The USAID/Kenya and East Africa Afya Jijini Program
USAID KENYA AND EAST AFRICA/AFYA JIJINI PROGRAM QUARTERLY AND ANNUAL PROGRESS REPORT – YEAR 4 (FY 2019)
OCTOBER 2019 This publication was produced for review by the United States Agency for International Development. It was prepared by IMA World Health. Prepared by IMA World Health for USAID/KENYA and East Africa
USAID KENYA AND EAST AFRICA/AFYA JIJINI PROGRAM FY2019 Q4 PROGRESS REPORT & FY2019 ANNUAL PERFORMANCE REPORT
1 JULY 2019 – 30 SEPTEMBER 2019 (Quarterly Report) 1 October 2018 – 30 SEPTEMBER 2019 (Annual Performance Report)
Award No.: AID-615-C-15-00002
Prepared for Dr. Teresa Simiyu, COR USAID/Kenya and East Africa C/o American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya
Prepared by: IMA World Health 1730 M Street N.W., Suite 1100 Washington, DC 20036
October 30, 2019
DISCLAIMER The authors’ views expressed in this report do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Prepared by IMA World Health for USAID/KENYA and East Africa
TABLE OF CONTENTS
ACRONYMS AND ABBREVIATIONS ...... 3
EXECUTIVE SUMMARY: FY2019/Q4 AND ANNUAL PERFORMANCE REPORT (APR) ...... 10
SUB-PURPOSE 1: INCREASED ACCESS/UTILIZATION OF QUALITY HIV SERVICES ...... 14 Output 1.1: Elimination of Mother-to-Child Transmission (eMTCT) ...... 14 Output 1.2 and 1.3 HIV Care, Support, and Treatment Service ...... 18 Output 1.4 Voluntary Medical Male Circumcision (VMMC) ...... 29 Output 1.5: TB/HIV Co-Infection Services ...... 30
SUB PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED REPRODUCTIVE, MATERNAL, NEONATAL AND CHILD HEALTH (RMNCH) AND FAMILY PLANNING (FP) ...... 35 Output 2.1: Maternal Neonatal Health (MNH) Services ...... 35 Output 2.2 Child health services ...... 43 Output 2.3 Family planning services ...... 45 Output 2.4: WASH Services Year 4 Quarter 4 and Annual Report ...... 48 Output 2.5: Nutrition services Y4Q4 and annual report ...... 54
SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS ...... 61 Output 3.1: Partnerships for Governance and Strategic Planning ...... 62 Output 3.2: HRH ...... 64 Output 3.3: Health Products and Technologies (HPT) ...... 65 Output 3.4: Strategic M&E Systems ...... 68 Output 3.5: Quality Assurance/ Quality Improvement (QA/QI) Systems ...... 72
B. CONSTRAINTS AND OPPORTUNITIES ...... 74
C. PERFORMANCE MONITORING ...... 75
D. PROGRESS ON GENDER STRATEGY ...... 75
E. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING . 76
F. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 77
G. PROGRESS ON LINKS WITH GOK AGENCIES ...... 77
H. PROGRESS ON USAID FORWARD ...... 77
I. SUSTAINABILITY AND EXIT STRATEGY ...... 78
J. GLOBAL DEVELOPMENT ALLIANCE (if applicable) ...... 79
K. SUBSEQUENT QUARTER’S WORK PLAN ...... 79
1 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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L. FINANCIAL INFORMATIOn ...... 79
M. ACTIVITY ADMINISTRATION ...... 79
IV. ANNUAL SUPPLEMENT TO QUARTERLY REPORT ...... 79
III. ACTIVITY PROGRESS OF Q4 AND ANNUAL PROGRESS REPORT ...... 79
V. GPS INFORMATION ...... 79
VI. SUCCESS STORY ...... 79
VII. ANNEXES AND ATTACHMENTS ...... 79
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ACRONYMS AND ABBREVIATIONS ACF Active Case Finding ACT Accelerating Children’s HIV/AIDS Treatment Initiative AGYW Adolescents Girls and Young Women ALHIV Adolescent Living with HIV AMSTL Active Management of the Third Stage of Labor ANC Antenatal Care APHIAplus AIDS, Population, and Health Integrated Assistance Plus APOC Adolescent Package of Care APR Annual Performance Report ART Antiretroviral Therapy AVD Assisted Vaginal Delivery AWP Annual Work Plan AYRSH Adolescent and Youth Sexual and Reproductive Health BCC Behavior Change Communications BEmONC Basic Emergency Obstetric and Newborn Care BHESP Bar Hostess Empowerment and Support Program BMI Body Mass Index CASCO County HIV/AIDS and STI Coordinator CBD Community-Based Distribution CBHIS Community-based Health Information System CECM-HS County Executive Committee Member- Health Services CCC Comprehensive Care Center CHA Community Health Assistant CHAI Clinton Health Access Initiative CHISP Nairobi City County Health Sector Strategic and Investment Plan CHMT County Health Management Team CHV Community Health Volunteer CLTS Community-Led Total Sanitation CME Continuing Medical Education CMLT County Medical Laboratory Technician CNAP County Nutrition Action Plan CNTF County Nutrition Technical Forum COC Continuum of Care COH Chief Officer Health COP Country Operational Plan COP Chief of Party CTLC County TB/Leprosy Coordinator CWC Child Welfare Clinic CYP Couple Year of Protection DAC DREAMS Advisory Committee DBS Dried Blood Spot DCM Differentiated Care Model DCOP Deputy Chief of Party DHIS2 District Health Information System 2 DICE Drop-In Center DMPA Depot-Medroxyprogesterone Acetate (also known as Depo-Provera) DOT Directly-Observed Therapy DQA Data Quality Assurance DREAMS Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe Women Initiative DRTB Drug Resistant Tuberculosis EBF Exclusive Breastfeeding Feeding
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EBI Evidence-Based Intervention ECD Early Childhood Development EID Early Infant Diagnosis EMMP Environmental Monitoring and Mitigation Plan EmONC Emergency Obstetric and Newborn Care EMR Electronic Medical Record eMTCT Elimination of Mother-to-Child Transmission EPI Expanded Program on Immunization FANC Focused Antenatal Care FBO Faith-Based Organization FGD Focus Group Discussion FHOK Family Health Options Kenya FMP Family Matters Program FP Family Planning FSB Fresh Stillbirth FSW Female Sex Worker GBV Gender-Based Violence GoK Government of Kenya HAART Highly Active Anti-Retroviral Therapy HCSM Health Commodity and Supply Management HCA HIV Cohort Analysis HCBF Healthy Choices for a Better Future HCMP Healthcare Management Plan HCW Healthcare Worker HCWM Health Care Waste Management HEI HIV-Exposed Infant HINI High-impact Nutrition Intervention HOYMAS Health Options for Young Men on HIV/AIDS/STIs HRIO Health Records and Information Officer HPT Health Products and Technologies HR Human Resources HRH Human Resources for Health HRM Human Resources Management HSS Health Systems Strengthening HTS HIV Testing Services HWWK Hope Worldwide Kenya HWMP Healthcare Waste Management Plan ICF Intensified Case Finding ICT Information Communication Technology IEC Information, Education, and Communication IEE Initial Environmental Examination IFAS Iron and Folic Acid Supplementation IMAM Integrated Management of Malnutrition IMCI Integrated Management of Childhood Illness INERELA International Network of Religious Leaders Living with or personally affected by HIV and AIDS INH Isoniazid IPC Infection Prevention and Control IPD Inpatient Department IPT Isoniazid Preventative Therapy IUCD Intrauterine Contraceptive Device KEMSA Kenya Medical Supplies Agency KEPI Kenya Expanded Program on Immunization KHQIF Kenya HIV Quality Improvement Framework 4 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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KII Key Informant Interview KMC Kangaroo Mother Care KMTC Kenya Medical Training College KP Key Population KQMH Kenya Quality Model for Health KSG Kenya School of Government L&D Labor and Delivery LARC Long-Acting Reversible Contraception LDP+ Leadership Development Program Plus LMIS Logistic Management Information Systems LMS Leadership Management and Sustainability project LTFU Lost-to-Follow-Up M&E Monitoring and Evaluation MAM Moderate-Acute Malnutrition MAP Men as Equal Partners MCH Maternal and Child Health MDR-TB Multi-Drug Resistant TB MDSR Maternal Death and Surveillance Response MDTs Multi-Disciplinary Teams MEC Medical Eligibility Criteria MHMC My Health, My Choice MIYCN Maternal Infant and Young Child Nutrition MLKH Mama Lucy Kibaki Hospital MMR Measles, Mumps, Rubella MNCH Maternal, Newborn, and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Review, Surveillance, and Response MSW Male Sex Workers MTC Medicine Therapeutic Committee MUAC Mid-Upper Arm Circumference NACC National AIDS Control Council NACS Nutritional Assessment Counseling and Support NASCOP National AIDS and STI Control Program NCC Nairobi City County NHIF National Health Insurance Fund NHRL National HIV Reference Laboratory NPA Nasopharyngeal Aspirates NPA/NG Nasogastic and Nasopharyngeal Aspirate NTLDP National Tuberculosis, Leprosy, and Lung Disease Program ODF Open Defecation-Free OI Opportunistic Infection OJT On-the-Job Training OPD Outpatient Department ORS Oral Rehydration Solution ORT Oral Rehydration Therapy OTP Outpatient Therapy OTZ Operation Triple Zero OVC Orphans and Vulnerable Children PAC Post-Abortion Care PAS Performance Appraisal System PCR Polymerase Chain Reaction (test) PEP Post-Exposure Prophylaxis PHDP Positive Health Dignity and Prevention 5 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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PHO Public Health Officer PITC Provider-Initiated Testing and Counseling PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission PNC Post-Natal Care PNS Partner Notification Services POC Point-of-Care POU Point-of-Use PPFP Post-Partum Family Planning PrEP Pre-Exposure Prophylaxis PSM Patient Self-Management PSS Psychosocial Support PSSG Psychosocial Support Group PT Proficiency Testing QA Quality Assurance QA/QI Quality Assurance/Quality Improvement QI Quality Improvement QIT Quality Improvement Team RDQA Routine Data Quality Assessment RED Reach Every District RH Reproductive Health RMNCH Reproductive, Maternal, Newborn, and Child Health RRI Rapid Results Initiative RTK Rapid Test Kit RUSF Ready-to-Use Supplementary Food RUTF Ready-to-Use Therapeutic Food SAB Social Asset Building SAM Severe Acute Malnutrition SBA Skilled Birth Attendants SCASCO Sub-County HIV/AIDS and STI Coordinator SCHMT Sub-County Health Management Teams SCMLT Sub-County Medical Laboratory Technician SCNTF Sub-County Nutrition Technical Forums SCPHN Sub-County Primary Health Care Nurse SCTLC Sub-County TB/Leprosy Coordinator SGBV Sexual- and Gender-Based Violence SIA Supplemental Immunization Activities SOPs Standard Operating Procedures SMLT Sub-County Medical and Laboratory Technologist SRH Sexual and Reproductive Health STI Sexually-Transmitted Infection STLC Sub-County Tuberculosis and Lung Disease Coordinator TA Technical Assistance TB Tuberculosis TIBU EMR for TB patient data TLD Tenofovir disoproxil fumarate, Lamivudine, and Dolutegravir TOR Terms of Reference TOT Training of Trainers TPA Treatment preparation and Adherence TWG Technical Working Group UCLTS Urban Community-Led Total Sanitation UCT Unconditional Cash Transfer UHAI Team an IMA innovation of technical support teams VAS Vitamin A Supplementation 6 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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VL Viral Load VMMC Voluntary Medical Male Circumcision WASH Water, Sanitation, and Hygiene WCD World Contraception Day WITs Work Improvement Teams WRA Women of Reproductive Age YFS Youth-Friendly Services
7 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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EXECUTIVE SUMMARY: FY2019/Q4 AND ANNUAL PERFORMANCE REPORT (APR)
Afya Jijini is a five year USAID-funded contract designed to strengthen Nairobi City County-level institutional and management capacity to deliver quality healthcare services. Specifically, the project aims to improve access to and uptake of quality health services in Nairobi City County (NCC) for the most pressing health issues, with a focus in the informal settlements. Afya Jijini provided technical assistance to 42 Comprehensive Care Clinics (CCCs) (29 of which are high volume sites); 43 elimination of mother-to-child transmission (eMTCT) sites; 78 HIV testing services (HTS) sites; 69 maternities; 189 integrated management of acute malnutrition (IMAM) sites; and 247 family planning (FP) service sites in NCC. The program continued to build on gains made from year one to three, focusing on strategies to achieve the UNAIDS 95-95-95 cascade targets, increasing access to and utilization of MNCH/FP WASH and nutrition services, strengthening county referral systems, and achieving other key deliverables outlined in the Year 4 Approved work plan through close collaboration with NCC, sub-counties, USAID, USAID-funded projects, and other implementers.
This report presents achievements, specifically in Quarter 4 (Q4), as well as results of the project’s annual progress for Year 4 (Y4).
Qualitative Impact
Sub-Purpose 1: Increased Access and Utilization of Quality HIV Services In Q4, the project continued to train and mentor health care workers (HCWs) to implement updated 2018 ART guidelines, the revised National AIDS and STI Control Program (NASCOP) HIV tools, and partner notification services to equip HCWs with necessary skills and knowledge for quality service delivery. In addition, the project accelerated activities towards 95:95:95 through the SURGE strategy. Assisted partner notification (aPNS) and index client follow up as well as eligibility screening were supported in 28 high volume facilities for more efficient and targeted testing. The project worked through peer educators to link those identified as HIV positive and return those lost to follow up (LFTU) back to care (BTC). The project continued to work with a grantee for community coverage for eMTCT, engaging community mentor mothers and male agents of change. In addition, the project supported and participated in the county’s eMTCT business plan development to fast track the eMTCT agenda. In Q4, 93% of clients in the CCC who had their viral load tested were suppressed. Enhanced adherence counseling (EAC) was offered to clients who were not suppressed and, in 29 facilities, high viremia clinics were implemented. Operation Triple Zero (OTZ) was implemented across 22 facilities for adolescents living with HIV (ALHIV) to further improve their suppression rate (80% in Q4). Early morning clinic hours were supported in four facilities reaching 645 men who were enrolled in psychosocial support groups. Through a grant to INERELA, the project continued to offer HIV testing services (HTS) in faith communities identifying 61 (6% yield) new HIV positive clients. To promote the journey to self-reliance (J2SR), the project supported integration of VMMC services at the facility level and supported formation and operationalization of the County VMMC Technical Working Group (TWG), and the sub county VMMC steering committees. Sexual gender based violence reporting was strengthened through monthly data review and feedback sessions while service provision was enhanced through distribution and utilization of referral tools such as Referral Pathways for Sexual Violence and Algorithms for Sexual Violence. The project increased support to adherence to tuberculosis (TB) medicines by establishing support groups for TB patients and directly observed therapy (DOTs) for drug resistant TB (DRTB) patients. Extended hours services were offered to reach male clients who had TB.
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Sub-Purpose 2: Increased Access and Utilization of Focused Maternal, Newborn, and Child Health (MNCH), FP, Water, Sanitation, and Hygiene (WASH), and Nutrition Services. In Q4, the project supported programs to reduce maternal, neonatal and childhood morbidity and mortality in Nairobi County. Afya Jijini supported a three-day training on Focused Antenatal Care (FANC) reaching 79 HCWs to improve their skills on management of pregnant women during ANC. The project also supported 55 CHVs who mapped households and reached 961 pregnant women referring 768 for early ANC and providing messages on ANC. Three open maternity days were held in Langata, Makadara and Eastleigh Health Centers with the aim of introducing maternity services to the community and increasing skilled birth delivery at the facilities. The project supported two MPDSR workshops reaching 25 HCWs and 30 CHVs from Embakasi West and Makadara sub counties where the highest maternal mortalities were recorded. KMC continued to be supported with 96% of the premature babies being discharged alive. CHVs supported mothers of newborns in the community with messages on care of premature and low birth weight babies.
During the quarter, supportive supervision, EPI micro planning meetings, and mentorship were supported to strengthen the cold chain, documentation and service provision to improve immunization coverage in the county. CMEs on IMNCI were supported in 55 facilities reaching 297 HCW to strengthen their capacity to manage diarrhea diseases and pneumonia in children under five years. CHVs referred 1,675 children for immunization and traced another 315 who had defaulted. Another 494 children were referred for management of diarrhea and 444 for treatment for pneumonia.
The project supported uptake of family planning (FP) through distribution and redistribution of FP commodities to ensure access to services. A total of 357 adolescents received information and services for FP through the Binti Shujaa model. In CCCs and PMTCT clinics, 15 clinicians received mentorship on FP integration and were given medical eligibility criteria (MEC) wheels, balanced counseling strategy plus (BCS+) cards, Tiahrt charts, and FP demonstration charts.
To further strengthen the J2SR, the county was supported to develop a County Environment and Sanitation bill by customizing the Kenya Environmental Sanitation and Health Policy. In Y4, six additional villages were triggered bringing the total number implementing urban community led total sanitation (UCLTS) to 40. The ECD model was implemented in eight estates in Makadara, Kamukunji and Kasarani sub counties. Afya Jijini reached 79,461 children with screening for malnutrition and 58,379 with handwashing messages.
Sub-Purpose 3: Strengthened and Functional County Health Systems. Afya Jijini has continued to support the County to strengthen systems to improve access and quality of health services in NCC targets. The project has focused on improving performance management and use of iHRIS for systematic capture of HRH data, and for HR decision-making. In Y3, the project continued to support the County through technical and logistical assistance to plan, implement, and monitor performance of the health sector. Stakeholder coordination has continued to improve with the County taking a lead role in planning and coordinating partners and stakeholder fora both at the county and sub county levels. To strengthen the supply chain, Afya Jijini has been working with the County and Sub County to strengthen pharmacovigilance and commodity coordination through capacity building sessions and supporting the quarterly technical working group forum. Following the finalization of the annual work plans (AWPs) in Q3, the County embarked on performance management activities ensuring staff begin to work on Performance Appraisal System (PAS) and linking their targets to the AWP. This was also followed by joint work planning (JWP) meetings with the County Health Management Team (CHMT), Sub-County Health Management Teams (SCHMTs), and Facility Health Management Teams (HMTs) to agree on activities that will be supported in Afya Jijini’s Year 4 work plan. Furthermore, the program supported the office of the
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County Stakeholder Coordinator to host the bi-annual county stakeholder meeting to validate the draft County Referral Strategy. The project held three meetings with County Public Service Management (PSM), the County Health Leadership Team and the County Public Service Board (CPSB) to discuss the transition and possible absorption of Afya Jijini-hired staff among other HRH issues. A key outcome of these meetings was the formation of a committee (headed by PSM) that will spearhead staff transition and the absorption process. Afya Jijini continued supporting sample networking for TB and HIV diagnostics and follow-up tests (CD4, VLs, EID, TB smears, and GeneXpert). In Y3, the project emphasized monitoring rejection rates and turn-around time for the results to ensure timely client management. Additionally, Afya Jijini provided five GeneXpert machines to mitigate service interruptions due to machine downtime. Afya Jijini worked in collaboration with the County QA/QI unit to build the capacity of HCWs on the use of QI principles to improve health care services through trainings and facility-based CME sessions. During the year (Q2, Q3, Q4), Afya Jijini supported the training of 95 HCWs drawn from facilities across all 10 sub counties on the Kenya Quality Model for Health (KQMH, 2011). Furthermore, the project continued to support the implementation of the county coaching strategy developed in Y3. The strategy focuses on the use of facility-based coaches to spearhead implementation of QI at the facility level. Afya Jijini began working with community sub grantees in Q3 to establish community work improvement teams (WITs), identify quality gaps and address them. One of the sub grantees, St. John’s Community Centre (SJCC), began working on a project to improve complete referral of mothers from the community to the facility. In Q4, Afya Jijini also sensitized the DREAMS team on the use of QI principles to improve service delivery in Afya Jijini. The team was able to form 18 community WITs in all safe spaces which have begun to identify gaps for improvement through QI.
Quantitative Impact (Y4, inclusive of Q4) In Q4, Afya Jijini targeted new antenatal care (ANC) clients at their first visit and offered HIV counseling and testing services to 13,224 bringing to an annual total of 52,195 of 66,420 targeted women at their first new ANC visit, with a yield of 4.6% positivity (76% of the annual target) in the 43 project- supported facilities. 2404 were identified as HIV positive achieving 79% of the annual target for identification of HIV positive pregnant women. In Q4, 1,970 newly-diagnosed clients were enrolled on treatment, representing an achievement of 110% of newly-diagnosed clients linked to treatment for the quarter. Out of the 2,184 patients who tested positive for HIV, 60% were linked and initiated on ART on the same day; 18% were initiated within the first two weeks of testing positive, 6% were linked after two weeks, 11% were linked outside the testing facilities while the remaining 11%, are being followed up. Furthermore, at the end of Y4, 99% (41,605 out of 42,105) of patients in care were on treatment. Of these, 32,810 of all 37,738 eligible clients or 86% of eligible clients reported having at least one viral load within the reporting period. This translated to an annual suppression of 93% as at APR.
In Q4, Afya Jijini supported the testing of 81,312 clients, with 2,185 (2.7%) new positives identified. The aPNS approach helped reach 4,484 partners of index clients, out of which 1,761 (39%) were tested for HIV and 414 (24%) tested positive. Cumulatively for Y4, 333,042 (150% of the annual HTS_TST) received HTS and 8,132 (117%) of the annual HTS-POS targets were identified as HIV positive. Through eligibility screening, the project managed to reduce the overall number of clients receiving an HIV test by 9,600 in the second half of the year, and subsequently, the yield increased from 2.3% at SAPR to 2.7% at APR.
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In Y4, the project cumulatively reached 6,446 clients (representing 103% of the annual target) with VMMC minimum package of care that included HTS and counseling; syndromic screening and treatment for STIs; provision of male and female condoms and promotion of their correct and consistent use; promotion of safer sex practices; provision of risk reduction counseling; and active linkages of HIV-positive clients from VMMC sites to HIV care and treatment programs. In Q4, 26,329 children under one year of age were reached with DTP3 vaccines; 25,198 were reached with measles vaccines; and 24,522 children were fully immunized (FIC). A total of 9,657 cases of pneumonia among under-five children were diagnosed and treated with antibiotics, and 18,579 cases of diarrhea were also treated at health facilities. In working towards achieving the project’s goal of reducing maternal and perinatal mortalities, the program worked with 183 facilities and 172 CHVs and reached 104,684 WRA with FP services, out of which 46,857 were new and 57,827 were revisits, consequently achieving 95,174 couple years of protection (CYP) over the quarter. Long-acting and reversible contraceptives (LARC) contributed to 65% of the total CYP. During Y4Q4, Afya Jijini’s WASH program improved and increased access and utilization of WASH services by strengthening service delivery and the capacity of the health system in the county to deliver WASH services and thereby reduce incidences of diarrheal diseases in children under five years. A total of 396 health workers and 175 CHVs were trained and sensitized on different WASH topics. A total of 29 health facilities provided diarrhea management services through their strengthened ORT corners, where 15,804 children were reached. Forty (40) communities (increased from 33 last year) were engaged in promoting sanitation by UCLTS, resulting in 1,147 sanitation facilities constructed or rehabilitated and benefitting over 900,000 people living in informal settlements Constraints and Opportunities (Y4, inclusive of Q4) Afya Jijini experienced and addressed several constraints during Y4 that affected project implementation. Frequent leadership changes at the County level have delayed service delivery and planned program implementation activities such as the human resource for health (HRH) transition. The recurring health care workers strikes following non implementation of the collective bargain agreement (CBA) had impact on services like MNCH with increased utility of the private facilities. Commodities have remained a problem and in the reporting period, outage of Anti-retroviral (ARV) drugs occasioned by change in national guideline required that close monitoring for uninterrupted services.
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SUB-PURPOSE 1: INCREASED ACCESS/UTILIZATION OF QUALITY HIV SERVICES
Output 1.1: Elimination of Mother-to-Child Transmission (eMTCT) Afya Jijini’s eMTCT approach in PY4 utilizes the global four-pronged approach to Prevention of Mother- to-Child Transmission (PMTCT) across the cascade. In Y4Q4, the program addressed each prong through multiple activities, as detailed in the Table 1 below.
Table 1: eMTCT Implementation by Prong (FY19/Q4) Prong Activity implementation Prong 1 Activities 1.1.1 and 1.1.9 provided patient education and HIV testing services (HTS) to 26,508 pregnant women at 1st visit, 3rd trimester, and FP to post-natal women at six weeks. In addition, condoms were distributed and PrEP was offered to discordant couples as part of prevention activities. Prong 2 Activities 1.1.1, 1.1.2, and 1.1.9 provided access to FP services through the integration of RH services in CCCs and client referrals. Prong 3 Activity 1.1.3 initiated 591 pregnant and 11 breastfeeding mothers on ART and monitored them for viral suppression and retention. Activity 1.1.4 tracked HIV-Exposed Infant (HEI) cohorts for eMTCT outcomes and impact. Facility-based and community-based mentor mothers continued to support retention, identification, and tracking of defaulters and led psychosocial support group (PSSG) activities at the facility and community levels. Prong 4 Activities 1.1.3, 1.15, 1.1.7, and 1.1.8 provided lifelong support to the mother and child and used the mother as the index client to reach out to other family members for HTS and linkages to other services.
13,282 14,000 12,864
12,000
10,000
8,000
6,000
4,000
2,000 601(5%) 591(98%) 0 Attending 1st ANC With Known Status Total Positives On HAART
Figure 1: eMTCT at 1st ANC in Q4
Identify 3,059 HIV-positive pregnant women through HIV testing and re-testing In Y4, Afya Jijini targeted new ANC clients at their first visit and offered HIV counseling and testing services to 12,864 of the 13,262 clients attending the first ANC visit, with a yield of 2% positivity (achieving 79% of the annual target) in the 42 project-supported facilities. 360 women already knew their HIV status and were not tested, but 241 were identified as HIV positive, achieving 79% of the annual target for the identification of HIV positive pregnant women.
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Afya Jijini ensured integration of HTS for all ANC clients at their first visit through the deployment of HTS counselors in high volume ANC clinics and provided mentorship to HCWs on HIV testing and proper documentation. Also, HTS for mothers at six weeks and six months postnatal were offered, per national guidelines, to reduce missed opportunities for prevention of transmission during the breastfeeding period.
Improve eMTCT-Maternal, Newborn, and Child Health (MNCH) integration Eighteen program-supported PMTCT nurses trained on eMTCT service delivery continued to support service integration in high volume facilities throughout the year. Afya Jijini, through KCCB sub grantee, started supporting two additional PMTCT facilities: UHAI Neema Hospital and Baldo Ipolita. There has been a collaboration with SP2 to identify pregnant women in the community and refer them for ANC services and subsequently provide HTS. To improve access to contraceptives for HIV infected women, eight facilities provided RH services within the CCCs.
Client receiving Male condoms 1,229
FP Injections 118
Pills Combined oral contraceptive 65
Implants insertion 34
Pills progestin only 40
Clients receiving Female Condoms 31
IUCD insertion 25
0 200 400 600 800 1,000 1,200 1,400
Re-Visits New Clients
Figure 2: Reproductive Health services within the CCCs
Enroll 2,914 HIV-positive pregnant women on ART and achieve 95% VL suppression In Y4, 2,398 women were identified as HIV positive, with 1,082 being newly identified through HIV testing during ANC visits. Another 1,316 women who attended ANC had a known HIV positive status. Of the 2,398 HIV positive women, 2,347 (98%) were initiated on HAART, and 51 declined treatment. Mentor mothers and nurses continue to follow up with the patients who declined treatment this quarter for possible initiation of ART.
Data from the maternal cohort analysis show that 513 eMTCT clients were eligible for a VL test at six months, and another 400 and 330 clients were eligible for a VL test at 12 and 24 months, respectively. A total of 420 samples for VL were collected for women who have been on 6 months of ART, 299 for women 12 months on ART, and 286 samples for women 24 months on ART. Of those tested, 92%, 94%, and 93% were virally suppressed, respectively; and 89%, 86%, and 92% of clients were retained in care at six, 12, and 24 months, respectively. Afya Jijini continued to support OTJ mentorship to build the capacity of nurses and clinical officers to monitor viral suppression and retention of mothers in the program. Furthermore, UHAI teams worked with facilities to initiate enhanced follow- up for clients who were not virally suppressed through the establishment of viremia clinics.
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Support and track HEI Afya Jijini continued to support HCWs to conduct HEI cohort analysis throughout the year. In Q4, 527 HHEI born between July and September 2018 cohort were enrolled for follow up, and 503 HEI from similar months in the 2017 cohort were also followed up. In the first review of the 2018 cohort, eight infants were reported as HIV-positive and all of them were linked to care, while 14 infants from the 2017 cohort were identified as HIV-positive with 100% initiation onto ART.
12 Month HEI Outcomes (N=527)
0.4% % Active in follow-up 8.0% % Identified as positive between 0 and 6.5% 12 months 1.3% % Transferred out between 0 and 12 months
% Missing 12 month follow-up visit
83.9% % Died between 0 and 12 months
Figure 3: 12 month HEI outcomes (N=527)
24 Month HEI Outcomes (N=503)
1% % AB negative at 18 months 14%
% Active at 18 months but no 12% AB test done % Identified as positive 2% between 0 and 18 months 2% % Transferred out between 0 and 18 months % Lost to Follow-Up between 70% 0 and 18 months % Died between 0 and 18 months
Figure 4:24month HEI outcomes (N=503)
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Increase mother-baby retention in the eMTCT cascade Afya Jijini, through its sub grant to St John’s Community Center (SJCC), continued to provide peer education and psychosocial support to PMTCT clients through mentor mothers to improve retention of the mother-baby pair in 19 facilities previously contributing to the highest rates of loss to follow up amongst supported facilities. Afya Jijini’s overall retention at one year for PMTCT clients on follow up during the July – September quarter is 86%. In addition, eight ‘male agents of change’ were engaged through SJCC and were instrumental in supporting assisted partner notification services (aPNS) in reaching male sexual partners of PMTCT clients. A total of 272 were reached with HTS services during the quarter as part of aPNS services.
Boost eMTCT focused stakeholder collaboration Afya Jijini continued to support collaborative activities with the county and sub-county teams during the reporting period. The project supported one eMTCT data review meeting to track eMTCT performance within Nairobi. The main gap identified was poor documentation of use of ART for newly diagnosed HIV positive pregnant women. It was agreed that the sub-county teams will focus mentorship on the use of the MOH 731 while giving regular feedback on reporting to facility teams. Afya Jijini also supported the development of the Nairobi County eMTCT business plan to fast track the eMTCT agenda. This process seeks to bring together both health and non-health stakeholders to discuss and agree on collaborative efforts to eliminate mother-to-child transmission of HIV in Nairobi County.
Strengthen ART linkages for HIV-positive infants In Q4, the program collected and networked 551 dried blood spots for Polymerase Chain Reaction (PCR) testing at the Kenya Medical Research Institute (KEMRI), with nine reported as HIV-positive. Of the samples collected, 547 were initial PCR tests, of which 463 infants under the age of two months (84% of the total) and 84 were done for infants older than two months. Afya Jijini continued to emphasize timely initiation of ART for all HIV positive infants through mentorship of HCWs. Mentorship activities also focused on updating the treatment status of the HIV positive infants on the NASCOP EID database.
Strengthen family-centered HIV testing and care Mentor mothers, nurses, and HTS counselors continued carrying out chart abstraction for index clients (HIV-positive pregnant and breastfeeding mothers) to establish family testing status throughout the year. During the quarter, 427 index clients were provided with family testing services as per the table described below.
Table 2: aPNS Cascade PMTCT Clinic – July – September 2019 # Index Clients Offered Index Testing Services 427 Index Clients Screened 424 Acceptance Ratio 99% Contacts Identified 727 Elicitation Ratio 1.7 Known Positive 66 Eligible (for testing) 661 Tested 272 Testing Rate 41% Positive 44 Linked 43 Yield 16.2%
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Increase adolescent-friendly ANC services Afya Jijini continued to support adolescent-friendly services by providing psychosocial support services for pregnant and breastfeeding adolescents as well as counseling support for adherence and clinic appointments. Through this, Afya Jijini achieved a high viral suppression rate of 91% for adolescents aged 15-19 in PMTCT care. Besides, 42% of pregnant women seen in all Afya Jijini supported facilities were under the age of 24, and all received HTS services at 1st ANC, with 1.2% identified as HIV infected, including known positives and 98% provided with ART. Furthermore, 18 adolescent champions were trained in Operation Triple Zero (OTZ) to improve viral suppression and retention in adolescents, including pregnant adolescents. Output 1.2 and 1.3 HIV Care, Support, and Treatment Service
Initiate 7,174 new clients on ART In Y4, 8,133 clients tested HIV positive across the 42 supported facilities. Of these, 6,796 (84%) were linked to care. This was achieved through enhanced mentorship on same-day enrollment; ART treatment preparation by adherence counselors, peer educators and clinicians; and proper documentation of the clients who transfer out immediately after testing HIV positive.
Boost HIV treatment adherence support Through working with 48 peer educators and 28 treatment preparation adherence (TPA) counselors (engaged under AMURT, a grantee), the project continued supporting adherence and retention to care and treatment for the CCC clients. The peer educators and TPA counselors received continuous mentorship and OJT on adherence and retention, including documentation of the different processes.
Strengthen HIV defaulter tracing Afya Jijini continued to work with 48 peer educators to strengthen appointment management and defaulter tracing in project facilities. Peer educators tracked clients who missed their clinical appointments using phone calls and home visits where feasible, resulting in 655 patients returning to care by end of Q4. During Y4Q4, the project intensified efforts to bring back clients who lost to follow-up (LTFU) as part of the SURGE strategy. This was done by contacting all clients listed as LTFU since May 2018 through phone calls and home visits where feasible before providing an outcome. Each facility also set weekly and daily targets of clients to be traced back to care, with peer educators and mentor mothers taking lead. Performance against the target was reviewed at weekly WIT meetings to identify root causes and set facility-specific strategies to improve the indicator. The project facilitated defaulter tracing with airtime and transport reimbursements. Continuous Mentorship on implementation of the new ART guidelines Afya Jijini continued to support a total of 97 HCWs - including clinicians, nurses, TPAs, HTS counselors, peer educators, and mentor mothers - through mentorship and OJT on effective implementation of the 2018 ART guidelines and optimization strategies. A meeting was held with the 97 HCWs to review progress of their performance and share the new implementation model.
Scale-up and support pediatric and adolescent ART As of end of Y4Q4, Afya Jijini supported 1,274 children (0-14 years) and 3,088 adolescents (15-24 years) to access treatment services. From the pediatrics enrolled, 1,013 (80%) had their VL tested with a resultant 87.7% suppression rate, while 2,508 adolescents had their VL tested, 88.5% adhered to clinic appointments and to ART, and 80% had a non-detectable VL In Q4, 22 adolescent peers were re-engaged and reoriented on the management of the OTZ interventions across 22 supported sites.
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Increase VL uptake and suppression VL Uptake: The program supported VL testing for 33,981 clients. Enhanced mentorship and OJT was provided to clinicians and TPAs to strengthen implementation of high viremia clinics in 29 facilities. Daily bleeding was conducted throughout Q4, reaching 8,472 clients and resulting in 7,674 (91%) suppressed. This translated to an annual suppression of 93% as at APR. Patients without a current VL were line listed and fast-tracked for sample collection through TPAs who conducted phone tracing.
VL suppression and review: During the quarter, the program worked through AMURT to continue the implementation of high viremia clinics in 22 facilities. The program sites identified 2,170 patients with non-suppressed VLs during Q4, of which 1,363 had a repeat VL after undergoing satisfactory enhanced adherence sessions. Of these, 331were switched to second-line therapy.
Implementation of the Differentiated Care Model (DCM) At the end of Q4, Afya Jijini continued to support DCM in 26 facilities, with 13,948 stable patient’s line listed and 8,259 enrolled. 2,995 patients had been on fast track for more than 12 months, of which 2,660 (88.8%) had their VLs done. Of these, 2,611 (98.2%), were virally suppressed, 2,289 scheduled appointments and 91.2% kept their appointment. Afya Jijini also continued to work with the county to support implementation of DCM through the QI approach in five high volume sites (Mbagathi, Dandora II, Kayole II, Westlands and Jericho). These facilities have been able to share best practices in implementation of DCM with other facilities within the program, which has led to improved quality of DCM services across all 26 DCM sites. A total of three facility-based coaching visits at Afya Jijini supported-sites and one NASCOP-led Extension for Community Health Outcomes (ECHO) session were conducted to support implementation.
Improve HIV treatment stakeholder collaboration Afya Jijini provided technical support toward the formation of a regional clinical TWG for the county for HIV treatment. The TWG is a collaborative effort of NCC, University of Nairobi, UMB, and other implementing partners (IPs) in the county. It has been tasked with providing clinical support to facilities in Nairobi, including reviewing patients failing second line and those with complicated cases and providing mentorship to HCWs. The project continued to provide airtime for the ECHO tele- mentoring platform at the STC Casino clinic. Furthermore, two monthly meetings were supported and snacks provided.
Roll out of early morning clinics targeting male clients During Q4, the program team intensified the implementation of male-only clinics to reach out to working-class men who preferred attending clinics early in the mornings. During the quarter Afya Jijini managed to scale up the services to Kangemi H/C, Ngaira H/C, Mbagathi and MLKH. During the period, a total of 645 men attended the early morning clinics and, through the support of the TPAs and the clinicians, formed PSSGs. In Y4Q4, plans are underway to integrate diabetes and hypertension screening services in male-only clinics at 8 supported facilities through trainings and continued mentorship.
Provide strategic HTS Increased access to targeted HIV testing at facility level: In Q4, Afya Jijini supported the testing of 81,312 clients, with 2,185 (2.7%) new positives identified through implementation of the SURGE strategies that were introduced in Q3 involving stringent use of the risk-based eligibility screening tool as well as index testing and aPNS to reduce over testing. The aPNS approach helped reach 4,484 partners of index clients, out of which 1,761 (39%) were tested for HIV and 414 (24%) tested positive. The project engaged 80 HTS providers and 20 eligibility screeners who received ongoing mentorship and OJT to ensure optimization of the high yielding strategies. The project also continued to work with Partnership for an HIV-Free Generation (PHFG), a grantee tasked with supporting HTS in 10 project facilities. HIV self-testing continued being implemented in 9 facilities targeting male partners of ANC clients as well as contacts of aPNS clients who preferred not to be tested using the conventional testing approaches. A total of 374 HIV self-testing kits were distributed, with a resultant 11 self- 19 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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reporting as positive. Cumulatively for Y4, 333,042 (150% of the annual HTS_TST) received HTS and 8,132 (117%) of the annual HTS-POS targets were identified as HIV positive. Through eligibility screening, the project managed to reduce the overall number of clients receiving an HIV test by 9,600 in the second half of the year, and subsequently, the yield increased from 2.3% at SAPR to 2.7% at APR.
Table 3: HIV Test Yields by Testing Points (FY19) Testing Point Tested Positive Yield Inpatient Services 8,240 310 3.76% Pediatric Services 163 1 0.61% Emergency 916 34 3.71% PITC TB Clinics 4,529 548 12.10% STI Clinic 691 10 1.45% PITC PMTCT (ANC 1 Only) Clinics 50,875 1,084 2.13% PITC PMTCT (POST ANC1) Clinics 44,926 167 0.37% VMMC SERVICES 2,994 2 0.07% Other PITC 133,361 3,020 2.26% VCT 80,940 2,082 2.57% Index Testing 5,412 874 16.15% TOTAL 333,047 8,132 2.44%
Increased targeted HIV testing at the community level: In Y4Q4, Afya Jijini continued implementing the SURGE strategy at the community level, focusing on micro-targeting by reviewing program data to identify areas of high concentration of People Living with HIV (PLHIVs) for targeted testing. A two-tiered screening approach was used to identify and test only eligible clients. The following were the community testing outreaches supported during the quarter: • Afya Jijini conducted targeted weekend outreach events focusing on the hotspots and on follow-up of identified index clients. These were done in Mukuru HC, Mama Lucy Kibaki Hospital, Kangemi HC, Mukuru MMM and STC Casino. Some of the hotspots identified were Githurai 45, Maji Mazuri, Pipeline, Kibera, Rongai, Target OVC homes, Masimba, Kona, Bottom Line, Village Inn, Manyatta, Dam Area, Trench, Deep Sea, Waruku, Jodalas, Awendo, Mti 1, ODM Zone, Mombasa Raha, Area 4a, and Jangwani. A total of 249 clients were reached out of which 13 (5.2% yield) HIV positive clients were identified and linked to Afya Jijini supported facilities. Challenges encountered during the outreach events included limited accessibility of some areas and linking clients who are identified at the outreach event but are unwilling to be enrolled on the same day. • The program worked with INERELA (a grantee mandated to reach the religious community with HIV services) to conduct targeted outreach events in the identified hotspots in Embakasi East, Embakasi West and Westland sub-counties. A total of 998 individuals (386 females and 612 males) were reached, of which 524 (208 females and 316 males) were new testers. The testing activities managed to identify 61 clients (44 females and 17 males) as positive, translating to a yield of 6.1%. All clients were linked to Afya Jijini supported facilities. A total of 15 HIV self-testing kits were distributed with subsequent follow-up to determine usage and results. None had positive results requiring confirmation at facility level, presumably having tested negative. • aPNS: In Y4Q4, Afya Jijini continued supporting implementation of aPNS as part of the SURGE Strategy in the supported facilities. Emphasis was placed on ensuring that all newly diagnosed clients and existing clients in the CCC and PMTCT clinics had their contacts elicited after being screened for intimate partner violence and traced for testing. For the existing clients, the focus was on ensuring that contact elicitation was done for the following categories of 20 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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index clients: LTFUs and defaulters being brought back to care, clients with high VLs, and clients with STIs, discordant couples, and partners of PMTCT clients. The facilities received mentorship, job aids, and SOPs to assist them in offering aPNS to their clients. Follow-up of elicited contacts was done through phone calls and home visits to the identified areas. Challenges encountered during elicitation of contacts included non-responsive clients, clients giving wrong information and non-willingness to disclose sexual contacts. Follow-up of elicited contacts also presented some challenges, including not being able to reach the clients due to wrong contact information, refusal of contacts to undergo a HIV test, and contacts being far away in other towns. The table below represents a summary of aPNS for Q4.
Table 4: aPNS Summary Q4 FY19 Male Female Clients offered PNS 1,091 2,113 Index clients screened 995 1,925 Contacts identified 2,598 1,886 Known positive 359 228 Eligible 2,239 1,658 Tested 958 803 Positive 217 197 Linked 202 188
Table 5: aPNS Summary FY19 Male Female Clients offered PNS 3,191 6,587 Index clients screened 2,987 6,101 Contacts identified 7,853 5,899 Known positive 938 652 Eligible 6,915 5,247 Tested 2,957 2,455 Positive 464 410 Linked 385 361
Newly-diagnosed clients enrolled into care In Q4, Afya Jijini continued working with the HTS providers and TPA counselors to support testing and linkage to care of newly diagnosed clients and providing mentorship on the use of the Linkage SOP which advocates for same day linkage, proper client follow up, and complete documentation of the linkage process. The total number of clients linked and initiated on treatment. All newly diagnosed clients were physically escorted to the CCC for enrollment. Using the Linkage SOP as guidance, all clients who opted to be enrolled in another facility were first enrolled in project supported facilities before being transferred out to their facility of choice. Clients who were not linked were followed up through phone calls and home visits by the HTS providers, who documented the process in the linkage register. Challenges faced in same day initiation included unwillingness on the part of the clients and a lack of knowledge, understanding and cooperativeness among facility staff. An audit of all positives identified in the quarter that were not initiated on treatment was done as shown in table six below.
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Table 6: High-level Results from Audit New positives Number Percentage Linked later to a TX facility 89 37% On follow up 41 17% Linked in non-Afya Jijini sites 35 14% Declined enrollment 24 10% Await disclosure before enrollment 14 6% On TB treatment 13 5% Dead 11 5% Unreachable 10 4% Admitted 3 1% Preferred personal doctor 2 1% Total 242 100%
Internal HTS QA strengthened During the reporting period, the project emphasized observed practice sessions for the HTS providers, with the results documented for follow-up actions. These sessions were done in conjunction with the sub-county health teams, facility management, and HFG. By the end of Y4, all HTS providers had undergone at least one session of observed practice, with the outcome documented within a file in the facility. Feedback was shared with the HTS providers. The project also partnered with the sub-counties and HFG to conduct joint supportive supervision to the HTS providers in the supported facilities. QI projects in positive identification, aPNS uptake, and linkage that had been taken up as part of SURGE, continued being monitored in the quarter. External HTS QA measures improved. Afya Jijini continued to work with the National HIV Reference Laboratory (NHRL) and the sub-counties to ensure HCWs providing HTS in the supported facilities were enrolled in proficiency testing (PT) round 19, and later, round 20. In Q4, the semi-annual facility-based Corrective and Preventive Action (CAPA) sessions continued being done for the 53 HTS providers and others who had unsatisfactory results in Q3. The project worked with the SCASCOs to provide monthly debrief sessions to the HTS providers in nine sub-counties as well as facility-based counselor supportive supervision sessions at St. Mary’s Hospital, Mbagathi Hospital, Kangemi HC, Kayole 2 HC, and Dandora 2 HC. The project also worked with the Sub-County Lab Coordinators to strengthen RTK supply chain management. Scale up of PrEP services: As part of Afya Jijini’s DREAMS component, the project ensured that 252 AGYWs received PrEP service. During the SURGE period, PrEP was provided to sexual contacts of aPNS clients who tested negative. These clients were then monitored for the period they were on PrEP. Mentorship on commodity management and service provision was provided to the HCWs to ensure uninterrupted service provision during the SURGE period, resulting in an uninterrupted supply of PrEP commodities across the year. Scale-up of condom promotion and contraception use: In Q4, Afya Jijini continued working in 36 project facilities to improve FP integration in HTS provision. In Q4, Afya Jijini supported distribution of male condoms from NASCOP to the two sub-county depots (Embakasi East and Embakasi West), from which the condoms were then distributed to the project-supported facilities within those two sub- counties. Mentorship on FP integration and job aids including TIART charts and FP counseling cards were provided at the facility testing points.
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Support HIV stigma reduction efforts: In Q4, Afya Jijini continued working to reduce stigma and discrimination in project facilities. The project, through AMURT, continued to support disclosure and PSSG activities in supported facilities. Disclosure efforts for the pediatric and adolescent clients were enhanced through working with OTZ champions stationed in 22 facilities. The project also ensured that job aids on patient rights, stigma reduction, and patient responsibilities were made available at the facilities at all service delivery points (SDPs) and that the HCWs were sensitized on how to use them. Improve stakeholder collaboration: In Q4, the project continued collaborating with key stakeholders in HTS provision including the sub-county teams and other implementing partners, namely AIDS Healthcare Foundation (AHF) in the project facilities. In Y4, the project participated in a national HTS TWG to discuss issues related to self-testing, HTS service quality assessments, commodity management for RTKs and propose a review of HTS guidelines.
DREAMS Support Strong Community Engagement and Leadership Support for DREAMS Success In Y4 Q4, Afya Jijini continued to harness strong community and facility stakeholders’ support to the DREAMS program to deliver behavioral, biomedical and socio-economic interventions to the adolescent girls and young women (AGYW) in both implementation sites, namely Mukuru (Embakasi East SC) and Kangemi (Westlands SC). Within COP19 implementation, 3,690 (73%) AGYW were newly enrolled (see the table below for age disaggregation). The overall primary layering of AGYW_PREV stood at 12,481 (9-14 years fully layered: 88%; 15-19 years fully layered: 86%; 20-24 years fully layered: 86%; and 25+ years old fully layered: 85%).
Table 7: Afya Jijini Y4 Q4 Cumulative DREAMS Achievements % DREAMS Indicators Target 9-14 15-19 20-24 24 + Total Achieved DREAMS new enrollment 5,053 1,335 1,526 829 0 3,690 73% Gender GBV 9,658 1,912 3,060 2,101 400 7,473 77% Community mobilization/norms 7,726 4,000 4,306 3,350 5,529 17,185 222% change HTS 4,042 649 2,904 2,067 382 6,002 148% Priority population HIV 5,053 1,812 3,017 2,866 604 8,299 164% prevention SAB interventions 5,053 2,686 4,779 3,650 842 11,957 237% Family Matters Program (FMP) 1,732 713 977 68 0 1,758 102% Education subsidies 3,416 784 1,092 256 0 2,132 62% Cash transfers 957 2 223 522 0 747 78% Financial Capability 5,053 1,685 2,938 2,175 0 6,798 135% Condom education and 4,042 50 3,460 2,860 0 6,370 158% promotion Contraceptive method mix 3,234 42 3,165 2,246 0 5,453 169% PrEP 1,166 0 320 728 141 1,189 102% Economic strengthening 959 4 458 560 81 1,103 115%
Empower AGYW (Core Area 1) Mentorship: Mentorship formed the heart of the DREAMS program implementation. In Y4Q4, Afya Jijini continued to provide routine Social Asset Building Sessions (SABS) at the 18 safe spaces in the two DREAMS implementation areas (10 in Mukuru and Pipeline; and 8 in Kangemi and Mt. View). A total of 11,957 AGYW (237%) (9-14 years: 2,686; 15-19 years: 4,779; 20-24 years: 3,650; and 24+ years: 842) participated in SABS. The topics covered by mentors empowered AGYW to make healthy choices, sound decisions and build resilience.
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These curriculum-based sessions were augmented with fun activities including dancing sessions, team building activities, inter-cluster competitions, and modelling sessions, all suggested and innovated by the AGYWs. Afya Jijini also line-listed AGYWs who had completed less than the standard primary package for their cohort so as to fast track uptake of missing services and prioritize secondary and/or contextual services based on an individual girl’s needs.
In this quarter, Afya Jijini worked with mentors to form and strengthen more Girl Group Coordinating Units (GGCUs). The already existing ones have identified income generating activities (e.g. soap making), where they produce and sell their products locally. Three of them are in the process of registering with the Ministry of Labor, Social Security and Services as self-help groups, an innovation that has helped the project to maintain the girls’ attendance and participation at the safe space. In both Mukuru and Kangemi, an inter-cluster debate competition was held with the various clusters represented by AGYW. These AGYWs were also given a chance to showcase their talents in dancing, acting and poetry recitation. Each talent showcased contained a theme based on the different topics that the girls have been taken through during mentorship sessions.
Within this quarter, 13 new girl groups (8 in Kangemi and 5 in Mukuru) were formed. The girl group model has been a successful vehicle through which new girls access layering of services and are retained in the program. One of the girl groups for the cohort aged 20-24 years in Kangemi is already registered as a self-help group with the state Department of Culture and Social Services and is offering catering services to the community whenever there are functions including birthday parties and weddings. The girl groups also discuss some of the key topics they have been taken through during mentorship sessions at the safe space (i.e. HIV/AIDS, nutrition and reproductive health. Apart from the usual mentorship, older girls also engage in training with a local partner [center for domestic training and development] who trains the girls on housekeeping and catering course at the safe spaces.
Condom promotion and distribution: In Y4Q4, Afya Jijini continued to use HIV Testing Services (HTS) and evidence-based intervention (EBIs) sessions to deliver condom efficacy education and distribute condoms to the AGYW aged 15-24 years. These platforms included SASA!, My Health My Choice (MHMC), Sister-2-Sister Kenya, During Y5-Q4, the program distributed male condoms within the safe spaces and hotspots in both Kangemi and Mukuru Kwa Njenga. This led to 3,366 AGYW (15- 19 years: 1,956; 20-24 years: 1,223; and 25+ years: 220) being reached with condom education. Among these AGYW, 1,299 AGYW received/collected 25,086 male condoms and 288 female condoms at the safe spaces, while 36,449 male condoms were collected from dispensers. A total of 61,383 condoms were distributed in Q4 alone. The table below shows the. No target was set for condom distribution under DREAMS.
Table 8: condom awareness/sensitization and provision at safe spaces Intervention Period 15-19 20-24 25+ Total % Target Achieved Condom education Year 4 3,510 2,860 0 6,370 4,042 158% Y4Q4 1,956 1,223 220 3,399 1,010 337% Condom Year 4 1,447 1,845 434 3,726 distribution Y4Q4 559 630 110 1,299
Evidence-based behavioral interventions (EBI’s): Afya Jijini grantee, HIV Free Generation (HFG), is implementing activities to meet the objective to increase knowledge and skills on comprehensive HIV prevention among AGYW. The target population were reached with NASCOP-approved evidence informed behavioral interventions, namely Healthy Choices for a Better Future (HCBF), Sister-2-Sister (S2S), and MHMC, which target young people aged 10-14 and 13-17 years.
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HFG engaged a total of 32 facilitators in the implementation of HCBF and MHMC in Kangemi and Mukuru. Additionally, HFG implements the S2S EBI which aims to increase AGYW confidence and self- efficacy in using both male and female condoms, reaching 1,100 AGYW.
Table 9: The table below shows a summary of EBIs quarterly and annual achievement for EBIs Period 9-14 15-19 20-24 Total Target % Achievement SASA Norms Change Year 4 2,457 3,153 1,924 7,534 5,053 67% Y4Q4 515 940 551 2,006 HCBF Year 4 2,139 0 0 2,139 1,010 47% Y4Q4 1,193 0 0 1,193 MHMC Year 4 0 1,931 0 1,931 2,021 105% Y4Q4 0 1,244 0 1,244 SISTER-2-SISTER-K Year 4 3 346 671 1,110 4,042 364% Y4Q4 0 346 671 1017 Contraceptive method mix: In Q4, 2,919 AGYW (15-19 years: 1,687; 20-24 years: 1,035; 24+ years: 197) were reached with information on the contraceptive method mix. DREAMS engaged a clinician to give adolescent/youth sexual and reproductive health (AYSRH) education on contraceptive method provision at the safe spaces, with a total of 1,342 AGYW in Mukuru and in Kangemi) accessing contraceptive methods mixes, including condoms, as shown below.
Table 10: Contraceptive methods Contraceptive Method 15-19 20-24 25+ Total Oral contraceptives 5 20 8 33 IUD/Implant 3 2 0 5 Coil 2 2 3 7 DMPA 1 2 0 3 Condoms 554 630 110 1,294
Pre-Exposure prophylaxis (PrEP) Pre-Exposure prophylaxis (PrEP). In Y4Q4, DREAMS capitalized on an approach of mentors and clinicians journeying with AGYW on PrEP in both Embakasi and Westlands Sub-Counties. This mitigated previous access challenges. In Y4Q4, 2,417 AGYW (see table below for age breakdowns) were reached with PrEP information in Q4 alone. The cumulative annual total for Y4 was 5,709 AGYW reached (see the table below for the age disaggregation). A total of 290 AGYW (15-19 years: 99; 20-24 years: 168; and 25+ years: 23) were enrolled on PrEP in Y4Q4, bringing the project to a cumulative annual total of 1,189 (15-19 years: 320; 20-24 years: 728; 25+ years: 141). Another 127 AGYW came for refills. Some of the critical lessons learnt in PrEP implementation with the AGYW, is that the Safe Space model of PrEP administration (taking the services to the Safe Spaces instead of Health Facilities) lowered stigma rates and boosted the AGYW confidence in service uptake. This was also enhanced by supportive follow-ups, regular feedback sessions with AGYW and integration of PrEP with other DREAMS services.
Table 11: Pre-Exposure prophylaxis (PrEP) Pre-Exposure prophylaxis Intervention Period 15-19 20-24 25+ Total Target YR 4 % PrEP Year 4 2,922 2,327 460 5,709 Information Y4Q4 1,361 905 151 2,417 PrEP Uptake Year 4 320 728 141 1,189 1,166 102% Y4Q4 99 168 23 290 *Grey boxes indicate that no target was set
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Post-violence care, gender-based violence (GBV): In Y4Q4, Afya Jijini continued to implement post violence care (PVC) through the project-engaged trauma counselor who works with the AGYW and mentors to sensitize the newly enrolled girls on GBV grading and reporting. During Y4Q4, two young women were rescued, with one taken to a safe house in Kibera’s Shofco Center and the other one taken to a temporary safe house in a Kwa Mama Miriam Children’s Home in Mukuru. The girl within Mukuru continues to get mentorship at Pipeline Safe Space while also undertaking a pastry-making course at St. Teresa’s College.
Additionally in Y4Q4, 42 Mentors in Mukuru were trained to sensitize AGYW on GBV, how to help fast track GBV screening and response, and to support closure of cases in the shortest time possible, through group or/and individual GBV counseling, to allow the girls to bounce back and achieve their DREAMS goals. In the community, SGBV sessions continued through the SASA! Intervention which was implemented by HFG. HFG engaged the services of the Sub-county Psychosocial Support/Gender Based Violence Coordinator, community health workers, and SASA! Activists to facilitate the sessions in the community. The sessions were conducted Kangemi through the 3 quarter 2 to 4, while in Mukuru, HFG re-engaged the previously trained SASA! Activists within Q4, having already implemented the same in the previous financial year. The table below depicts the SASA! Activity within Y4:
Table 12: SASA! Activity coverage within Y4 Ward Target Q 1 Q 2 Q 3 Q 4 Total % reach Reached Mukuru 500 0 0 0 474 474 95% Kangemi 2,000 0 244 362 1,007 1,613 81% Total 2,500 0 244 362 213 2,087 83%
HIV Testing Services: In Y4 Q4, the project line-listed AGYW aged 15-24 years who learned their HIV status for the first time during Y4. Only one AGYW turned HIV positive, but she was successfully linked to treatment. The known positives who reported that they were already in care and adherent to treatment were given adherence and safer sex counselling as part of the positive living messaging. Upon request, parents and caregivers of the AGYW were also reached with HTS during the implementation of FMP sessions, which further boosted AGYW HTS uptake. Of the Eligible DREAMs Girls HTS coverage was at 88%.
Table 13: HIV testing Age group (years) Tested for HIV Negative New Positive Known Positive 9-14 108 108 0 0 15-19 1,125 1,124 0 1 20-24 716 715 1 0 25+ 131 131 0 1 Total 2,080 2,077 1 2
Interventions to reduce risk among AGYW sex partners During Y4Q4, Afya Jijini, through HFG, intensified activities to characterize AGYW Male Sexual Partners (MSPs) in Embakasi South and Westlands Sub-Counties during mentorship sessions at the safe spaces. A total of 3,723 newly enrolled AGYW from the 15-24 years age cohort participated, providing the project with critical feedback on unique MSP characteristics.
Through the male sexual partners characterization conducted within the safe spaces with mentors and their AGYW 15-24 years, the project learned that the top five types of MSPs for DREAMS participants are schoolmates, other male peers out of school, college students, teachers and sports coaches. The project purposes to reach these males with targeted services within the community like condom
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education and distribution, VMMC information and referral for services, SASA! Mobilization, HIV testing services among other biomedical interventions. Additionally, the top five types of MSPs for DREAMS participants are schoolmates, other male peers out of school, college students, teachers and sports coaches. The top five most common venues where AGYW and MSPs meet are video dens, pool game venues, sports events, chips joints/restaurants, and birthday parties, while the top 5 motivators for sexual contact are gifts/money, infatuation, peer pressure, returning favors (e.g. leakage of exams), and sexual exploration. The information obtained from the exercise guided the follow-on design and prioritization of HIV risk reduction services to AGYW. The AGYW MSPs were reached with condom education and distribution of 17,280 male condoms, VMMC referrals, GBV prevention information, and PrEP information. A total of 227 men received HTS through HFG.
Strengthening families. Parental and caregiver program During Y4Q4, Afya Jijini supported the implementation of the Family Matter Program (FMP1 and FMP2) sessions both in Mukuru and Kangemi. A total of 1,388 parents graduated in FMP1 and 630 in FMP2, increasing knowledge and providing skills for parents and caregivers to hold conversations relating to sex and sexuality with AGYW to help them evade behaviors that might put them at risk of getting infected with HIV. Afya Jijini also held feedback meetings with FMP parents across all 18 safe spaces to gauge the impact of the FMP program on parenting skills, particularly on communication. Most caregivers gave positive feedback about being able to communicate issues around sex and sexuality with their girls with ease and without experiencing unnecessary embarrassment.
Unconditional cash transfer (UCT) program: In Y4Q4, Afya Jijini continued to work with the mentors and field assistants to identify AGYW aged 15-24 years who met specific vulnerability criteria for cash transfer and prioritized them based on standard operating procedure. In Y4, 125 AGYW from Kangemi were given a cash transfer while 114 from Mukuru received their additional cycles. This intervention rapidly reduces the AGYWs’ economic vulnerability. Some of the UCT recipients use the cash to start small businesses.
Education subsidies program In Y4Q4, the project continued to identify the school-aged AGYW who were unable to pay school fees and thus unable to attend school thereby increasing their vulnerability. Education subsidy vetting committee meetings were convened in both Mukuru and Kangemi to assess and allocate school fee subsidies to AGYWs based on their needs and the availability of funds. Within Y4Q4, school fees were disbursed to 614 AGYW aged 15-19.
Interventions to mobilize communities for change During Y4Q4, HFG conducted SASA! activities at the community level in areas closer to where AGYW MSPs hang out and managed to reach a total of 795 people (466 female and 329 male) in Embakasi South Sub County and 3,803 people (2,416 female and 1,387 male) in Westlands Sub County. The men who had been previously reached with SASA! Took an active role during the outreach events to challenge their fellow men to prevent violence and HIV infection among women and girls in their communities.
Combined socio-economic approaches In Y4Q4, AJ trained 2,951 AGYW (9-14 years: 779; 15-19 years: 1,100; 20-24 years: 932; and 25+ years: 140) on financial capability skills. Another 307 were trained on entrepreneurship skills, where started their own businesses with 180 already earning income from these ventures in both Kangemi and Mukuru. Within the year, 20 AGYW have gotten paid employment opportunities and are currently earning a living. A total of 71 received vocational training.
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Table 14: uptake of the social-economic approaches Age cohort Employment Vocational Training Entrepreneurship Training DREAMS linkage Total 15-19 2 1 111 115 20-24 8 0 182 190 25+ 0 0 14 14 Total 10 1 307 319
Cross-Cutting DREAMS Activities Stakeholder engagement: During this quarter, Afya Jijini conducted the final Year-4/COP-18 cycle DREAMS Advisory Committee (DAC) Quarterly Data Review meeting, bringing together both Mukuru and Kangemi community teams to review the performance of the previous quarter and plan for the final quarter of the implementation year. During the meeting, program performance was reviewed, successes and challenges identified, next steps agreed upon, and work plans for onward progression were created. In the same period, the program conducted a GBV sensitization workshop for program field teams in Mukuru, to refresh their knowledge on running of GBV sessions and supporting PVC activities for the AGYW in the program.
Donor Engagement: During the reporting period, Afya Jijini received two donor visits. One visit included individuals from the Washington, DC-based DREAMS teams, who visited Afya Jijini DREAMS sites in Mukuru and Kangemi, in order to become familiar with the work that the program has been doing. One key suggestion stemming from the visit is to incorporate an OVC screening tool to support accurate vulnerability assessment for newly enrolled AGYW.
External Partnerships: Within this reporting period, Afya Jijini created contacts with representatives of the University of Nairobi School of Psychiatry and a research fellow at the University College of London (UCL), who are currently conducting the NIH/Fogarty Foundation-funded INSPIRE study on mental health for pregnant adolescents in primary care settings. The team approached Afya Jijini for a learning engagement and to understand how both parties can benefit from their package of free training workshops on psychosocial support for girls who have experienced/are experiencing GBV. The team is currently attached to Kangemi Health Center implementing comprehensive mental health care for peri-partum adolescents. In Y5, Afya Jijini will advance discussions to try to advance the partnership and provide support to AGYW.
AGYW Transition: During this reporting period, Afya Jijini conducted the first ever graduation ceremony and transitioned 209 AGYW out of the program after they were vetted for having received all the DREAMS services and they could effectively demonstrate reasonable levels of empowerment and resilience. The ceremony was graced by the County Deputy Director of Public Health, Dr. Carol Ngunu. The Sub-County Medical Officer of Health (SCMOH) representative for Embakasi East was the Master of Ceremonies. Parents/care givers, the DREAMS Advisory Committee, implementing partners, the vocational training institutions, the local administration, Afya Jijini leadership, staff and volunteers as well as community stakeholders were among those who witnessed this special occasion.
M&E and QA/QI: The reporting period saw the program conduct a Quarterly Data Review meeting at Clarion Hotel, bringing together both technical and field teams to review the Afya Jijini/DREAMS quarterly performance and plan for implementation. During the meeting, data was reviewed, gaps identified, remedial actions suggested, and work plans for onward progression created to clear all backlogs of data entry. In Y4, Afya Jijini continued to implement QI interventions at the community level in all 18 safe spaces. Areas for improvement such as timely data transcription and simultaneous capture multiple services in singular sessions have been identified with support from the DREAMS technical team and QA/QI advisor.
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Routine data verification processes During the quarter, the M&E and program team conducted four data verification exercises at Kware, Sisal, Great Mission, and Lea Toto safe spaces as part of routine supportive supervision. Key areas that were strengthened included real-time documentation/updates of data into the system, the need to conduct data quality checks by sampling and following up of safe spaces, and documentation and implementation of the cash transfer protocol for six cycles in a year.
Output 1.4 Voluntary Medical Male Circumcision (VMMC) In Q4, Afya Jijini continued support for VMMC through technical support and mentorship on service delivery, particularly the dorsal slit technique of VMMC using the National curriculum by NASCOP, in seven sites within Nairobi County (Mbagathi, RTI, Biafra medical, STC Clinic, Kayole 2, Mathare N and Korogocho H/C). This ensured that VMMC service delivery was uninterrupted in low social economic community set-ups, such as Mathare slums, Ngomongo slums in Korogocho, Kabiria slums in Waithaka and Soweto slum in Kahawa West. To guarantee availability of services during weekends and public holidays, Afya Jijini supported three dedicated teams (each comprising a surgeon, assistant surgeon, HTS provider, and infection prevention officer) in each of the three following facilities: Mbagathi Hospital, Railways Training Clinic (RTC) and Biafra Medical Clinic. This quarter these teams reached 684 clients with VMMC services - Mbagathi 181 clients, Biafra 353 clients and RTC 150 clients - ensuring services were provided throughout the August holiday both as in reaches and outreaches.
Key Y4 Results: In Y4, the project cumulatively reached 6,446 clients (representing 103% of the annual target) with VMMC minimum package of care that included HTS and counseling; syndromic screening and treatment for STIs; provision of male and female condoms and promotion of their correct and consistent use; promotion of safer sex practices; provision of risk reduction counseling; and active linkages of HIV-positive clients from VMMC sites to HIV care and treatment programs. During the reporting period, the program advocated for integration of VMMC services into routine service delivery. This was done by ensuring all supported facilities displayed and included VMMC services in their service charters. Additionally, with the support of the county VMMC focal person, the program supported formation and operationalization of the Nairobi county VMMC TWG and sub-county VMMC steering committees in the 10 sub-counties as part of journey to self-reliance in VMMC services provision.
Table 15: VMMC Results Disaggregated by Age: Period <9 10-14 15-19 20-24 25-29 >30 Total Oct-Dec 2018 2,318 1,120 203 79 45 3,765 Jan-Mar 2019 12 151 168 133 133 89 686 Apr-Jun 2019 1 807 385 124 59 35 1,411 Jul-Sep 2019 1 506 233 32 26 17 815 APR 14 3,782 1,906 492 297 186 6,677
To promote VMMC uptake and HIV prevention, Afya Jijini supported health talks through trained community VMMC mobilizers/champions in supported sites to promote positive male norms and address myths and misconceptions that may hinder service uptake. There were challenges in availability of commodities and consumables, specifically sterile gloves, sodium hypochlorite solution (JIK), washing powder, Chlorhexidine gauze dressing, and refreshments for the 10-14 year-olds because facilities received limited amounts from KEMSA. To mitigate these challenges, Afya Jijini procured and distributed the non-medical commodities to the supported sites on a quarterly basis to ensure the services were provided to the clients at no cost, in turn allowing the low social-economic communities to access these services in the Government of Kenya facilities.
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Gender Based Violence (GBV) Strengthen community gender norms: In this reporting period, the project continued to strengthen community awareness on effective referral pathways through stakeholder engagement. Follow-up of key gate keepers and community defenders was accelerated through sustainable engagement with media platforms through which case issues were coordinated and networked using WhatsApp. InY4Q1, Afya Jijini trained community defenders in Mukuru and Kangemi to improve chain of custody through community referral. These trained teams have continued to report increased surveillance and efficient referral coordination and reporting of SGBV cases. Subsequently this coordination is expected to continue identifying opportunities for strengthening dialogue on norms change.
Work with the county and sub-counties to strengthen comprehensive Post-Rape Care (PRC) chain of custody by improving the networking: In Y4Q4, Afya Jijini enhanced its coordination with the county and sub- county teams by improving survivor management of distress through community level assessment and referral in DREAMS safe spaces for both Mukuru and Kangemi. 37 cluster leads, field assistants, and mentors (33 female and four male) were sensitized on trauma care through psychosocial linkage. This was also coordinated in a series of follow-up sessions in certain facilities (Pumwani Hospital, Mukuru Health Centre and Kangemi Health Centre) where 27 health facility team members (22 females and five males including NBU, GBV, adolescent clinic, maternity, labor ward nurses, clinical officers, and administrative officers) were sensitized to enhance the chain of custody within the sub-county and county. The county continues to enhance linkage and partnership to improve PRC management and litigation through structured government organs.
To effectively manage chain of custody, forensic evidence specimens - which include the clothing taken from the survivor as evidence - are supposed to be collected by the state as a duty bearer at health facilities and taken to the court as evidence. This was reinforced with the linkage to the police through the launch of the Police SOP Manual, which also outlines the roles and responsibilities of the police in coordinating and collecting forensic evidence to complete the chain of custody in GBV survivor management and to which Afya Jijini provided TA.
Operationalize GBV clinics: In Y4Q4, Afya Jijini enhanced mentorship support services through coordination of the county and sub-county GBV focal persons as a sustainable approach where facilities were provided with direct onsite coaching on the appropriate PRC recording as well as forensic evidence collection coordination. The facilities supported this quarter included Mukuru Health Center, Kangemi Health Center, Westlands Health Center, Pumwani Hospital, and Gertrude’s Hospital. This will be further strengthened across the county with planned supervision visits in the coming quarter.
Strengthen utilization of SGBV guidelines GBV reporting tools: In Y4Q4, Afya Jijini continued to follow up on select health facilities where referral tools such as the Referral Pathways for Sexual Violence and Algorithms for Sexual Violence were distributed to oversee effective utilization. Through the county and sub-county GBV focal persons, Afya Jijini continued to emphasize a review of reporting trends from the MOH 705, 364-(A & B) and SGBV Monthly Summary to address the areas of improvement and learning as captured in DHIS2 data. While quarterly surveillance and reporting has improved, the greatest improvements are the longitudinal follow up reporting and consistency in the prevention of new HIV infections. Output 1.5: TB/HIV Co-Infection Services The program continued to work in collaboration with the Nairobi county TB health management team to implement a TB program focused on the five I’s (Intensified case finding, Immediate HAART, Integration, Infection prevention, and Isoniazide preventive therapy [IPT] ) as per the WHO TB standards.
Continuous quality improvement: Afya Jijini worked in collaboration with the County TB and Leprosy Coordinator (CTLC) on developing sustainable systems by giving TA on implementation using a QI
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approach. In collaboration with USAID funded TB-ARC, the project trained all 23 Sub-County TB and Leprosy Coordinators (SCTLCs) in CQI. Afya Jijini also offered TA to CTLC to monitor the 2018 poor performing TB indicators (i.e. cure rate of 43% and IPT for children under five at 53%) cutting across 10 sub-counties. CQI progress charts were distributed to HCWs to monitor and document progress at the supported facilities. Monthly data review meetings were also held in nine sub-counties. WITs at facility level monitored TB indicators for poor performance and worked towards improving these as demonstrated below in CQI process at Kangemi HC. This process has resulted in improvements against key TB indicators. Most notably, the TB cure rate increased from 48% in 2018 to 69% in 2019 and facility teams were motivated to regularly review their performance to identify and address gaps.
Photo 1: QI process demonstrated on talking walls at Kangemi HC
Strategically scale for Active Case Finding (ACF) In Q4, Afya Jijini offered TA and mentorship on ACF to two CTLCs and 23 SCTLCs to sensitize TB and OPD clinicians to further conduct eligibility screening among coughers who were identified by cough monitors at OPD and other health SDPs. This was to engage clinicians in ACF and to ensure that only eligible patients are sent for GeneXpert testing. SCTLCs conducted ACF review meetings at the 42 supported facilities to select facility case finding focal persons who would work closely with the cough monitors. The process is still ongoing and will be completed in Y5Q1, so all 42 facilities will have a focal person who will closely monitor TB ACF at all SDPs and ensure correct documentation in the TB presumptive registers.
In Y4, the project identified 5,780 (105%) persons with TB out of a target of 5,499. Afya Jijini, in collaboration with the county, continued to strengthen ACF through QI projects using data for decision making. Facilities used different strategies as developed by TB WITs to achieve their targets. Some conducted outreaches at various hot spots while others did contact invitation at facilities eliciting household members from index clients diagnosed. To improve identification of patients with TB, the project also trained 60 clinicians on TB LAM from across all 10 sub-counties targeting facilities with inpatient services. This training was provided after the NLTBP made the TB LAM tests available in all the piloting counties. In Nairobi, TB LAM is currently available at MLKH, St. Mary’s and Mbagathi hospitals only to HIV patients whose CD4 count is less than 200. Afya Jijini also distributed 58 ACF stamps to be used at all SDPs clinical cards of person seeking health services identifying those who had been screened for TB.
Strengthen community TB treatment monitoring and defaulter tracing In Q4, Afya Jijini continued to support SCLTC to strengthen community TB case identification. ACF was conducted with cart loaders and street families at Kawangware main market following 10 new diagnosis of bacteriological confirmed TB and one confirmed case of DRTB. A team of 10 HCWs lead by SCTLC conducted outreach at the market and gave prevention messages to stall owners. The stall
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owners and food canteens were given cough etiquette posters in both English and Kiswahili. A total of 168 clients were screened and 55 presumptive cases identified, and their sputum collected for GeneXpert. A total of three clients were found to have TB.
In Y4, Nairobi County reported 243 cases of TB treatment interrupters. This was a major concern for the NLTBP and Nairobi County TB team. Afya Jijini supported the CTLC to implement a TB DCM model, sensitized 23 SCTLCs, and cascaded this approach down to clinicians at facility level through CMEs and OJTs. As part of this approach and in response to the high number of treatment interrupters, the clinicians offered extended hour TB services targeting men. TB support groups offering health education and adherence counseling were also piloted at 58 facilities. In addition, the project supported three nurses to offer direct observed therapy (DOT) to 6 DRTB patients who were unable to access care at facilities. Forty-eight TB treatment interrupters were traced through project supported cough monitors and restarted on treatment.
Improve IPT In Q4, data quality assessments (DQA) on IPT were conducted at two facilities (Kayole II and MLKH) by USAID Kenya and Washington teams. The two facilities demonstrated IPT uptake of above 80% with incomplete documentation in IPT registers and incomplete data reconstruction in IQ care. Corrective action was discussed with the cluster team at Afya Jijini using the previous line list developed at the facilities to update registers and IQ care on patient outcomes. Going forward, IPT will be included as one of the SURGE indicators to monitor both uptake and documentation.
In Y4, Afya Jijini conducted eight CMEs targeting 136 HCWs at all 42 TB facilities on the new contact management register, which replaced the IPT pediatrics register. The project also supported CTLC to conduct a sensitization workshop for 41 HCWs from private and FBO facilities who had capacity gaps due to high turnover. This year, a total of 5,825 clients were initiated and 5,557 completed TB preventive therapy (TPT) as shown in the table below. The current IPT coverage of patients on care who have started and completed is 86%.
Table 16: TPT Breakdown by Age TPT <15 >15 Completed IPT 299 5,258 Initiated on IPT 357 5,468 Completion Rate 84% 96%
Strengthen TB infection and prevention control In Q4, the Afya Jijini project supported three SCTLCs to conduct WIT meetings for TB at Kivuli, Melchizedek (Dagoretti), Mukuru HC, Mukuru MMM (Embakasi), AMURT and Kangemi HC (Westlands). The facilities revised work plans and ensured availability of an IPC focal person. The project continued to support 31 cough monitors at Afya Jijini facilities who continue to conduct health talks at facilities and to fast track coughers at OPDs.
In Y4, Afya Jijini supported SCTLCs to conduct semiannual IPC assessment across 36 Afya Jijini supported facilities. This has ensured facilities have work-plans and have an assigned focal person to be in charge of IPC. Afya Jijini also supported three SCTLCs to conduct HCW screenings at MDH, Kayole II, Soweto’s St Mary’s hospital and Mathare North HC. A total of 186 HCWs were screened, with 19 presumptive cases and four HCWs found to have TB, which were subsequently initiated on treatment.
Boost TB-HIV integration and provision of immediate ART for TB clients In Q4, Afya Jijini continued to support 82 HTS counselors, ensuring 100% testing for all patients found to have TB, and offered mentorship to clinicians the during SURGE period to reduce missed opportunities for testing at TB clinics. HIV testing and HAART initiation improved during SURGE activities from 86% in SAPR1 (Oct `18-Mar `19) to 88% in SAPR 2 (Apr-Sep `19). 32 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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Linkage officers were assigned at all SURGE facilities to ensure TB/HIV co-infected patients were linked to care and treatment. Daily audits were conducted, and linkage data submitted to Afya Jijini facility- based program officers. Below is the quarter four TB cascade.
1,800 1,583 1,600 1,440 1,400
1,200 91% Of the 403 HIV 1,000 positive patients, 87% of them 800 were on HAART. 600 403 400 352
200
- New TB Cases Knowing HIV Status Total HIV Positive (Includes On HAART KP)
Figure 5: Q4 TB cascade
7,000
6,000 5,740 5,321 5,000
4,000 93% of the HIV 93% Positive patients 3,000 were on HAART.
2,000 1,504 1,398
1,000
0 New TB Cases Knowing HIV Status Total HIV Positive On HAART (Includes KP)
Figure 6: Year 4 progress cascade
Strengthen pediatric TB diagnosis and treatment In Q4, the project supported SCTLCs in conducting school screening at 3 sub-county schools after six cases were bacteriologically confirmed at Dagoretti High School and Mutuini Secondary in Dagoretti SC, and St George’s High School in Kasarani. A total of 1,600 students and 43 teachers and support staff were screened for TB, with 56 presumptive cases tested with GeneXpert. Two new cases were diagnosed, and one was started on treatment. One student is still being followed up by the SCTLC after the guardian insisted on seeking a second opinion before treatment is initiated. Teachers and students were sensitized with IPC messages and with posters on cough etiquette that were displayed on school notice boards and in classes.
Afya Jijini, in collaboration with the Nairobi County TB health team, held a stakeholder’s meetings where 40 participants - comprising school health nurses, SCTLCs and education officers, - met to
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finalize the school screening algorithm and the referral booklets to be used in identifying TB cases in primary and secondary schools. These will be launched in January 2020. In Y4, Afya Jijini worked in collaboration with SCTLCs to conduct OJT among 116 HCWs on nasogastric and nasopharyngeal aspirate for GeneXpert testing. The clinicians at Level II facilities are now able to conduct TB pediatric testing, thereby decongesting MLKH and Mbagathi Hospital. This year, a total of 420 children were diagnosed with childhood TB and started on treatment.
Multi-drug resistant (MDR-TB) In Q4, Afya Jijini conducted a joint supportive supervision visit with CTLC on MDR-TB quality of care at Dandora II, Rhodes, Kahawa West HC and Makadara HC. During the visit, it was noted that there was a delay in updating patient follow-up routine results in patient logbooks. SCTLCs were tasked with communicating directly with Lancet Laboratories within one week and sending results to clinicians by email. This enabled patients to review their results during clinical monthly review meetings. Afya Jijini conducted a CME in Embakasi Sub-County where 25 TB clinicians were updated on management of MDR-TB patients to improve on quality of care and follow-up. In Y4, a total of 17 patients were diagnosed with MDR-TB. The project supported STLCs in conducting monthly sub-county MDR-TB clinical review meetings where patients were informed of their results and adverse events were monitored and documented. A total of 16 patients reported hearing loss and their treatment was subsequently switched. In Y4, MDR-TB surveillance was at 76% (total number of all relapse and retreatment cases sent for GeneXpert or culture).In collaboration with TB ARC, four sub-county medical officers were trained on management of MDR-TB patients and were informed of the need to include MDR-TB patient updates in clinical patient review meetings.
Strengthen county TB coordination In Q4, Afya Jijini supported the CTLC to conduct data review meetings with the 23 SCTLCs, a forum where mentorship was offered to SCTLCs to enable them to harmonize data between transfers in and transfers out, thus avoiding duplication of registration. Afya Jijini team also participated in National TB site assessments conducted at 14 supported facilities. TA was offered to TB clinical and laboratory staff on gaps identified onsite, including incomplete documentation in patient clinical cards and delays in documenting GeneXpert results in presumptive registers.
In Y4, and in collaboration with TB ARC and the county TB team, Afya Jijini supported and participated in data-driven supervision Photo 2: TB clinic structure at Mama Lucy Kibaki where facilities’ performance was evaluated Hospital. using data for decision making. Afya Jijini supported STLCs to conduct facility monthly data review meetings across all sub-counties in which targets were set according to previous performance. Afya Jijini, in collaboration with TB ARC, supported the CTLC in conducting quarterly partner meetings in Nairobi County, where support and activities for partners were shared and discussed to avoid duplication of efforts. The project also supported a forum to reward the highest performing facilities and SCTLCs.
Journey to self-reliance Afya Jijini is currently offering TA to SCTLCs on inclusion of clinicians in ACF instead of only using cough monitors for case finding at facilities. The ACF stamps at triage ensures that clinicians screen all patients seeking services at all SDPs. In year 5, the project will ensure scale-up of utilization of presumptive case registers among clinicians through OJT and mentorship. Afya Jijini supported MLKH to refurbish two containers for a permanent TB clinic and to integrate HIV services beginning in Y5Q1. 34 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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SUB PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED REPRODUCTIVE, MATERNAL, NEONATAL AND CHILD HEALTH (RMNCH) AND FAMILY PLANNING (FP)
Output 2.1: Maternal Neonatal Health (MNH) Services strengthen County and sub-county MNH service quality and coordination Afya Jijini has continued supporting NCC in implementing its reproductive, maternal, neonatal and child health (RMNCH) activities across the ten sub-counties. The program supported NCC in marking World Contraceptive Day (WCD) on 26th September at Embakasi West Sub-County. The theme this year was “The Power of Options,” guided by the motto, “A World Where Every Pregnancy Is Wanted.” The celebrations were aimed at encouraging young people to take responsibility for contraception and learn about all the options available to make an informed choice. It also aimed at educating the entire community on the benefits of using contraceptives correctly and consistently. Service delivery was carried out as part of the build-up to activities resulting in the following achievements: 28 outreach events supported across the county; 1,017 implants inserted; 289 intra-uterine contraceptive devices (IUCDs) inserted; 998 oral contraceptives given, along with cervical cancer and HIV screenings.
To achieve quality care in RMNCH, the program produced 75 assorted SOPs, job aids, and guidelines from WHO, UNFPA and other recognized bodies in the field of RMNCH, and sourced other IEC materials from the Division of Reproductive Health (DRH). The range of SOPs covered the continuum of care from ANC to PNC, child health, and FP. Of importance were job aids on maternal resuscitation, the updated guidelines on Integrated Management of Neonatal and Child integrated management of newborn and childhood illnesses (IMNCI), 2016 Medical Eligibility Criteria (MEC) wheels, and other updated SOPs. The main beneficiaries of these job aids were the newly supported facilities and those that had recently upgraded to maternities and MNCH services. The materials were distributed to all 69 program-supported maternities by the end of the quarter.
During the quarter, the program supported a one-day FP TWG; a total of four FP TWG meetings were supported in Y4. Key issues discussed during the meetings were strategies to increase FP uptake such as addressing issues leading to stock outs; proper quantification to avoid stock outs; consistently offering FP method mix services at all facilities; training on updated FP guidelines; OJT/mentorship for health workers, Contraceptive Technology Update (CTU) to increase uptake of long-term methods; targeted in-reaches and outreach events in low uptake communities; integrating FP services with other services such as HIV treatment and child welfare clinics (CWC;) community mobilization for FP services through community health volunteers (CHVs); community based distributors (CBDs); Barazas; Dialogue Days; churches; strategically placing IEC materials for clients on FP in high traffic areas; partnering with the private sector to provide FP services at subsidized rates; strengthening advocacy for FP through FP Champions; and improving the enabling environment for FP services in health facilities through provision of equipment, commodities, and commodity management training. With support from Afya Jijini, Nairobi County CHMT and IMNCI trainers trained 60 health service providers on IMNCI in August 2018. During the quarter, a joint supportive supervision/follow up visit was carried out to assess the implementation of the strategy post training to ensure adherence to guidelines and establish challenges in implementing the IMNCI strategy. The exercise revealed that despite the introduction of the “neonatal” element last year (2018), updated guidelines were still missing in the facilities. Some of the challenges noted were that most trained HCWs were not posted in service delivery areas where they could practice IMNCI, high staff turnover in private facilities and consequently loss of trained staff, a lack of commodities and ORT corners in facilities, and a poor knowledge on child rights among clients. The county has taken up these challenges for action within the next quarter. 35 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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During the quarter, the program supported the NCC polio campaign in the month of July. A series of activities were supported including a two-day microplanning meeting where SCHMTs were trained on the polio campaign objectives; introduced to mapping and documentation; sensitized on the house-to- house strategy; given information on the Supplemental Immunization Activity (SIA) and trained on logistics for SIAs; trained on administration of Oral Polio Vaccine (OPV); trained on enhancing Acute Flaccid Paralysis (AFP) Surveillance; updated on Advocacy, Social Mobilization, and Communication (ACSM); and developed an outline for implementation timelines. The campaign reached a total of 978,118 (111%) children compared to the 938,133 children (106% coverage, an increase of 39,985 children) vaccinated as of September 2018. Of these, there were 73 zero doses, four cases of AFP, and two cases of Adverse Event Following Immunization (AEFI) reported and treated.
The program supported NCC in carrying out a one-day orientation to sub-county public health nurses (SCPHNs) and sub-county Expanded Programme on Immunization (EPI) depot managers on updates regarding the pneumococcal vaccine (PCV) switch. In 2019, the Ministry of Health changed presentation of the PCV10 from the two-dose vials to the four-dose vials. The four-dose formulation is expected to have smaller volume and therefore occupy half the space in cold chain as compared to the previous two-dose presentation. The new four-dose presentation will be used for up to 28 days in line with the Multi-dose Vial Policy (MDVP) and is therefore anticipated to reduce wastage.
Following high cases of neonatal deaths due to asphyxia in the previous quarters, Afya Jijini, in partnership with the County Child Health Coordinator, planned and held a class for 25 HCWs on Helping Babies Breath (HBB). The participants were drawn from the county facilities with the highest neonatal mortality. The trainees are expected to run HBB corners in most facilities and mentor colleagues on the skill in order to improve child survival.
Boost ANC attendance (uptake and completion of 4+ ANC visits) In Y4 Q4, Afya Jijini attained 24,600 (92% of the quarterly target) women who completed their 4th ANC visits contributing 82% to the annual target and a coverage of 105% in the program catchment population. The program continued screening for pregnancy for women of reproductive age (WRA) seeking services in health facilities at all service delivery points in order to identify pregnancies early and initiate timely ANC. The program staff, jointly with sub-county nurses, continued to conduct OJTs and mentorship touching on ANC with an emphasis on dangers in pregnancy, reaching 142 HCWS in Q4 and 729 HCWs in the entire year. Additionally, the program reached 217 HCWs through CMEs on different ANC topics such as danger signs in pregnancy, hypertensive disorders in pregnancy, and the need for iron/folate supplementation in pregnancy. In addition, PMTCT nurses continued to support RH-HIV integration by ensuring zero missed opportunities for all pregnant women who tested positive at any MCH service delivery point while at the same time supporting ANC service delivery. Mentorship sessions also emphasized the need for promoting completion of 4+ANC visits for better pregnancy outcomes.
During the quarter, the program supported a three-day focused antenatal care (FANC) training for Makadara, Embakasi East, and Westlands sub-counties. A total of 79 HCWs were trained. The trainings utilized sub-county trainers who used the approved national training curriculum. The training was in response to gaps identified in ANC service delivery at health facilities and the capacity gaps for new staff who were offering services at ANC clinics. The FANC trainings focused on understanding FANC, preparing individualized birth plans, identifying and managing ANC health problems, organizing ANC, identifying risky pregnancies, ANC counseling, malaria in pregnancy, anemia in pregnancy, PMTCT, TB in pregnancy, ultrasonography factors, strategies to increase skilled care, M&E and record keeping, postnatal overview, introduction to action plans, and presentation of the work plans.
Post test results showed improved knowledge on FANC by all participants. Facility-based action plans were developed during the training and these will be followed up on during supportive supervision visits by the SCHMTs.
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Subsequently, the program’s 55 CHVs mapped 961 pregnant women and referred 768 for early ANC initiation. The CHVs also conducted 7,032 household visits while providing appropriate and timely ANC messages during the visits. Additionally, 143 women were noted to have danger signs and referred for further management in health facilities, 434 women were noted to have completed four ANC visits and referred for delivery at health facilities, and 138 defaulters were traced and brought back for ANC care.
Number of women who received at least 4 ANC visits 30,000 100% 92% 90% 25,000 90% 80% 78% 76% 70% 20,000 60% 15,000 50% 40% 10,000 30% Performance % 20% No of Pregnant Mothers Mothers No of Pregnant 5,000 10% 0 0% Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 July to Sept 2019 Period by Quarter
Target Achievement % Performance
Figure 7: Afya Jijini Year 4 Performance: 4+ ANC
In summary, 961 pregnant women at different stages of ANC visits were identified and counseled on the importance of attending all ANC visits for better pregnancy outcomes and were given information on individual birth preparedness with an emphasis on danger signs during pregnancy. In Q2, there was a two month industrial action leading to the temporary decrease illustrated in the bar chart above.
Boost Adolescents ANC attendance (uptake and completion up to 4+ visits)
In Q3, focus group discussions (FGDs) were held in ten health facilities targeted at understanding adolescents and young people’s responsiveness to RH services. The findings indicate that 96% are relatively aware of what RH is and 89% had some experience with RH issues that include unsafe abortions, urinary tract infections (UTIs), painful menses, and pregnancies. This finding confirmed the need to further engage adolescents and young people on the importance of RH. A total of 26% had little or no knowledge on RH or where they could access RH services when in need. Participants noted that they seek help from their peers, while others search the internet for quick solutions. Very few willingly visited health centers and those who did were not comfortable due to a lack of youth friendly services. They cited stigma and ridicule as the barriers to services. This means that the program must continue strengthening health services by engaging in attitude change discussions both at facility and community level while also engaging adolescents to assist peers to mobilize and navigate services.
Increase safe deliveries within NCC The program in Q4 distributed 4,200 maternity files to 69 program-supported maternities to improve documentation of patients’ information and for labor monitoring though partographs. The project also focused on advocating for fund allocation at the facility level to sustain the supply of files as part of the
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journey to self-reliance. The project had a breakthrough at Pumwani Maternity Hospital where the facility started allocating funds for maternity files. Discussions on the same are ongoing with management at Mama Lucy Kibaki Hospital and Mbagathi Hospital. However, Level 2 and 3 facilities are still challenged by irregular or non-reimbursement of National Hospital Insurance Fund (NHIF) Linda Mama claims, which limits funds available to purchase some commodities and supplies e.g. files, Jik, etc.
Afya Jijini also supported mentorships, CMEs/OJTs on EmONC signal functions, and mentorships/OJTs on Respectful Maternity Care (RMC), reaching 361 HCWs on various topics such as antepartum hemorrhage (APH), postpartum hemorrhage (PPH), ruptured uterus management, newborn resuscitation, assisted vaginal delivery, correct use of the partograph, and HIV testing in maternities.
The program continues to support maternity tours during first ANC visits in the public health centers. These tours, supplemented by CHVs’ efforts at the community level, have resulted in increased skilled deliveries in the health facilities. Of the total deliveries in the quarter, 996 were referrals from the community by the CHVs who also linked 600 mothers for Linda Mama registration. Despite completion of the last phase of the Leadership Development Plus (LDP+) program in Q3 and not having a class in Q4, its benefits continue to yield results even in Q4. The facilities that participated continuously demonstrate consistency in maintaining a high number of deliveries over time, which is associated with leadership principles taught during LDP+ and also better leadership skills demonstrated during work improvement team (WIT) meetings.
During the quarter, maternity open days were conducted in three facilities, namely Langata, Makadara, and Eastleigh Health Centers. The events targeted pregnant and breastfeeding mothers and involved prior community mobilization by CHVs. A total of 462 people attended.
Percentage of women giving birth who received uterotonics in the third stage of labor (or immediately after birth)
30,000 120% 100% 100% 25,000 86% 83% 100% 20,000 80% 15,000 60% 10,000 40% % Useof Oxytoxin No. of deliveries 5,000 20% 0 0% Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 July to Sept 2019 Reporting period by quarters
Total Deliveries Oxytoxin given % mother received Oxytoxin Figure 8: Afya Jijini Quarterly Performance on Skilled Deliveries
During the quarter, a total of 24,181 deliveries (103% of the quarterly target) contributing to 107% of the annual target and 101% coverage of expected deliveries. A corresponding 99.7% received oxytocin during the third stage of labor or after delivery. Additionally, there were no reported cases of oxytocin stock out in Nairobi County during the reporting period.
Of the 713 maternal complication reported in the quarter, 263 (37%) cases were due to PPH. This was a decline compared to the Q3 contribution of PPH cases, which was 39%. This is mainly attributed to continued mentorship, OJT and QI activities in the maternities. In the quarter, all PPH cases were
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managed using the PPH care bundle which includes active management of third stage of labor (AMTSL), use of uterotonics, and use of fluids for rehydration. A total of 57 cases were transfused with blood and blood products. As in previous quarters, the biggest challenge in managing hemorrhage cases was late referral from referring facilities and inadequate blood and blood products.
In the same period, 25 CHVs working with HealthRight (HRI), an Afya Jijini grantee, supported the enrollment of 522 pregnant women into Linda Mama at Pumwani, St. Mary’s, St. Francis, MLKH, and Mbagathi Hospitals. The main challenge affecting enrollment included non-acceptance of Linda Mama services at the two faith-based referral hospitals, St. Mary’s and St. Francis. Other challenges included refugees who couldn’t access Linda Mama due to lack of national identification documents, especially at Pumwani due to the Eastleigh population.
The program also supported a two-day ultra-sonography coaching session for maternity nurses in Westlands sub-county. A total of 17 nurses were coached on the use of ultrasound machines following USAID’s procurement and distribution through the Kenya Medical Supply Authority (KEMSA). Similar coaching will be organized to cover the rest of the facilities supplied with equipment. This will go a long way in reducing perinatal deaths, which are taken as an index of efficacy of not only ANC and PNC but also of the socioeconomic status of the community. Moreover, Fresh Still Births (FSBs) can be reduced extensively if both maternal and fetal conditions are closely and accurately monitored.
Maternal Complications Maternal Complications 2% 2% 0 APH (Ante partum 14% Haemorrage) 37% 18% Eclampsia
Obstructed Labour
27% PPH (Post Partum Haemorrage) Ruptured Uterus
Sepsis
Figure 9: Afya Jijini NCC PPH Cases and Responses
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PPH Cases Response and its contribution to Maternal Deaths 350 100% 100% 300 90% 90% 86% 82% 80% 250 70% 200 62% 57% 60% 50% 50%50% 150 40%
No of MD No MD of 100 30% 22% 22% 22% 20% 50 14% 10% %due MD to PPH 0 0%
Reporting Period by Quarters PPH cases Transfused Total maternal Death contribution of PPH to MD
Figure 10: PPH cases response
Maternal and Perinatal Death Surveillance and Response (MPDSR) activities at health facilities:
In Y4, 2,914 perinatal deaths and 119 direct maternal deaths were reported in high volume facilities, which include Mama Lucy Kibaki, Mbagathi Hospital, St. Francis, Pumwani Maternity and other mid- level and private facilities. None of the other facilities reported any maternal deaths, which is attributed to linkage to ambulance services amongst these facilities which has resulted in better referral systems being available. Of the maternal deaths, 50% were due to PPH, 14% other indirect causes (HIV and meningoencephalitis), 21% eclampsia, and 14% APH. All 14 maternal deaths were audited and actions to prevent similar occurrences were put in place.
Overall, the program reported a facility-based maternal mortality ratio of 130 deaths per 100,000 live births and a perinatal mortality ratio of 24 deaths per 1,000 live births by end of Y4. This was an improvement in newborn mortality rates (NMR), but not in maternal mortality rates (MMR), as compared to 2018. The Y4 MMR ratio was 108 per 100,000 live births and the NMR ratio was 33 deaths per 1000 live births. There was a remarkable improvement in reporting through the national Kenya DHIS2 which may have contributed to capturing more information this year and thus the higher numbers in MMR.
In Q4, 663 perinatal deaths were reported (195 FSB, 222 macerated still births [MSB], 246 neonatal deaths) out of which the 246 early neonatal deaths were audited as follows: 81 were due to asphyxia, 21 to neonatal sepsis, and 144 to other causes. Of the 14 maternal death cases reported, the big maternities contributed to 85%: MLKH – 4 deaths (28%), Pumwani Maternity Hospital – 5 deaths (36%), and Mbagathi Hospital – 3 deaths (21%). The program staff are currently focusing on addressing the poor maternal and perinatal outcomes in these facilities and the surrounding communities by working with the CHMT, SCHMT, health facilities, and communities to address some of the first, second and third delays contributing to occurrence of deaths.
During the quarter, Afya Jijini supported two MPDSR training workshops for Embakasi West and Makadara sub-counties in which a total of 25 HCWs and 30 CHVs were reached. The training entailed an MPDSR overview and explained linkages with Integrated Disease Surveillance and Response (IDSR). The trainings were purposefully conducted in the two sub-counties with the highest maternal mortality, with special focus given to feeder facilities for MLKH, which had the highest mortality rates.
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Afya Jijini, jointly with the MPDSR trainers, will continue supporting post-training follow-up and ensure timely reviews and responses.
In Q4, 61 MPDSR committee meetings were held in the following facilities: MLKH, St Francis, St. Mary, Pumwani, Makadara, Mukuru and Mathare North. These meetings received technical assistance from program staff at the 14 facilities. The program also supported the distribution of 600 MPDSR tools to the 10 sub-counties, including the five referral maternities. In the reporting period, 30 CHVs in Makadara sub-county were trained on the community MPDSR system. The CHVs were taken through the MPDSR process: notification of a death, verbal autopsy, and why it was essential for improved surveillance of all maternal and perinatal deaths in the community. The training was necessary due to the lack of verbal autopsy committees knowledgeable on the community MPDSR process. The program supports community verbal autopsy committees in the referral and high-volume facilities to audit all deaths happening at the community level.
Quality improvement (QI) in maternities
WIT activities continued in maternities in Q4 to improve documentation, patient monitoring and general quality of services. From some of the WIT projects below, there was demonstration of improvement at maternities.
Table 17: Progress in maternities Facility WIT project Baseline Score at end of Target score score Q4 in 6 months (mid-line evaluation) St. Mary’s Hospital 4-hourly vitals monitoring for 4% 90% 100% mothers in labor St. Francis Hospital Documentation on partograph 7% 82% 97% Pumwani Maternity Waste segregation in the labor 2.7% 27% 80% Hospital ward Mutuini Hospital Complete and accurate 10% 40% 70% documentation of partograph Ngara HC Increasing SBAs 20% 68% 90% Reuben Health Center Improve on documentation 18% 70% 85% (maternity file) Kayole 1 Health HIV counseling and testing in 0% 80% 100% Center the maternity Kayole 2 Health Improve on maternity file 10% 60% 80% Center documentation Embakasi Health HIV counseling and testing in 30% 80% 100% Center the maternity St John Hospital Improve documentation of 33% 92% 80% partograph
Improving HCW attitude through training and coaching HRI, a grantee, continued with RMC activities to address staff attitudes in the big five hospitals (Pumwani Maternity, Mbagathi County, MLKH, St. Mary’s Mission, and St. Francis Community Hospital), and six program-supported health centers (Mathare North, Makadara, Mukuru HC, Mukuru Reuben HC, Kayole 1 HC, and Eastleigh HC).
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Improve uptake and provision of PNC at target health facilities In Q4, Afya Jijini continued mentorship to the HCWs on timely documentation of PNC within two days of delivery. The program staff, jointly with county mentors, reached a total of 147 HCWs from 24 facilities, and another 123 HCWs through CMEs on accurate documentation of PNC services by working with SCPHNs. The program also addressed the gaps in PNC documentation through support to PNC WITs, specifically addressing documentation gaps. In Q4, 12,902 newborns (51% of total deliveries in the quarter) were reported to have received PNC care within 48 hours, contributing to 108% of the annual target.
One class of PNC training was conducted at Ruaraka sub-county. A total of 25 nurses (21 females and 4 males) attended the training. Following the PNC training, joint mentorships with the SCPHNs on the PNC register continued focusing on the gaps noted during chart abstractions. These gaps included post-natal checkups, documentation of post-natal vital signs, initiation of breastfeeding, immunization documentation, counseling of women on FP, documentation of mother and baby danger signs, and post-partum family planning (PPFP). The nurses were also mentored on proper documentation of HIV testing during the postnatal period.
Kangaroo Mother Care (KMC): Prematurity and low birth weight remain a major contributor of newborn mortality and KMC is one key intervention supported by the program to address poor newborn outcomes. During the reporting period, the program staff continued mentoring HCWs on KMC whereby 26 HCWs were reached. A total of 481 premature low birth weight babies were admitted to KMC, of which 464 were discharged alive with some babies from the previous quarter also discharged during the reporting period, translating to a 96% success rate. Three percent (3%) or 16 babies died while undergoing KMC. The program plans to conduct follow-ups within the community using the project’s community approaches.
During the quarter, CHVs visited households and identified 1,025 newborns within the 80 community units and offered PNC messages to their mothers on topics such as recognizing danger signs in the newborn as well as the mother after delivery. The CHVs also reached 384 mothers with KMC messages to demystify prematurity and low-birth weight in the community, while increasing the awareness of mothers of the importance of PNC. The CHVs also mapped and referred 641 mother/baby pairs for postnatal services.
% Infants receiving Pospartum care within 2-3 days 30,000 70% 25,000 59% 60% 51% 52% 50% 20,000 44% 40% 15,000 30% 10,000 20%
No. Of deliveries 5,000 10% 0 0% Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 July to Oct 2019 % infants given PNC 2days Axis Title
Deliveries MOH_711 PNC Infants receiving Pospartum care within 2-3 days AfyaJijini % Infants receiving Pospartum care within 2-3 days
Figure 11: Infants receiving postpartum care
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Table 18: Quality Improvement in PNC Facility WIT project Baseline Score at end Target score of Q4 score in 6 (mid-line months evaluation) Mutuini Hospital Complete documentation of PNC 10% 40% 80% register in maternity
Kangemi HC PNC documentation in maternity 0% 30% 80% Ngara HC PNC documentation in maternity 0% 50% 80% Kibera Health PNC documentation in maternity 0% 50% 70% Centre Mukuru Health PNC documentation in maternity 5% 50% 60% Centre St John Hospital Improve PNC documentation in 48 0% 95% 70% hours Kibera South Accurate and complete 0% 50% 70% documentation of postnatal register Waithaka Heath Accurate, complete documentation 0% 70% 90% Centre of postnatal register at maternity
Scale-up gender-sensitive approaches to MNH Men play a crucial role in decision making and determining health-seeking behavior for women who need MNCH services, consequently influencing most MNCH outcomes. During the reporting period, 3,279 couples were taught how to recognize danger signs and prepare an individual birth plan. This accomplishment was due to the sensitization of 47 CHVs in Q2 and engagement of 10 male/female champions in Q3. MLKH, Makadara, Bahati, Eastleigh, Embakasi, Kayole I, Kayole II, Dandora 2, Kahawa West, and Korogocho Health Centers are ‘We Men Care’ implementing facilities with a service desk that is attended by a male champion. A total of 6,450 men were reached to support their partners in accessing MNH services. The program also continued to distribute IEC materials and reporting tools used during health sessions. Male beneficiaries received services such HIV testing and 2,603 were screened for hypertension; obesity and reached through couples’ engagement. 1,415 men received ANC messaging while 828 women were supported by their male partners for skilled delivery, 621 women received PNC, and 832 women received FP.
Output 2.2 Child health services During the quarter, the project continued working with NCC’s health department to prevent and treat vaccine-preventable diseases including diarrhea and pneumonia in children under five in the informal settlements. The total catchment population is estimated at 89,247, with 113% diphtheria- tetanus-pertussis (DPT3) coverage under one year of age in the targeted population.
In Q4, 26,329 children under one year of age were reached with DTP3 vaccines; 25,198 were reached with measles vaccines; and 24,522 children were fully immunized (FIC). A total of 9,657 cases of pneumonia among under-five children were diagnosed and treated with antibiotics, and 18,579 cases of diarrhea were also treated at health facilities. The county has not been able to procure Amoxicillin DT from KEMSA due to administrative challenges. Caregivers must purchase Amoxicillin DT from private chemists, a setback for the management of pneumonia despite early diagnosis. The project continues to advocate for unbroken supply chain management, but this is tied to financial commitment by the County.
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The annual coverage for immunization for children under one year for DPT3 vaccines was at 98% reaching a total of 101,688 children; 98,802 children were reached with measles vaccines contributing to 98% coverage; and 98,902 children at 98% coverage were documented as fully immunized (FIC). In Y4, a total 6,266 cases of pneumonia among under-5 children were diagnosed and treated with antibiotics, and 80,840 cases of diarrhea were also treated at health facilities.
Strengthening county and sub-county planning/supportive supervision for child health
During this quarter, the program performed supportive supervision in Kasarani, Westlands, Kamukunji, Makadara and Embakasi sub-counties. The supervision team noted good practices in immunization documentation in ledger books, permanent registers and tally sheets, cold chain maintenance, and nutrition interventions.
The program provided Kasarani and Dagoretti sub-counties with logistical and technical support during EPI microplanning meetings. During the training sessions, 127 participants were taken through the immunization status in the sub-counties, learning how to improve immunization coverage, reach communities with immunization, reach target populations, document in the registers and the tally sheets, use defaulter tracking and appointment management, and about the linkages between community and facilities. During routine technical assistance sessions, mentorship was carried out on cold chain management, ledger books, documentation and reporting at 27 facilities reaching 67 HCWs.
Following a data review that showed low immunization coverage for the measles II vaccine, EPI outreaches at Ng’ando informal settlements in Dagoretti sub-county were launched by the CHMT and have so far reached 160 children with immunization services. Similarly, Embakasi East conducted an integrated outreach event reaching 296 children for immunization as a mop up activity.
Improving facility child health service provision
The program supported the Sub-County Child Health Coordinators and SCPHNs to carry out IMNCI mentorship in eight sub-counties (i.e. Langata, Dagoretti, Kangemi, Westlands, Embakasi East and West, Ruaraka, and Kasarani), reaching 73 HCWs (including nurses, registered clinical officers [RCOs], and medical officers [MOs]) in 24 facilities. They were mentored on assessment, classification, identification, treatment and referral for pneumonia in children. Updated IMNCI guidelines, job aids, policy documents as well as IMNCI charts, booklets, and recording forms for the children were used during the sessions. Sessions also covered identification of danger signs, classification of dehydration, and signs and symptoms and management of diarrhea using oral rehydration solution (ORS) and zinc.
During the same period, facility-based CMEs were conducted in 55 facilities reaching 297 HCWs. As a result, HCWs are able to diagnose and treat diarrhea and pneumonia using the current guidelines. We have seen improvement in ORT corners, completeness of registers, and routine health talks in MCH clinics/waiting bays, the latter of which was a practice that had started to dwindle.
Strengthening knowledge and uptake of infant and child health services at the household and community level
During the quarter, CHVs reached a total of 11,479 children within households and gave health talks to caregivers on the importance of immunization. They also referred 1,675 children for immunization and traced 315 who had defaulted from immunization.
The 172 CHVs supported by the program visited 7,032 households and educated caregivers on the importance of exclusive breastfeeding for six months and complimentary feeding up to 2 years, washing hands during four critical times, and appropriate and timely referral when they notice danger signs of pneumonia and diarrhea or any other condition that cannot be managed at the community level. 44 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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Consequently, 784 caregivers were reached with messages on diarrhea management, 659 were reached with messages on other illnesses (e.g., TB, fever), and the CHVs referred 494 and 444 children under-5 years for management of diarrhea and pneumonia, respectively, in the 10 health facilities where the CHVs were linked.
Output 2.3 Family planning services FP remains one of the highest impact lowest costing interventions in the prevention of maternal and perinatal deaths in our catchment area. It also contributes to economic growth and reduces child mortality, unplanned pregnancies, and unsafe abortions.
In working towards achieving the project’s goal of reducing maternal and perinatal mortalities, the program worked with 183 facilities and 172 CHVs and reached 104,684 WRA with FP services, out of which 46,857 were new and 57,827 were revisits, consequently achieving 95,174 couple years of protection (CYP) over the quarter. Long-acting and reversible contraceptives (LARC) contributed to 65% of the total CYP. A key challenge over the quarter was commodity stock-outs, especially for injectable contraceptives (Depo-Provera), single rod implants (Implanon), and IUCDs. The Facility Commodity Drug Requisition and Recording (FCDRR) reporting tool was available since the program supported the printing and distribution of the tool in each sub-county.
The Binti Shujaa model reached 357 adolescents with FP services in the quarter. The project’s annual CYP contribution was 280,690 in Y3 compared to 370,216 in Y4, an increase of 75%. This has contributed to 40% of CYP coverage among WRA in the program’s catchment.
Couple Year of Protection Achievement and LARC Contribution Oct 2017 - Sept 2019 120,000 80% 71% 70% 100,000 66% 66% 61% 58% 60% 80,000 50% 50% 60,000 43% 40% 30%
Total CYP 40,000 20%
20,000 15% % LARC Contribution 10% 66,521 75,295 80,262 76,739 84,765 91,388 98,890 95,175 0 0% YR 3 Q1 YR 3 Q2 YR 3 Q3 YR 4 Q3 YR 4 Q1 YR 4 Q2 YR 4Q3 YR4 Q4 Period by Quaters
Total CYP LARCs CYP LARC Contribution to CYP
Figure 12: Quarterly CYP Performance and LARC Contribution
Strengthening county and sub-county FP coordination and service delivery
In the reporting period, Afya Jijini assisted in the redistribution of FP commodities from the main stores to the sub-county stores in Kamukunji, Langata, Makadara, Embakasi West, Ruaraka and Westlands to improve coverage. During a project supported in-charges meeting for Embakasi East and West, Makadara, Kamukunji and Langata sub-counties, the County MNCH/FP Programs Officer re-sensitized 265 facility in charges and 79 SCHMT members on the US FP and abortion policies.
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Improving access and quality of facility-based FP services In Q4, the program supported facilities by re-distributing commodities between sub-counties to ensure continued service provision with minimal interruption. Afya Jijini program officers, jointly with sub-county mentors, continued to mentor and offer support to health care providers to improve quality and access to FP services. Among the departments of interest were the CCC, PMTCT, and postnatal, maternity and FP clinics. In building the capacity of healthcare providers and to enhance FP integration, Afya Jijini distributed 15 counseling cards, 15 MEC wheels (2016) and 15 Tiahrt charts to 12 facilities. Two facilities (Lengo Medical Centre and Kangemi Health Centre) were supported with sphygmomanometers to ensure the suitability of FP methods given to clients. A total of 26 HCWs (18 female and 8 male nurses) were mentored on how to provide FP counseling to FP clients. The HCWs were drawn from Pumwani Maternity, Kahawa West, Mathare North, Langata HC, Ngaira HC, Ngong Road HC, Mbagathi Hospital, Pumwani Maternity, Korogocho, Dandora HC, Kayole 2 SCH, Mutuini HC, Mukuru MMM, Kangemi Ruben HC and Mukuru HC.
The program, through SCPHNs, supported CMEs on integration of PPFP within service delivery points, reaching a total of 32 HCWs (26 female and 6 male) at Guru-Nanak Hospital, Makadara HC, Bahati HC, Mukuru HC, and Ngong Road HC. At Bahati, Dandora 2, and Makadara Health Centres, the 20 Binti Shujaa mentors that were trained in Y4Q1 continued with peer mentorship in their respective communities, reaching 357 girls with FP messages and referring them for services. A total of 15,220 adolescent girls had received a modern contraceptive method across the program facilities by Q4. Overall, the project reached a total of 38,540 adolescents within the year contributing to a coverage of 16% among adolescents in Nairobi County. The Binti Shujaa mentorships contributed to the rise of numbers within Q3 and Q4, especially due to immense social mobilization during the graduation period in Q3.
MOH_711 Adolescent Family planning uptake 15-19 yrs 16,000 15,220 13,855 14,000 12,000 10,000 8,000 4,991 6,000 4,474 4,000
No of Adolescents reached 2,000 0 Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 Jul to Sep 2019 Period by Quarters
Figure 13: family planning uptake among adolescents
In Q3, at Dandora II Health Centre a total of 212 Binti Shujaas participants graduated as champions after having achieved four critical milestones in MCH. In Q2, 10 adolescent-focused psychosocial support group sessions for young and first-time mothers below 19 years were held to improve longitudinal follow up from ANC through to post-natal care and immunization.
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Table 19: MOH_711 Adolescent Family Planning Uptake 10-19 Years FP FP uptake uptake FP FP 10-14 15-19 Total uptake uptake Total Total FP yrs. yrs. New 10-14 15-19 Revisits Revisit New FP New New 10-19 years years 10-19 10-19 10- Revisit Period clients clients years Re-visits Re-visits Years Years 19 10-19 Oct to Dec 2018 207 1,553 1,760 388 1,083 1,471 4,991 35% 29% Jan to Mar 2019 168 1,284 1,452 340 1,230 1,570 4,474 32% 35% Apr to Jun 2019 250 5,954 6,204 401 1,046 1,447 13,855 45% 10% Jul to Sep 2019 326 6,163 6,489 225 2,017 2,242 15,220 43% 15% Total 951 14,954 15,905 1,354 5,376 6,730 38,540 41% 17%
Integration of RH/HIV services
Afya Jijini continues to support a total of 30 facilities in offering FP in the CCCs and PMTCT service delivery points through OJT/mentorship on FP services, distribution of FP registers, and re-distribution of FP commodities and equipment. In Q4, a total of 258 new and 1,542 revisit clients who are HIV positive were reached with modern FP methods in the CCCs and PMTCT rooms at the facilities. Inadequate infrastructure to enable optimal integration remains a key challenge in most CCCs, but the program is working jointly with the SCHMTs on a long-term solution. HIV testing by program HTS counselors continued in MCH departments, FP rooms, and labor and postnatal wards in the five referral hospitals and health centers. In the CCC and PMTCT rooms, a total of 15 clinicians (5 male and 10 female) were mentored to provide quality FP services and were provided with MEC wheels, BCS+ cards, Tiahrt charts and FP demonstration charts.
Strengthen household and community access to FP messaging and commodities
Table 20: Household access to FP messaging and commodities FP Method New Clients Re-Visits Total IUCD insertion 5 25 30 Female condoms 2 31 33 Pills progestin only 0 40 40 Implants insertion 17 34 51 Pills combined oral contraceptive 17 65 82 FP injections 39 118 157 Client receiving male condoms 178 1,229 1407 Total 258 1,542 1,800 In Q4, 172 CHVs supported by the program continued to offer FP information at the household level and during dialogue days conducted across 511 community health units (CUs). The CHVs reached 7,032 households and 2,109 WRA with messages on the importance of FP. The CHVs distributed 8,326 condoms and referred 1,526 clients for LARC.
Gender-sensitive FP approaches In the Y4Q4, the program worked with the Mathare Youth and Sports Association, a platform for adolescents and young people, to identify and engage 14 male champions to reach peers through structured sports. Champions engaged peers with messages about RH services at six neighboring health facilities. During the year, the project was involved in a design challenge with the Young African Leaders Initiative (YALI) and the Civic Leadership Cohort for 2019 who engaged health sector stakeholders through interviews and brainstormed solutions that have been integrated into our routine activities.
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Output 2.4: WASH Services Year 4 Quarter 4 and Annual Report Summary of strategy, achievements and operating environment During Y4Q4, Afya Jijini’s WASH program purposed to improve and increase access and utilization of WASH services by strengthening service delivery and the capacity of the health system in the county to deliver WASH services and thereby reduce incidences of diarrheal diseases in children under five years. In pursuit of this mandate, in Y4 Afya Jijini supported the county and sub-county levels through provision of technical assistance to 29 high volume facilities and 64 other health facilities and the surrounding communities in informal settlements. Afya Jijini built on the successes and lessons learned in Y1, Y2, and Y3 and focused on sustainability and skill transfer in delivery of WASH services. Utilizing the Urban Community Led Total Sanitation (UCLTS) approach, the project promoted sanitation and reduction of open defecation in informal settlements. The project provided a grant to a local organization to support implementation of project activities. A total of 223 health workers and 175 CHVs were trained and sensitized on different WASH topics. A total of 40 health facilities provided diarrhea management services through their strengthened ORT corners, where 15,804 children were reached. Thirty-nine (39) communities (increased from 33 last year) were engaged in promoting sanitation by UCLTS, resulting in 1,147 sanitation facilities constructed or rehabilitated and benefitting over 900,000 people living in informal settlements. One village had ODF claims during the year, based on reports by the Sub-County WASH Focal Person and the County WASH Coordinator. The verification process is scheduled in Q1Y5. Additionally, the project facilitated treatment of 13,234, 960 liters of water, benefitting over 500,000 people in informal settlements.
County-level WASH support Improving collaboration and networking: During Y4Q4, the project participated in forums and stakeholder meetings held in the county and all sub-counties. These included consultation meetings, planning meetings, and other forums attended by the county staff and other WASH partners. These forums afforded the project the opportunity to pursue and discuss areas of collaboration, learning, and sharing of experience. Afya Jijini also participated in a forum organized by the county on emergency preparedness for WASH diseases, during which an action plan was developed to aid in preparedness and response to the cholera epidemic currently occurring in the county. Also in Y4, the project supported the county with the development of the County Essential Package for WASH, which will be utilized in health education provision for children and communities in informal settlements. Afya Jijini also served as one of the co-conveners, alongside the county, and the secretariat of the Urban Sanitation TWG to develop the County Environmental and Sanitation Bill, through adoption of the prototype bill developed by the national government, and localizing the Kenya Environmental Sanitation and Hygiene Policy. Several consultative meetings and one workshop were held, resulting in the draft bill and the development of a roadmap which will be presented to the County Assembly. This year, the project also supported the County WASH Cordinator and project advisor to participate in the 2019 USAID Family Health Implementing Partners Symposium at Nakuru, where they shared the project’s experience in implementing UCLTS. In March, Afya Jijini was also featured in the USAID booth during the sixth annual devolution conference held in Kirinyaga County. Over 1000 conference delegates visited the booth. The project also presented an abstract on UCLTS at the first African Behavior Change Communication Conference in Kenya and gave an oral presentation on urban sanitation: https://asbc-conference.org/.
48 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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Capacity Building on WASH and Reporting: Afya Jijini provided technical and logistical support to the County Public Health Department’s quarterly forum attended by Sub-County WASH Focal Persons, Deputy Director of Public Health and the County WASH Coordinator. Each sub-county presented their progress reports. In addition, the 24 participants were sensitized on the cholera status in Nairobi County and the County WASH Coordinator’s planned intervention strategies. In Y4Q4, Afya Jijini continued strengthening the capacity of the county to deliver WASH services through a quarterly County Public Health Department forum, attended by Sub-County Public Health Officers (SCPHOs), heads of public health programs in the county, and Sub-County WASH Focal Persons. The forum has continued to ensure improvement in activity coordination, health worker’s capacity development, and increased visibility of project activities. During the year, the project also partnered with the office of County WASH Coordinator and County Health Records and Information Officer (CHRIO) in the training of 41 Sub-County WASH Focal Persons, SCPHOs, and Sub-County Health Records and Information Officers (SCHRIOs) on DHIS2 and reporting of UCLTS activities through the Ministry of Health (MoH) Community Led Total Sanitation online portal. As a result of the training, reporting rates of county environmental health and WASH activities through form MoH 708 and DHIS2 has improved from less than 10% to over 70% on DHIS2. To further improve data availability and reporting on UCLTS, the project supported the county in data collection (sanitation and hygiene provision levels and gaps) in all villages in Nairobi County. This data is to be used for planning and monitoring of progress in implementation of sanitation. During the year, the project supported the Office of County WASH Coordinator to undertake three supportive supervision visits in all the 10 sub-counties. During Y4Q4, the project supported the Office of the County WASH Coordinator to perform follow-up visits in 10 sub-counties to review actions agreed on during previous supervision visits. Capacity building for improvement of WASH activities implementation at the sub-county level was also undertaken. Strengthening awareness and promoting WASH through global awareness days: In Y4, Afya Jijini supported and participated in the promotion of hygiene and sanitation awareness through two global awareness days. • World Toilet Day on 19th November 2018 was held at Child Survival Grounds, Kamukunji Sub-County. The theme was “When Nature Calls.” The event took place in one of the villages where the project is implementing UCLTS. • Global Handwashing Day (GHWD) took place on 15th October 2018 at Gitwamba Primary School in Kasarani Sub-County. Over 3,500 children and 500 adults participated and were reached with hygiene messages. The project distributed 300 t-shirts, set-up two event banners, and provided technical assistance in planning for the event. Prior to the GHWD, Afya Jijini supported Kasarani and Kamukunji sub-counties in conducting handwashing promotion in schools and ECD centers. At Kamukunji, 144 children, the majority of whom were less than 8 years old and/or in ECDs, and 35 adults were reached with education on handwashing. At Kasarani Sub-County, 549 children in five ECD centers were reached with WASH and handwashing messages. Water treatment chlorine tablets were also distributed to the five ECD centers.
49 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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Sub-county and facility-level WASH support Improving WASH in health facilities: In Y4Q4, to improve knowledge on provision of WASH services and handwashing practices in health facilities, the project distributed 117 posters with messages on critical handwashing times, proper handwashing procedures, safe handling of water, and proper disposal of feces. In total, the project distributed of 496 posters to 56 health facilities with information on the critical handwashing times and procedures as a means of improving handwashing in health facilities during Y4. In addition, to promote infection prevention and control (IPC) and facilitate waste management in health facilities, the project procured and distributed 508 waste bins for waste segregation and disposal of healthcare waste to 29 health facilities. Also in Y4, to promote of provision of WASH services in health facilities, the project supported five CMEs on IPC to sensitize 156 health workers on topics such as healthcare waste management (HCWM), personal protection and handwashing, and water supply management in health facilities. During the year, the project also supported a one-day sensitization of 57 CHMT and SCHMT members on IPC to accelerate implementation and monitoring of IPC work plans at health facilities and sub- counties. This was a collaborative activity with the project’s HSS teams. Support functional oral rehydration therapy (ORT) corners at supported facilities: In Y4Q4, the project continued to support volunteers called WASH Champions to maintain ORT corners in 28 health facilities for management of diarrhea cases. The WASH Champions linked patients to their communities for continuation of service provision and for diarrhea preventive services. Service delivery gaps noted in ORT corners were addressed through the health facility and the SCHMT. A total of 76,305 children were attended to in ORT corners, and over 5,000 caregivers benefitted from counseling on management of diarrhea in children. During the quarter, nine health facilities in Starehe Sub-County experienced stock-out of ORS and zinc. In response, the project, working with various other facilities from Kasarani Sub-County, redistributed the commodities across facilities. In total, 76,305 children received ORS and zinc during the year, contributing to 83% of all diarrhea cases reported in Afya Jijini supported facilities.
Number of children under five who received zinc supplementation during an episode of diarrhea 25,000 140%
122% 117% 120% 20,000 105% 100% 90% 15,000 80%
10,000 60% No No of Cases 40% 5,000 % Cases Supplemented 20%
0 0% Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 July to Sept 2019 Reporting period by Quarter
Performance Target % Quarterly performance
Figure 14: Zinc supplementation
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Number of Households (HH) with Handwashing Facilities and Number of Diarrhea Cases Treated 600,000 6% 5% 500,000 5% 5% 400,000 4% 4% 3% 300,000 420,857 459,409 3% 200,000 397,792 538,912 2% No. of HH 100,000 1% % Diarrhea Cases % Diarrhea 0 0% Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 Jul to Sep 2019 Reporting Period by Quarter
Number of households with hand washing facilities % Diarrhea cases Reported
Figure 15: Households with handwashing facilities
Implement and scale UCLTS in Nairobi’s informal settlements Post triggering monitoring and follow up: In Y4Q4, the project continued collaborating with communities, the county, and other sanitation actors in the county to promote triggered villages in the informal settlements being open defecation free (ODF). During the quarter, 28 post-triggering monitoring and follow-up field visits were facilitated. Changes in sanitation behavior were documented, and community sensitization undertaken during the events on better sanitation and hygiene behavior. In Y4, Afya Jijini, in collaboration with the Sub County Public Health Department, and using the UCLTS approach, supported pre-triggering activities and triggering of six additional villages. This increased the number of villages triggered with support of the project from 33 to 40. As a result, 6,681 households with population of 54,366 in these six villages started gaining access to improved sanitation. Cumulatively, the project reached 119,107 households with population of 665,277 by end of Y4. During Y4, the project supported 108 post-triggering follow-up and monitoring sessions in triggered villages to ascertain progress towards ODF through implementation of the post-triggering plan. Positive changes were observed in construction or improvement of sanitation facilities. The project also supported an assessment of Gitwamba village in Kasarani Sub-County following ODF claims. This is the first village to have ODF claims in the county. Based on findings from the assessment, the village sanitation team and the county are planning to undertake the next stage of verification of the claims, as per the CLTS protocol. Several challenges have been experienced in the implementation of UCLTS. Many households still do not have access to toilets, especially at night when existing latrines are closed or are located outside of homes. Frequent fires have posed a challenge to community members by affecting the gains made in putting up sanitation blocks, especially at Kuwinda and Dam view villages. Land ownership questions have also contributed to open defecation. For example, at KPA village, the community had constructed latrines after triggering, but these were taken down when the village was being demolished. In some villages like Majengo in Ruaraka Sub-County, villagers complained that matatu touts and commercial sex workers were defecating in public since there were no public toilets.
51 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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In Dagoretti Sub-County, alcoholism was cited by community members as a contributor to poor sanitation as villagers allege that drunkards defecate in the open. Absentee landlords in many triggered villages are also still a barrier. In neighbourhoods where landlords are absent but caretakers are available for management of the premises, it was observed that the caretakers are afraid to give the landlord’s contact information for fear of losing their job. This has been a challenge in engaging landlords. Attrition of natural leaders (NLs) was also observed as a challenge in some villages. Promotion of handwashing has also been hampered by theft of handwashing equipment in some villages like Kajiji in Dagoretti. Capacity building in UCLTS and WASH: In Y4Q4, the project continued providing OJT to Sub-County WASH Focal Persons, NLs, Public Health Officers (PHOs), Community Health Assistants (CHAs) and other health workers in all 10 sub- counties to strengthen UCLTS implementation. The sessions undertaken covered reporting of community UCLTS progress and outcomes after triggering; providing post-triggering motivation and support; building capacity of NLs and sanitation champions; and scaling-up sanitation activities. The OJT contributed to improved knowledge, skills, and quality of facilitation during triggering and post- triggering monitoring and follow-ups. In Y4, in collaboration with KUMEA, a grantee, Afya Jijini also supported training sessions for 175 community leaders and CHVs from project WASH sites in Starehe, Makadara and Embakasi East Sub- Counties to build their capacity in WASH and UCLTS so that they may act as champions and community resource persons in their respective communities, including in ECD centers. The training topics included the importance of water for health, improving water quality in the community, causes of water contamination, health problems caused by unsafe water, water treatment at household level, water treatment methods, and safe water storage. On sanitation, the participants were trained on the definition of sanitation, components of sanitation and the sanitation ladder, health problems caused by poor sanitation, (UCLTS, and environmental sanitation. On hygiene, the participants were trained on definition of hygiene, types of hygiene, handwashing, and home and food hygiene. Additional community-based WASH support activities Community sensitization on sanitation In Y4Q4, Afya Jijini partnered with Nairobi County in undertaking hygiene and sanitation awareness in informal settlements through action days and dialogue1 days. During these events, community members were sensitized on basic and adequate sanitation, ways of making water safe for prevention of diseases and for improved hygiene, and correct and consistent handwashing. Demonstrations were made on how to build handwashing devices using locally available materials. During the quarter, the project supported six sanitation dialogue and action days in the sub-counties2. During these community events, over 10,000 people were reached with messages on hygiene and sanitation. Overall, the project supported 23 sanitation dialogue and action days in all 10 sub-counties, reaching an estimated 23,655 people with water, sanitation and hygiene messages through health talks and demonstrations on water treatment and handwashing throughout the year.
1 Sanitation dialogues are community-based activities where sanitation champions and village leaders hold meetings with their community members to discuss sanitation issues and other issues pertaining to child health and overall sanitation improvement for villages. 2 Starehe, Kamukunji, Dagoretti, Embakasi East, 52 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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Promoting environmental sanitation through clean-ups: In Y4Q4, the project supported six community dialogues3 and health action days in the form of clean- ups to promote environmental sanitation. The dialogues and clean-ups also aimed to devise sustainable solutions towards solid waste and water point management in the villages. This quarter, the project supported all 10 sub-counties in undertaking 13 clean-up and sanitation action days, where over 10,000 people were reached. In Y4, the project continued supporting environmental sanitation by supporting 119 clean-ups and action days in informal settlements, where over 100,000 people benefitted and were reached with WASH messages. Diarrhea and cholera prevention and control In Y4, the project supported cholera response activities through sensitization of communities, especially informal settlements. The activities undertaken included educating communities on matters related to domestic water treatment, sanitation, personal hygiene, and disease prevention. During the exercise, treatment of water from public sources and disinfection of filled latrines and septic tanks was undertaken. As a result of this activity, 32,998 households were visited, and health education reached 93,667 people with key health messages on WASH. A total of 18 ECDs and schools were visited and over 10,000 children reached with health messages on handwashing and water quality. The project distributed 21,190 chlorine tablets for treatment of drinking water. A total of 138 food premises were also reached with hygiene messages for prevention of cholera in Embakasi East, and 155 health talks were undertaken in 13 villages. Promoting WASH-friendly ECDs, daycare centers, and schools through the community outreach model: In Y4Q4, the project supported improvement of sanitation and hygiene health seeking behavior of children, their caregivers (teachers and parents), and the community in informal settlements through the ECD and Small Doable Approach (SDA) models. ECD and daycare centers were reached with messages on hygiene, maintenance of drinking water quality, and safe disposal of excreta - all aimed at preventing diarrhea in children under five. During the review period, the project supported 60 CHVs in promoting handwashing and proper excreta disposal in daycare centers in informal settlements in four sub-counties. CHVs also distributed IEC materials (posters) on handwashing. The interventions reached 34,051 children. Supporting safe water and household water treatment technologies: Most households in informal settlements get water from illegal connections, street vendors, and other sources which are unsafe, easily damaged, or contaminated, necessitating sanitizing drinking water at the point of consumption. The project supported distribution of 668,121 chlorine tablets (AquatabsTm) for Point-of-Use (POU) water treatment of 13,234,960 liters of drinking water. These products were distributed to households during home visits, in ECD and daycare centers, and schools. The project, in partnership with the sub-counties, collected 411 water samples from boreholes, water tanks and piped water taps in schools and other public places in informal settlement for bacteriological analysis and testing of residual chlorine using rapid test kits previously procured by the project. A total of 401 residual chlorine tests were undertaken. The sampling and testing of water informed the actions and interventions to be undertaken, which included health education on safe water and liaising with Nairobi Water and Sewerage Company (NAWASCO) for water chlorination and repair of damaged pipes to prevent contamination.
3 Community dialogues are interactive, participatory communication processes aimed at reaching workable solutions to issues affecting the community. 53 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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Promoting handwashing at community level: In Y4, the project supported promotion of handwashing as a cross-cutting issue during all project supported activities and interventions. During UCLTS follow-up visits and sanitation dialogues, handwashing practice was included as one of the capacity building subjects for community members. Emphasis was placed on the importance of handwashing and the critical times to wash hands. IEC materials on handwashing were distributed by both the project and by the county government. Output 2.5: Nutrition services Y4Q4 and annual report During the reporting period, the project, working with Nairobi County, sub-counties, and health facilities, set out to ensure that health facilities were complying with the national maternal and child feeding policies and were offering quality counseling in nutrition for mothers and their children, especially the HIV-infected dyad. The program also set out to strengthen the facilities’ capacity to deliver nutrition services. Through the county and sub-county nutrition technical forums4 (CNTFs and SCNTFs, respectively), Afya Jijini strengthened leadership, advocacy and planning for nutrition activities. The project focused on the roll out of high impact nutrition interventions (HINI) including Vitamin A supplementation (VAS), the baby friendly hospital initiative (BFHI), and promotion of exclusive breast feeding (EBF). Working with the community teams, the project strengthened the community-facility referral system and provided nutrition education reaching caregivers and children under five in informal settlements through the ECD model. County-level nutrition support Strengthen county coordination: In Y4, the project supported two CNTF meetings. The meetings’ core agenda was to develop a County Nutrition Action Plan (CNAP) document for 2019-2023 and review progress towards reducing the alarming defaulter rate at the Integrated Management of Malnutrition (IMAM)-Outpatient Therapeutic Program (OTP) sites. Participants reviewed the effectiveness of the WhatsApp group created during the prior CNTF meeting for weekly monitoring of the IMAM program. The WhatsApp group instigated effective measures at site/facility level for defaulter tracing and has resulted in a notable reduction of defaulters at most IMAM sites. It was further noted that children from Mbagathi Hospital’s stabilization center (in-patient) referred to OTP have been defaulting and this could be mitigated by discharging them with some rations of Ready to Use Therapeutic Foods. It was further agreed that all children presenting with malnutrition be screened for TB to avoid missing any underlying medical conditions. In Y4, the project supported an ECD inception meeting at the county level to sensitize the county, sub-county, and other nutrition implementing partners on the monthly ECD/daycare Growth Monitoring and Promotion (GMP) approach, which is now being implemented in four sub-counties: Makadara (Bahati and Maringo areas), Kamukunji (California and Biafra areas); Kasarani (Ruai and Njiru), and Kasarani (Dandora 1 and Kariobangi). The inception meeting also deliberated on the achievements, effectiveness, and challenges of implementing Afya Jijini’s ECD/daycare model as an entry point to community nutrition services. The model was noted to be effective in implementing HINI activities in urban informal settlements and has now been included in the counties 2019/2020 Annual Work Plan, ensuring scalability and sustainability. Other partners have also embraced the approach and have started implementing it in Nairobi’s urban informal settlements (e.g. Concern Worldwide is currently in three sub-counties with support of UNHCR). Quarterly nutrition supportive supervision support: During the year under review, Afya Jijini supported three nutrition-specific supportive supervision visits. The visits focused on assessing the facilities’ capacity to offer quality services ranging from nutrition assessment to referral and strong linkages with community activities. Key gaps identified included data quality and reporting in DHIS2.
4 A multi sectorial forum involving CHMTs and SCHMTs, key nutrition implementing partners, and other stakeholders including the ministries of agriculture, education and water services. 54 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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In order to improve data quality and reporting, a total of 10 Data Quality Assessments (DQAs) were supported in the ten sub-counties, where a total of 123 facilities completed data quality checks using MoH tools to assess the accuracy and completeness of all indicators. Post DQA, there has been an increase in the reporting rate of key nutrition indicators, such as VAS documentation. Overall reporting across the sites increased by 7-10%. Findings from the DQA also showed evidence of good workflow among the healthcare workers, that MoH tools were available and in use with 90-98% accuracy levels in terms of completion, and there is task shifting in Child Welfare Clinic (CWC) and OTP service delivery points. It was further noted that there is need for capacity building on data management and completion of page summaries on primary data collection tools (a gap at approximately 25% of the facilities). Key recommendations given to address DQA findings included harmonizing data in all nutrition tools when transmitting; consistently verifying facility data; lobbying for an EMR system for nutrition services; continuous capacity building for HCWs on data and commodity management; lobbying for employment of more nutrition staff; and conducting frequent DQAs, OJT/CMEs, and mentorship in documentation. To ensure the findings and recommendations from the DQA are implemented, the project supported a one-day meeting to review and evaluate the follow-up actions, attended by sub- county HRIOs and sub-county nutrition officers (SCNOs) during Q4 which has subsequently led to improvement in data collection and summarization. Sub county support: In Y4, a total of eight SCNTF5 were supported by the project. The forums were for quarterly reviewing of nutrition activities to strengthen coordination at the sub-county level. These forums resulted in better nutrition intervention outcome at both facility and community levels. Some key issues raised from the forum discussion were low coverage for VAS and deworming among the under-fives. In Q2, it was recommended that all facilities represented check documentation at the service delivery point, confirm the availability and use of deworming medicine, and ensure VAS stock availability and use, especially during the Malezi Bora activity. In Q4 the project supported SCNTF in both Kasarani and Embakasi West sub-counties whose key deliverable was joint activity planning amongst the various partners implementing in those sub- counties. Outreach activities were to be cost-shared between Concern Worldwide (CWW) and Afya Jijini, thus increasing coverage of the targeted population. Partner’s coordination support: In Y4, Afya Jijini continued to collaborate with other nutrition implementing partners to ensure greater impact at the community level and to avoid duplication of activities. The project collaborated with CWW to support active case finding (ACF) in the 10 sub- counties. Afya Jijini supported two SCHMT members and five HCWs per sub-county while CWW supported 3 HCWs and CHVs. The project further collaborated with the Medical Collaboration Committee (CMM- Italy) who supported the VAS campaign in Starehe Sub-County for five days reaching 2,341 under-five children. In addition, the project also had a meeting with The Action Foundation (TAF)6. TAF works with schools and ECD centers to support learners with diverse needs, which include health and nutrition. The two organizations agreed to set up a follow-up with county nutrition team on working methodologies. Support for nutrition days: During Y4, the project continued to support Malezi Bora to improve maternal and child health services uptake in Nairobi’s informal settlements. Focus was given to children under five years, pregnant and lactating mothers, and adolescents to accelerate nutrition services such as deworming, VAS, iron and folic acid supplementation (IFAS), other micronutrient supplementation,
5 Kasarani, Starehe, Dagoretti, Embakasi East, Westland and Embakasi West Sub-Counties 6 Local organization that provides holistic development opportunities to children and young people with disabilities in low income areas.
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GMP, and ACF at the facility and community level. The year’s theme was, “strengthening maternal health services for universal health coverage.” The project supported two planning meetings through the county. The county and sub-county health teams, nutrition implementing partners, other relevant county departments, and multi-sectoral players participated to strategize on the activities for the nutrition weeks. These included community mobilization by CHVs and relaying nutrition messages through the media and SCNOs who were tasked with passing the information to local radio stations in their sub-counties, door-to-door, and at churches. The project further supported a Malezi Bora launch which was held at Kibagare in Westlands Sub- County. The project displayed a branded roll up banner, a street banner, and gave out 400 t-shirts. In addition, Afya Jijini engaged 25 CHVs for community mobilization prior the launch. A total of 156 mothers who attended the launch were educated on maternal and infant young child feeding practices Facility-based nutrition strengthening activities Ensuring growth monitoring and nutrition assessments. In Y4 the project ensured that HCWs performed correct nutrition assessments, provided counseling, and completed documentation by offering mentorship on use of anthropometric tools and MoH data tools. In Q4, 55 HCWs attended a CME on reporting forms MOH 713, 410 A and B, and 734 and the use of the BMI wheel and adult MUAC tape. Capacity building: During Y4, a total of 28 HCWs were taken through the three-day BFHI training to update them on the new maternal, infant and young child nutrition (MIYCN) guidelines. The staff were drawn from Pumwani, Mama Lucy Kibaki, and Neema Uhai hospitals that have the potential to implement BFHI. Also, in collaboration with AMREF, Afya Jijini supported sensitization on monthly documentation of the VAS monthly monitoring chart, which looks at total target population achievement versus the monthly targets. A total of 73 HCWs from Dagoretti Sub-County were sensitized. Additionally, CMEs on the Logistic Management Information System (LMIS) were conducted in Langata, Makadara and Kasarani sub-counties, with the aim of improving provision of nutrition services at the health facilities. A total of 82 HCWs were taken through the use of bin cards, how to order commodities from KEMSA, and filling the S11 tool. This ensured timely ordering and resulted in a consistent supply of commodities. IEC/Job aid support: Afya Jijini, in collaboration with UNICEF, supported dissemination of the MIYCN policy at Pumwani Maternity to 50 HCWs who received 55 copies of the policy. The project distributed 120 copies across the different service delivery points during Q4. Strengthening nutrition assessment and counseling (NACS) services: In Y4, 42 facilities were supported to ensure proper integration of nutrition services and assessment of clients at the CCCs. The project distributed adult MUAC tape and BMI wheels to the facilities as need arose. Ten (10) nurses from facilities from Dagoretti Sub-County were coached on use of the HEI card and of adult MUAC tapes. These facilities were also provided with notebooks in which to document nutrition interventions at the CCCs. In Y4Q4, the project supported Ngong Road, Kangemi, and Dandora II HC CCCs with bathroom scales to ensure NACS integration. In addition, the project lobbied for a height board for Garrison Health Centre CCC. Further strengthening facility HINI provision: In Y4 the project continued to support facilities with re- distribution of IFAS to prevent stock-outs. Nutrition education and counseling for EBF, complementary feeding, and maternal nutrition continued daily.
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Furthermore, seven community conversations were supported in seven sub-counties 7 to reach mothers with information on cost-effective nutrition interventions at the community level. Six facility based8 CMEs were supported by the project reaching 130 HCW to create more awareness on HINIs and focusing on topics that included IMAM, VAS, EBF, complementary feeding, and micronutrient powders (MNPs). The project further supported re-distribution of MNPs from depots to 15 facilities for supplementation in children aged 6-23 months. In addition, CHVs were sensitized and given MNPs to distribute to caregivers at the community to increase coverage. In Q4, 4,500 children received MNPs at the household level. The project also supported dissemination of the national IFAS policy and distributed 300 copies (30 per sub-county) to supported MNCH sites. Fifty (50) IFAS counseling cards were given to five facilities in each sub-county to guide the HCWs on providing key information to mothers on why, when, and how they should take IFAS. At ANC service delivery points during the reporting period, the project reached a total of 129,829 pregnant women who attended their first ANC and subsequently received IFAS and nutrition counseling, contributing to a coverage of 137% of the catchment population as shown in the graph below:
Figure 16: Nutrition messages uptake among pregnant mothers Strengthen integrated management of malnutrition (IMAM) at priority health facilities: During Y4, the project continued to support logistics for the re-distribution of nutrition commodities to ensure OTP programs ran smoothly and to reduce defaulters due to lack of commodities. The project supported re-distribution of fortified blended flour from SOS Village to Ngara, Ngaira, Huruma Lions, Police Remand, South B Clinic, and Jumuia Hospital. The project also continued to photocopy reporting tools for facilities. Copies of MOH 734 and 713 were distributed to Kariokor and Kasarani sub-counties this year. The project further continued engagement of four nutritionists who provided services at Starehe, Embakasi East, Makadara, Kasarani and Ruaraka Sub-Counties to ensure uninterrupted OTP services. The nutritionists rotated within the sub-county as needed but mainly supported eight facilities that have human resource gaps. In Q4, through the Uhai teams, the project disseminated the new MIYCN policy to 60 sites.
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Community-based activities Active case finding (ACF): In Y4, the project used trained CHVs to conduct two rounds of ACF through MUAC screening. VAS and deworming were also provided to the under-five population. A total of 180 severe acute malnutrition (SAM) cases (four with edema) and 2,046 moderate acute malnutrition (MAM) cases were identified and referred to nearby facilities. Another 52,256 children were at risk, while 293,817 were graded normal out of the 348,299 under-fives who were screened
Table 21: MUAC screening for Active Case Finding
<115mm 115- 125-135mm >135mm OEDEMA TOTAL* 125mm
Sub- M F M F M F M F M F M F county
Westlands 5 5 59 84 3,445 3,098 9,141 10,281 0 0 12,650 13,468
Ruaraka 2 6 39 68 2,718 3,349 23,804 24,960 0 0 26,563 28,383
Dagoretti 4 4 13 16 766 843 8,424 9,161 0 1 9,207 10,024
Makadara 5 9 26 30 2,390 2,412 8,164 10,314 0 0 10,585 12,765
Kasarani 13 17 28 50 2,871 3564 19547 19,958 0 0 22,459 23,589
E. East 6 2 59 60 1,563 1,458 17,036 18,087 0 0 18,664 19,607
E. West 5 6 244 273 1,100 1,164 12,132 12,615 0 0 13,481 14,058
Langata 0 2 60 52 2 7 18,509 20,746 0 0 18,571 20,807
Kamukunji 10 22 48 90 10,058 1709 5,562 6,146 1 0 15,678 7,967
17 40 329 418 4,783 4,956 20,415 18,815 1 1 Starehe 25,544 2,4229
TOTALS 67 113 905 1,141 29,696 22,560 142,734 151,083 2 2 173,404 9 *Total columns are not inclusive of oedema cases Vitamin A supplementation (VAS): In Y4, two rounds of VAS were carried out for children aged 6-59 months in the community, reaching a total of 211,925 children and translating to 88% of the annual targets. In Q4, a total of 58,342 (73% of the quarterly target) under-five children were reached.
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Vitamin A Supplementation 250,000 300% Performance at 263% 200,000 88% aganist 250%
194% 200% 150,000 150% 100,000 100% 71% 73% 50,000 50%
0 0% Oct to Dec 2018 Jan to Mar 2019 Apr to Jun 2019 July to Sept 2019
Performance Target % Quarterly performance
Figure 17: Vitamin A supplement Deworming: In Y4, the project supported CHVs and HCWs in the ten sub-counties to deworm a total of 254,889 under-fives; 110,684 under-fives in Q1 and the remaining 144,205 were mainly reached during Malezi Bora campaigns. In Q4, to ensure continuity in availability of deworming medicine in the facilities and during community activities, the project supported redistribution from the depot to all ten sub-counties. Community conversations: In Y4, the project continued to support community conversations to enhance awareness and skills for behavior change promotion on maternal nutrition and young child feeding. The ten community conversations were integrated with child health community outreach activities at Langata’ s Raila Village, Embakasi East at PCEA Pipeline, and in Kamukunji at Kiambiu to pregnant and lactating mothers. The services offered included immunization, FP, GMP, deworming, IFAS, MNPs and education on optimal infant feeding practices. A total of 391 under five children were screened for malnutrition, 288 were given VAS, 233 were dewormed, and 580 mothers and 20 fathers were reached with nutrition information. In Q4, six community conversations were held at Westlands in Kibagare area, Mukuru of Embakasi East, Dandora I of Kasarani, Kawangware in Dagoretti SC, and Kiambiu and Biafra at Kamukunji. In total, two SCHMT members, five HCWs, and ten CHVs were supported in each sub county to conduct mobilization. A total of 552 mothers and their children were given milk and bread as they sat in the sessions. Community based nutrition – the ECD Model: In Y4Q1, 60 CHVS were engaged to conduct monthly GMP in ECDs in Westlands, Kasarani, Dagoretti and Langata sub-counties, while CHAs and nutritionists were supported to supervise them and for data compilation. A total of 90,743 children were screened. Of these, 18 SAM cases and 208 MAM cases were identified. Another 54,953 children were reached with handwashing information and demonstration. From Q2-Q4in Y4, the, in coordination with the county, shifted focus to Makadara, Kamukunji, Langata and Kasarani sub-counties based on need. An inception meeting was held in April, and together with the CHA and the community strategy coordinator, 50 CHVs were trained and deployed to implement the ECD approach. During Q4, a total of 79,461 children were screened and 59 SAM cases and 219 MAM cases were identified. Another 58,379 children were reached with handwashing information and demonstrations, and 38 with diarrhea were referred to the link facility. The project further provided the CHVs with identification badges, introductory letters, and equipped them with reporting tools, branded bags, and t-shirts. Since May, the program has screened 27,744 children, identifying two SAM cases and 51 MAM cases. In addition, 21,063 children have been reached with handwashing information and demonstrations, and 52 children were supported with diarrhea management.
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This year, the project supported 11 data review meetings, and from the discussions held, the CHVs saw the need to continue mapping exercises since there are other ECDs, daycare centers, and night care centers that were previously unidentified. Best practice, which was reported by the CHVs, was that in one of the daycare centers, parents contribute 10 shillings daily for the teacher to buy charcoal to warm the children’s food during lunch. This started after the CHV talked to the caretakers and is currently being scaled up in Kariobangi and Kasarani SC. During data reviews meetings held in Q4, it was reported that a major cause of malnutrition in the target areas was poor feeding practices. In response, the teachers were sensitized on preparation of low budget, balanced diets for the children and were advised to pass the information to parents. At Friends’ Centre and Dr. Kiarie ECD in Maringo, Makadara SC, the CHVs noted a change in the children’s diets after the teachers and caregivers were sensitized on good nutrition practices. The ECD centers have started preparing millet porridge during break time and cooking rice with green grams or with beans for the children instead of plain mashed potatoes at lunch. Table 22: Q4 ECD data for 4 sub-counties Month Sub- Total SAM MAM Referred with Reached with Q4 county screened diarrhea handwashing knowledge June Langata 6,218 6 11 0 56 Kamukunji 6,066 2 5 0 0 Kasarani 1,487 12 15 7 16,068 Makadara 5,444 9 33 5 0 July Langata 5,334 4 12 0 53 Kamukunji 5,584 2 7 3 1,644 Kasarani 14,708 7 26 13 20,749 Makadara 6,453 7 38 2 659 August Langata 5,269 1 7 0 107 Kamukunji 3,539 2 1 5 1,214 Kasarani 15,106 2 36 1 16,926
Makadara 4,253 5 28 2 903 Total 79,461 59 219 38 58,379
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SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS Three years after devolution of health functions to counties, Nairobi City County (NCC) government continues to experience capacity challenges which pose threats to provision of the highest attainable standards of health care as envisioned in the Kenyan constitution.
To augment capacity building efforts for the county health department to effectively steer the health sector, Afya Jijini has focused the last 4 years on strengthening the management capacities of health management teams (HMTs). Health systems priority areas included: partnerships for governance and strategic planning, human resources for health (HRH), health products and technologies (HPT), and health information systems and quality improvement:
Partnerships for Governance and Strategic Planning: During the period under review, Afya Jijini provided technical support to both county and select referral facility management teams to undertake policy review and formulation, strategic and annual work planning, and budgeting. In addition, through technical assistance and coaching, the program helped the department to institutionalize results-based management principles through the development and implementation of a monitoring and evaluation framework. Furthermore, and to harness the resources and improve synergy amongst stakeholders in NCC, Afya Jijini helped the county to establish regular stakeholders’ coordination and management systems.
Human Resources for Health (HRH): The County continued to face challenges related to institutional weaknesses in dealing with the transitioning, merging, managing and harmonizing of the terms and conditions of the devolved staff with those from the defunct city council against a backdrop of an overall shortage of skilled health sector workers. Addressing these challenges required both new institutional arrangements and structures and tools and technical capacities from the county leadership. In response to these HRH challenges, Afya Jijini, in collaboration with HRH Kenya, focused on supporting the county HMT (CHMT) through training in leadership and management, reviewing and adopting new management structures, HRH policies, and developing and implementing strategies including norms and standards. Specifically, the priorities identified included strengthening of human resources information systems; review of organization, management and coordination structures; and review of performance management mechanisms and disciplinary management systems.
As a result of these HRH capacity strengthening interventions by Afya Jijini, the county health department prioritized HRH issues in county health policy, strategies, and in the county integrated development plan (CIDP). In addition, Afya Jijini supported the department in undertaking an HRH audit to inform future policies and strategies, adopt a new organizational structure, and strengthen advisory committees at all levels. In addition, the department identified gaps in staff establishment, operationalized HRH coordination mechanisms, and implemented management mechanisms and tools like HRH-Technical Working Group (TWG) and the iHRIS. Performance appraisal institutionalization is also ongoing.
Health Products and Technologies: Afya Jijini has focused on supporting the county to improve the management of medical and laboratory products. The project continued to support capacity building of the county to quantify, accurately forecast, and appropriately allocate health commodities. This has been realized through operationalization of the Nairobi County Health Commodities Security Committee and establishment of sub-county technical working groups and facility-based commodity management structures and systems. Consequently, the county recorded sustained improvement of the commodity inventory management at facility levels. This has translated to improved quality diagnostic services as well as commodities consumption reporting rates. For instance, the monthly Rapid HIV Test Kits (RTKs) reporting rates increased from 82% to above 97% between 2016 and 2019.
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Health Information Systems and Quality Improvement: Afya Jijini, guided by KQMH, supported the health department to mainstream quality assurance/improvement (QA/QI) principles and practices at county, sub-county and facility levels using QA/QI structures. As a result, the health department is progressively institutionalizing performance measurement, problem identification, and improvement of service delivery at all levels. This achievement has been realized through establishment and operationalization of QA/QI structures and mechanisms at these levels. Specifically, some selected facilities have developed QI dashboards highlighting service delivery priority indicators, data abstraction tools, and formation of Work Improvement Teams (WITs). QI through cross-facility learning has also been adopted.
Output 3.1: Partnerships for Governance and Strategic Planning From the outset, the NCC health sector experienced myriad challenges as a result of weak leadership and management capacities. The major areas of weaknesses included weak technical leadership and management structures and weak skills and processes at the county, sub-county and facility levels. For the last three years, capacity strengthening on health sector institutional management, including strategic and annual planning, had largely concentrated at the county and sub-county levels, giving less attention to the facility level where patient care takes place. Having identified this gap, in Y4 Afya Jijini embarked on a health facility leadership capacity strengthening process which included training on leadership skills and strategic and annual work planning.
In Q4Y4 Afya Jijini also continued to focus on building the capacities of the county health department to effectively manage stakeholder engagement events as well as sector performance monitoring and evaluation. In the last four years the project supported the department in laying a firm foundation through the development of policies, strategies, structures and mechanisms. In addition, to ensure that the county interventions and policies were aligned with national policies, the program continued to deepen its support for the department to disseminate and adopt national policies and other operations instruments. Below are the specific details of Afya Jijini support to the county under the partnership for governance and strategic planning.
Leadership capacity development: Afya Jijini prioritized and worked to strengthen the leadership and management capacity of managers to facilitate effective stewardship of the sector. A total of ten senior health managers took approved senior management courses offered by the Kenya School of Government. In the facilities where these officers are based, a positive change in staff attitude towards work and responsiveness to client needs were observed. To sustain the gains made, there is need for continued training of managers to mitigate the effects of frequent staff restructuring and turnover. . As part of leadership capacity development, in Y4Q4 Afya Jijini also facilitated the capacity building of facility in-charges on financial management. This was in response to financial decentralization and direct disbursement of funds to these facilities by the county government. This intervention improved governance at the facility level and improved quality of services offered.
Health sector coordination: As part of the partnership coordination capacity strengthening efforts, Afya Jijini supported the development of a stakeholder coordination framework. Guided by this framework, Afya Jijini provided both technical and financial support to the county to undertake a stakeholders’ forum. In this forum, which attracted more than 150 partners including more than 20 implementing partners, the department encouraged partners to continue engaging through this framework to foster closer collaboration between implementing partners and the government to enhance efficiency and synergy. The county noted the overall decline in donor funding and in Q4 committed to continue prioritizing the activity for budgetary allocation during the annual budgeting process.
In addition, the county shared policy updates and the annual work plan priorities with all stakeholders to guide partners’ in their planning of support to the county. The forum further provided a platform for the partners to share their activities and areas for potential collaboration with other partners. The project further supported the development of stakeholders’ reports including recommendations for follow-up for deliberation in subsequent meetings. The county has taken full leadership of this forum 62 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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and institutionalized its operations. More efforts are needed from Afya Jijini to ensure that adequate resources are allocated to this activity and the outputs of the engagement are continuously evaluated against health outcomes.
Health sector policy development and dissemination: During Y4, the project continued to provide technical support to policy development capacity. In this regard, Afya Jijini supported the department to develop county specific policies, strategies, and guidelines as well as dissemination of both national and county policies, strategies and guidelines. Amongst the policies disseminated included the National Family Planning Policy, the RTK quantification and allocation guidelines, and the County Referral Strategy. In addition, the program provided technical support during the review of the County Health Bill 2019, which has been forwarded to the County Assembly for debate before being accepted into law. Overall, the CHMT and sub-county HMT members and hospital management teams continued to benefit from technical assistance on the policy and strategy development processes and coaching focusing on problem definition and prioritization, policy options formulation, and the role of stakeholders in policy development and implementation.
Annual work plan development and implementation: Routine annual work planning has taken root and been fully institutionalized in the county. During the year under review, Afya Jijini has progressively deepened its support to strengthening the county health department in annual work planning processes, especially in ensuring harmonization/synchronization with overall county planning and budgeting cycles. Other technical support for planning included harmonization of plans from the community to the county level. Emphasis was put on ensuring cascading of program-based budgeting (PBB) to sub-counties and facilities. Regarding the integrity of the structure and content of annual work plans, the project continued to support the department to ensure logical alignment between programs and sub-programs (a county designation for a group of interventions in the health sector for budgeting purposes).
Furthermore, to fast track Annual work plan implementation, the program continued to support the county in holding regular performance reviews at all levels. Although annual work planning is now routinely undertaken by the county, a lot still needs to be done to identify and define the quality of interventions with high positive impact on health outcomes. This may entail reorganizing, restructuring, and strengthening the capacity of the planning unit of the department.
Referral facility strategic and annual work planning and budgeting: During the first three years of the program, Afya Jijini supported strategic and annual planning at the county and the sub-county levels. In Y4 the efforts focused on high volume referral Pumwani Maternity Hospital Team during strategic planning facilities. To facilitate the county health strategy visioning process implementation cascade, Afya Jijini provided support to strengthen the capacity of the hospital management teams from referral facilities from both public and faith-based organizations (FBO) to develop facility-specific medium-term strategies and annual work plans. Some of these facilities included St Francis Community Hospital, Pumwani Maternity Hospital, Mama Lucy Kibaki, and Mbagathi Hospital. Y4Q4 saw greater intensity of planning at facility levels. As result of the improved planning and budgeting capacities, the facilities are now able to integrate and synchronize planning, quality improvement, and performance appraisal mechanisms. Draft strategies for Pumwani Maternity Hospital and St Francis Community Hospitals have been completed and the rest will be finalized in Y5.
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Medium term expenditure framework (MTEF): In Y4, the project provided technical and writing support to the department to perform financial and expenditure analysis in order to inform the next MTEF budgeting processes. The support specifically targeted the MTEF TWG to enable them to develop the MTEF report. The report formed part of the advocacy tools for engaging various stakeholders, including members of the County Assembly Health Committee and County Treasury, with the sole intention of increasing budgetary allocation to the sector. This process has now been institutionalized and is regularly undertaken by the county
Output 3.2: HRH Strengthening HRH coordination within the county: HRH TWGs: Recognizing the varying capacity gaps in HRH development and management amongst the counties, Afya Jijini, in collaboration with HRH Kenya Program, NCC RETIREMENT PROJECTION 2019- supported the counties to establish 400 2025 and operationalize systems and platforms for HRH cross-county 300 male female145 total learning on best practices. The HRH 122 112 200 111 coordination mechanism, the 86 87 93 110 Nairobi Metropolitan Inter-cluster 82 83 89 100 60 57 67 HRH TWG and Stakeholders’ 26 40 30 35 28 26 23 Forum, regularly brought together 0 six counties to share successes and YR- 2019YR- 2020YR- 2021YR- 2022YR- 2023YR- 2024YR- 2025 challenges in HRH management and development. Figure 18: NCC Retirement Projection
Afya Jijini also continued to support the Nairobi county HRH TWG to implement its role in adoption and implementation of HRH policies. One of the major achievements included operationalization of the iHRIS dashboard, which now provides better visualization of HRH data for management. Figure xx shows a six-year staff retirement projection, which the HRH unit uses to effectively prepare for exit management.
HRH Transition Plan: To support the county in addressing its HRH shortage, Afya Jijini, together with the county health department, hired, recruited, and deployed various cadres to project sites to boost service delivery. Due to inadequate budgetary provisions, Afya Jijini continued to manage the payroll. To ensure uninterrupted services and sustainability, Afya Jijini and the county, through the County Public Service Board (CPSB), have begun discussions on transitioning staff to the county payroll by 2020.
Performance Management: To improve institutional management and coordination structures, Afya Jijini continued to provide technical capacity and mentorship to the CHMT to review and develop a new functional organogram with five key directorates including directorates of administration and human resources. The organogram has been submitted to the CPSB for review and approval. Once approved, the new structure is expected to be robust and efficient to facilitate HRH management and development. Additionally, the project supported the county in developing draft job descriptions for staff at all levels.
Leadership Development Program (LDP)+: In Y4, a total of 60 participants (representing 10 teams of six people from 10 high-volume health facilities in NCC) completed the LDP+ program with support from Afya Jijini. Review of the impact of this intervention on service delivery showed improved quality of service delivery. Below are some of the notable service delivery achievements realized:
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Facility Target for Post-LDP Project Results Increase percentage of ANC clients
delivering at the facility from 26% to Mathare North Health Centre 36% 35% Reduce immunization dropout rate Waithaka Health Centre for measles from 50% to 10% 9% Increase monthly average deliveries Bahati Health Centre 69 from 43 to 76 54 (Results were affected by Increase monthly average deliveries Westlands Health Centre maternity staff transfers and the from 58 to 73 nurses’ strike in 2019) Reduce the percentage of neonatal
Mbagathi Hospital sepsis in babies admitted to NBU 7.3% from 8.4% to 6% Mukuru Health Centre Increase monthly average deliveries 54 from 62 to 70 Reduce the Percentage of SBAs from Pumwani Maternity Hospital 0.6% 1% to 0.5% Increase monthly average deliveries Ngara Health Centre 53 from 40 to 69 Increase the percentage of PNC at Mama Lucy Kibaki Hospital 29% two weeks from 16% to 30% Increase monthly average deliveries Dandora II Health Centre 50 from 31 to 50 . Output 3.3: Health Products and Technologies (HPT) In order to ensure availability and effective management of HPT, in Y4 Afya Jijini’s supply chain team supported its county counterparts in consolidating the gains made in the past 3 years. The established HPT management mechanisms, including TWGs and the Medicines and Therapeutics Committees for referral facilities, are fully operational. Support to the county to undertake holistic forecasting and quantification for county health commodities was prioritized in Y4. Effective commodity management using an electronic system was rolled out in selected referral facilities.
Targeted support supervision and mentorship: Mentorship to 10 sub-counties, 33 facilities, and selected hospital laboratories was undertaken using a comprehensive support supervision instrument. The gaps identified included staff shortages, poor storage facilities, inventory management, and slow uptake of information technology in the management of commodities. The project continued to ensure availability of commodity inventory and other commodity management tools. This has resulted in sustained improvements in commodity reporting rates. Some of the selected tools printed and distributed are highlighted in the table below:
Type of Commodity Management Tool Quantities distributed in Y4 ART Daily Activity Registers (DARs) 250 Facility Consumption Data Report & Request (F-CDRR) 50 Facility Monthly ARVs Patient Summary (F-MAPS) 50 Temperature Control Logs 120 Counter Requisition and Issue Vouchers 200
Laboratory supportive supervision and mentorship: The project supported the SCMLCs in performing supportive supervision in Afya Jijini-supported facilities using the SIMS supervision tool throughout the reporting period. Mentorship was done in areas which required improvement.
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Commodity Technical Working Group (CTWG). During Y4, the project supported the CTWG in implementing activities as defined in the terms of reference. The group leadership capacity to effectively steer the process is still weak and needs further support. The project continued to support the county to ensure the forum functions as a platform for sharing updates and addressing emerging issues affecting commodity management, including pharmacovigilance and reporting using tools like F-MAPS and F-CDRR.
During Y4, CTWG identified and reported five medicines that were at risk of expiry due to low consumption. All the medicines had months of stock greater than the recommended three-month buffer. These medicines included Acyclovir 400mg, AZT/3TC/NVP 300/150/200mg, AZT/3TC 60/30/50mg, AZT/3TC 60/30mg and NVP 200mg. A redistribution process was initiated to minimize this expiry risk.
To strengthen commodity management at the facility level, the project continued to support the CTWG in reviewing and developing standard operating procedures (SOPs) as well as the minimal package9 for delivering pharmaceutical services. During the year under review, 23 SOPs were reviewed and adopted. The SOPs are instrumental in institutionalizing good commodity management practices as well as good pharmaceutical care practices.
Of significance, the project further supported the county health teams to develop, launch and operationalize the Mbagathi Hospital formulary. The formulary now guides the facility in good pharmaceutical practices.
Quantification and allocation of laboratory commodities: As a result of the transfer of quantification and allocation of laboratory commodities functions, particularly of RTKs to the county by the Ministry of Health, Afya Jijini, in collaboration with other partners, continued to strengthen the county’s capacity to take on this role. In addition, the program also continued to support the county to quantify and forecast CD4, TB, and viral load (VL) commodities. This process has been institutionalized as part of laboratories’ regular joint planning efforts. These interventions have resulted in reduced incidences of stock-outs and minimal interruption of HIV and TB service delivery.
Commodity storage. During Y4, the project facilitated improvement of commodity storage capacities in 17 facilities through installation of 66 storage shelves and 11 cabinets. Based on results from supportive supervision visits and other oversight activities, it was determined that additional support will be required to facilitate storage systems in the county referral facilities. The photos below show the Mama Lucy Kibaki Hospital medicine store before and after storage shelf installation.
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Mama Lucy Kibaki referral hospital store before installation
Mama Lucy Kibaki referral hospital store after installation Photo 3: Commodity storage at facility level Redistribution of commodities: To ensure the availability of commodities in all the project-supported facilities, Afya Jijini continued to support the county to track stock levels by facility and redistribute medical commodities as appropriate. Following the revision of the National ART Guidelines in July 2018, the country has experienced intermittent shortages of some ARVs, necessitating redistribution of available ARVs to cater to all patients during short-lived supply disruptions. The redistribution process also included HIV and TB laboratory commodities.
Facility-level commodity management information systems: In Y4, the project initiated discussions with the Clinton Health Access Initiative (CHAI) and the county on modalities of rolling out WebADT (an EMR software for commodity management) and other existing solutions (such as IQCare) at all ARV dispensing points to ease the commodity reporting processes. The program supported the county to review commodity security performance including the quality of information in the national commodity management portals.
ARVs and family planning commodities monthly reporting rates: The reporting rate of ARVs has improved remarkably and has consistently been maintained above 90% since September 2018 following facility- charges training on DHIS-2 reporting. Support to ensure internet availability and the active role played by the sub-county teams have also contributed to this improvement. Family planning commodities reporting has improved by six percentage points to currently 88% over the same period.
Laboratory commodities monthly reporting rates: At the inception of Afya Jijini, the RTKs reporting rates were at 83% and 5% in HCMP and DHIS-2, respectively. Following provision of technical support and capacity strengthening for the county teams, the reporting rates have since improved to 98% and 75% for HCMP and DHIS-2, respectively.
Pharmacovigilance: To ensure patient safety and sustain continuous surveillance in Y4, the program supported sub-county teams to undertake pharmacovigilance CMEs at the hospital level through mentorship to hospital staff. In total, 162 health care workers (HCWs) were reached with CMEs. Monitoring and reporting of adverse drug reactions and other medicine-related problems have been low in the county for the last four years of the program. This has been attributed to a shortage of staff in most of the county hospitals.
CME on pharmaceutical care plan and pharmacovigilance. During Y4, the project continued to ensure improved quality of pharmaceutical services through continuous CMEs on pharmacovigilance and the pharmaceutical care plan. In Q4 the project supported pharmacists from 4 sub-counties to conduct mentorship sessions at facilities on pharmacovigilance. As a result, six facilities were reached and a total of 162 HCWs benefitted from the CMEs and mentorship sessions. In addition to sensitizing the county staff on pharmacovigilance, Afya Jijini project staff were also sensitized. Monitoring and reporting of adverse drug reactions and other medicine-related problems still remain a challenge in the county. 67 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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In Y4, through mentorship and support from the project to Mama Lucy Kibaki Hospital, pharmacists, other pharmacy staff, and members of the medicines and therapeutics committee were sensitized on the pharmaceutical care plan. The purpose of this CME was to improve the quality of pharmaceutical services at the hospital, especially for patients in chronic care such as those on ART.
Laboratory safety and quality improvement strengthening: Safety in the laboratory is a priority in the quality improvement and accreditation process. Afya Jijini continued to support facilities in adhering to safety and infection prevention control through establishment of infection prevention committees, development of guidelines and SOPs, and a biosafety and biosecurity refresher training. In Y4, 21 medical laboratory technologists from Afya Jijini-supported facilities were trained on biosafety and biosecurity. In addition, Afya Jijini continued to provide mentorship and on-job-training to supported facilities to implement laboratory continuous quality improvement focusing on the six Laboratory Core-Essential Elements (CEEs).
Laboratory sample management: To improve access to prompt and quality laboratory services, Afya Jijini continued to support the county in sample networking from the targeted facilities to the referral laboratories. Priority support areas included the sample referral system and result information management. The outcome of this intervention was improved communication amongst key players. In Y4, four additional facilities were equipped and trained to do remote logging for VL and early infant diagnosis (EID), leading to real-time access to VL and EID results which allowed for effective client management and clients to know their status quickly. Additionally, the project facilitated the county in tracking sample rejection rates, result turn-around-times (TATs), and GeneXpert utilization rates.
During the reporting period, the average VL sample rejection rate was at 0.7%, which was much lower than the expected upper limit of 2%. Efforts to further improve this are ongoing. Result TAT for VL and EID were recorded at 12 days compared to the expected 10. This was due to delayed sample analysis by the KEMRI VL testing laboratory as a result of VL equipment downtime. This has since been resolved and Afya Jijini has maintained close communication with the labs to monitor and aim to reduce the TAT. The project also supported scale up of TB GeneXpert testing in six facilities. There was a slump in the utilization rate due to a nationwide stock-out of GeneXpert cartridges. It is envisaged that the capacity strengthening on forecasting and quantification as well as redistribution will reduce stock-out frequency. Biosafety infrastructure challenges constrained rapid scale up of this intervention.
Output 3.4: Strategic M&E Systems
Build County capacity to monitor and evaluate priority health service delivery areas effectively
Collaborate with relevant stakeholders to review progress Health Delivery Areas (SCHRIOS, M&E TWG): During the reporting period, the project continued to work with relevant stakeholders, County Department of health and Medical services and other USAID funded partners, These included USAID’s Kenya Health Management Information System (KeHMIS) in strengthening mHealth – roll out of Ushauri and mLab; University of California, San Francisco (UCSF): Supported DREAMs data management, and USAID’s Health IT program in Collaborated on Family Health indicator definitions and reporting.
Support sub-counties and high-volume facilities with airtime for uploading data to DHIS2: Afya Jijini continued to support monthly data upload to KHIS in 10 subcounties within Nairobi County. This has ben achieved by providing 11 temporary data clerks who work 4 days every monthh to ensure complete and accurate reporting. The subcounties are also provided with data bundles to ensure internet connectivity. This has greatly improved the staff morale in ensuring consistent reporting in the national information system and has continued to maintain high reporting rates of all data elements.
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Carry out supportive supervision and Data review forums to sub-counties and facilities on service delivery data: The project also supported the 10 sub counties to conduct data review meetings in order to address reporting gaps and share best practices across the various program areas. The team continued to support the 24 surge sites to collect and submit surge data using an ODK tool on a daily basis as a way of monitoring services towards meeting the daily targets. The sites are also supported to review report surge data every Monday morning, as a way of monitoring their progress towards the set goals. These forum are also used to address challenges experienced and derive or review existing strategies towards meeting the weekly targets. On facility service delivery data, the project supported sites to plot Quality Improvement (QI) charts on indicators generated from WITs to measure progress over time. Charts to display monthly data were also developed to facilitate data sharing and use in the sites. This has strengthened and drastically increased the demand for data for decision making.
During the quarter, the project conducted a TB/HIV data review meeting for Kasarani sub county health management team. The key areas were on optimization of DHIS 2 reporting system in order to improve reporting rates and commodity management by adopt Push Method in supply, capacity building, continuous support supervision and reinforce quarterly data assessments.
Afya Jijini Collaborative Fora: The project supports a TB stakeholders meeting for Ruaraka Sub County for SCTLCs and TB focal point persons. The gaps identified were meant to strengthen IPT uptake among children under 5 years, utilization of presumptive registers at the CCC and PMTCT, active case finding roll out to other departments, TB defaulter tracing and documentation, increase TB uptake at the CWC by line listing children through contact tracing and IPT initiation.
Improve facility-level data collection and use Collaborate with partners (Palladium Group) to scale-up the IQCare system to incorporate all modules: Strategic EMR scale-up to 29 program-supported C&T sites to full EMR functionality:
During the quarter, the project supported the upgrade of the EMR System with two major upgrades; In the first half the upgrade was from version 1.0.0.7 to version 2.0.0 which introduced the PMTCT module and the universal care. In the final half we had version 2.0.0 to version 2.1.1 which fixes the bugs and errors reported from the previous initial version. This was done in 11 of the 29 EMR sites 6 among them being high volume. The project then offered mentorship and OJTs to facility staff on the newly introduced features. The project further scaled up use of eHTS by installing the AFYA mobile and LiveHapi in 21 sites (79%). The project collaborated with the system developers (Palladium) by sending feedback/reporting bugs and issues with the upgrades and enhancements. This has yielded the review of the dashboard statistics, and the enhancement of the queueing system which were priority areas for the facility staff. Program Officers attended a workshop to increase the knowledge and hands-on skills of SDP’s ToT to support available HMIS II products implementation in Nakuru to increase their knowledge on new and upcoming systems. The products covered were Kenya EMR, IQcare, HTS mobile APPs, Dwapi, IL, LiveHapi and the Data Warehouse (DWH) and SPOT; End to end navigation.
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The project further supported facilities to upload data to the national data warehouse by installing DIWAPI and capacity building champions on how to routinely have it done. For facilities where internet connection was a challenge the program officers picked a copy of the database and uploaded the data from the office. This led to an improved reporting rate from 69% in August to 88% in september.
Photo 4: Source: National Data Warehouse; showing completeness scores of Afya Jijini data
Develop and implement a service performance dashboard to inform/facilitate decision-making:
The M&E department provided support to Care and Treatment sites in developing site specific implementation plan, with individualized targets. Each facility reviewed and monitored their performance daily while weekly performance done with involvement of the facility in charge. This was done by developing customized data collection tools (on excel and ODK platforms), populating and updating surge dashboards to display weekly performance against targets. Further, the project continued to support updating of the existing facility dashboards in order to improve use of data for decision making for service delivery. Some of indicators monitored include: identification of positives through eligibility screening, retention, attrition, TLE and TLD optimization and aPNS cascade.
Photo 5: A service performance dashboard The project supported WITs at the CCC to design a quality improvement project on “Optimization” 70 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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of all clients eligible for optimization are regularly reviewed. This was enforced from the NASCOP’s circular on stability of optimized clients to reduce the number of daily appointments to decongest the clinics. Further, the project assisted clinicians and HTS councilors in eliciting contacts for PNS through regular data reviews using data generated from the line lists; targeting new positive clients, defaulters brought back to care, STI clients and those in viremia clinics.
Capacity building of HCWs to strengthen M&E technical areas: During the quarter, the team continued to offer technical support to both surge and non-surge sites to enhance proper documentation especially on eligibility screening and aPNS. The team also provided mentorship on documentation in ANC, maternity and PNC registers; especially on HTS to minimize missed opportunities throughout the cascade of care. To strengthen retention, the team developed a questionnaire to be administered to clients brought back to care. This was done after characterization of the LTFU and defaulter on follow up to assist in understanding who is most likely to fall out of treatment and put in measures to avert the losses. Support routine M&E acitvities: As part of routine M&E support to facilities, the M&E team supported sites in setting up eligibility screening desks and tally sheets to help in daily data collection of patients screened, as well as reporting of daily reporting for selected surge indicators. Other activities inclided; distribution of MOH and program level data collection tools. During the quarter, the supported TB activities by generating a line list of IPT all clients to assess the outcomes. The IPT coverage was 92% and completion at 88%. The teams were mentored on consistent and correct documentation and reporting of consumption data. Kayole II HC continued to perform well in surge from the structures in place to screen clients for HTS and elicitation of aPNS clients. Data collection and reporting tools were also printed and distributed; they included eligibility screening registers and tally sheets for outpatient departments, line listing registers, appointment diaries and defaulter registers. The team also provided mentorship and technical support on proper use of these tools.
Strengthen and integrate community-based health information systems (CBHIS)
Community RDQA: During the quarter the project conducted RDQA in six sub counties Embakasi East and West, Kamukunji, Kasarani, Ruaraka and Makadara with a total of 218 community units being assessed. This Contributed to 84% coverage of all units within the six targeted sub counties. Key areas that were highlighted that required strengthening included; continues advocacy on availability of tools, to eradicate persistent erratic supply of CBHIS tools (MOH 513,514, and 100). This has over the funding period necessitating Afya Jijini to supplement tools by Printing and distributing to the neediest sites. To improve on the coverage it was agreed that the County CU focal persons to liaise with the Health records department and review the denominators on number of CUs in Nairobi county, Continued CMEs/ Mentorships and OJTs on documentation processes to be offered to CHVs to reduce discrepancies between MOH, 411; MOH 515 and KHIS reports. A feedback meeting was conducted in two sub counties where key findings were shared and action plan developed and shared with the respective persons as below; Support distribution of community reporting tools to 10 sub-counties: The program provided MoH registers by photocopying and distributing through the CHAs and CSSFPs offices MoH 513, 514, and 515. 100 referral tool photocopies were also supplied to the following sub-counties except Langata: Westlands, Dagoretti, Embakasi West and East, Kasarani, Makadara, Kamukunji, and Kasarani. In total, more than 31,483 assorted photocopies were distributed to various CUs in the respective sub-counties.
Community data review meetings: The project supported two data review meetings in Kasarani and Makadara sub counties; these provided findings on the RDQA and support supervision to Community Health services members and Faculties in charges, CHAs and CHWs. The gaps included; Some CHWs not reporting monthly; Some CHWs reporting commodities which are not accounted by depot managers; Data inter-consistencies especially MOH 514 and MOH 515; Lack of registers and reporting 71 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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tools; Knowledge gaps among CHWs on indicators; Each CHW to ensure that they visit 33 HHs per month; Each CHW to ensure that they participate in community monthly activities (feedback and dialogue days.)
Output 3.5: Quality Assurance/ Quality Improvement (QA/QI) Systems County QA/QI TWG: In Y4, Afya Jijini continued to support the County QA/QI TWG to coordinate annual work planning as well as implementation and evaluation of QA/QI activities in the county. During evaluation of QA/QI interventions, each Sub-County QI Focal Person (SCQIFP) presented quarterly reports highlighting key achievements, challenges and plans for the next quarter. This approach facilitated sharing of sub-county best practices. In addition, the project continued to support the TWG to review the quality performance indicators.
As a result of this support, QA/QI interventions are being institutionalized by the county as indicated by the almost 10% increase (79% to 87%) in the proportion of facilities reviewing their performance, identifying gaps, and taking corrective measures. To improve client feedback mechanisms, the project further supported the county in developing and implementing a standard client satisfaction tool. The work of the TWG is operationalized by the facility QI teams at the facility level. In addition, the project has supported the TWG to establish inter-county learning and sharing of best practices. This has now become an annual event implemented by the county. Progressively, sub-counties and facilities are being assessed by the county health management team on QI improvement effort levels as part of the institutionalization of QI.
County QA/QI coordination and work plan: Since Y1, the project has supported the county QA/QI unit to develop, implement and evaluate an annual county QA/QI work plan. In Y4Q4, the program supported the county in evaluating the implementation of the 2018/2019 county work plan. The focus of the 2018/2019 work plan was to strengthen implementation of QI at the facility level and implement a reward mechanism. This mechanism has transformed itself into the Annual Health Service Delivery Awards (HSDA) event and uses KQMH tools for the assessment. Working with the SCQIFPs, the project continued to support building the capacity of HCW on QI implementation. During Y4, Afya Jijini assisted the county in training 41 HCWs from supported facilities on quality management using the KQMH and the Kenya HIV Quality Improvement Framework (KHQIF). As a result of this intervention more clients have been retained on care.
Supportive supervision: The project continued to support the county QA/QI and Infection Prevention Control (IPC) units in conducting supportive supervision at health facilities in five sub- counties (i.e. Kasarani, Ruaraka, Starehe, Makadara and Embakasi East) to ensure mainstreaming of QA/QI interventions in routine service delivery.
QI coaching and mentorship: In Y4, the Afya Jijini technical team provided further support to county teams to deepen coaching and mentorship to facility QI teams in order to ensure quality service delivery performance reviews based on clear targets and indicators. One of the key interventions was mentoring the facility QI coaches. The QI teams have been central in accelerating HIV/AIDS epidemic control interventions as illustrated in the facility QI success story below. Additionally, these facilities have been supported in developing and using a minimum package of care and SOPs for key HIV services, based on the 2018 guidelines on the use of ARVs for treatment and prevention of HIV in Kenya.
QI best practice sharing forums: In Y4, Afya Jijini supported all ten sub-counties in holding 12 best practice sharing forums aimed at facilitating learning among facility QI teams within a sub-county. In Q4, Afya Jijini provided technical and logistical support for Kasarani and Embakasi West sub-counties to hold quarterly best practice sharing fora. The facility teams were able to share their SURGE performance and best practices in improving SURGE performance. Working with the county and sub- county focal persons, Afya Jijini supported the awarding of the three best performing facilities per sub- county in all the best practices sharing forums held in Y4.
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Supportive supervision, mentorship and coaching: In Y4, the project supported all 10 SCQIFPs in conducting facility-based supportive supervision, mentorship and coaching in 112 facilities throughout the year. In Q4, the project supported Westland’s Sub-County in conducting facility supervision and mentorship on QI and IPC implementation in six project-supported facilities. The ongoing technical support has enabled the sub-counties to provide mentorship to facilities to develop and implement their annual QI and IPC work plans.
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B. CONSTRAINTS AND OPPORTUNITIES During the implementation period in Q4 and throughout Year 4, the project encountered various challenges, opportunities and lessons learned based on the social, political and economic environment. Challenges Leadership and management: The frequent and unpredictable changes in top leadership teams at the county level resulted in occasional delays in service delivery and program implementation like the planned HRH transition. However, the changes resulted in more proactive and collaborative leaders who are ready to guide the health sector in the desired direction. As similar changes are still anticipated at the county level, sustained capacity building support will be necessary to ensure continuity of health service delivery. The public sector nurses’ strike: The nurse cadre in the public sector went on a prolonged national industrial strike, which affected service delivery especially in MNCH over non-implementation of the Collective Bargaining Agreement (CBA). Considering possibilities of similar industrial actions in the future, it is critical that strengthening of the private sector is prioritized to mitigate the impact of strikes. The intermittent shortage of ARVs: The ARV shortages were caused by the change in national ART guidelines, which resulted in uncertainties in procurement planning at the national level. Continuous monitoring and redistribution at the facility level have been key to effective stock management.
Opportunities SURGE Implementation: The initial focus of SURGE has been on identification of HIV+ clients and linkage to ART, with emphasis on client retention in care and viral suppression. In Q4, SURGE provided an opportunity for the Afya Jijini team to reinforce the integration of service in other components of care. Data Quality Assessment: During this period of SURGE implementation, data was collected and entered into the SURGE dashboard daily. At facility level, data was entered into the registers by the facility staff. The data was then cleaned and abstracted by the project’s M&E assistants who submitted reports to the Afya Jijini’s technical program representative. These data quality assessments provided an opportunity to enhance data accuracy and timeliness. Lessons Learned Capacity building of health workers is critical in achieving targets and objectives at facility level. Afya Jijini, through the LDP+ program, trained and mentored Nairobi City County Health Workers that were identified as key facility leaders. All trainings are followed-up by site-based coaching/mentorship to reinforce leadership skills. It emerged that the LDP+ approach is very effective in enabling hospital teams to achieve measurable results within a limited timeframe, addressing priority challenges identified by the hospital staff and mobilizing human and material resources to implement evidence-based action plans. Partnership for success: The successful implementation of the program depends on close collaboration with the sub-county and county leaders in the health department. Afya Jijini’s implementing partners, national governments, and other development partners. These players all have competing priorities and engage in a time-consuming consultative approach to achieve synergies and ensure stakeholder buy-in. This represents both an opportunity and a constraint, but overall, the success of Afya Jijini to date owes a lot to the high-level partnerships and close engagement with partners from the health department.
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C. PERFORMANCE MONITORING Afya Jijini continued to regularly and systematically collect and analyze information to track progress of program implementation against both contractual and annual targets provided as outlined in the Monitoring and Evaluation plan. This will be done with a focus to linking activities and resources to the objectives, targets and results. Program reports and progress were used both internally and externally to guide strategies and prioritization of resources to achieve transparency and efficiency in implementation. Internal data dashboard were used to routinely monitor program performance, refine approaches, and report on progress and performance towards achieving project targets. Data was shared with the Afya Jijini leadership and the technical teams to aid in planning and improving strategies, as wells as with USAID, in accordance with the provisions of the contract. The data was also shared with the Nairobi CHMT during quarterly data review and county TWG meetings, and well as in national level TWG meetings. Where necessary, project performance data was shared with partners and allied projects for potential collaboration and synergy to achieve efficiency. Data quality analysis and use was weaved into regular meetings, supervisory visits, and mentoring visits to the offices and facilities, as they provided opportunities for discussions around what the data is revealing about patient needs, facility responsiveness, and how services can be improved for better health outcomes. It is expected that this approach will build local capacity, as well as empower frontline workers to use the data for professional development, advocate for new resources, demonstrate what is working, and allow managers to better adapt to changing environments. Collaborating, Learning and Adapting: The M&E Plan incorporated the CLA model to ensure systematic sharing, discussions, and operationalization of lessons learned. The project team worked with the county M&E TWG to utilize a community-of-practice model to support collaboration and learning. Through this method, project results and feedback received were disseminated both in- person and virtually with the relevant communities of practice.
D. PROGRESS ON GENDER STRATEGY Afya Jijini continues to integrate its gender strategy through a provider-responsive package of services that are geared towards reducing gender disparities and vulnerabilities. The program focused its interventions in improving the availability of quality accessible and sustainable service delivery. As a result, we have fewer cases of clients delaying access to care, more clients completing prevention prophylaxis, and fewer sero-conversions from those coming after 120 hours. Similarly, in this reporting period, of the 218 cases of SGBV screened, 217 were issued with PEP within 72 hours. This means that provider confidence and responsiveness has been increased and that survivors have also been provided with appropriate linkage pathways during incidences of violence. We plan to improve litigation linkage and referral through appropriate transcription of the PRC forms in the coming period. In this implementation period, a design challenge with the Young African Leaders Initiative (YALI), Civic Leadership Cohort for 2019, engaged stakeholders to come up with solutions targeting AGYW for Afya Jijini, which have been integrated into our routine activities. These include engaging in more outreach events to showcase best practices and exploring performance based incentives for adolescent volunteers that would guarantee retention. In Y5, we will explore social media/phone applications for referrals and mobilization. The program accelerated initiatives targeting adolescent clients on AYSRH in response to feedback collected during focus group discussion (FGDs) with AGYWs across four sub-counties. The FGDs indicated a need for mental health screening using the Edinburg Post Natal Depression scale and WHO Depression Anxiety Scale. The FGDs and the mental screenings instigated follow up on ART retention through viral load tracking and networking of the AGYW who participated.
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At facility level, Afya Jijini has encouraged adoption of flexible operating schedules to attract populations that otherwise cannot access facility services due to competing priorities. Responses include early morning clinics for men and working populations that cannot attend normal CCC operational hours. In Q2, Afya Jijini staff participated in the USAID facilitated Training on Strategies for Trauma Awareness and Resilience. These skills brought forth the importance for evidence based programming for trauma and burnout management for both the staff and the clients, who are possible perpetrators of violence. Gender-based barriers to seeking and accessing HIV care, support services, and treatment are based on internal stigma, as well as fear of external stigmatization. In this implementation period, Afya Jijini supported the County to focus its response on gender inclusion through interventions such as male- only clinics in selected facilities. The program also intensified the national rapid response initiative for identifying pediatric and adolescent clients on care. This activity also provided an opportunity to follow up on retention through viral load tracking and networking for improved service optimization. Eastern Mennonite University, through USAID, facilitated a training workshop on Strategies for Trauma Awareness and Resilience, which has escalated the vital role of healing among the survivors of gender-based violence and the need for debriefing of healthcare workers to support their mental health.
E. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING During Y4, the program supported adherence to laboratory biosafety and biosecurity, and infection prevention control (IPC) standards as prescribed in the national and international standards. Twenty- one medical laboratory technologists in Afya Jijini-supported facilities were trained on Biosafety and Biosecurity. The five-day training was aimed at equipping the participants with knowledge and skills to prevent hazardous agents generated during service delivery from affecting the healthcare workers, clients, patients, and the environment. Additionally, post-training follow-up was done to reinforce implementation at the facility level. Afya Jijini supported the certification of biosafety cabinets and safety hoods to ensure the safety of the users (HCWs) and the environment. Twenty-four biosafety cabinets and safety-hoods were certified of which 21 (88%) passed the certification while three failed to be certified due to a malfunctioning motor. Corrective measures have been initiated to fix the biosafety cabinets. Facility staff was sensitized on adherence to safety precautions including use of PPEs and waste segregation and disposal. Mentorship will be done in the coming year on the management of hazardous laboratory material, both biological and chemical. SOPs and job aids on management of biological spillage will also be provided. Technical guidance on access to PEP following occupational exposure will be offered too. In Y4, to promote of provision of WASH services in health facilities, the project supported 5 CMEs on IPC to sensitize 156 health workers on topics including healthcare waste management (HCWM), personal protection and handwashing, and water supply management in health facilities. During the year, the project also supported a one-day sensitization of 57 CHMT and SCHMT members on IPC to accelerate implementation and monitoring of IPC work plans at health facilities and Sub Counties.
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F. PROGRESS ON LINKS TO OTHER USAID PROGRAMS The program continued to work with other USAID implementing partners such as HIV Free Generation (HFG), KUMEA, HRI RMC, AMURT, UCSF, and NHP plus to conduct joint planning sessions, support community led activities as well as support trainings at both the County and Sub- County level. In Y4, the program continued to work closely with Palladium to scale up the utilization of EMRs in facilities. In addition, the program worked with UCSF to train HCWs in use of data for decision making for the DREAMS intervention. Furthermore, Afya Jijini worked with the Kenya HRH program to streamline HRH practices at the County. The program brought together all the grantees together with representatives from the NCC in a conference to review their performance in the past year, the challenges faced and how to move going forward. In addition, discussions were held on how they can collaborate so as to synergize in activity implementation.
G. PROGRESS ON LINKS WITH GOK AGENCIES In Y4, the program continued to work closely with GOK agencies such as KEMSA, KEMRI and the Nairobi County Health Services to build the capacity of Health Care Workers and strengthen their capability to provide quality health services. Throughout the year, the program worked with the Nairobi County Health services to carry out joint supportive supervision visits, provide CMEs and OJTS at both the sub-county and facility level helping to improve the skills of HCWs. The program also worked with KEMSA to distribute medical equipment in all Afya Jijini supported facilities in Nairobi County. The program HRH component advanced the discussions with the Nairobi County Health services aimed at reaching agreement with the County Public Service Board (CPSB) on the transition of project hired technical volunteers supporting Service Delivery into the County pay roll. In addition, the program continued to work with KEMRI to ensure EID, VL and sputum samples were processed timely and results shared with clinicians.
H. PROGRESS ON USAID FORWARD Through Afya Jijini’s grants under contract (GUC) program, the program is currently engaging with eight local partner organizations. These grantees are engaged in direct technical assistance activities across the spectrum of Afya activities including implementing Respectful Mothers Care, eMTCT activities, HCT, and supporting DREAMS implementation. The partners implement evidence-based interventions that contribute to the achievement of USAID and PEPFAR annual targets and are provided close technical coaching and capacity strengthening support to ensure effective implementation of the activities. The local organizations AJ currently grants to include the following: Women Fighting AIDS in Kenya (WOFAK), St. Johns Community Center (SJCC), Partnership for an HIV Free Generation (HFG), Healthright International (HRI), Kujenga Maisha East Africa (KUMEA), Ananda Marga Universal Relief Team (AMURT), Kenya Council of Bishops (KCCB), and International Network of Religious Leaders Living with or Personally affected by HIV (INERELA+ Kenya). In addition, Afya Jijini sub-contracts with three local organizations. These include the Christian Health Association of Kenya (CHAK), Mission for Essential Drug Supplies (MEDS), and National Organization of Peer Educators (NOPE). These three organizations with IMA form the core implementation consortium. In addition to leading key components of the project, IMA supports the sub-contractors with capacity building in the form of mentorship, technical assistance, and monitoring. As outlined in the section below, Afya Jijini works in close partnership with Nairobi County’s Health Department at both the County and Sub County levels. Activities are implemented jointly with health officials with the aim of enhancing the capacity of county counterparts and transitioning management and oversight of AJ interventions to the County. Following the implementation of SURGE earlier this year, AJ has witnessed increased ownership by facilities of their performance in terms of testing, HIV positive patient identification, client retention, PMTCT, and engagement with hard to reach populations as well as an understanding of patient data and the analysis of it. 77 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
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I. SUSTAINABILITY AND EXIT STRATEGY Afya Jijini’s approach to sustainability is to design and implement health interventions that can be taken over within a finite time by county governments, local communities (direct beneficiaries), and other partners. By working with Nairobi County to institutionalize best practices in service delivery and health systems strengthening such as the performance appraisal system, the Nairobi County Government is gradually becoming more responsive to the needs of its target population. Both the LDP+ facility-based programs and the QIT approaches at the facility and sub-county level have instilled a sense of ownership towards improved quality services. Afya Jijini is working with the County Public Service Board and the County Health Department to prepare to transition administration of program supported staff to NCC as part of the transition. These discussions will continue into Y5. In addition, the program is involved with and supports the MTEF process as well as the County’s annual work planning. Our engagement is an opportunity to advocate for adequate resourcing of critical health interventions currently funded by Afya Jijini. Additionally, the program’s work planning aligns with County priorities as a result of our close partnership with the County. They are fully briefed at the facility, Sub County and county level on annual program targets and share responsibility for their achievement.
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J. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE) N/A.
K. SUBSEQUENT QUARTER’S WORK PLAN Please find information concerning planned activities in the Year 5 work plan.
L. FINANCIAL INFORMATION
M. ACTIVITY ADMINISTRATION
IV. ANNUAL SUPPLEMENT TO QUARTERLY REPORT
V. ACTIVITY PROGRESS OF Q4 AND ANNUAL PROGRESS REPORT
VI. GPS INFORMATION Please find attached the updated list of supported facilities (Attachment 2) with GPS information.
VII. SUCCESS STORY Afya Jijini has attached the success story for Q4/APR report separately. It highlights evidence-based approaches that if men are actively engaged in Sexual Reproductive Health of their partners, the outcomes improve.
VIII. ANNEXES AND ATTACHMENTS Attachment 1: GIS _Afya Jijini GIS report Attachment 2: Snapshot 1_Y4Q4_ Improving Health outcomes through men engagement Attachment 3: Y4Q4_Detailed Performance Achievement Table Attachment 4: Year 5 Work plan
Annex 1: UCLTS impact: New sanitation facilities in triggered sites and other results
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Sub-County Sanitation intervention changes (Year 4) Other changes/community initiatives Langata Kuwinda Village: 23 new toilets constructed. Kuwinda Village: 258 households with handwashing facilities and waste bins for KPA Village: 8 new latrines constructed but taken down improvement of handwashing and solid during demolition of the village. waste management.
Bangladesh Village: 15 new latrines constructed after triggering, 10 under construction. Kasarani Gituamba Village: 35 new facilities constructed after triggering. Village with ODF claims. Assessment undertaken Baraka Kajiji: Community, by its own to ascertain status. Plans are underway for verification. initiative, organized monthly clean-ups.
Red Soil (Mwiki): 3 new facilities.
Biafra Maili Saba Village: 4 new facilities.
Baraka Kajiji: 1 public facility renovated and in use. Community committee was formed to ensure that all households pay the toilet fee for maintenance of the public facility.
Downtown Village: 1 latrine constructed at the village post- triggering.
Kanyama Village: 2 toilets constructed.
Embakasi West Kanguruwe: Construction of sewer line as a result of Kanguruwe: Community linking with advocacy work by the community. A total of 201 sanitary county government for collection of facilities constructed after triggering. Over 10 premises waste, facilitated by youth groups. draining sewer to drain stopped. City Carton Village: 343 handwashing City Carton Village: 381 new latrines constructed after facilities procured by community to triggering. There were only 16 serving 440 plots before promote handwashing. triggering. Additionally, 18 plots connected to sewer.
Embakasi East Kamola Village: 31 toilets and latrines constructed since Soweto: Regular collection of solid waste triggering. by a community youth group who are paid Mradi Village: 17 new latrines constructed. Ksh. 100 per month. Tassia Kijiji: 14 new facilities since triggering. Bahati Soweto Village: 21 new facilities constructed. Majority of the houses were connected to the sewer line. Sisal Village: 100 new facilities constructed (84 Freshlife, 12 pit latrines and 4 pour-flush type). Ruaraka Majengo Village: 4 functional toilets and a urinal constructed after triggering; 2 not completed. Improved uptake of sanitation through use of latrines. Landlords engaged in promotion in sanitation. Power Village: 4 latrines (Freshlife) constructed after triggering. Note that no latrines existed before triggering. Makadara 63 toilets constructed in all villages in the sub-county after Increased activities to ensure triggering (Paradise – 13, Kingstone – 5, Silver – 2, Milimani – environmental sanitation through 23,Sinai – 20) community clean-ups. Community ensuring waste is collected once a week at a fee of 10 shillings by a community-based group. This is an improvement since previously there were heaps of garbage identified in several corners which had a combination of used diapers and feces in papers. 80 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019
Kamukunji Sagana Village and neighboring villages (Kiambiu): 151 toilets Youth involved in collection of garbage at constructed after triggering (there were 3 latrines before Kitui and Kiambiu Villages. triggering).
Motherland Village: 1 toilet block renovated (was not in use before triggering).
Kitui Village: 23 latrines constructed after triggering last year, 5 latrines connected to sewer line.
Westlands Matopeni Village: 1 public block with 5 doors renovated for Damview: 2 bathrooms constructed by use after triggering. community members as effort to promote sanitation. Damview Village: 8 new toilets, 1 urinal. Kibagare Village: Community established Kibagare Village: 16 new toilets constructed after triggering, toilet block for production of biogas (with and one public block renovated. One block constructed (with 6 toilets and 6 bathrooms) and one 6 toilets). All hanging toilets (discharging in open drains) handwashing facility. brought down. Youth undertaking garbage collection, to enhance environmental sanitation and earn livelihood. Involvement of administration in enforcement of sanitation, where a member of the village was arrested for dumping waste. Dagoretti Madiaba Village: Open space where open defecation used to Madiaba Village: Landlords providing happen has been fenced off by community members. 17 waste receptacles to their tenants and latrines which were not functional were rehabilitated. Athi contracted CBOs (youth groups) for Water Services laying new sewer line in the community, waste collection and proper disposal attributed partly to advocacy efforts by the community leading to improved environmental sanitation. Maranatha Village: 16 water closets connected to the sewer line after triggering and 13 pit latrines that were not Maranatha village: 70%of households have functional were rehabilitated. sacks/receptacles for waste storage awaiting collection for proper disposal. Kajiji Village: 2 latrines built. Improvement by reduction of open defecation sites. Bushes cleared where open defecation was taking place. Kajiji: Community adopting use of sacks for each household for collection of waste Matopeni Village: 2 latrines constructed after triggering. 6 after triggering and sanitation dialogues. latrines which had filled up and were not used were rehabilitated and now in use. Matopeni: Landlords contracting CBOs to collect solid waste. Starehe Kosovo Village: 44 new latrines constructed. 2 public latrines Kisii Village: Improved waste disposal. renovated. 4 new latrines (Freshlife) installed in 2 schools. Households contribute Ksh. 20 for collection of the waste by youths. Kisii Village: Improved fecal disposal (used to be done in open drains). 4 new facilities constructed. Kiamaiko: 4 bathrooms constructed. One receptacle provided for waste collected. Kiamaiko Village: 4 latrines constructed (after training about open sewers). Kosovo: Established strong landlords’ forum to champion water and sanitation issues in the village.
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KENYA
USAID-Kenya and East Africa Afya Jijini Program Physical Address: 9th Floor I Goodman Tower Building Website: www: imaworldhealth.org
82 | USAID/Kenya and East Africa Afya Jijini Program Progress Report for FY4 (Q4) and Y4 2019