westlands HC, Karura Dispensary, Mji Wa Huruma Dispensary and Lower Kabete Dispensary). The main findings were as follows: inadequate inventory management practices, lack of SOPs, inadequate staffing levels, limited storage space, and incomplete drug consumption records. It was agreed that these deficiencies would be mitigated through mentorship sessions, trainings, development of SOPs and advocacy through the County Pharmacist office.

Orientation session for the new Makadara Sub county Pharmacist. A new Pharmacist was assigned to the sub- county in November 2018. She was briefed on the activities supported by Afya Jijini in the sub-county and plans for the remaining quarters of Y4. During the meeting, it was agreed that Afya Jijini’s support would focus on the following topics: staff in need of training in DHIS2 and reporting tools (F-MAPS, F-CDRR), development of a directory of pharmacy personnel in the sub county to enhance and ensure ease of communication, supportive supervision (scheduled for January 2019), exploring modalities of using peer educators in the clinics lacking pharmacy personnel for inventory management, exploring the possibility of purchasing a refrigerator for Kaletra Solution, and organizing for pharmacovigilance CMEs in all AJ sites.

Sub county Pharmacy Forums. In Y4 Q1, Afya Jijini supported the Sub-county Pharmacist in Embakasi East to hold a forum for all facility-based pharmacy staff. A session on pharmacovigilance was conducted. Case studies were used to demonstrate how to fill out and report using pharmacovigilance tools and the use of Facility monthly ARVs patient summary (F-MAPS) forms, facility consumption data reports, and monthly commodity requests (F-CDRR) were also demonstrated.

Quantification and Allocation of RTKs: Coordinated by the County Medical Laboratory Officer, Afya Jijini continued to support quarterly Rapid HIV Test Kits (RTKs) allocation. In Quarter 1, the RTKs’ allocation was done online by the Sub-county Medical Laboratory Coordinators (SCMLCs), the County and Sub- county AIDS and STIs Coordinators (C/SCASCOs), and the implementing partners. The county-level RTK allocation was based on consumption data and therefore the issue of stock-outs was minimized. Previously, the RTK allocations was done at the national level, but the allocation is now decentralized at county level. Afya Jijini supported Nairobi County to perform RTK allocations at county level which has picked up the process and sustained. Forecasting and Quantification of GeneXpert Commodities: During the quarter, there was a nationwide stock-out of GeneXpert cartridges. The stock-out of cartridges resulted in the facilities reverting to TB microscopy testing which is less sensitive compared to molecular GeneXpert TB testing which also detects Rifampicin resistance. The gene expert cartridges were however distributed towards the end of the Quarter. Afya Jijini, in close collaboration with the SCMLCs, continued to support the monitoring of stock levels for GeneXpert cartridges and falcon tubes, and consumption data submitted to the National TB program. This consumption data is utilized to inform allocation and supply of the commodities. Afya Jijini will continue to engage with the county GeneXpert TWG, National TB program and other TB implementing partners to improve the supply of the cartridges.

RTKs Reporting Rates: Afya Jijini continued to support laboratory commodity reporting through both the Health Commodity Management Platform (HCMP) and DHIS2. In Y4 Q1, the HCMP Rapid HIV Test kits reporting rates in Nairobi City County was sustained at at average reporting rate of 97% in comparison to the National annual reporting rate of 84 %. Afya Jijini will continue to collaborate with the county and sub-county laboratory coordinators in year 4 to further improve the DHIS-2 reporting rates.

Activity 3.3.2: Strengthen facility level commodity management (inventory management and commodity security)

Re-distribution of ARVs. Due to the change in updated ART Treatment guidelines in August 2018, some of the drugs for regimens that were being phased out were in short supply which led to the need for redistribution of the available quantities. Ten facilities benefited from this initiative. The ARVs that were frequently re-distributed were TDF/3TC/EFV, NVP solution, TDF/3TC, ABC 300mg and FTC 300mg.

Support supervision. Fifteen sites (i.e., St. Joseph Mukasa, St. Francis, Melchizedek, Kivuli, Mama Lucy, Mukuru HC, Mukuru Reuben, Jamaa, Gertrude’s Githogoro, FHOK Langata, STC Casino, Soweto Kayole PHC, Kayole 2, Kariobangi North, Mathare North) received supportive supervision and mentorship visits from Afya Jijini staff. The visits focused on improving inventory management practices and reporting. It was noted that the updating of records (e.g., stock cards and daily activity registers) on a transactional basis was low and needed to be improved. Facilities without bin cards and daily activity registers were supplied with the same. Inventory management was supported for ARVs, TB medicines and family planning commodities.

Assessments for storage capacity. Ten sites (i.e., Makadara HC, Jericho HC, Bahati HC, Lunga Lunga HC, Kangemi HC, Westlands HC, Kayole 2, Kariobangi North, Soweto Kayole PHC, Mathare North) were assessed for storage capacity. It was noted that all the sites needed improvement in their storage capacity. It was agreed that there was a need to procure standalone shelves to increase storage capabilities in these sites. Six more sites (i.e., Dandora 2, Mama Lucy, Kahawa West, Mutuini, Ngara HC, STC Casino) will be visited in Q2.

Activity 3.3.3: Strengthen facility-level commodity management (information systems) Support Supervision. Six sites in Makadara Sub-county (i.e., Makadara HC, Lunga Lunga HC, Metropolitan, Jamaa, Jericho, and Bahati) were given support supervision targeted at reporting since they had a poor track record of reporting their ART consumption and as a result did not order adequate stocks for monthly resupply. In order to address this challenge staff were taken through F-MAPs and F-CDRR, the tools for reporting ARVs. So as to ensure that they report patient numbers, ART consumption and quantify for monthly orders accurately.

Development of tools to enhance pharmaceutical data management. Counter requisition, issue voucher, and commodity security report templates were developed. During supportive supervision visits, it was observed that forms for the transfer of commodities from the ‘department of issue’ to the ‘department of use’ which are usually supplied by the County were out of stock, hence the decision to develop one. The project also identified a need to prepare monthly commodity security reports for ARVs, so an Excel template has been developed.

Monthly commodity security reports. Beginning in November 2018, the supply chain team started preparing commodity security reports for ARVs. The reports highlighted some of the supply chain performance indicators such as reporting rates, completeness of reports, reporting on time, and stocking according to plan. The reports also highlighted areas that needed support from the program. In Q2, the reports will be analyzed further to yield indicators for all tracer commodities identified by USAID.

Figure 17: ARVs reporting rate

Figure 18: FP reporting rate

Activity 3.3.4: Strengthen facility-level commodity management (patient safety): Pharmacovigilance (PV) CME: The Embakasi East Sub-county pharmacist conducted a PV CME during the quarterly Pharmacy staff forum. Nineteen staff from sites in the sub-county were sensitized on the importance of pharmacovigilance. The staff were from AJ sites and non-AJ sites. PV tools were demonstrated and distributed. A PV CME was also done at IMA offices for the program team to sensitize them on PV with the understanding that they would cascade it down to staff at site level.

Activity 3.3.5: Strengthen facility-level commodity management (QA)

Distribution of Job Aids: 800 job aids were printed and distributed to all ten sub-counties. Each sub-county received ten sets of the eight job aids. They included the following: good record keeping practices, an expiry tracking chart, good inventory management practices, a medication use counselling checklist, pharmacovigilance framework, pharmacovigilance tools, good inventory management practices and good dispensing practices.

Activity 3.3.6: Collaborate with related USAID and donor-supported HPT projects In the period under review, the Afya Jijini HPT Advisors attended and participated in the USAID Supply Chain implementing partners meeting to learn about USAID’s vision for supply chain programs aiming at enhanced commodity security and accountability of commodities. In Y4 Q1, Afya Jijini collaborated with the Clinton Health Access Initiative (CHAI) to create user rights guidelines for the viral load/EID NASCOP system for Laboratory County and Sub-county Coordinators. The user rights will enable the SCMLCs to access the VL and EID platform to directly get timely viral load and EID results. Other than the results, the VL/EID platform will be useful to analyze and monitor laboratory indicators like turn-around-time, VL uptake, sample rejection rates. Afya Jijini also collaborated with KEMRI and the Association of Public Health Laboratories (APHL) to train laboratory technologists on remote logging of viral load and EID samples in KEMRI’s online sample management portal. This will ensure reduced turnaround time and sample rejection rates due incomplete documentation. Ten facilities were trained in remote logging and real time results access. Quarterly RTK allocation was done online by all Laboratory Sub-county Coordinators to ensure timely distribution of RTKs by KEMSA. Additionally, the program supported redistribution of HIV and TB commodities coordinated by the County and Sub-county Health Management Teams, to minimize service interruptions. This was done in Makadara Sub County. Activity 3.3.7 Environment Monitoring and Mitigation Plan (EMMP). Afya Jijini continued to provide support and mentorship on the implementation of biosafety and biosecurity strategies to ensure clients’ and patients health and safety. The support includes hands-on mentorship on waste segregation and disposal and development of safety manuals and SOPs to address waste segregation and management processes. The program also supported the certification of biosafety cabinets and Hoods in 13 Afya Jijini-supported facilities, to ensure personnel and environmental safety.

Activity 3.3.8 Laboratory strengthening activities. Coordination of laboratory services: In Y4 Q1, the project held a Laboratory County and Sub-county Coordinators meeting. The aim of the forum was to sensitize the Laboratory Sub-county Coordinators on viral load and EID data/results access and tracking of quality indicators; provide corrective action and preventive action during supportive supervision visits and mentorship, and to improve data quality and reporting on DHIS2 and HCMP platforms. In addition, the County and Sub-county Laboratory Coordinators were given user rights to access data on NASCOP’s VL/EID website.

Laboratory Support Supervision and mentorship: Afya Jijini conducted joint quarterly site supportive supervision visits with the Sub-County Medical Laboratory Coordinators (SCMLCs) at the facility level. The following is the summary performance of the L-CQI CEEs for the Afya Jijini supported facilities.

Laboratory Continuous Quality Improvement (L-CQI) Performance Afya Jijini continued to provide mentorship and on-the-job-training to supported facilities to implement laboratory continuous quality improvement (L- CQI). The following is the description of the quarter one CQI performance:

“Eighty-five percent (85%) of the laboratories are implementing quality management systems and meet the required standard as per the SIMS tool. More than 85% of the laboratories have their laboratory technologists trained on biosafety and are adhering to the biosafety standards. They have biosafety SOPs and or safety manuals available and in use in all the supported facilities. The gaps on staff biosafety trainings was noted in private and mission

facilities due to a reported high staff turnover, during the next quarter the program will focus on conducting biosafety trainings for these facilities. The laboratories have the results information management systems in place, with some labs having the EMR while others have the manual system (Registers). Within the laboratories, waste management is done as per the IPC guidelines. Waste segregation is done as per the recommended color codes, there are waste management SOPs, and job aids. In addition, all the supported laboratories were sensitized on new viral load sample testing platform at KEMRI, which utilize plasma preparation tubes for VL analysis and with increased sample stability for up to 6 days at 2-80 C from the time of sample collection. A job aid was developed to guide the facilities on sample management and specific laboratory emails created for results access. During the quarter, there was stock out of GeneXpert cartridges resulting to TB GeneXpert testing interruptions in all Afya Jijini supported facilities. The facilities opted to do microscopy for TB diagnosis to reduce on service delivery interruptions.”

Laboratory sample networking: In quarter one, Afya Jijini focused on monitoring of the sample networking indicators to ensure access to quality laboratory results. The average turnaround time for viral load results was six days and 11 days for EID. The VL sample rejection rates was 0.5, which is within the universally acceptable sample rejection rates of less than 2%.

Output 3.4: Strategic M&E Systems

Activity 3.4.1: Build County capacity to monitor and evaluate priority health service delivery areas effectively. Collaborate with relevant stakeholders to review progress Health Delivery Areas (SCHRIOS, M&E TWG): During this quarter, the project held a strategy meeting with the County and Sub-county HRIOs to discuss priority activities in the Y4 work plan and budget, highlight development of the county M&E Plan, and reemphasize use of EMRs in priority sites. The team agreed to conduct EMR supportive supervision visits, and improve on reporting for postpartum care given to mother and the baby through CMES at facility in the subsequent quarter.

Train CHMT, SCHMT Member sand HCW from High volume facilities on use of national HIS platforms: During the reporting period, the program, in collaboration with the county office trained SCHRIOs and SCASCOs from the ten sub counties in Nairobi on EMR use and troubleshooting of system related issues. The training was aimed at improving clinical care of patients, improve accuracy in reporting and ease in report generation. This training has improved use of EMR from 17 care and treatment sites by end of Yr3 Q4 to 29 sites by end of Q1 Yr4.

Support sub-counties and high-volume facilities with airtime for uploading data to DHIS2: The program continued to support routine monthly uploads into DHIS2 by supporting 11 data entry clerks who work four days per month in all ten sub-counties and one high volume facility (Pumwani Hospital). The clerks were provided with airtime to facilitate data entry. The reporting rates across the popular data sets (MOH 711 and 731) remain at 85%. The project is working to strengthen the commodity reporting rates which were as low as 63.5%, but are now improving and are currently are at 85% for contraceptives.

Figure 19: Facility Contraceptives Consumption Report and Request Form – July 2015-Dec 2018

Carry out supportive supervision and Data review forums to sub-counties and facilities on service delivery data: The program provided technical support to facility staff to conduct a data sharing and review meeting using a predesigned dashboard that displays key indicator performance. The tool helps in visualizing performance, missed opportunities, and any other gap and interventions/actions taken promptly. Targets for the FY19 reporting calendar were shared with the facilities. The team focused on the indicators included on MOH 731 and MOH 711. Afya Jijini Collaborative Fora: The program continued to collaborate with other USG implementing partners to strengthen the reporting system and increase data use for decision making at all levels. Key partners and the areas of collaboration include the following: • USAID’s Kenya Health Management Information System (KeHMIS) program • University of California, San Francisco (UCSF): Supported DREAMs data management • USAID’s Health IT program: Collaborated on Family Health indicator definitions and reporting • Evidence for Action (E4A): Collaborated on surveillance activities on MPDSR • USAID SQALE program

Activity 3.4.2: Improve facility-level data collection and use. Collaborate with partners (Palladium Group) to scale-up the IQCare system to incorporate all modules: During the reporting period, Afya Jijini participated in a user acceptance testing of the PMTCT module of IQCare at Palladium offices. The purpose of the meeting was to identify gaps in the PMTCT module and provide suggestions on areas of improvement before roll-out. The module captures all MCH related data including PMTCT for HIV positive women and HEI data. Afya Jijini identified St. Marys’ Mission Hospital as a center of excellence for the piloting of the module, due to the availability of network infrastructure at MCH, and management appreciating use of EMR in all the service delivery points, compared to other Afya Jijini HVF sites.

Strategic EMR scale-up to 29 program-supported C&T sites to full EMR functionality: The program has continued to support HIV care and treatment facilities to implement IQCare for patient clinical management and reporting by revamping already broken down infrustrucuture – cables, LAN, computer hard drives, general maintainance, and troubleshooting any system related issues. By the end of this reporting period, a total of 29 (70%) facilities were using the system at different levels.

The program managed to scale up three more facilities to point of care reporting (POC) in addition to the three already on POC. These are Mathare North Health Center, Mukuru Health Center and special treatment clinic; bringing the total facilities utilizing EMRs at point of care to six. Data Migration at Mama Lucy Kibaki hospital, Jericho and Ngong Road health centers is ongoing with 48%, 41% and 35% of the records respectively in the system by the end of the quarter. The exercise is anticipated to be complete by

the end of Q2. The team conducted an audit on 15 facilities with EMR to check for completeness of records. The scores are shown in the graph below, with an average score of 85.1%.

Figure 20: Average Output Analysis for 15 Facilities Consistently Using EMR

Support routine M&E acitvities: During the reporting priod, a three-day M&E meeting was held to discuss the revised indicators following the revision of the indicator manual, and a review of sub purpose 2 indicators and the revised data collection template. There continues to be an acute shortage of HTS registers, Daily Activity Registers, ICF cards, Green cards, HEI cards across the supported facilities. Distribution of patient files, Green cards, HTS and Daily Activity registers, ICF and HEI cards and manilla papers in an effort to plug the gap of shortage of tools is ongoing.

Afya Jijini continued to offer routine monthly logistic support for sub-county and facility M&E activities, DHIS data entry in all ten sub-counties, quantification of medical commodities, supply and redistribution of registers, M&E/ICT Assistants, and UHAI Cluster M&E Officers. The program made a decision to carry out an inventory of reporting tools in response to the irregular provision of registers to facilities and, based on the results of the inventory, made a purchase request for all registers required to collect data for the program. While the purchase request is being processed, Afya Jijini printed and photocopied reporting tools and distributed them across the facilities (i.e. DAR, HEI, HTS, ICF) as an interim measure. In the quarter, the project conducted EMONC assessments in 34 facilities. Some of the key challenges identified was that 89% of the sampled facilities did have correct documentation on use of Oxytoxin while the rest required mentorship and OJTs on filling of the partograph. Support quarterly Sub-County data quality assurance (DQA) and RDQA at health facilities: During the reporting period, NASCOP, together with PEPFAR, conducted a national DQA including a review at Mbagathi DH and St. Mary’s Mission Hospital. Overall performance for Mbagathi was at 96% while St. Mary’s scored 81%. Action points for the DQA will be implemented in the subsequent quarters.

An EMR RDQA to assess completeness, consistency and accuracy of patient records in IQCare was conducted at the following facilities: Reuben Center Mukuru, Bahati H/C, Mathare north H/C, Westlands H/C, St Mary’s hospital, St Francis Mission Hospital, STC Casino, Soweto PHC, Ngaira H/C, Mukuru H/C, Mbagathi District Hospital, Makadara H/C, Lunga Lunga H/C, Kangemi H/C and Gertrude’s main hospital.

Activity 3.4.3: Strengthen and integrate community-based health information systems (CBHIS). In Q1, Afya Jijini worked in collaboration with the sub-county community focal person to harmonize the reporting structure, indicator definitions, and reporting timelines for the CBHIS data to the national system.

A database was developed for monitoring the achievements of CHVs working at community units and ORT corners. By the end of the quarter, all the CHVs identified were using the correct MOH tools for reporting with 99% Community units reporting to DHIS2 platform.

Community RDQA: In partnership with UCSF, the project conducted a DQA for the DREAMs project focusing on the following arears: M&E System, consistency of data across the system, and file completeness. Several gaps were identified mainly on documentation including the following: cash transfers not signed; use of old service uptake forms; and a few home visit records were also lacking in detail. The team developed action points with the respective officers and immediate actions taken as appropriate. In terms of completeness of data into the system, the M&E assistant’s line listed all the active AGYWs and updated the service uptake data in the DREAMs database. Support distribution of community reporting tools to ten sub-counties: Afya Jijini supported distribution of 500 registers of MOH 100 to the ten sub-counties after identifying a shortage of the tools. Other tools were photocopied and distributed included MOH 513, 514 and 515 to five sub-counties, namely Dagoretti, Embakasi West, Kamukunji, Kasarani and Starehe. Two health facilities (Bahati and Makadara Heath Centers) were issued with file boxes to help in tracking and filing of the referral uptake in the two prioritized health centers. Other areas of collaboration included the following: development of the Community Health Training Curriculum convened by the USAID SQALE project; participation in the community health learning event by the county; and meetings on indicators definitions reporting through the national system.

Output 3.5: QI Systems 3.5.1 Support to county level Q1 teams County QA/QI TWG: In Y4 QI, Afya Jijini continued to provide technical support for quarterly County QA/QI Technical Working Group (TWG) meetings. The County QA/QI focal person has taken a leadership role in the planning, organizing and live communication regarding the coordination of QA/QI activities. In Q1, the project participated in the quarterly TWG meeting where all ten sub-counties and stakeholders shared their QI activities for the quarter. Subsequently, the Sub-county QI Focal Persons (SCQIFPs) presented quarterly reports for each sub-county, which highlighted key achievements, challenges and plans for the next quarter. The key achievement in the quarter was that the county QI dashboard, developed in Y3, was is now in use at all levels. The SCQIFPs were able to share performance for each indicator. The dashboards indicated that all sub counties had achieved their targets in QI mentorship and coaching in the quarter. The main challenge highlighted was that the majority of facility teams have not developed annual QI work plans to guide QI activities at the facility level. It was also noted that very few facilities have established routine client feedback mechanisms. The TWG developed an action plan to address poor performance against some indicators through increased engagement of facility managers and facility QI coaches to build their capacity to develop QI work plans and to establish facility specific client feedback mechanisms. County QA/QI best practices sharing forum: In Y4 Q1, the program provided logistical and technical support for the annual county QI best practices sharing forum in collaboration with the University of Maryland’s PACT Endeleza program. This event was held on the 6th and 7th November 2018 with 30 facilities (three from each sub-county) sharing their QI best practices. The county TWG constituted a five-member judging panel which assessed the facilities based on the flow of the power point and poster presentations, use of the Plan Do Study Act QI cycle, achievement of set targets and measures to sustain QI achievements. The best three facilities were recognized and given an award by the county Director of Health Services, Dr. Lucina Koiyo. The best facility in QI implementation in the county was Ruben Medical Centre, an Afya Jijini-supported facility. Support supervision: In the period under review, the project supported the county QA/QI and IPC focal persons to conduct supportive supervision in 20 health facilities in five sub-counties (i.e., Kasarani, Ruaraka, Starehe, Makadara and Embakasi East). The main aim of the supervision visit was to follow up the progress of implementation of QI procedures and to establish a baseline on the implementation of Infection Prevention Control (IPC) at the facility level. We found that QI implementation was going on well with most facilities holding regular QI meetings as evidenced by meeting minutes. The gaps identified using the dash board, lack of annual QI work plans and client feedback mechanisms, and were also noted during the

supervision. There were, however, numerous gaps identified in implementation of IPC at the facility level ranging from administrative issues to poor waste management. The county QI and IPC focal persons are now working on developing an action plan to address IPC implementation gaps at all levels. Activity 3.5.2: Strengthen facility-level QI coordination and processes. Capacity building: This quarter, Afya Jijini continued to work in collaboration with SCQIFPs to build the capacity of HCWs in QI implementation through facility-based coaching and mentorship and CMEs. To this end, the project supported CMEs at the facility-level in four health facilities (i.e., Ngara, Dandora II, Mathare North and Korogocho). The CMEs focused on facility Quality Improvement Team (QIT) functions, with an emphasis on the Plan-Do-Study and Act cycle (PSDA) and work environment improvement using 6S (Sort, Set in order, Shine, Standardize, and Sustain). The CMEs have been instrumental in strengthening existing QI structures and activities such as regular WIT meetings and implementation of QI projects to address service delivery gaps.

QI coaching and mentorship: Afya Jijini provides ongoing coaching and mentorship through the UHAI teams and program advisors to all facilities on implementation of QI activities. The program team regularly participates in facility-level QIT and WIT meetings to provide coaching and participate in decision making. In Q1, the program continued to support the 51 HIV and 61 MNCH facility WITs as a result of which a total of 182 WIT meetings were held in the quarter. The teams were able to improve various service delivery indicators as observed during the various sub county QI forums and illustrated in the facility QI success story below.

Facility QI success story: Kayole II Sub County Hospital (SCH) QI success story

In 2017, the CCC/TB team in Kayole II SCH began implementation of a Differentiated Care Model (DCM) in line with the 2016 national guidelines on use of ARVs for treatment and prevention of HIV. The implementation of the DCM is aimed at decongesting HIV clinics through identification of stable patients who do not need regular contact with the clinic and extending the period between their appointments. The uptake in Kayole II SCH, however, remained low with only 170 out of 1989 patients being enrolled in the DCM by April 2018. In May 2018, the CCC/TB WIT team identified the low numbers of categorized patients as the main cause of low uptake of the DCM. The team decided to implement a QI project to improve the number of categorized clients from 14.5% in May 2018 to 81% by October 2018. The team conducted a root cause analysis using a fishbone diagram to determine the barriers to categorization of patients for the DCM. The main barriers identified were poor documentation of patient categorization, lack of patient and staff sensitization on the DCM, and low uptake of CD4 testing for new patients. The team came up with change ideas to address the root causes identified. These included development of a categorization log book, sensitization of all CCC staff on the DCM through CME, and sensitization of patients on the DCM through health talks. The team also worked to streamline CD4 sample collection to improve CD4 uptake for new patients. Through the implementation of these change ideas, the team was able to improve categorization of patients from 14.5% in May to 81% in October 2018. The team was able to enroll 443 patients to the DCM resulting in decreased work load for the clinicians, provision of patient centered care, increased patient satisfaction, and reduced patient waiting time.

Figure 21: Improving Categorization of Patient for DCM

Activity 3.5.3: Strengthen sub-county level QI coordination and processes.

Coordination of facility QI coaches: Afya Jijini continued to provide technical and logistical support for facility QI coaches meetings. In the quarter under review, the Sub-counties in focus were Westlands and Kasarani. The forums were used to build the capacity of facility coaches to address QI and IPC implementation gaps identified during supervision and coaching visits. To address the gaps, an action plan was developed.

Supportive supervision, mentorship and coaching: In Y4 Q1, the project supported two SCQIFPs (Westlands and Langata) to conduct QI and IPC supportive supervision visits, mentorship sessions, and coaching. Fourteen facilities were visited in both sub-counties with QI implementation noted to be progressing well in most facilities. IPC implementation was, however, not up to national standards with most facilities lacking functional IPC committees and IPC work plans. This will be addressed through capacity building of facility in charges and QI coaches on development and implementation of QI and IPC work plans. Activity 3.5.4 Strengthen community-level QI processes.

During the quarter, the DREAMS program began to implement QI at the community level in 18 safe spaces, with all safe spaces having identified gaps for improvement through QI. All 18 teams have been implementing QI projects on improving documentation of DREAMS services, improving PrEP uptake and increasing the proportion of girls who have received the minimum package of care. The projects will be reviewed in Q2 after six months of implementation.

B. CONSTRAINTS AND OPPORTUNITIES

Transition in Leadership: With the recent dismissal of the county health secretary, the governor nominated a different Acting County Executive Member (CEC-M) for Health and Chief Officer CEC of Health. This has further resulted in uncertainty over the implementation of some activities as there is no clear direction from the county government on who is taking over. In WASH, demolition of villages, fire outbreaks, and urban to rural migration of natural leaders has set back the gains made by the department in triggering and sensitizing the community on sanitation. In Nutrition, a shortage of nutritionists and stock outs of essential ready-to-use therapeutic foods (RTUF) has affected continued progress in eliminating malnutrition in informal settlements for children under five. In TB, a shortage in GeneXpert cartridges has affected proper diagnosis of the disease. This has forced many facilities to revert to using TB Microscopy. Budget Constraints

In Y4 Q1, budget constraints have led to layoffs of productive personnel needed in supported facilities in Nairobi County. For example, in facilities where there was a total of five HIV and Testing counsellors, the number has been reduced to three leading to overstretched and multitasked health care workers (HCWs). This has affected productivity and provision of quality health care services to clients. In DREAMS, the program is unable to cater for AGYWs taken for vocational training and provide them with startups kits due to cash constraints. Additionally, lack of financial resources has made it harder to sustain Cash Transfers and educational subsidies, resulting in a palpable discord between AGYWs and the project. This has made it harder to recruit and retain AGYWs. Reporting Challenges Some PEPFAR reporting requirements do not match with the current national reporting tools which challenges efforts to strengthen the Kenyan national reporting system. To meet PEPFAR’s reporting requirements, the project develops separate templates to collect the required data from supported sites. OPPORTUNITIES Program partnership with Local and Private Organization: During the reporting period, DREAMS explored collaborations with local and private organizations to ensure sustainability of activities in both Mukuru Kwa Njenga and Kangemi Wards. Furthermore, the collaborations will help in delegating activities of the proposed expansion to Parklands and Karura wards in Westlands Sub-County. Within the informal settlements, existing youth groups and community leadership have taken ownership of WASH and Nutrition activities making it easier to mobilize communities for change. Additionally, WASH has partnered with Sanergy, an organization dedicated to building affordable and proper sanitation facilities in informal settlements. WASH creates demand while Sanergy supplies the product (e.g. latrines), thereby achieving their target of increasing access and utilization of sanitation amenities in Nairobi County. In QI, the facilities have become more proactive in implementing QI activities as a result of the programs’ technical assistance towards WITs, and Sub-County best sharing forums. As a result, facilities have spearheaded their own QIT activities that are responsive to their unique situations.

C. PERFORMANCE MONITORING

The project continued to routinely collect, document, manage, and utilize information to measure performance, make course corrections, and improve the achievement of project objectives. Monitoring was based on broad PEPFAR and MNCH strategies as well as targets advanced by USAID across all sub- purposes. Weekly program strategy meeting was held at IMA offices to identify gaps and develop measures of closing the gaps. The project also continued strengthen county, sub-county, and facility reporting systems through DQA/RDQAs, regular data review meetings, joint support supervision, and mentorship. Please see section 3.4 for additional TA provided for performance monitoring during the review period.

D. PROGRESS ON GENDER STRATEGY

Synergy with other Implementing Partners: Afya Jijini continued to work with other implementing partners through the County stakeholder mechanism ensuring that AJ-activities were synergized with others and will help the County to achieve its goals.

E. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

During this reporting period, to promote IPC and facilitate waste management in health facilities, the project procured and distributed 300 waste bins in high volume facilities in the county. This followed supportive supervision visits that identified an issue with waste segregation at the point of production.

To promote IPC in health facilities, the project funded one CME at Mama Lucy Kibaki Hospital, where 32 participants were sensitized on healthcare waste management, personal protection for IPC, and handwashing.

Laboratories continued to provide technical support and mentorship at the facility level to ensure adherence to biosafety and biosecurity requirements during HIV and TB testing processes. The facility staff were mentored on the development of safety manual and, at facilities that already had safety manuals, the laboratories emphasized adherence to biosafety requirements.

Waste segregation and proper disposal was a key component addressed during the supportive supervision visits. The segregation of waste is done in the laboratory and other HIV and TB service delivery points.

Additionally, Afya Jijini supported certification of biosafety cabinets and safety hoods in 15 facilities. This was done to ascertain the cabinets were in good working condition and therefore protecting the healthcare workers during TB diagnosis. Three safety cabinets were faulty, two were repaired and the remaining one will be repaired in Q2.

At facilities which do not have incinerators, the project noted there were improvements in how the facility- level management is handling the waste referral plan using their own resources. For example, in Westland H/C, the facility management referred the accumulated waste with TA from the AJ team.

F. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

The program continued to work with other USAID implementing partners such as HIV Free Generation (HFG), KUMEA, HRI RMC, AMURT, UCSF, and NHP plus to conduct joint planning sessions, support community led activities as well as support trainings at both the County and Sub-County level. In Y4, the program continued to work closely with Palladium to scale up the utilization of EMRs in facilities. In addition, the program worked with UCSF to train HCWs in use of data for decision making for the DREAMS intervention. Furthermore, Afya Jijini worked with the Kenya HRH program to streamline HRH practices at the County. The program brought together all the grantees together with representatives from the NCC in a conference to review their performance in the past year, the challenges faced and how to move going forward. In addition, discussions were held on how they can collaborate so as to synergize in activity implementation.

G. PROGRESS ON LINKS WITH GOK AGENCIES In Y4, the program continued to work closely with GOK agencies such as KEMSA, KEMRI and the Nairobi County Health Services to build the capacity of Health Care Workers and strengthen their capability to provide quality health services. Throughout the quarter, the program worked with the Nairobi County Health services to carry out joint supportive supervision visits, provide CMEs and OJTS at both the sub- county and facility level helping to improve the skills of HCWs. The program also worked with KEMSA to distribute medical equipment in all Afya Jijini supported facilities in Nairobi County. The program HRH component also held a consultative forum in partnership with the Nairobi County Health services aimed at reaching agreement with the County Public Service Board (CPSB) on the transition of project hired technical volunteers supporting Service Delivery into the County pay roll in 2019/2020. In addition, the program continued to work with KEMRI to ensure EID, VL and sputum samples were processed timely and results shared with clinicians.

H. PROGRESS ON USAID FORWARD Through Afya Jijini’s grants under contract (GUC) program, the program is currently engaging with eight

local partner organizations. These sub-grantees are engaged in direct technical assistance activities across the spectrum of Afya activities including implementing Respectful Mothers Care and supporting DREAMS implementation. The partners implement evidence-based interventions that contribute to the achievement of USAID and PEPFAR annual targets, and are provided close technical coaching and capacity strengthening support to ensure effective implementation of the activities. The local organizations AJ currently sub-grants to include the following: Women Fighting AIDS in Kenya (WOFAK), St. Johns Community Center, and Partnership for HIV Free Generation (HFG), HealthRight International (HRI), and Network for People Living with HIV/AIDS in Kenya (NEPHAK), Kujenga Maisha East Africa (KUMEA), Ananda Marga Universal Relief Team (AMURT), and Gertrude’s Children’s Hospital.

I. SUSTAINABILITY AND EXIT STRATEGY By working with the County to institutionalize best practices in service delivery and health systems strengthening such as the performance appraisal system, Afya Jijini is helping the County to be responsive to the needs of its target population. Both the LDP+ facility-based projects and the QIT approaches at the facility and sub-county level have ensured that facilities take ownership of their QI activities and are motivated to improve the quality of services they provide beyond the program implementation phase. Afya Jijini has been holding discussions with the county public service board together with the County Health Department to prepare to transition administration of project supported staff to NCC as part of the transition. These discussions will continue into Q2. J. GLOBAL DEVELOPMENT ALLIANCE (if applicable) N/A.

K. SUBSEQUENT QUARTER’S ACTIVITIES Please find information concerning planned activities in Annex 1

L. FINANCIAL INFORMATION

M. ACTIVITY ADMINISTRATION Personnel

A candidate for the HSS Director was identified and name forwarded to USAID. Approval for the candidate was received in December 2018. He will be reporting in February 2019

Contract Modifications and Amendments N/A

III. ACTIVITY PROGRESS OF Q1 FY 2019 PROGRESS REPORT AGAINST FY TARGETS

See attached.

IV. ANNUAL SUPPLEMENT TO QUARTERLY REPORT Not applicable during this reporting period

V. GPS INFORMATION Please find attached the updated list of supported facilities (Attachment 2) with GPS information.

VI. SUCCESS STORY Afya Jijini has attached two success stories to the report (Attachments 3 and 4). The stories highlight innovations and evidence-based approaches performed in Q1, and are rich with qualitative detail.

ANNEXES AND ATTACHMENTS Attachment 1: AJ Performance Achievement Table Y4 Q1 Attachment 2: GIS _Afya Jijini GIS report Attachment 3: Snapshot 1- Y4Q1 SGBV Experience Attachment 4: Snapshot 2- Increasing Nutrition Services Uptake at Reuben Health Centre

ANNEX 1: SCHEDULE OF FUTURE EVENTS

DATE LOCATION ACTIVITY

TBD All sub counties Joint quarterly support supervision except Kamukunji TBD Nairobi County County HTS TWG meeting TBD (Bi-annual) Nairobi Laboratory Stakeholders Meeting January 2019 TBD Bi-Annual stakeholder forum TBD TBD Dissemination of County Health Sector Investment and Strategic Plan 2019/2020-2020/2023 TBD TBD Health service delivery awards January 2019 TBD Bi-Annual stakeholder forum