USAID Kenya Nutrition and Health Program Plus

QUARTERLY PROGRESS REPORT

October 01 to December 31, 2018

JANUARY 2019 This publication was produced for review by the United States Agency for International Development. It was prepared by Kenya Nutrition and Health Program plus

Kenya Nutrition and Health Program plus

Year 5 Quarter 1 Progress Report

October 1 – December 31, 2018

Award No: AID-615-H-15-00001

Prepared for Ruth Tiampati United States Agency for International Development/Kenya C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya

Prepared by FHI360 Nutrition and Health Program plus 2nd Floor Chancery Building, Valley Road P.O Box 38835 00623 Nairobi, Kenya

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 CONTENTS ...... I ACRONYMS AND ABBREVIATIONS ...... III EXECUTIVE SUMMARY ...... VII I. INTRODUCTION ...... 10 II. PROJECT IMPLEMENTATION PROGRESS AND KEY ACHIEVEMNETS...... 10 1 IMPROVED ACCESS & DEMAND FOR QUALITY NUTRITION INTERVENTIONS AT COMMUNITY & FACILITY LEVELS ...... 10 1.1 Strengthening Leadership, Advocacy and Policy Planning ...... 10 1.2 Improved Nutrition Service Delivery Management, Coordination and Implementation ...... 14 1.3 Improved Nutrition Related Behaviour ...... 21 1.4 Increasing Opportunities for Learning and Sharing of Best Practices in Nutrition ...... 30 1.5 Increased Knowledge and Skills for Health Care Workers ...... 30 2 STRENGTHENED NUTRITION COMMODITY MANAGEMENT ...... 32 2.1 Improving Production, Supply and Distribution of Nutrition Commodities ...... 32 2.2 Improving Quality and Safety of Food Commodities and Agricultural Products ...... 39 2.3 Strengthening Sustainability & Innovation in Nutrition Commodity Development & Management 40 3 IMPROVED FOOD AND NUTRITION SECURITY ...... 42 3.1 Increased Market Access and Consumption of Diverse and Quality Foods ...... 42 3.2 Increased Resilience of Vulnerable Households and Communities ...... 55 4 MONITORING AND EVALUATION ...... 67 4.1 Facility Reporting ...... 67 4.2 Supportive supervisions ...... 68 4.3 Household monitoring ...... 69 III. ACTIVITY PROGRESS – QUANTITATIVE IMPACT ...... 75 IV. RESEARCH AND DEVELOPMENT ...... 80 V. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 82 VI. PROGRESS ON LINKS TO OTHER GOK AGENCIES ...... 83 VII. IMPLEMENTATION CHALLENGES ...... 83 VIII. LESSONS LEARNT ...... 84 IX. SUBSEQUENT QUARTER’S WORKPLAN ...... 84 STATUS OF ACTIVITIES PLANNED FOR THE REPORTING PERIOD ...... 84 PLANNED ACTIVITIES FOR THE SUBSEQUENT QUARTER ...... 89 X. SUCCESS STORIES ...... 93 WONI WOMEN GROUP: ‘’A GOAT FOR EVERY MEMBER’’ DESIRABLE OUTCOMES OF IGA TRAININGS ...... 93 ANNEX I: PERFORMANCE DATA TABLES ...... 96 ANNEX 1: SUMMARY OF COMMODITIES DISTRIBUTED ...... 96 ANNEX 2: NUMBER OF HIV POSITIVE CLINICALLY MALNOURISHED CLIENTS WHO RECEIVED THERAPEUTIC AND/OR SUPPLEMENTARY FOOD ...... 98 ANNEX 3: NUMBER OF PLHIV NUTRITIONALLY ASSESSED VIA ANTHROPOMETRIC MEASUREMENT ...... 100 ANNEX 4: NUMBER OF CHILDREN UNDER 5 WHO RECEIVED VITAMIN A FROM USG SUPPORTED PROGRAMS ...... 102 ANNEX 5: NUMBER OF PEOPLE TRAINED IN CHILD HEALTH AND NUTRITION THROUGH USG-SUPPORTED PROGRAMS) ...... 103 ANNEX 6: NUMBER OF CHILDREN UNDER FIVE (0-59 MONTHS) REACHED WITH NUTRITION SPECIFIC INTERVENTIONS BY USG-SUPPORTED NUTRITION PROGRAMS ...... 104 ANNEX 7: NUMBER OF PREGNANT WOMEN REACHED WITH NUTRITION-SPECIFIC INTERVENTIONS THROUGH USG-SUPPORTED PROGRAMS (RAA) ...... 105 ANNEX 8: COMPREHENSIVE NACS IMPLEMENTED PROVIDING SERVICES BEYOND CCC/ART SITES ..... 106 ANNEX II: GIS INFORMATION ON AGRI NUTRITION GROUPS/ACTIVITIES ...... 107

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ACRONYMS AND ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care APHIAplus AIDS, Population and Health Integrated Project ARI Acute Respiratory Infections ART Antiretroviral Therapy ARV Antiretroviral ASAL Arid and Semi-Arid Lands AU African Union AVCD Accelerated Value Chain Development AWP Annual Work Plan BCC Behavior Change Communication BFCI Baby Friendly Community Initiative BMI Body Mass Index CASCO County AIDS and STIs coordinator CBO Community-Based Organization CCC Comprehensive Care Centers CDH County Director of Health CEC County Executive Committee CECM County Executive Committee Member CHA Community Health Assistant CHC Community Health Committee CHEW Community Health Extension Worker CHMT County Health Management Team CHU Community Health Unit CHV Community Health Volunteer CIDP County Integrated Development Plan CLA Collaboration, Learning and Adaptation CME Continuous Medical Education CMMB Catholic Medical Mission Board CMSG Community Mother Support Group CNAP County Nutrition Action Plan CNTF County Nutrition Technical For a CNC County Nutrition Coordinator COHA Cost of Hunger Africa CORPS Community Own Resource Persons CRH County Referral Hospital CS-CDRR Central Site - Facility Consumption Data Report and Request CU Community Unit CWC Child Welfare Clinic DALF Department of Agriculture, Livestock and Fisheries DD Dietary Diversity DHIS District Health Information System DTC Drought Tolerant Crops ECDE Early Childhood Development Education E-CDRR Electronic Consumption Data Report and Request EMR Electronic Medical Records EMMP Environmental Mitigation and Monitoring Plan ENA Essential Nutrition Actions ENP Equatorial Nut Processors – Fortified Ltd FAO Food and Agriculture Organization FATVAH Frequency, Amount, Texture, Variety, Active feeding, Hygiene FBF Fortified Blended Food FBP Food by Prescription F-CDRR Facility Consumption Data Report and Request FEW Frontline Extension Worker

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FFS Farmer Field School FGD Focus Group Discussion FHI Family Health International FtF Feed the Future FY Fiscal Year GAM Global Acute Malnutrition GIZ German Corporation for International Cooperation GMP Growth Monitoring and Promotion/Good Manufacturing Practice GOK Government of Kenya HACCP Hazard Analysis and Critical Control Points HCW Health Care Worker HiNi/HINI High Impact Nutrition Interventions HIV Human Immunodeficiency Virus HMIS Health Management Information System HMT Health Management Team HRIO Health Records Information Officer IEC Information, Education and Communication IFAS Iron and Folic Acid Supplements IGA Income Generating Activity ILRI International Livestock Research Institute IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IP Implementing Partner IR Intermediate Result IRB Institutional Review Board ITK Indigenous Traditional Knowledge IYCF Infant and Young Child Feeding KALRO Kenya Agriculture and Livestock Research Organization KEBS Kenya Bureau of Standards KEFRI Kenya Forestry Research Institute KEMRI Kenya Medical Research Institute KENAS Kenya Accreditation Services KCMSD Kenya Crops and Dairy Marketing Systems Development KDHS Kenya Demographic and Health Survey KEMSA Kenya Medical Supplies Authority KII Key Informant Interview KIPPRA Kenya Institute of Public Policy Research and Analys KNAP Kenya Nutrition Action Plan KNBS Kenya National Bureau of Statistics K-RAPID Kenya Resilience Arid Lands Partnerships for Integrated Development KSA Kenya School of Agriculture KSG Kenya School of Government LMIS Logistics Management Information System LMS Livestock Market Systems LVCT Liverpool Voluntary Counselling and Testing M&E Monitoring and Evaluation MCH Maternal and Child Health MIYCN Maternal Infant and Young Child Nutrition MCHIP Maternal and Child Health Integrated Program MNCAH Maternal, Newborn, Child and Adolescent Health MNCH Maternal Newborn and Child Health MOALF&I Ministry of Agriculture, Livestock Fisheries and Irrigation MOE Ministry of Education MOH Ministry of Health MT Metric Ton MtMSG Mother-to-Mother Support Group

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MUAC Mid-Upper Arm Circumference NACS Nutritional Assessment, Counseling and Support NASCOP National AIDS and STI Control Program NDMA National Drought Management Authority NDU Nutrition and Dietetics Unit NGO Non-Governmental Organization NHIF National Hospital Insurance Fund NHPplus Nutrition and Health Program Plus NI Nutrition International NIT National Implementation Team NITWG Nutrition Information Technical Working Group NRT Northern Rangelands Trust OJT On Job Training OTP Out-patient Therapeutic Program OVC Orphaned and Vulnerable Children PEPFAR President’s Emergency Program for AIDS Relief PHO Public Health Officer PLWHIV People Living with HIV PMEP Performance Monitoring and Evaluation Plan PREG Partnerships for Resilience and Economic Growth RIDEP Rural Initiative Development Program RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health RTI Research Triangle Institute RUTF Ready-to-use Therapeutic Food SBC(C) Social Behavior Change (Communication) SC Sub-County SCALE+ System-Wide Collaborative Action for Livelihoods and Environment plus S-CASCO Sub County AIDS and STIs coordinator SCH Sub County Hospital SCHMT Sub-County Health Management Team SCHRIO Sub-County Health Records Information Officer SCNO Sub-County Nutrition Officer SCNTF Sub-County Nutrition Technical Fora SCPHN Sub-County Public Health Nurse SCPHO Sub-County Public Health Officer SDG Sustainable Development Goals SFP Supplementary Feeding Program SMART Standardized Monitoring and Assessment of Relief and Transitions SME Small and Medium Size Enterprise SMT Senior Management Team SQA Supplier Quality Audit SQUEAC Semi-Quantitative Evaluation of Access and Coverage STI Sexually Transmitted Infections SUN Scaling Up Nutrition TA Technical Assistance TB Tuberculosis TOT Training of Trainers TWG Technical Working Group UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VAS Vitamin A Supplementation VB Vertical Bag WASH Water, Sanitation and Hygiene WFP World Food Program WHZ Weight-for-Height Z-score

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WSR Whole System in the Room ZOI Zone of Influence

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EXECUTIVE SUMMARY

The overall goal of the Kenya Nutrition and Health Program Plus (NHPplus) is to improve the nutrition status of Kenyans. It is a five-year national program with county level mandates, running from January 1, 2015 to December 31, 2019. Its objectives are to increase access and demand for nutrition services at community and facility levels, and to strengthen nutrition commodity management in the country. It also works with Feed the Future (FTF) partners in Busia, Tharaka Nithi, Kitui, Samburu and Marsabit counties to improve food and nutrition security and to implement nutrition-related activities that aim at ending preventable child and maternal deaths, and contribute to reduction of stunting by 10% in its zones of influence. The program uses integrated approach to address determinants at different levels in the causal chain analysis of undernutrition.

The implementation strategy encompasses strengthening public health and food systems through capacity building in nutrition leadership, advocacy and capacity building for multi-sectoral and integrated responses; increasing availability and coverage of nutrition services at high volume facilities in areas with the highest burden of HIV; effective nutrition commodity supply chain; scale up of multi-sectoral agri-nutrition programming using evidence-based pathways of food production, income generation and women’s empowerment to improve food and nutrition security; nutrition-sensitive and social behavior change interventions including High Impact Nutrition Interventions (HINI) interventions under NACS, MCH and community service delivery platforms. This report describes progress and accomplishments of assigned outputs and outcomes during the period of October to December 2018.

To further strengthen leadership capacity for multi-sectoral planning and implementation of county projects, the program supported senior management training of seven county government officers from Samburu, Marsabit and Kitui counties. In addition, the program supported participation of County Executives Members Committee (CECM) and Director of Health participation in the review of Kenya Nutrition Action Plan ( KNAP) and the 2nd African Union International Conference on maternal, newborn and child health. The program also supported county coordination forums among them County Technical Forums, County and sub-county health management teams meetings and Technical Working Groups in different counties. Regarding advocacy, the program participated in the training on Cost of Hunger Africa-Kenya and provided technical assistance to the national implementation team.

Under direct service delivery, the program supported strengthening of community nutrition interventions through outreach services and baby friendly community initiative (BFCI). In this respect, the program supported vitamin A supplementation of 370,448 children aged between 6 and 59 months. During the period, 27 community Units in the five counties reported performance of BFCI based monitoring of 0-11.9 months old infants. The following BFCI monitoring coverage of infant was reported in different counties; 53% to 106% in 10 CUs in Busia county, 35.7% to 89.9% in 2 CUs in Marsabit county, 12% to 83% in 5 CUs in Samburu county, 35.5% to 36.6% in 3 CUs in Kitui County and 37% to 58.1% in 2 CUs in Tharaka Nithi county.

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During the quarter, the program procured 424.8MT of Fortified Blended Flours (FBF) and 9.32MT of Ready to Use Therapeutic Foods (RUTF). 50% of the procured commodities were distributed to 153 health facilities across 29 counties. The program reached 39,399 patients. In addition, the program supported 5 counties through data review meetings at sub county level and data quality audits at facility level to ensure continuous collection and collation of quality data. At national level, the program participated and contributed to the national quantification of nutrition commodities.

To ensure continuous supply of safe reliable foods, supplier quality audits (SQA) were conducted in 2 food processing companies and recommendations shared for further improvement. Score of 82% and 68% were awarded to Equatorial Nut Processors Ltd and Proctor and Allan Ltd respectively. These achievements were consistent with self-improvement interventions following preceding SQA. The program, through independent laboratories, further tested FBF sampled from health facilities to test for safety, quality, and consistency with shelf life. The commodities were found to meet requirements for microbial, physical and chemical thresholds. However, evidence of early induction of oil oxidation was detected and corrective actions initiated with the manufacturer. In addition, the journey towards diversified nutrition commodities gained momentum following confirmation that eight local companies had capacity to provide extrusion services. Among them Proctor and Allan Ltd had a more advanced system and offered better prospects of producing commodities with properties of interest among them instant flours and improved bulk density albeit expected higher costs.

In accordance with the policy to re-orient service delivery to ensure that resources available are focused on sustaining gains, the program proposed alignment with other PEPFAR mechanisms to contribute more effectively toward achieving the 95-95-95 goal. To ensure maximum effectiveness in nutrition service delivery, the program confirmed that 29 counties contributed to 92% of patient numbers. Accordingly, the program proposed to commence a phase out process to guide service delivery support to high yielding counties and sites.

The program through the multi-sectoral approach continued to promote dissemination of contextualized agri-nutrition packages to household members through community group platforms and with greater emphasis on lead mothers reaching individual households directly. The interventions reached a total 22,518 households. Based on these interventions, the direct beneficiaries for dietary diversity contextualized packages were 1,537 households (represented by 1,412 females and 125 males). The package on production technologies through home gardening reached 3,229 households (2,622F, 607M), WASH 14,014 households (8,158F, 5846M), cooking/food preparation demonstrations 3,738 households (3,2452F, 583M) and 1,591 pregnant mothers. Indirect beneficiaries were 2,545 (1,245F, 1,300M) children under 0-23 months and 4,072 (2,163F, 1,909M) children 24-59 months. A technical team comprising 2,239 frontline staff drawn from MOALF, MOH and MOE (CHVs/CHEWs/ FEWs/ ECDE teachers and community resource persons) supervised implementation of the activities.

To improve collaboration and strengthen multi-sectoral engagements to improve food and nutrition security, the program facilitated a 3-day SCALE+ Workshop for Kitui county stake

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holders. The workshop attracted 45 participants from county government, implementing partners, CBOs, processors and private sector. Using a participatory approach, the forum identifies early childhood stunting was identified as a high priority need (“elephant in the room’’) in Kitui county. Action plans were developed and await mobilization to start focused actions to mitigate stunting.

During the quarter, the program carried out further analysis of the cross-section household survey in Tharaka Nithi and Busia counties. The purpose of the survey was to assess adoption rate and outcomes of community level interventions. The activity covered 1,162 (629 in Busia, 537 in Tharaka Nithi) households and represented 98.7% response rate. The findings on household (HH) food security indicated that 17.4% HH and 11.2% HH in Busia and T/Nithi counties respectively experienced hunger. The proportions that experienced severe hunger were 2.4% in Busia and 1.5% in T/Nithi. The findings on women dietary diversity using five food groups cut-off point were relatively comparable in Busia county (42% in Butula, 47% in Nambale, 54% in Samia and 50% in Teso North). In Tharaka Nithi large variations that were consistent with intra-county ecologic contexts (45% in Tharaka North, 25% in Tharaka South and 85% in Maara). The corresponding findings of minimum acceptable diet for children (MAD), based on equal or more than 4 food groups showed the following intra-county distribution Butula 28%, Nambale 31%, Samia 31% and Teso North 42% in Busia. In T/Nithi, MAD was reported by the following proportions of respondents Maara 41%, Tharaka South 23% and Tharaka North 20%. Regarding hand hygiene, 13.7% and 9.5% of caregivers washed their hands in all the four critical handwashing times in Busia and Tharaka Nithi counties respectively. Furthermore, majority (87.9% in Busia and 73.9% in Tharaka Nithi) of caregivers used soap and water in handwashing. The findings on the status of under-five year-olds showed stunting rates at 25.4% and 21.1% for Tharaka Nithi and Busia counties respectively. The findings of the survey underscored the need to strengthen adoption rates using participatory approaches to improve MAD and hand washing hygiene to thresholds that are associated with significant reduction of the risk of growth faltering.

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I. INTRODUCTION

The Kenya Nutrition and Health Program Plus (NHPplus) aims to improve the nutrition status of Kenyans. The five-year national program with county level mandates, runs from January 1, 2015 to December 31, 2019. Its objectives are to increase access and demand for nutrition services at community and facility levels, to strengthen nutrition commodity management in the country and improve food and nutrition security in the focus counties of Busia, Tharaka Nithi, Kitui, Samburu and Marsabit. NHPplus approach encompasses capacity building for strengthened leadership in the nutrition sector, advocacy and well-coordinated multi-sectoral and integrated responses; strengthening capacity for nutrition services delivery in high volume facilities in areas with the highest burden of human immunodeficiency virus (HIV); provision of nutrition commodities; promotion of agri-nutrition approaches founded on food production, income generation and women empowerment as pathways for improved food and nutrition security; nutrition sensitive and social behavior change interventions through the Nutrition Assessment, Counselling and Support (NACS) framework, as well as Maternal Child Health and community platforms. Working in collaboration with Feed the Future implementing partners, the program is strengthening food and nutrition security through implementation of nutrition-related activities that aim at ending preventable child and maternal deaths and contribute to reduction of early childhood stunting by 10% in its zones of influence.

NHPplus utilizes an integrated approach to address underlying factors, intermediate and immediate determinants of undernutrition. It exploits multi-sectoral approaches that encompass capacity building to strengthen nutrition leadership, advocacy and coordination of integrated transdisciplinary responses to address its objectives. Food and nutrition security interventions are guided by evidence-based pathways of food production, income generation and women’s empowerment. The complementary nutrition-specific interventions incorporate social behavior change interventions and High Impact Nutrition Interventions (HINI) through Nutrition Assessment and Counselling Services (NACS) in Maternal and Child Health (MCH) at facility and community service delivery platforms. The program improves outcomes of all interventions by ensuring efficiencies in nutrition commodity procurement and distribution along with site support activities while addressing quality control and safety of procured nutrition products. This report describes program implementation progress, key achievements, challenges and lessons learnt during the period of September – December 2018.

II. PROJECT IMPLEMENTATION PROGRESS AND KEY ACHIEVEMNETS

This section outlines the project implementation progress and key achievements in line with the specific intermediate result areas (IRs), sub-IRs and, to varying extents, the required outcomes under each sub-IR.

1 Improved Access & Demand for Quality Nutrition Interventions at Community & Facility levels

1.1 Strengthening Leadership, Advocacy and Policy Planning

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Strengthened long term capacity of the government of Kenya (GOK) and other stakeholders to direct, manage and finance Kenya’s nutrition programs To sustain long term capacity of the government to direct and manage nutrition, the program continued to facilitate key County officers from the Ministry of Health and Department of Agriculture, Livestock and Fisheries (DALF) to attend the Senior Management Course at the Kenya School of Government in the focus Counties. `Three County government officers, Samburu County Nutrition Coordinator and two DALF officers from Marsabit County, successfully completed the Senior Management Course with distinction and credit respectively. It is expected that the knowledge and skills gained from the course will assist them to provide more efficient and effective leadership in management of nutrition activities among other duties and responsibilities

In Kitui County, the county Government announced the suspension of the existing CHVs and the plan to embark on a fresh process of vetting and recruiting new CHVs the Kitui County Director of Health convened a two – day workshop in which NHPplus participated. The purpose of the workshop was to review and develop guidelines for engagement of CHVs by the County government and development partners. In attendance were Sub- and County Health Management Teams ((S)CHMT), Afya Halisi, Liverpool Voluntary Counselling and Testing (LVCT) and Catholic Mission Medical Board. During the workshop guidelines for recruitment and engagement of the new CHVs in the community during were developed. These included the selection criteria, roles and terms of reference of CHVs. Follow-on activities include drafting of a document on the proposed guidelines to be presented to the County Assembly for review and endorsement. Once endorsed, the County government will use the guidelines in the recruitment of the new CHVs.

For Tharaka Nithi County, NHPplus financially supported the County Executive Committee (CEC) Member of Health, County Director of Health and County Nursing Manager to participate in the 2nd African Union International Conference on Maternal, Newborn and Child Health (MNCH). The conference themed: “Maintaining Momentum and Focus Towards Ending Preventable, Maternal, Newborn, Child and Adolescents’ Deaths by 2030” was jointly organized by the African Union (AU) and the Government of Kenya through the Ministry of Health (MOH) to brainstorm on how to improve maternal and child health. The three – day event which drew more than 500 participants deliberated on a raft of issues including leadership, accountability and governance for MNCH, early infant diagnosis of HIV, sexual reproductive health and rights, and breaking the cycle of early marriages as key to ending teen pregnancies among other health issues affecting women, girls and children. Through sharing of experiences and lessons learnt, it is anticipated that the participants will tailor MNCH interventions to their prevailing conditions and realities.

Strengthened country capacity for multi-sectoral planning processes and establishing linkages between strategic planning, budgeting and resource use During the reporting period, the program facilitated the County Executive Committee Members (CECMs) for Health from Tharaka Nithi to participate in a national advocacy forum for roll out of the Kenya Nutrition Action Plan (KNAP) 2018 – 2022 targeting all CECMs for Health from across the Country. This was a follow – up of the validation meeting which was conducted in the previous quarter that proposed a review of the draft KNAP by the CECMs to increase their ownership of the document. The Government has adopted the participatory approach in the development of this key document through involvement of various nutrition stakeholders. The 11 FY 19 Q1 October – December Quarterly Report

KNAP will provide a road map for coordinated multi – sectoral implementation of nutrition interventions by government and relevant stakeholders for maximum impact. Once the document is finalized and launched at the national level, the program will facilitate development of County Nutrition Action Plan (2019 – 2023) in the five focus Counties.

Strengthened coordination with non-health sector ministries, partners, programs and projects for improved nutrition To strengthen coordination and implementation of activities for improved nutrition outcomes, the program continued to provide technical and logistical support to the secretariat of multi – sectoral nutrition technical forums at both County and sub – County levels in Marsabit, Samburu and Tharaka Nithi Counties during the quarter. Participants included the CHMT, SCHMT and implementing partners (IPs).

In Marsabit County, members discussed planned sub-County activities with key focus on governance, coordination, service delivery, human resource as well as the quarterly implementation plan by IPs. Thirty participants from CHMT, SCHMT, World Vision Kenya, UNICEF, Concern Worldwide and German Corporation for International Cooperation (GIZ) were represented during the meeting. It was reported during the meeting that all four sub-counties had conducted at least one sub-County nutrition technical forum meeting. However, it was reiterated that monthly SCNTF meeting should be routinely held to improve County level coordination.

Despite recent skirmishes, Marsabit County managed to scale up Vitamin A supplementation and deworming across the 4 sub-Counties during the Malezi Bora week activities. From joint support supervision conducted in all the sub-Counties, the following were highlighted for follow-up: • There were variations between the primary data collection tools (registers) and the malezi bora report. It was recommended that the health facility staff should ensure proper documentation in the register with the summaries done on a continuous basis to reduce data discrepancies. • There is need for capacity building of newly recruited health workers on how to use the health management information systems (HMIS) • There were gaps in the updating of the VAS and deworming monitoring charts. Noteworthy, tallying of the 12 – 59 months cohort in the chart was not done.

In view of the above, it was proposed that sub-County nutrition officers (SCNOs) should use a standard implementation framework to capture all the priority activities and share with the CNC for compilation. These should also include a training needs database for each sub–County. In Saku sub–County, NHPplus participated in a joint planning meeting with SCHMT, Concern Worldwide, Food for the Hungry and APHIAplus Imarisha. Some of the key agenda items discussed were harmonization of SCHMT and implementing partners’ health and nutrition activities and schedule of monthly planning and review meetings. In addition, non–reporting health facilities, low uptake of antenatal clinic (ANC) services, iron and folic acid supplementation (IFAS) and family planning were discussed. It was reported that 65% of the CHVs were submitting their reports with 59% of households visited. During the meeting, joint planning, target setting and indicator review meetings, support supervision, data quality audit, training of newly recruited Community Health Assistants (CHAs) on MOH reporting tools, rewarding of the best performing health facilities,

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WASH activities and health facility HINI gap assessment were prioritized. It was also recommended that continuous mentorship of the newly recruited nutritionists and CHAs on IMAM and community – facility linkages should be instituted to bridge identified knowledge gaps.

As the lead for Partnership for Resilience and Economic Growth (PREG) consortium activities in Marsabit County, NHPplus played a key role in mobilization of PREG members, County government line ministries and community members to participate in assessment of the current integration and multi – sectoral approaches utilized in nutrition specific and sensitive nutrition programming in Northern Kenya. During the first week of December, an independent nutrition expert engaged PREG members and line ministries in discussions to identify gaps, challenges and opportunities for collaboration and integration of nutrition into PREG activities to address high chronic malnutrition levels in the region; identify and recommend innovative ways of integrating nutrition into existing PREG interventions; assess the role of gender and inclusion in PREG nutrition programming and gauge level of mainstreaming by partners. NHPplus will explore using the resultant assessment report for informed activity programming once it is ready.

In Tharaka Nithi County, the program participated in a stakeholders meeting convened by the County department of health services and sanitation. The meeting was attended by the two Chief Officers of Public Health and Sanitation and Medical Services, County Director of Health, County Health Management Team (CHMT) and Fifteen implementing partners. The objective of the meeting was mainly to review status of health in the County, determine strategic direction of health sector, map out operation areas of implementing partners and share work plans for better coordination of health and nutrition activities. NHPplus utilized this opportunity to establish the Tharaka North and Tharaka South multisectoral sub–County Nutrition Technical Forums (SCNTF)which will comprise of partners and members from the different sectors of health, education, agriculture, gender and social services. The forum will be used to coordinate nutrition activities across the different sectors as well as provide a platform for learning and sharing of new information and best practices at sub – County level.

In Samburu County, the program facilitated the County Nutrition Technical Forum (CNTF) meeting where 26 participants drawn from MOH, DALF, MOE, World Vision and NHPplus were in attendance. During the meeting, funding of Malezi Bora activities by MOH and partners, redistribution of IMAM supplies, integrated community outreaches and staffing levels at health facilities were discussed.

Busia County conducted several planning and TWG meetings in which NHPplus participated during the quarter. These included the County Monitoring and Evaluation (M&E) TWG, Commodity TWG and sub – County Agri–nutrition planning meeting. Some of the key agenda items were development of a costed M&E plan, meeting calendar, and review of the implementation status of M&E activities in FY 2018/19 annual work plan. Noteworthy, three key nutrition indicators were included in the County M&E Framework. These include i) initiation of breastfeeding within one hour after birth, ii) bi – annual Vitamin A supplementation and iii) Iron and folic acid supplementation during pregnancy. Terms of reference were developed; status of nutrition commodities and expired health commodities were discussed during the Commodity TWG meeting. In Samia sub–County, the program conducted the quarterly agri–nutrition planning

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meeting with members from MOH and DALF. Some of the key issues discussed included review of performance based on the set targets and planning for upcoming activities.

In Kitui South sub–County, NHP plus participated in a stakeholder meeting convened by the department of health with support from Afya Halisi. The meeting was attended by representatives from the Community Health Strategy, Department of Early Childhood, Administration, Afya Halisi, Catholic Medical Mission Board (CMMB) and World Vision. The participants shared their program targets, implementation progress and challenges followed with discussion on how to leverage on each other to increase coverage of health and nutrition services in the community.

Strengthened capacity of policy makers to advocate for nutrition As part of ongoing efforts to build a body of evidence for informing national efforts on increasing financing for nutrition, training was conducted for the National Implementation Team (NIT) in Nakuru county. The objective of the training was to build capacity for developing national estimates for the Cost of Hunger in Africa – Kenya study (COHA). The study demonstrates the dire social and economic consequences of child undernutrition. It aims to demonstrate that addressing malnutrition is not just a moral obligation but also an economic one by highlighting the costs to the national economy of not addressing child undernutrition and the possible economic returns if appropriate investments in nutrition are undertaken.

The training was attended by 38 representatives from the National Treasury, Ministry of Agriculture, Ministry of Labour & Social Protection, Ministry of Education, Ministry of Health, Ministry of Devolution and ASAL, University of Nairobi, KEMRI, Kenya Institute of Public Policy, Research and Analysis (KIPPRA), Kenya National Bureau of Statistics (KNBS), and Council of Governors. The training was facilitated by the World Food Program (WFP), Africa Union office in Addis Ababa and organized through the National Treasury. Following the training, the Principal Secretary National Treasury officially constituted the secretariat for COHA Kenya to coordinate national activities including the kick-off launch in February 2019.

1.2 Improved Nutrition Service Delivery Management, Coordination and Implementation Improved nutritional status of vulnerable groups (HIV positive, OVC, TB); Strengthening care, support and follow–up of vulnerable groups can go a long way in improving their nutritional status. Hence for patients living with HIV/TB, the program continued to provide technical assistance (TA) and nutrition commodity support in high volume health facilities in Marsabit County. As a result of NACS training conducted in the previous quarter and technical assistance from NHPplus apprentices, marked improvement in coverage and quality of NACS services was observed. Some of the key improvements were noted in documentation of patient level data in MOH 407A and MOH 407B, increase in regular and timely patient follow–up appointments, no nutrition commodity stock–outs and increase in number of patient assessments where 40 % of were provided with nutrition commodity support throughout the reporting period. However, some challenges were reported including staff shortages and lack of integration of nutrition services in care and treatment centres in Loiyangalani. For example, Catholic Mission Health Centre provides HIV care and treatment services only whereas Loiyangalani Dispensary provides only nutrition services. The SCASCO was tasked with follow–up on how best to provide integrated HIV and nutrition services in these health facilities. 14 FY 19 Q1 October – December Quarterly Report

Increased coverage of quality nutrition services (NACS inclusive of HINI) both at facility and community levels Health facility data review meetings Except for Tharaka Nithi County, NHPplus supported health facility in–charges data review meetings in 8 sub–Counties across four focus Counties in order to review performance and reporting of key nutrition and Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) indicators at health facility and community levels, and to discuss the reporting of Malezi Bora data from Early Childhood Development Education (ECDE) and community activities in the link health facilities. In attendance were CHMT representatives, SCHMT, health facility in–charges, Community Health Extension Worker (CHEWs) and implementing partners. Using District Health Information System (DHIS) reports, the sub–County HRIOs took participants through targeted indicators which were assessed by health facility in terms of coverage, reporting and data quality. All nutrition indicators were reviewed using a nutrition score card. Subsequently, poorly performing indicators were flagged and discussed with the aim to identify gaps and potential solutions in the affected health facilities. The identified gaps and challenges were also used to inform and guide in–charges and SCHMT on the requisite follow–up support supervision, on-job training (OJT) and/or mentorship activities in the specific health facilities. Notably, promising and/or best practices from well performing health facilities were also identified and discussed for possible scale–up in other health facilities. In Samburu County, a nurse from Lengusaka Dispensary was recognized for providing immunization services without a fridge to the community. It was reported that the nurse was using a cool box to carry vaccines every Wednesday and market days from Wamba Health Centre.

In Marsabit County, it was noted that coverage for most MNCH indicators were found to be generally good e.g.1st ANC visit, skilled birth deliveries, immunization and VAS. However, low uptake of family planning and coverage for 4th ANC visits was observed. Good performance in a few health facilities were attributed to strong bi–directional community-facility linkages spearheaded by CHAs and CHVs. Based on the above deliberations, health facility in–charges were tasked with follow–up on the below issues: • Strengthen documentation and reporting of nutrition and health activities done to reduce data discrepancies and missing reports • All health facilities should be registered with Linda Mama (NHIF) to improve access for pregnant women and infants to quality and affordable health services • Community Health Strategy Focal Person and SCHRIO were tasked with mentorship of newly recruited CHAs on reporting to ensure community services done are reported in the DHIS.

In Kitui County, health care workers (HCWs) were sensitized on upcoming Malezi Bora activities and encouraged to ensure that pregnant women, lactating mothers and children within their catchment population are reached with the essential package of MCH services during the campaign weeks.

Overall, the indicator data review meetings with health facility in–charges were used as a platform to address emerging cross–cutting challenges and technical updates. These included updates on

15 FY 19 Q1 October – December Quarterly Report

medical and non–medical supplies stock out, shortage of health facility staff, poor health facility infrastructure and among other issues.

HINI Gap Assessment As part of routine health facility support activities, the program conducted HINI gap assessment jointly with the SCHMT across 11 health facilities in Butula and Teso North sub–Counties of Busia County. The health facilities assessed were Bumala A, Bumala B, Ikonzo, Khunyangu and Sikarira in Butula; and Aboloi, Kolanya, Kamuriai, Ang’urai Dispensary, Akichelesit and St. Mary’s Chelelemuk in Teso North. The purpose of the assessment was to gauge capacity of the health facility to provide HINIs. All the health facilities assessed scored above 25% as shown in Table 1 and were found to have capacity to provide HINI services. However, the findings of the HINI gap assessment will be used to inform OJT and mentorship activities required by the health facility staff and other relevant health facility support.

Table 1: HINI Gap Assessment Scores from 11 health facilities in Busia County Health Facility Capacity IYCN Micronutrient Deworming Hygiene & Overall for MAM Sanitation Score Percent (%) Score Teso North Sub-County Aboloi Disp. 28 38 48 64 50 36 Kamuriai Disp. 15 32 29 82 14 26 Akichelesit Disp. 48 63 77 83 72 59 St.Mary’s 18 50 50 68 68 39 Chelelemuk Ang’urai 71 79 81 82 82 76 Kolanya 46 37 32 68 59 43 Butula Sub-County Bumala A 49 58 64 82 82 57 Ikonza Model 46 63 78 82 82 59 Sikarira 41 57 56 55 64 51 Bumala B 44 43 64 82 77 48 Khunyangu 63 53 61 64 64 58

OJT and mentorship activities On-the-job training (OJT) on documentation, use of Baby Friendly Community Initiative (BFCI) reporting tools such as BFCI FORM 1 – 5, other MOH community reporting tools and filing of reports was conducted in Nangina Health Centre and Samia sub-County for health facility staff, nutrition volunteer, SCNO and NHPplus nutrition apprentice. After the activity, the participants were tasked with follow–up on proper arrangement of BFCI documentation such as mother-to- mother support group (MtMSG), Home visit follow–up and outreach quarterly plans in their respective files. It is expected that better documentation will greatly assist in close monitoring of beneficiaries, timely reporting and follow–up of planned BFCI activities in the community.

In Kitui County, the program also conducted OJT for 8 health care workers on NACS protocol from Kitui Rural, Kitui South, Mwingi West and Mwingi North sub–Counties. During the exercise, health care workers were taken through how to fill adult and reporting tools and referral for close 16 FY 19 Q1 October – December Quarterly Report

patient follow–up. In addition, EMR database were updated in Mutomo Mission Hospital, Kyuso Hospital, Migwani Hospital and Kitui County Referral Hospital to assist with patient follow–up and generation of timely health facility reports.

Strengthened capacity at community, dispensary and health center levels for targeted interventions as dictated by local nutrition needs and context Malezi Bora Activities During the malezi bora week, the program supported VAS and deworming of under 5 children across 28 sub–Counties in the five focus Counties. To increase VAS coverage for Semester 2, several strategies including supplementation in ECDE centres, active supplementation in static health facilities, community supplementation in each village by CHVs under supervision of CHEWs, community mobilization and SCHMT support supervision during supplementation were employed. Prior to the supplementation activities, the program facilitated sub–County malezi bora planning meetings where targets for VAS and deworming were set for the respective field teams. All health care workers participating in the exercise were given targets of the list of ECDE centres to be covered with specific timelines. The set targets were based on 90% coverage of the 6–59 months old children in the catchment population. In addition, the list of link health facilities was shared for integration and entry of Malezi Bora data into DHIS. Vitamin A supplies were also redistributed to all the sub-Counties from the Nutrition and Dietetics Unit (NDU) stores in Kitengela.

Subsequently, the community strategy team comprising of Public Health Officers (PHOs), CHEWs, CHVs and ECDE ward officers conducted extensive social mobilization activities in all ECDE centres and community units across the Counties. Community outreaches were also conducted in far flung and hard to reach areas in the focus Counties. To ensure data entry in DHIS from malezi bora activities, the program facilitated sub–County data review meetings to discuss performance and follow–up on status of DHIS data entry in the link facilities by health facility HRIOs. It was agreed that the data entry for malezi bora activities should be finalized by the end of October 2018. Each SCHMT member was assigned one ward with the responsibility to supervise and coordinate team members. All sub - County ECDE coordinators were also involved in the exercise where their key role was mobilization of school communities and other families through teachers to come for Vitamin A and deworming in the nearest health facility and schools during the malezi bora activities. Table 2 shows the focus Counties’ VAS and deworming performance during the malezi bora activities of October-November 2018.

A total of 370,448 children 6 – 59 months were supplemented with Vitamin A whereas 230,104 children 12 – 59 months were dewormed in the five focus Counties. Worth noting is that Kitui County achieved 100% of their set target for VAS. However, Samburu County VAS performance was lower compared to the previous campaign. This was occasioned by delayed initiation of the supplementation activities in the ECDE centres due to competing health care workers training activities in the County. As a result, most of the ECDE centres closed for the holiday before their children were supplemented and/or dewormed. Noteworthy, skirmishes in most areas of the Marsabit County highly affected supplementation activities during the malezi bora campaign. However, program support was credited for the improved coverage for the second semester 2018.

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Table 2: Focus County VAS Performance During Malezi Bora Activities in October – November 2018 County Sub County FY18 VAS Performance Deworming (Semester 2) 6 - 59 months 12 - 59 months Number of Children Samburu Samburu Central 17,264 15,513 Samburu East 8,762 5,195 Samburu North 8,399 7,444 Sub – Total 34,425 28,152 Tharaka Nithi Chuka 4,483 4,572 Igambang’ombe 3,102 3,102 Mwimbi 2,752 2,752 Muthambi 2,699 1,690 Tharaka North 3,879 3,952 Tharaka South 7,806 8,156 Sub – Total 24,721 24,224 Marsabit Moyale 9,187 8,862 Laisamis 5,763 4,557 North Horr 4,404 3,632 Saku 8,563 6,828 Sub – Total 27,917 23,879 Busia Teso North 19,383 1,159 Butula 18,468 4,631 Matayos 13,637 0 Bunyala 6,491 7,315 Nambale 13,233 0 Samia 10,797 10,652 Teso south 15,356 , Sub – Total 97,365 23,757 Kitui Kitui Central 18,315 16,631 Kitui East 16,052 17,164 Kitui Rural 14,790 12,520 Kitui South 27,610 14,148 Kitui West 14,526 13,503 Mwingi Central 22,657 26,340 Mwingi North 17,712 15,537 Mwingi West 15,253 14,249 Sub – Total 146,915 130,092 TOTAL 331,343 230,104

In Kitui and Busia Counties, nutrition education on maternal, infant and young child nutrition and food demonstration using locally available food items to prepare nutritious complementary foods for children 6 – 23 months was conducted. Mothers and caregivers were counselled on how to conduct responsive feeding. A total of 638 people including 23 pregnant women from 7 community in Teso North and Samia sub - Counties participated in the nutrition education and food demonstration sessions done during malezi bora activities. The topics discussed during the nutrition education sessions included Frequency, Amount, Texture, Variety, Active feeding, and Hygiene (FATVAH) complementary feeding recommendations for 6 – 23 months, use of animal source foods, consumption of at least 5 food groups and diversified diets for women of reproductive age. A total of 677 children of 6 – 59 months and 40 children of 0 – 59 months were

18 FY 19 Q1 October – December Quarterly Report

reached with Vitamin A supplementation and growth monitoring respectively during the nutrition education and food demonstration sessions done in the community. One hundred children (100) 12 – 59 months were also dewormed in Samia sub – County. In Teso North sub – County, none of the children assessed was found to be underweight.

Growth Monitoring Activities To increase identification and timely treatment of undernourished cases in the community, the program intensified ECDE growth monitoring and promotion activities which were initiated in the previous quarter across the five focus Counties. In collaboration with ECDE teachers, health care workers from the link facilities conducted growth monitoring for the children in the ECDE centres including younger out-of-school children who had been mobilized by the CHVs from the catchment area. This involved measurement of the weight and height of the children, interpretation and documentation of the information in the mother and child health (MCH) handbook growth charts and child welfare clinic (CWC) registers of the link health facility. All children who were found to be undernourished and/or with faltering growth were referred to the link health facility for treatment. In addition, nutrition counselling on infant and young child feeding was provided to the mothers and caregivers present during the growth monitoring activities. A total of 14,673 children 0 – 59 months were reached with growth monitoring activities through both ECDE centres and villages with 148 of them referred to link health facilities for further management of acute malnutrition (IMAM). The largest number of undernourished cases were identified and referred in Marsabit County. The program will follow–up on the referred undernourished cases in the link health facilities and in the community through CHVs to ensure all the cases are treated. Table 3 is a summary of the growth monitoring activities by focus County.

Table 3: Children 0-59 Months old Reached with Growth Monitoring Activities in Five Focus Counties County Sub – County Total Reached with Underweight Referred for Growth Monitoring 0 – 59 months IMAM services Busia Teso North, Samia 371 11 11 Tharaka Nithi Tharaka North, 8638 171 35 Tharaka South Samburu Samburu North 69 2 2 Marsabit Moyale 4483 169 100 Kitui Kitui East, Kitui South, 1112 354 - Mwingi North and Mwingi Central TOTAL 14673 707 148

In Moyale sub–County, 17% of the 4,483 children 0 – 59 months assessed were below the age of two years. A total of 100 children were found to be wasted and were referred to the link health facility for IMAM services. In addition, 265 children were supplemented with Vitamin A whereas 263 children dewormed during the exercise. Documentation of the growth monitoring activities was captured in the CWC registers of the link health facilities. As a result of these accelerated growth monitoring activities, an increased number of new IMAM admissions were observed in the DHIS reports for the month of October 2018. In Samburu County, growth monitoring outreach was conducted in two ECDE centres with Elbarta Ward.

19 FY 19 Q1 October – December Quarterly Report

To build capacity for growth monitoring in ECDE centres, a total of 58 ECDE teachers from Endau/Malalani and Voo/Kyamatu wards in Kitui East sub - County were trained on child growth assessment. They were taken through the importance of growth monitoring, how to measure weight, height and mid upper arm circumference, signs of malnutrition, plotting and interpretation of growth charts, referral of undernourished and children at risk of undernutrition to health facilities for further examination and management. VAS, deworming and nutrition counselling on infant and young child feeding, WASH in schools and importance of establishing vegetable and fruit gardens which can be consumed as well as serve as a learning centre were also covered. After the training, the teachers will be used to create awareness among parents and caregivers of their pupils on the importance of growth monitoring. In addition, they will support health facility staff to conduct growth monitoring activities in their ECDE centres including referral of identified undernourished cases to link health facilities for treatment. A total of 1,112 children 0 – 59 months received growth monitoring for the first time in four sub – Counties where 354 of them were found to be underweight. In addition, 1,505 children 6–59 months were supplemented with Vitamin A during the exercise. Table 4 is a summary of the growth monitoring activities done in Kitui County:

Table 4: Summary of Growth Monitoring Activities in Kitui County. Sub - County Number Number of children under Number of Number of of villages 5 who received growth children under children under monitoring for the first five who are 5 who received time underweight VAS Kitui East 7 337 58 304 Kitui South 4 266 258 870 Mwingi North 14 318 19 282 Mwingi Central 5 191 19 48 TOTAL 30 1,112 354 1504

Increased capacity of community units to mobilize communities to demand quality nutrition services; To increase demand and access to nutrition and health services among local communities, the program conducted integrated outreaches in hard to reach areas in four sub – Counties: Tharaka South, Tharaka North, Samburu East and Samburu North sub – Counties. During the outreach activities, a multi–disciplinary team of health care workers provided nutrition interventions together with other essential health services. These included such as VAS, growth monitoring, deworming, MIYCN counseling, immunization, ante – natal clinic services, family planning and integrated management of childhood illnesses (IMCI) among other services. A total of 1,113 children 0–59 months, 32 pregnant women and 88 women of reproductive age were reached with various nutrition and health services. Further, 372 men participated in the outreach activities; 803 children 6 – 59 months and 756 children 12 – 59 months were supplemented with Vitamin A and dewormed respectively with 224 children aged 0 – 18 months were immunized. In Tharaka Nithi County, 51 women of reproductive age were provided with family planning services. In Samburu County, 86 children were treated for childhood illnesses mainly diarrhoea and acute respiratory infections (ARI) and referred to link health facilities for further management. Thirteen undernourished children 6 – 59 months were identified and referred to the link health facilities for IMAM services. Notably, 22 people were also screened for hypertension in Lolparuai village in Samburu East sub – County. Tables 5 and 6 summarize the integrated outreach activities: 20 FY 19 Q1 October – December Quarterly Report

Table 5: Summary of outreach activities by intervention in the focus County Sub– VAS (6–59 Deworming Growth Immunized Family Counselled IMC County months (12–59 monitoring (0–18 Planning on MIYCN Children old) months old) (0-59 Months old) Services (Pregnant under 5 months) (WRA) Women) Number Reached Tharaka N. 260 232 0 81 51 5 0 Tharaka S. 541 516 0 25 0 0 0 Samburu E. 2 2 57 3 0 6 46 (Lolparuai) Samburu N. 0 6 0 115 0 0 40 (Charda & Nteremka) TOTAL 803 756 57 224 51 11 86

Table 6: Number reached by age cohort during integrated outreaches Sub – County WRA Pregnant Men 0 – 59 Months 5 – 9 10 – 19 women Children years years Tharaka North 62 5 22 275 18 33 Tharaka South 0 0 301 652 0 0 Samburu East (Lolparuai) 26 4 0 29 0 0 Samburu North 0 23 49 157 0 0 (Nteremka and Ncharda) TOTAL 88 32 372 1113 18 33

1.3 Improved Nutrition Related Behaviour Increased adoption of optimal nutrition practices and essential nutrition actions To increase adoption of essential nutrition actions in the first 1,000 days of life, the program continued to support implementation of the Baby Friendly Community Initiative (BFCI) activities in 25 community units across the five focus Counties. These included targeted CHV home visit follow–up of children less than one year, mother-to-mother support group (MtMSG) meetings with women of reproductive age and caregivers of young children, and bi–monthly community mother support group (CMSG) outreaches where tailored MIYCN information was shared with the mothers, family members and the community at large.

BFCI CMSG Outreaches During the quarter, the program conducted bi–monthly BFCI outreaches in 10 community units in Busia County. The main aim of these outreaches was to promote optimal MIYCN practices, increase access and demand for essential health and nutrition services. During outreach activities, health and nutrition promotion was carried out with support from CHVs and health care workers. This included cooking demonstration on how to make nutritious complementary foods that meet the FATVAH criteria and discussions on healthy diet for pregnant and lactating women, hygiene and sanitation, child development milestones and stimulation, among other topics. In addition, immunization, family planning counselling services, treatment services, nutrition assessment and counselling, growth monitoring, deworming, IFAS and VAS were also offered. A total of 639 people including 23 pregnant women and 383 children 0–59 months were reached in 10 21 FY 19 Q1 October – December Quarterly Report

community units (CUs) namely Sigulu, Budalanga, Wakhungu, Luchululo, Bukhulungu and Serekeresi in Nangina and Aterait, Kolanya, Akobwait and Changara in Teso North during the outreach activities.

Mother–to–Mother Support Group (MtMSG) Meetings During the quarter, five BFCI MtMSG meetings were held in Lorubae, Kisima, South Horr and Nachola CUs in Samburu East, Central and North sub - Counties. A total of 160 mothers and /or caregivers of children under five including 13 pregnant women participated in the group meetings. Some of the topics discussed exclusive breastfeeding for the first 6 months, continued breastfeeding for up to 2 years and beyond, importance of IFAS during pregnancy and how to initiate and manage income generation activities. Cooking demonstration on how to prepare nutritious complementary foods for children 6 – 23 months and healthy diet for women of reproductive age which meet FATVAH and minimum dietary diversity (DD) requirements respectively. Similarly, 69 MtMSG meetings were conducted across 10 community units in Teso North and Samia sub–Counties with 1,246 mothers including 130 pregnant women from households with 2,131 under five years children in attendance. In addition to promotion of optimal MIYCN practices, danger signs during pregnancy, importance of individual birth plan and ANC visits, child development milestones, stimulation, household and baby WASH practices, agri–nutrition technologies, resilience and climate change adaptation strategies, crop and livestock production were covered during the meetings.

BFCI Coverage and Outcome Indicators To monitor adoption of optimal MIYCN practices, community health volunteers conducted targeted home visit follow–up of children less than one year. Five outcome indicators namely i) early initiation of breastfeeding ii) use of pre-lacteal feeds iii) exclusive breastfeeding iv) introduction of semi–solid and v) iron–rich foods during complementary feeding were assessed during the home visits on a monthly basis. From the activity monitoring reports, a significant improvement in adoption of optimal MIYCN practices among BFCI beneficiaries was observed. With the on–going intensified promotion of animal source foods by both frontline health and agriculture workers, it was noted that there was some improvement in the use of animal source foods in complementary feeding among the BFCI cohorts. Apart from Kitui County, there was also a marked increase in the number of home visit follow–up conducted for target beneficiaries by CHVs across most of the community units implementing BFCI activities. This was occasioned by the cancellation of CHV contracts with the Kitui County government on 31st July 2018 which led to the disruption of all community health services including BFCI activities across the County. As a result, only Kakuyu/Kyandali community unit in Kitui County continued to implement BFCI activities during the quarter with Waita and Mwambui community units resuming work in October 2018. Noteworthy, Gakombe community unit did not conduct any home visit during the quarter. Tables 7a-e is a summary of the BFCI outcome indicator reports by focus County:

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Tables 7a-e: Baby Friendly Community Initiative (BFCI)Outcome Indicators by County and Community Unit

Table 7a: Marsabit County Loiyangalani Community Unit Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 100% 100% 100% % of infants initiated on breastfeeding within one hour after birth 2. Pre-lacteal feeding 12% 0% 0% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 92% 95% 92% % of infants on exclusive breast feeding 4. Breastmilk and semi-solid foods 80% 73% 81% % of infant who received semisolid food and breastmilk 5. Iron rich / animal or fortified foods 77% 70% 71% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 72 61 62 Total No. of children (0 – 11.9 months) in catchment population (data from EPI 167 register) 5. Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 43.1% 35.7% 37.1%

Goro - Rukesa Community unit Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 99% 98% % of infants initiated on breastfeeding within one hour after birth 2. Pre-lacteal feeding 1% 1% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 61% 58% % of infants on exclusive breast feeding 4. Breastmilk and semi-solid foods 76% 74% % of infant who received semisolid food and breastmilk 5. Iron rich / animal or fortified foods 39% 36% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 95 98 Total No. of children (0 – 11.9 months) in catchment population (data from EPI register) 109 5. Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 87% 89.9%

Table 7b: Busia County Sigulu, Budalanga, Wakhungu, Luchululo, Bukhulungu and Serekeresi Community Units - Nangina dispensary Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 99% 100% 99% % of infants initiated on breastfeeding within one hour after birth 2. Pre-lacteal feeds 0.4% 1% 0.6% % of infants given was given water/liquids, milk/infant formula, or other food/drink in the first three days of life

23 FY 19 Q1 October – December Quarterly Report

3.Exclusive Breastfeeding 100% 95% 98% % of infants on exclusive breast feeding 4. Breastmilk and semi-solid foods 89% 90% 89% % of infant who received semisolid food and breastmilk 5. Iron rich / animal or fortified foods 91% 90% 91% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 430 442 568 Total No. of children (0 – 11.9 months) in catchment population (data from EPI register) 536 536 536 5. Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 80% 83% 105%

Aterait, Changara, Kolanya and Akobwait Community Units - Changara dispensary Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 100% 98% 98% % of infants initiated on breastfeeding within one hour after birth 2. Pre-lacteal feeds 0% 7% 0% % of infants given was given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 78% 49% 40% % of infants on exclusive breast feeding 4. Breastmilk and semi-solid foods 77% 19% 31% % of infant who received semisolid food and breastmilk 5. Iron rich / animal or fortified foods 86% 19% 42% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 289 287 143 Total No. of children (0–11.9 months) in catchment population (data from EPI register) 271 271 271 5. Coverage – No. of children 0–11.9 months being reached through BFCI activities 106% 106% 53%

Table 7c: Tharaka Nithi County Matakiri Community Unit - Nkondi Health Centre Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 99% 100% 99% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 0.8% 0% 0% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 96% 100% 100% % of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 93% 95% 94.6% % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 86% 81% 84.7% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 108 100 92 Total No. of children (0 – 11.9 months) in catchment population (data from EPI register) 186 186 186 Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 58.1% 53.8% 49.5%

Kathangachini CU – Kathangachini Health Centre Indicator Oct. Nov. Dec.

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1.Early Initiation into Breastfeeding 83% 79% 83% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 8.8% 8.8 % 8% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 92% 82% 91.6 % of infants on exclusive breast feeding % 4.Breastmilk and semi-solid foods 82% 72% 92.5 % of infant who received semisolid food and breastmilk % 5.Iron rich / animal or fortified foods 18% 63.6% 94% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 63 59 50 Total No. of children (0 – 11.9 months) in catchment population (data from EPI register) 135 135 135 Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 47% 44% 37%

Table 7d: Kitui County Waita and Mwambui Community Units – Waita Health Centre Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 86.2% 76.6% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 3.7% 3.1% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 81.7% 84.8% % of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 91.7% 88.5% % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 91.7% 69.6% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 109 109 Total No. of children (0 – 11.9 months) in catchment population (data from EPI 307 register) Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 35.5% 35.5%

Kakuyu/Kyandali Community Unit – Kalatine Dispensary Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 95.6% 95.6% 95.2% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 2.2% 2.2% 2.4% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 90% 80% 81% % of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 68.9% 62.2% 64.29% % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 68.9% 62.2% 61.9% % of infants who received iron-rich (animal or fortified) foods

25 FY 19 Q1 October – December Quarterly Report

Total No. of children (0 – 11.9 months) reached with BFCI this month 45 45 42 Total No. of children (0–11.9 months) in catchment population (data from EPI 123 register) Coverage – No. of children 0–11.9 months being reached through BFCI activities 36.6% 36.6% 34.2%

Table 7e: Samburu County Kisima Community Unit – Kisima Health Centre Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 100% 100% 100% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 0% 0% 0 % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 100% 100% 100% % of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 100% 55% 66% % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 42% 55% 66% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 64 46 53 Total No. of children (0–11.9 months) in catchment population (data from EPI register) 226 Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 28% 19% 23%

Lorubae and Lderkesi Community Units - Archers Post Health Centre Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 93% 89.6% 100% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 8.5% 0% 0% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 100% 91.7% 94% % of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 80% 60% 88 % % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 75% 70.8% 75% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 47 48 37 Total No. of children (0–11.9 months) in catchment population (data from EPI register) 320 Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 15% 15% 12%

Nachola Community Unit – Nachola Health Centre Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 62% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 19% % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 46% 26 FY 19 Q1 October – December Quarterly Report

% of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 46% % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 38% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 147 Total No. of children (0 – 11.9 months) in catchment population (data from EPI register) 178 Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 83%

South Horr Community Unit – South Horr Health Centre Indicator Oct. Nov. Dec. 1.Early Initiation into Breastfeeding 62% % of infants initiated on breastfeeding within one hour after birth 2.Pre-lacteal feeding 0 % of infants given water/liquids, milk/infant formula, or other food/drink in the first three days of life 3.Exclusive Breastfeeding 100% % of infants on exclusive breast feeding 4.Breastmilk and semi-solid foods 86% % of infant who received semisolid food and breastmilk 5.Iron rich / animal or fortified foods 13% % of infants who received iron-rich (animal or fortified) foods Total No. of children (0 – 11.9 months) reached with BFCI this month 87 Total No. of children (0 – 11.9 months) in catchment population (data from EPI register) 182 Coverage – No. of children 0 – 11.9 months being reached through BFCI activities 48%

Improved capacity of GOK Ministries, Counties, NGOs, IPs and CBOs to implement effective nutrition SBCC activities

BFCI Training Activities To strengthen behaviour change communication component of BFCI activities, NHPplus rolled out integration of Familia Bora approach which involves provision of practical information and support through CHVs to households with pregnant women and children less than 24 months to adopt seven excellent actions. This approach sought to strengthen interpersonal communication and social mobilization skills of the CHV for promotion of key accelerator nutrition behaviours during the first 1000 days of life. These excellent actions defined who must carry out the recommended behaviour, small doable actions and the benefits to be accrued by carrying out accelerator behaviours and/or actions. To execute this integration, the program conducted a five– day training-of-trainers (TOT) on Familia Bora for 79 health care workers including NHPplus apprentices drawn from 11 sub–counties implementing BFCI activities in the focus Counties. A two–day training on Teachback methodology was conducted to build facilitation skills of the participants, improve their mastery of the technical content of the training and understanding on how it can be integrated within BFCI activities. All training participants were given the opportunity to prepare for selected training sessions and present to the other participants. Subsequently, the TOT participants conducted a three-day training for 188 CHVs previously trained on BFCI from 15 community units in Tharaka Nithi, Busia, Marsabit and Kitui Counties. In Tharaka Nithi County, the 38 TOTs which included 10 NHPplus apprentices trained on Familia Bora approach

27 FY 19 Q1 October – December Quarterly Report

within BFCI context further trained 23 CHVs from Matakiri and Kathangachini community units in Tharaka South and Tharaka North sub–Counties respectively.

During the CHV training activities, Familia bora household score cards for the target beneficiaries were given to the CHVs for distribution to eligible households. In addition, the program provided identification and behavior change communication (BCC) materials with printed MIYCN messages for distribution to the beneficiaries. These included carry-on bags, caps, reflector jackets for CHVs and lesos, head scarfs and aprons for MtMSG members.

As part of preparatory activities, the program conducted a one–day sensitization for Community Health Committee (CHC) members of Madende Dispensary in Nambale sub-County. A total of 20 members participated in the sensitization meeting. The objective of the sensitization was to share information on BFCI and build support and ownership from the members prior to initiation of BFCI activities. Madende Dispensary is one of the new scale-up sites for BFCI activities in Nambale sub–County.

After CHV training in Loiyangalani CU, there was positive feedback regarding the Familia Bora scorecard which allows for individual monitoring of each household. It was felt that it would add value to the existing BFCI interventions since it assigns specific responsibilities to the mothers, family members, health facility staff and the community at large. In addition, the use of structured methodology and standardized social behavior change communication (SBCC) materials for consistency of messaging to the target beneficiaries was applauded. Noteworthy, recognition of caregivers who successfully adopted excellent actions through presentation of certificates and commendation letters during community celebrations was also highly approved as a missing link in the previous BFCI implementation strategy. However, it was noted that the housing designs of pastoralist communities might be a challenge when hanging the Familia Bora scorecard as a calendar. This is because most of the households reside in short round huts which increase the likelihood for destruction of the scorecard by children and smoke from the fire plane. In the interim, it was proposed that the scorecards should be folded and kept in safe places within the houses.

Together with the SCHMTs, action plans were developed by the TOTs with the six (6) community units earmarked for Familia Bora roll out in Saku, Moyale and Laisamis. The status of BFCI activities in the CUs is summarized in Table 8

Table 8: Status of BFCI and Familia Bora activities in six community units in Marsabit County Sub-County Ward Community Unit Status of Implementation Saku Sagante Goro-Rukesa Already implementing BFCI – Moyale Uran Golole CU • Home visit follow – up, MtMSGs and Golbo Godoma CU Outreach activities are on - going Saku Karare Karare CU New CUs targeted for BFCI and Familia Bora Moyale Golbo Odda CU approach training. Laisamis Laisamis Merille CU.

28 FY 19 Q1 October – December Quarterly Report

Due to insecurity occasioned by the extended Moyale–Ethiopia border clashes, implementation of BFCI activities in Godoma CU in Golbo ward was put on hold during the quarter. A newly posted nutritionist has been trained and will revive BFCI activities given its poor MIYCN indicators once security is restored in the area. In addition, the program with support from CNC pushed for the inclusion of 8 health care workers from 6 health facilities; 2 CHAs, 3 nutritionists and 3 nurses, in a BFCI training supported by Red Cross. It is expected to strengthen implementation of BFCI activities in the County.

BFCI CHV Review Meetings At the beginning of the reporting period, all community units implementing BFCI activities conducted mapping of their households to identify children 0–24 months, pregnant women and adolescents. The data obtained was used by CHAs to determine CHV work load in terms of number of targeted home visits expected from each CHV in a month, number of MtMSGs that can be established per village and inform planning of adolescent friendly activities in the community.

To coordinate and monitor performance of implementation activities, the program conducted monthly BFCI review meetings with CHVs, CHAs and link health facility staff in Kitui, Marsabit and Samburu Counties. Based on BFCI reports from CHVs, progress of targeted CHV home visits, MtMSG meeting and BFCI outreach activities including gaps, challenges and upcoming planned activities were discussed during the meeting. In addition, BFCI refresher training and updates addressing identified knowledge gaps from CHV reports was also conducted. Some of the frequent gaps discussed included documentation of home visits and MtMSG meeting activities, low coverage of target beneficiaries, how to identify target BFCI beneficiaries through household mapping and how to form MtMSGs in the community.

In Mwingi Central, the programs supported monthly BFCI review meetings in 4 community units: Waita, Mwambui, Kalatine and Tharaka. Notably, NHPplus apprentices were oriented on a BFCI management system which allows for automated collation, aggregation and reporting of BFCI data.

For Marsabit County, three BFCI review meeting were conducted with CHVs from Loiyangalani, Goro Rukesa and Golole community units. A total of 75 CHVs, 7 CHAs, 1 Nutritionist, 3 nurses and 6 NHPplus apprentices participated in the review meetings. During the meeting, updates on formation of CMSG in Goro Rukesa and Golole CUs, dissemination of household mapping report, feedback from BFCI CHV reports, orientation of CHAs and CHVs on BFCI reporting tools, review of the BFCI and updates on establishment of CMSGs and MtMSGs were discussed. It was reported that nine MtMSG were established in Goro Rukesa and Golole CUs whereas 4 MtMSG meeting were held in Loiyangalani. The CHVs were commended for the general improvement in home visit follow–up of target beneficiaries and documentation of BFCI activities across all the community units. However, it was reported that some of the caregivers were uncooperative during home visits. In addition, some of the CHVs were illiterate which affected proper documentation of BFCI activities. Hence, it was recommended that community dialogues on BFCI and CMSG outreaches should be intensified to increase awareness and ownership among

29 FY 19 Q1 October – December Quarterly Report

community members. In addition, CHVs with low literacy were to be closely supported by CHAs and other literate colleagues to ensure accurate information is captured.

Similarly, the program conducted three review meetings in Lorubae, Lderkesi and Kisima CUs in Samburu County. The CHVs were taken through how to fill BFCI Form 1 and MIYCN indicators. These included exclusive breastfeeding for the first 6 months, baby attachment and positioning, breastfeeding difficulties, complementary feeding, growth monitoring and immunization. Some of the challenges discussed included weak documentation of growth monitoring information especially height in the MCH handbook at the health facility, poor communication on expected delivery dates and change of residence by BFCI beneficiaries, low uptake of referrals and illegal sale of therapeutic and supplemental feeds by parents and care givers affecting treatment outcomes of undernourished children. These challenges made it difficult for CHVs to follow up on the BFCI beneficiaries.

1.4 Increasing Opportunities for Learning and Sharing of Best Practices in Nutrition Operations research implemented to support the learning agenda As a follow–up of IFAS implementation science inception activities from the previous quarter, the national core research team conducted a two – day bottleneck analysis workshop for iron folic supplementation program. The purpose of the workshop was to generate an inventory of bottlenecks at all levels of the health service delivery system for IFAS and identify possible questions for implementation research in the County. A total of 39 participants from the health sector comprising of nurses, nutritionists, pharmacists, physicians, health information officers from Busia, Kitui, Marsabit and Tharaka Nithi Counties including representatives from NHPplus, Kenya Medical Research Institute (KEMRI) center of health public research, Kenya Medical Supplies Authority (KEMSA) and Nutrition International (NI) were in attendance. The four Counties were selected for implementation of IFAS research activities based on maternal and child health performance indicators as well as regional and ethnic representation. Following the bottleneck assessment workshop, the development of research proposal begun using KEMRI ethical and scientific review committee guidelines. It is envisioned that the proposal will be submitted for review by Nutrition Research TWG and subsequently to KEMRI institutional review board (IRB) for approval by end of February 2019.

1.5 Increased Knowledge and Skills for Health Care Workers

BFCI and Familia Bora Training Activities To strengthen capacity for implementation of nutrition behavior change communication activities, the program conducted a five–day TOT training on Familia Bora approach for 19 participants in Marsabit County. The Familia Bora approach seeks to strengthen promotion of key accelerator nutrition behaviors within BFCI activities. Subsequently, a total of 28 CHVs were trained on Familia Bora approach in Loiyangalani community unit. The Familia Bora TOTs are expected to further train the remaining community units implementing BFCI activities during the next quarter.

In Busia County, a total of 56 HCWs and 34 CHVs from Samia, Teso North and Nambale sub– Counties were also trained on BFCI for service provider and Familia Bora approach respectively.

30 FY 19 Q1 October – December Quarterly Report

Noteworthy, all new BFCI sites which have not undergone BFCI training will be taken through an updated BFCI training curriculum which incorporates modules from the Familia Bora approach.

31 FY 19 Q1 October – December Quarterly Report

2 Strengthened Nutrition Commodity Management

2.1 Improving Production, Supply and Distribution of Nutrition Commodities

Improving Efficiency and Availability of Nutrition Commodities Commodity Procurement and Distribution NHPplus coordinated procurement of 424.8MT of Fortified Blended Flours (FBF) and 9.32MT of Ready to Use Therapeutic Foods (RUTF) and subsequently distributed 214.2MT (50%) of FBF to 153 health facilities across 29 counties reaching 39,399 patients (Figure 1). The performance in distribution compared to previous quarters was attributed to down time in the manufacturing plant. However, buffer stocks from supplies in Quarter 4 (July to September 2018) mitigated stock-outs in the sites. Further, supplier quality audits and various batch tests were conducted on the commodities (see sub-section 2.2) to ensure that the country quality standards were attained and maintained. The distribution of RUTF will be done in the subsequent quarter.

Figure 1: Trends in Nutrition Commodities Distributed and Patients Served, 2015 – 2018

Improving Commodity Management To increase data collection and use to inform strategic plans for improved commodity management, the program undertook several activities including participating in national quantification for nutrition commodities convened by the Nutrition and Dietetics Unit (NDU), facilitating data review meetings convened by various counties, and providing data collection and summary tools to health facilities.

Commodity Quantification

32 FY 19 Q1 October – December Quarterly Report

The national quantification for nutrition commodities was convened by NDU with support from the United Nations Children’s Fund (UNICEF). Participation was drawn from the National AIDS and STI Control Program (NASCOP) - HIV Program, National TB program, Kenya Medical Supplies Authority (KEMSA), Nutrition and Health Program plus (NHPplus) and Kenya Red Cross. Discussions focused on building assumptions, developing quantification models and development of draft nutrition sector F&Q report for FY19. In addition, there were discussions on program updates, harmonized technical specifications for various nutrition commodities and anthropometric equipment and review of supplier end user monitoring tool. The draft report will be finalized in the next quarter.

It was noted that the revised MOH 734B (Facility Consumption Data Report and Request – FCDRR) for nutrition commodities had not been uploaded on DHIS nor had KEMSA linked the electronic Consumption Data Report and Request (e-CDRR), mainly used in the Arid and Semi-arid counties, to DHIS. This, therefore, creates a bottleneck in dissemination of the tool to the other counties. NDU, together with KEMSA and HIS team are following up to ensure that this link is created.

Data Review Meetings NHPplus together with Afya Pwani collaborated to conduct data review meetings in the four (4) sub counties of Taita Taveta County. The county had also requested KEMSA to join the team in order to further strengthen the commodity component especially the LMIS version of MOH 734 commonly used in the ASAL counties. The key issues that were highlighted from the meeting were: 1. County reporting rates range between 80-90% on DHIS for MOH 734, MOH 733, and MOH713. The lack in 100% achievement was attributed to Wundanyi Sub County (SC) whose Nutrition Officer (SCNO) was tasked to follow up with specific facilities that have not been consistent in reporting. 2. Health workers refreshed on the admission and discharge criteria for NACS, out-patient therapeutic program (OTP) and supplementary feeding program (SFP) using the mid-upper arm circumference (MUAC) and weight-for-height z-score (WHZ); Prescription of nutrition supplements to the clients in different client (age) categories and emphasis on importance of giving the correct prescription per client. 3. Data collection and summary tools for both services and commodity management were reviewed (MOH 407A, MOH 407B, MOH 732, MOH 409, MOH 734 and appointment cards); areas of weakness were discussed extensively to ensure that the health workers were collecting relevant/correct data. 4. KEMSA introduced the Logistics Management Information System (LMIS) that is mainly used for reporting and requesting nutrition commodities supplied by the authority. 5. Good practices in inventory management (monitoring of expiry dates, receiving of commodities, filing of proof of delivery documents, proper recording to ensure accountability of nutrition commodities) were also covered during the week long activity.

Health workers recommended the following to improve services: - Harmonization of nutrition services registers (MOH 407A, MOH 407B, MOH 713, MOH 733, OTP and SFP registers) - Conduct quarterly data review meetings at Sub-County level to cater for all programs including HIV, TB, CWC, and any other program with nutrition indicators - SCNOs to follow up with facilities that were not represented in the meeting to ensure uniformity of messages passed during the forum - In DHIS, there are two (2) versions of the MOH 733B (Summary tool for nutrition services. For the short term, SCHRIOs to select the latest version during upload of data; In the long term, the

33 FY 19 Q1 October – December Quarterly Report

issue needs to be followed up with the Nutrition Information Technical Working Group (NITWG) for removal. - SCNOs to follow up with the County Health Records Information Officer (CHRIO) for facilities lacking the datasets in DHIS.

Kisumu County requested for performance reports from the program for their data review meeting. After the meeting, the county nutrition coordinator shared the main highlights from this meeting which included a) the need to have one version of MOH733B in DHIS as this could be contributing to lower reporting rates for nutrition services and b) support for data quality audits as there was a noted deterioration in quality of data e.g. from DHIS the county seemed to have adequate stocks in all facilities with HIV nutrition program. However, physical verification in several facilities revealed that they were out of stock for some of the nutrition commodities. The program intends to support the county in this activity in the coming quarter.

It is worth noting that county nutrition officers are using the data uploaded on DHIS to convene and facilitate these data review meetings, findings are provided by themselves and the only challenge is support for such forums.

Capacity Building for NACS Following NACS training in Marsabit County in the previous quarter, compounded by technical assistance from the NHPplus apprentices, great improvements have been noted both in coverages and quality of care offered. The following are the key positive highlights; a) Streamlining of patients’ registration and follow up in MOH 407A and 407B i.e. improved documentation, b) patients keeping appointments, c) adequate stocks throughout the reporting period and d) increase in number of patients who were assessed as well as those who received commodity support. The following are the challenges reported and recommendations; - In Loiyangalani sub county, care and treatment for HIV services is provided at the Catholic Mission Health Center while the Nutrition services are provided by Loiyangalani Dispensary (GoK facility) therefore, there is need for harmonization to ensure that patients in both facilities receive both services (ART and nutrition services). The Sub-County AIDS and STIs Coordinator (SCASCO) was informed for follow up and potential integration of the services. - The skirmishes in Saku and Moyale affected the services uptake during the first two months of the quarter but generally, there was noted improvement compared to previous last quarters. A thorough analysis will be shared in the coming quarter. - Staffing challenges.

In Kitui County, NHPplus supported on job training (OJT) on NACS protocol for eight (8) health care workers within Kitui Rural, Kitui South, Mwingi West and Mwingi North sub counties. During the exercise the health care workers were trained on how to fill nutrition daily activity registers, criteria for admission and discharge from both supplementary and therapeutic feeding programs, prescription doses for the different age categories, nutrition services and commodity reporting. In Mutomo Mission Hospital, Kyuso Hospital, Migwani Hospital, Kitui County Referral Hospital, the team conducted OJT for the Nutrition EMR.

Site Visits NHPplus visited four (4) facilities in Kiambu County – Gatundu District Hospital, Gachororo Health Centre, Thika Level 5 Hospital and Limuru Health Centre. Of the four facilities visited, one (Gatundu District Hospital) report using the Nutrition EMR software. The objective of the visits was to improve service data recording and reporting, strengthen capacity for MCH reporting and improve stock/inventory

34 FY 19 Q1 October – December Quarterly Report

management. Table 9 is a summary of observations made during the site visits and recommended subsequent actions.

35 FY 19 Q1 October – December Quarterly Report

Table 9: Key Observations and Recommended Actions During Facility Site Visits in Kiambu County Facility Key Observations Action Items Kiambu County  All facilities had adequate data collection and summary tools.  County Nutrition Coordinator (CNC) to lobby 1. Gatundu District Hospital for more anthropometric equipment especially (EMR facility)  All facilities had adequate nutrition commodities except for Gachororo infant baby scale, MUAC Tapes and BMI wheel Health Centre which was attributed to inconsistent reporting. 2. Gachororo Health Centre  CNC to lobby for/disseminate to the sub  Nutritionists and SCNO have been granted rights by the County records counties available job aids and policy tools. Health 3. Thika Level 5 Hospital department to upload nutrition data into DHIS directly. facilities to display all job aids and update VAS monitoring charts. 4. Limuru Health Centre  NACS data elements cross checks on EMR vs DHIS tallied for Gatundu (other facilities still using manual system)  CNC to follow up with the Sub County Nutrition Officers for OJT sessions for those facilities that  Bin Card quantities vs Physical Count quantities tallied. have challenges in recording and reporting.

 Data cross checks for commodities dispensed using MOH 409 (Daily  Nutritionists in-charge to ensure all nutrition Activity Register for Nutrition Commodities) vs MOH 734B summary service outlets are equipped with nutrition data tool showed slight disparities e.g. for Gatundu, FBF for adults, 465 bags collection tools and finally merged in the EMR were recounted on DAR against 480 bags reported on MOH 734B system. summary tool.  OJT conducted on-site for Commodity Module In Limuru HC, Commodity data crosschecks did not tally for June 2018 with the expectation that the facility will start commodity reports. Prescription forms (MOH 732) were used but this utilizing dispense and commodities Reporting information was not transferred to MOH 409 which feeds into the module within the EMR. summary tool MOH 734 and subsequently into DHIS. Bin Cards were also not updated  NHPplus to update EMR and provide a refresher on the same to more staff.  Facilities well equipped with anthropometric equipment used for nutrition assessment except for MUAC Tapes, BMI Wheel and infant baby scale

 MIYCN poster, MIYCN guidelines, IMAM protocol and VAS posters are not available. VAS Monitoring chart not displayed where available (Gatundu)

36 FY 19 Q1 October – December Quarterly Report

Proposal for the implementation of the Phase-out Process The objective of the phase-out process under the IR2 component is to align NHPplus support to beneficiary counties/sites with other PEPFAR mechanisms and ensure maximum effectiveness in service delivery. This process will respond to the policy to re-orient service delivery to ensure that resources available sustaining gains made in delivery of high-quality nutrition services in high yielding counties and sites with a view to contribute toward achieving the 95-95-95 goal.

During the quarter, the program reviewed nutrition services and ART data reports to confirm demand patterns for care and treatment services, nutrition assessment (FN_ASSESS), (FN_THER), nutrition commodities consumption to guide identification of phase-out counties. Table 10 shows that during the period 2015 to 2017, 27 counties contributed about 92% of patient yields (FN_THER). Marsabit, Kilifi, Isiolo and Baringo counties will be retained because of their uniqueness. Marsabit is a focus county for the program and has some of the highest rates of maternal and early childhood undernourishment in the country. Kilifi has unique demands because of high incidence of adolescent pregnancies, undernourishment and demand for PMTCT services. The program proposes conditional phase out 15 low volume counties in Table 10 below to allow for sharing of information and remote technical assistance when possible.

The program proposes the following steps - 1. Convene Program Phase-out Planning meetings: Hold consultative meeting with national level – NASCOP/Commodity Management TWG; Sensitize groups for phase-out preparedness

2. Prepare County Reports on Nutrition Investments in Comprehensive Care and Treatment - Document investments for phase out counties, outcomes and impact (estimates) during LOP and recommendations for follow-on actions including data reports, case studies, lesson learning, guidelines, published government reports - Conduct a brief remote assessment on status of Nutrition Services in care and treatment and beyond (RMNCAH)

3. Collaborate with NASCOP/TWG and COG Health Secretariat to convene county or sub- national phase-out meetings. The program task team will engage county governments representative at the level of CEC/Director and CNCs platforms Collaborate with NASCOP in drafting framework for post-phase remote support especially for sites with strengthened EMR capacity.

4. Convene sub-national learning sessions for CNCs and key personnel in the nutrition space using regional community of practice approaches. Table 10: County Reporting Rate, Contribution to Patient Targets & Recommendations for Phase Out # County DHIS Program Number *Total % Nutrition Reporting Reporting of Health Patients Contribution Comm: Recommen Rate-2018 Rate - 2018 Facilities on Food to patients FY19 MT dation & yield allocation Rationale 1 HOMA BAY 78.6 80.1 47 35,348 10.8% 190.78 Retain. Contributing 2 BUSIA 76.8 83.3 20 30,176 9.2% 162.87 to 91.7 % of 3 KIAMBU 59.3 66.3 22 21,628 6.6% 116.73 patient target 4 NAIROBI 57 60 36 19,086 5.8% 103.01 5 TURKANA 17.4 73.2 14 16,831 5.1% 90.84 6 NAKURU 43 64.3 25 16,758 5.1% 90.45 7 UASIN GISHU 24.5 70.1 12 13,890 4.2% 74.97 8 KISUMU 67.4 66.3 20 13,886 4.2% 74.95 9 MACHAKOS 17.9 69.2 13 11,045 3.4% 59.61

37 FY 18 Q4 July – September Quarterly Report

10 MIGORI 39 57.7 13 10,766 3.3% 58.11 11 KIRINYAGA 5.4 91.7 13 10,658 3.2% 57.52 12 BUNGOMA 28.8 49.3 12 10,573 3.2% 57.06 13 KITUI 17.9 36.9 35 8,851 2.7% 47.77 14 VIHIGA 33.8 80.6 9 8,362 2.5% 45.13 15 SIAYA 79.4 73.6 18 7,994 2.4% 43.15 16 MAKUENI 6.7 83.3 8 7,523 2.3% 40.60 17 MERU 10.8 70.8 10 7,238 2.2% 39.06 18 NYANDARUA 42.1 76 9 7,198 2.2% 38.85 19 KAKAMEGA 69.6 68.5 14 6,517 2.0% 35.17 20 MURANG'A 8.7 65.4 20 6,485 2.0% 35.00 21 NYERI 0.9 69.5 9 5,941 1.8% 32.06 22 TRANS NZOIA 21.4 76.7 5 4,943 1.5% 26.68 23 MOMBASA 77.4 54.2 10 4,632 1.4% 25.00 24 T/-NITHI 19.4 38 18 4,388 1.3% 23.68 25 SAMBURU 15.2 89.6 4 3,491 1.1% 18.84 26 NAROK 68.8 26.1 37 3,307 1.0% 17.85 27 EMBU 77.8 58.3 5 3,139 1.0% 16.94 28 LAIKIPIA 46 75 3 2,701 0.8% 14.58 Phase Out - Low volume 29 KAJIADO 69.9 50 8 2,119 0.6% 11.44 30 TAITA 63.3 45 5 1,103 0.3% 5.95 TAVETA 31 MARSABIT 1.4 34.7 6 1,029 0.3% 5.55 Retain 32 KILIFI 22.7 61.7 5 2,887 0.9% 15.58 Retain 33 KERICHO 18.8 35.6 11 2,742 0.8% 14.80 PO. Low volume 34 KISII 54 35.4 12 2,457 0.7% 13.26

35 NANDI 18.3 94.5 3 1,973 0.6% 10.65 36 ISIOLO 27.8 91.7 2 1,937 0.6% 10.45 Retain 37 BARINGO 23.8 60 5 1,912 0.6% 10.32 Retain 38 BOMET 21.9 50 4 1,514 0.5% 8.17 39 ELEGEYO- 30.3 61.1 6 1,503 0.5% 8.11 MARAKWET 40 NYAMIRA 70.8 75 2 1,415 0.4% 7.64 41 KWALE 54.1 41.7 4 1,308 0.4% 7.06 42 GARISSA 0.2 100 1 225 0.1% .21 43 WEST POKOT 36.9 10 5 222 0.1% 1.20 44 LAMU 41.7 10.4 4 189 0.1% 1.02 45 TANA RIVER 1.4 22.2 3 113 0.0% 0.61 46 WAJIR 1.9 8.3 1 1 0.0% 0.01

47 Mandera 1.2 0 0 Excluded 548 328,004 1,770.30 *Review period - Jan 2015 to June 2018

38 FY 18 Q4 July – September Quarterly Report

2.2 Improving Quality and Safety of Food Commodities and Agricultural Products

Supplier Quality Audits (SQA) The bi-annual SQA were conducted in two (2) companies – Equatorial Nut Processors (ENP)- Fortified Ltd and Proctor & Allan Ltd.

Equatorial Nut Processors scored 82% compared to78.65% from previous audit conducted in May 2018. The score translates to “close critical and major gaps and engage, request continual improvement schedule”. There was great improvement in the analysis of individual verification results, leading to better monitoring of objectives and providing factual inputs to management review meetings and subsequent decision making. Among the gaps noted was a lapse in control of non-conforming products and reworks which were not labelled and securely stored respectively. In addition, renewal of medical covers for the employees had not been done and monitoring of water quality was not consistent. By the end of the quarter the medical records had been updated and controls put in place to ensure that monitoring of water quality was done.

Proctor & Allan Ltd scored 68.3%, an improvement from the previous 59.75% translating to “Fail - Do not engage, re-audit after improvements”. The number of minor non-conformances reduced significantly from the previous audit signifying deliberate effort to improve. The food safety culture has improved since the last audit. Notable is improved documentation, personnel understanding of requirements and willingness to improve. However, the articulation of the food safety management system to control hazards is still weak in especially these areas: i) the Hazard Analysis and Critical Control Points (HACCP) plan ii) the control of non-conforming materials including re-works, and iii) pest management among others It was recommended that the food processor should review the system and deploy more training, awareness and practice of the documented system. Re-audit has been slotted for January 2019.

Equatorial Nut Processors were audited for re-certification of ISO 22000:2005 where a notice for approval for recertification was awarded. The current certificate expires on 22nd January 2018. In addition, for the on-going laboratory certification by Kenya Accreditation Service (KENAS), an assessment was conducted mainly to assess the Laboratory activities, processes and the competence of Laboratory staff. The report was tabled before the Board and a decision is expected in January 2019.

Reports from ENP indicated that there was need for heightened alertness on pest control activities due to challenges experienced with post-harvest management of previous season stock of maize from suppliers. Deliberate actions were undertaken in compliance with Environmental Mitigation and Monitoring Plan (EMMP) to ensure that this did not affect quality of the finished products.

Post-Batch Testing of FBF Overall, there food processors’ ability to self-regulate for safety and quality ensuring continued, reliable supply of safe, locally procured food commodities. However, post-distribution analysis to confirm shelf life suggested occurrence of peroxidation indicated peroxide values ranging between

39 FY 18 Q4 July – September Quarterly Report

15.69 meqO2/kg and 32.30 meqO2/kg. These values are beyond recommended induction level of < 10 meqO2/kg. This observation suggests early oxidative breakdown of fats and oils. The program has recommended preventive actions to the manufacturers including expanding internal analytical capacity to monitor peroxidation.

2.3 Strengthening Sustainability & Innovation in Nutrition Commodity Development & Management

Food manufacturing entities Efforts to have an expanded manufacturing base for nutritious commodities by the private sector has yielded some achievements for the program. Notably, Proctor & Allan Ltd (P&A) has expressed willingness and commitment in improving their systems to the same level as Equatorial Nut Processors and other international food companies. Given that the company has invested heavily in state-of-the-art equipment, this can only elevate the business. As stated above, the SQA that was conducted during the quarter showed improved performance with only a few gaps to be closed. The program intends to engage the food processor once the score mark of >70% is achieved.

Country capacity to provide extrusion services Review of the country capacity to manufacture extruded composite flours revealed that eight entities had full range or partial capacity to extrude composite and single grain (cereal or legume) flours for different applications. Majority of these companies had installed Insta Pro Ltd single screw dry extruders. These companies are Equatorial Nut Processors Ltd, Proctor and Allan Ltd, Soy Afriq Ltd, Pro Soy Ltd, Insta Products (EPZ) Ltd (dormant), Popular Nutrifoods Ltd, Bidco Ltd and Promasidor Ltd. Only one company (P&A) capacity for wet extrusion. Under the above stated effort, it is expected that the program will collaborate with P&A to produce instant FBF products. Invariably, it would be beneficial to guide other high potential and promising companies to upgrade their production systems with a view to improve quality of extruded foods.

In line with the workplan, the FHI360 procurement recommended acquisition of one consultant to facilitate design of improved products and engagement of dry extrusion to produce improved FBF trial products. In addition, the program proposed procurement of a second consultant to assist in sensory evaluations once the improved trial products become available. Recruitment of these consultants was nested in the requested budget re-alignment.

Increased Diversity in Products for Management of Malnutrition NHPplus has continued to foster/facilitate linkage between Department of Agriculture in Tharaka Nithi County and Tharaka Green Gold Community Support Group (CBO). During the quarter the Department of Agriculture linked the group with Kenya Forestry Research Institute (KEFRI) where the Institute expressed interest in working with the group in research and promotion of the group’s Non-Wood products with a special interest on Tamarind and Baobab products. The CBO has produced various food products with the local trees e.g. Baobab – Juice, Jam and Powder for Smoothies, Tamarind – Juice and Jam. The group also uses Tamarind as a preservative for meat and sweetener for infant’s porridge. The popularity of baobab fruit and its constituent powder has grown in recent years, due to the high concentrations of nutrients and minerals that it contains.

40 FY 18 Q4 July – September Quarterly Report

Tamarind trees are spread to almost all areas of Tharaka-South and Tharaka-North Sub-Counties and a useful and desirable source of nutrition in the area, but the communities are not aware of the health and nutritional benefits of these fruit trees. The promotion of these local fruits will improve dietary diversity and reduce nutrient gaps among pregnant and lactating women and children 6–23 months of age. The program will follow-up to ensure KEFRI provides the technical support in research.

Collaboration with Kenya Bureau of Standards Composite flours: Composite flour formulations based on KEBS Standards KS1808 (Composite flours) and KS EAS 349 (processed cereal-based Infant and Young Children - specifications), KS EAS 768 (Fortified milled maize (corn) products – specification) the provide guidelines on regulatory requirements. Of interest to the NHPplus implementation is alignment of candidate food commodities these standards and closure of gaps between KS/EAS standards and the WHO recommended macro and micro nutrients requirements for preventive and treatment of clinically undernourished individuals. In this respect, the opportunity to strengthen the response to the prevailing need to prevent and correct moderate malnutrition in early childhood through expanding KS EAS 349 and KS 1808 Standards with respect to zinc, iron and iodine fortification would lender the Standards more responsive the prevailing micronutrient deficiencies1. Furthermore, available scientific evidence underscores the importance of animal source proteins (ASF) in recovery from malnutrition and prevention of undernourishment in early childhood. Article 7.2 (Protein Enrichment) of KS1808 and article 6.3 (Protein) of KS EAS 349 provide details protein requirements. However, while KS EAS 349 explicitly recommends ASF (Casen) as the reference protein, KS 1808 is implicit and optional. Revision of the Standards and or provision of guidelines to the industry and general population for compatible animal source foods and inclusion of appropriate zinc salt, iodine and iron in fortification have significant public health and economic merits. The program will collaborate with KEBS to facilitate development of guidelines to encourage enrichment of processed foods with the nutrients stated above in both supplementary food formulations and general retail foods that are designed for children and convalescence.

1 KNMS – 2011/12 41 FY 18 Q4 July – September Quarterly Report

3 Improved Food and Nutrition Security

The expected outcomes of this Intermediate Result Area include improved nutrition status of the beneficiary communities through increased access and consumption of quality and diverse foods, as well as building resilience of vulnerable households and communities. The process involves promotion of practices and interventions targeting the underlying causes of malnutrition. The expected overarching impact is reduction of stunting by 10%, through targeted interventions, smart integrations and linkages with other partners through the government mechanism.

During the quarter, NHPplus continued with the implementation of the agri-nutrition package at the community level. It focused on imparting knowledge and practical skill development through demonstrations to influence behavior of the households in production and utilization of certain foods for food security and dietary diversity (DD). In line with the proven pathway for addressing undernutrition, economic empowerment of the community formed an integral part of the target outcomes that significantly contributed to resilience building. The approach involved utilization of lead mothers as first tier beneficiaries from community groups, facilitated by frontline staff (CHVs/CHEWs/FEWs/ECDE staff, Community Resource Persons) with occasional direct dissemination by the frontline staff. The multi-sectoral approach involving agriculture, health education and private sectors, as well as faith-based organizations was used. The target population was children under 5 years, pregnant and lactating women and women of reproductive age. Appropriate technologies for ensuring availability of food during lean times as well as increasing bio-availability of nutrients were promoted for adoption. Collaboration and linkages with partners provided synergies and leveraged on existing opportunities that aimed at addressing community nutrition concerns. At program level nutrition specific and sensitive interventions converged through agri-nutrition packages and BFCI structures at community level improving achievement of target outcomes. Specific contextualized packages promoting consumption of animal source foods were emphasized within the diversified diet efforts, WASH and production technologies through home gardening and consumption through cooking and food preparation demonstrations.

Overall the beneficiaries were 22,518 households. On the basis of interventions, the direct beneficiaries for DD contextualized packages were 1,537 households represented by 1,412 Females and 125Males, production technologies through home gardening 3,229 households (2,622F, 607M), WASH 14,014 households (8,158F, 5846M), cooking/food preparation demonstrations 3,738 households (3,2452F, 583M) and 1,591 pregnant mothers. Indirect beneficiaries were 2,545 (1,245F, 1,300M) children under 0-23 months and 4,072 (2,163F, 1,909M) children 24-59 months.

3.1 Increased Market Access and Consumption of Diverse and Quality Foods

10% reduction in stunting rates in the feed-the-future (FtF) /MNCH regions In contributing towards reduction of stunting in the focus zones, the program approach focused on practical interventions for improving access and consumption of diverse and quality foods through production technologies and safe handling and food preparation practices. The interventions are as summarized in Table 11.

42 FY 18 Q4 July – September Quarterly Report

Table 11: Summary of interventions and beneficiaries per county and sub-county Agri-Nutrition Package County Sub-County Beneficiaries Female Mal Total e Generic Agri-Nutrition Package Dietary diversity in complementary Busia Samia 286 14 300 feeding and pregnant mothers Teso North 684 0 684 Climate smart sensitization Samia 95 59 154 Promotion of locally fortified flours Tharaka Tharaka North 68 12 80 Nithi and South Promotion of egg as animal source food Tharaka North 160 40 200 and South Promotion of utilization of drought Kitui Kitui East 119 0 119 resistant crops (DTCs) in preparation of delicious family meals e.g. green grams, samosa and millet/sorghum cakes Sub-Total 1412 125 1537 Home gardening Vertical bag (VB) garden technology Tharaka Tharaka North Nithi and South 162 20 182 Post-harvest handling Sambur Samburu u Central 219 388 607 Demonstration on establishment and Kitui Kitui East management of VBs 722 36 758 Production technologies for Vegetables Marsabi Moyale 395 45 440 (kales, spinach), staples (maize, beans t and cowpeas) and ground nuts and pasture production; VB farming Kitchen garden for spinach, kales, cow Laisamis 90 0 90 peas and arrow roots (Loiyangalani) Production of DTCs, growing neem and mangrove Establishment and management of VBs Kitui Kitui South 706 42 748 Mwingi North 142 29 171 Mwingi Central 186 47 233 Sub-Total 2622 607 3229 WASH Promotion of handwashing and food Busia Samia and Teso 1047 299 1356 hygiene North Promotion of hand washing Tharaka Tharaka North 4846 5093 9939 Nithi and South WASH Sensitization in 10 Pry Schools Sambur Samburu East 300 300 600 WASH Sensitization at Mothers support u Samburu East 209 209 groups

43 FY 18 Q4 July – September Quarterly Report

Agri-Nutrition Package County Sub-County Beneficiaries Female Mal Total e Community sensitization on Kitui Kitui East 722 36 758 handwashing at critical points, treatment Kitui South 706 42 7,48 and storage of drinking water Mwingi North 142 29 1,71 Mwingi Central 186 47 2,33 Sub-Total 8,158 5,84 14,014 6 Preparation of complementary foods for Busia Samia and Teso 1133 211 1344 children above 6 months and women of North reproductive age (WRA) Promoting consumption of diverse and Tharaka Tharaka North 150 0 150 nutritious food for improved health and Nithi and South nutrition Preparation of recommended Sambur Samburu East 26 0 26 supplementary and complementary diets u Samburu 38 38 for children 6 – 59 months old for Central required dietary nutrients in hygienic Samburu North 76 5 81 condition and diets for WRA Preparation of complementary food Kitui Kitui East 119 0 119 from diversified foods and utilization of drought resistant crops in preparation of delicious and nutritious family meals Sub-Total 3245 583 3738 Grand Total 15,437 7,161 22,51 8

Table 12 shows the distribution of children and pregnant women reached through the interventions shown in Table 10 by gender, county and sub-county

Table 12: Children and Pregnant Mothers Reached by Gender, County and Sub-County

Beneficiary County Sub-county Number reached Category Female Male Total Children Samburu Samburu East 73 53 126 under 2 Samburu Central 9 10 19 years (0-23 Months) Samburu North 16 10 26 Marsabit Moyale 128 153 281 Laisamis 41 32 73 Busia Samia and Teso North 635 727 1362 Kitui Kitui East 107 79 186

44 FY 18 Q4 July – September Quarterly Report

Kitui South 129 139 268 Mwingi North 24 21 45 Mwingi Central 72 68 140 Tharaka Nithi Igambang’ombe 11 8 19 Total 1245 1,300 2,545 Samburu Samburu East 86 89 175 Children 24- Samburu Central 14 7 21 59 Months Samburu North 33 34 67 Marsabit Moyale 315 341 656 Laisamis 68 82 150 Busia Samia and Teso North 1352 1010 2362 Kitui Kitui East 44 48 92 Kitui South 120 149 269 Mwingi North 69 66 135 Mwingi Central 39 68 107 Tharaka Nithi Igambang’ombe 23 15 38 Total 2163 1909 4072 Pregnant Busia Samia, Teso North 725 725 Mothers Samburu Samburu East 31 31 Samburu Central 3 3 Samburu North 9 9 Kitui Kitui East 326 326 Kitui South 93 93 Mwingi North 233 233 Mwingi Central 171 171 Total 1,591 1,591

Contextualized High impact packages In increasing access to and consumption of diversified and quality foods along the multisectoral nutrition pathways of improved food production, income and women empowerment, the program delivered specific focus county contextualized agri-nutrition packages to the target households. Dissemination was done both as theory and demonstrations to impart appropriate knowledge and skills to the household members mainly through champion mothers, with backstopping from frontline extension staff. Only two contextualized proven high impact, simple, practical and easily adoptable packages from food and nutrition security were disseminated in addition to WASH and Economic empowerment packages. Multi-sectoral teams comprising of frontline extension staff from MOALF, MOH and MOE provided the trainings and supervision of the champion mothers delivering the packages. The supervisors ensured quality control of the messages by champion mothers. Key target beneficiaries included women of reproductive age (15-49 years), children 0- 23 months and 24 months to 5 years. The implementation of this sub-component focused on both the first level beneficiaries through community groups to deliver specific agri-nutrition packages 45 FY 18 Q4 July – September Quarterly Report

and the second level beneficiaries receiving the package through lead mothers who are members of the community groups. A total of 2,067 households (1,897F, 170M). Others were WASH, income generation and cooking demonstrations.

Effective linkages established with private sector, food security/livelihoods/economic strengthening programs through FtF and non-USG funded programs During the quarter the program continued with efforts to create new and strengthen existing linkages with private sector, food security/livelihoods/economic strengthening programs through FtF and non-USG funded programs.

National level PREG Forums, FtF Nutrition TWG and other non-PREG actors The program during the period participated in the collaboration, learning and adaptation (CLA) activities organized by PREG leadership. To strengthen coordination and linkages among USAID and other partners in resilience building and food and nutrition security platform, the program participated in the PREG monthly and FtF Nutrition TWG bi-monthly meetings that attracts all PREG partners and agri-nutrition stakeholders respectively.

Focus Counties The program continued as chair and deputy chair of Marsabit and newly formed Samburu counties PREG committees respectively.

System-wide Collaborative Actions for Livelihoods and Environment (SCALE+) Methodology NHPplus has been promoting SCALE+ methodology cascade to the counties to improve collaboration and strengthen linkages among food and nutrition security stakeholders in handling common development challenges in the counties relating to food and nutrition security. So far, SCALE+ activities have been initiated in the two counties if Tharaka Nithi and Kitui..

Tharaka Nithi SCALE+ During the reporting period, the program supported by members of the County SCALE+ Steering Committee finalized the taskforces action plans developed during the whole system in the room (WSR)conducted in the previous quarter training to improve food safety in Tharaka-Nithi County. Some of the proposed activities have been included in the year 5 work plan. Some of the benefits realized by the program after commencing use of the SCALE+ Methodology in its programming including: • Encouraging collective actions in all operations in the county engaging the departments of Health, Education, Agriculture and Social Services. • Increase in the number of people reached by various interventions • The County started taking up some of the program success factors of the implemented projects and implementing them with own funds, fostering sustainability • Improved program engagement and collaborations with other implementing organizations in the county with partners now cost sharing activity budgets and committed to coordination actions agreed upon jointly during planning.

46 FY 18 Q4 July – September Quarterly Report

• County Officers trained on SCALE+ Methodology have started encouraging the involvement of all relevant stakeholders in the County planning and response activities across all departments.

Outcomes/adoption

The County started taking up some of the program success factors of the implemented projects and implementing them with own funds fostering sustainability

In the coming quarter the program will start the implementation of a selection of the proposed post-SCALE+/WSR action plans.

Kitui SCALE+ In Kitui during the quarter the program supported SCALE+ Workshop. The exercise brought together 51 (33M,18F) participants drawn from Kitui county ministries of MOALF, MOH, National Drought Management Authority (NDMA), World Food Program, Research Triangle Institute (RTI) International, Afya Pwani, Afya Halisi, Afya Uzazi, Afya Jijini, Caritas-Kitui, Christian Aid -OVC, Life skills Promoters, ILRI-AVCD, cereals/legumes aggregators & transporter and CBOs (MAVO, Athi Horticulture farmers and Kenze Farmers) (see Table13). Through the SCALE+ WSR the participants agreed that stunting in under-five children in Kitui county is the major problem which calls for multi sectoral approaches to address. The action plans by Agriculture sector are complete and submitted for screening and possible support by the program and other partners. The Health Team and Implementing Partners are yet to be submitted their work plans.

Table 13: Distribution of SCALE+ Workshop Participants by Organization and Gender

ORGANIZATION Female Male Total AFYA HALISI 2 0 2 AFYA JIJINI 0 1 1 AFYA PWANI 1 0 1 AGGREGATORS/FARMERS 0 4 4 ASDSP 0 1 1 CARITAS KITUI 0 1 1 CHRISTIAN AID CASE OVC 1 0 1 CONSULTANT UNIVERSITY 0 1 1 AVCD 1 0 1 KYES 0 1 1 LIFESKILLS PROMOTION 1 0 1 RTI 0 1 1 WFP 0 1 1 NHPPLUS STAFF 1 4 5 NHPplus Food and Nutrition Security Apprentices 5 4 9 NDMA 0 2 2 MOALF 2 7 9

47 FY 18 Q4 July – September Quarterly Report

MOH 4 5 9 TOTAL 17 34 51

Kenya Agriculture and Livestock Research Organization (KALRO) collaboration Busia: The program continued collaborating with KALRO-Bioversity project to promote production and consumption of gooseberries. The program supported the spread of technology to its group members through facilitating program implementing team to provide technical support in establishment of the crop. At least 43 households from 12 program group members have taken up the technology. The program intends to spread this to the ECDE centers in the next quarter and to more households during the rain season by providing transport for seedlings from KALRO to households.

Outcomes/adoption Program groups and members have accessed fruit seedlings for gooseberries, jackfruit and guavas though the collaboration.

Adoption of gooseberries

Private sector partnership NHPplus continued to work with Tharaka Green Gold, a local CBO in Tharaka Nithi county. The CBO has proved to be a formidable platform for promoting various technologies aimed at improving food and nutrition security. The strategy is quite sustainable once the lead farmers are trained on any technology, they voluntarily spread it to other community members within their groups. This formula has been used to reach other households at minimal cost bridging the gap left by few government extension systems. Currently there are efforts to promote production of vertical bag gardens by the CBO to as many households as possible.

Outcomes/adoption NHPplus/Tharaka Green Gold partnership efforts have attracted a second local CBO - Rural Initiatives Development Program (RIDEP) in Tharaka Nithi procured the shade net and approached the group for the technical support in making the program initiated vertical bags and has done 60 bags for the CBO @ Ksh. 200 per bag making Ksh 12,000. The bags were then distributed48 to the local farmers for FY establishment18 Q4 July – Septemberof vertical bagQuarterly gardens. Report

Linkages with Vocational Centers to promote cottage industry To expose communities to income generating opportunities and diversified livelihoods, the County Department of Agriculture linked Tharaka Green Gold CBO with the Kenya Forestry Research Institute (KEFRI). During the reporting period, the Institute’s Director visited the CBO and expressed interest in working with the group in research and promotion of the group’s Non- Wood products with a special interest on Tamarind and Baobab products.

USAID investments in programs aimed at improving food security and nutrition are strengthened and coordinated

Home gardening/dietary diversity demonstration gardens During the quarter the program continued supporting maintenance of dietary diversity demonstration gardens and kitchens gardens through facilitating the MOALFI technical officers to reach out to groups and households to provide technical support. The officers disseminate through demonstrations skills on how to grow various nutrient dense value chains, climate change adaptation practices like water harvesting, vertical bag gardens, zai pits, sunken beds among other interventions. These interventions specifically aim at imparting skills of improving access to diversified diets through improved production of both crops and livestock value chains. A total of 2,699 households benefitted represented through 2,137F, 562M.

Nasuma Demo garden in Busia

In Marsbit County, training and demonstration on vegetable and fruit production, vegetable preservation and value addition technologies and crop varieties tolerant to weather variations, diseases and pests was conducted. The program supported the establishment of two dietary diversity demonstration gardens in Golole (Uran ward) and at Kinisa (Heilu/Manyatta ward). Among the main objectives was to set up a demonstration garden as a learning platform for access to diversified foods in addition to passing production technologies for diversified food to the pastoral communities for onward scale up at the household level. In focus were vegetables (kales, spinach), staples (maize, beans and cowpeas) and newly introduced ground nuts. Vertical bag garden technology was also promoted. For the livestock sector, pasture production was promoted, and the group harvested 10kgs of seed. 49 FY 18 Q4 July – September Quarterly Report

Key challenges experienced in Marsabit were;  Lack of proper fencing for the demonstration plots exposing them to livestock destruction.  Very high temperatures compounded with water scarcity at the household level hence need to promote shade nets technology  Pest infestation to be sorted through imparting skills on environmentally friendly Integrated Pest Management (IPM) approach that limits use of chemical products and promotes biological controls to control crop pests and diseases.  Inadequate water storage facilities at Golole and Kinisa where demonstration is taking place.  The Moyale-Ethiopia border clashes had a negative impact on agri-nutrition activities with the frontline service providers focusing most of their efforts in monitoring groups and giving them support in promotion of already disseminated packages. The clashes resulted in missed training and monitoring opportunities for the community as the officers could not access the region to provide technical backstopping.

Through the existing 35 groups (29 in Moyale and 6 in Loiyangalani), a total of 530 households benefitted with 804 children out of which 354 were children under the age of two.

In Loiyangalani Marsabit the program is currently integrating BFCI implemenation with agri- nutrition for six (6) MtMSGs. CHVs are the facilitators for both nutrition specific and sensitive interventions due to low coverage of the frontline extension workers. During the quarter follow up on uptake of technologies was done focusing on; ➢ Production of early maturing and drought resistant crops and vegetables (cowpeas and amaranthus) was noted to be doing well in the harsh environment ➢ Demonstrating the brick cooler technology for preserving vegetables and fruits at one of the CHVs who is one of the agri-nutrition champion mothers. ➢ Promotion of Neem tree at the bare ground of Elmolo bay as part of agro-forestry ➢ Establishment of 6 community kitchen gardens where small scale production of spinach, kales, cow peas and arrow root is being demonstrated to the pastoral community.

Outcomes/adoption

• The group members have taken up the idea of kitchen garden where kales,

spinach and tomatoes are planted. Even in areas where vertical bags dried up due to the lack of water, it was noted that use of kitchen gardens is doing well despite the harsh weather. • Poultry production at the household level is being embraced with around 5 groups initiating the activities during this reporting period. • The frontline service providers linked 4 groups in Moyale to Concern Woldwide where they benefited from pasture seeds. • One group in Golbo ward were trained on yoghurt making as an income generating activities. They made and sold some yoghurt though for a short perod as animals gets away from the villages in search for pasture • Most groups have merry go round as a way of raising funds for home use.

50 FY 18 Q4 July – September Quarterly Report

Busia In Busia county a variety of technologies contextualized per ward were disseminated with considerable evidence of adoption of previously disseminated technologies with desirable outcomes. The interventions were kitchen gardening technologies like vertical bags, sunken beds, raised beds, zai pits and compost making, aflatoxin management for better health and wealth. Other areas covered include, DTCs, early land preparation, enterprise choice for adaptation to the changing climate and agribusiness, water harvesting, conservation agriculture, protection of river banks, acquisition of financing for agricultural production, agroforestry, legislation on tree cover on farms, nutritional value of indigenous fruit trees e.g. tree tomato, loquats, guavas, jackfruit (fennesi) and issuance of indigenous fruit tree seedling. In livestock mostly were local poultry production and vaccination and rabbit rearing. The activities were conducted in the focus zones of Samia and Teso North sub-counties mostly through lead mothers, benefitting 1,138 households represented by (1,065F, 73M), 3,724 children under 5 years and 725 pregnant mothers.

Outcomes/adoption Adoption of the home gardening technologies to improve access to diversified foods has been excellent in Busia with nearly 80% of group members practicing at least a technology. Most prominent are the planting of fruit trees, making of zai pits, sunken beds, chicken rearing and rabbit keeping.

Christine Mande in her spinach and Groundnut in members farm pumpkin leaves farm

51 FY 18 Q4 July – September Quarterly Report

A member’s nursery bed Leonard Ochwada with the wife and their local chicken

Integration of different vegetables in vertical bag Adoption of sunken beds

Tharaka Nithi In Tharaka Nithi the program continued to promote technologies to improve access to nutritious foods through champion mothers’ door to door dissemination to the households. The messages centered on encouraging the beneficiaries to engage in vegetables farming to boost food and nutrition security. The technology promoted was the vertical bag gardens for year-round access to vegetables.

Outcomes/adoption After the successful promotion and adoption of vertical bag garden technology among the 61 Community Support Groups in Tharaka-North and Tharaka-South Sub-Counties, one group has managed to design their own type of the vertical bags with technical support from NHPplus. The group has procured a sewing machine from their group savings a product of IGA trainings and is now stitching the vertical bags and selling them to the community. A local CBO - Rural Initiatives Development Programme (RIDEP) procured the shade net and approached the group for the technical support in making the bags and has done 60 bags for the CBO @ Ksh. 200 per bag making Ksh 12,000. The bags were then distributed to the local farmers for establishment. The technology is fast spreading within the community spearheaded by the groups. One community support group has set up the vertical bag gardens in a church, health facility and a school compound to provide vegetables and disseminate the technology and educate community on nutrition.

52 FY 18 Q4 July – September Quarterly Report

Outcomes/adoption Promoting the egg value chain for increased egg consumption among the under- fives in the program zones of influence (ZOI) In Tharaka Nithi to promote utilization of animal protein for children and women at household levels, community support groups in the program ZOIs expanded their poultry value chain to enhance egg and meat production for use in their households. The groups distributed 57 chicks of the improved indigenous chicken to 19 additional group members with each member receiving 3 chicks. The improved indigenous chicken can survive under Kituiharsh weather conditions, withstands feed fluctuation and are hardy. The enterprise will In Kituinot only to improve ensure an access extra to income diversified for the foods members, emphasis but alsowas improveplaced on the water nutrition saving status technologies of throughthe children promotion in their of verticalhouseholds. bag gardens,Poultry productssunken beds, (eggs use and of meat) shade have nets been to grow identified fast growing as highthe value best vegetables source ofand cheap fruits for and household quality protein consumption especi allyand income for those, and suffering demonstrations from on malnutrition. establishment of kitchen gardens. Demonstrations were done either at beneficiary household, church compound or ECDE centers. The youth in Mutomo technical training center after, training by the program continued, to produce vertical bags and selling to the local community at a sub subsidized price

During the period the program supported training of frontline agriculture officers and leaders of CBOs on wet milling technology. The participants were taken through importance of agribusiness in addressing food and nutrition security, wet milling disc machine operation procedure, good mechanical practices, food handling, safety and hygiene, social groups dynamics and how wet milling technology can be utilized in processing of complementary foods at household. The operators of wet milling machines were trained on food handling safety measures. The team then reached out to the community to promote adoption and utilization of wet milling technology in production of complementary foods at Kaliku, Waita and Mathima areas. The technologies benefitted 2,029 households represented by (1,875F, 154M), 1,242 children under 5 years and 326 pregnant mothers.

Samburu In Samburu the agri-nutrition contextualized package to improve food and nutrition security covered various nutrition sensitive interventions. Among the technologies promoted was DTC ground nuts. One farmer from Samburu North, Tuum managed to harvest about 5 kgs from his small irrigated farm after planting about ½ kgs. of seed. He roasted, repackaged the ground nut and sold to his neighbors and some consumed at his household. Post-harvest sensitization was conducted in 20 villages in Samburu Central benefitting 607 people (219F, 388M)

Cooking/Food Preparation demonstrations To improve consumption of nutrient dense foods demonstrations on different recipes were prepared for different counties targeting mostly complementary foods for children over 6 months. Nutritious locally available diversified foods were used during the activities, some done during Malezi Bora period. Emphasis was on enriching baby foods especially with vegetables and animal source foods as food mapping and household surveys recently conducted by the program revealed this as a glaring gap contributing significantly to child malnutrition and stunting. The reference manual used was the Kenya Recipe Booklet printed by the program. Table 14 the cooking/food preparation activities in the counties 53 FY 18 Q4 July – September Quarterly Report

Table14: Cooking/Food preparation activities in the counties and specific recipes County Objective Recipe Description Samburu Giving the mothers and care givers Method knowledge and skills on, preparation of Boiling, mashing, fortification, blending recommended supplementary and and stewing complementary diets for children above six Recipe months and below 5years of age to get the Mashed potatoes/ugali/bananas/ required dietary nutrients in hygienic pumpkins meals, vegetables and animal condition and diets for women of source supplements from eggs reproductive age Busia Preparation of complementary foods for Method and recipe children above 6 months and women of Food groups, peanut enrichment, peanut reproductive age powder preparation, pumpkin drying, egg yolk enrichment preparation, dried meat powder enrichment preparation Kitui Preparation of complementary food from Enrichment of baby foods with vegetables diversified foods and utilization of drought and animal source foods resistant crops in preparation of delicious Green grams samosa and millet/sorghum family meals cakes Tharaka Promoting consumption of diverse and Mixed green vegetable flour, pumpkin Nithi nutritious food for improved health and flour, sweet potato flour, baobab fruit nutrition flour, peanut flour Encouraging change in the knowledge and practices regarding dietary habits among the communities.

WASH Activities Water Sanitation and Hygiene are a key appendage of nutrition education if the gains for nutrition are to be realized. Improving nutrition requires far more than improving the quality and quantity of food. We must also break the cycles of environmental contamination and disease that stem from dirty water, inadequate sanitation, and poor hygiene. During the quarter WASH activities were conducted across all counties to complement food and nutrition security and income generation interventions for improved nutrition. WASH had the highest number of beneficiaries at 14,014 households represented by 8,158F, 5846M with Tharaka Nithi carrying the bulk over 9,000 households.

Tharaka Nithi To increase the awareness about the importance of handwashing with soap as an easy, effective and affordable way to prevent diseases and save lives, the Public Health officers conducted demonstrations on handwashing to school-going children during the ECDE Vitamin A Supplementation. The PHOs encouraged the pupils to make handwashing a part of every meal in the efforts to eliminate all preventable diseases through embracing the recommendations.

Marsabit The beneficiaries of the agri-nutrition messages also benefitted from other packages including importance of exclusive breastfeeding, antenatal care and skilled deliveries, IMAM services available and WASH i.e. Water treatment, hand washing, safe water storage, food handling and hygiene.

54 FY 18 Q4 July – September Quarterly Report

Samburu The diarrhea indicators for the month of August 2018 for Samburu East showed slight increases in the number of cases compared to the month of July 2018. The data set report from DHIS (MOH 705 A <5) showed that the facilities reporting a high number of diarrhea cases for outpatient under 5 year’s attendance were: • Wamba Health Centre- 77 • Lodungokwe Health Centre-20 • Ngilai Dispensary -19 • Laresoro Dispensary-15

Because of the increase of diarrhoea cases, mothers from the four facilities and children from near schools were sensitized through program support on the personal hygiene, food, environmental, water treatment and safe waste disposal. Water treatment demonstration was done, and pupils were tasked to write compositions entitled “HYGIENE”. Other beneficiaries were mothers in 16 MtMSGs

Busia and Kitui In Busia and Kitui the WASH messages that basically touched on hand washing at critical times and handling of feces in the compound where children interact with the environment were disseminated alongside contextualized high impact agri-nutrition packages for these counties.

Public Health Officer Demonstrates Handwashing to ECDE Pupils at Twathanju Primary School in Tharaka-North during the Malezi Bora Weeks.

3.2 Increased Resilience of Vulnerable Households and Communities

The program has continued to support a community driven development approach to enhance social, economic, and environmental resilience, through effectively linking vulnerable clients with food security, livelihood and economic support initiatives relevant to local contexts. It also builds capacity for communities to increase resilience through trainings and other resilience supporting initiatives. Capacity building human resource at the counties for effective service delivery was a key ingredient towards attaining these goals, addressing a key required outcome in enhanced human capacity for increased agriculture sector productivity. Against this background, during the quarter the program in collaboration with MOALFI distributed 879 copies of the National Agri- 55 FY 18 Q4 July – September Quarterly Report

Nutrition Resource Manual with the ministry conducting sensitization. Resilience building initiatives like income generating activities and financial inclusion as well as capacity building communities on adoption of climate change technologies alongside screening for malnutrition as part of early warning surveillance were undertaken.

Strengthening community-based early warning surveillance of nutrition, linked to animal health and other trigger indicators PREG - Building resilience through partnerships The program during the period participated in activities organized by PREG leadership to strengthen coordination and linkages among USAID and other partners in resilience building and food and nutrition security platform. In the counties the program continued as chair and deputy chair of Marsabit and Samburu counties PREG committees respectively. The PREG brings together humanitarian and development partners to build resilience among vulnerable pastoralist communities in northern Kenya. It includes both USAID programs and implementing partners. USAID PREG works with the Kenya National Drought Management Authority (NDMA) and county governments to coordinate resilience and economic growth activities.

Community Screening for Malnutrition and Referrals to the Health facilities In Samburu during cooking demonstration session in South-Horr, mothers present were screened using mid-upper arm circumference (MUAC) and those identified as malnourished were referred to South Horr Health centre for management. A total of 26 mothers were screened and their results are shown in Table 15.

Table 15: Nutrition status of pregnant and lactating women screened in South-Horr Number of pregnant women and lactating mothers screened using (MUAC) TOTAL Pregnant women MUAC (Red) indicating severe malnutrition referred for treatment 6 Pregnant women MUAC (yellow) indicating moderate malnutrition referred for 3 treatment Pregnant women with MUAC (green) indicating normal nutrition status 2 Lactating mothers MUAC (red) indicating severe malnutrition referred for treatment 6 Lactating mothers MUAC (yellow) indicating moderate malnutrition referred for 4 treatment Lactating mothers with MUAC (green) indicating normal nutrition status 5 Total 26

Climate change adaptation Busia In the wake of climate change the program continued its efforts towards sensitizing communities on practices that can mitigate climate change impacts on agriculture productivity. In Busia county climate smart agriculture trainings were conducted to 154 (95F, 59M) members and 24 pregnant mothers of 5 groups Bujibu, Serekeresi, Nasura, Wakhungu and Dirakho in Samia sub-county a relatively ASAL sub-county of Busia. Indirect beneficiaries were 29 (14F, 15M) children under 24 months and 109 (56F, 54M) children 24-59 months. The training covered the 3 pillars of climate smart agriculture i.e. productivity, adaptation and mitigation through open discussions and sharing of experiences

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Documentation of farmer indigenous traditional knowledge (ITK) The community participatorily discussed the desirable indigenous knowledge and practices that contribute to food stability. In the discussions were drought tolerant crops, early land preparation, enterprise choice for adaptation to the changing climate and agribusiness, water harvesting, conservation agriculture, protection of river banks, acquisition of financing for agricultural production, agroforestry, legislation on tree cover on farms, nutritional value of indigenous fruit trees e.g. tree tomato, loquats, guavas, fennesi (jack fruit). After the training participants were issued with indigenous fruit tree seedlings.

Reduced number of households with moderate or severe hunger

Promotion of Drought Tolerant Crops (DTCs) To mitigate against climate change, the program continued to promote adoption of DTCs for food security in all counties. Focus value chains include sorghum, millet, green grams, cowpeas, cassava which is in line with the big four national agenda. This advocacy has led to significant behavior change by farmers to take up these value chains in place of the ever-failing maize crop. To complete the cycle the community groups are taken through appropriate food preparation technologies on different recipes to promote consumption of the DTCs as evident from food mapping and household monitoring surveys.

Solar Drying In Tharaka Nithi county the local CBO is aggressively promoting solar drying as part of resilience building efforts for food security. This technology ensures food is available in dry form during lean periods.

Chicken production Chicken are an easy enterprise to keep. It guarantees ready animal source foods for nutrition as well as income from meat and eggs. The program is promoting the value chain in all the counties.

Tharaka Green Gold CBO Coordinator The CBO Coordinator shows the group’s working in the group’s Solar Drier improved local chicken breeds

Marsabit Introduction of Neem trees and Mangrove at Elmolo in Loiyangalani.

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Loiyangalani is a remote, dry, isolated, ASAL region at the shores of Lake Turkana with poor connecting infrastructure making access to any type of food materials difficult.

Neem Efforts to improve the environment and productivity of the ecosystem in Loiyangalani Marsabit continued following the planting of 300 seedlings of Neem trees at Elmolo village. However, around 30% survived and flourishing despite the care from the households. This is attributed to highly saline water and soil. However, the surviving trees are doing well which is expected to change the bare and dry environment in a near future.

Neem trees progressing well in Elmolo Loiyangalani

Mangrove (Ref. KWS, 1996) On the same efforts during the quarter, towards transforming the bare unproductive ecosystem in Loiyangalani the program introduced some mangroves at the two El-molo villages which is situated right on the shore of Lake Turkana. The mangrove ecosystem provides socio-economic, ecological, environmental, cultural, scientific and educational value to the people in varying degrees. Direct and indirect products from the mangroves form the basis of mangrove-dependent economic activities. While the ecosystem' is valued for the extractable resources it supports, it also provides ecological values and non-consumptive services. Mangroves in Kenya are found in Coast along the sea shores and are of 9 species growing up to medium height and shrubs and grow in saline habitats. The plant takes 10-15 years to reach maturity. Heights vary from 1-27m with average at 5.8m. With their roots submerged in water, they thrive in hot, muddy and salty conditions. The beneficial effects of mangroves include; • food, resting, breeding and nursery grounds for fish. • environmental protection- act as wind breakers which reduces the force of winds, lowering the chances of property getting destroyed during the wind storms. • protects soil from erosion. 58 FY 18 Q4 July – September Quarterly Report

• provide medicinal herbs, timber, fuel and building materials in future • Shade providing conducive grounds for fish processing

Outcome/results

Mangrove at planting and current state

Brick Cooler technology at Loiyangalani The program has been trying innovations that will improve access to diversified diets especially hard to reach isolated remote areas. One place is Loiyangalani which houses the Elmolo. Much of the fruits and vegetables that reach the place lose nutrients due to the extreme temperatures compounded by lack of proper storage facilities. While refrigerated cool stores are the best method of preserving fruits and vegetables, they are expensive to buy and run. Being a rural set up which is poorly developed, there is a lot of interest in simple low-cost alternatives, which depend on evaporative cooling which is simple and does not require any external power. The basic principle relies on cooling by evaporation. When water evaporates it draws energy from its surroundings which produces a considerable cooling effect. Evaporative cooling occurs when air, that is not too humid, passes over a wet surface; the faster the rate of evaporation the greater the cooling. The efficiency of an evaporative cooler depends on the humidity of the surrounding air. Very dry air can absorb a lot of moisture so greater cooling occurs. A simple brick cooler was constructed through support of the program on trial basis at one of the CHVs homestead using locally available materials.

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The group members at the cooler

Outcome/results The champion CHVs reported that the technology is working whereby they are storing vegetables like kales, tomatoes, pepper, cabbage and even drinking water. It was reported that the vegetables can stay fresh for around 4 days which was not the case in the past. The brick cooler is also utilized during community celebrations like ordination of a priest where the church members also get an opportunity to appreciate the technology. The group members are benefitting from the pilot. The technology will now be promoted within the community improving access to fresh vegetables and fruits. The fresh vegetables reach the place only 2 or 3 times in week hence the importance of the technology. Already there is demand for the same facility from another group.

Improving food production through demonstration of appropriate technologies During the program supported the establishment of two dietary diversity demonstration gardens i.e. one in Golole (Uran ward) and the second one at Kinisa (Heilu/Manyatta ward). The main objective was to use them as technology learning platform for improving access to diversified foods. in addition to passing production technologies for diversified food to communities for onward scale up at the household level. Technologies disseminated include vegetables, maize, beans, cowpeas, ground nuts, pawpaw and mango production. Pasture production and preparation of appropriate pasture seed was demonstrated on the gardens.

Enhancing Human Capacity for Increased Agriculture Sector Productivity

Staff Support for Senior Management Training

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To improve technical and managerial knowledge and skills of the extension staff during the quarter the program supported 5 county officers from the MOALFI for Senior Management Courses at the Kenya School of Government (Table 16)

Table 16: Distribution of Trainees by County County School Number Kitui Mombasa KSG 2 Busia Baringo KSG 1 Marsabit Embu KSG 2 Total 5

Economic Empowerment/Financial Inclusion Training to Community Kitui County In Kitui County, Woni women group is an Agri-Nutrition mother to mother support group in Ndandini, Athi ward in Kitui South consisting of 30 members that was formed in February 2017. The mothers gained knowledge on the type of foods to consume, exclusive breastfeeding, complimentary feeding, preservation of vegetables, integrated water, sanitation and hygiene (WASH) and planting of drought resistant crops (DTCs) such as millet and green grams. These production technologies are coupled with appropriate food preparation technologies for maximum nutrient bio-availability for the children and target groups. The mothers have been taught ways of incorporating income generating activities (IGAs) in their groups that will help them in ensuring they provide the best care for their children. IGAs are crucial resilience building component in the nutrition system safeguarding against shocks and bridging dietary diversity gaps through nutrient dense food purchases.

Outcome/results

This group in particular is outstanding in their use of table banking (a Grameen bank model) where they saved as little as 20 Kenya shillings from February to July 2017 and in December they would give their families a Christmas treat. In 2018, the mother’s increased their contributions with the agenda that each member of the group had to own a goat to ensure increased supply of milk in their homes for their children and by July they had set aside ninety-six thousand shillings with which they used to buy goats depending on the member shares earned.

In 2019, the group's agenda is buying each a water tank to help in water harvesting during the rainy seasons for use during the dry season

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Woni Women Group Members keenly follows discussions on how to keep records for group Income Generating Activities & members in the Goat for every Member parade in Ikutha Ward Kitui South Sub County, Kitui County

Tharaka Nithi Economic empowerment is a critical input in resilience building. During the period community groups in Igambang’ombe sub-county were sensitized on financial inclusion for economic empowerment and resilience building. The outcome was to increase resilience of the communities to cope with any emerging shocks through cushioning by the savings and alternative income sources for improved purchasing power of food and non-food products. During the training, labor-saving technologies in agriculture e.g. vertical bag farming which can help reduce women’s workload and thus increase the time available for child care significantly contributing to improved nutrition were also promoted. 25 members all women benefitted and indirectly 57 children under 5 years.

Promotion of Cottage Industry Through Linkages with Vocational Centers. To expose communities to income generating opportunities and diversified livelihoods, the County Department of Agriculture linked Tharaka Green Gold Community Support Group (CBO) with the Kenya Forestry Research Institute (KEFRI). During the reporting period, the Institute’s Director visited the CBO and expressed interest in working with the group in research and promotion of the group’s Non-Wood products with a special interest on Tamarind and Baobab products. The CBO has produced various food products with the local trees e.g. Baobab – Juice, Jam and Powder for Smoothies, Tamarind – Juice and Jam. The group also uses Tamarind as a preservative for meat and sweetener for infant’s porridge. The popularity of baobab fruit and its constituent powder has grown in recent years, due to the high concentrations of nutrients and minerals that it contains. Tamarind trees are spread to almost all areas of Tharaka-South and Tharaka-North Sub-Counties and a useful and desirable source of nutrition in the area, but the communities are not aware of the tree health and nutritional benefits. The promotion of these local fruits will improve dietary diversity, improve community income and reduce nutrient gaps among pregnant and lactating women and children 6–23 months of age.

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Demonstrating how to prepare Baobab fruit juice during the community support groups training.

Samburu In Samburu county 38 mothers in South Horr, 36 in Nachola and 30 in Marti were taken through intensive Financial Inclusion and Income Generating Activity training. Covered was importance and benefits of carrying out IGAs, how to identify the locally available resources and the cost of other materials requisite for starting the various IGAs, challenges they are likely to encounter and their solutions and identification of the products and services market they want to pursue and their profit margin.

Busia In Busia 684 mothers from mother to mother support groups in Samia and Teso Nortth sub counties benefitted from IGA trainings. The message was disseminated to neighboring households by champion mothers.

Leonard Ochwada IGA chick rearing unit Farmers OFSP IGA plot

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John Omira’s IGA apiary Member’s IGA rabbitry unit

Outcome/Adoption Case Studies

Outcome/results The messages have since made significant difference in the income levels of the groups and individual group members. The beneficiaries have uptaken IGAs on different value chains and services starting small and growing by day. The findings are summarized in the table below.

Table 17 Outcomes and impact of different technologies and IGA trainings in Busia county Group Outcome of IGA trainings and other integrated technologies Dhirakho SHG • established a diet diversity garden on raised beds and on other kitchen gardening technologies • all members have replicated the technologies in their households • have merry go round, bee keeping, solar project, school fees fund for needy members and tissue culture bananas project as IGAs Namasango SHG • one of the members has embraced vegetable growing as an IGA and has now earned 12,000/= and 15,000/= from sale of local chicken and depends on them for livelihoods • Salome Ouma has started container garden and has 2 vertical bag gardens • 2 members have started groundnut farming as IGA • one member started buying and selling vegetables as an IGA from those who are producing and selling to the market making a profit of at least 500 /= per sale • 8 members have an average of 20 chicken per household and have started utilizing the eggs for children diets Miti Mingi SHG • members have tree seedlings project as an income generating activity (IGA) • group has table banking and has reached 8000/= savings pool

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Group Outcome of IGA trainings and other integrated technologies • group has 60 chairs for hiring during social events as IGA • members have started keeping chicken to utilize local eggs and sell for money with 100 birds between them • members have 12 pigs and 2 rabbits as an IGA Luchululo CU • one member selling vegetables and another local chicken as an IGA Group • 9 members have replicated kitchen garden technologies in their households • group has established a chick rearing unit and Leonard Ochwada has successfully reared 50 chicks and sold them at 100/= making a total of 5000/= and 2 pigs at 7000/= as IGAs • group members have started vaccinating their chicken after trainings • group has installed at least 200 leaky tins in the community and members are using them for WASH • Davis Wafula has started keeping pigs and has so far sold 2 cross bred pigs for 27000/= as IGA Tazama Bujibo • group has established a dietary diversity garden showcasing different CBO technologies i.e. zai pits, sunken beds, raised beds as well as drip irrigation • group has table banking and now has 76,000/= savings pool to loan members • group has one tent and its hired out at 2500/= per day, they also offer outside catering services to the community as IGA • one member (John Omira) makes hives for sale at 4000/= per improved hive and has also bought vertical bag as a replicate as IGA • 8 members have replicated the water harvesting technologies zai pits and sunken beds Nasuma Vision • established 2 vertical bags and a kitchen garden showcasing different SHG technologies • all members have a variety of underutilized fruits like goose berries, jackfruits, guavas for improving nutrition • 7 members have replicated the kitchen garden technologies in their households’ especially sunken beds, zai pits and vertical bags • members have merry go round and table banking Madete Kabiri SHG • have established a diet diversity garden showcasing different technologies i.e. zai pits, sunken beds, raised beds, vertical bags, tyre garden etc. • group has a chick rearing unit for raising chicks and one member has replicated it • 8 members have replicated one or two kitchen garden technologies in their households • group has merry go round • group has a dairy cow and got 120,000/= from the sale of milk as IGA • members harvested 80 kgs of unshelled groundnuts in their bulking plot and distributed to members to plant • one member planted orange fleshed sweet potatoes is now making money from the vines and the potatoes already sold 5000/= as IGA Mudoma Mother to • one member selling vegetables and another local chicken as an IGAs Mother SG • 5 members have replicated 2 or more kitchen garden technologies

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Group Outcome of IGA trainings and other integrated technologies • members have started several IGAs like selling omena, eggs etc • all members have started local poultry project for nutrition and IGA Budalanga CU • one member has sold chicken worth 10,000/=and has ready market orders group with Ambiance Hotel in Bumala also has 2 pigs as IGA • 3 members have replicated the kitchen garden technologies in their households • group has merry go round • group has established a diet diversity garden showcasing different technologies i.e. vertical bags, e.t.c;

The National Agri-Nutrition Resource Manual During the quarter the program in collaboration with FAO and MOALFI distributed the 879 copies of the National Agri-Nutrition Resource Manual to all the 47 counties during the regional county sensitization workshops on Food Composition Tables and the Recipe Books. The latter two were printed by NHP. Sensitization meetings were carried out during the dissemination. The distribution was as in Table 18.

Outcome/results A questionnaire has since been circulated to 11 IPs to provide feed back on how

beneficial the manual has been. So far six have responded with 5 saying the manual has been very useful to their program enriching the knowledge base of the field implementers and using the technologies therein in their day to day community activities. One partner has actually used it to support the MOALFI to develop the Agri-nutrition dialogue cards.

Table 18: Regional Sensitization on Food Composition Tables, Recipe Book and Agri Nutrition Resource ManualA questionnaire has since been circulated to 11 IPs to provide feed back on how CLUSTERbeneficial the manuCOUNTIESal has been. So far six have responded with 5 sayingVENUES the manual has 1. been21 Counties very useful to1. theirMakueni program enriching12. the Vihiga knowledge base of theTown: field implementers and2. using Kwale the technologies therein13. Machakos in their day to day communityNAKURU activities. One partner3. Kilifi has actual ly used it to14. support Bomet the MOALFI to develop the Agri- nutrition dialogue 4.cards. Kitui 15. Laikipia 5. Kisumu 16. Nakuru 6. Homabay 17. Nandi 7. Migori 18. Trans Nzoia 8. Nyamira 19. Kericho 9. Busia 20. Uasin Gishu 10. Kakamega 21. Narok 11. Bungoma

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2. 26 Counties 1. Nairobi 14. Siaya Town: 2. Kajiado 15. Kisii MACHAKOS 3. Mandera 16. Elgeyo Marakwet

4. Wajir 17. West Pokot 5. Garissa 18. Baringo 6. Turkana 19. Nyandarua 7. Muranga 20. Isiolo 8. Kiambu 21. Marsabit 9. Meru 22. Samburu 10. Embu 23. Nyeri 11. Tharaka Nithi 24. Kirinyaga 12. Taita Taveta 25. Tana River 13. Mombasa 26. Lamu

4 Monitoring and Evaluation

4.1 Facility Reporting

During the quarter a total of 529 of the designated delivery points submitted service and commodity data to the program for archiving, quality control, reporting support and quantification and rationalization of commodity supplies, accounting for 96.5% reporting rate (n=548). On average, supported facilities submitted their data 1.67 days after the agreed deadline with a minimum of -10 and maximum of 16 days after the deadline.

The program supported nutrition assessments for a total of 223,628 clients, against a quarterly target of 96,238. In comparison to the preceding quarter, the decrease in assessed patients represented by 9.2%. The program also supported a total of 39,399 malnourished client with nutrition commodities, against a quarterly target of 36,065 clients, during the reporting period. A summary of client assessments and commodity interventions are shown in Tables 19 and 20.

Table 19: Summary of Total Number of Patients Assessed

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Reporting Yearly October- January- July- Total April-June Year Target December March September Achievement 2014-2015 196,800 34,695 45,002 33,306 40,466 153,469 2015-2016 140,122 83,292 103,783 108,281 39,104 334,460 2016-2017 350,000 88,254 118,249 188,221 146,757 541,481 2017-2018 385,000 201,603 226,246 215,352 246,379 889,580 2018-2019 385,000 223,628 223,628 Total 1,456,922 631,472 493,280 545,160 472,706 2,142,618

Table 20: Summary of Total Number of Patients Provided with Commodities Reporting Yearly October- January- July- Total April-June Year Target December March September Achievement 2014-2015 120,000 10,666 8,290 8,962 11,928 39,846 2015-2016 99,885 18,316 26,882 30,361 32,908 108,467 2016-2017 109,874 24,089 24,773 34,538 25,968 109,368 2017-2018 144,278 37,812 36,456 42,647 47,046 163,961 2018-2019 144,278 39,399 39,399 Total 474,037 90,883 96,401 116,508 117,850 421,642

4.2 Supportive supervisions During the quarter, supportive supervision of 9 facilities in two focus counties (Busia and Kitui) was done. Based on the exercise the Table 21 summarizes the key highlights and way forward.

Table 21: Key Highlights and Recommended actions from Supportive Supervision of Nine Health Facilities in Busia and Kitui County No. of facilities Findings Actions by NHPplus visited Busia 3 - There is Increased ownership - Noted improved reporting and of the monitoring and data integration into the evaluation process and DHIS. nutrition data at facility level. - Due to other competing - Scale up supportive activities 3 facilities were supervision to more facilities visited. in the coming quarter. Kitui 6 - Documentation and reporting - Facilitate OJT with SCNO on gaps by newly hired MOH NACS data capture and staff reporting (problematic sites). - Most facilities showing good - Continue recommending to response in adoption and use different health teams use and of bin cards although two adoption of DAR Tool as well facilities are not effectively as bin cards in controlling utilizing DAR for nutrition nutrition commodities stock commodities levels.

Scale up supportive supervision to more facilities in all the focus counties will be done in the coming quarter. to ensure that reporting and quality of data dimensions are strengthened

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4.3 Household monitoring During the quarter, analysis of the household monitoring activity of the two focus counties, namely Tharaka Nithi and Busia was done. This was done based on the key elements assessed during the exercise. A total of 1,162 (629 in Busia, 537 in Tharaka Nithi) households were sampled in 7 (4 in Busia and 3 in Tharaka Nithi) sub counties. The key objective of the exercise was to monitor and assess the status of NHPplus interventions at the household level. In addition to the household dietary and women dietary diversity scores which were shared last quarter, the following are some of the results from the exercise.

Proportion of children 6–23 months of age who receive a minimum acceptable diet Based on the analysis done to assess the minimum acceptable diet for children across the four sub counties In Busia county namely; Butula (n=98), Nambale (n= 52), Samia(n=55) and Teso North (n=60). Overall only 32% of children consumed at least 4 food groups in Busia county. 42% of children in Teso North consumed at least 4 food groups, 31% in Nambale, 31% in Samia and 28% in Butula. In Tharaka Nithi county assessment was done across three sub counties namely; Maara (n=93), Tharaka North (n= 51) and Tharaka South (n=65). The results showed that only 30% of children consumed at least 4 food groups in Tharaka Nithi county. 41% of children in Maara consumed at least 4 food groups, 20% in Tharaka North and 23% in Tharaka South

Minimum acceptable diet for Children 100% 90% 80% 77% 80% 72% 69% 69% 68% 70% 70% 58% 59% 60%

50% 42% 41% 40% 31% 31% 32% 28% 30% 30% 23% 20% 20% 10% 0% Butula Nambale Samia Teso North Aggregate Maara Tharaka Tharaka Aggregate North South Busia Tharaka Nithi

<4 food groups >=4 food groups

Figure 2: Distribution of Children less than 24 Months by Diet Quality and Sub-County

Further analysis showed that the food groups mainly consumed by children in the two counties were grains, white roots and tubers and vegetables. however, in Tharaka Nithi county there was a considerable amount consuming legume as compared to Busia county. In Busia county the proportion consuming flesh was high compared to Tharaka Nithi. Eggs were the least consumed food type in both counties.

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Food groups consumed by children

93.6% Grains,roots and tuber 96.7%

27.2% Legumes and nuts 61.7%

44.5% Dairy products 52.6%

64.9% Vitamin A-rich fruits and vegetables 45.9%

20.8% Other fruits and vegetables 32.1%

44.2% Flesh foods 7.2%

6.8% Eggs 5.7%

Busia Tharaka Nithi

Figure 3: Food Group Consumption by Children

Stunting It is worth noting that the assessment results indicated that as compared to the baseline values of KDHS 2014, there has not been significant change in the stunting rates in both counties (Tharaka Nithi and Busia). The values have remained stagnant. In Tharaka Nithi county the prevalence of stunting stood at 25.4% (21.1-30.2, 95% Confidence Interval) while Busia county prevalence rate of stunting stood at 21.1(17.9-24.7, 95% Confidence Interval). This was based on 528 and 631 under five years children from Tharaka Nithi and Busia counties respectively. Thus, there is need for multifaceted approach to address the stunting issue.

Coping strategy 28.0% and 18.4 % of the respondents in Busia and Tharaka Nithi counties respectively reported to have either employed one or more strategy in event of food and/or money shortage. The weighted CSI was 17.6 and 20.9 for Busia and Tharaka Nithi counties respectively with the highest numbers of the households Relying on less preferred and less expensive foods as shown in the Tables 22 and 23.

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Table 22: Household coping strategy index Busia County Strategy Percentage of Frequency Severity Weighted HH (N=625) score (0-7) score (1-3) score=Freq*weight Rely on less preferred and less 25.8% (n= 2.96 2.96 expensive foods 161) 1 Borrow food, or rely on help from a 10.2% 1.75 3.5 friend or relative (n=64) 2 18.9 % 2.39 2.39 Limit portion size at mealtimes (n=118) 1 Restrict consumption by adults in 13.6% 2.08 6.24 order for small children to eat (n= 85) 3 Reduce number of meals eaten in a 17.1% 2.46 2.46 day (n=107) 1 CSI 17.55

Table 23: Household coping strategy index Tharaka Nithi County Percentage of Frequency Severity Weighted Strategy HH (N=526) score (0-7) score (1-3) score=Freq*weight Rely on less preferred and less 16.7% (n= expensive foods 88) 2.97 1 2.97 Borrow food, or rely on help from a friend or relative 10.8% (n=57) 2.37 2 4.74 Limit portion size at mealtimes 12.2% (n=64) 2.97 1 2.97 Restrict consumption by adults inorder for small children to eat 6.5% (n=34) 2.56 3 7.68 Reduce number of meals eaten in a day 10.5% (n=55) 2.49 1 2.49 CSI 20.85

Water 80.3% of households sampled in Busia county obtained their drinking water from improved water sources namely; piped water, borehole, protected spring or protected shallow wells as shown in the figure below, the rest (19.7%) obtained water from unsafe sources. Same pattern was replicated in Tharaka Nithi where 74.3% of households sampled obtained their drinking water from improved water sources namely; piped water, borehole, protected spring or protected shallow wells while the rest (25.7%) obtained water from unsafe sources.

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Source of drinking water

74.3% Piped and protected water system 80.3%

22.2% River or Spring 14.7%

1.9% Unprotected shallow well 3.0%

0.4% Others 1.1%

Earth pan or dam with infiltration well 0.5%

Water trucking or Water vendor 0.6%

0.6% Earth pan or dam 0.3%

Tharaka Nithi Busia

Figure 4: Distribution of households u Source of Drinking Water

Hygiene Assessment results revealed that most caregivers in Busia and Tharaka Nithi counties did not wash hands after taking their children to toilets as shown in the tables below. On average, only 13.7% and 9.5% of caregivers washed their hands in all the four critical handwashing times in Busia and Tharaka Nithi counties respectively. It is encouraging that majority of the caregivers used soap and water in handwashing.

Table 24: Distribution of Care Givers by Hand Washing Practices in Busia Sub County Hygiene Teso Busia Butula Nambale Samia North county (n=191) (n=131) (n=128) (n=158) (n=608) After toilet 75.4% 68.7% 79.7% 92.4% 79.3% Before cooking 48.2% 32.1% 56.3% 68.4% 51.6% Before eating 85.3% 90.1% 90.6% 90.5% 88.8% After taking children to the toilet 11.5% 19.8% 20.3% 39.2% 22.4% Before feeding a child 19.4% 25.2% 25.8% 31.0% 25.0% Hand washing in all 4 critical times 3.7% 7.6% 15.6% 29.1% 13.7% Hand washing by soap and water 90.4% 82.8% 94.2% 84.2% 87.9%

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Table 25: Distribution of Care Givers by Hand Washing Practices in Tharaka Nithi Sub County Hygiene Maara Tharaka Tharaka South Tharaka Nithi (n=257) North (n=97) (n=161) County (n=515) After toilet 84.0% 88.7% 70.8% 80.8% Before cooking 50.6% 55.7% 42.2% 48.9% Before eating 58.8% 50.5% 43.5% 52.4% After taking children to the toilet 24.9% 23.7% 24.8% 24.7% Before feeding a child 22.6% 30.9% 13.0% 21.2% Hand washing in all 4 critical times 8.0% 11.3% 10.7% 9.5% Hand washing by soap and water 78.4% 37.1% 87.5% 73.9%

Sanitation Regarding sanitation the assessment results showed that in Busia county ,1.9 % of the respondents relieved themselves in the bushes (open defecation) while 72.3% of the households own traditional/improved latrine. Same scenario was displayed in Tharaka Nithi county, where 1.7 % of the respondents indicated that they relieve themselves in the bushes (open defecation) while 82.7% of the households own traditional/improved latrine as shown in Table 26;

Table 26: Distribution of Households by Sanitation Practices in Busia and Tharaka Nithi Busia County Tharaka Nithi County Sanitation practice (n=618) (n=525) In the bushes, open defecation 1.90% 1.70% Neighbour or shared traditional pit or improved latrine 25.70% 15.60% Own traditional pit or improved latrine 72.30% 82.70%

Household hunger Score Based on the analysis 15% of the households in Busia county had moderate hunger with 2.4% having severe hunger in the household. Butula sub county had the highest proportion (19.6%) with moderate hunger in the household while Teso North had the lowest proportion (8.0%) with moderate hunger in the household. In Tharaka Nithi county 9.7% of the households had moderate hunger with 1.5% having severe hunger in the household. Maara and Tharaka south sub counties had the highest proportion (11.9% and 10.1% respectively) with moderate hunger in the household while Tharaka North had the lowest proportion (9.7%) with moderate hunger in the household

73 FY 18 Q4 July – September Quarterly Report

Household Hunger Score : Busia County 100.0% 90.7% 90.0% 82.8% 82.6% 77.8% 79.3% 80.0% 70.0% 60.0% 50.0%

Percentage 40.0% 30.0% 19.6% 20.0% 17.0% 14.9% 15.0% 8.0% 10.0% 2.6% 3.7% 2.2% 1.2% 2.4% 0.0% Butula Nambale Samia Teso North Busia County Little to no hunger in the household Moderate hunger in the household Severe hunger in the household

Figure 5: Distribution of Households by Hunger Score in Busia County

Household Hunger Scale: Tharaka Nithi County 100.0% 95.9% 87.7% 88.8% 90.0% 86.3% 80.0% 70.0% 60.0% 50.0%

Percentage 40.0% 30.0% 20.0% 11.9% 10.1% 9.7% 10.0% 3.1% 3.6% 0.4% 1.0% 1.5% 0.0% Maara Tharaka North Tharaka South Tharaka Nithi County

Little to no hunger in the household moderate hunger in the household Severe hunger in the household

Figure 6: Distribution of Households by Hunger Score in Tharaka Nithi County

74 FY 18 Q4 July – September Quarterly Report

III. ACTIVITY PROGRESS – QUANTITATIVE IMPACT

The NHPplus PMEP provides for specific indicators and their targets for which progress by the end of Quarter 1 (October– December 2018) is summarized below. Detailed performance monitoring data is presented in the ANNEX I.

Number of mechanisms created to facilitate coordination on an ongoing basis as a result of USG Assistance at national level: To strengthen coordination and implementation of activities for improved nutrition outcomes, the program supported 10 fora at different levels namely; national, county and sub county levels. In Marsabit County Nutrition Technical Forum (CNTF) and Sub County Nutrition Technical Forum (SCNTF) were supported. In Tharaka Nithi the program attended the stakeholder forum coordinated by the county government where two Sub County Nutrition Technical Forum were formed. The program supported sub county agricultural planning meeting in Busia county in addition to attending County M&E TWG and Commodity TWG. In Kitui the project participated in stakeholders meeting organized by Afya Halisi. At national level the project participated in PREG partners meeting and Agri- Nutrition TWG.

Number of health facilities with established capacity to manage acute under nutrition: The FY19 target for this indicator was set at 160 health facilities. During the quarter the program identified a total of 11 health facilities in Busia county with capacity to manage acute malnutrition using the HINI gap assessment tool. All the eleven facilities were found to have capacity in management of acute malnutrition and as a way forward the program will continue to build their capacities in the areas where gaps identified to ensure that they are able to handle acute malnutrition efficiently.

Number of individuals receiving nutrition-related professional training through USG-supported programs (RAA): During the quarter the program continued investing in skills building both for health care workers and community health volunteers to improve nutrition service delivery and demand creation. A total of 327 (117 M, 210 F) individuals received nutrition related professional training supported by USG. The trainings mainly dwelt on baby friendly initiative with the aim increasing the BFCI coverage.

Number of children under 5 yrs. who received Vitamin A from USG supported programs: During this financial year, the program is expected to support Vitamin A supplementation for a total of 440,389 children under 5 years. During the quarter, a total 351,456 under-fives were reached with Vitamin A supplements.

Number of children under five who are underweight: Overall, the program seeks to support identification of 28,292 under 5’s who are underweight within the focus counties. During the quarter, through program activities such as growth monitoring a total of 13,866 underweight children were identified within the focus counties.

Percentage of PLHIV who are nutritionally assessed using anthropometric measurement: Cumulatively, the program targets to conduct nutrition assessment for a total of 385,000 clients. 75 FY 18 Q4 July – September Quarterly Report

During the quarter, a total of 223,628 out of a target of 96,250 clients were nutritionally assessed using anthropometric measurements.

Proportion of clinically undernourished PLHIV who received therapeutic or supplementary food: Cumulatively, the program targets to provide direct commodity support to a total of 144,278 malnourished adult, pregnant-post natal and child clients. During the quarter, a total of 39,399 out of a target of 36,070 clients were nutritionally assessed and provided received commodity support

Percentage of female direct beneficiaries of USG nutrition-sensitive agriculture activities consuming a diet of minimum diversity (RAA). As per the previous quarter monitoring results for the two counties (Busia and Tharaka Nithi). 54% (48% in Busia, 60% in Tharaka Nithi) of the female beneficiaries were consuming a diet of minimum diversity.

Number of community members trained on income generating activities at community level: The project reached 1,641 community members with income generating activities training.

76 FY 18 Q4 July – September Quarterly Report

Table 27: Summary Results to Date

IR 2018-2019 Indicator Achievement Target Q1 Q2 Q3 Q4 IR1: Improved Access and Demand for Quality Nutrition Intervention at Community and Facility Levels IR1.1: Strengthened Leadership, Advocacy and Policy Planning 1.1.1 # of mechanisms created to facilitate coordination on an ongoing basis as a result of USG Assistance (e.g. forum, working group, MOU, shared plans, associations, budgeting work planning, projects) Note 10 10 that it is important to identify best practices as they emerge. C4.0 Development of budget lines for nutrition in county work plan 3 - 1.1.3 4.5.1(24) Numbers of Policies/Regulations/Administrative Procedures in each of the following stages of development as a result of USG assistance in each case: Stage 1: Analyzed; Stage 2: Drafted and presented - - - - - for public/stakeholder consultation; Stage 3: Presented for legislation/decree; Stage 4: Passed/approved; Stage 5: Passed for which full and effective implementation IR1.2: Improved Nutrition Service Delivery Management, Coordination and Implementation 1.2.1 3.1.9.2(2) Number of health facilities with established capacity to manage acute undernutrition (S) 160 11 C5.0 Comprehensive NACS implemented at health facilities (beyond CCC/ART sites) 400 400 1.2.3 (DO 2; 2.2.1; (2)) % of facilities submitting timely, complete and accurate information - (These are among 92% 96.5% 3.1.9.2(2) Number of health facilities with established capacity to manage acute undernutrition (S)) 1.2.5 Percentage of PLHIV who are nutritionally assessed via anthropometric measurement (FN_ASSESS) 385,000 223,628 1.2.6 Proportion of clinically undernourished PLHIV who received therapeutic or supplementary 144,278 39,399 food(FN_THER) HL.9-1 Number of children under five (0-59 months) reached with nutrition specific interventions by USG- 440,389 supported nutrition programs 351,456 1.2.7 3.1.9.2(3): Number of children under 5 who received Vitamin A from USG supported programs 440,389 351,456 HL9-2 Number of children under 2 (0-23 months) reached with community level nutrition interventions 60,358 9,767 through USG-supported programs (RAA) HL9-3 Number of pregnant women reached with nutrition-specific interventions through USG-supported 100,887 21,702 programs (RAA) Custom Custom: Number of children under five who are Underweight (WAZ) 28,292 13,866 1.2.9 IR1.3: Improved Nutrition Related Behavior C6.0 Number of standardized SBC nutrition materials distributed (and revised if necessary) to community 3 - health and agricultural extension workers supported by USAID IP’s IR1.4: Increased Opportunities for Learning and Sharing of Best Practices in Nutrition Number of implementation science questions answered 2 -

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IR 2018-2019 Indicator Achievement Target Q1 Q2 Q3 Q4 IR1.5: Increased Knowledge and Skills of Health Care Workers (HCW) in Nutrition HL9-4 Number of individuals receiving nutrition-related professional training through USG-supported 327 programs (RAA)

IR 2018-2019 Indicator Achievement Target Q1 Q2 Q3 Q4 IR2: Strengthened Nutrition Commodity Management IR2.1: Improved Production, Supply and Distribution of Nutrition Commodities 2.1.3 SC_STOCK: The percentage of storage sites where commodities are stored according to plan, by level in supply 100% 100% system. C8.0 Diversification and capacity building of nutrition commodity producers. NHPplus # of Nutrition commodities procured by type (FBF) 2,170 424.8 NHPplus # of Nutrition commodities distributed to active health facilities points by type(FBF) 2,170 214.2 C9.0 % of nutrition commodity distribution (procured by NHPplus) managed by KEMSA NA NA C2.0 # of active health facilities reporting stock outs for FBF and RUTF in the preceding six months) <20% <20% IR2.2: Improved Quality and Safety of Food Commodities and Agricultural Products 2.2.1 44.5.1(24) Numbers of Policies/Regulations/Administrative Procedures in each of the following stages of development as a result of USG assistance in each case: Stage 1: Analyzed; Stage 2: Drafted and presented for - - public/stakeholder consultation; Stage 3: Presented for legislation/decree; Stage 4: Passed/approved; Stage 5: Passed for which full and effective implementation 2.2.2 4.5.2 [42] number of private enterprises producer organizations, water user’s associations, women’s groups, trade and business associations and community-based organizations [C0Bs] that applied improved technologies or 2 2 management practices as a result of USG assistance [RiA] [ IR2.3: Strengthened sustainability and innovation in nutrition commodity development and management C1.0 Reduction in the cost of production of commodities 2% NA NA NA NA IR3: Improved Food and Nutrition Security IR3.1: Increased Market Access and Consumption of Diverse and Quality Foods 3.1.1 # of people trained. Mentored, provided TA at National/County Level on SCALE, Household Food Production, TA to develop effective strategies and approaches on improving food utilization and dietary diversity, Diet 230 diversity in community settings, Food preparation and safety, Ag practices that assist in responding to identified 45 environmental threats; Food recipe manuals reviewed/developed 3.1.1.1 # of partners within the 5 focus counties trained on SCALE+ 11 9 3.1.1.2 # of FBF value chain players (processors, aggregators, farmers) from 5 focus counties trained on SCALE+ 120 4

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IR 2018-2019 Indicator Achievement Target Q1 Q2 Q3 Q4 3.1.2 # of county/sub-county TOTs trained on agri Nutrition including agri-business 21 3.1.3 # of CHVs/FEWs/ECDEs trained on agri nutrition at community level 0 3.1.4 # of mothers and child care givers trained on agri-nutrition dietary diversity household activities at community 8,504 19,839 level 3.1.5 # of hearth sessions (cooking demos) conducted disaggregated by ward/county and gender 3,100 373 3.1.6 # of demonstration gardens established within the 5 focus counties 50 3.1.7 # of HH visits conducted disaggregated by group and ward/county 19,839 8,504 C7.0 Collaborations across MNCH, HIV/AIDS and FtF partners and government partners utilizing SCALE methodology for advocacy and planning 3 0 C3.0 Effective linkages with service delivery providers: 3 1 C10.0 Technical assistance to FtF partners to expand number of poor small-scale farmers through value chain analysis 50% 0 C6.0 # of standardized SBC materials distributed (and revised if necessary) to community health and agricultural 6 3 extension workers supported by USAID IPs. C11.0 Technical assistance to support FtF partners to adapt existing agri nutrition tools to include HH production and consumption of nutritious food 40% 0 IR3.2 Increase resilience of vulnerable households and communities E.G.3.3- Percentage of female direct beneficiaries of USG nutrition-sensitive agriculture activities consuming a diet of 50% NA 10 minimum diversity (RAA) 3.2.9 EG.11-6: Number of people using climate information or implementing risk reducing actions to improve 1,697 resilience to climate change as supported by USG assistance 3.2.11 # of tools/templates/models provided by target institutions in order to facilitate devolution at the local level as a 1,000 879 result of USG assistance 3.2.3 # of 5-member teams consisting of 1 CHEW, 1 Home Econ, 1 Extension services, 1 ECDE trained on Agri 0 Nutrition including agri-business 3.2.4 # of communities supported to conduct participatory disaster risk reduction assessments 20 0 3.2.5 # of households screened at least twice during the year 2,944 26 3.2.6 # of community members trained on income generating activities at community level 7,108 1,641

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IV. RESEARCH AND DEVELOPMENT

Analysis of the household monitoring activity in Busia and Tharaka Nithi Counties and preceding food mapping activities in Busia, Kitui and Tharaka Nithi Counties indicated that while majority of adult diets achieved the recommended dietary diversity, but shortfalls were evident in complementary foods. Busia county has unique opportunity because of availability of locally produced drought tolerant ground nuts and imports from Uganda. While ground nuts nutrient and energy density are well established, concerns about safety due to aflatoxin contamination is widespread. Prior to recommending ground nuts as an ingredient in the complementary foods, the program analyzed for their suitability based on aflatoxin contamination and peroxide content2.The findings are shown in Table 28.

Table 28: Peroxidation and total aflatoxin in ground nut products in Busia County

Products Sampling Peroxide Value, Total aflatoxins Moisture points meqO2/kg ppb content, % Sampled in June 2018 Whole Grains Teso North 7.32 5.0 - Butula 7.11 0 - Busia* 27.2 8.3 - Samia 5.04 0 - Flour Samia 1.6 29.9 - Butula 5.65 26.1 - Nambale 2.85 24.1 - Busia* 5.37 24.0 - Paste Busia 1.6 32.4 - Sampled in November 2018 Whole Grains Samia 1.55 0.3 6.19 Busia 3.75 1.3 5.39 Teso North 2.97 0.4 6.12 Nambale 2.66 0.3 5.75 Butula 6.44 0.3 6.06 Flour Nambale 2.55 25.6 3.34 Teso North 3.29 1.7 5.13 Samia 6.67 16.4 3.65 Butula 1.97 26.3 6.15 Paste Busia 24.46 27.9 0.54 Teso North 18.85 26.7 0.56 *- Imported from Uganda

The peroxide value indicated that induction of decomposition (peroxide value (PV) >3 meqO2/kg) had taken place in two-thirds of samples. However, except pastes and one sample of nuts from Uganda whose PV was above 10 meqO2/kg, all other samples conformed to acceptable threshold/cut-off point.

2 Fats and oils undergo oxidative decomposition leading to the formation of hydroperoxides. The presence of hydroperoxides oil has already been damaged by oxidation. After induction, the process can be accelerated by certain storage conditions such as temperature, light and metal ions. The products of decomposition have been associated with changes in organoleptic properties and corresponding validity of product shelf life and various pathologies and disease status mainly because of the free radical formation.

80 FY 19 Q1 Oct– Dec Quarterly Report

The total aflatoxin content in flour and paste samples were generally way above the limit set out for staple foods (10 part per billion, ppb). Evidently, these products are not suitable for use an ingredient in formulation of complementary and human consumption in general. There is urgent need to conduct an analysis of ground nuts value chain to identify the point of contamination. Anecdotal evidence and experience from ICRASAT (Personal communication) suggests that upon contacting water, the fungi responsible for production of aflatoxins explodes with resultant exponential increase in production of aflatoxin. The program will enhance the capacity of county MOH and MOA to improve safety of the ground nuts so that they are comfortably included in community and household complementary food formulations. The overall aim of this intervention is to prevent aflatoxin contamination to exceed 2 ppb.

Green leafy vegetables in complementary foods In order to achieve minimum dietary diversity in complementary foods, inclusion of vegetables from the core cultural foods offer an opportunity that can last all year round. Both indigenous and exotic green leafy vegetables are generally good sources of vitamins and minerals3. From the view point of flesh vegetables, it can be confirmed that sweet potato leaves and amaranthus leaves cook within 10 minutes. The cooked vegetables are easily pureed by pasting them through a metal wire sieve mesh. In the case for other indigenous and exotic vegetables, production of puree requires powered mechanical blenders or milling equipment. For these vegetables, blanching, drying and milling offers an opportunity for improved availability throughout the year. The practice of milling vegetable into powder is established in Kenya albeit apparent low popularity. However, it is noteworthy that the following green leafy materials that are used in mixed/composite traditional food (mukimo) and medicinal beverages are available in retail outlets – Stinging nettle (Urtica dioica), neem tree leaves among others. Blending of up to 5% (w/w) of powdered green leafy vegetables with cereal flour delivers both improved micronutrients and phytonutrients in the IYC foods.

2.5% 5% 10%

Figure 7: Samples of maize flour enriched with stinging nettle powder

3 Kenya Food Composition tables, 2018 81 FY 19 Q1 Oct– Dec Quarterly Report

Other solar died exotic and indigenous green leafy vegetables that are acceptable among the IYF core foods could also be considered. t is plausible that solar drying, milling and appropriate packaging could improve accessibility of the vegetables all the year round.

A B C

Figure 8: Vegetable powder made from cow peas (A), amaranth (B) and spinach (C) leaves

V. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

NHPplus continued to collaborate and create linkages with other USAID programs as follows;  Cost-shared data review meetings in Taita Taveta with Afya Pwani; facilitated sessions together with County officials, KEMSA National  Participated in bi-monthly FtF Nutrition Technical Working Group and PREG monthly meetings where all FtF nutrition and PREG partners respectively meet.

County Level Marsabit  Two agri-nutrition groups involved in pasture production have been linked to LMS small grants done proposal awaiting outcome  The Biqila agri-nutrition group which has a dietary diversity demonstration plot has been also linked to the Kenya Climate Smart program. Their proposal to expand the demonstration garden to 1 acre submitted and awaiting outcome with optimism  The frontline officers linked 4 agri-nutrition groups to Concern Worldwide where they received pasture seeds for planting.

Kitui  To strengthen linkages among food and nutrition security players, the program supported SCALE+ Workshop that brought together 51 (33M,18F) participants drawn from Kitui county ministries of MOALF, MOH, NDMA, WFP, RTI International, Afya Pwani, Afya Halisi, Afya Uzazi, Afya Jijini, Caritas-Kitui, Christian Aid -OVC, Life skills Promoters, ILRI- AVCD, RTI-KYES, cereals/legumes aggregators, transporters and community based organization (MAVO, Athi Horticulture farmers and Kenze Farmers.

82 FY 19 Q1 Oct– Dec Quarterly Report

Samburu  PREG consultative and mentorship meeting for Lead and Deputy lead (NHPplus) with AFRICA LEAD.  In Samburu, NHPplus is a member and County Deputy lead of PREG joint planning PREG activities with NRT, NHPplus and Africa Lead.

VI. PROGRESS ON LINKS TO OTHER GOK AGENCIES

Kenya Nutrition and Health Program Plus continued to collaborate with government sectors at both National and County Levels. The program:  Supported the MOALF to print the Food Composition Tables and the Recipe Books  Supported the MOALFI to distribute the National Agri-nutrition Resource Manual, Food Composition Tables and the Recipe Book  Supported training of 5 MOALFI county staff for Senior Management Course at KSG  Trained 22 Kitui Government staff on SCALE+ methodology

VII. IMPLEMENTATION CHALLENGES

 Insecurity concerns in Saku and Moyale sub counties in Marsabit county affecting all nutrition specific and sensitive activities at Godoma community units despite the earlier investments made.  Low coverage of the frontline extension service providers coupled with the vastness and poor terrain remained a major challenge with the program competing for attention of the line sectors with other organizations which have a huge workforce with staff in all sub- counties  Dependency syndrome by communities especially in ASAL counties  Transport challenges for NHPplus apprentices with long distances between the communities residing in ASAL with limited means of public transport affecting the necessary follow up by the officers.  Lack of ready to use therapeutic feeds for the adults meant for treatment of severe malnutrition in some counties eg Marsabit  Lack of fencing materials for dietary diversity demonstration gardens exposing them to livestock damage  Climate change and drought resulting in very high temperatures compounded with water scarcity at the household level as well as for supporting demonstration gardens  Lack of money by communities to buy the recommended foods after basic nutrition education trainings  Lack of access to the markets where they can buy these foods even when they have money  Competing household chores involving women  Cultural barriers related to family support or permission to buy and prepare certain recommended foods as the husbands, mothers-in-law and grandmothers have a lot of influence  Poor turn out of group members for trainings due to other competing livelihood activities with some members inactive and only show up when they suspect handouts  Low adoption of economic empowerment interventions especially table banking where some members ran away with members money after being loaned  Champion mothers requesting input support when reaching out to more mothers and household  Program restrictions on purchase of inputs for demonstrations 83 FY 19 Q1 Oct– Dec Quarterly Report

VIII. LESSONS LEARNT

 Utilization of the same platform using the multi-sectoral approach to pass health, nutrition and agriculture extension messages increase coverage in terms of the number of the people reached as well as saving time and resources  Income generating activities can be a good cementing agent ad empowerment tool for group members if well handled with proper rules guiding financial transactions or else can act as a disincentive without proper controls  Using Mother Support group platform for passing agri-nutrition message is important in ensuring larger coverage and bridging the frontline staff shortage gap  Consultative meeting between COR/AOR on specific IRs as happened for IR3 are healthy as they iron out any gray areas between the parties and agree on common vison for the program especially as relates to outcomes.

IX. SUBSEQUENT QUARTER’S WORKPLAN

Status of Activities Planned for the Reporting Period Table 29 shows the status of activities planned for the reporting period and explanations for observed deviations. Most of the planned activities were accomplished. Table 29: Status of activities planned for the reporting period IR1: Improved Access and Demand for Quality Nutrition Interventions at Community & Facility Levels Status at end Explanation for Planned Activities for Quarter 1 of Quarter 1 Deviation MARSABIT COUNTY Submit documentation of two Marsabit County MOALF Done officers for the Senior Management Course at Kenya School of Government. Initiate Process for Development of the County Nutrition On–going Discussions initiated Action Plan. during the CNTF Facilitate secretariat of Multi-Sectoral Nutrition technical Done forums to hold October CNTF meeting Participate in Sub- County Nutrition Technical Forum Done (Saku Meetings sub-county) Conduct HINI OJT Gap Assessment for 30 Facilities in Deferred to To be done in Quarter Laisamis, North Horr, Moyale and Saku Q2 2 Facilitate Quarterly Indicator Review Meeting in 2 Sub- Done Counties (Moyale and Laisamis) Conduct Routine Growth Monitoring for Children Under 5 Done at ECDE Centres and Refer Identified Undernourished Cases for Treatment Facilitate Vitamin A supplementation in the community, Done Static health facilities and ECDE centers during Malezi bora activities Facilitate SCHMTs to conduct Vitamin A supplementation Done supervision Support the monthly BFCI CHVs meeting for Done Loiyangalani, Golole, Godoma and Goro Rukesa. CHVs Conduct Monthly Household Visits Done Conduct Bi-monthly BFCI outreach in 4 community units Partially The activity was implementing BFCI. Done partially achieved 84 FY 19 Q1 Oct– Dec Quarterly Report

Status at end Explanation for Planned Activities for Quarter 1 of Quarter 1 Deviation Scheduled Bi-monthly CMSG driven integrated facility or through community community outreach and referral for 1st ANC and new level growth monitoring deliveries Facilitate CHIS Quarterly indicator review meetings for Deferred to The review should be Laisamis and Moyale Q2 preceded by CHIS sensitization for CHAs TOT training on Familia bora Approach Done Training of CHVs on Familia Bora Approach Done for The remaining CUs will Loiyangalani be trained in Q2 Conduct Household mapping to identify the target Done beneficiaries SAMBURU COUNTY Facilitate payment of senior management course fee at KSG Done for County Nutrition Coordinator (CNC) and County Director of Agriculture Facilitate Secretariat of Multi-Sectoral Nutrition Technical Done Forums to Hold CNTF Meeting Conduct HINI Gap Assessment for 10 Health facilities from Not Done Deferred to Quarter Samburu North, East and Central Sub-counties 2 Conduct 5 Community-Based Outreaches: Archers Post, Done Kisima, South - Horr and Marti. Conduct Vitamin A and Deworming in ECDEs and Done Community Units across 3 Sub - Counties during Malezi Bora Period Conduct Growth Monitoring in 5 CUs during Outreach and Done ECDEs in South-Horr, Nachola, Kisima, Marti, Lorubae and Lderkesi Conduct 5 Community Based Outreaches; Archers Post, Partially Done Done in Lorubae and Kisima, South-Horr and Marti Marti Conduct BFCI CMSG Bi-monthly Outreach, Meeting and Done Done in Kisima, CHVs Monthly Meeting for Lorubae and Lderkesi CUs, Lorubae and Lderkesi South-Horr and Kisima, Archers-post CUs Conduct BFCI CHV Training for Wamba CU Not Done Deferred to Quarter 2 (3rd and 4th week of January 2019) Conduct CHV Familia Bora Training from 5 CUs (Kisima, Not done Deferred to Quarter Lorubae and Lderkesi, Nachola and South-Horr) 2 Conduct Health Workers Training on Growth Monitoring Not done Deferred to Quarter and Promotion for Samburu Central and Samburu East Sub 2 – Counties Conduct NACS joint support supervision and mentorship at Not done Deferred to Quarter the Sub-county level; Samburu North, East and Central 2 THARAKA NITHI COUNTY Facilitate Tharaka Nithi County Nursing Services Manager Partially done. County Nursing Services to attend a Senior Management Course at Kenya School Manager Preparing the of Government Paper Work for Submission. Facilitate Health Workers and ECDE Teachers to Done Conduct Monthly Growth Monitoring at the ECDE Centres. Conduct HINI Gap Assessments in Health Facilities. Not Done Conduct BFCI Training for Mother-to-Mother Support Not Done Groups.

85 FY 19 Q1 Oct– Dec Quarterly Report

Status at end Explanation for Planned Activities for Quarter 1 of Quarter 1 Deviation Facilitate CHVs to Establish Community (Village) and Done Facility Based Mother-to-Mother Support Groups. Facilitate CHEWs and CHVs to Conduct Monthly Done Supervision Visits during the MtMSGs Meetings Facilitate SCHMTs to conduct Outreach Services Done Planning and Review Meetings. Support Malezi Bora Activities across 6 Sub-Counties in Done the County: Social Mobilization, ECDE VAS and Deworming. Conduct Three - Day Training for CHVs on Familia Bora Done SBCC Materials. Conduct County Nutrition Technical Forum (CNTF) for Established the Sub- Tharaka Nithi County. County Nutrition Technical Forums. Facilitate CHVs to Establish Community (Village) and Done Facility Based Mother-to-Mother Support Groups. Planned Activities for Quarter 1 Status at end of Explanation for Q1 Deviations KITUI COUNTY Participate in Planning Meeting to Develop Costed AWP Done The activity was funded With Nutrition Targets in Kitui County by Afya Halisi and Ministry of Health Conduct OJT in NACS health facilities as per identified Done needs Conduct Three – Day NACS Sensitization for newly Not Done Deferred due to recruited County nutrition officers competing activities Conduct Sensitization Meetings For 37 Health Facilities on Partially Done Nutrition Electronic Monitoring and Reporting System BFCI Monthly Review Meetings at Kalatine CU, Tharaka Done CU And Waita/Mwambui CU Facilitate Malezi Bora Activities in 8 Sub Counties (Kitui Done East, Kitui South, Kitui Rural, Kitui Central, Kitui West, Mwingi North, Mwingi Central and Mwingi West) Quarterly HiNi / NACS Indicator Review Meeting at Sub Not Done Deferred Due To - County Level Competing Activities Facilitate Health Facility Managers Review Meeting Done Conduct Five Day BFCI Training for CHVs, CMSG, Lead Not Done Deferred due to Mothers and Facility Mother Care Groups in Voo, Zombe, competing activities Endau, Kandwia, Kasaala, Ikanga And Kamutei CUs Conduct One -Day BFCI Sensitization for Community Not Done Deferred due to Health Committee, Primary Health Care Facility competing activities Committee, and Community Leaders at Voo CHU, Zombe CHU and Endau Conduct One - Day Meeting for CHVs to Sensitize Them Done on Household Mapping Template in Voo, Zombe, Endau, Ikanga, Athi, Ikutha and Kandwia Conduct Monthly BFCI integrated outreach activities in the Partially one 4 focus Sub Counties (Kitui East, Kitui South, Mwingi North & Waita/ Mwambui BFCI monthly review meetings Done Conduct BFCI Training for CHEWs, Health workers Done Agriculture Extension workers for Kitui East Sub Counties

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Facilitate SCHMT Support Supervision of MtMSGs during Not Done Coincided with polio World Breastfeeding Week in Mwingi North and Mwingi campaign in Kitui Central Sub – Counties County Conduct BFCI MtMSG meetings within Kakuyu/Kyandali, Done Waita/Mwambui and Gakombe villages Facilitate CHVs to establish community (village) mother Done care groups in Voo, Zombe, Endau and Kandwia Conduct BFCI Monthly Review Meeting at Kalatine CU, Done Tharaka CU and Waita/Mwambui CU Conduct BFCI Outreaches in Waita/Mwambui, Kalatine Done and Tharaka Wards Facilitate NACS Support Supervision in Kitui central, Kitui Not done Deferred due to Rural, Kitui West and Mwingi North competing activities BUSIA COUNTY Facilitate Development of Joint Work Plan with New USG Not Done Projects and other Non - USG Implementing Partners Facilitate Quarterly Multi Sectoral Nutrition Forum Not Done Activity deferred Meeting NACS Sensitization for key facilities and other USG IP Not done Activity deferred Partners Conduct NACs support supervision in health facilities Not Done Activity deferred Conduct Monthly HINI OJT in Health Facilities Not done Activity deferred Conduct Health Facilities In - Charges Indicator Review Partially Done Meetings In 4 Sub - Counties: Nambale, Butula, Samia and Teso North Conduct Data Review Meetings for Done Growth Monitoring Promotion Activities Conduct One Day Orientation for CHVs on the Seven Key Done messages in Familia Bora Scorecard Conduct Quarterly Support Supervision in Health Facilities Not Done Activity deferred Support monthly CHVs meeting in CUs implementing CUs Done Conduct Health Facility Mentorship on BFCI Done Documentation Support monthly MTMSG meetings in CUs implementing Done BFCI Conduct CMEs on BFCI Not Done Activity deferred Conduct Outreaches In 4 Wards in Samia Sub - County, 6 Partially Done Wards in Teso North Sub - County, 4 Wards in Nambale Sub - County and 6 Wards in Butula Sub - County Support Bi - Monthly BFCI CMSG Meetings Done Target Setting and Planning Meeting With all Health Care Done Workers in all Sub Countie Conduct Social Mobilization in all Wards within the 7 Sub- Done Counties Conduct 85 cooking demonstrations across the 5 CU Done implementing BFCI activities Facilitate Vitamin A Supplementation and Deworming in Done Community by CHEW, PHOs, Nurses, CHVs Support SCHMT to conduct monthly supervision on BFCI Done Sub county sensitization on BFCI in Nambale and Butula Done Conduct BFCI Training for Health Care Workers in Done Nambale and Butula Conduct BFCI Training for CHVs Done Household mapping in CU implementing BFCI Done Selection and Training of CSMG members Done

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IR 2: Strengthened Nutrition Commodity Management Planned Activity Status at Explanation for Deviation end of Q1 Procurement and distribution of nutrition commodities – Done FBF and RUTF Participate in the Pipeline Sub Committee meeting Partly done Monthly engagement; only had one meeting during the quarter Conduct Site Supervision visits/data review meetings in focus Done counties, Kiambu, Taita Taveta Participate in National Forecasting and Quantification for Done Draft Report to be shared in the nutrition commodities activities convened by Nutrition and coming quarter Dietetics Unit Support distribution of data collection and summary tools Done On-going activity (demand driven) Supplier Quality Audits debrief to the 3 food processors Done ENP and Insta IR3 Improved Food and Nutrition Security Planned Activity Status at Explanation for end of Q1 Deviation National level Initiate process to develop facilitators guide, job aids and participants manual and curriculum for in-service trainees from the Done new National Agri-nutrition Resource Manual Support meeting to sensitize stakeholders on digitization of the food Evidence gathered showed KALRO had the and nutrition security information management system Suspended information and ministry consulted accordingly Support national forums that improve collaboration, adaptation of Done an best practices and improve learning on going County level Train 9 FBF value chain players (processors, aggregators, farmers) from Kitui on SCALE+ to coalesce actions on food safety Initiate process to finalize distribution, launching and pre-testing Done manual in counties Train 30 CHVs/CHWs/FEWs/ECDE teachers on agri-nutrition in Postponed Due to funding issues Busia Ward/Community/Household level Establish 2 more community groups Done 6 formed in Loiyangalani Marsabit county Carry out Agri-nutrition package dissemination and implementation Done through new model of 2 high impact packages taken through to households by champion mothers to2000 households Promote access and consumption of nutrient dense DTCs as energy Done and plant protein sources especially sorghum, millet and cowpeas through dissemination and adoption of appropriate supportive technologies by 1,000 households Promote access and consumption of vitamin dense green leafy Done vegetables including all local vegetables, spinach, sweet potato leaves through dissemination and adoption of appropriate supportive technologies by 2,000 households Support establishment of 150 vertical bags Done Data yet to be confirmed Establish 10 dietary diversity promotion demonstration gardens in Done the focus counties in ECDE centers and community Facilitate at least 400 champion mothers to visit 10 households Done passing one key impact oriented agri-nutrition package

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Planned Activity Status at Explanation for end of Q1 Deviation Conduct sensitization on financial inclusion/Income generating Done activities to the existing groups alongside the agri-nutrition package Conduct screening of households on malnutrition Done Carried out during Malezi Bora Finalize food mapping reports Done

Planned Activities for the Subsequent Quarter

Activities planned for the subsequent quarter are outlined below

Planned Activity Status at Explanation for end of Q2 Deviation IR1: Improved Access and Demand for Quality Nutrition Interventions at Community & Facility Levels Marsabit County Facilitate Development of County Nutrition Action Plan. Facilitate Quarterly County Nutrition Technical Forum. Facilitate Sub-county level Nutrition technical forums for Laisamis, Saku and Moyale. Conduct HINI gap Assessment for 30 Health facilities from Moyale, Saku, Laisamis and North Horr Conduct target setting meetings for Moyale and Laisamis Facilitate Quarterly Joint support supervision at the sub-county level with key focus on NACs sites. Conduct Bi-Monthly Growth Monitoring at ECDE Centers in Saku, Moyale and Laisamis Support Monthly BFCI CHVs Meeting for Loiyangalani, Golole, Godoma and Goro Rukesa. Facilitate CHIS Quarterly Indicator Review Meetings for Laisamis And Moyale Facilitate CHVs, CHEWs and CMSG to Conduct Regular Community Dialogue Days for 4 BFCI Units: Loiyangalani, Goro- Rukesa, Golole And Godoma. CHVs Conduct Monthly Household Visits for Loiyangalani, Goro- Rukesa and Golole CUs Conduct CHVs BFCI training for Merille and Odda CUs Training on Familia Bora Approach for Goro-Rukesa and Golole Community Health Volunteers Samburu County Facilitate Payment of Senior Management Course Fee at KSG for County Director, Ministry of Agriculture Facilitate Secretariat of Multi-Sector Nutrition Technical Forums to Hold Quarterly Meeting Conduct HINI Gap Assessment for 22 Health facilities from Samburu North, East and Central Sub-Counties Facilitate Development of Annual Work Plan and Budget aligned to County M&E Target and CNAP

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Planned Activity Status at Explanation for end of Q2 Deviation Conduct Community Data Review Meetings with CHVs, CHEWs and Community Focal Persons Conduct Growth Monitoring in 5 CUs and 52 ECDEs Centres: South-Horr, Nachola, Kisima, Marti, Lorubae and Lderkesi Conduct 5 Community - based Outreaches: Archer’s post, Kisima, South-Horr and Marti Conduct Bi – monthly CMSG, Monthly CHVs Meeting and Outreaches for Lorubae and Lderkesi CU, South-Horr and Kisima, Archer’s Post Conduct BFCI CHV training for Wamba and Lpashie CUs Conduct Familia Bora Training for TOT and CHVs from 4 CUs: Kisima, Lorubae and Lderkesi, Nachola and South – Horr Conduct OJT for Health Facilities on Growth Monitoring in Samburu East, North and Central Tharaka Nithi County Documentation of the County Nursing Services Manager for the Senior Management Course at Kenya School of Government Facilitate Development of County Specific Multi – sectoral Action Plan (2019 – 2023) Facilitate Monthly Multisectoral Nutrition Technical Forum Meetings at Sub – County Level Conduct IFAS Training for CHVs Implementing BFCI Activities Conduct Routine Growth Monitoring at the ECDE centres Facilitate Implementation of BFCI Activities in the Community Units Roll Out Familia Bora Approach within BFCI Implementing Community Units Conduct Training of NHPplus Apprentices on IMAM, NACS, Child Growth Monitoring and BFCI Conduct Outreach Services in Hard to Reach Areas Conduct Joint Supervision of Health Facilities and Community Level Program Activities with SCHMTs Kitui County Facilitate Development of County Multi - Sectoral Nutrition Action Plan (2019 - 2023) Conduct Quarterly County Multi - Sectoral NTF Meetings Conduct OJT on HINI/NACS as per identified needs in all 8 Sub - Counties Conduct NACS supportive supervision in 8 Sub - Counties Support HINI/NACS Data Review Meetings in 4 sub counties: Kitui East, Kitui South, Kitui South and Mwingi Central Facilitate Active Case Finding of SAM Cases Through Regular Screening Conduct Health Facility Managers Quarterly Review Meetings in Kitui South, Kitui East, Mwingi North and Mwingi Central

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Planned Activity Status at Explanation for end of Q2 Deviation Conduct BFCI Bi-Monthly Community activities in 9 CUs: Kalatine, Tharaka, Waita/Mwambui, Voo, Endau, Kaumu, Ikanga, Athi and Ikutha CUs Support MtMSG meetings in CUs implementing BFCI Conduct monthly BFCI data review meetings with CHVs in activities in 9 CUs: Kalatine, Tharaka, Waita/Mwambui, Voo, Endau, Kaumu, Ikanga, Athi and Ikutha CUs Conduct regular community dialogue days within Kalatine CHU, Tharaka CHU, Waita/Mwambui CHU, Muthungue CHU, Endau CHU and Kaumu CHU in areas Conduct BFCI/Familia Bora Training for CHVs in Mwingi North (Tharaka, Kalatine, Kandwia) Kitui East (Kaumu, Voo, Endau) and Kitui South (Ikanga, Ikutha and Athi) Sub Counties Busia County Quarterly multisectoral nutrition forum NACS support supervision activities Monthly HINI OJT activities Health Facilities In – Charges Indicator Review Meeting in Nambale, Butula, Samia and Teso North sub – Counties Growth Monitoring Promotion Data Review Meetings Familia Bora TOT Training in Butula sub – County Integrated BFCI – Familia Bora training for CHVs in Butula and Nambale sub – Counties Monthly CHV BFCI review meeting Health Facility mentorship on BFCI documentation Monthly BFCI MTMSG meetings Conduct outreaches in 4 wards in Samia sub county ,6 wards in Teso North sub county ,4 in Nambale sub county and 6 in Butula sub county Training of CHVs on BFCI/Familia Bora in Butula and Nambale Support Bimonthly BFCI CMSG meeting Target setting and planning meeting with all health care workers in all sub counties Selection and training of CMSG in Nambale and Butula BFCI SCHMTM support supervision Conduct BFCI assessment of implementing CU Conduct CME on MIYCN in 13 facilities Teso North, 3 facilities in Samia and 11 facilities in Nambale Facilitate the SCHMTs and CHEW to conduct monthly supervision visits to selected groups at community Units level Conduct outreaches in 6 wards in Teso North sub county, 4 wards in Samia and 4 in Nambale sub county IR 2: Strengthened Nutrition Commodity Management Procurement and Distribution: Nutrition commodities, data collection and summary tools Participate in Commodity Pipeline Sub Committee monthly meetings

91 FY 19 Q1 Oct– Dec Quarterly Report

Planned Activity Status at Explanation for end of Q2 Deviation Conduct Site Supervision visits/data review meetings in focus counties, Kisumu, Homabay and Kakamega Follow up with KEBS on review of composite flours policy Procurement and Distribution: Nutrition commodities, data collection and summary tools IR3 Improved Food and Nutrition Security National Level From the developed new National Agri-nutrition Resource Manual develop the facilitators guide, job aids and participants manual and curriculum for in-service trainees Support national forums that improve collaboration, adaptation of best practices and improve learning County Level Conduct Scale+ county level training for stakeholders (processors, aggregators, farmers), IPs and government staff Facilitate Quarterly SCALE + Meetings Facilitate exchange visit of staff across counties Ward Level/Community/Household Level Deliver 2 high impact practical nutrition sensitive interventions (specific per county as in the county plans) through the contextualized agri-nutrition package complete with WASH and IGAs to the households through champion mother’s model/outreaches targeting mothers and child care givers through value chain approach targeting improved access and consumption of diversified nutrient dense foods Support CHVs/CHEWs/FEWs to deliver specific practical high impact specified packages Establish and brand 10 dietary diversity demonstration gardens Promote any two cottage level technologies among Wetmiling, groundnut milling, solar drying technologies and vertical bag manufacturing to HHs in ZOI Promote poultry value chain to improve access and consumption of eggs to children under the one egg per child per day agenda Facilitate Community Managed Disaster Risk Reduction Training for sub-county officers/frontline extension providers from MOH, MOALF and MOE in ASAL counties Facilitate community sensitization on climate change adaptation practices in all counties Facilitate dissemination of seasonal weather forecast recommendations in 3 ASAL counties one season each Conduct Mass screening of children and mothers during hot spot areas confined during the SMART survey and other outreach activities Training community members on income generating activities and financial inclusion

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Planned Activity Status at Explanation for end of Q2 Deviation Capacity building communities on appropriate food production technologies through promotion of DTCs, water harvesting technologies among others Documentation of at least 2 good practices

X. SUCCESS STORIES

WONI WOMEN GROUP: ‘’A GOAT FOR EVERY MEMBER’’ DESIRABLE OUTCOMES OF IGA TRAININGS

Profile Woni women group is an Agri-Nutrition mother to mother support group in Ndandini, Athi ward in Kitui South consisting of 30 members that was formed in February 2017. The group was established after the women received teachings from Mr. Samson Nyamai a Community Health Volunteer who was trained as a Trainer of Trainers in Agri Nutrition package through the support of NHPplus. The criteria for recruitment in the group is pregnant women and mothers with children of children aged two years and below.

Woni Women Group Members keenly follows discussions on how to keep records for group Income Generating Activities

93 FY 19 Q1 Oct– Dec Quarterly Report

Interventions The mothers gained knowledge on the type of foods to consume, exclusive breastfeeding, complimentary feeding, preservation of vegetables, integrated water, sanitation and hygiene (WASH) and planting of drought resistant crops (DTCs) such as millet and green grams. These production technologies are coupled with appropriate food preparation technologies for maximum nutrient bio-availability for the children and target groups. Economic Empowerment and IGAs Outcomes The mothers have been taught on ways of incorporating income generating activities (IGAs) in their groups that will help them in ensuring they provide the best care for their children. IGAs are crucial resilience building component in the nutrition system safeguarding against shocks and bridging dietary diversity gaps through nutrient dense food purchases. This group in particular is outstanding in their use of table banking (a Grameen bank model) where they saved as little as 20 Kenya shillings from February to July 2017 and in December they would give their families a Christmas treat. In 2018, the mother’s increased their contributions with the agenda that each member of the group had to own a goat to ensure increased supply of milk in their homes for their children and by July they had set aside ninety-six thousand shillings with which they used to buy goats depending on the member shares earned.

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A Goat for every Member of Woni Mother Support Group parade with their goats in Ikutha Ward Kitui South Sub County, Kitui County

Future Plan In 2019, the group's agenda is buying each a water tank to help in water harvesting during the rainy seasons for use during the dry season. (Reported by Jacqueline Mwende)

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ANNEX I: PERFORMANCE DATA TABLES

Annex 1: Summary of commodities distributed INDICATOR TITLE: Amount of Commodities Distributed INDICATOR NUMBER: SC_STOCK UNIT: Activity Title Date M Sub-total Reporting Results: Additional Re-worked Reporting Period Reporting Period Reporting Period Reporting Period End of Project Criteria % FY 2019 Target 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 Target allocation County per county Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Baringo 1.2% 250 - 250 250 250 998 - 8,182 3,806 Bomet 1.0% 213 - 213 213 213 851 - 5,028 3,546 Bungoma 2.7% 585 482 585 585 585 2,338 482 8,654 9,810 Busia 6.2% 1,448 1,889 1,448 1,448 1,448 5,790 1,889 14,140 24,990 Elgeyo Marakwet 1.0% 205 - 205 205 205 820 - 3,256 3,222 Embu 1.5% 309 115 309 309 309 1,236 115 18,275 5,398 Garissa 0.1% 19 - 19 19 19 76 - 2,833 281 Homa Bay 7.8% 1,737 853 1,737 1,737 1,737 6,949 853 32,642 29,023 Isiolo 0.6% 114 - 114 114 114 454 - 2,991 2,135 Kajiado 1.4% 295 65 295 295 295 1,179 65 6,823 4,960 Kakamega 2.8% 626 141 626 626 626 2,505 141 12,146 10,902 Kericho 0.4% 114 - 114 114 114 455 - 8,943 3,228 Kiambu 3.6% 856 278 856 856 856 3,423 278 15,052 15,821 Kilifi 1.1% 221 - 221 221 221 884 - 6,051 3,613 Kirinyaga 3.1% 670 382 670 670 670 2,682 382 12,167 11,861 Kisii 1.1% 293 - 293 293 293 1,171 - 5,658 8,487 Kisumu 6.4% 1,407 1,145 1,407 1,407 1,407 5,628 1,145 27,110 24,783 Kitui 2.2% 610 513 610 610 610 2,440 513 8,521 12,669 Kwale 0.9% 178 - 178 178 178 711 - 3,441 3,428 Laikipia 0.7% 152 50 152 152 152 610 50 2,251 2,576 Lamu 0.5% 95 - 95 95 95 382 - 4,072 1,412 Machakos 3.1% 691 621 691 691 691 2,765 621 15,669 11,472 Makueni 1.9% 438 320 438 438 438 1,751 320 6,385 6,841

96 FY 19 Q1 Oct– Dec Quarterly Report

INDICATOR TITLE: Amount of Commodities Distributed INDICATOR NUMBER: SC_STOCK UNIT: Activity Title Date M Sub-total Reporting Results: Additional Re-worked Reporting Period Reporting Period Reporting Period Reporting Period End of Project Criteria % FY 2019 Target 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 Target allocation County per county Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Mandera 0.0% ------Marsabit 0.6% 125 - 125 125 125 501 - 2,994 2,568 Meru 2.0% 421 122 421 421 421 1,683 122 9,158 6,961 Migori 4.2% 881 167 881 881 881 3,525 167 18,130 14,696 Mombasa 2.0% 417 - 417 417 417 1,669 - 22,225 6,459 Murang'a 1.6% 363 293 363 363 363 1,453 293 10,490 5,827 Nairobi 7.4% 1,634 865 1,634 1,634 1,634 6,535 865 36,617 26,781 Nakuru 2.9% 726 411 726 726 726 2,903 411 12,464 12,805 Nandi 1.0% 214 - 214 214 214 856 - 8,175 3,422 Narok 1.3% 321 98 321 321 321 1,282 98 5,510 7,202 Nyamira 0.6% 147 - 147 147 147 587 - 1,253 2,256 Nyandarua 1.8% 416 186 416 416 416 1,665 186 9,935 7,632 Nyeri 1.8% 369 113 369 369 369 1,474 113 10,426 6,092 Samburu 1.8% 409 382 409 409 409 1,638 382 5,658 7,022 Siaya 6.8% 1,404 451 1,404 1,404 1,404 5,617 451 30,378 22,126 Taita Taveta 0.6% 152 133 152 152 152 610 133 5,645 2,606 Tana River 0.3% 50 - 50 50 50 199 - 736 1,050 Tharaka Nithi 1.3% 297 165 297 297 297 1,188 165 8,020 5,302 Trans Nzoia 1.3% 321 397 321 321 321 1,282 397 4,222 5,374 Turkana 4.4% 927 901 927 927 927 3,710 901 17,517 16,188 Uasin Gishu 2.3% 523 237 523 523 523 2,092 237 4,876 9,407 Vihiga 1.9% 454 125 454 454 454 1,817 125 6,510 7,690 Wajir 0.1% 26 - 26 26 26 105 - 636 429 West Pokot 0.5% 100 - 100 100 100 401 - 1,987 1,417 Blank - - 1,425 - Total 100% 22,222 11,900 22,222 - 22,222 - 22,222 - 88,889 11,900 465,278 385,573 Note: All Quantities in 18kg Cartons

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Annex 2: Number of HIV positive clinically malnourished clients who received therapeutic and/or supplementary food

INDICATOR TITLE: Number of HIV positive clinically malnourished clients who received therapeutic and/or supplementary food INDICATOR NUMBER:FN_THER UNIT: DISAGGREGATE BY: COUNTY Geographic Location Activity Title Date M ALL Data Management, Reporting Results: Additional Criteria Results Baseline Achieved Reporting Period Reporting Period Reporting Period Reporting Period FY 2017/19 Target (January Prior 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 2015) Periods County % Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Baringo 2.2% 1,668 0 808 130 808 808 808 3,231 130 Bomet 1.1% 910 1 412 165 412 412 412 1,650 165 Bungoma 1.2% 356 3 440 875 440 440 440 1,761 875 Busia 0.4% 4,429 23 134 2,129 134 134 134 537 2,129 Elgeyo Marakwet 0.5% 766 1 172 150 172 172 172 689 150 Embu 5.9% 4,739 0 2,144 417 2,144 2,144 2,144 8,577 417 Garissa 1.0% 536 0 371 70 371 371 371 1,482 70 Homa Bay 6.4% 1,167 2 2,294 2,950 2,294 2,294 2,294 9,176 2,950 Isiolo 0.7% 1,842 0 259 252 259 259 259 1,037 252 Kajiado 1.6% 2,308 0 565 505 565 565 565 2,260 505 Kakamega 2.5% 2,118 1 892 873 892 892 892 3,568 873 Kericho 3.1% 1,120 0 1,117 371 1,117 1,117 1,117 4,468 371 Kiambu 2.8% 1,661 2 1,025 2,879 1,025 1,025 1,025 4,101 2,879 Kilifi 1.5% 906 1 542 243 542 542 542 2,170 243 Kirinyaga 2.2% 4,019 1 804 1,070 804 804 804 3,216 1,070 Kisii 1.2% 993 1 439 140 439 439 439 1,755 140 Kisumu 5.4% 473 1 1,945 881 1,945 1,945 1,945 7,782 881 Kitui 1.3% 224 2 481 1,971 481 481 481 1,923 1,971 Kwale 0.6% 884 0 229 162 229 229 229 916 162 Laikipia 0.3% 2,676 2 108 306 108 108 108 433 306 Lamu 1.2% 702 0 428 - 428 428 428 1,711 - Machakos 3.3% 513 1 1,187 873 1,187 1,187 1,187 4,749 873

98 FY 19 Q1 Oct– Dec Quarterly Report

INDICATOR TITLE: Number of HIV positive clinically malnourished clients who received therapeutic and/or supplementary food INDICATOR NUMBER:FN_THER UNIT: DISAGGREGATE BY: COUNTY Geographic Location Activity Title Date M ALL Data Management, Reporting Results: Additional Criteria Results Baseline Achieved Reporting Period Reporting Period Reporting Period Reporting Period FY 2017/19 Target (January Prior 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 2015) Periods County % Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Makueni 0.9% 1,480 3 340 524 340 340 340 1,359 524 Mandera 0.0% 2,769 ------Marsabit 0.7% 5,284 0 248 428 248 248 248 993 428 Meru 2.0% 2,080 1 716 998 716 716 716 2,866 998 Migori 3.7% 6,153 1 1,341 682 1,341 1,341 1,341 5,362 682 Mombasa 7.1% 1,764 0 2,558 127 2,558 2,558 2,558 10,232 127 Murang'a 2.8% 1,766 0 1,007 1,015 1,007 1,007 1,007 4,028 1,015 Nairobi 9.1% 764 1 3,282 4,290 3,282 3,282 3,282 13,129 4,290 Nakuru 2.4% 1,765 2 854 1,824 854 854 854 3,415 1,824 Nandi 2.4% 1,974 0 855 269 855 855 855 3,419 269 Narok 1.0% 532 1 370 374 370 370 370 1,478 374 Nyamira 0.0% 4,827 - - 228 - - - - 228 Nyandarua 2.4% 1,239 1 854 494 854 854 854 3,418 494 Nyeri 2.6% 58 0 956 632 956 956 956 3,823 632 Samburu 0.7% 1,541 2 258 578 258 258 258 1,031 578 Siaya 6.5% 398 0 2,337 1,368 2,337 2,337 2,337 9,347 1,368 Taita Taveta 1.7% 2,473 0 600 120 600 600 600 2,400 120 Tana River 0.1% 692 0 28 - 28 28 28 113 - Tharaka Nithi 2.1% 103 0 746 1,380 746 746 746 2,984 1,380 Trans Nzoia 0.5% 296 3 193 469 193 193 193 770 469 Turkana 3.3% - 2 1,197 3,569 1,197 1,197 1,197 4,788 3,569 Uasin Gishu 0.0% - - - 1,653 - - - - 1,653 Vihiga 0.9% - 3 335 923 335 335 335 1,340 923 Wajir 0.1% - - 50 - 50 50 50 199 - West Pokot 0.4% 413 0 143 42 143 143 143 574 42 Total 100.0% 74,511 65 36,065 39,399 36,065 - 36,065 - 36,065 - 144,278 39,399

99 FY 19 Q1 Oct– Dec Quarterly Report

Annex 3: Number of PLHIV nutritionally assessed via anthropometric measurement INDICATOR TITLE: Number of PLHIV nutritionally assessed via anthropometric measurement INDICATOR NUMBER:FN_ASSESS UNIT: DISAGGREGATE BY: COUNTY Geographic Location Activity Title Date M ALL Data Management, Reporting Results: Additional Criteria Results Baseline Achieved Reporting Period Reporting Period Reporting Period Reporting Period (January FY 2017/19 Target Prior 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 2015) Periods County % Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Baringo 2.2% 4,904 8,198 2,155 1,672 2,155 2,155 2,155 8,621 1,672 Bomet 1.1% 2,504 4,138 1,100 1,080 1,100 1,100 1,100 4,402 1,080 Bungoma 1.2% 2,674 32,237 1,175 12,994 1,175 1,175 1,175 4,700 12,994 Busia 0.4% 815 60,700 358 8,860 358 358 358 1,433 8,860 Elgeyo Marakwet 0.5% 1,045 3,386 459 944 459 459 459 1,837 944 Embu 5.9% 13,019 4,546 5,722 1,381 5,722 5,722 5,722 22,887 1,381 Garissa 1.0% 2,250 1,829 989 684 989 989 989 3,956 684 Homa Bay 6.4% 13,928 152,961 6,121 33,525 6,121 6,121 6,121 24,485 33,525 Isiolo 0.7% 1,575 964 692 469 692 692 692 2,768 469 Kajiado 1.6% 3,431 4,319 1,508 1,358 1,508 1,508 1,508 6,032 1,358 Kakamega 2.5% 5,415 36,501 2,380 8,212 2,380 2,380 2,380 9,520 8,212 Kericho 3.1% 6,782 20,159 2,981 6,159 2,981 2,981 2,981 11,923 6,159 Kiambu 2.8% 6,225 52,650 2,736 10,788 2,736 2,736 2,736 10,943 10,788 Kilifi 1.5% 3,293 17,704 1,447 5,603 1,447 1,447 1,447 5,789 5,603 Kirinyaga 2.2% 4,882 7,963 2,146 2,177 2,146 2,146 2,146 8,582 2,177 Kisii 1.2% 2,664 1,896 1,171 336 1,171 1,171 1,171 4,683 336 Kisumu 5.4% 11,812 35,710 5,191 6,417 5,191 5,191 5,191 20,765 6,417 Kitui 1.3% 2,919 11,866 1,283 6,188 1,283 1,283 1,283 5,132 6,188 Kwale 0.6% 1,391 1,635 611 290 611 611 611 2,445 290 Laikipia 0.3% 657 2,986 289 1,890 289 289 289 1,156 1,890 Lamu 1.2% 2,598 - 1,142 - 1,142 1,142 1,142 4,567 - Machakos 3.3% 7,865 12,678 3,168 2,794 3,168 3,168 3,168 12,672 2,794 Makueni 0.9% 2,062 15,562 906 4,062 906 906 906 3,625 4,062 Mandera 0.0% ------

100 FY 19 Q1 Oct– Dec Quarterly Report

INDICATOR TITLE: Number of PLHIV nutritionally assessed via anthropometric measurement INDICATOR NUMBER:FN_ASSESS UNIT: DISAGGREGATE BY: COUNTY Geographic Location Activity Title Date M ALL Data Management, Reporting Results: Additional Criteria Results Baseline Achieved Reporting Period Reporting Period Reporting Period Reporting Period (January FY 2017/19 Target Prior 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 2015) Periods County % Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Marsabit 0.7% 1,507 1,164 662 950 662 662 662 2,649 950 Meru 2.0% 4,350 7,245 1,912 2,259 1,912 1,912 1,912 7,648 2,259 Migori 3.7% 8,139 9,942 3,577 1,328 3,577 3,577 3,577 14,308 1,328 Mombasa 7.1% 15,531 11,324 6,826 3,497 6,826 6,826 6,826 27,303 3,497 Murang'a 2.8% 6,115 13,915 2,687 3,230 2,687 2,687 2,687 10,750 3,230 Nairobi 9.1% 18,084 129,073 8,759 29,135 8,759 8,759 8,759 35,035 29,135 Nakuru 2.4% 5,184 33,441 2,278 7,375 2,278 2,278 2,278 9,113 7,375 Nandi 2.4% 5,190 29,511 2,281 6,675 2,281 2,281 2,281 9,123 6,675 Narok 1.0% 2,244 17,108 986 3,174 986 986 986 3,945 3,174 Nyamira 0.0% - 4,089 - 4,900 - - - - 4,900 Nyandarua 2.4% 5,188 4,811 2,280 793 2,280 2,280 2,280 9,120 793 Nyeri 2.6% 5,803 8,361 2,550 2,132 2,550 2,550 2,550 10,202 2,132 Samburu 0.7% 1,565 1,919 688 953 688 688 688 2,751 953 Siaya 6.5% 14,188 8,529 6,236 2,121 6,236 6,236 6,236 24,942 2,121 Taita Taveta 1.7% 3,643 2,931 1,601 216 1,601 1,601 1,601 6,404 216 Tana River 0.1% 172 - 76 - 76 76 76 302 - Tharaka Nithi 2.1% 4,530 1,950 1,991 1,660 1,991 1,991 1,991 7,964 1,660 Trans Nzoia 0.5% 1,169 7,187 514 1,564 514 514 514 2,055 1,564 Turkana 3.3% 7,268 21,880 3,194 9,309 3,194 3,194 3,194 12,777 9,309 Uasin Gishu 0.0% - 43,582 - 13,841 - - - - 13,841 Vihiga 0.9% 2,034 39,941 894 9,342 894 894 894 3,576 9,342 Wajir 0.1% 302 - 133 - 133 133 133 530 - West Pokot 0.4% 871 1,089 383 1,291 383 383 383 1,532 1,291 Total 100.0% 219,000 889,580 96,238 223,628 96,238 - 96,238 - 96,238 - 385,000 223,628

101 FY 19 Q1 Oct– Dec Quarterly Report

Annex 4: Number of children under 5 who received Vitamin A from USG supported programs

INDICATOR TITLE:3.1.9.2(3): Number of children under 5 who received Vitamin A from USG supported programs INDICATOR NUMBER:FtF UNIT: DISAGGREGATE BY: COUNTY Geographic Location Activity Title Date M ALL Data Management, Reporting Results: Additional Criteria Baseline Results Reporting Period Reporting Period Reporting Period Reporting Period (December Achieved FY 2019 Target If other criteria are important, add 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 lines for setting targets and tracking 2014) Prior Periods Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved County % N N N N N N N N N N N N Busia - 100,730 122,840 137,957 137,957 137,957 Kitui - 88,085 137,564 160,232 160,232 160,232 Marsabit - 32,466 27,182 48,484 48,484 48,484 Samburu - 24,799 31,618 50,339 50,339 50,339 Tharaka Nithi - 38,958 32,252 43,376 43,376 43,376 Total - 285,038 351,456 440,389 440,389 440,389 Data reported here is based on bi-annual child health activities conducted in Nov 2018 and May 2019

102 FY 19 Q1 Oct– Dec Quarterly Report

Annex 5: Number of people trained in child health and nutrition through USG-supported programs)

INDICATOR TITLE: (3.1.9(1) Number of people trained in child health and nutrition through USG-supported programs) INDICATOR NUMBER:USAID/MSI UNIT: Geographic Location Activity Title Date M Data Management, Reporting Results: Additional Criteria Baseline Reporting Period Reporting Period Reporting Period Reporting Period If other criteria are important, add (December FY 2019 Target 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 lines for setting targets and tracking 2014) County % Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N Busia 218 Kitui Tharaka Nithi 61 Marsabit 48 Samburu Total 327 •

103 FY 19 Q1 Oct– Dec Quarterly Report

Annex 6: Number of children under five (0-59 months) reached with nutrition specific interventions by USG-supported nutrition programs

INDICATOR TITLE: 3.1.9(15): HL.9-1 Number of children under five (0-59 months) reached with nutrition specific interventions by USG-supported nutrition programs INDICATOR NUMBER: FtF UNIT: Geographic Location Activity Title Date M Data Management, Reporting Results: Additional Criteria Baseline Reporting Period Reporting Period Reporting Period Reporting Period If other criteria are important, add (December FY 2019 Target lines for setting targets and tracking 2014) 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 County Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved % N N N N N N N N N N N Busia - 122,840 137,957 137,957 137,957 Kitui - 137,564 160,232 160,232 160,232 Marsabit - 27,182 48,484 48,484 48,484 Samburu - 31,618 50,339 50,339 50,339 Tharaka Nithi - 32,252 43,376 43,376 43,376 Total - 351,456 440,389 440,389 440,389 Data reported here is based on dewormed children 12 – 59 months done bi-annually in November and May .

104 FY 19 Q1 Oct– Dec Quarterly Report

Annex 7: Number of pregnant women reached with nutrition-specific interventions through USG-supported programs (RAA)

INDICATOR TITLE: 3.1.9(15): Number of pregnant women reached with nutrition-specific interventions through USG-supported programs (RAA) INDICATOR NUMBER:FtF UNIT: Geographic Location Activity Title Date M Data Management, Reporting Results: Additional Criteria Baseline Reporting Period Reporting Period Reporting Period Reporting Period If other criteria are important, add lines (December FY 2019 Target for setting targets and tracking 2014) 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved County % N N N N N N N N N N N Busia - 7,438 6,082 7,438 7,438 7,438 29,750 Kitui - 9,524 6,731 9,524 9,524 9,524 38,097 Marsabit - 3,049 3,002 3,049 3,049 3,049 12,194 Samburu - 2,613 2,699 2,613 2,613 2,613 10,451 Tharaka Nithi - 2,599 3,188 2,599 2,599 2,599 10,396 Total - 25,222 21,702 25,222 25,222 25,222 100,887

105 FY 19 Q1 Oct– Dec Quarterly Report

Annex 8: Comprehensive NACS implemented providing services beyond CCC/ART sites INDICATOR TITLE: 3.1.9(15): Comprehensive NACS implemented providing services beyond CCC/ART sites INDICATOR NUMBER: UNIT: Geographic Location Activity Title Date M Data Management, Reporting Results: Additional Criteria Results Baseline Achieved Reporting Period Reporting Period Reporting Period Reporting Period If other criteria are important, (December FY 2019 Target Prior 31/Dec/18 31/Mar/19 30/Jun/19 30/Sep/19 add lines for setting targets and 2014) tracking Periods County % Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved N N N N N N N N N N N N Busia 15.6% - 19 Kitui 41.0% - 26 Marsabit 13.3% - 7 Samburu 10.5% - 9 Tharaka Nithi 19.6% - 11 Total - 72 - -

106 FY 19 Q1 Oct– Dec Quarterly Report

ANNEX II: GIS INFORMATION ON AGRI NUTRITION GROUPS/ACTIVITIES

Activity Start Date End Date County Longitude Latitude Sub County Ward

Child Growth Assessment/ Growth Monitoring 15-Oct-2018 19-Oct-2018 Tharaka Nithi 37.5817 0.9160 Tharaka-South Marimanti Child Growth Assessment/ Growth Monitoring 15-Oct-2018 19-Oct-2018 Tharaka Nithi 38.0157 -0.1026 Tharaka-North Gatunga Integrated Community Outreaches 22-Oct-2018 26-Oct-2018 Tharaka Nithi 37.5817 0.9160 Tharaka-South Marimanti Integrated Community Outreaches 22-Oct-2018 26-Oct-2018 Tharaka Nithi 38.0157 -0.1026 Tharaka-North Gatunga Familia Bora TOT Training 12-Nov-2018 26-Oct-2018 Tharaka Nithi 37.5817 0.9160 Tharaka-South Marimanti Familia Bora CHVs Training 14-Nov-2018 16-Nov-2018 Tharaka Nithi 37.5817 0.9160 Tharaka-South Marimanti Households Mapping 15-Oct-2018 19-Oct-2018 Tharaka Nithi E37°57'25" S0°2'25" Tharaka-South Nkondi Households Mapping 15-Oct-2018 19-Oct-2018 Tharaka Nithi 38.1471 -0.0976 Tharaka-North Gatunga Community Mother Support Groups (CMSGs) Meetings 6-Nov-2018 6-Nov-2018 Tharaka Nithi E37°57'25" S0°2'25" Tharaka-South Nkondi Community Mother Support Groups (CMSGs) Meetings 24-Oct-2018 24-Oct-2018 Tharaka Nithi 38.147090 -0.097560 Tharaka-North Gatunga Mother-to-Mother Support Groups Meetings 1-Oct-2018 31-Dec-2018 Tharaka Nithi E37°57'25" S0°2'25" Tharaka-South Nkondi Mother-to-Mother Support Groups Meetings 1-Oct-2018 31-Dec-2018 Tharaka Nithi 38.1471 -0.0976 Tharaka-North Gatunga Food Preparation Sessions 1-Oct-2018 31-Dec-2018 Tharaka Nithi 37.5817 0.9160 Tharaka-South Marimanti Food Preparation Sessions 1-Oct-2018 31-Dec-2018 Tharaka Nithi 38.0157 -0.1026 Tharaka-North Gatunga Promote the Vertical Bag Farm Technology: 1-Oct-2018 31-Dec-2018 Tharaka Nithi 37.5817 0.9160 Tharaka-South Marimanti Promote the Vertical Bag Farm Technology: 1-Oct-2018 31-Dec-2018 Tharaka Nithi 38.0157 -0.1026 Tharaka-North Gatunga Promotion of the Egg Value Chain for Increased Egg 1-Oct-2018 31-Dec-2018 Tharaka Nithi Tharaka-South Marimanti Consumption Among the Under Fives in the Program ZOIs: 37.5817 0.9160 Promotion of the Egg Value Chain for Increased Egg 1-Oct-2018 31-Dec-2018 Tharaka Nithi Tharaka-North Gatunga 38.0157 -0.1026 Consumption Among the Under Fives in the Program ZOIs: Promotion of Nutrition Sensitive Interventions E.g. Improved 1-Oct-2018 31-Dec-2018 Tharaka Nithi Tharaka-South Marimanti WASH Practices 37.5817 0.9160 Promotion of Nutrition Sensitive Interventions E.g. Improved 1-Oct-2018 31-Dec-2018 Tharaka Nithi Tharaka-North Gatunga 38.0157 -0.1026 WASH Practices Financial Inclusion Training to Community Support Groups 26-Nov-2018 28-Nov-2018 Tharaka Nithi Igambang'ombe Igambang'ombe 37.8312 -0.3354

107 FY 19 Q1 Oct– Dec Quarterly Report

Activity Start Date End Date County Longitude Latitude Sub County Ward

Addressing the challenges faced on IGAs initiated as identified in 10-Dec-2018 10-Dec-2018 Samburu Samburu North Nachola 36.7124 1.7833 the November follow up activity. Follow up of IGA activities in Marti. 11-Dec-2018 11-Dec-2018 Samburu 36.7223 1.6016 Samburu North Nachola Food preparation and cooking (cooking demonstrations) 12-Dec-2018 12-Dec-2018 Samburu 36.9195 2.0993 Samburu North Nyiro Food preparation and cooking (cooking demonstrations) 13-Dec-2018 13-Dec-2018 Samburu 36.7124 1.7833 Samburu North Nachola Attending the CMSGs Bi-monthly BFCI meeting in Nachola 14-Dec-2018 14-Dec-2018 Samburu 36.7124 1.7833 Samburu North Nachola Nutrition assessment, counseling and supplementation at Baragoi 17-Dec-2018 17-Dec-2018 Samburu Samburu North El-Barta 36.7923 1.7852 sub county hospital nutrition clinic Support supervision of MCH clinic at Baragoi catholic dispensary. 18-Dec-2018 18-Dec-2018 Samburu 36.7923 1.7852 Samburu North El-Barta Integrated outreach at nteremuka. 19-Dec-2018 19-Dec-2018 Samburu 36.9615 1.5298 Samburu North El-Barta Food preparation and cooking (cooking demonstrations) 12-Dec-2018 12-Dec-2018 Samburu 36.4833 0.5511 Samburu Central Kisima Food preparation and cooking (cooking demonstrations) 11-Dec-2018 11-Dec-2018 Samburu 36.4831 0.5532 Samburu Central Kisima WASH activities in primary schools 15-Oct-2018 15-Oct-2018 Samburu Samburu East 37.2016 0.9355 WASH activities in primary schools 15-Oct-2018 15-Oct-2018 Samburu Samburu East 37.0704 1.1011 WASH activities in primary schools 16-Oct-2018 16-Oct-2018 Samburu Samburu East 36.9756 1.2405 WASH activities in primary schools 17-Oct-2018 17-Oct-2018 Samburu Samburu East 37.0328 1.3604 WASH activities in primary schools 17-Oct-2018 17-Oct-2018 Samburu Samburu East 37.1702 1.1868

WASH activities in primary schools 17-Oct-2018 17-Oct-2018 Samburu Samburu East 37.1709 1.1364 WASH activities in primary schools 18-Oct-2018 18-Oct-2018 Samburu Samburu East 37.0884 1.0226 WASH activities in primary schools 18-Oct-2018 18-Oct-2018 Samburu Samburu East 37.1276 1.3273 WASH activities in primary schools 19-Oct-2018 19-Oct-2018 Samburu Samburu East 37.2142 0.7959

108 FY 19 Q1 Oct– Dec Quarterly Report

Activity Start Date End Date County Longitude Latitude Sub County Ward

WASH activities in primary schools 19-Oct-2018 19-Oct-2018 Samburu Samburu East 37.1025 0.8088

Food preparation and cooking (cooking demonstrations) 18-Dec-2018 18-Dec-2018 Samburu 37.6700 0.6478 Samburu East Achers Post Community outreach 15-Nov-2018 15-Nov-2018 Samburu 37.6600 0.6808 Samburu East Achers Post integrated outreach at ncharda. 20-Dec-2018 20-Dec-2018 Samburu 36.7212 1.4743 Samburu North Nachola Bi monthly outreach 1-Nov-2018 1-Nov-2018 Busia 34.0913 0.3031 Samia Nangina Supervision of Agri nutrition group 1-Nov-2018 1-Nov-2018 Busia 34.1321 0.2756 Samia Nangina Foods Demonstration 2-Nov-2018 2-Nov-2018 Busia 34.0321 0.2207 Samia Bwiri/Nanguba Bi monthly outreach 6-Nov-2018 6-Nov-2018 Busia 34.0713 0.2711 Samia Nangina Agri nutrition demonstration/Support supervision on Vertical bags 7-Nov-2018 7-Nov-2018 Busia 34.1321 0.2756 Samia Nangina MtMSG Monthly Meeting 16-Nov-2018 16-Nov-2018 Busia 34.1031 0.2748 Samia Nangina Cooking Demonstration 20-Nov-2018 20-Nov-2018 Busia 34.0975 0.1673 Samia Bwiri/Nanguba Familia Bora Health Workers Training 13-Dec-2018 13-Dec-2018 Busia 34.1189 0.2825 Samia Namboboto CHVs Monthly Meeting 17-Dec-2018 17-Dec-2018 Busia 34.0983 0.2772 Samia Nangina Familia Bora CHVs Training 18-Dec-2018 19-Dec-2018 Busia 34.1189 0.2825 Samia Namboboto Climate Smart Agri nutrition Training 20-Dec-2018 20-Dec-2018 Busia 34.0118 0.1999 Samia Bwiri HINI Gap Assessment 8-Nov-2018 8-Nov-2018 Busia 34.2582 0.3379 Butula Kingandole HINI Gap Assessment 7-Nov-2018 7-Nov-2018 Busia 34.3518 0.3922 Butula Marachi North HINI Gap Assessment 6-Nov-2018 6-Nov-2018 Busia 34.2295 0.3460 Butula Marachi Central HINI Gap Assessment 6-Nov-2018 6-Nov-2018 Busia 34.1926 0.3000 Butula Marachi West HINI Gap Assessment 7-Nov-2018 7-Nov-2018 Busia 34°19'40.5"E 0.327392 Butula Marachi North MtMSG meeting 14-Nov-2018 14-Nov-2018 Busia 0.4330 34.2249 Teso North Angurai East MtMSG meeting 13-Nov-2018 13-Nov-2018 Busia 0.4241 34.2335 Teso North Angurai East MtMSG meeting 13-Nov-2018 13-Nov-2018 Busia 34.2335 2.0424 Teso North Angurai East Facility in charges meeting 5-Nov-2018 5-Nov-2018 Busia 0.2273 34.0250 Samia Agenga Nanguba BFCI Sensitization meeting 7-Nov-2018 7-Nov-2018 Busia Nambale Bukhayo East 0.4771 34.3467

109 FY 19 Q1 Oct– Dec Quarterly Report

Activity Start Date End Date County Longitude Latitude Sub County Ward

FAMILIA BORA Sensitization meeting 5-Dec-2018 5-Dec-2018 Busia 0.4553 34.2386 Nambale Township MtMSG meeting 14-Nov-2018 14-Nov-2018 Busia 34.2249 0.4330 Teso North Angurai East MtMSG meeting 13-Nov-2018 13-Nov-2018 Busia 34.2335 0.4241 Teso North Angurai East MtMSG meeting 13-Nov-2018 13-Nov-2018 Busia 34.2335 2.0424 Teso North Angurai East MtMSG meeting 4-Dec-2018 4-Dec-2018 Busia 34.1956 0.3742 Teso North Malaba Central MtMSG meeting 9-Nov-2018 9-Nov-2018 Busia 34.1956 0.3742 Teso North Malaba Central CHV Monthly meeting 27-Oct-2018 27-Oct-2018 Busia 34.4259 0.7325 Teso North Angurai East MTMSG 18-Dec-2018 Busia 34.4259 0.7325 Teso North Angurai East Training of Goro Rukesa Community heath volunteers on BFCI 17-Sep-2018 21-Sep-2018 Marsabit 38.0550 2.3411 Saku Sagante Jaldesa Community Health volunteer monthly meeting 14-Dec-2018 14-Dec-2018 Marsabit 38.0550 2.3411 Saku Sagante Jaldesa Sensitization of the Community Health committee, primary health 19-Sep-2018 19-Sep-2018 Marsabit 38.5832 3.5915 Moyale Uran care facility management committee, administrators and community leaders on BFCI. Data review through health facility in-charges meeting 27-Sep-2018 27-Sep-2018 Marsabit 38.3841 3.3334 Moyale Sololo

CHVs monthly meeting and mentorship 13-Dec-2018 13-Dec-2018 Marsabit 38.5832 3.5915 Moyale Uran Familia Bora Training for TOTs and the CHVs 12-Nov-2018 16-Nov-2018 Marsabit 36.7139 2.7600 Laisamis Loiyangalani Planting Mangroove trees 31-Oct-2018 31-Oct-2018 Marsabit 36.6983 2.8281 Laisamis Loiyangalani

Installation of brick cooler 2-Nov-2018 3-Nov-2018 Marsabit 36.7181 2.7561 Laisamis Loiyangalani **** Note that the Household Beneficiaries mainly include the project target beneficiaries such as children under five years, pregnant and lactating women

110 FY 19 Q1 Oct– Dec Quarterly Report