USAID AFYA PWANI QUARTERLY PROGRESS REPORT

JULY-SEPTEMBER 2017 This publication was produced for review by the United States Agency for International Development. It was prepared by Dr Eileen Mokaya, Chief of party, Afya Pwani.

USAID AFYA PWANI FY 2017 Q4 PROGRESS REPORT

1st July 2017– 30th September 2017

Award No: Aid-615-C-16-00002

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

Prepared by Pathfinder International-Kenya The Watermark Business Park, Karen, Fountain Court, 1st Floor Ndege Road, off Langata Road P. O. Box 1996 – 00502 Karen NAIROBI, KENYA Office : +254-20-3883142/3/4 Mobile : +254-733-618359/+254-722-516275 Fax : [+254 20] 2214890 www.pathfinder.org

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.

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 i

I. AFYA PWANI EXECUTIVE SUMMARY ...... 7

II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 10

SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES10 Output 1.1: Elimination of Mother to Child Transmission (eMTCT):...... 10 Output 1.2: HIV Care and Support Services ...... 18 Output 1.3: HIV Treatment Services ...... 22 Output 1.4 HIV Prevention and HIV Testing and Counseling ...... 31 Output 1.5: Tuberculosis/HIV Co-infection Services ...... 34

SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH and FP, WASH and NUTRITION ..... 38 Output 2.1: Maternal, Newborn and Health services ...... 39 Output 2.2: Child Health Services ...... 45 Output 2.3 Family Planning Services and Reproductive Health (FP and RH) ...... 47 Output 2.4 Water, Sanitation and Hygiene (WASH) ...... 53 Output 2.5 Nutrition...... 57

SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS ...... 62 Output 3.1 Partnerships for Governance and Strategic Planning ...... 62 Output 3.2: Human Resources for Health (HRH)...... 66 Output 3.3 a): Health Products and Technologies (HPT)...... 67 Output 3.3 b): Health Products and Technologies- Facility Report ...... 70 Output 3.4: Monitoring and Evaluation Systems ...... 74

III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) ...... 76

IV. CONSTRAINTS AND OPPORTUNITIES ...... 77

V. PERFORMANCE MONITORING...... 79

VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH ...... 90

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 97

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 97

IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 98

X. PROGRESS ON USAID FORWARD ...... 99

XI. SUSTAINABILITY AND EXIT STRATEGY ...... 99

XII. SUBSEQUENT QUARTER’S WORK PLAN ...... ERROR! BOOKMARK NOT DEFINED.

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 ii

XIV. ACTIVITY ADMINISTRATION ...... 101

XV. SUCCESS STORIES ...... 101

Figure 1 Number of ANC Clients Tested for HIV Oct 2016-Sept 2017 ...... 10 Figure 2 PMTCT HAART and HEI Prophylaxis Oct 2016-Sept 2017 ...... 12 Figure 3 RTK reporting rates July -Sept 2017...... Figure 4 ART uptake for pregnant women and HEI prophylaxis July –Sept 2017 ...... 14 Figure 5 Comparing Q4 TX_CUR against APR targets ...... 23 Figure 6 Afya Pwani Treatment Cascade ...... Figure 7 Test and Start July -Sept 2017 ...... 24 Figure 8 Afya Pwani Improved VL uptake Oct 2016-Sept 2017 ...... 27 Figure 9 Trend Analysis for the 1st and 4th ANC Visits October 2016 to September 2017 39 Figure 10 Trends in SBA and live births October 2016-June 2017 ...... 43 Figure 11 Trends in maternal deaths, stillbirths and Neonatal deaths October 2016 and September 2017 44 Figure 12 Trends in Child Health Indicators October 2016-September 2017 ...... 45 Figure 13 : Trends in Diarrhea Cases Managed at facilities in the 7 sub-counties for Oct 2016 to June 2017 ...... 46 Figure 14 Uptake of FP Services, New clients and re-visits for Oct-Dec 2016, Jan-Mar 2017, Apr-Jun 2017 ...... 47 Figure 15 Trends in FP method mix for the period Oct 2016 – June 2017 ...... 48 Figure 16 Trends in CYP for October 2016 – September 2017 ...... 48 Figure 17 Distribution of CYP by Method for October 2016 – September 2017 ...... 49 Figure 18 Contraception commodity reporting trends (June 2016 - May 2017) ...... 53 Figure 19 Afya Pwani Underweight Trend Analysis Oct 2016- Sept 2017 ...... 61 Figure 20 Stunting Trends Oct 2016- Sept 2017 ...... 62 Figure 21 Health Budgetary Allocation for FY 2015/16, 2016/17 and 2017/18 for Kilifi, Kwale, Lamu, Mombasa and Taita Taveta Counties ...... 64 Figure 22: Mombasa Indicator tracking data by County TWG ...... 68 Figure 23 HIV Laboratory Commodity Reporting Rates ...... 68 Figure 24 Coast DHIS2 Commodity reporting rates...... 69 Figure 25 Kongowea Health Center Commodity Management Performance ...... 71 Figure 26 Kisauni Health Center Commodity Management Performance ...... 72 Figure 27 Comparative Commodity Management Indicator Analysis for Afya Pwani Facilities Visited Twice (Q1 to Q4) ...... 73 Figure 28 Comparison of EMR DQA Findings ...... 74 Figure 29 Comparison of 1st and 4th ANC ...... 76 Figure 30 FY 17: Average Annual Reporting Rates for Major Reports ...... Figure 31 Kwale County EMR Uptake August 2017 ...... 90

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ACRONYMS AND ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care APH Antepartum Hemorrhage APHIA AIDS, Population and Health Integrated Assistance APHIAplus AIDS, Population and Health Integrated Assistance-People-centered, local universal access and sustainability ART Antiretroviral Therapy ARV Antiretroviral ASRH Adolescent Sexual Reproductive Health AYLHIV Adolescents and Youth Living with HIV AYSRH Adolescent and Youth Sexual Reproductive Health BEmONC Basic Emergency Obstetric and Newborn Care CASCO County AIDS and STI Control Officer CCC Comprehensive Care Center CD4 Cluster of Differentiation 4 CDC Center for Disease Control and Prevention CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHMT County Health Management Team CHS Community Health Strategy CHV Community Health Volunteer CLTC County Leprosy and Tuberculosis Coordinator CME Continuing Medical Education COP Chief of Party COR Contracting Officer Representative CPGH Coast Provincial General Hospital CQI Continuous Quality Improvement DCOP Deputy Chief of Party DDIU Data Demand and Information Use DISC Drop in Support Centre DOT Directly Observed Therapy DQA Data Quality Assessment EBI Evidence Based Interventions EID Early infant diagnosis EMTCT Elimination of Mother to Child Transmission EmONC Emergency Obstetric and Newborn Care EMR Electronic Medical Records FANC Focused Antenatal Care FBO Faith Based Organization FCDRR Facility Consumption Data Report and Request Form FMAPS Facility Monthly ARV Patient Summary FP Family Planning FSW Female Sex Worker GBV Gender-Based Violence GOK Government of Kenya HAART Highly Active Antiretroviral Therapy HCSM Health Commodities and Services Management

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HCW Health Care Worker HEI HIV Exposed Infant HFMC Health Facility Management Committee HINI High Impact Nutrition Interventions HIV Human Immunodeficiency Virus HMIS Health Management Information System HMT Health Management Team HPT Health Products and Technology HRIO Health Records Information Officer HRH Human Resources for Health HSS Health Systems Strengthening HTC HIV Testing and Counseling HTS HIV Testing Services HVF High Volume Facility IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IPT Isoniazid Preventive Therapy IYCF Infant and Young Child Feeding KAIS Kenya AIDS Indicator Survey KeHMIS Kenya Health Management Information System Project KEMSA Kenya Medical Supplies Agency KHSSSP Kenya Health Sector Strategic and Investment Plan KHQIF Kenya HIV Quality Improvement Framework KP Key Populations LTFU Lost to Follow Up MCH Maternal and Child Health M&E Monitoring & Evaluation MNCH Maternal, Newborn and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MSM Men Who Have Sex with Men MSW Male Sex Worker NASCOP National AIDS and STI Control Program NGO Non-governmental Organization OI Opportunistic Infection OJT On Job Training ORS Oral Rehydration Salts ORT Oral Rehydration Therapy OVC Orphans and Vulnerable Children PBB Program Based Budgeting PEP Post Exposure Prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PHPD Positive Health Dignity and Prevention PITC Provider Initiated Testing and Counseling PLHIV People Living with HIV PMP Performance Monitoring Plan PMTCT Prevention of Mother to Child Transmission PSS Psychosocial Support Services

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PrEP Pre-exposure Prophylaxis QA Quality Assurance QI Quality Improvement RH Reproductive Health RTK Rapid Test Kits SCASCO Sub-County AIDS Control Officer SCHMT Sub-County Health Management Team SCLTC Sub-County Leprosy and Tuberculosis Coordinator SCHRIO Sub-County Health Records Information Officer SDGs Sustainable Development Goals SI Strategic Information SIMS Site Improvement Monitoring System SMS Short Message Service SOP Standard Operating Procedure SRH Sexual and Reproductive Health SW Sex Workers STI Sexually-transmitted Infection TA Technical Assistance TB Tuberculosis TOT Trainer of Trainers TWG Technical Working Group UNAIDS Joint United Nations Program on HIV/AIDS UNFPA United Nations Population Fund USAID United States Agency for International Development USG United States Government VCT Voluntary Counseling and Testing VMMC Voluntary Medical Male Circumcision VL Viral Load WASH Water, Sanitation and Hygiene WHO World Health Organization YFS Youth Friendly Services YLHIV Youth Living with HIV YPLA Young Person with Living with AIDS 3Ps Pathfinder International, Plan International and Palladium Group

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I. AFYA PWANI EXECUTIVE SUMMARY

During the July-September 2017 quarter, the United States Agency for International Development (USAID) Afya Pwani project focused on organizing work planning for the second year of implementation of the Project. Unlike the previous year, the team invited all the County Health Management Teams (CHMTs) from all five coastal counties being supported by the Project to participate in the work planning process which took place in July 2017 in Mombasa. By supporting this activity, project staff were ensuring that Year 2’s activities were aligned with the County work plans and priorities. The work plan was successfully submitted, and a conditional approval made subject to revisions as per comments from the USAID team. These revisions have been made and the work plan has been approved moving into the next quarter and Year 2 of activities. The grantee selection process was also finalized during the quarter, which saw grantees settle on their work plans for activities to commence in the next quarter. A two-day orientation session will be organized for the grantees in October 2017, where all participants were through compliance requirements like reporting, branding and marking, as well as orientation on the Project overall. Other milestones achieved during this quarter were the signing of Memorandums of Understanding (MOUs) with Kilifi, Taita-Taveta and Kwale Counties as part of efforts to fast track the recruitment and deployment of contracted facility based staff who will play a pivotal role in improving access and utilization of HIV, Maternal, Neonatal and Child Health (MNCH), Reproductive Health (RH)/Family Planning (FP), Water, Sanitation and Hygiene (WASH) and Nutrition health services across the five coastal counties that the Afya Pwani project is supporting. Qualitative Impact Between July and September 2017 there were 8,878 first ANC visits of which 8,718 clients were offered HIV Testing Services (HTS) and 307 were identified to be positive, a yield of 3.5%. Moreover, 1,713 PLHIV were identified and 1,533, 89% were linked to ART (See Output 1.2: HIV Care and Support Services). In FY 17, the Project had target of ensuring that 45,907 PLHIV were currently on ART, by the end of Q4, 45,943 PLHIV were on ART having received drug refills within the last 3 months, representing 100% of the Annual Program Target (APR) target. In the FY 17, the Project tested 385,533 adults and 30, 451 children against targets of 391,299 and 18,511 respectively. Compared to the annual targets, this is 99% and 165% achievements for adults and children.

In terms of supporting Maternal, Neonatal and Child Health (MNCH), Afya Pwani reached a total of 5,714 clients with Focused Antenatal Care (FANC) services in the County. It should be noted that the number of FANC clients decreased from 9,938 last quarter, to 4,224 during the July-September 2017 period; this decline is attributable to the nationwide nurse’s strike which began in 1st of June 2017 and is still ongoing. Between July and September 2017, 2,857 clients completed 4 FANC visits as compared to 2,995 clients that were reached in the April to June 2017 quarter; a decline of 138 clients. Cognizant of the effect that this industrial action by the nurses is having on MNCH service delivery, the Afya Pwani team will focus on scaling up community mobilization efforts as well as supporting outreach activities to help mitigate these effects and increase ANC attendance by pregnant women across all the seven sub-counties in Kilifi in the next quarter. The Figure below provides a more detailed breakdown of these trends. During the period under review, the Afya Pwani project also continued to provide targeted Health Systems Strengthening (HSS) interventions in all the five counties: Taita Taveta, Kilifi, Mombasa, Kwale and Lamu. The interventions included dissemination of guidelines, annual work plan (AWP) performance reviews, commodity management trainings, Electronic Medical Records (EMR) deployment and support as well as

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 7

data demand and use support. Afya Pwani also supported counties to finalize compilation of key working documents namely: Lamu Critical HRH Gaps Reports, Lamu County Health Department Staff Establishment and Taita Taveta, Lamu and Kilifi County Budget Analysis (CBA) reports among others. These documents will provide health managers at different levels with the necessary information and tools for advocacy and management. During the annual work planning engagements with Counties, it emerged that hospitals lacked plans to guide implementation of their priority activities. In Kwale, substantial progress was attained through finalization of hospital AWPs for Lunga Lunga, Msambweni, Kinango and Kwale Hospitals. This was the Project’s initial step towards bridging the existing gap in health facility planning and consequently review of performance against specified indicators, which will build the capacity of hospital management teams in annual work planning and budgeting and consequently, better inform the County-level AWP. In terms of Health Products and Technology (HPT) management, Afya Pwani supported Technical Working Group (TWG) meetings which have become instrumental oversight bodies. A key challenge identified by TWG across the Counties was poor reporting rates, one of the priorities listed for follow up. Moreover, the Project supported commodity management trainings and EMR supply chain module mentorship to enhance commodity management practices including effective supply chain management. County, Sub-County and facility staff were also trained on EMR use and additional support provided to facilitate them to conduct data reviews. To enhance data demand and utilization for service delivery, the project also provided mentorship sessions for health workers across the different levels of health management on data demand and information use. This mentorship process is expected to equip health workers with the skills to analyze data and design priority health interventions geared to improved service delivery outcomes. Constraints and Opportunities The major challenges faced by the Afya Pwani team this quarter revolved around the ongoing nurse’s strike which commenced fully at the beginning of June 2017. Several project supported sites have seen their maternity departments remain closed during the quarter with many clients now seeking services at private facilities. The Afya Pwani team and the relevant County Health Management Teams are now trying to work closely with these facilities to ensure that clients receive high quality health services despite the strike. The other challenge that staff faced during the quarter was due to the elections, which saw Afya Pwani offices close for an extended period due to election related incidences.

Quantitative Impact

Table 1 Afya Pwani Performance Summary Table

Theme Core Indicator APR-JUN 2017 JUL-SEP 2017 OCT 2016- SEP 2017 Results % Results % Results % COP 17 Annual Target HIV Testing HTS_TST: HTS Received 99,879 32% 94,400 31% 417,116 135% 308,420 and Linkage Results HTS_TST: HTS Positive 2,098 17% 1,713 14% 9,337 75% 12,430 Results

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TX_NEW (N, DSD): New 1,770 15% 1533 13% 7,682 67% 11,494 (92%) on ART (Linked to (84%) (89%) (82%) Treatment) TX_CURR (N, DSD): 46,441 101% 45,943 100% 45,943 100% 45,907 Receiving ART VL Performed 16,096 34% 20,866 45% 36,962 79% 46,760 Viral Load VL Suppression Rates 13521 90% 16,484 90% 29,200 90% 46,760 (100%) Monitoring (84%) (79%) (79%) PMTCT_STAT: New ANC 20,495 20% 8,878 9% 82,659 82% 101,359 clients EMTCT PMTCT_STAT: Known 20,459 20% 8,718 9% 81,616 81% 101,359 Results PMTCT_STAT: Positive 546 12% 307 7% 2,263 48% 4,699 Issued HAART 507 11% 295 6% 2,171 46% 4,699 HAART Uptake 93% 100% 96% 100% 96% 100% 100% HEI Prophylaxis 507 292 2,169 EID DNA-PCR 456 468 1,711 HEI No. Confirmed 12 10 83 Positive HEI Positivity Rate 3% 2% 5% No. Linked to ART 12 10 83 MNCH Pregnant women 2,991 10% 732 2% 11,351 37% 30,785 completing 4 ANC visits

Skilled Birth Attendance 6,771 22% 1403 5% 19,743 64% 30,785

Fully Immunized 4,735 13% 2879 8% 22,718 60% 37,760 Children(FIC) under 1

year PNC Infants receiving 6,665 22% 1403 5% 19,284 63% 30,785 Postpartum care within 2-3 days Total Underweight 4,835 2% 1678 1% 18,064 8% 10% of 228,701

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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES

Output 1.1: Elimination of Mother to Child Transmission (eMTCT): a) Early Identification of HIV-positive pregnant women and increase for demand services HIV Testing Services: In the 4thquarter of FY 17, there were 8,878 first ANC visits of which 8,718 were offered HIV Testing Services (HTS) and 307 were identified to be positive, a yield of 3.5%. Overall in FY17, the Project offered HTS to 81,853 (98%) clients out of the 82,659 clients who visited Afya Pwani supported sites for their 1st ANC visits. More detailed information on these trends for each quarter in FY 17 can be seen in the Figure 1 below.

Number of ANC Clients Tested for HIV Oct 2016-Sept 2017

120000 98% 101298

100000

82659 81853 80000

60000 98% 99% 101%

40000 98%

30162

29601

25325 25325 25325 25325

23124

22918

20616 20495

20000

8878 8718

0 Q1 Q2 Q3 Q4 Total Target New ANC Clients Tested

Figure 1 Number of ANC Clients Tested for HIV Oct 2016-Sept 2017

It should be noted that in Lamu County, 69 mothers from 4 facilities (Witu-61, Moa-3, Kizingitini-3 and Matondani-2) were not tested for HIV during their 1st ANC visit due to lack of test kits and the Project could not support redistribution at that time because of the heightened insecurity in the County at time. Most of these mothers have since come back and got tested in their subsequent ANC visits. As part of efforts to support early identification of HIV positive pregnant women and to increase demand for HTS project supported mentor mothers conducted health talks to mothers who came for services at the MCH. The talks promoted HIV testing, partner testing, early uptake of ANC visits, birth preparedness and skilled

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delivery. Emphasis on family and partner testing during health talks was also done. The Project has also partnered with traditional birth companions, community health volunteers (CHVs) and other community health actors to identify pregnant women early, refer/escort them for early ANC hence early HTS uptake. Afya Pwani also trained 90 and 144 traditional birth companions in Kwale and Mombasa counties respectively on their role in early identification of HIV positive mothers, referral to early ANC services and ensuring that women delivery in a health facility.

The Project also supported HTS services in all supported facilities that were open for services during the quarter. HTS counselors were deployed in 17 facilities1 in Kilifi County to ensure all pregnant women, breast feeding women and their children who sought any services at the facility were offered HIV testing services. Since most public facilities were closed due to the nurses’ strike, the Project supported nine2 high volume private facilities with HTS counselors to provide HTS to ANC, PNC and Child Welfare Clinic (CWC) clients. In hard to reach areas of Kwale County, the Project supported Lunga Lunga Sub-County service providers (9 males, 7 females) with transport and lunch to conduct integrated outreaches at Kwa Nyanje, Chindi, Mambani, Mtsunga and Nesserian outreach sites reaching 43, 1st ANC mothers and 186 Provider Initiated Testing and Counselling (PITC) Clients. All the 43, 1st ANC mothers were found to be HIV Negative. For the 186 PITC Clients, 8 tested HIV Positive and were started on Highly Active Antiretroviral Therapy (HAART) at Mwangulu and Kilimangodo Dispensaries.

In Taita Taveta County, to improve access to HTS among pregnant mothers especially during the nurses’ strike, the Project conducted Continuous Medical Education (CME) on the new HTS guidelines for non- nursing cadres of health workers e.g. clinical officers, nutritionists etc. to offer quality HTS at Moi County Referral Hospital, Mwatate Sub-County Hospital, Taveta Sub-County Hospital, Wesu Sub-County Hospital and Wundanyi Sub-County Hospital where 80 (25 males, 55 females) health workers were reached. The core principles of HIV testing (the 5Cs): Informed consent, confidentiality, and counseling, correct test results and connection (referral and linkage to care), the HIV Testing and Counselling protocol and the HIV testing algorithm were emphasized.

i) Linkage of HIV positive to ART: Of the 307 women who tested positive in the quarter 295 (96%) were started on ART immediately. In Kilifi and Lamu Counties provided ART to all the newly identified HIV positive pregnant mothers. In Mombasa County, eight mothers (four from Mother Amadeas Medical Clinic, two Nguuni Health Center, one Santa Maria Medical Clinic and one from Majengo Dispensary) were not linked to ART. These were tested in private non-ART sites. The Project is strengthening the referral systems from private to public facilities as well as liaising with the CHMT to build capacity of private providers to provide ART. In Taita Taveta, one mother from Eldoro Dispensary declined to be started on ART, follow up has been unsuccessfully so far. In Kwale County, three mothers from Ngathini (one) and Kilimangodo (two) facilities who were tested in the lab declined to be started on ART, initial follow up was unsuccessful. The HTS counselors and peer educators will continue to follow them up.

To ensure that mothers identified for HIV at ANC are always successfully linked to onward treatment services, resulting in minimal missed opportunities and timely initiation of antiretroviral therapy the Project utilized the HTS providers and mentor mothers as patient escorts to ensure all the identified

1 Kilifi, Malindi and Mariakani hospitals, Marafa, Mtwapa, Muyeye, Gongoni, Vitengeni, Rabai, Matsangoni, Ganze, Chasimba health centers, Mambrui, Mtepeni, Ganda, Baolala and Sabaki Dispensaries. 2 Mephis Medical clinic, Deteni Medical clinic, Mabati Clinic, Mariakani Community Clinic, Dagamra Medical clinic, Baobab medical clinic, Kijanaheri, Kambi ya Waya, St Mary’s Msabaha.

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mothers were linked to care. Also, referral forms were utilized to refer mothers from the testing point to the enrolment site for those who preferred to take ART from a different site. The referrals forms are regularly reconciled to monitor the names and numbers of diagnosed clients enrolling for treatment and care. Delays between referral and enrolment on care were reviewed and lists of not enrolled were generated and used for tracing among those who had given prior consent for follow up. Weekly analysis of missed opportunities for ART was done to identify gaps in linkage and addressed them.

Afya Pwani staff conducted four CME sessions in Mwatate Sub-County Hospital, Taveta Sub-County Hospital, Wesu Sub-County Hospital, and Moi-Voi County Referral Hospital, reaching 96 (39 males, 57 females) health workers on the updated ART guidelines, where emphasis was placed on linking all HIV positive mothers and infants to HAART soonest possible and ensuring that they are retained in care. In the same county, an analysis of missed opportunities done in Mwatate, Wesu, Moi Voi and Taveta Hospitals showed that most missed opportunities for ART were those tested in the lab and those who preferred to start ART from another site. To address these gaps, the facilities adopted escorting all newly identified positive pregnant and breastfeeding mothers to the CCC for ART (MNCH closed due to strike) and linkage registers placed in all testing points. Enhanced counselling was offered to those who preferred to start ART from another site and their detailed contact information recorded, and a follow up phone call done later to confirm linkage. See Figure 2 below.

3000 98% PMTCT HAART AND HEI PROPHYLAXIS Oct 2016-Sept 2017 97% 2570 97% 2466 2461 2500 97% 96% 96% 96%

2000 95%

1500 94%

93% 943 93% 1000 917 915 774 747 747 92% 546 507 507 500 307 295 292 91%

0 90% Q1 Q2 Q3 Q4 Total Pregnant Women Positive Issued HAART HEI given prophylaxis HAART Uptake( %)

Figure 2 PMTCT HAART and HEI Prophylaxis Oct 2016-Sept 2017

b) Addressing the supply and availability of services Task shifting: to mitigate on the effects of the nurses’ strike, the Project empowered mentor mothers, peer educators and HTS counselors in supported facilities to provide some basic services that did not

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require technical skills, screen mothers for danger signs and make appropriate referrals, send clients to pharmacy for ART refill or to clinical/medical officers accordingly. Mentor mothers also line listed the EMTCT mothers in their facility and called them to come for drug refills and viral load (when appropriate) despite the strike. Commodities: Afya Pwani has continued to support RTK reporting rates July -Sept 2017 120 commodity reporting, quantification, forecasting 97 100100 99 100 and ordering of HIV 100 91 88 85 87 80 commodities. During the 76 strike, the Project 80 collaborated with CHMTs 57 to make reports and orders 60 47 for those facilities that had 39 not reported. In addition, 40 the Sub-County Medical 24 Laboratory Technologists 20 (SCHMLTs) have continuously been 0 supported with airtime for Mombasa Kilifi Kwale Taita Taveta Lamu online Rapid Test Kit (RTK) Source: HCMP reporting to ensure Figure 3 RTK reporting rates July -Sept 2017 continuous availability of commodities. The Commodity Management Advisor is currently supporting Kwale and Kilifi to address their low reporting rates for RTK in the Health Commodity Management Program (HCMP) platform. See Figure 3 above. Redistribution of 900 RTKs was done in Kilifi county benefiting Ganze Health Center and Mariakani Sub- County Hospital. During the month of September 2017, Afya Pwani project supported 1 RTK allocation meeting at Kwale Resource Centre to develop centralized planning, quantification, redistribution plans and allocation of RTKs to the health facilities. The 21 ((17 males, 4 females) technical team members supported for the meeting were SCMLT, Sub County Aids and Sexually Transmitted Diseases Coordinators (SCASCO), Laboratory Managers and Quality Assurance Officers from the 4 main hospitals of Msambweni County Referral Hospital, Kwale Sub-County Hospital, Kinango Sub-County Hospital and Lunga Lunga Sub- County Hospital. Laboratory Networking: To support Early infant diagnosis (EID) and improve the turnaround time for EID samples, the Project supported transportation of Dry Blood Sampling (DBS) Polymerase Chain Reaction (PCR) and viral load samples from the peripheral facilities to the testing laboratory at CPGH. Health workers were given transport and lunch reimbursements when taking the samples to collection laboratories where they are later taken to CPGH for analysis or CPGH directly. To further support this process, the Project has now engaged three motor riders for quick transportation of plasma samples to CPGH for analysis. The staff equally facilitates the printing and distribution of EID and viral load results. Integration of services: As a minimum package of care, the provision of integrated services is essential in making sure that clients spend less time at the facility and still receive the best quality of care. Afya Pwani has continued to ensure that HIV services are offered in Maternal and Child Health (MCH) for mother-

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baby pairs in 41 HVFs3. In a few facilities like Kwale Sub-County Hospital, Tiwi Health Center, Kwale SCH and Tiwi Health Center family days where integrated services are offered to mother-baby pair and their family members on the same day have been supported. The Project has also integrated the collection of EID and viral load samples into MCH to avoid missed opportunities when referred to the lab. CME on FP integration into Comprehensive Care Clinic (CCC) were conducted at Mazeras Dispensary, Samburu Health Centre, Kinango Hospital, Mkongani Dispensary, Tiwi Health Centre, Kwale Hospital, Diani Health Centre, Kikoneni Health Centre, Lungalunga Hospital, Vitsangalaweni Dispensary and Mwangulu Dispensary to reduce the incidence of unwanted pregnancy among Women of Reproductive Age (WRA) living with HIV reaching 54 (24 males, 30 females) health workers.

c) Enrollment and retention of HIV-positive pregnant women and HIV-exposed infants In the last quarter, the Project identified 307 positive pregnant women, and enrolled 295 (96%) into ART. The reasons for non-enrollment of the 12 mothers have been discussed under linkage to ART above. See Figure 4 below.

ART uptake for pregnant women and HEI prophylaxis July –Sept 2017

200 181 173 173

150

100 61 58 56 45 45 45 50 7 6 6 13 13 13 0 Mombasa Kilifi Kwale Taita Taveta Lamu Number of Positive Pregnant Mothers Number on ART Number of HEI on prophylaxis

Figure 4 ART uptake for pregnant women and HEI prophylaxis July –Sept 2017

The project has employed several interventions to ensure that mother-baby pairs are retained in care throughout the ANC and post-natal period:

Mentor-mothers: Afya Pwani has continued to support work of 45 mentor mothers to provide psychosocial services (PSS) and peer support, health education, defaulter identification and follow as a core strategy in ensuring retention of mother-baby pairs. In Q3, the mentor mothers were trained while

3 Kinango, Msambweni, Samburu, Taru, LungaLunga, Kwale, Mkongani, Shimba Hills, Mazeras, Diani, Vanga, Tiwi, Waa, Kilifi, Malindi, Mtwapa, Vipingo, CPGH, Port Reitz, Tudor, Kongowea, Likoni, Mvita, Miritini, Bokole, Jomvu, Mikindani, Chasimba, Gongoni, Muyeye, Moi Voi, Taveta, Wundanyi, Ndovu, Mwatate, Njukini, Sagalla, Buguta, Mpeketoni, Lamu, Witu.

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in this quarter, they have been supervised and mentored on doing their work well. The Project has introduced a weekly dashboard of tracer indicators that they use to monitor their work effectively.

Mother-baby register: To enhance longitudinal, follow up of mother baby pairs, Afya Pwani has also supported the adoption of the mother-baby pair register across three facilities (Moi Voi County Referral Hospital, Taveta and Mwatate Sub-County Hospital in Taita Taveta County, a best practice that has been scaled up from what was being implemented successfully in Kwale County. The mother-baby pair register has made it easier for facilities to account for each mother and their HEI, thus improving the quality of PMTCT services provided for these clients.

Mother- baby pairing-HEI/family days: Follow up on mother-baby pair was done through the support of HEI days at Kinango Hospital, Kwale Hospital, Diani Health Centre and Tiwi Health Centre where mothers and babies were seen on the same day with integrated services offered including Nutritional Assessment Counselling and Support (NACS), laboratory (when appropriate), immunizations and growth monitoring and psycho social support group meetings.

Support groups: Mentor mothers were supported to conduct monthly psychosocial support group sessions for HIV positive pregnant and breastfeeding mothers. The aim is to provide psychosocial and educational support to clients through the provision of health education and sharing of the mentor mother’s experience, to create awareness and facilitate the uptake of available PMTCT services, to empower women and facilitate positive living. The facilities supported in Kilifi were 184, 33 support group sessions conducted reaching 896 women. In Mombasa 70 group sessions were conducted in 13 facilities5 with 528 mothers reached. In Kwale County, 19 EMTCT support groups were supported in 11 facilities6; 57 sessions conducted reaching 380 mothers.

Weekly dashboards: The Project also introduced a weekly community dash board to tracking of mother- baby pair missed appointments, defaulters traced, support group sessions and health education sessions conducted. Through the weekly tracking there is improved client follow up and prompt support to facilities by the project to address emerging gaps.

Defaulter tracing: The Project has successfully worked with mentor mothers and peer educators to quickly identify missed appointments from appointment diaries and followed them up immediately. The success rate across the counties has been above 80% as shown in the Table 2 below.

Table 2 Afya Pwani Defaulter Tracing Rates July-Sept 2017 County Missed Traced back Still on follow up Lost to follow appointments up Taita Taveta 29 27 2 0 Kwale 44 39 5 0 Mombasa 41 39 2 0 Kilifi 277 211 35 7 Afya Pwani 391 316 44 7

4 KCH, Vipingo, Mtwapa, Mariakani, Rabai, Matsangoni, Gede, Bamba, Ganze, Chasimba, Gongoni, Mambrui, Vitengeni, Oasis, Marafa, Vitengeni, Muyeye and Marereni. 5 CPGH, Tudor, Port Reitz, Likoni, Kongowea, Kisauni, Bamburi, Chaani, Magongo, Mlaleo, Utange, Bokore, and Ganjoni. 6 Kwale, Tiwi, Mkongani, Diani, Msambweni, Kinondo, Kikoneni, Vitsangalaweni, Lungalunga, Kinango and Mazeras.

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Where necessary home visits have been made by mentor mothers in addition to making phone calls. Peer follow up by members of support groups has also been used effectively where mothers come from the same geographical area.

d) Increasing PMTCT service quality Supportive Supervision: The Project supported joint supportive supervision in Kilifi County reaching 10 HVFs7 with 13 (6 males, 7 females) health workers benefitting. The health workers were also mentored on follow up of missed opportunities for HAART and provision of quality services. In Taita Taveta County, Sub-county pharmacists, SCMLTs and SCASCOs in the 4 sub-counties were supported to conduct supportive supervision for health workers at 24 health facilities8, where emphasis was placed on the EMTCT cascade and viral load monitoring for pregnant and breastfeeding women. In Lamu County, 18 health care workers (13 males, 5 females) from 10 facilities9 were reached during a joint integrated CHMT supportive supervision supported by the project. They were also mentored on viral load and EID sample collection, packaging and transportation to the testing laboratory.

On Job Training/Mentorship/training: Afya Pwani has also successfully utilized mentorship and on the job training as a key strategy of improving the capacity of health workers to provide quality services. In Ganze sub county of Kilifi County, the project provided on the job training (OJT) to 21 (5 males,16 females) health workers from Dzikunze, Kachororoni, Dida, Madamani and Muryachakwe Dispensaries on safe and correct DBS sample collection for DNA-PCR for early infant diagnosis. Twenty-one (11 males, 9 females) service providers from Rabai and Kaloleni sub counties also benefitted from a training on EID, VL monitoring and HTS conducted by the project in close partnership with the CHMT. This has led to increased access and quality of EID and VL tests done, with reduced number of rejected DBS samples reported. In Kwale County, Afya Pwani staff and SCASCOs provided OJT to 48 (14 males, 22 females) health care workers of various cadres including Clinical officers, nurses, and laboratory technologists, from 9 facilities10 on the EMTCT guidelines with an emphasis on the recently introduced changes on EID, ART prophylaxis for infants and use of new molecules (DTG) in pregnancy. In Taita Taveta County, the project reached 80 (26 males, 44 females) service providers with mentorship on HTS, ART provision for pregnant and breastfeeding women and HEI, EID and VL sample collection and treatment monitoring.

Work Improvement Teams (WITs): There are 7 facilities (Chasimba, Gongoni, Bamba, Rabai, Kilifi, Malindi and Mariakani) in Kilifi County with WITs for EMTCT; although they have not met regularly for a great part of the year owing to the instability in the health sector. In the next quarter the Project will focus on reviving these WITs and scale up QI in all supported HVFs across the five counties in line with the Kenya Quality Model for Health (KQMH) and other national guidelines on QI.

Clinical staff: This quarter, the Project identified dire staffing gaps in HVFs that were impeding on the quality of service delivery and partnered with the CHMTs to fill in those gaps. Five health workers (one Nurse each in Mariakani, Mtwapa and Gede and two Clinical officers in Gongoni and Chasimba health

7 Shangia dispensary, Tsangatsini dispensary, Gotani Health Center, Vishakani dispensary, Chalani dispensary, Kombeni Dispensary, Makanzani Dispensary, Rabai H/Centre, Bwagamoyo Dispensary, Kambe Dispensary 8 Rekeke HC, Mata Disp, Kitobo Disp, Kimorigo Disp, Ndilidau Disp, Challa Disp, Mahandakini Disp, Njukini HC, Bura HC, Kighombo Disp, Saghaighu Disp, Mwambirwa SCH, Msau Disp, Kwamnengwa Disp, Maktau Disp, Mpizinyi HC, Mgange Nyika HC, Mgange Dawida HC, Mbale HC, Wesu SCH, Mwanda HC, Werugha HC, Wundanyi SCH, Nyache HC) 9 Faza Health Centre, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu 10 Kwale Hospital, Msambweni Hospital, Lungalunga Sub County Hospital, Kinango Hospital, Mazeras Dispensary, Samburu Health Centre, Kinondo Kwetu, Kikoneni Health Centre and Diani Health Centre

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 16

centers) in Kilifi County, and two (CPGH and Likoni) in Mombasa County were engaged to provide EMTCT services, and ensure integration of EMTCT services into MCH service areas.

EID uptake: In Q4, the Afya Pwani provided EID to 707 infants out of which 33 were positive, positivity rate of 4.7%. The table below provides more information. See Table 3 below.

Table 3 EID Uptake July-September 2017 Total Initial PCR Repeat PCR Infants < 2M Infants>2M

Tested 878 707 147 337 541 Positive 35 33 2 11 24 Percentage 4.0% 4.7% 1.4% 3.3% 4.4%

The Project has improved the capacity of health workers to collect DBS for EID hence the good uptake. The positivity rate is high in the quarter at 4.7% with Kilifi being the highest at 6.0%. The Project will conduct clinical and social care audits for all HEI who tested positive, in attempts to understand the factors that contributed to the outcomes, draw lessons for improvement in the care of other mother-baby pairs. It should be noted that 20 of the 33 HEI who tested positive in the quarter have been linked to ART, confirmatory EID samples collected and baseline VL tests done. One died, two were from Mtongwe (Afya Pwani no longer supports the facility) and 10 are still being followed up. See Table 4 below.

Table 4 DNA-PCR EID July -Sept 2017 DNA-PCR EID July -Sept 2017 County Infants tested- Positive results Positivity initial

Mombasa 324 13 4.0% Kwale 116 5 4.3%

Kilifi 215 13 6.0% Lamu 8 1 12.5% Taita Taveta 44 1 2.3% Total initial PCR 707 33 4.7%

Audits of positive HEI: To identify gaps in quality of EMTCT services and inform guide programmatic decisions, Afya Pwani conducted audits for infants who were confirmed positive as shown in the charts below. From the 13 audited below, 7 of them had their first recorded encounter to services during the post-natal period, consequently were not on ART (2 of those who had an ANC visit declined ART) and there was mixed feeding in 5 of them. The Project will work with the sub grantees to promote early uptake of ANC services and strengthen pre-and post-test counseling to reduces chance of clients being in denial. See Table 5 below.

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Table 5 Positive Infants Audi- July-September 2017 POSITIVE INFANTS AUDIT N=13 Status of Age of ANC Visit HAART for Place of Feeding Status of mother mother mother delivery options infants

Alive 13 20- 5 At 6 HAART 3 Facility 6 EBF 2 on HAART 7 24 least for 1 mother Dead 0 25- 8 No 7 Not on 9 Home 3 MF 5 LTFU 1 49 ANC HAART visits ERF 1

Lessons Learnt 1. Continuous OJT and mentorship is Key to improving knowledge and skills and consequently improving the quality of services offered and boosting staff morale. 2. Task shifting and strengthened intra-facility referral are effective ways of mitigating on the effects of the nurses’ strike. 3. Clinicians and other health cadres need to be involved in eMTCT and MNCH services to improve quality and access of eMTCT services especially in circumstances of staff shortages.

Output 1.2: HIV Care and Support Services a) Linkage to increase uptake of care and support services among PLHIV Table 6 Linkage Rates July -Sept In the 4th quarter, 1,713 PLHIV were identified and 1,533, 89% were linked to ART as shown in LINKAGE July -Sept 2017 the table. During the quarter under review, the County HTS_POS TX_NEW Unlinked % Project supported the printing and utilization of LINKAGE linkage registers in supported testing points, Mombasa 650 576 74 89% both in static and outreaches to improve linkage Kilifi 625 564 61 90% and its documentation. Weekly review of testing Kwale 265 249 16 94% and linkage performance was done, missed Taita 112 87 25 78% opportunities identified and immediate follow up Taveta started. HTS providers and peer educators were Lamu 61 57 4 93% sensitized to be linkage officers/facilitators who Afya 1,713 1,533 180 89% physically escorted newly identified clients to the Pwani ART clinics. Same day enrollment of those identified to be positive has been prioritized through strengthening of pre-and post -test counselling and linkage to a peer educator for psychosocial support immediately (data included in section 1.3). Integration of ART into MNCH, TB and inpatients department have also contributed to improved linkage of HIV positive clients. See Table 6 on the right.

Health workers and counsellors usually make follow up to ensure that patients who preferred to enroll in other facilities apart from the testing facility, have reached and linked to ART. Support for airtime is provided to follow up such clients to ensure that they reach the receiving facility. In Taita Taveta County, monthly facility data review meetings were conducted in Wesu Sub-County Hospital, Ndovu Health

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Center, Moi-Voi County Referral Hospital, Mwatate Sub-County Hospital and Taveta Sub-County Hospital where linkage gaps are discussed and solutions identified. It was realized that most of those not linked are the patients who decline, those tested in the ward and are discharged before linkage and those tested in the laboratory, to address this, the Project and the county will do refresher counselling trainings/workshops for the HTS providers in those departments. a) Provision of the standard package of care: Commented [FWM1]: Numbering from here gets confusing i.e. i) HIV treatment: HIV treatment services are covered under Output 1.3: HIV Treatment there are a’s following each other Services. ii) Positive Health, Dignity, and Prevention (PHDP)

To ensure all patients on ART receive a minimum package of PHDP, the project continued to engage peer educators by providing a monthly stipend, reporting tools and on job training/mentorship. A total of 34 (15 males, 19 females) peer educators in Kilifi County based at 15 facilities11 were supported. The minimum package for PHDP provided include disclosure of HIV status; partner/family testing and engagement; condom use; family planning, sexually transmitted infections and treatment adherence. In the quarter, the 34 (15 males, 19 females) peer educators in Kilifi county conducted 918 informal, small group sessions reaching 5,505 clients at the CCCs; (48 support group sessions conducted for newly enrolled PLHIV reaching 720 clients; 48 support group sessions conducted for already on care PLHIV reaching 1,200 clients), 3,060 one-to-one counseling/education sessions held targeting PLHIV during clinic days; 168 condom demonstrations done reaching 2,268 clients. In Kwale County, 165 PHDP sessions were held where 2,178 (480 males, 1,698 males) PLHIV were reached with messages of adherence, disclosure, condom use, drug abuse, family testing, TB and nutrition while 330 PLHIV from Taveta Sub-County Hospital, Mwatate Sub-County Hospital and Moi-Voi County Referral Hospital were reached in Taita Taveta County. To enhance adherence among couples and positive living, Kinango Hospital has a couple support group which consists of eight couples who meet monthly and are supported with refreshments during the meetings. Kinondo and Diani health facilities have discordant couples support groups which consist of five and seven couples respectively who meet monthly, where adherence, condom use and dual FP are usually emphasized. Defaulter Tracing: To ensure that all missed appointments were identified, the ART facilities booked all their clients in the appointment diary both at the TB and CCC clinic. At the end of each clinic day all clients who did not turn up at the clinic are transferred to client follow up register. Then within 24 hours those clients with phone numbers are reached directly or indirectly through their treatment buddies. The client follows up register is updated with phone call responses. Returnees within 7 days continue with care while the non-returnees within seven days in this case defaulters are scheduled for physical follow up by peer educators, mentor mothers, CHAs, PHOs and fellow support group members. The outcome from the physical tracing is used to fill the client follow up form/register and then clients re-booked in the departmental diary as per new appointment date. Weekly community dashboards are used to monitor missed appointments and defaulter tracing in every facility. In Kwale County, carefully selected 30 (17 males, 13 females) peer educators were trained and deployed to 12 HVFs12 who do follow up for missed appointments including home visits when necessary. The Project also supported 61 support groups during their monthly meetings in the following facilities; Kinango, Samburu, Mazeras, Kwale, Tiwi, Mkongani, Msambweni, Diani, Kinondo, Kikoneni, Vitsangalaweni and Lungalunga, with 152 sessions being held reaching 699 (237 males, 462 females). In Taita Taveta County, 5 support group meetings were supported

11 Rabai, Mariakani, Chasimba, Mtwapa, Vipingo, KCH, Matsangoni, Gede, Muyeye, Malindi, Marafa, Mambrui, Gongoni, Marereni, Ganze and Bamba. 12 Kinondo, Kinango, Kwale, Msambweni, Lungalunga, Tiwi, Mkongani, Samburu, Mazeras, Kikoneni, Vitsangalaweni and Diani.

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in Mwatate Sub-County Hospital, Wundanyi Sub-County Hospital, Moi-Voi County Referral Hospital, Ndovu Health Center and Taveta Sub-County Hospital reaching 60 (15 males, 45 females) clients. See Table 7 below.

Table 7 Defaulter tracing in Afya Pwani supported counties July -Sept 2017 Defaulter tracing in Afya Pwani supported counties July -Sept 2017

County Missed Traced Lost to Transferred Still Died Appointment Back Follow out followi ng Kilifi 1,912 1,653 69 77 82 31 Mombasa 1800 1556 183 104 297 28 Kwale 771 657 29 24 54 7 Taita Taveta 103 58 6 7 31 1 Total 4586 3924 287 212 464 67

a) Screening for and prevention of specific opportunistic infections.

To prevent opportunistic infections among PLHIV, all clients are on cotrimoxazole or Dapsone as per the national guidelines. The Project mentored service providers on screening for TB among PLHIV during clinical visits using the Intensive Case Finding (ICF) tool and starting those without TB on Isoniazid Preventive therapy (IPT). A cross section of file reviews in the quarter showed that 8 out 10 patients were screened for TB in their last clinical visit. Uptake of IPT is shown in the TB section. Due to the unavailability of the CrAg test to rule out cryptococcal meningitis in adult PLHIV who present with a baseline CD4 count of ≤ 100 cells/ml are referred to private laboratories for serum CrAg test. This has delayed management of such patients because some of them cannot afford this test. b) Reproductive health services

During the quarter under review, Afya Pwani also supported integration of RH services in to CCCs across the supported HVFs. Women are screened for pregnancy at every visit and those screening negative are offered dual FP services. Annual cervical cancer screening for HIV positive women of ages 18-65 years was also provided by leveraging on other implementing partners working in the counties, clients with suspicious lesions were referred for cryotherapy. c) Screening for and management of non-communicable diseases

As part of the standard package of care, PLHIV have their blood pressure measured at every visit. Screening for other non-communicable diseases (NCDs) like diabetes was also done appropriately. Renal function tests, liver function tests and lipid profiles were also requested appropriately to screen for kidney, liver disease and dyslipidemias that may be adverse effects of prolonged ART use; all of which have been supported as part of efforts to provide the standard package of care for the HIV clients being supported by the Project. d) Mental health screening and management

As part of standard care, all the clients are to be screened for mental and health and alcohol and drug use. However most of the health workers have not been trained on this package and the use of the screening tool. In light of this gap the Project will support CME to enhance the capacity of health workers to use the

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Public Health Questionnaire -9(PHQ-9) depression tool, CRAFFT part B and CAGE-AID screening tools for adolescent and adult substance abuse respectively. In Taita Taveta county, the above screening tools for mental health assessments have already been printed and distributed to 10 health facilities.13 e) Nutrition services

For PLHIV to fight off opportunistic infections through a recovered immune system and respond well to ART, they should be well nourished. Poor nutrition has led to non-adherence of treatment among many PLHIV leading to non-suppression. Since many facilities did not have anthropometric tools to support them in offering NACS, the Project procured and distributed Body Mass Index (BMI) wheels to 19 facilities14 in Kwale County. In Taita Taveta County, the nutritionists and SCASCOs were supported to conduct CME on NACS in five health facilities (Taveta Sub-County Hospital, Moi County Referral Hospital, Ndovu Health Center, Mwatate Sub-County Hospital and Bura Health Center) where 85 (42 males, 43 females) health workers were reached. Together with the CHMTs, Afya Pwani conducted supportive supervision to health workers on NACS, commodity security and storage and reached 20 (8 males, 12 females) in Mombasa, 26(10 males, 16 females) in Kilifi and 18 (7 males, 11 females). To mitigate on the effects of the nurses’ strike, the project built the capacity of other cadres (mentor mothers, peer educators, clinical officers, data clerks) of service providers to conduct nutritional assessment and refer those with malnutrition to nutritionists for proper management. The other cadres included clinical officers, CHAs, CHVs, mentor mothers and peer educators, a total of 30 health workers were reached, Mombasa 9 (2 males ,7 females). Kwale 12 (4 males, 8 females) and 9 (3 males, 6 females) in Kilifi. f) Prevention of other infections All the HIV exposed and infected children on follow at the maternal and child health clinic receive the scheduled immunizations as per the expanded program of immunizations. In the reporting quarter, the county did not have any stock out of any vaccines. I.Addressing specific needs of children living with HIV Family days: To improve access to HIV services for children living with HIV, family days (where parents had joint clinical appointments with their children) were supported monthly across the Project supported HVFs. Care givers support groups: Three caregivers support group meetings were conducted in Msambweni, Diani and Lungalunga health facilities in Kwale County with 48 caregivers were being reached. In Moi Voi County Referral Hospital, a pediatric ART clinic has been started on Mondays when the pediatrician is available to review difficult or failing patients. The Project will scale up pediatric ART clinics to other facilities based on learning from Moi Voi County Referral Hospital.

II. Addressing specific needs of young people Teen clubs/ adolescent support groups: To reach young people with HTS services and link those living with HIV (YLHIV) to treatment the project trained 19 (10 males, 9 females) facility based youth peer educators drawn from 7 facilities15 in Kilifi County. These peer educators will strengthen linkage of HIV positive clients to treatment by escorting them to the nearest CCC and providing peer psycho-social

13 Moi-Voi County Referral Hospital, Taveta Sub-County Hospital, Mwatate Sub-County Hospital, Wesu Sub-County Hospital, Wundanyi Sub- County Hospital, Mgange Nyika Health Center, Bura Health Center, Ndovu Health Center, Bughuta Health Center and Njukini Health Center. 14 (Kwale Hospital, Kinango Hospital, Msambweni Hospital, Lungalunga Hospital, Kinondo Kwetu, Kikoneni HC, Vanga Dispensary, Vitsangalaweni Disp, Mwangulu Dispensary, Ukunda Catholic Dispensary, Diani Health Centre, Tiwi Health Centre, Waa Dispensary, Ng’ombeni Dispensary, Mkongani HC, Shimba Hills HC, Mazeras Dispensary, Samburu Health Centre and Ndavaya Dispensary 15 Malindi, Kilifi, Mtwapa, Ganze, Vipingo, Tezo and Matsangoni

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support to the newly identified HIV positive adolescents or youths. To improve retention and adherence to treatment and appointments, in Mariakani Sub-County Hospital, Malindi Sub-County Hospital, Vipingo Health Center, Ganze Health Center, Mambrui Dispensary and Gede Health Center were supported to conduct psychotherapy sessions targeting members of the teen clubs. Twenty-four support group sessions were conducted for children, adolescents and youth reaching 310 beneficiaries. In the quarter, Afya Pwani established a youth center in Moi Voi County Hospital in Taita Taveta County where 33 youths regularly for HIV services and 15 regular members attend the adolescent support group sessions at Wundanyi SCH. In Sagalla youth center, 12 community opinion leaders and 13 religious leaders were sensitized on the activities of the youth center and the importance of allowing youth to be meeting at the center for HIV and requested to promote the use of the center among their congregants for HIV prevention and SRH services. In Kwale county, the project supported 7 adolescent support groups 7 facilities16; 15 sessions conducted reaching 107 (43 boys, 64 girls) with PHDP messages.

Adolescents and children living with HIV in school: Adolescents and children in school face peculiar challenges associated with stigma, discrimination and lack of support from caregivers while at school. As such, the adherence to treatment has been poor among this group. To cater for adolescents and children living with HIV in schools the project trained 30 (11 males, 19 females) teachers living with HIV affiliated to the Kenya Network of HIV Positive Teachers (KENEPOTE) on positive health dignity and prevention to address stigma, discrimination and adherence issues affecting Adolescents and Youth Living with HIV (AYLHIV) in primary schools in the seven sub-counties of Kilifi county. The 30 teachers will be supported to provide adherence support to the children and adolescents in schools with the consent of care givers. Afya Pwani also supported the youth zone at CPGH to conduct a 3 days’ holiday camp in August where 200 school going adolescents and young people17 participated in treatment literacy sessions were held for the different age groups guided by the NASCOP curriculum that emphasized on adherence to ART and appointments, sexual and reproductive health and disclosure. Twenty (6 males, 14 females) caregivers volunteered to accompany their adolescents were also taken through a separate session on age appropriate disclosure. The youth zone also delivers ART to AYLHIV who are in boarding school or at home who cannot make it to the facility with consent from the AYLHIV and the caregiver.

Output 1.3: HIV Treatment Services In FY 17, the Project had target of ensuring that 45,907 PLHIV were currently on ART, by the end of Q4, 45,943 PLHIV were on ART having received drug refills within the last 3 months, representing 100% of the Annual Program Target (APR) target. These trends are illustrated in more detail in the Figure 5 below:

16 Diani, Mazeras, Kinango, Tiwi, Msambweni, Vitsangalaweni and Lungalunga 17 Age distribution: 10-14 years 72(37 males,35 females), 15-19years 72(34 males, 38 females), 20-24 years 56(29 males, 27 females).

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Comparing Q4 TX_CUR against APR targets Afya Pwani 45943/45907=100%

20000 18206

18000 17010 14735 16000 14583 14000 12000

10000 7792 8000 7417

6000 5225

4000 3736 1297 2000 1200 0 Kilifi Kwale Lamu Mombasa Lamu

APR target Achievement

Figure 5 Comparing Q4 TX_CUR against APR targets

To achieve the above results, the Project has endeavored to have all clients seen in 50000 46441 45943 46819 Afya Pwani Treatment supported facilities receive a minimum Cascade standard package of care as described in 40000 the ART revised guidelines of December 2016. 30000 Test and Start: In the concluded quarter, 20000 863 (51%) of the 1533 PLHIV started on ART were started on the same day of 10000 1713 1533 testing, 494 (29%) from day 2 to 2 weeks 0 and 167 (10%) from 2 weeks to one TX_CUR Q3 HTS_POS TX_NEW TX_CUR Q4 TX_EXP month. Eighty nine percent of newly diagnosed PLHIV had been started on ART TX Cascade by the end of the first month. This dispels the fear that clients might be highly Figure 6 Afya Pwani Treatment Cascade resistant to starting ART immediately on diagnosis. Please see the Figure 6 (on the right) and Figure 7 below for more information on these trends.

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Test and Start July -Sept 2017

180, 10%

167, 10%

863, 51% 494, 29%

Number started on ART –same day Number started on ART within 2 weeks Number started on ART within a month Unlinked by end of 1st month

Figure 7 Test and Start July -Sept 2017

To improve on the proportion of PLHIV starting ART on the same day, Afya Pwani will, in Year 2 invest in adherence and treatment preparation counselors and also standardize the quality of pre-and post-test counseling in addition to strengthened linkage. The capacity of private providers and non-ART sites will be built through mentorship and OJT to increase number of sites providing ART thereby reducing missed opportunities for ART. a) Quality improvement for adult treatment Supportive supervision: To ensure that health care workers provided services meeting the standards set by the Ministry of Health (MOH), Afya Pwani supported joint supportive supervision in Kilifi County reaching 10 HVFs18 with 13 (6 males, 7 females) health workers being supervised. The health workers were also mentored on monitoring of quality of care indicators like proportion of PLHIV receiving nutritional categorization in each clinical visit. In Taita Taveta County, Sub-County pharmacists, SCMLTs and SCASCOs in the 4 sub-counties, were supported to conduct supportive supervision for health workers at 24 health facilities 19 with emphasis done on the treatment cascade and treatment monitoring using clinical indicators and viral load measurement. In Lamu County, 18 health care workers (13 males, 5 females) from 10 facilities20 were reached during a joint integrated CHMT supportive supervision supported by the project which emphasized on viral load and CD4 sample collection, packaging and transportation to the testing laboratory. Mentorship and on the job training was conducted by 7 (5 males and 2 females) Trainer of Trainers (TOTs) on the revised ART guidelines trained in quarter one from four HVFs in Lamu (Hindi dispensary, Witu Health Centers, Mpeketoni Sub-County Hospital and Lamu County Hospital) who reached 12(8 males, 4 females) health care workers on the 8 components of standard package of care to children, adolescents

18 Shangia dispensary, Tsangatsini dispensary, Gotani Health Center, Vishakani dispensary, Chalani dispensary, Kombeni Dispensary, Makanzani Dispensary, Rabai H/Centre, Bwagamoyo Dispensary, Kambe Dispensary. 19 Rekeke HC, Mata Disp, Kitobo Disp, Kimorigo Disp, Ndilidau Disp, Challa Disp, Mahandakini Disp, Njukini HC, Bura HC, Kighombo Disp, Saghaighu Disp, Mwambirwa SCH, Msau Disp, Kwamnengwa Disp, Maktau Disp, Mpizinyi HC, Mgange Nyika HC, Mgange Dawida HC, Mbale HC, Wesu SCH, Mwanda HC, Werugha HC, Wundanyi SCH, Nyache HC). 20 Faza Health Centre, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu.

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and adults living with HIV. In Mombasa County, Afya Pwani staff partnered with the CHMT to mentor 13 (8 males, 5 females) service providers from 10 facilities21 on initiating ART, viral Load monitoring and using data to inform clinical decisions through having weekly dashboards of treatment cascades and quality of care indicators. This mentorship on sample collection contributed to a viral load uptake of > 97% in the county. Additionally, the Project also supported health care workers to open CCCs for extended hours in Mikindani and Likoni Catholic facilities to cater for PLHIV working in Export Processing Zones (EPZ) companies who did not have a valid viral load result. Trainings/Sensitizations/CMEs: In Kwale county, 30 (14 males, 16 females) peer educators and linkage officers from 12 facilities22 were taken through a two days’ orientation on provision of PHDP to PLHIV, adherence support, strengthening intra and inter-facility referrals, TB screening, promotion of FP among PLHIV and correct condom use. Following the orientation, peer educators and linkage officers conducted health talks at facility waiting bays, community gatherings like weddings and funerals, Chiefs’ Barazas, dialogue meetings and community action days reaching 4,726 (1,789 males, 2,937 females) community members with various messages. During the two-day sensitization, the peer educators and linkage officer were also sensitized on GBV referrals and support. The topics covered included; introduction to sexual and gender based violence, dynamics of gender based violence, responding to sexual and gender based violence, prevention of SGBV, gender based violence and the law. In the same county, to improve on viral load monitoring for PLHIV, the Project conducted eight viral load sensitization meetings at Kinondo Kwetu (two), Msambweni Hospital (one), Kinango Hospital (one), Kwale Hospital (one) Diani Health Centre (two) and Tiwi Health Centre with 59 (28 males, 31 females) health care workers participating. Areas addressed in in these meetings included viral load test uptake, viral load suppression and possible reasons leading to non-suppression among PLHIV and case management for unsuppressed PLHIV. Following the sensitization, the Project supported the health workers in 20 facilities23 to line list all clients without a valid viral load result and called them back to the facility for sample collection. In Taita Taveta County, Afya Pwani conducted a CME on pharmacovigilance at Taveta SCH reaching 33 (13 males, 20 females).

JOB Aids and guidelines: Ensuring correct dosing for children and fully implementation of the revised ART guidelines, Afya Pwani printed and distributed job aids and the Revised ART guidelines (2016) to health facilities in Kilifi, Lamu and Kwale that enabled the service providers to have reference when offering care treatment services. The job aids included pediatric dosing chats which has helped in switching to appropriate dosages and regimen once a child is eligible to graduate to adult regimen or has changed in the weight band warranting change in adjustment of the dosage.

WIT meeting: In Mombasa County, Afya Pwani staff supported work improvement teams in CPGH, Kisauni, Portreitz and Tudor County Hospital to improve viral load uptake from 75% to 99% in a period of three months. In Kisauni, in their ongoing QI project, the WIT identified low suppression rate as their gap and attached case managers to all unsuppressed clients for enhanced adherence counselling and intensified follow up until the client is suppressed. In Kilifi County, seven facilities (Gongoni, Chasimba, Bamba, Rabai health Centers and Kilifi and Malindi and Mariakani Hospitals) were trained on QI through Afya Pwani support, have formed work improvement teams, they are still at initial stages of WIT activities.

21 CPGH, Tudor, Portreitz, Likoni, Utange, Kisauni, Mikindani, Kongowea, Mrima, Ganjoni, 22 Kinango, Tiwi, Kinondo, Kwale, Msambweni, Mazeras, Samburu, Diani, Kikoneni, Lungalunga, Vitsangalaweni and Mkongani 23 : Lungalunga Hospital, Kikoneni Health Centre, Vitsangalaweni Dispensary, Mwangulu Dispensary, Kinango Hospital, Samburu Health Centre, Mazeras Dispensary, McKinnon Road Dispensary, Taru Dispensary, Mnyenzeni Dispensary, Kwale Hospital, Tiwi Health Centre, Mkongani Health Centre, Shimba Hills Health Centre, Ng'ombeni Dispensary, Waa Dispensary, Msambweni Hospital, Diani Health Centre, Ukunda Catholic Dispensary and Gombato Dispensary

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In the next quarter, Afya Pwani will strengthen existing WITs and scale up to cover 46 facilities contributing to 80% of the Projects’ PLHIV currently on treatment. Adherence counselor Support: In Mombasa, the Afya Pwani project recruited and deployed an adherence counselor to CPGH, who provides enhanced adherence counselling for patients at increased risk of, suspected or confirmed treatment failure. The counsellor focused on discussing viral load results with clients; assess possible barriers to adherence; behavioral, socio-economical barriers or structural and then together with the client develop a joint adherence plan with SMART targets.

Differentiated care: Table 8 Afya Pwani Differentiated service delivery Afya Pwani is currently in its phase one of implementing differentiated care service Afya Pwani Differentiated service delivery delivery to improve on the Facility Number Number of Number Number Number quality of care to clients and Name of files reviewed of PLHIV of PLHIV of clients reduce the burden on the facilities for stable unstable started health care system. categorization on DSD. Sensitization and CMEs have Lamu 2 120 72 48 57 been conducted in the 14 Kilifi 4 543 183 360 183 phase one facilities24 and Kwale 1 655 453 102 75 categorization of patients Taita 5 1091 809 282 65 began as shown in the table. Taveta In the coming quarter, the Mombasa 3 302 256 46 0 project will build on the Afya 14 2711 1773 838 380 efforts of this quarter to Pwani enroll more clients on DSD. All facilities are implementing the facility based fast-track model except Mwatate which is implementing a community ART group model. See the table above for more information on the Project’s achievements in terms of supporting differentiated service delivery this quarter. See Table 8 above.

Treatment monitoring: In FY 17, the Project did 44,509 viral load tests representing 95% of PLHIV reported in the Project as at end of March 2017. To achieve this uptake, the Project line listed all patients in supported facilities and reviewed their files for valid viral load result. All who did not have were called to the facility for sample collection even if their clinic day was not due. Service providers in 20 CCCs25were mentored on sample collection so that they did not have to refer clients to the laboratory. The process maps were also redesigned to ensure that clients had their lab work ups done first before drug refills, this ensure sustainability of the high uptake of VL in supported facilities as shown in the graph on viral load uptake below. In facilities that did not have a skilled health worker on site, due to the nurses and clinical officers strike, the Project supported roving lab technologists to conduct viral load outreaches to such facilities. Afya Pwani also created demand for viral load among PLHIV through health talks using peer educators, mentor mothers and in support group sessions. In Moi Voi County Referral Hospital and Kinondo Kwetu

24 CPGH, Ganjoni, Portreitz, Kisauni, Kilifi, Mariakani, Mtwapa, Vipingo, Mpeketoni and Lamu CRH, Kinondo, Kinango, Diani, Taveta, Mwatate and Moi Voi. 25 In both high and low volume facilities- Kinondo Kwetu, Msambweni Hospital, Kinango Hospital, Kwale Hospital, Diani Health Centre, Tiwi Health Centre, CPGH, Tudor, Portreitz, Likoni, Utange, Kisauni, Mikindani, Kongowea, Mrima, Dzikunze, Kachororoni, Dida, Madamani and Muryachakwe

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Health Center, with clients’ consents, the Frontline SMS platform was also utilized to send treatment literacy to PLHIV and reminded them on viral load tests.

For more information on Afya Pwani’s viral load uptake and suppression rates please see the table and the Figure 9 below:

Table 9 Afya Pwani Viral Load Uptake and Suppression Rates County TX_CUR SAPR Tests % VL uptake Suppressed % Suppression

Mombasa 18,638 18656 100% 15847 85% Kilifi 14,698 13843 94% 11389 82% Kwale 8,002 6268 78% 5053 81% Taita Taveta 4,202 4476 107% 3577 80% Lamu 1,220 1266 104% 973 77% Afya Pwani 46,760 44509 95% 36839 83% Source: https://viralload.nascop.org/partner/counties as at (19/10/2017)

Afya Pwani Improved VL uptake Oct 2016-Sept 2017 7000 5780 5774 6000 shift 5024 5000 4601 4027 4000 2930 3000 2564 2714 2533 1763 2000 1512 795 1000 0 0

VL tests done

Figure 8 Afya Pwani Improved VL uptake Oct 2016-Sept 2017

As Figure 8 above shows, the suppression rate in FY17 was 83%, (Mombasa 85%, Kilifi 82%, Kwale 81%, Taita Taveta 80% and Lamu 77%). To improve the suppression rates across all the counties, the Project is

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 27

employing a quality of care based approach to clinical and psychosocial services with minimum service packages to be provided to all PLHIVs. The Project will also differentiate care according to the characteristics of each patient, with high patients considered to have an increased risk for non- adherence given more targeted support. Cohort based support groups will be formed for newly identified PLHIV and offered intensified PHDP, and monitored as a cohort.

The Project has also continued to provide technical assistance to facilities on the case management for unsuppressed clients. Enhanced adherence counseling and a case manager approach has been employed. Afya Pwani has continued to support MDT meetings in four counties; Mombasa 4 facilities26, Kwale 1227, Kilifi28 and MDT meeting in Mombasa, August 2017 Taita Taveta 5 facilities29. In year two, the project will partner with the Lamu CHMT to establish a County level MDT where all the unsuppressed clients in the county will be discussed for improved care since the number of unsuppressed PLHIV is small.

I. Treatment for children While most of the interventions discussed under the adult section were also integrated with those for children; in Mombasa county, specialized mentorship was done in CPGH, Port Reitz, Mrima, Ganjoni and Likoni to nine (three males, six females) health workers on pediatric treatment with focus on pediatric drug dosing and the use of Lopinavir/Ritonavir pellets instead of the syrup. In Kwale County to ensure there is correct dosing for children, Afya Pwani printed and distributed Job Aids to the health facilities that enabled the service providers to have reference for the dosing according to weight and age of the children. This has helped in switching to age appropriate dosages and regimen. The viral load suppression for this quarter among children 2-9 years and 10-14 years is 65% and 66.5% respectively, far below the 90% targets. In Year two, the Project will conduct care givers training to reach 46 HVFs. To improve the quality of services for children, the project will build the capacity of health workers through mentorship and OJT. Roving specialists including pediatricians and psychologists will be engaged to provide specialized care to children and adolescents not adhering to treatment, with adverse drug reaction and not virally suppressed.

II. Treatment for young people At the CPGH, the Project has supported provision of ART services in the youth zone away from the main CCC, this has provided a conducive environment for adolescents and youths there. At Mariakani Sub- County Hospital in Kilifi the Project has supported a teen club for adolescents and youths which has 70 members and a special day has been set aside where adolescents are seen at the clinic. The teen club has resulted in improved adherence and retention with suppression rates of 67% for the 15-19 and 89% for the 20-24 years. CPGH youth zone is discussed under care and support services.

26 Tudor, Portreitz, CPGH, Kisauni 27 Msambweni Hospital, Lungalunga S/C Hospital, Kikoneni Health Centre, Mkongani Health Centre, Tiwi Health Centre, Mazeras Dispensary, Kinondo Community Clinic, Kinango Hospital, Kwale Hospital, Diani Health Centre, Vitsangalaweni Dispensary and Samburu Health Centre 28 namely Kilifi, Mariakani, Mtwapa, Oasis, Gongoni, Rabai, Ganze, Gede, Matsangoni, Chasimba, Marereni Muyeye, Vipingo, Marafa and Bamba 29 Taveta SCH, Mwatate SCH, Moi CRH, Wesu SCH and Wundanyi SCH

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III. Treatment for Key populations (KPs) In Kwale During the reporting period July- September 2017, through collaboration with the Linkages project at Ukunda ICRH drop in Centre, three clients tested positive and were started on HAART at the facility. There were a total of seven KP clients who are on HAART; Diani Health Centre (five), Kwale Hospital (one), Kinondo Kwetu (one). Six out of the seven are virally suppressed, only one at Kinondo Kwetu has not yet achieved viral load suppression. The client has already been called and is under enhanced adherence and counseling support.

b) Strengthened Laboratory Networking Services An efficient laboratory system is among the pillars of a successful HIV program. Afya Pwani has significantly improved the efficiency and effectiveness of its laboratory system in the Coast region over the past six months through several interventions such as:

Joint supportive supervision sessions were conducted in Mombasa, Kwale and Kilifi Counties reaching 29 (21 males, 8 females) health workers in 4 facilities in Kwale (Msambweni Hospital, Gombato Dispensary, Mwachinga Dispensary and Mbuwani Dispensary), 17 facilities in Mombasa30and 3 (Chasimba Health Center, Mtwapa Health Center and Mariakani Hospital) in Kilifi County. The supervision addressed issues of biosafety in the Laboratory and infection control, quality assurance (QA) and quality control, proper documentation and release of results. Sub County Coordinators meetings: Afya Pwani also conducted quarterly Sub-County Laboratory coordinators meeting for Lamu County to address stock outs of RTKs by empowering the Sub-County Coordinators (16 males, 7 females) in doing proper forecasting and quantification, improve efficiency of sample referral networks for both viral load and sputum for GeneXpert, reducing sample rejection rates, proficiency testing and corrective measures for failed testers. Six (four males, two females) health workers in three facilities (Lamu County Referral Hospital, Mokowe Health Center and Shella Dispensary) in Lamu County were mentored on RTK forecasting and quantification, increasing viral load uptake, specimen collection, packaging and transportation, reducing Turn Around Time (TAT) to less than three days from sample collection to dispatch to CPGH. To improve on the quality of lab services, the Project distributed lab Standard Operating Procedures (SOPs) and mentored 34 (23 males, 11 females) health care workers on their use in 28 facilities31. OJT on specimen collection: During the reporting period, SCMLTs were supported to conduct OJT and mentorship to 44 (19 males, 23 females) service providers from 15 facilities32 in Kwale County on harvesting, packaging, labeling and transportation of plasma viral load samples. In Taita Taveta County, 15 (5 males, 10 females) health workers who included laboratory technicians, clinical officers and Lay counsellors from Moi County Referral Hospital, Ndovu Health Center, Mwatate Sub-County Hospital and Taveta Sub-County Hospital were trained on the sample collection using OJT. In the quarter, only 3 EID

30 CPGH, Kisauni, Mlaleo CDF HC, Bamburi Dispensary, Kisauni Dispensary, Kongowea Dispensary, Maweni CDF Dispensary, Junda CDF Dispensary, Marimani CDF Dispensary, Utange Dispensary, Mvita dispensary, Tudor Sub county hospital, Port Reitz hospital, Chaani dispensary, Magongo dispensary, Bokole dispensary and Likoni HC. 31 Mtwapa HC, Mariakani hospital, Mlaleo CDF HC, Bamburi Dispensary, Kisauni Dispensary, Kongowea Dispensary, Maweni CDF Dispensary, Junda CDF Dispensary, Marimani CDF Dispensary, Utange Dispensary, Mvita dispensary, Majengo clinic, Ganjoni dispensary, Railways dispensary, Tudor Sub county hospital, Port Reitz hospital, Chaani dispensary, Magongo dispensary, Bokole dispensary, Miritini dispensary, Jomvu dispensary, Mikindani dispensary, Likoni dispensary, Mrima dispensary, Shika Adabu dispensary, Mbuta dispensary, Mtongwe dispensary 32 Msambweni County Referral Hospital, Diani Health Centre, Ukunda Catholic Dispensary, Kwale Sub County Hospital, Tiwi Health Centre, Mkongani Health Centre, ShimbaHills Health Centre, Kinondo Kwetu Clinic, Kinango Hospital, Ndavaya Dispensary, Vigurungani Dispensary, Mazeras Dispensary, Samburu Health Centre, Taru Dispensary and Mnyenzeni Dispensary.

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and 10 viral load samples from the 5 counties were rejected at the lab, a testament to the good quality of samples collected by health workers because of the mentorship and OJT that has been done along the year. Corrective measures have been done to the facilities that originated the rejected samples. CMEs on biosafety and good Laboratory practices were conducted in Taveta Sub-County Hospital where 20 (12 males, 8 females) health workers were reached.

Lab networking: Afya Pwani has continued to strengthen laboratory networking in all the five supported counties thereby reducing the average turnaround time for both viral load and EID tests to less than 10 days from sample collection to receipt of results through deployment of 3 motor riders who collect samples from facilities and deliver results daily in Kwale, Kilifi and Mombasa Counties. Printing of viral load and EID results has also been decentralized to Afya Pwani regional offices there by improving efficiency. The use of mobile technology (SMS to 20027) has also been rolled out across the five counties with clinical officers, lab technologists, nurses, peer educators and adherence counselors among the cadres that are using it so far. CPGH Molecular lab: Afya Pwani has also continued to provide HRH, technical, commodities and logistical support to the Coast region molecular laboratory at the Coast Province General Hospital. Through streamlining work flows and removing bottlenecks, the lab has reduced the turnaround time from receipt to dispatch of results from more than 30 days in March 2017 to less than 5 days in September 2017. See Table 10 and 11 below.

Table 10 EID tests conducted at the Afya Pwani supported CPGH Molecular Lab Month Total Rejected Tested samples Valid Positive Valid Failed samples samples (including positive/ negative samples/ received repeats) negative Results Results results July 569 3 527 496 23 473 0 August 418 0 438 420 11 409 0 Septem 577 0 614 583 18 565 0 ber Total 1564 3 1579 1499 52 1447 0

Table 11 Viral Load tests conducted at the Afya Pwani supported CPGH Molecular Lab Month Received Rejected Not Virally Total Tests Done (including Samples Samples suppressed Suppressed repeats) JULY 7518 8 993[14%] 6080[86%] 7639 AUGUST 5137 0 717[17.2%] 3462[82.8%] 4484 SEPTEMBER 7997 2 1471[18.9%] 6302[81.1%] 8472 Total 20652 10 1857 15844 20595

Lessons Learnt. 1. Working in shifts and extended hours to create room for all samples brought processed. 2. Consumables proposed to be dispatched to counties immediately on receipt to Coast General Lab. 3. Increasing the pool of health workers who can collect viral load and EID samples was an effective strategy to improve viral load uptake.

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Output 1.4 HIV Prevention and HIV Testing and Counseling a) Reaching Priority Populations

In the FY 17, the Project tested 385,533 adults and 30, 451 children against targets of 391,299 and 18,511 respectively. Compared to the annual targets, this is 99% and 165% achievements for adults and children.

Demand creation: In Kilifi County, the Project conducted 250 health talks sessions reaching 9,500 people both at the facility and community level utilizing community health assistants, HTS providers, CHVs and peer educators with emphasis on Test and Treat. Other topics covered included FP, Sexually Transmitted Infections (STIs), nutrition and cancer screening. In Kwale County, Afya Pwani collaborated with six community units (Shirazi, Milalani B, Kingwede, Vingunjini A, Vingunjini B and Vingunjini C) in Msambweni Sub-County to the build capacity of 60 (26 males, 34 females) CHVs to create demand for HTS and the TEST and START approach. Access: Afya Pwani continued to support 36 HTS counselors, (Mombasa-12, Kilifi-12, Taita Taveta-4 and 2 in Kwale) in high yielding facilities and outreaches in areas that had been identified to have high yields through GIS mapping.

Availability of RTKs: To ensure availability of RTKs, Afya Pwani supported SCMLTs, Lab Managers and QA Officers to have a RTK Allocation meeting at the Kwale Resource Centre to discuss on matters related to ordering, storage, reporting and redistribution of RTKs within the County, 21 (14 males, 7 females) health service providers participated in the meeting. The Project also provided TA, airtime to SCMLTs in all the counties to support management, reporting and ordering of HTS commodities. In Taita Taveta county, sub-county pharmacists, SCMLTs and SCASCOs in the 4 sub-counties, were supported to conduct supportive supervision for health workers in 24 health facilities33 to address among other issues, correct reporting and ordering of RTKs.

Reaching men and couples The Project also supported workplace testing in Kilifi county, in Gongoni Salt firms, Pwani Oil, Mzuri Sweets, EPZ Kikambala and Umoja Rubber, testing 1,856 people (840 males, 1,016 females) with 13 people identified to be positive and linked to treatment services. In the same county, the Project supported outreaches informal settlements and hard to reach areas testing 8513 (3,729 males, 4,784 females) people, 18 testing positives (5 males, 13 females) and all linked to treatment. An outreach targeting 164 motor vehicle mechanics working in garages around Mvita health center was conducted with zero being positive. In Kwale County, during the Commemoration of the World Contraception Day, 20 Counsellors and 10 Mobilizers were supported with lunches and transport to offer HTS Services to men and women at Samburu Health Center and Kinango Hospital reaching 285 men, 3 tested positive and were linked to start HAART. Home testing was done for 45 (22 males, 25 females) sexual partners of index clients with only 1 (f) being found to be positive. In all the testing activities, above, the yield in outreaches is very low. The Project will minimize on this strategy and emphasize on eligibility screening of clients in testing approaches adopted for Year 2. Reaching infants and children In collaboration with Nilinde, the Project support HTS testing for OVC in Chasimba and Bamba LIPs reaching 199 OVC (87 males, 112 females) and none was positive. In Kwale County, the Project supported

33 Rekeke HC, Mata Disp, Kitobo Disp, Kimorigo Disp, Ndilidau Disp, Challa Disp, Mahandakini Disp, Njukini HC, Bura HC, Kighombo Disp, Saghaighu Disp, Mwambirwa SCH, Msau Disp, Kwamnengwa Disp, Maktau Disp, Mpizinyi HC, Mgange Nyika HC, Mgange Dawida HC, Mbale HC, Wesu SCH, Mwanda HC, Werugha HC, Wundanyi SCH, Nyache HC

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20 (12 males,8 females) HTS providers to offer HTS in Golini, Tiwi, Mwamkompya and Gonja LIPs of Matuga and Lungalunga sub Counties reaching 689 OVC with none being positive. The project has continued to support the integration of HTS into MNCH, CWC, post-natal clinic, pediatric wards and OPD service areas to reach children and their mothers through placing of HTS counselors in those service areas. In Taita Taveta County, 50 (20 males, 30 females) health workers from Moi County Referral Hospital, Mwatate Sub-County Hospital and Taveta Sub-County Hospital were taken through a half-day CME and mentorship on pediatric HIV testing and linkage.

Reaching young people The Project supported HIV testing in 2434 tertiary institutions of learning in Kilifi County reaching 4560 students (2,071 males, 2,489 females), 3 (1 males, 2 females) were identified to be living with HIV and were linked to treatment. In Taita Taveta County,1 university and 4 colleges (JKUAT university, KMTC, CIT college, Bura TTC and Mwanjila Youth Polytechnic) were targeted for HTS, reaching 449 (336F, 113 M) young people, with none testing HIV positive. In Mombasa County, outreaches targeted three institutions (Technical University of Mombasa, Methodist University and Kenya Institute of Management who were reached with messages on HIV prevention and treatment and offered HIV counseling, testing and linkage services, 1047 (511 males, 536 females) young people were counseled and tested for HIV, 13% of female (70 of 536) and 5.5% of male (28 of 511) were found to be HIV positive and were linked to care services. In Kwale County, through Collaborating with K-YES project, Afya Pwani identified mobilizers in 12 facilities that will be referring their peers to access Counselling and Testing Services from the facilities plus other Health related services of RH/ Prevention of early Pregnancy education, STI screening & Treatment and different Contraception methods.

In Year 2, Afya Pwani project will enhance targeted outreaches with eligibility screening in select learning institutions with high yields and intensify facility based testing of young people especially pregnant women attending ANC to ensure 100% testing. The Project utilized peers to reach other youth and adolescents in Mwatate, Kalahari, Mworoto, Bangladesh, Dunga-Unuse informal settlements of Changamwe sub county, 210 youth were counseled and tested for HIV (97 males and 113 females), where 2 youth tested positive and were linked to ART.

i.Reaching Key populations In collaboration with Linkages, Afya Pwani project provided TA to Teens Watch Centre and Ukunda ICRH DICE Ukunda on HTS, HAART and Pre-exposure Prophylaxis (PrEP) services. By September 2017 the centers had enrolled 230 Clients on PrEP with all of them offered HTS. In Mombasa, support was given to Ganjoni and Kisauni drop in centers on HTS, ART provision and TB/HIV integration services. b) Improving the quality of HIV Testing Services The Project has utilized several strategies to ensure quality of HIV testing services including participation in proficiency testing, counsellor supervision, on job mentorship, observed practice, job aids provision and strict adherence to the latest HTS guidelines.

Proficiency testing (PT): Afya Pwani has supported SCMLTs in the 5 counties to carry out corrective OJT for 56 (16 males, 40 females) HTS providers in Mombasa, 1 in Kilifi, 56 (21 males, 35 females) in Taita

34 Chasimba Youth polytechnic ,North coast MTC, Wesseman Language College, Dimples beauty college, Imarra TTC , Pwani University, KMTC Kilifi, CPK Ufanisi University , Kilifi Sadia College, Mkwajuni Polytechnic, Kilifi College of accountancy, Pwani Training institute ,Guru institute of technology, Thiyani Tailoring college ,Gede Youth Polytechnic ,Mariakani Technical Training, Institute, Telea TTC , Muyeye polytechnic , Nusra TTC, Jilore polytechnic, Kakuyuni polytechnic, Vitengeni Polytechnic , Jaribuni Polytechnic and Glory Tailoring School.

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Taveta and Lamu 33 (10 males, 23 females) who failed round 16 proficiency. Among the reasons for unsatisfactory PT results included failure to follow correct steps indicated in the PT job aids during reconstitution of the panel, cross contamination during reconstitution, incorrect incubation temperature and procedure, failure to incubate the sample overnight, failure to fill in the results correctly among other reasons. The corrective OJT participants are taken through sample reconstitution and filling in the results using the PT job aids. The Project has enrolled service providers into round 17 of PT testing as follows: 156(60 males, 96 females) Mombasa, 161(82 males, 79 females) Kilifi, 12 (7 males, 5 females) Kwale, 51(24 males, 27 females) Taita Taveta and 10 (7 males, 3 females) in Lamu Counties. Counselor supervision: The Project collaborated with the CHMTs to conduct counselor supervision in four counties as shown in the table below. The sessions aimed at helping counselors overcome the physical, mental and emotional exhaustion arising from repeatedly listening to client emotional issues and building the capacity of the providers to deal with transference. The sessions were utilized for giving updates in practice and correcting any gaps that had been identified during supportive supervision. See Table 12 below.

Table 12 Counselor Supervision Counselor Supervision Number of group Number of HTS sessions counselors supervised Male Female Total Mombasa 14 24 64 88 Kilifi 13 26 43 66 Taita 18 26 43 50 Taveta

Support supervision: In Q4, Afya Pwani provided support supervision and mentorship on the HTS algorithm and the 5C’s (Informed consent, counseling, confidentiality, correct results and connection) principles, HTS optimization, linkage and documentation in 935 health facilities in Mombasa reaching 42 (8 males, 34 females),19 facilities36 in Kilifi reaching 38 (15 males, 23 females) ,6 facilities in Taita Taveta 37 reaching 14 (6 males, 8 females) and two38 in Kwale County. In Taita Taveta 65 (21 males, 44 females) health workers benefitted. Job Aides on the HTS Algorithm were printed and distributed to 8 facilities39 in Kwale, 3 in Kilifi (Chasimba, Mariakani and Mtwapa) and 14 in Taita Taveta40 during the reporting period. These job aides were particularly helpful in providing step by step guidance on the HTS protocol to newly employed service providers. CMEs, On the Job training and observed practice: HTS supervisors sat in during HTS sessions to observe pretest counseling, HIV test preparation and testing, interpretation of results and post counseling for a negative or positive results and identified gaps during the process which they supported the HTS providers

35 Coast provincial general hospital (CPGH), Tudor sub county hospital (TSCH), Likoni sub county hospital (LSCH), Portreitz sub county hospital, Mrima health center, Kongowea health center, Jomvu health center, Kisauni HC, and Magongo health center. 36 Chasimba health center, Mtwapa health center, Mariakani sub county hospital, and Gede health center, Shangia dispensary, Tsangatsini dispensary, Ndatani dispensary, Gotani Health Center, Vishakani dispensary, Chalani dispensary, Kombeni Dispensary, Makanzani Dispensary, Rabai H/Centre, Bwagamoyo Dispensary, Kambe Dispensary 37 Moi CRH, Mwatate SCH, Taveta SCH, Wesu SCH, Wundanyi SCH and Ndovu HC 38 Kinondo Kwetu and Kinango 39 Diani H/C, Kinondo Kwetu, Bofu Dispensary, Kafuduni Dispensary, Msambweni County Referral Hospital, Mrima Catholic Dispensary, Vyongwani Dispensary & Mwangulu Dispensary 40Taveta SCH, Njukini HC, Ndongo Purple clinic, Mwatate SCH, Mwambirwa SCH, Bura HC, Horesha Clinic, Joy clinic, Wesu SCH, Wundanyi SCH, Nyache HC, Dawida Clinic, Moi CRH and Bughuta HC

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to improve on. Thirty-eight (15 males, 23 females) HTS providers from 10 facilities41 in Kilifi and Mombasa Counties benefitted. Afya Pwani also supported a one day CME to 45 Clinical officers (19 males, 26 females) in Kwale County and 67 (30 males, 37 females) on PITC and the HTS protocols to improve their skills and knowledge on HTS and provide HTS services in their consultation rooms. In Lamu County, the CHMT was supported to provide OJT to 12 health care workers (8 males, 4 females) from Hindi dispensary, Witu health Centers, Mpeketoni Sub-County Hospital on the HTS algorithm. Staffing: To ensure access and quality of HTS services, the Project continued to support 32 HTS Mombasa (13 females), Kilifi 20 (6 males,14 females) and Kwale 2 (1 male, 1 female) counselors placed in high yielding service delivery points in 29 HVFs42 to provide targeted testing and linkage for those who test positive. Lessons learnt 1. Physical escort of HIV positive individuals to the CCC for direct linkage to care and enrollment of HIV positive patients before discharge has proved to be a good practice which ensures that no missed opportunities in enrolling them to CCC. 2. The project needs to strengthen partnerships with private facilities to improve linkage of newly identified PLHIV to ART since most private facilities are non-ART sites.

Output 1.5: Tuberculosis/HIV Co-infection Services a) The 5I’s: ICF: TB is the main cause of illness and death for people living with HIV; about one quarter of deaths of people with AIDS are linked to TB. Intensified efforts to diagnose multidrug-resistant TB, to enroll the patients in treatment and to improve treatment outcomes are urgently needed. In addition, TB is linked to chronic diseases such as diabetes and factors that lead to ill health, such as tobacco and drug use, alcoholism and malnutrition. These are often associated with poverty, crowded living conditions and poor access to basic hygiene. Pregnant women and young children are very vulnerable to TB. On this note, 60 (26 males, 34 females) CHVs from the following community units; Shirazi, Mililani B, Kingwede, Vingujini A, Vingujini B and Vingujini C in Msambweni area which has a high TB burden in the county, were taken through a 2 days’ sensitization on how to provide Directly Observed Treatment (DOTs) for treatment adherence. The CHVs will be identifying TB cases symptoms in the community during their household visits and then referring the cases to the facilities for early diagnosis and treatment. A total of 6,000 households will be reached with the message as each CHV is in responsible of 100 households. While adopting best practices to maximize on Afya Pwani Support, facility based active case finding has been observed to be giving higher yields with the involvement of CHVs as mobilizers/cough detectors who were sensitized in the Community Units (CUs) in Kwale.

In Kilifi County, during the reporting period, Afya Pwani supported TB Intensive case finding at Rea Vipingo and Kiwandani in Kilifi South. The Project supported mobilization, health Care workers to do the screening and the lab staff who harvested the samples and analyzed them in their testing labs. At Rea Vipingo, a total of 400 community members were screened for TB using a simple screening questionnaire, 101 suspected cases were tested using Gene Xpert analysis and none was positive although three clients were started on TB treatment due to radiographic features suggestive of TB. Given the high numbers of false

41 Kilifi (Mariakani SCH, Mariakani community and Mabati clinic, St Lukes clinic, Dagamra and Rabai HC, Chasimba HC, Mtwapa HC) and Mombasa (CPGH and Kisauni H/C). 42 CPGH, Kilifi CH, Likoni SCH, Mariakani SCH, Port Reitz SCH, Malindi SCH, Tudor SCH, Mtwapa HC, Magongo HC, Marafa HC, Kisauni HC, Rabai HC, Miritini HC, Bamba SCH, Chaani HC, Muyeye HC, Jomvu HC, Ganze dispensary, Kongowea HC, Chasimba HC, Mlaleo HC and Gongoni HC.

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positive from the screening tool, the project will collaborate with the County TB/Leprosy Coordinator and revise the tool as well as improve on the training for community health volunteers on TB screening. In Kiwandani in Kilifi South, CHVs mobilized for tracing of contacts of TB patients, 106 samples were taken for GeneXpert and 3 tested positive and the patients started on TB treatment.

In Mombasa County, the Afya Pwani team continued to focus on increasing access to and utilization of TB/HIV health services during the quarter. The Project provided mentorship to 6 Facilities43 reaching 12 (7 males, 5 females) service providers on TB screening at CCC using the ICF cards for both adult and pediatrics, in addition to the use of the TB presumptive register. In Lamu County, during the reporting period, mentorship was done on ICF for TB by sensitizing the Clinical and non-Clinical staff on triaging for clients who are coughing. The practicing of open doors and windows policy as a way of preventing TB infection in facilities was emphasized.

IPT coverage: As shown in the table below, the cumulative uptake for IPT among eligible clients is above 80% in Mombasa, Kwale, Kilifi, Taita Taveta and 63% in Lamu County. The Project will support the CHMT in Lamu to hold a one day CME on IPT uptake and conduct a joint supervision to address any gaps on IPT that will be identified. Additionally, Afya Pwani will strengthen the commodity management system through distribution of IPT and other commodities to the Indian Ocean Islands of Faza and to facilities like Witu when security situation improves. Continuous OJT and mentorship to health care workers on the use of the IPT register, IPT for PLHIV who do not have TB and IPT for the under 5’s was supported by the project during the reporting period July-September 2017 in Kwale and Mombasa Counties. Mentorship was done at Tiwi Health Centre, Shimba Hills Health Centre, Mkongani Health Centre, Matuga Dispensary and Vyongwani Dispensary reaching 52 HCW (24 males, 28 females) health care workers.

During the reporting period, a meeting was supported for Table 13 IPT uptake in 5 supported counties the four SCLTCs, four Kilifi Mombasa Lamu Kwale T/Taveta Total SCASCOs and four SCHRIOs In Taita Taveta to discuss on the low uptake of IPT for PLHIV who do not have TB. It was Number currently on 14,698 18,638 1,220 8,002 4,202 46760 realized that most of the HIV care (SAPR) facilities report using the Number of TB Cases 1271 2485 238 623 407 5024 interim tool, as there is no Eligible for IPT 14424 16013 945 7350 3786 42518 official reporting tool, but the Number ever given IPT 11394 12331 550 5880 2846 33001 SCHRIOs don’t do the data as at June 2017 entries for all facilities in the Number given IPT in 211 1428 42 56 530 2267 DHIS. It was agreed that Q4 facilities will still be Cumulative given 11605 13759 592 5936 3376 35268 encouraged to continue IPT reporting and the SCHRIOs committed that they will do % cumulative 80% 86% 63% 81% 89% 83% the data entry as soon as they uptake of IPT receive the reports. The Project will support a review

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 35

of all the clients’ files, identify those eligible for IPT and called them for initiation within the next two months. See Table 13 above.

Infection prevention and control (IPC): Through TA and CME support to facilities, IPC committees have been established and IPC plans developed in the following facilities: Kinondo Kwetu, Lungalunga Hospital, Kinango Hospital, Kwale Hospital, Tiwi Health Centre and Samburu Health Centre. This is to make sure that cross infections are minimized at health care settings for both the patient and the service provider. In Mtwapa Health Center, TB patients have a separate day from HIV clients to avoid cross-infection. Health workers have been advised to ensure free flow of air in TB clinics, waiting bays and coughing clients triaged. Since many facilities do not have IPC plans, in year two, the project will support sites to develop IPC plans and implement them. Integration of HIV/TB services: Integration of Table 14 Integrated TB/HIV Co-infection Rates July to Sep 2017 services is a hallmark of a quality service delivery Integrated TB/HIV Co-infection Rates July to Sep 2017 mechanism to promote a holistic approach to Kilifi Kwale Lamu Mombasa Taita Taveta Total addressing clients’ needs. Number of TB case 1041 378 71 571 77 2,138 identified Afya Pwani has continued to offer mentorship on integrated HIV/TB service Number tested for HIV 1026 356 71 564 75 2,092 provision at Ukunda Catholic Dispensary, Mkongani Health Centre, Shimba Hills Health Uptake of HTS among TB 99% 94% 100% 99% 97% 98% Centre, Tiwi Health Centre, patients Kwale Hospital, Waa Dispensary, Kombani Number HIV positive 261 70 14 172 10 527 Dispensary, Matuga Dispensary, CPGH, Tudor, Kisauni, Mrima, Kongowea, Positivity 25% 20% 20% 30% 13% 25% Mlaleo and Wundanyi Number started on ART 254 62 14 170 8 508 Hospital, on HIV- TB integration, with an emphasis on 100% testing of TB clients reaching 90 health care % HAART uptake 97% 89% 100% 99% 80% 96% providers (51 males, 39 females). TB/HIV Collaborative meetings with 24 (6 males, 18 females) participants was supported in Kwale County with the agenda including, HTS for TB clients, IPT initiation for PLHIV and reporting mechanisms since there was a problem with the data collection tool. An agreement was reached to use the interim tool up to the time the Ministry will roll out a reporting tool for the IPT. HTS for all TB patients was seen to be doing well. See Table 14 above.

During the quarter under review, the Project has also endeavored to ensure that health workers are screening all the HIV positive clients on follow up during the care and treatment visits. This has been through the distribution of screening tools and mentorship and OJT on the use of the tools. In Kilifi County, seven sub-county TB and Leprosy coordinators (5 males, 2 females) were supported to distribute and

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mentor health workers on the GeneXpert algorithm and use of the presumptive TB registers. Currently, Kilifi, Malindi and Mariakani Hospitals, Mtwapa, Oasis, Vipingo, Chasimba, Rabai, Gongoni, Marafa, Marereni, Gede, Bamba, Ganze are using the registers to track suspected cases of TB. Thirty-five presumptive registers were printed and distributed to facilities during the reporting period July- September 2017. Because of these efforts, 91% (1,921 of 2,114) TB patients were tested for HIV and 91% of them linked to ART as shown in the table above.

Immediate ART initiation for HIV/TB co-infected persons: As a standard package in the management of TB/HIV Coinfected Clients, all clients whether TB Co infected or not are to be initiated on HAART after diagnosis. This is in implementing the ANZA SASA Campaign of achieving the 90:90:90 strategies. In Kilifi County, 1,026 TB patients were tested out of all the 14,01 clients registered in the quarter giving a 99% HTS uptake (9 declined), identifying 261 HIV-TB coinfected clients. Out of the 261 clients, 254 were started on ART giving a 97% ART uptake with 4 being delayed due to fear of IRIS. They were all given cotrimoxazole prophylaxis appropriately.

Support to MDR Tuberculosis There are 65 MDR patients under the Table 15 Patients on treatment for MDR TB July-Sept 2017 support of the project as shown in the table below. The project has employed multiple strategies to improve clinical care for MDR COUNTY DR Clients Treatment patients that include clinical review Status meetings, CMEs and Lab networking. KILIFI 17 On Treatment

Clinical review meetings: The project MOMBASA 30 On treatment supported 5 clinical review meetings for KWALE 6 On Treatment MDR TB patients in Marikebuni Dispensary, Chamari Dispensary, CPGH, Samburu TAITATAVETA 12 On Treatment Health Centre and Nyango Dispensary during the quarter with 17 (9m, 11f) having LAMU 0 their capacity to manage MDR patients TOTAL 65 enhanced. These review meetings are useful for the continuous review of how the patients are responding to treatment, observe any possible drug side effects like conducting Audiometry and the need to have family/ contact screening for early detection of cases. See Table 15 above.

CME: Afya Pwani supported CME on Pediatric TB including MDR in Moi County Referral Hospital, Mwatate Sub-County Hospital and Taveta Sub-County Hospital where 73 (36 males, 37 females) health workers were reached. A CME session on GeneXpert utilization was held in Taveta Sub-County Hospital reaching 20 (9 male, 11 female) health workers. In Taita Taveta County, project staff supported a sensitization meeting to 18 (10 males, 8 females) CHMT members on the recently launched short-term TB regimen which reduced MDR TB treatment from a minimum treatment duration of 20 months to 9 months. In Kilifi County, the Project supported CME at Chasimba Health Center and Mariakani Hospital on management of MDR patients reaching 26 (13 males, 13 females) service providers. MDR detection and surveillance: The Project has continued to support lab networking for GeneXpert samples to testing labs through provision of transport for samples. This has led to improved utilization of the GeneXpert machine and prompt diagnosis of TB suspects. Following this robust and strengthened laboratory networking, all Afya Pwani supported facilities in the five counties of Mombasa, Kilifi, Kwale,

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Taita Taveta and Lamu were able to access gene Xpert tests for both TB diagnosis and surveillance for resistance to Rifampicin. All the patients found to have TB and Rifampicin resistance. See Table 16 below.

Table 16 Gene Xpert Testing COUNTY TESTING FACILITY TOTAL TESTED TB POSITIVE RIFAMPICIN RESISTANCE KINANGO HOSPITAL 67 15 0

KWALE MSAMBWENI 210 41 2 HOSPITAL KWALE HOSPITAL 105 23 0 LAMU LAMU HOSPITAL 260 22 0

KILIFI MALINDI HOSPITAL 511 84 1

KILIFI HOSPITAL 616 60 0

TAITA TAVETA MOI CRH 542 46 0

MOMBASA TAVETA HOSPITAL 213 18 0

LIKONI 321 68 0 CPGH 688 146 7 GANJONI 394 86 3 PORTREITZ 54 24 0 BOMU 617 97 3 MTONGWE 111 19 5 TOTAL 14 TESTING LABS 4709 749 21

Lessons Learnt 1. The stock out of IPT is mostly due to incorrect ordering from the facility level and not at KEMSA. 2. Task shifting has been helpful in mitigating the effects of the nurses’ strike. 3. An efficient lab networking system not only reduces the turnaround time for tests but also motivates health workers to harvest gene Xpert samples there by improving its utilization for TB diagnosis.

SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH AND FP, WASH AND NUTRITION

During this quarter under review, Afya Pwani reached a total of 5,714 clients with Focused Antenatal Care (FANC) services in the County. It should be noted that the number of FANC clients decreased from 9,938 last quarter, to 4,224 during the July-September 2017 period; this decline is attributable to the nationwide nurse’s strike which began in 1st of June 2017 and is still ongoing. Between July and September 2017, 2,857 clients completed 4 FANC visits as compared to 2,995 clients that were reached in the April to June 2017 quarter; a decline of 138 clients. Cognizant of the effect that this industrial action by the nurses is having on MNCH service delivery, the Afya Pwani team will focus on scaling up community mobilization

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efforts as well as supporting outreach activities to help mitigate these effects and increase ANC attendance by pregnant women across all the seven sub-counties in Kilifi in the next quarter. Figure 9 below provides a more detailed breakdown of these trends.

Trend Analysis for the 1st and 4th ANC Visits October 2016 to September 2017

12000 10894

10000 8527 8000 6943

6000 4230 3398 4000 2995 2857 2857 2000

0 Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017

New ANC clients Pregnant women completing 4 ANC visits

Figure 9 Trend Analysis for the 1st and 4th ANC Visits October 2016 to September 2017

Output 2.1: Maternal, Newborn and Health services a) Increase demand for MNCH/FP services i) Community awareness and community dialogues sessions 1. ‘Mama’ Groups

The ‘Mama’ group concept was first piloted last quarter at Ganze Health Centre in Ganze Sub-County. ANC mothers who attended their first visit in May 2017 were given a similar return date for 6th June 2017, which saw 42 mothers booked and placed in a cohort. In June, 29 out of the 42 mothers attended the first meeting and maintained participation in the ‘Mama groups’. It should be noted that the 13 mothers who had dropped out of the cohort, had decided to continue with the normal ANC clinic. During the quarter under review, three ‘Mama’ group meetings were held and participants were taken through how to develop a birth plan, the importance of good nutrition, what the different stages of labor are, facility delivery in response to delivery emergencies, and finally a tour of the maternity department so as to make sure all ‘Mama’ group members we comfortable in readiness for delivery. Out of the 29 women who started attending the ‘Mama’ group meetings, 12 have already delivered- however all 12 clients had to deliver in private hospitals because of the health workers strike in the public sector. It should also be noted that all the mothers who delivered also received Post-Natal Care (PNC) and their babies were seen within 48 hours of delivery as per the national guidelines; all mothers also opted for exclusive breastfeeding for the first 6 months. Moreover, the ‘Mama’ group participants also received FP counselling and two mothers opted for Bi-Tubal Ligation for FP.

Despite the success of the ‘Mama’ Group concept- there were some challenges that curtailed the success of this initiative. Several clients were unable to access services (including immunization) due to the ongoing Nurses’ strike. As was mentioned many of the ‘Mama’ group members delivered at private facilities, but many members incurred high financial costs as ANC profile investigations are normally

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charged at Kshs 300 in public facilities, but cost Kshs 1000 in the private facilities, and so many mothers could not afford to have their ANC profiles done. Lastly, several ‘Mama’ group members were unable to access RH/FP services because of lack of support from their spouses due to socio-cultural barriers. The pictures below illustrate the ‘Mama’ groups in action.

Mama group members during one of the breastfeeding demonstration at Ganze Health Centre

2. Advocacy meetings with opinion leaders Between July and September 2017- Afya Pwani also supported meetings with 30 opinion leaders from Banda la Salama Village in Chonyi, Kilifi South. The participants included but were not limited to; Kaya Elders, Imams, Pastors from different denominations, Wazee wa Nyumba Kumi, area Chief and CHV representatives. The meeting was coordinated by two area Public Health officers (PHOs). Project staff used this meeting as a platform for sensitizing these opinion leaders on the importance of seeking health care especially for pregnant women and children. Emphasis was also put on the leaders’ role in addressing cultural and religious beliefs that negatively affect health seeking behavior. Moving forward, each participant was tasked to use their various community forums and social capital to give information to community members on the importance of ANC attendance, facility deliveries, postnatal care, FP use and immunization.

Opinion leaders in a session at Banda Ra Salama, Chonyi. The area chief illustrating a point during the meeting

Afya Pwani also supported a meeting for 23 religious leaders in Malindi Sub-County Hospital in Malindi Sub-County. The main of this meeting was to urge religious leaders; who are key stakeholders in the

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community, to partner with the County Government Department of Health to devise ways of curbing the retrogressive socio-cultural and religious practices that have been actively curtailing access and uptake of health services for communities in Malindi Sub-County, with the hope of increasing positive health outcomes for these populations and working to achieve a health community.

During the meeting discussions focused on addressing cultural and religious barriers to accessing health services. Emphasis was put on early ANC attendance, emphasizing on 4 ANC attendance, skilled deliveries, FP use and immunization which the religious leaders were encouraged to support. Some of the key issues that were addressed head on included but was not limited to the negative effects of ‘Mwenye’ Syndrome when it comes to women accessing health services, especially RH/FP and MNCH. Moving forward the Project will organize and facilitate more meetings with other religious leaders who were not in attendance. Importantly, the participants who were present during this meeting were also called onto share age appropriate, positive health information on sexuality with their community members, and were subsequently linked to the youth focal person in Malindi.

3. Male involvement Between July and September 2017, Project staff also followed up the 17 male champions that were trained in the previous quarter at Ganze Health Center in September 2017. Afya Pwani facilitated a follow up meeting which gave the male champions a platform to provide feedback on what they have been doing since the training in June 2017. During this quarter, the Afya Pwani supported male champions reported supporting sensitizations for men on health issues especially FP, acting as role-models in accompanying their wives for health services and sensitizing elders on the importance of encouraging positive health seeking behaviors and discouraging negative cultural practices. More specifically, these male champions have been working with chiefs, religious leaders and “Mangwe” (local brew dens) owners to create forums where they can share positive health information with community members who frequent these areas. These male champions have also been coordinating and working closely with CHVs to help immunization defaulter tracing.

Of note is that one of the Afya Pwani trained male champions has decided to take a pro-active role towards gender mainstreaming by allocating house-hold chores to his children irrespective of gender, arguing that male involvement should start at an early age. An indication that the positive information that was disseminated and shared with the Male Champions during their training session last quarter has taken root and has the potential to be adopted by other community members in the area.

ii) Improve access by optimizing functional existing County health services; Faith based health facilities (including use of outreach and private sector service provision)

During the quarter, Afya Pwani also supported 9 outreaches in Rabai and Magarini Sub-Counties where a total of 232 pregnant women were able to receive high quality ANC services. These outreaches play a pivotal role in helping to ensure that pregnant women who are living in hard to reach areas are still able to access vital ANC services.

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b) Enhancing Provision of High Quality Services i) Support supervision

Due to the nurses’ strike, which has been going on for four months since 1st June 2017, many clients are having to seek services in private facilities across the seven sub-counties. To ensure that clients are able to access high quality health services in these private facilities, Afya Pwani project staff worked with Ganze SCHMTs to carry out support supervision for seven private facilities44 that have been providing services to clients during the nurse’s strike, helping to ensure that the MNCH/FP services being delivered were high quality. During the support supervision by the Afya Pwani team, the following gaps were identified; lack of emergency trays, basic equipment such as weighing scales not functioning, some clinics operating without licenses, perinatal deaths were not being reviewed and there was poor documentation in the data tools. The team have since made recommendations to address these gaps and will these sites will be re-visited in the next quarter to follow up on the progress made to address the same.

Table 17 below shows planned actions for identified gaps:

Table 17 Identified Gaps and Plan of Actions Identified gap Plan of action Lack of emergency trays Facilities to have emergency tray in place Faulty weighing scales Facilities to have weighing scales repaired or to procure new ones Perinatal deaths not reviewed Facilities to do perinatal death audits regularly to identify and address preventable causes Clinics operation without licenses Support these facilities to be licensed to offer services

In terms of the public facilities that Afya Pwani supports, project staff conducted support supervision across 15 facilities in Kilifi North Sub-County45. During these supervision visits, staff identified the following gaps: Poor infection prevention, missing reporting tools, inconsistent cold chain monitoring and commodity stock-outs. During the routine visits, staff also documented the facilities were minimal support was being offered during the strike; the Project team is currently working on developing mitigation measures that will limit the effects of the strike on clients- ensuring services continue up until this issue is resolved. To help address the lack of tools at the facilities visited, the Afya Pwani team also facilitated the distribution of the MOH 706 tool to those experiencing shortages.

ii) Facility Quality Improvement During the quarter under review, Afya Pwani also supported a 3-day QI orientation training for 27 health workers in Rabai Sub-County;46 the training was conducted between 31st July 2017 to 2nd August 2017 at Kombeni Girls Hall, Rabai. The main objective of the training was to orient the participants on the Kenya Quality Model for Health (KQMH) and how to institutionalize the same across these facilities. Subsequently, participants established work improvement teams(WITs) in their facilities and Afya Pwani project staff will follow up after three months to assess the functionality and progress made by these

44 Bamba Medical and Maternity, Huruma Medical, Chamalo Medical, Malanga AIC, Havila Medical Clinic, Sokoke Imani Medical and Mariango Medical clinic in Ganze Sub-County. 45 Kadzinuni, Takaungu, Mavueni, Mnarani, Rokamaweni, Kiwandani, Konjora, Zowerani, Mtondia, Mijomboni and Watamu dispensaries; Gede, Matsangoni, Ngerenya Health Centres and Chumani Medical Clinic. 46 Rabai Health Center (10), Kombeni Dispensary (3), Makanzani Dispensary (3), Bwagamoyo Dispensary (3), Ribe Dispensary (2), Lenga Dispensary (2), Deteni medical clinic (1) and Kokotoni dispensary (3).

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WITs. By supporting these activities, project staff are working towards its mandate to ensure that clients access high quality health services, so as to increase the number of women attending four ANC visits, delivery at the facility and receiving PNC as per the national guidelines.

c) Increase utilization of MNH services especially emergency care by addressing existing barriers (cost) and improve coverage of services

i) Skilled birth attendance

During the quarter, a total of 1,403 deliveries occurred with a skilled birth attendant (SBA) in project supported facilities across the seven sub-counties in Kilifi, a decrease to 5,443 deliveries as compared to the 6,846 deliveries that occurred in the previous reporting period. This quarter, a total of 1,373 live births were also recorded across the seven sub-counties compared to 6,738 live births in the previous quarter; a decrease of 5,365 deliveries. The drastic decrease in the number of live births recorded can be attributed to the ongoing nurses’ strike that has seen several maternity wards remain closed throughout the quarter. Clients are now seeking services in the private facilities which have remained functional. Cognizant that most clients were seeking services in private facilities, the Project has been working closely with these facilities to ensure that clients access high quality health services; Project staff will continue to work closely with these facilities until the nurse’s strike is called off to ensure that there no gaps in terms of service delivery and that all clients seeking MNCH services are attended to. Figure 16 below shows the trend in SBA and live births from October 2016 to June 2017. See Figure 10 below.

Trends in SBA and live births October 2016- September 2017 8000 6846 6738 7000 6274 6108 6000 5295 5108 5000 4000 3000 2000 1403 1373 1000 0 Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017

Skilled Deliveries Live birth

Figure 10 Trends in SBA and live births October 2016-June 2017

ii) Maternal and neonatal deaths: During the reporting period July to September 2017 there were six maternal deaths recorded as follows: two from Kilifi County Referral Hospital, one from Malindi Sub-County Hospital, and three from Mariakani Sub-County Hospital. A further, 74 fresh stillbirths, 24 macerated stillbirths and 8 neonatal deaths were also recorded across Afya Pwani supported sites, compared to 123, 72, 50 deaths respectively in the previous quarter. The trends outlined above are due to the significant decrease in the number of live births that were recorded this quarter because of the nurse’s strike. The fact that there were 24 macerated still births is an indication that more needs to be done to increase uptake of FANC amongst

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 43

clients in Kilifi- Project staff have noted this trend and will work closely with the Afya Pwani grantees to work towards increasing the number of clients accessing FANC in the next quarter. Figure 11 below provides more information on the maternal deaths, stillbirths and Neonatal deaths trends for Afya Pwani supported sites this quarter.

Trends in maternal and neonatal outcomes October 2016 - September 2017

140 123 120 107 100 80 74 75 80 72 72 60 50 43 36 40 24 20 8 5 6 6 6 0 Neonatal deaths Fresh Still Birth Macerated still Birth Maternal Deaths

Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017

Figure 11 Trends in maternal deaths, stillbirths and Neonatal deaths October 2016 and September 2017

iii) Support for Maternal and Perinatal Deaths Surveillance and Review (MPDSR) meetings

In line with national guidelines and regulations, Afya Pwani also supported and facilitated MDSR meetings at Mariakani Sub-County Hospital to review these maternal deaths. During the review, it was concluded that the maternal deaths and the causes of death were Post-Partum Hemorrhage (PPH), Ante-Partum Hemorrhage (APH) and a ruptured uterus due to mal-presentation. Upon further review, it was highlighted that these deaths were attributed to the following: delayed referral, delayed intervention and lack of blood for the clients. Cognizant of these barriers and challenges, the following recommendations were made and will be followed up in the next quarter: Staffs to liaise with other health facilities for ambulance services in case of a crisis; for timely referrals; Rural health facilities to refer all high-risk clients to the Sub-County Hospital for better care; Laboratory to lobby and stock enough blood products; Public health department to facilitate awareness creation against harmful practices such as abdominal massage and herbal consumption in pregnancy and lastly the DMOH team to conduct supervision to the private clinics which offer substandard services.

iv) Improved gender norms and sociocultural practices

Please see Section VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH for more information on activities aimed at improving gender norms and socio-cultural practices. d) Strengthen Health Information System i) Data review meetings Between July-September 2017, Afya Pwani supported Quarterly Data Review meetings for all the Sub- Counties that were attended by all SCHMTs members and HVFs in-charges from all seven sub-counties in Kilifi. The main indicators discussed during these meetings included but were not limited to RH/FP, ANC,

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Immunization and skilled deliveries. Participants identified key challenges affecting these indicators and the following recommendations and action points made: data recording and reporting needs to be consistent across all HVFs and supported sites, there needs to be increased community involvement if there are to be improvements in regards to MNCH indicators. Afya Pwani’s grantees will be implementing their activities in the next quarter and it is hoped that these organizations, many of them Community Based Organizations (CBOs) will be able to address this challenge moving forward.

Lessons Learnt 1. Utilization of male champions to engage other men helps in behavior change that helps to improve health seeking behavior and support for women and other marginalized members of communities across Kilifi County. 2. The Mama group initiative has helped to improve ANC attendance and facility delivery. The members of this group have also acted as change agents, motivating other women to seek services and delivery at the facility. 3. Meetings with opinion leaders will go a long way in facilitating improved health seeking behavior by communities in Kilifi County.

Output 2.2: Child Health Services a) Immunization

During the quarter under review, 2,879 children under 1 year were fully immunized compared to 4,787 in the previous quarter a decline of 1,908; additionally, only 3,058 children received the measles vaccines compared to 4753 the previous quarter, a decline of 1,695. As was the case for Maternal and Neonatal Health (MNH) services, this drastic decline in the number of children accessing immunization services is attributable to the ongoing health workers strike in the public facilities. These negative trends are also reflected in the number of children who received the Penta 1 and Penta 3 vaccines. It should be noted that a significant number of clients have been seeking services in private facilities because of the strike, and Afya Pwani project staff will endeavor to work closely with the relevant facilities are providing high quality child health services for clients. For more detailed information on the immunization trends for clients receiving services in Kilifi since October 2016 please see Figure 12 below:

Trends in Child Health Indicators October 2016-September 10000 2017 8389 8171 8000 74707249 7475 68796933 7064 6265 Penta 1 6000 5606 4753 4787 4756 Penta 3 4000 3607 3058 2879 Measles 2000

FIC under 1 0 year Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017 Figure 12 Trends in Child Health Indicators October 2016-September 2017

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i) Outreach activities During the quarter under review, Afya Pwani successfully supported 16 outreaches; 2 in Rabai Sub- County, 7 in Magarini Sub-County and 7 in Kaloleni Sub-County. Kilifi County is vast with many hard to reach areas and marginalized populations. Cognizant of these factors, Project staff will continue to support the provision of outreach services for clients living in these areas to ensure that all clients have access to these vital health services. The table below provides more information on the number of clients who accessed different vaccines during the Afya Pwani supported outreaches. See Table 18 below.

Table 18 Number of Children Immunized July-Sept 2017 Vaccine Number of children immunized BCG 419 OPV 1st dose – 308 2nd dose – 266 3rd dose – 225 PENTA 1st dose – 304 2nd dose – 276 3rd dose – 227 PCV 10 1st dose – 244 2nd dose – 266 3rd dose – 230 ROTA 1st dose – 262 2nd dose – 259 Measles 9 months’ dose – 261 18 months’ dose – 30

b) Management of diarrhea

Between July and September 2017, a total of 2,788 children under 5 years were managed for diarrhea at Afya Pwani supported facilities compared to 8,459 children in the previous quarter, a decrease of 5,671. Despite the fact that this decline is attributable to the ongoing nurses’ strike, in the next quarter the Afya Pwani project will strive to help fill this gap by getting clinical staff who are part of the team to provide child health services as part of efforts to increase the number of clients being immunized in line with national guidelines and protocols. Cognizant that the end of the nurses’ strike is unknown, the Project team will continue to work closely with Kilifi CHMT to put in place mitigation measures to ensure as many clients access services as possible. The graph below provides more information on the number of diarrhea cases managed across Afya Pwani project sites from October 2016 to September 2017. See Figure 13 below.

Trends in Under 5 Diarrhea Cases Oct

2016 - Sept 2017 10,000 8,459 8,000 7,076 6,921

6,000

4,000 2,788

2,000

0

Oct-Dec Jan-March April-June July-Sept Figure 13 : Trends in Diarrhea Cases Managed at facilities in the 7 sub-counties for Oct 2016 to June 2017

USAID AFYA PWANI PROGRESS REPORT Q4 July-September 2017 46

Moving in to Year 2, the Project will focus on the operationalization of Oral Rehydration Therapy (ORT) corners across all supported health facilities in line with national guidelines, documentation of diarrhea cases as well as participating in WASH activities as part of prevention of diarrhea at the community level in the county.

Lessons Learnt 1. Private facilities have played a key role in offering services especially during the health workers strike especially for immunization services. They should be supported to optimize service delivery.

Output 2.3 Family Planning Services and Reproductive Health (FP and RH) During the quarter under review, Afya Pwani has continued to be committed to increasing access and utilization of RH/FP services in Kilifi County; the Project reached 7,217 new clients with high quality FP services which included access to and the utilization of injectable contraceptives, pills, implants, and Intrauterine Contraceptive Devices (IUCDs). This is an increase of 1,435 new clients compared to the previous quarter’s figure of 5,782. In terms of the number of re-visit clients there was a reduction of 7,032 from the previous quarter’s 11,552 revisits to this quarter’s figures which lie at 4,520- a drastic decline in the number of clients accessing service from project supported facilities. Following analysis of project data for the quarter, it seems that most clients needing refills for their FP needs may have sought services in private facilities or got them over the counter at pharmacies, hence the negative trends in the numbers. Moving into Year 2 and the next quarter, project staff will work on developing mitigation measures to reduce the impact of the nurse’s strike on accessibility of RH/FP health services for clients- this is especially pertinent given the fact that it is unknown when this strike will come to an end. The figure below captures these trends in new and revisit FP clients over the three quarters (Oct 2016- September 2017). There has been a steady decline in the number of revisit clients since October 2016, which is partly attributable to the consecutive industrial actions that have been experienced across the country since December 2016 (which came to an end in March 2017) and now the nurses’ strike which commenced in June and is still ongoing. See Figure 14 below.

Trends in FP New and Re-visits October 2016 - September 2017 20000 14768 15000 13154 11552 10000 7244 7038 7217 5782 4520 5000

0 Oct-Dec 2017 Jan-Mar 2017 Apr-Jun 2017 Jul-Sep 2017

New FP Visits Re-visits

Figure 14 Uptake of FP Services, New clients and re-visits for Oct-Dec 2016, Jan-Mar 2017, Apr-Jun 2017

In terms of the preferred method mix for FP clients in Kilifi County during the quarter, injectables remain the most popular. However, of note is that, unlike the previous quarters, the July-September 2017 quarter saw a sharp rise in the number of condoms being provided to clients. This upward spike can be attributed

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to the fact that due to the Nurses’ strike, condoms were readily accessible, unlike other long acting reversible methods which require nurses to be present for insertion et cetera. It should be noted that there were also a considerable number of implants inserted for clients during the quarter under review. The graph below provides more information on these trends from October 2016-September 2017. See Figure 15 below.

Trends in FP method mix October 2016 - September 2017 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 condoms FP Injectables IUCD Implants Pills Sterilization Natural FP

Oct-Dec 16 Jan-Mar 17 Apr-Jun 17 JUL-SEP 17

Figure 15 Trends in FP method mix for the period Oct 2016 – June 2017

In terms of the total number of clients who accessed FP services for the quarter- 11,737 clients were reached, compared to the previous quarter where a total of 17,334 clients were seen; whilst the total number of clients accessing Couple Years of Protection (CYP) for this quarter stood at 7,807, compared to 15,937 from the previous quarter. The decline in CYP can be explained by the sharp rise of clients seeking shorter acting methods (see number of Condoms provided this quarter) coupled with the reduction in the number of revisit clients due to the Nurses’ strike. As was mentioned previously, Afya Pwani staff will endeavor to put in place mitigation strategies (including calling on clinical Project staff to step in to provide services), so as to increase the number of revisits clients and ensure that all clients are able to access LARCs and any other method of their choice as per the United States Government (USG) FP compliance requirements. The graph below provides more information on these trends. See Figure 16 below.

Trends in CYP October 2016 - September 2017 18532 20000 17313 15937 15000

10000 7807

5000

0 OCT-DEC 16 JAN-MAR 17 APR-JUN 17 JUL-SEP 17

Figure 16 Trends in CYP for October 2016 – September 2017

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The graph below provides a breakdown of the methods that contributed the highest to CYP between October 2016 and September 2017; where implants, injectables, Intrauterine Devices (IUDs) and sterilization have contributed the most during this period. Project staff will continue to work together with the recently oriented Grantees to increase demand and uptake of RH/FP services as part of reducing the unmet need of the same for clients in Kilifi County. See Figure 17 for more information.

Trends in CYP by Method Oct 16- Sep 17 12000 10000 8000 6000 4000 2000 0 Pills Injections IUD Implants Sterilization Condoms

Oct-Dec 16 Jan-Mar 17 Apr-Jun 17 Jul-Sep 17

Figure 17 Distribution of CYP by Method for October 2016 – September 2017

In Year 2, the Project will continue to provide TA, mentorship and OJT to health service providers to maintain and improve the uptake of LARCs and permanent methods of FP across the seven sub-counties while ensuring that the supported facilities continue to adhere to the USG legislative and FP policy requirements of voluntarism and informed consent.

a) Capacity building for FP

During the quarter under review, Afya Pwani also supported a 5-day training for 30 Community Health Extension Workers (CHEWs) on RH/FP at Eden Rock Hotel, Malindi. The CHEWs were drawn from Kilifi North (5), Kilifi South (2), Rabai (4), Kaloleni (4), Malindi (5), Ganze (6) and Magarini (4) sub-counties and were equipped with the RH/FP knowledge needed to enable them to promote uptake of RH/FP health services at the community level. More specifically, participants were taken through the following: Anatomy and physiology of the male and female reproductive system; FP methods, how they work including their side effects and management of the same; Importance of counselling and informed choice in FP and finally accurate, complete and timely reporting and record keeping for FP health services and commodities. It is hoped that this training, coupled with the grantee activities revolving around RH/FP will see increased demand for and uptake of much needed RH/FP health services for clients in Kilifi County.

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CHEWs having group discussion on FP methods during the training

b) FP outreaches Cognizant that Kilifi is a County characterized by several hard to reach areas, Project staff continued to support 15 RH/FP outreaches in Kaloleni and Rabai Sub-Counties, where a total of 223 clients were counselled on FP. As a result of this intervention, a total of 87 clients received implants, 92 clients requested the Depo injection, and 16 clients received pills; an indication of not only the success of this particular intervention, but of the demand for these services in these sub-counties. The Project team will build on these gains in the next quarter as part of efforts to ensure that clients are able to access the method of their choice despite living in hard to reach areas. Additionally, during these outreaches, a total of 135 clients were also screened for cancer and those clients with irregularities being referred to the respective facilities.

c) Stakeholder forums

i. Support for the World Contraception Day activities

During the July-September 2017 quarter, the Afya Pwani project also supported World Contraceptive Day (WCD) activities in Kilifi County; this year’s theme was “It’s your life, it’s your choice”, with the following sub-themes: 1) Know your body 2) Know your partner and finally 3) Know your options.” Project staff actively participated in planning meetings with the Kilifi CHMT and 25 other stakeholders supporting the event, including but not limited to: Afya Pwani Staff, National Council for Population and Development (NCPD), JHPIEGO, USAID Human Resources for Health (HRH), and Kenya Youth Muslim Development Organization (KYMDO). Stakeholders developed a WCD budget, planned for pre-event activities and D-

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day activities which included service provision and awareness/demand creation. The WCD pre-event was held at Pwani University where: 2000 students were given information on FP; 5000 thousand male condoms were distributed; HIV testing done for 123 students (where all tested negative); 15 students were treated for Sexually Transmitted Infections (STIs); 30 students screened for cervical cancer screening; Breast examination done for 30 students. 2 students were found with breast lumps and were referred and lastly 3 students took up FP methods (Implants-2, Depo injection-1).

The main WCD event was celebrated in Matanomanne, in Ganze Sub-County, an area which has the poorest FP indicators in Kilifi County. The function was officiated by the County Executive Committee Member of Health (CEC) for Kilifi County; other esteemed guests included but were not limited to Kilifi County Director for Health, Deputy District County Commissioner for Ganze Sub-County, Kilifi CHMT and SCHMT members, Kilifi Kenya Medical Training College (KMTC) principal and students, health workers, CHVs and community members. Additionally, one of the Afya Pwani trained Male Champions also gave a speech on the importance A peer educator at Pwani University demonstrating of male involvement in supporting and promoting female condom use during the World Contraception positive health seeking behaviors at the Day Pre-event. community level, including RH/FP, ANC and child health services in the County. During these celebrations, 1000 community members were reached with positive FP information; 68 clients accessed FP services (Implants- 57, IUCD- 3, Pill-s 3, Implant removal- 5); Cervical cancer screening done for 119 clients, out of which 1 client was positive for abnormalities, and 3 clients were diagnosed of being symptomatic and were referred to facilities for further investigations and treatment. Lastly, a total of 16 clients accessed HTS with all testing negative. The success of this particular event is illustrated in the picture below, which shows the long queues of women waiting to receive RH/FP services during the WCD 2017 event.

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Women queuing for services during the World Contraception Day on 26th September 2017

d) Family Planning Commodity Reporting

i) Commodity reporting Cognizant that a core component of delivering high quality RH/FP services is ensuring that there are adequate supplies of FP commodities, the Afya Pwani project facilitated the provision of airtime for internet bundles for the county and seven sub-county pharmacists to be able them to upload commodity data into DHIS 2 in a timely and effective manner to prevent stock outs of vital RH/FP commodities. It should be noted that due to the health workers strike, this quarter was characterized by delayed reporting into DHIS2. This is reflected in the figure below which reports that for the month of June 2017, FP commodity reporting stood at 62.8% as compared to the previous month’s rates of 87%. See Figure 18 below for more information.

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Figure 18 Contraception commodity reporting trends (June 2016 - May 2017)

Moving forward into Year 2 and the next quarter, project staff will continue to provide facility staff with the relevant TA and support (including airtime) to ensure that FP commodity data is entered correctly and in good time to allow for accurate forecasting and quantification of FP commodities for facilities to prevent stock outs.

Lessons Learnt 1. It is important to focus efforts on equipping youth with FP information to help them understand FP and therefore making right choices. 2. There is unmet need for RH services in the training institutions which can be addressed by activities such as integrated outreaches. 3. Private facilities which have supported service delivery during the health workers strike lack capacity to offer the full range of FP services and can be supported to offer these services.

Output 2.4 Water, Sanitation and Hygiene (WASH) a) Improved access to safe and adequate water for drinking, domestic and animal use i) Capacity building of community artisans on Operation & Maintenance (O&M)

To improve the O&M of water points, a second group of 19 community artisans (6 females, 13 males) were trained on O&M of Water, Sanitation and Hygiene systems in Kilifi. These artisans were selected from the catchment communities around the HVFs in Magarini, Ganze, and Kaloleni Sub- Counties. The linkage facilities are Bamba, Ganze, Jaribuni, Vitengeni, Gotani, Ngomeni, Marafa, Mariakani, Marereni and Adu. The artisans were trained on meter reading, servicing, pipeline burst repairs, community sanitation and hygiene systems and the construction of new water extensions; these sessions included hands-on demonstrations/practical sessions to enhance skills transfer. It is expected that the trained artisans will be able to provide affordable and skilled labor to the communities, enhance water supply,

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safety and promote construction of sanitation and hygiene facilities in the communities to reduce the prevalence of WASH related diseases especially diarrhea in children. b) Improved access to and use of improved sanitation at community and institution level i) CLTS Triggering in additional communities;

During the reporting period, the Project worked with Kilifi County public health staff and CHVs to trigger 14 villages with a population of 3,497 people as part of efforts to achieving open defecation free (ODF) communities in Ganze, Kilifi North and Kilifi South Sub Counties. By supporting the implementation of these activities, Afya Pwani was working towards improving access to and use of improved sanitation at the community level. The table below provides more detailed information of the Villages that were triggered and the number of people living in those respective communities. See Table 19 below.

Table 19 Triggered Villages S/NO NAME OF VILLAGE SUB COUNTY POPULATION

1 Kikwanguloni Ganze 240 2 Kadhameni ‘B’ Ganze 228 3 Vimburuni Ganze 186 4 Mgamuni Ganze 217 5 Dungicha Ganze 191 6 Mhoni A&B Ganze 188 7 Madeteni Ganze 103 8 Vimbirini Ganze 114 9 Karira Ganze 98 10 Ferry Kilifi north 417 11 Skuli Kilifi North 360 12 plantation Kilifi north 483 13 Mwembe kati Kilifi South 289 14 Mafisini Kilifi South 383 TOTAL 3497

ii) Facilitating CLTS Review meetings In order to track the progress realized within the triggered villages, Afya Pwani project staff also incorporated review meetings at each Sub-County to assess the progress made in regards to the implementation of CLTS amongst cluster communities. These meetings were also apt platforms for the Afya Pwani team to provide TA and supportive mentorship for identified CLTS champions from the triggered communities, who have and will continue to play a pivotal role in helping their communities improve access to and use of improved sanitation at the community level. During the quarter under review, two CLTS review meetings were held at Ganze and Vitengeni, which were attended by community based CLTS promoters, community leaders (including government provincial administrators) who oversee 41 villages that are supported by Afya Pwani, as the Project works to make them ODF. The key outcome from this meeting was the drafting and development of action plans to mop up villages so that they can attain ODF status. These activities were further supplemented by the construction of 203 new latrines benefiting 1,218 people (548 males, 670 females), all of whom have gained access to sanitation services reducing the risk of fecal related diseases as a direct result of the Project.

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Village mapping during CLTS triggering

ii) CLTS verification for self-claim villages

Afya Pwani also worked closely with and supported the Sub-County verifying team to confirm the ODF status of 10 villages in Ganze Sub-County in Dida Sub-location in Sokoke ward47. A total of 373 households were visited during this verification exercise, of which: 359 households had household latrines; 17 households had shared latrines, and 192 households had functional handwashing stations. In the same 10 villages where the verification was done, 2,874 people (1,293 males, 1,581 females) have accessed improved sanitation at the community level, as a result of Afya Pwani’s CLTS activities. The pictures below provide an illustration of the a newly constructed pit latrine after triggering. See Table 20 below.

Latrines constructed after triggering during verification this quarter.

47 Dida center, Kizingo, Ziara Kaembeni, Kahingoni center, Mkwafu wa charo, Kafitsoni, ngamani, Chagani, Kadzandani and Mpango Villages.

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Table 20 Summary of verified ODF claim villages No. Name of village Total No. of Population No. of Hand washing H/holds latrines facilities

1 Dida center 68 503 62 39 2 Kizingo 31 211 31 14 3 Ziaralufa 24 172 24 12 4 Ziara Kaembeni 42 364 42 20 5 Kahingoni center 41 335 39 22 6 Mkwaju wa charo 36 120 34 16 7 Kafitsoni ngamani 21 225 21 9 8 Chagani 38 310 38 37 9 Kadzandani 38 252 34 10 10 Mpango 34 382 34 13

TOTAL 373 2874 359 192

iv) Third party Certification for ODF communities

Following the successful verification of the 10 ODF villages during the quarter, Afya Pwani also facilitated the certification process for 20 ODF communities48 in Dida and Mwahera sub-locations in Ganze Sub-County by a third party; a certifier from Kilifi County Medical Training College. All 20 villages were confirmed to be and certified as being ODF. Moving forward the CLTS promotors will make follow up visits to the few households who lack handwashing stations and the next step in the process will be to engage the CLTS National hub for accreditation of the ODF villages and formally give certification.

v) BOMS review meeting on comprehensive school health implementation Pupils washing hands at mounted Tippy tap To ensure that the program realizes expected results in target schools a follow up review meeting was held with the previously trained School Board of Management members together with health teachers

48 Kang’ambani N, Kang’ambani S, Kang’ambani C, Dindiri, Sosoni, Mugumoni, Shitaki, Kafitsoni Ngamani, Dida center, Ziara Kaembeni, Ziara lufa, Kafitsoni A, Kafitsoni B, Chagani, Mkwaju wa Charo, Kadzandani, Kahingoni center, Katsakaka Kambogu, Kizingo, and Chuda.

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and health club patrons from 13 primary schools.49 Each school developed its workplan on starting hygiene interventions in schools through simple activities such as the installation of tippy taps for hand washing. Most the schools have already started school hygiene promotion through school open day events to demonstrate the construction and use of improvised tippy taps made from locally available materials at strategic areas within the school compound. The adoption and sustained practices of hand washing with soap and proper use of latrines for proper fecal disposal will go a long way in improving the health of the school children thus enhance their learning.

C) Improved hygiene behaviors to prevent childhood diarrhea i) Implementation of hygiene promotion activities at community level Between July and September 2017, the hygiene champions trained in the last quarter rolled out hygiene promotion interventions in all the seven sub-counties of Kilifi County, using community dialogues, Chief Barazas and home visits to reach community members with positive health messages on proper hygiene practices. During these hygiene promotion sessions, Afya Pwani also supported and facilitated the mounting of tippy taps for household members, as well as providing information on the importance of practicing hand washing using soap, using household water treatments, latrine construction and proper use to maintain cleanliness and prevent various disease causative agents and vectors. A total of 24 community dialogue sessions were held this quarter, and 1,742 households visited. Because of this Afya Pwani support, 168 households now have new hand washing facilities, 433 households are practicing household water treatment, and 12 households have constructed and are using new latrines. The efforts of the Program towards ensuring safe water for drinking at household level are slowly bearing fruits as informed by the household visits, and the Project making gains towards hygiene promotion Hygiene champion demonstrating on mounting activities at the community level. tippy taps

Lessons Learnt 1. Due to many competing tasks at home, community based training encourages more women to participate than hotel based trainings so that they attend to their other family needs.

Output 2.5 Nutrition a) Improved provision of nutrition services for Pregnant and lactating mothers, children under 5 and PLHIV

i) Facilitation of Nutrition CME sessions To improve the quality of services provided by the health care workers, Afya Pwani facilitated 16 CME sessions50 targeting the front-line health care workers from five health facilities on Infant and Young Child Feeding (IYCF) practices of initiating breastfeeding within half hour after delivery, maintaining lactation, assessing breastfeeding sessions, baby positioning and use of growth charts to assess malnourishment. By building the capacity of health workers on these topics, the Project is working to

49 Maojo, Mweza Moyo, Ganze, Danicha, Mwahera, Kagombani, Palakumi, Mwapula, Mayowe, Kwadadu, Mikamini, Lwandani, and Mitsedzini 50 Gotani-2, Gongoni-6, Ganze- 1 Vitengeni-1, Marafa-6

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improve the provision of nutrition services for pregnant and lactating women and children under 5, especially those living with HIV, across all the seven Kilifi Sub-Counties.

ii) Nutrition counseling with CHVs and care givers To scale up outreach services provided by CHVs to help reduce cases of malnutrition of children in the community; 50 CHVs (10 males, 40 females) from Ganze and Vitengeni health facilities were trained to conduct nutrition counselling, case identification and referral for care. From the informal discussions with the caretakers of children in the community, they affirm that the health care workers and volunteers have demonstrated improved capacity in supporting households with nutrition interventions than before. This has been demonstrated by health facilities starting to conduct nutrition reviews/audits and initiating defaulter tracing and referral to Supplementary Feeding Program (SFP) and Outpatient Therapeutic Program (OTP) by CHVs through home visits.

iii) Commemoration of the world breastfeeding week The Project in collaboration with other partners, also supported Kilifi County to commemorate breast-feeding week in Kaloleni and Magarini Sub-Counties through dissemination of breast feeding messages in community gatherings and home visits. In Kaloleni Sub- County, these activities were A nutritionist counselling a mother on breastfeeding issues. facilitated by Gotani Health Facility where 537 children under 5-years were assessed (303 girls and 234 boys) and 657 Caregivers (403 females and 254 males) received breastfeeding messages. The activity was also conducted Gongoni Health facility where 535 boys and 1,319 girls were assessed and 1,532 male and 2,472 female caregivers received breastfeeding messages. b) Improved community nutrition practices and household food security at the community level

i) Supporting communities with improved nutrition practices and nutrition education

Afya Pwani supported and facilitated meetings for four mother support groups which have been tasked with promoting good nutrition practices at household levels in support sub-counties as part of efforts to increase access and utilization of health services, especially for some of the most marginalized populations and communities living in hard to reach areas. In Magarini Sub-County, Afya Pwani project staff worked closely with a community support peer group supported by the Nilinde OVC Program called Tushauriane, facilitated nutrition education sessions in partnership with health care workers and agricultural extension officers attached to that sub-county on eight key messages; namely importance of continued breast- feeding, timely introduction of complementary foods, consistency of complementary foods, dietary diversity, feeding sick children, responsive feeding, family nutrition and hygiene practices. In the next quarter, project staff will work towards facilitating integrated FP messaging with these nutrition education

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sessions will also be explored. These activities have gone a long way to building the capacity of health workers and CHVs working in these sub-counties as they work towards supporting improved nutrition practices at the household level which is expected to lead to improved nutrition for children under 5.

Afya Pwani project staff also focused on identifying the availability and prices of local foods in local markets in Magarini Sub-County; more specifically the Project nutritionist and CHVs conducted a local food group market survey that will help to inform the modification of the local recipes, amounts and consistency of meals and responsive feeding for the community members that the Project is supporting in the area, especially for children aged 6-24 months. Using this information, the Project has been able to work with Mama support group (mentioned above) members to deliberate on nutrition needs and options for target populations. Meals were then centrally prepared meals based on the proposed and agreed recipes, where the support group members were also actively encouraged to try the recipes and other feeding recommendations at home as part of efforts to improve nutritionals practices at the household level.

Caregivers of children from Tushauriane support group in a cooking education session with support from the Nutritionist.

ii) Supporting mother to mother support groups in nutrition interventions Nutrition interventions at household level entails working with community groups to implement many interventions. During the period under review, three other mother support groups (Safi, Mwangaza and Jere-Hani support groups) begun a food item monthly ‘merry-go-round’ of corn flour (Ugali flour), as part of efforts to try and cushion caregivers from the highly priced corn flour during the months of May-July (due to drought situation)51 with some members repackaging and selling the surplus for legumes and other food types. This initiative adopted by one group in Magarini has evolved to poultry farming as an alternative source of animal protein with members supporting each other with a seeder stock of three chicks of the local breed that are free range and more resistant to poultry diseases. This quarter, Afya Pwani also collaborated with the Anglican Development services who train the caregivers on local poultry farming. Afya Pwani has continued to encourage male participation and involvement in the activities of the mother support groups which has seen two men have join the Jere-Hani support group. They have started reaching out to their peers to support kitchen gardening and related nutrition issues.

51 https://www.theguardian.com/global-development/2017/jun/02/drought-centre-stage-kenya-election-campaign-food-prices-rise

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Caregivers tending to their gardens

Although the kitchen gardening initiative uptake has been slow because of the culture of sharing, 10 caregivers are active and have managed to successfully setup their garden and are motivating others to replicate52.

iii) Kitchen gardening demonstrations at health facility level Between July and September 2017, Afya Pwani supported 25 (4 male, 21 female) members from the Tushauriane support group to set up and manage a kitchen garden demonstration site at Gongoni Health facility. This site is now being used for nutrition education for patients attending both the ANC and HIV care clinics. In a period of 3 months, the group has been able to make savings of Kshs 800 out of vegetable sales, which they used to buy a pipe for watering their crop. Five members have replicated this in their households and this initiative is showing immense potential in terms of scale up and adoption of the same at the household level in neighboring villages and areas.

C)Enhanced County Capacity to prioritize nutrition initiatives

i) Roll out of Baby Friendly Hospital Initiative (BFHI) in target health facilities

The BFHI-is an approach that aims at improving the care of pregnant women, mothers and newborns at health facilities that provide maternity services for protecting, promoting and supporting breastfeeding. During the quarter, Afya Pwani supported and facilitated an inception meeting for the implementation of BFHI with key focal health care workers at the County level to assess the existing tools and develop sub-county plans to roll out this initiative, in line with set national standards, so that they are accredited by the National hub. Moving into Year 2 and the next quarter, the Afya Pwani project will support the implementation of the BFHI in select health facilities that offer maternal and child health services. In the next quarter, project staff will work to initiate this process by working to implement the

52 Strong social fabric at the community level encourages some caretakers to continue to borrow from their neighbors and not willing to establish their own. Households with kitchen gardens will always allow their neighbors to have some vegetable even if it is not enough.

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following: Sub-counties will develop context specific and submit for review by the County teams; Strategic staff from selected health facilities with high numbers of SBAs will be trained on the Hospital Self-Appraisal, and breastfeeding/infant feeding policy checklist of the 10 principles; Health facilities will conduct self-appraisals and submit them to the set committees; BFHI TOTs at the County will review the appraisals from the health facilities and carry out a County based validation, feedback and mentoring sessions; Qualifying health facilities will be recommended for accreditation by the National BFHI monitoring team; Health facilities not meeting the BFHI threshold will be supported by the sub county teams to meet the guidelines; Accredited hospitals will be used to mentor other facilities through CMEs to ensure at least 80% of the health facilities promote breastfeeding at all service delivery points; Health facilities will work with the breastfeeding mothers visiting the pilot hospitals as agents of change who will transfer the BFHI benefit to the communities, and additionally work with the same communities to identify the enabling factors and barriers to breastfeeding and other maternal, infant and young child feeding practices and lastly, Project staff will work to ensure that HVs are trained on the Baby Friendly Community Initiative to promote breast feeding in the community.

In the next quarter, Afya Pwani will work to support the County to hold a planning meeting with other implementing and development partners working in the area from PSK, Kenya Red Cross, International Medical Corps (IMC), International Committee for the Development of People (CISP) and the United Nations Children’s Fund (UNICEF) for a knowledge attitude and practice survey for Kilifi County. The graphs below, illustrate the impact that Afya Pwani’s activities have had on the communities in Kilifi County that have been supported with nutrition services during the quarter and from October 2016- September 2017.

AFYA PWANI UNDERWEIGHT TREND ANALYSIS OCT 2016-SEPT 2017

400 369 350 307 300 240 250 200 139 150 121 97 89 100 64 75 45 38 50 15 0 Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017 Severely underweight 0-<6 months Severely underweight 6-23 months Severely underweight 24-59 months

Figure 19 Afya Pwani Underweight Trend Analysis Oct 2016- Sept 2017

Figure 19 above illustrates positive trends in terms of reductions in the number of children who were several underweight aged between 0-6 months, 6-23 months and 24-59 months. The July-September 2017 quarter saw figures for both these cohorts at its lowest, with the graph showing a steady decline in reported cased from October 2016 up until September 2017. Moving into the next quarter, Afya Pwani will work towards to ensuring that these gains are maintained at a minimum and built on by continuing to implement activities at the community and household level that will see the nutritional status of infants

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and children under five years improve during the rest of the Project’s implementation period. See Figure 20 below.

2000 STUNTING TRENDS OCT 2016-SEPT 2017 1800 1600 1400 1200 1000 800 600 400 200 0 Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017

Stunting 0-<6 months Stunting 6-23 months Stunting 24-59 Months

Figure 20 Stunting Trends Oct 2016- Sept 2017

The Kenya Demographic Health Survey (KDHS) 2014 reported that stunting rates in Kilifi County, where over 30% of infants and children under five years were stunted. As has been mentioned above, Afya Pwani staff have been working towards implementing interventions geared towards increased access and utilization of nutrition services across Kilifi to help reduce the numbers of infants and children that are stunted. The figure above, aptly illustrates the efficacy of the Project’s activities to address these issues; more specifically there have been steady declines in the numbers of infants (ages 0-6, 6-23, 24-59) months who have been reported to be stunted. Positive trends that the Project will work on maintaining and building on in Year 2 and the in the next quarter.

Lessons Learnt

1. The auxiliary staff with continuous capacity building and supportive supervision can provide a continuum of care especially in hard to reach villages in Kilifi County.

SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS

Output 3.1 Partnerships for Governance and Strategic Planning 3.1.1: Revitalize county health coordination and collaboration mechanisms Dissemination of the Kilifi County Health Services Improvement Fund Policy and the Act The Public Finance Management Act, 2012 requires that the county revenues generated be deposited into the County Revenue Fund (CRF) account. However, most health facilities in Kilifi County continue to experience challenges in accessing or utilizing internally generated funds from their level four referral facilities to support general operations and maintenance. In response, the County enacted the Health Services Improvement Fund Act, 2016 to provide a legal framework for the department to collect, retain

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and expend 75% of the generated revenue to cover operations of health facilities without contravening the law and 25% goes to support community strategy. Afya Pwani supported the dissemination of the Act together with the accompanying policy guidelines and regulations. The dissemination exercise brought together 43 (Male 29: Female 14) participants comprising of facility managers, County Health Management Team (CHMT), Sub-County Health Management Teams (SCHMT) and other stakeholders. Afya Pwani will continue to provide support geared towards improving managers’ capacities on financial management, planning and budgeting to enhance efficiency in the utilization of the generated revenues. In addition, the project will monitor progress and propose improvements to be made in managing the finances by the department. Kwale County Health Stakeholders Forum Stakeholders forums provide opportunities for various players within the sector to coordinate their activities with a view to enhance synergy. Kwale County held its annual health stakeholders’ forum on 21st September 2017. The forum brought together participants from the county health department, implementing partners and private sector (both profit and non-profit). Afya Pwani provided planning and technical support in collaboration with the health department. Despite the progress, weakness in the level of engagement among partners beyond the annual forums was observed. As a result, Afya Pwani in collaboration with other stakeholders committed to revise the steering committee ToR and define the roles of the proposed thematic groups. 3.1.2 Support five counties in strategic, annual work planning and budgeting process a) Kilifi County AWP Finalization The team supported finalization of the county health department’s AWP by aligning it with the procurement plan and the approved program based budget for FY2017/18. During the exercise, Afya Pwani set out to document possible challenges impacting the health department and possible risks to be faced during implementation of the program based budget by the health department. Some of the challenges highlighted include centralization of budgets and budgeting processes. Others include implementation of tight controls on disbursement and payments (including signing of vouchers) by county treasury, heavy reliance and preference for line item budgeting across the leadership levels and lack of departmental autonomy in financial management.

b) Full Year Review of Kwale County Annual Work-Plan Performance During the period under review, Kwale County was supported to undertake a full year review of their 2016/17 Annual Work plan (AWP) performance. The 3-day workshop brought together 37 participants among them hospital management, sub-county and county level program officers. County and sub-county performance evaluation was based on key performance indicators that are monitored at the national level through DHIS 2. It was noted however, that there was a huge gap in hospital specific planning and performance reviews which needed to inform county planning and monitoring processes. Moving forward, it was agreed that planning processes at all levels of health services delivery, including at the facility level should be strengthened. In FY 2017/18, Afya Pwani supported the development of PBB aligned AWPs for all the four HVFs53. However, there great need to further enhance the capacity of all facilities, including primary healthcare facilities to undertake planning. For effective implementation of

53 Msambweni, Lunga Lunga, Kwale and Kinango Hospitals.

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these facility plans, the team will work with the county Monitoring and Evaluation (M&E) unit to develop facility-based indicators to support monitoring of performance at these levels.

3.1.4 Support the strengthening of health financing systems Conclusion of budget analysis reports Afya Pwani provided technical assistance to Kwale, Kilifi, Lamu and Taita Taveta counties to complete the health budgetary allocation and absorption capacity analysis for FY 2015/16, FY 2016/17 and FY 2017/18 as shown in the figure below. The county budget analysis reports indicated that there has indeed been a marginal increase in the percent of county budgetary allocation to health in FY 2015/16, FY 2016/17 and FY 2017/18. However, in Mombasa and Taita Taveta counties, the percentage of budgetary allocation to health have shown inconsistent growth over the three years while Kilifi, Kwale and Lamu county have surpassed the recommended allocation of 30 percent to the department. Moving forward, the Afya Pwani team will strive to provide an in-depth analysis that focuses on whether the budgetary allocations e.g. Total operations, maintenance and capital investments, that the team is seeing is having any impact on service delivery indicators in the five counties.

Health Budgetary Allocation for FY 2015/16, 2016/17 and 2017/18 for Kilifi, Kwale, Lamu, Mombasa and Taita Taveta Counties

40% 33% 32% 30% 30% 31% 27% 28% 27% 27% 30% 25% 24% 23% 24% 25% 19% 20%

10%

0% Kilifi Kwale Lamu Mombasa Taita/Taveta

2015/16 2016/17 2017/18

Figure 21 Health Budgetary Allocation for FY 2015/16, 2016/17 and 2017/18 for Kilifi, Kwale, Lamu, Mombasa and Taita Taveta Counties

Figure 21 above, shows that Kwale County recorded the highest increment in health allocation from 24 percent in FY 2016/17 to 33 percent in FY 2017/18, whilst Taita Taveta County significantly declined between FY 2015/16 and 2016/17 from 27 to 19 percent, but rose to 31 percent in FY 2017/18. It should be noted that these health allocations were categorized broadly into recurrent and development expenditures, with recurrent expenditures comprising of personnel emoluments, operations and maintenance, purchase of pharmaceutical and non-pharmaceutical commodities among others while development allocation included upgrading, construction or refurbishment of buildings and purchase of medical and non-medical equipment. It should be noted that the proportion on HRH allocation is extracted from the Personnel emoluments budgetary allocation detailed in the approved County health

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PBB budgets for the respective year in comparison to the total county health budget. The increased allocation of resources to the health sector could be attributed to the recruitment of new staff54. The analysis above shows that there is a huge proportion of the health budget that is consumed by personnel emoluments, on average about 70 percent. In Taita Taveta, during the FY 2016/2017, 71 percent of total health budget was spent on personnel (86 percent of recurrent allocation) while in Mombasa it was 66 percent in the same financial year. Lamu county recorded the lowest allocation of 53 percent to personnel. The high allocation to personnel emoluments means that only a small part of the budget is left to cater for important operations and maintenance activity including purchase of health commodities. Without adequate allocation to operations and commodities, the counties are incapable of improving the quality of health services offered to their residents. In light of these gaps, Afya Pwani will continue to offer technical guidance to the departments on areas of budgetary prioritization to improve service delivery and the budget absorption capacity. In addition, the Project will strengthen the working relationship and advocacy between county treasury, county assembly and the departments to foster continuous engagements to ensure increased budgetary allocation to the sector.

3.1.5 Foster counties' engagement with private sector providers Mombasa Private Health Facilities Forum Afya Pwani also participated in the Mombasa county private health providers meeting held on 28th July 2017 at the Medicell Pharmaceutical Company boardroom. The purpose of the forum was to enable the private providers to have a mechanism for discussing emerging issues regarding healthcare delivery and regulations. It was noted that the avenue for engagement between the County government and these providers was weak curtailing constructive dialogue between these stakeholders. During the meeting, Afya Pwani committed to supporting the County Health Department (CHD) in strengthening public-private partnership (PPP) mechanisms and other processes. Moving forward, some of the areas of focus will include but is not limited to supporting counties to fast track health facilities accreditation and advocate for increased National Hospital Insurance Fund (NHIF) coverage. The Afya Pwani team will also work on scaling up this type of engagement across the other project supported counties. Lessons Learnt 1. CHD is progressively becoming aware of the budget cycle timelines and implications on health planning. However, Afya Pwani must continue and sustain capacity building of the S/CHMT and Hospital Management Team (HMT) on budgeting and planning to enhance advocacy and resource allocation. 2. Although most counties undertake Program Based Budgeting (PBB) as a legal requirement, in practice line item budgeting continue to be used as the main budgeting approach. This will require high level advocacy on adoption and implementation of PBB as required by law. 3. Stakeholder mapping at county level has enabled leveraging of available resources, skills and technical assistance which in turn ensure counties and facilities are able to fully implement planned activities.

54 The development of County HRH staff establishment provides a breakdown of number of staff and their cadre against the norms to provide a true picture of the HR landscape. iHRIS is able to provide the staff age group.

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Output 3.2: Human Resources for Health (HRH)

Lessons Learnt: 3.2.1: HRH management strengthening During the quarter, the Lamu County HRH Staff Establishment was validated and critical facility HRH staffing gaps recognized and documented. The two documents55 will be useful in defining Lamu County HRH investment priorities. Similarly, the development processes for the Kilifi County HRH Strategic plan and the HRH Staff establishment were initiated during the period. The Project initiated HRH staffing data collection and review of the iHRIS system for Kilifi county in preparation for development of the key HRH documents. Additionally, Afya Pwani provided the required TA in reviewing and validating of the situational analysis report for the county as one of the key stages in the development of the county HRH Strategic plan. In Kwale, Msambweni County Referral Hospital received TA to develop the Hospital Staff Establishment and determine the hospital’s HRH critical staffing needs. So far, the hospital has an approved Staff Establishment and has clearly documented its critical staffing needs. Both documents will be essential in supporting the county health leadership to advocate on matters HRH. Afya Pwani will support the dissemination of the documents to all key stakeholders in the next quarter. Afya Pwani also concluded the development of the Facility-Based Staff Management framework to pave way for select counties (Kilifi, Kwale, & Taita-Taveta) to recruit facility-based staff supported by the project. In this process, the counties signed Memorandum of Agree (MOA) with the Project that clearly outlined responsibilities for each party in the management of the intended health workforce. The framework outlines county engagement tools such as; Memorandum of Understanding (MOUs), Facility Based Staff Handbook and the facility based staff transition plan to help document the framework. Based on the provisions of the framework, counties begun the recruitment process of the targeted health workers in an effort aimed at mitigating the current acute shortage of health workers in select public health facilities. Engagements with Mombasa County to agree and sign the MOA are at an advanced stage.

Afya Pwani, based on the agreed framework will provide the required HRH support in the recruitment, placement and management of this group of staff. The Project will continue to provide required TA and technical backstopping to ensure the framework yields the desired results. Going forward, the engagement will focus more on the County Public Service Boards who constitutionally, are charged with the responsibility of recruiting and managing staff at the counties. This is to ensure a seamless and cordial working relationship to better manage the targeted staff. MOA signing ceremony between Kilifi County and Afya Pwani, July 2017

55 Lamu County Critical HRH Gaps Report, Lamu County Health Department Staff Establishment

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3.2.2: County HRH Stakeholders engagement mechanisms The USAID Afya Pwani project participated in the planning and hosting of the second joint Regional HRH ICC and TWG held in Kwale County. During the meeting, the joint initiative was lauded by county leadership teams and the Afya Pwani and the HRH Kenya (National Mechanisms) projects encouraged to continue working together to ensure that HRH ICC and TWG are institutionalized in the region and used as a platform to define HRH agenda for the region. Lessons Learnt 1. County Health Department has begun to appreciate the need to develop HRH planning and management tools that will inform key HRH decisions as well as be used as justification when seeking increase in resource allocation to the department. While there are national policy guidelines on HRH issues the need to have them customized to county specific needs has been eminent.

Output 3.3 a): Health Products and Technologies (HPT) Develop/ revise a roadmap and co-ordinate meetings to improve commodity management at county level During the July-September 2017 quarter, Afya Pwani supported Taita Taveta, Mombasa, Kwale, Lamu and Kilifi CHMTs to convene quarterly commodity security TWG meetings. The meetings were used to review the past quarter’s progress and set priorities for the next quarter.

During the Kwale County TWG meeting, sub-county reporting rates for commodity data were shared and reporting trends across sub-counties reported for each program studied. Generally, the TWG observed improved reporting for TB commodities and non-reporting sub-counties tasked to upload commodity data to DHIS 2. Moving forward, Afya Pwani was asked to support the production of commodity reporting tools and job aids currently not available56. The TWG also requested that the Project facilitate the development of disposal guideline/Standard Operating Procedures (SOPs) for health commodities and the designing of an indicator tracking tool for all program commodities data. In Taita Taveta, The TWG adopted the previously developed forecasting and quantification report for use to support resource mobilization and budgeting for commodities. The TWG also reviewed the reporting rates for commodities on DHIS2. Due to the low reporting rates (Annex IV), it was agreed that henceforth, Commented [FWM2]: I think this needs to be linked to the said all DHIS2 data uploads be coordinated by the Sub-County Health Records and Information Officers annex (SCHRIOs) to improve timely and quality reporting. The sub-counties will also be provided with access rights and sub-county and facility level data audits undertaken. The TWG also established a secretariat to coordinate and monitor the implementation of activities and facilitate information sharing and worked to ensure rational procurement of commodities by reviewing facility orders before submission with the respective program commodity coordinators. The TWG also resolved to advocate for pharmaceutical staff recruitment to ensure commodity management at HVFs is coordinated by trained staff. So far, seven pharmaceutical technologists have been deployed to various rural facilities. Further, the TWG committed to complete disposal of expired commodities from Wundanyi Sub-County which has completed the legal procedures and forms for disposal. A similar process will be conducted in the remaining sub-counties upon completion of proper documentation for commodity disposal.

256 ART, RH and Malaria Facility Consumption Data Report and Request summaries, Facility Monthly ART Patient Summaries

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In Mombasa, the TWG reviewed program commodity data from DHIS2 (generated by an analytical indicator tracking tool). The review focused on the reporting rates, and stock status for the different programs. The review process enabled the TWG to identify anomalies in reporting rates. As shown in Figure 22 below, Mombasa recorded less discrepancies in beginning and ending FP stock balances in the months of March and April 2017; more discepancies were recorded in subsequent months. The TWG participants then used this data to help design their quarterly plan and most imortantly, appropriate interventions for different commodity challenges.

Figure 22: Mombasa Indicator tracking data by County TWG

Similarly, in Lamu, the TWG reviewed the forecasting and quantification budget summaries for health products. The TWG also discussed the Terms of Reference (TOR) with respect to the performance of the existing committee and its membership. Commodity data on DHIS2 was observed to be very low as shown below compared to other counties and the County HRIO tasked to work with program staff to address the gaps in reporting.

HIV Laboratory Commodity Reporting Rates 100% 80% 60% 40% 20% 0% May June July

Kilifi Kwale Mombasa Lamu

Figure 23 HIV Laboratory Commodity Reporting Rates

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See Figure 23 for more information on reporting rates. The low reporting trends for commodities was discussed by the five county TWGs. The challenges identified included wrong data sets allocated to facilities in the DHIS2 leading to higher denominators, lack of reporting tools for appropriate data capture as well as limitations in user rights to the platform. The decline in reporting rates across all counties was also attributed to temporary closure of tier 2 facilities during the period hence failure to submit commodity reports. Afya Pwani has been working with the 5 counties to determine the required tools through the county TWG and following up individual sub county teams to liaise with the health records information officers to correct data sets and facilitate access in DHIS2. See Figure 24 below.

Coast DHIS2 Commodity reporting rates 100 90 80 70 60 50 40 30 20 10

0

FP FP FP FP FP

RTKs RTKs RTKs RTKs RTKs

Malaria Malaria Malaria Malaria Malaria

HIV Nutr HIV Nutr HIV Nutr HIV Nutr HIV Nutr HIV Mombasa Kilifi Kwale Taita Taveta Lamu

May June July

Figure 24 Coast DHIS2 Commodity reporting rates

Work with appropriate CHMTs and SCHMTs staff to support indicator-based pharmacovigilance assessment to improve ADR reporting and assessment of medicines Afya Pwani undertook pharmacovigilance trainings in Kilifi and Taita Taveta counties during the quarter which targeted 5657 health workers58 and focused on pharmacovigilance concepts and framework for medicines quality assurance. The guidelines for assessment, documentation and reporting of adverse drug reactions (ADR) and poor-quality medicines were also demonstrated to the participants. To support pharmacovigilance reporting, participants were oriented on electronic reporting of ADR and poor-quality medicines and on the online reporting platform in the pharmacy and poisons board website. Participants were also guided to create online pharmacovigilance accounts for use in future reporting. Lastly, during

57 Taita Taveta- 28 participants (Male: female ratio,17:11) and 28 (male: female ratio,12:16) in Kilifi 58 Nurses, nutritionists, clinical officers, supply officers, health records and information officers, pharmaceutical technologists, Lab technologists and Pharmacists.

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the quarter, CME on pharmacovigilance was also provided to Taveta sub-County. A total of 35 hospital staff were sensitized to support monitoring and detection of ADRs and poor-quality medicines.

Optimization of EMR in 30 HVFs to inform facility-based medicines and therapeutic committees: The IQCare supply chain module was also installed at the Malindi Sub-County Hospital during the quarter, which saw a total of six (male: female ratio, four: two) pharmacists were trained on the system’s use. The Afya Pwani project also supported pharmacy personnel to update their commodity stock status. It is expected that with consistent use of the system at the CCC, the Hospital will also be able to generate accurate routine reports (facility consumption data report and request (FCDRR) and monthly ART patient summary (MAPS). Capacity building on commodity management A 3-day training on commodity management, appropriate medicines use and pharmacovigilance was undertaken for 56 participants (Male: female ratio, 29: 27) from Taita Taveta and Kilifi Counties. During the training, participants developed action plans that the respective CHMT would follow up to ensure implementation. These action plans are meant to address commodity management challenges (poor documentation, storage, stock outs and non-reporting) experienced at facility level. Lessons Learnt Kilifi County Commodity Management Training, July 2017 1. There is a weak commodity management information system (including flow) across the health management levels and lack of understanding of individual commodity management roles and responsibilities at the facility level. This has resulted in poor data quality. 2. Institutionalization of effective commodity management systems in counties is anchored on functional commodity security TWGs.

Output 3.3 b): Health Products and Technologies- Facility Report i) Capacity building on commodity management

During the quarter under review, Afya Pwani staff visited 3 facilities59 to provide commodity management supportive supervision. OJT on proper inventory management, good storage practices, logistics management information systems and pharmacovigilance was done for 14 health workers (9 male and 5 female) from different cadres60. Job aids were also distributed during the visits to further equip the health workers with knowledge and skills on good commodity management in the different departments61 handling commodities. Marked improvement in practices in all the facilities was noted since they were being visited for the second time. The Figures below illustrate Kongowea’s and Kisauni Health Centre’s Commodity Management Performance (the Pharmacy and Laboratory) between Quarter 1 and 4, and

59 Mlaleo Health Center, Kisauni Health Center and Kongowea Health Center in Mombasa County 60 Pharmaceutical Technologists, Nutritionists, Laboratory Technologists, Laboratory Technicians and Support Staff 61 Pharmacy, Medical Stores, Comprehensive Care Clinic, MNCH/FP Clinic, Nutrition Clinic, TB Clinic and Laboratory

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there have been marked improvements across all areas- a positive indication that the Project is having an impact. See Figure 25 and 26 below.

Kongowea Health Center Commodity Management Performance 100 90 80 70 60 50 40 30

PercentageScore 20 10

0

StorageAreas StorageAreas StorageAreas StorageAreas

Resourcesand… Resourcesand… Resourcesand… Resourcesand…

Aggregate Score Aggregate Score Aggregate Score Aggregate Score

Availability and Use of… Availability and Use of… Availability and Use of… Availability and Use of…

InventoryManagement InventoryManagement InventoryManagement InventoryManagement Pharmacy Quarter 1 Pharmacy Quarter 4 Laboratory Quarter 1 Laboratory Quarter 4

Figure 25 Kongowea Health Center Commodity Management Performance

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Kisauni Health Center Commodity Management Performance 100 90 80 70 60 50 40

30 PercentageScore 20 10

0

StorageAreas StorageAreas StorageAreas StorageAreas

Aggregate Score Aggregate Score Aggregate Score Aggregate Score

InventoryManagement InventoryManagement InventoryManagement InventoryManagement

Availability and Use of MISTools Availability and Use of MISTools Availability and Use of MISTools Availability and Use of MISTools

Resourcesand Reference Materials Resourcesand Reference Materials Resourcesand Reference Materials Resourcesand Reference Materials Pharmacy Quarter 3 Pharmacy Quarter 4 Laboratory Quarter 3 Laboratory Quarter 4

Figure 26 Kisauni Health Center Commodity Management Performance

It should be noted that the scores were obtained using a scored supportive supervision checklist where the different aspects of commodity management carry different weights in contributing to the aggregate score depending on their importance as follows (see Table 21 below):

Table 21 Weighting of Commodity Management Aspects in the Afya Pwani Scored Supportive Supervision Checklist Commodity Management Aspect Contribution (%) Resources and Reference Materials 10 Storage Areas 20 Availability and Use of MIS Tools 30 Inventory Management 40 Total 100

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120.0 Commodity Management Indicator Analysis

100.0

80.0 First Visit 60.0 Second Visit Percentage 40.0

20.0

0.0

Indicator Figure 27 Comparative Commodity Management Indicator Analysis for Afya Pwani Facilities Visited Twice (Q1 to Q4)

The indicators to the left in the Figure 27 above are supposed to increase over time while the ones to the far right are supposed to decrease over time. The output indicators all increased in the second visit (inventory management, storage practices, availability and use of management information system tools and availability and use of electronic dispensing tools). This shows that facility staffs are managing commodities better after supportive supervision and OJT. However, the outcome indicators (stock status and expiries) the changes are less pronounced and deteriorate slightly in some instances e.g. expiries and stock above minimum stock. Trends that can be explained by other variables that come into play, for example allocation of money by the County Governments for procurement of commodities and the procurement cycles. In Kilifi County which forms the bulk of the facilities in the sample, procurement is biannual. The last supply was December 2016. The order submitted in June 2017 to KEMSA hasn’t been supplied yet and stocks are running low. Some essential commodities were not supplied at all in December 2016 despite being ordered for example Zinc/DTS packs and this has caused a perennial shortage of the commodity. The expired commodities have not been disposed and the results are cumulative (showing a slight increase). Program commodities remained largely available but there were instances of facilities not receiving the quantities they order especially of Cotrimoxazole Tablets and Cotrimoxazole Suspension from KEMSA MCP. Cognizant of these challenges that Afya Pwani project has stepped in and support counties in terms of Forecasting and Quantification and advocacy for budget allocation for commodities, as well as liaising with KEMSA to ensure the supply of vital RMNCH commodities when they are ordered. Between July-September 2017 County and Sub-county officers were also supported with airtime for upload of commodity data into DHIS 2 and HCMP. Redistribution of commodities was enhanced via the Pwani Commodity Managers WhatsApp group where information can be easily shared. Other useful information for example guidelines on the use of Dolutegravir, a newly introduced antiretroviral medicine, was also shared. Some commodity reporting tools were photocopied bound and distributed for example

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HIV RTK monthly reporting tools to Taita Taveta County to ensure that facilities had the necessary tools for accurate and timely reporting as per the national guidelines.

Output 3.4: Monitoring and Evaluation Systems

3.4.1 Conduct Data Quality Audits (RDQAs, DQAs) to strengthen data collection systems and processes at facility level Routine Data Quality Audits ( RDQAs) aim at providing information on the quality of routine data being captured in both EMR and manual systems at facility level. During the period under review, Afya Pwani supported Kwale, Kilifi, Lamu, Taita Taveta and Mombasa counties to undertake EMR DQAs reaching 29 facilities62. Findings from the DQAs provided insights on EMR use and reporting discrepancies that need fixing to facilitate facilities’ transition to the Point-of-Care (POC) and eventually paperless system.

This exercise was a follow-up to a DQA conducted through a comparison of data in IQTools, MOH 731 and DHIS2 data for key Indicators. Indicators of interest were: Enrolled in Care, started on ART, current on ART, current on care, and TB Screening. The initial DQAs were conducted in February 2017. For paper-based sites, Afya Pwani also sampled 10-15 files for a review of data (on parameters mentioned above) in the hardcopy tools and compared this to data in the EMR per patient record. Hard copy registers on ANC/PMTCT data were also reviewed. Issues identified during the data quality audit were discrepancies in numbers reported and IQCare reports, backlog of files that have not been updated in the EMR, defaulters who required tracing and outcomes documented in the EMR, IPT data that has not been updated in the EMR and gaps in HEI data documentation in the system. To help address and mitigate these challenges in the next quarter, project staff provided OJT and mentorship on the use of the EMR generated linelists on defaulter tracing, viral load, IPT dispensed, TB screening and general understanding of indicators i.e current on ART, to help in data cleaning. Previously, there were knowledge gaps on use of EMR. Moving forwardm Afya Pwani will continue to offer technical support to the facilities to ensure optimal EMR use. See Figure 28 below.

EMR Uptake and Data Quality in High volume sites 98% 96% 95% 94% 91% 91% 91% 87% 72% 67% 70% 74% 70% 68% 67% 56% 52% 52% 44%

12% 10% 10% 10%

2% 2% 7%

Moi Voi Moi BamburiHealth Tiwi Rural MtwapaH/C KilifiCounty VipingoH/C Mwatate PortReitz Sub-county Likoni CoastPGH MalindiSCH Vanga Kinango

Hospital

Centre Hospital

Feb-17 Aug-17

Figure 28 Comparison of EMR DQA Findings

62 Lamu County: Witu health Centre, Lamu Sub-county hospital. Kilifi County: Kilifi County Hospital, Bamba SCH, Mariakani SCH, Vipingo H/C, Mtwapa H/C, Gede H/C, Gongoni H/C. Taita Taveta County: Taveta SCH, Mwatate SCH, Wesu SCH, Moi Voi County Hospital. Kwale County: Kwale SCH, Msambweni SCH, Kinondo Kwetu, Diani H/C, Tiwi H/C, Vanga H/C, Kinango SCH, Vitsangalaweni dispensary, Mwaluphamba dispensary, Lunga SCH Mombasa County: Port Reitz hospital, Mlaleo H/C, Bamburi H/C, Likoni SCH, Mrima H/C, Kongowea H/C

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Despite the aforementioned challlenges, the Figure above illustrates that significant gains have been made in regards to the utilization of EMR system use across the Afya Pwani supported counties; where there have been notable improvements made, especially in regards to improve the consistency of manual and system generated reports between the two periods. Initial DQAs conducted in February 2017 show an average consistency of 34%, while the follow-up DQAs show an average consistency of 84% . This indicates that there has been marked improvements between EMR generated and manual reports between February 2017 and August 2017. In addition, Afya Pwani has managed to operationalize facilities where EMR had previously stalled i.e. Malindi SCH, Kinango SCH and Moi Voi county referral hospital, Coast PGH and Port Reitz hospitals. The Project will continue to build on these gains in the next quarter

3.4.2 IQCare upgrades and troubleshooting The team conducted IQCare trouble shooting at various facilities63 while also conducting a follow-up on progress of data entry and EMR use. Most of the facilities are on hybrid utilizing both retrospective data entry (RDE) and point-of care (POC) implementation. The health care workers were mentored on the use of the various data use line-lists in the system for effective patient management. In addition, the Afya Pwani team also conducted an upgrade of the IQTools in 29 sites out of 55 targetted EMR sites to the latest version 3.5.1.2 which has improved decision support tools in line with the new ART care and treatment guidelines. The reporting tool has also been improved to ease data extraction and include more updated reports and registers according to the revised HIV guidelines.

Afya Pwani in collaboration with Kenya Health Management Information System (KenyaHMIS) project also trained the healthcare workers across the region on the latest versions of IQCare, IQTools and the greencard in readiness for transition to revised tools.

3.4.3 Quarterly Data Review Meetings Between July-September 2017, Afya Pwani also supported data review meetings for sub-counties64 in Kilifi County which comprised of facility in-charges and SCHMTs. During these meetings, project staff helped to review service delivery data for the period June 2016-June 2017 focusing on MNH and HIV Care & Treatment indicators. ANC attendance was discussed in depth with concerns arising from the discrepancies noted in 1st ANC and 4th ANC attendance as shown in the Figure 29 below.

63 Bamba Sub-District Hospital, Mariakani SCH, Mtwapa health Centre, Malindi hospital, Muyeye Health Centre, Gede Health Centre, Rabai Health Centre, Kilifi County Referral Hospital 64 Rabai, Magharini, Kilifi North, Kilifi South, Malindi, Kaloleni, Ganze sub-county

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1st & 4th ANC 13195

10416 10210 8769

5726 5160 4398 4131

Jul to Sep'16 Oct to Dec'16 Jan to Mar'17 Apr to Jun'17

4th ANC 1st ANC

Figure 29 Comparison of 1st and 4th ANC Source: DHIS 2 (4th August 2017)

Discussions by participants centered around indicators on 1st and 4th ANC attendance, as well as gestation at 1st visit and data collection on ANC visits. Issues identified were poor documentation and late presentation and recommendations were made to conduct data quality audits and tools training to improve data collection and use to address these issues in the next quarter. The performance of these indicators will be assessed in subsequent quarters.

3.4.4 Data Demand and Information Use Trainings Afya Pwani also conducted a Data Demand and Information Use (DDIU) training in Kilifi county targeting sub-county AIDS & STI coordinators, sub-county health records and information officers, facility in-charges and facility-based health records and information officers. The participants were also trained on navigating IQ Care, IQ Tools, use of excel for analysis and the DDIU framework. The most immediate impact of these activities has been an increase in the uptake of the EMR since county and facility health care workers are better able to navigate and use the system for patient care and reporting and this is demonstrated by figure 4 above on EMR uptake. Other notable outputs have been that health care workers are better able to conduct in-depth data analysis and use the data for decision making as well as data presentation during quarterly data review meetings and tracking performance of indicators over time.

Lessons Learnt 1. There is weak capacity in correlating service delivery input and output data to inform decisions. 2. Institutionalization of EMR in the health sector requires policy and health workers training curriculum review to encompass the role of digital systems in health service delivery.

III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) Please see Attachment II for the full performance summary tables.

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IV. CONSTRAINTS AND OPPORTUNITIES

Table 22 Summary of Challenges and Recommendations for July-September 2017 What were the challenges encountered during the quarter? How were these challenges addressed?

1.1 EMTCT

RTKs not in enough stocks especially for HTS • Improve the skills of the SCMLTS to forecasting and outreaches ordering of RTKs

Not all health care workers have been updated on the • OJT and mentorship to these health workers New testing and ART guideline.

Nurses’ strike impeded service delivery in many • The project supported task shifting to mentor facilities mothers and referred the mother-baby pairs to clinicians and pharmacy for prescriptions and drug refills. In other facilities, mothers were given drugs for longer periods and requested to call the sub county or Afya Pwani when they needed any help before the strike ended. Support group meetings were continued during the strike. 1.3. Treatment Services

Limited space for consumable storage • Training, OJT and mentorship on going.

Abbott reagents failure in the month of August • Targeted outreaches in the private facilities, learning institutions and in informal settlements Abbott Reagents for processing DBS taking long hours • Redistribution of RTK was done to areas with stock for extraction(5hours) outs. • County lab coordinator advised to do the right quantification of RTK and to clean up the HCMP balance which does not tally with the physical RTK counts at the facility which is affecting distribution of RTK from KEMSA. Laboratory renovation. • Not yet addressed.

1.4 Prevention, Testing and Counselling

Some health workers not updated on new testing • Training, OJT and mentorship on going. algorithm.

Health workers strike resulting to small number at the • Targeted outreaches in the private facilities, learning facilities for PITC institutions and in informal settlements

Erratic supply of RTKS • Redistribution of RTK was done to areas with stock outs. • County lab coordinator advised to do the right quantification of RTK and to clean up the HCMP balance which does not tally with the physical RTK

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counts at the facility which is affecting distribution of RTK from KEMSA. Health worker strikes reduced uptake of HTS services • The project seconded HTS counselors to private across all county. facilities to offer testing there since many clients are being attended there. 1.5 HIV/TB Co-infection

Lack of support for monitoring tests for TB patients • Facilities provide waivers where possible e.g. audiometry, ECG, blood tests for MDR patients

Erratic supply for DR TB and IPT Afya Pwani Commodity Advisor supported facilities to improve on ordering correctly.

Strike by nurses has affected provision of TB services in • Task shifting and making appropriate referrals by facilities manned by nurses. CHVs/peer educators.

Stigmatization of TB patients who put on masks for • Health education is being done in facility and infection prevention and control. community forums.

SUB-PURPOSE 2: MNCH

MNCH Services

Health Workers strike slowed down service • Most program activities have had to be re-scheduled delivery and activity implementation. several times or put on hold

Skills gaps on data capture and reporting • Mentorship of providers on documentation and reporting

ANC profile investigations are charged at Ksh 300 in the • The program plans to support some facilities in lab public facility and Ksh 1000 in private facilities. Most networking for antenatal profile investigations in year mothers could not afford this

WASH & NUTRITION SERVICES

Most schools especially in Ganze don’t have adequate • The BOMs to be supported to fundraise locally and water supply as a good enhancer to sustain hand engage the county and other partners to give washing practice assistance

Long time was taken to identify local artisans for • encourage the ministry of water to identify and training because there is no regular inventory by the register existing artisans so that they can easily be ministry of water mobilized

The department of water has few staff who are • Initiate discussions to explore opportunities of overstretched in supporting many WASH partners in offering refresher training for other staff the County

The County delayed planning of this years the World • Support the county to hold regular interpectoral breastfeeding week that was marked in the first week planning and review meetings e.g. health, education of September instead of Early August and agriculture so that the events are celebrated timely There a few staff employed by at the county and sub • Encourage the County focal persons to delegate county level from the health department to maximally when they have other competing tasks

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support in some of the field based activities especially making follow ups of interventions

SUB-PURPOSE 3

3.1 Partnerships for Governance and Strategic Planning

HMT have inadequate knowledge on the budgeting • Continuous capacity building of HMT on planning, process. This limits their participation in budget- budgeting and costing. making and prioritization of programs.

Weak capacity of health planning coordinators to • Advocate for strengthening of the planning and meaningfully steer the planning and budgeting budgeting unit. processes.

3.3 Health Products and Technologies

Parallel commodity management approach at the • Health commodity management policy review to county level resulting in inefficiency in the harmonize ‘pharmaceuticals and non- management of commodity security. pharmaceuticals’ management processes.

• Industrial action by nurses leading to non- • Consider broadening the scope and role of HRIOs to reporting on commodity management encompass commodity management reports. information from health facilities.

3.4 Monitoring and Evaluation

Rotation and high staff turnover including industrial • Identification of EMR champions in all counties to action leading to the need to constantly train new crop spearhead EMR trainings and facility support. of staff on the EMR.

V. PERFORMANCE MONITORING

During the July-September quarter, Afya Pwani continued strengthening strategic monitoring and evaluation systems. Focus was on strengthening M&E systems at facility, sub-county and county levels with an aim to improve MOH staff skills in correct data collection, reporting, accurate and complete reporting in DHIS2, use of EMR, use of data for decision making and program improvement. Cognizant of the ongoing industrial action, the team worked to put measures in place that ensured up to standard documentation and reporting practices. Unlike previous quarters where data was collected quarterly, the Afya Pwani started to work within the MOH monthly reporting cycle to maximize opportunities to offer technical support in report preparation and minimize avoidable errors like missed opportunities in linkage and HAART initiation among PMTCT clients. Over the reporting period the quality of the data submitted to the sub-counties for data entry has increased tremendously, thus increasing the confidence on the data for decision making. Activities conducted towards strengthening M&E systems across the project sites

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included routine site visits, mentorship, data review and gap analysis meetings at all levels of service delivery, data quality assessments, dissemination of reporting tools and taking part in the recently concluded SIMS. Depending on the specific M&E needs, each Facility/sub-county and county was supported by ensuring that they are facilitated/issued TA to ensure: • Their data management processes achieve complete, accurate and timely data collection and reporting at facility and sub-county level • Their capacity is improved in data analysis, dissemination and use of data at all levels of service delivery • And that a culture of ensuring data quality assurance systems and practices at all points of service delivery is maintained.

Strategically, the team focused on site level data quality improvement (DQI) through regular monthly data verification, data quality audits, sub-county performance review meetings, and application of SIMS tool. Having invested greatly in ensuring that the Project was felt at the facility level, 9 project Health Record Information Officers ensured that all sites supported under the project received technical support at least once during the reporting period, and a follow up visit made within the same period to address previous or emerging data quality related issues.

i) Data Demand and Information Use (DDIU)/Performance Review Meetings/Data Sharing

Afya Pwani’s Strategic Information (SI) team supported facility based data review meetings for HVFs and the performance review meetings at sub-county levels. The focus of the meetings was to discuss performance in all project supported thematic areas including HIV services, RH/FP, MNCH, as well as WASH and nutrition. These review meetings were integrated with OJT and mentorship on data collection, analysis, reporting and use. Facility staff in Modambogho, Mwambirwa, Shelemba, Mpinzinyi Dispensaries and Tausa Health Center in Taita-Taveta were also guided on reporting of indicators and corrections were made on the MOH 731 summaries. In Kwale County, data review meetings were held at Msambweni County Referral Hospital, Kinondo Kwetu Health Center, Diani Health Centre, and Tiwi. Whilst in Mombasa 18 facilities also benefitted from the same support65. Lastly, in Lamu County- Afya Pwani provided central support and facilitated the provision of performance review meetings with the CHMT and facility teams during the quarter as well.

In Taita-Taveta county facility data review meetings were conducted in Mwatate Sub-County Hospital and Moi-Voi County Referral Hospital where significant improvement was noted in reporting quality of the MOH 731 indicators in Mwatate Sub-County Hospital. In Moi-Voi County Referral Hospital had data quality gaps on abstraction from the source tools and EMR to the summary tools were identified and a data cleaning exercise on MOH 731 was initiated (it is still ongoing at the time of writing the report). Additionally, Afya Pwani also supported data sharing sessions in a meeting with the CASCO and SCASCOs in the County to identify and address data quality gaps. Some of the issues and gaps that were discussed include but are not limited to the following: Low latrines coverage Insufficient nutrition commodities; Gaps in knowledge on the new ART treatment guidelines; Knowledge gap on documenting client ever on ART; Viral load documentation and tracking inconsistent; Low uptake of HIV services by adolescents and

65 CPGH, Port Reitz SCH, Tudor DH, Likoni DH, Kisauni Dispensary, Utange dispensary, Mrima Health Centre, Magongo Dispensary, Mikindani Health Centre, Jomvu Model Health Center, Mlaleo Health Center, Miritini CDF dispensary, Ganjoni Dispensary, Kongowea Health Centre, Likoni Catholic Dispensary, Chaani dispensary, Railways dispensary and Mvita Dispensary.

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young people; Low Family planning uptake due to inconsistent availability of FP commodities; Low number of mothers delivering in the health facility; Low numbers of mothers completing 4 ANC visits; Low number of women screened for cervical cancer; Low Immunization coverage; High number of still births; and lastly knowledge gaps in terms of health indicators and reporting tools – especially for fully immunized children.

Moving forward, the Afya Pwani team worked with the S/CHMTs to draft the following recommendations that will be worked on in the next quarter: Conduct updates trainings to health service providers on Enhanced diarrhea management; Conduct sensitization meetings to CHEWs/CHAs on diarrhea prevention and control; Conduct follow up visits to 500 triggered villages; Conducting community dialogues on importance of constructing, use of latrines and behavior change; Capacity build on the new ART treatment guidelines; Train and provide viral load tracking tools; Capacity build health workers on adolescents and youth friendly services; Training on FP commodities management; Training on LARCs (Post-pregnancy FP Methods; Providing mother/baby friendly services post-delivery; Motivating TBA on conducting deliveries in the health facilities; Conduct integrated outreach services; Conduct MNCH quarterly data review Meeting; Conduct quarterly Integrated Community outreach; Conduct supervision and mentorship program; Conduct 1 integrated Outreaches per month for 11 health facilities; Support CHV to conduct defaulter tracing- avail defaulter tracing register to every facility; Conduct perinatal audit and Conduct DQA to harmonize data across the board.

In addition to the sub-county review meetings held above, the Project also supported facility level performance review meetings. During these forums, the facilities presented PowerPoint presentations by program staff for them to generate data to be shared during the actual day for review meeting. The review focused mainly on MNCH program activities in the facility. Some gaps and strengths were discussed and way forward arrived at as indicated in the Table 26 below:

Table 23 Performance Review Gaps and Recommendations GAPS IDENTIFIED RECOMMENDATIONS BY WHO BY WHEN Clinicians not updating files Files to get updated every Clinicians Immediate in IQ care day by the CCC clinician and the HRIO in charge. Phone numbers not going Get the correct/current Peer educators at the Ongoing through during defaulter Phone numbers when CCC. tracing defaulters come Get the precise home address to enable physical racing as an alternative.

Data review meetings To be held with consistency Facility in charge Before 5th of every Stella. month

During these forums, facility best practices were also identified during these forums and facilities encouraged to continue integrating QI in their routine processes of service delivery including proper documentation and reporting. Some of the identified best practices include but are not limited to: Data entry done at facility level which has helped reduce data entry errors; In-reaches for FP are conducted to target women at the community level; Facility has youth friendly services e.g. FP services; HTS counsellors do escort reactive clients from VCT to CCC department for further management e.g. linkage; Effective

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communication among the staffs in the facility thus provides conducive environment for OJT good staff relation, coordination in daily, conflict resolution among staffs.

ii) Roll out of SIMS Between July and September 2017, several facilities were visited in the reporting period to sensitize them on the standards of service delivery, documentation, and reporting as envisioned in the site improvement system package. With the support from relevant MOH staff, the assessment was made and OJT and Mentorship provided. In terms of HTS, the following was observed during SIMS: HTC register available and in use; Page summaries well done; Register well filled per guidelines; Some SOPs were not available so the program officer took note of that and liaised with service delivery manager for them to get printed and lastly Program HRIO updated performance trends in form of graphs on walls. Afya Pwani project staff will work on building on these gains in the next quarter. In regards to PMTCT, the SIMS reports also highlighted that the ANC registers were available and in use at MCH departments and page summaries were well done. However, it was also found that these registers were not well completed as per the national guidelines and the HEI register was not up to date; Afya Pwani HRIOs have already provided TA on how to fill and updating the same. Lastly, some client’s files did not have nutrition assessment (BMI) so program HRIO together with the facility CCC in charge updated BMI in some files and the facility in charge promised to follow the trend in updating nutrition assessment. In terms of HIV Care and Treatment, the SIMS report highlighted that ART registers were available and up to date; Daily Activity Registers (DAR) were available and in use, and were well filled per guidelines; Viral load results were printed and the program HRIO assisted in filing all results in respective files; Did a simple DQA for the EMR system in place to check for accuracy and completeness of data entry and facilities were at 97% in terms of accuracy for all indicators. However, despite these gains, it was found that some Job Aids were missing, and Afya Pwani HRIOs and service delivery managers tasked with getting the same for each respective facility. It should be noted that all PMTCT files were transferred to CCC due to the nurses’ strike. Lastly, there were some tools that were out of stock (e.g. DAR for ARVs and OIs) and during the facility visits, the Afya Pwani staff were tasked to helping to print and distribute some of these tools for continuity of services in the next quarter. iii) OJT and Mentorship on HIV Tools in CCC During the July September quarter, Afya Pwani worked to strengthen reporting both at facility level through offering TA support, OJT and mentorship to healthcare workers across Project supported sites. The Afya Pwani TA package include but was not limited to support on: correct use on the HEI, ART, ANC and IPT registers; use of EMR; proper documentation in the blue card, and reporting using the MOH 731. During the quarter, Afya Pwani also supported site visits during clinic days, to promote and encourage complete and accurate documentation during the same. By supporting these activities, Afya Pwani was supporting the provision of one-on-one interaction with health care workers which has gone a long way in helping to greatly enhances their data reporting and collection skills at the facility level. It is the projects hope that such investments will go a long way in changing any wrong attitudes towards documentation and develop a system that can be sustained beyond the life of the project. Some of the issues observed or done during the clinic days include the following: For HTC- HTC register available and in use, page summaries well done, register well filled per guidelines and consistent reporting was done; PMTCT- ANC register available and in use at MCH, register well completed per guidelines, all new first visits were clearly indicated in the register with a different ink; page summaries well done, post-natal register available and in use, and PNC register well completed per guidelines; HIV Care and Treatment- Pre-ART and ART register available and in use, ART register not up to date (HRIO updating it), HRIO supported the facility in arranging the filing system per age groups and DAR in use but the CCC in charge requested to be mentored on how to populate MOH 731 report using the DAR.

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During the monthly visits to the facilities during the quarter under review, project staff also encouraged health care workers to rely on updated source documents when preparing reports to ensure the data generated is useful for informed decision making at facility level as well as other levels. Afya Pwani staff also helped to collect data from all project supported sites in preparation of MOH reports, during these activities it was flagged that some facilities had data discrepancies, including but not limited to Sabaki Dispensary, Garashi Dispensary and Freddie Msena Hospital, all of had discrepancies in their MOH 731 registers. This was corrected during Data for Accountability, Transparency and Impact (DATIM) data collection, where the Project team helped health care workers to revise the MOH 731 and submit the revised copies to SCHRIOs for DHIS2 entry.

It should be noted that there were some facilities whereby ART registers were not up to date but the project staff with CCC staff worked hand in hand and update them before leaving; as was the case in Tsangatsini, Ganze Health Centre, Vitengeni Health Centre, Matsangoni Health Centre, Marereni Dispensary, Chasimba Health Centre and Baolala Dispensary. Another major challenge faced by health workers across Project supported sites this quarter revolved around the ability not to be able to print viral load results for filling in the patient folder. Afya Pwani was able to step in to support these facilities by printing the results from the website and delivered them to the facilities and helped in the filing of the results. This is something that the program would continue to support to make it easy for clinicians reviewing the clients to easily find the viral load results for proper management of clients. Project staff will also continue to follow up on the updating of ART registers in all facilities and make sure that all facilities formerly in the habit of not updating registers do so on time to make reporting on retention as accurate as possible. Of note is that during these visits, project HRIOs emphasize the importance of completeness of data on the blue card including calculating the BMI of client and to screen client using the Intensive Case Finding (ICF) cards.

iv) MNCH/FP/WASH/NUTRITION Support Supervision, OJT and Mentorship During the quarter under review, Afya Pwani staff worked to strengthen strategic information for MNCH, RH/FP, WASH and Nutrition health services by supporting and facilitating support supervision, OJT and mentorship at the project, facility and sub-county and county levels. The Afya Pwani team were able to assess different departments during the quarter and the following findings were highlighted: the help of the team, several departments are assessed as follows: RH/FP- FP register available and in use, FP register page summaries well done which is recommendable, and registers well completed per guidelines; PNC- Post Natal register available and in use, and page summaries done partially in PNC register (HRIO will provide TA to update the register); ANC- ANC register available and in use, all new visits well indicated in the register with a different ink, consistent data in ANC register and MOH 711 report; Maternity and delivery- Maternity register (MOH 333) available and in use, register was well completed per guidelines; WASH and Nutrition- ORT register available and in use but no specific ORS corner. To address this gap, Afya Pwani will support facilities to set up a functional ORT corners where necessary. Some facilities have also asked for support from Afya Pwani to assist with commodities (Zinc and ORS) due to stock outs.

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OJT and Mentorship in Kitobo Dispensary, August 2017

v) Patient Files Audit During the quarter under review, the Project also helped facilities to clean their shelves and cabinets by removing files of clients that had not visited the facility for more than three months. The file audit helps in determining the actual number of clients in the clinic. This created more space for new files to be added in those cabinets. Project staff also worked closely with facility and separated the filing area for pediatrics and adolescent from the adult files to make follow up easy and real-time. In the process of the file audit, the project staff together helped in updating ART and Pre-ART registers as well the EMTCT dashboards. Some facilities had a very big gap of non-updated ART registers but with support from project HRIOs the files were updated. It was realized during the visit facility was not using ICF cards when screening PLHIV. Project staff also supported facilities to audit client’s files and separate non-active files from filing area to create more space for new files. Lastly, project HRIOs also supported facility to arrange client files in a straight numerical filing system for easy file retrieval. vi) Data Quality Audit Afya Pwani also conducted DQAs and Routine Data Quality Audit (RDQAs) for supported sites as part of efforts to identify and address data gaps at all levels, from primary data sources to the reporting platforms i.e. DHIS 2 and the DATIM. In Kwale the DQAs were conducted in Msambweni County Referral Hospital, Diani Health Centre, Kwale Sub- County Hospital, Lunga Lunga Sub-County Hospital, Kinondo Kwetu, and Tiwi Health Center, where gaps were identified and action points developed at the facility. In Mombasa DQAs were conducted in CPGH, Kisauni dispensary, Shika Adabu Dispensary and Mrima Dispensary where source documents were compared with reporting summaries, and gaps/best practices and reasons for disparities identified. Arithmetic and counting errors were identified and corrected and measures to avoid repetition of the same mistakes put in place. There was a county led RDQA was conducted towards the end of September which is still on going and a full report will be shared once the exercise is complete. In Taita-Taveta county, DQAs were supported in Kasighau Health Centre, Njukini Health Centre, Kitobo, Divine Mercy-Eldoro Mission, Challa and Ndilidau Dispensaries with areas of focus being on: Identification and Linkage to Treatment, Care and Treatment, TB/HIV and PMTCT. See Table 27 below.

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Table 24 DQA findings, Taita-Taveta County, September 2017 Facility Findings Action Point i. Kasighau ▪ Feb 2017 not reported in DHIS2 Report to be updated in DHIS Health ▪ Tallying and aggregation errors in Mar-17, OJT done on reporting and Centre Apr-17 and May-17 reports updated. ▪ ART register not updated. ▪ Care and Treatment ▪ IPT tallying inconsistencies for Nov-16, Jan- 17, Feb-17 and May-17 ▪ Consistency noted from source tools to summary tools. Few errors noted in reporting in DHIS2

ii. Njukini ▪ General consistency noted from the source The facility to follow-up and Health to summary and DHIS2 in most areas. update the HEI statuses Centre ▪ IPT numbers has few inconsistencies between the source and DHIS2 ▪ On PMTCT, all 1st ANC clients tested in the visit. ▪ HEI register lacks completeness

iii. Kitobo ▪ Good documentation and transcription for Data reconstruction and cleaning Dispensary in HTS indicators. OJT and mentorship on ART ▪ Good utilization of DAR activity sheet but reporting done inconsistency in summary and DHIS2 ▪ IPT and HEI register not in use and ART register missing entries ▪ Dec 2016 report missing in DHIS2 ▪ Knowledge gap in some PMTCT indicators e.g. KPs iv. Divine ▪ Minimal inconsistencies between the TA provided on register Mercy summary and source tools completeness accurate Eldoro ▪ Good utilization of DAR with few reporting. Mission incomplete entries. The facility needs to get PMTCT Dispensary ▪ ART register not complete mothers who refuse treatment. ▪ Cohort analysis is a challenge

v. Challa ▪ Good documentation in DAR, though some OJT and TA on documentation. Dispensary clients miss being documented. Facility to update HEI and ART ▪ ART register is incomplete thus cohort register analysis is a challenge ▪ ANC register missing visit type in some entries ▪ Data consistency was observed across all mechanisms ▪ HEI register not updated

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vi. Ndilidau ▪ Known positive in HTS summaries and Follow up mentorship was done Dispensary DHIS2 Facility to update all registers ▪ Aggregation of total values in MOH 731 Data cleaning. summaries had inconsistencies. ▪ ANC register well updated.

Cohort analysis and interpretation was noted as a crosscutting challenge and was put as an area of focus for the coming quarter. In Kilifi the project supported a program wide DQA various data elements and indicators as indicated in the Table 28 below:

Table 25 (List of Indicators for DQA conducted in Kilifi in September 2017 INDICATOR SOURCE REGISTER REPORTING FORM

Immunization/KEPI

BCG Permanent Register 710 Immunization defaulters traced and Permanent Register/Quire 515 referred for immunization Book/MOH 514/Referral Forms

Measles under 1 Permanent Register 710 FIC Permanent Register 710 ANC

1st ANC client ANC 4th ANC clients ANC Pregnancies among AY (10-14) ANC Pregnancies among AY (15-19) ANC ANC Defaulters traced and referred to ANC/Referral Forms 515 ANC MATERNITY

Total Deliveries Maternity Register 711 Maternal complications Maternity Register 711 Maternal deaths Maternity Register 711 Maternal Deaths among AY (10-19) Maternity Register 711 Live births Maternity Register 711 Still Births Maternity Register 711 POST NATAL CARE Children reviewed postnatally within PNC Register 711 72 hrs.

FP Clients by Method

New Clients on FP (All except condoms) Family Planning 711

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Adolescent Family planning uptake 10- 14 yrs. Adolescent Family planning uptake 15- 19 yrs. Test and Linkage

Total Receiving HIV positive results HIV Testing Register MOH 731 Number enrolled into care PRE-ART REGISTER MOH 731 HIV care & treatment

Starting ART ART-REGISTER MOH 731 ART Net Cohort ART-REGISTER (July 2015-June MOH 731 2016) PMTCT

HIV Positive Pregnant Women ANC Register/Mat/PNC MOH 731 Pregnant women receiving HAART ANC Register MOH 731 Infants on Prophylaxis ANC Register MOH 731 HEI with Positive PCR Results HEI Register/Lab Register (July 2015-June 2016) HEI HIV positive enrolled into care PRE-ART REGISTER WASH

Households using treated water CHV Summary MOH 514/513 MOH 515 Households with handwashing CHV Summary MOH 514/514 MOH 515 facilities Households with functional latrine use CHV Summary MOH 514/515 MOH 515 NUTRITION

Exclusive breastfeeding CWC 711 Vit. A given at 6 Months Permanent Register 711 Severely malnourished (MUAC red) CWC 711 Moderately malnourished (MUAC CWC 711 yellow) Children underweight CWC 711

The DQA findings from Kilifi are yet to be analyzed. Once the data has been reviewed and a report prepared, the findings shall be disseminated to all relevant stakeholders and ensure proper measures are put in place to minimize data gaps in future. vii) Reporting During the quarter, the Project also supported the MOH M&E department from Afya Pwani supported counties with internet bundles to upload the data in the DHIS 2, retrieve aggregated data for analysis, and disseminating the information to all relevant stakeholders. Afya Pwani also supported previews of the reports to identify and remove any errors in the data before the data is uploaded to the MOH reporting platform. Through this kind of support, emanating and imminent data quality issues were neutralized

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timely and remedial actions implemented. Project staff also continued to encourage timeliness in reporting through ensuring facilities have all reporting tools and have the capacity to fil the reports correctly. Despite the recurrent health care workers strikes experienced in FY17, reporting of major service delivery reports (MOH 731, MOH 711, and MOH 710) has least been affected (except for most of the facilities which were run by the nurses and remained closed completely hence affecting the reporting rates). The figure below showcases the average annual reporting rates for major reports for Afya Pwani supported sites for the period October 2016 and September 2017. The trends below highlight that apart from the MOH 713 Nutrition register and the MOH 515 CHEW registers, reporting rates have been above 80% across the board. Project staff will work on maintaining these gains in the next quarter, working towards getting these reporting rates closer to 100%.

FY 17: Average Annual Reporting Rates for Major Reports

MOH 515 Community Health Extension Worker… 72

MOH 713 Nutrition 64

Facility Contraceptives Consumption Report and… 83

MOH 717 Service Workload 90

MOH 710 Vaccines and Immunisation 91

MOH 711 93

MOH 731-3 Care and Treatment 93

MOH 731-2 PMTCT 95

MOH 731-1 HIV Counselling And Testing 97

0 20 40 60 80 100 120

Figure 30 FY 17: Average Annual Reporting Rates for Major Reports

Figure 30 above shows the month by month reporting rates for Kilifi County is provided in the Table 29 below to provide sample trends in terms of reporting rates during Year 1.

Table 26 Reporting rates in FY 17 for Kilifi MOH MOH MOH MOH MOH 710 MOH 713 MOH 717 MOH 515 FCDRR 731-1 731-2 731-3 C 711 Vaccines and Nutrition Service CHEW HTS PMTCT & T Immunization Monthly Workload Summary

Oct-16 99 98 92 99 98 69 100 67 99 Nov-16 99 97 92 99 95 61 97 73 76 Dec-16 100 98 92 99 98 71 100 75 64 Jan-17 100 98 91 98 97 68 97 85 71 Feb-17 99 97 91 94 99 69 100 59 93 Mar-17 98 99 93 96 97 73 97 72 98

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Apr-17 97 96 95 98 93 79 71 62 99 May-17 97 98 100 98 93 75 88 65 96 Jun-17 96 93 95 90 84 52 83 77 81 Jul-17 96 94 97 90 85 51 89 82 78 Aug-17 95 91 93 90 87 56 85 79 78 Sep-17 86 82 87 70 63 49 68 69 60 Annual 97 95 93 93 91 64 90 72 83 Average

It should be noted that the DATIM data collection and verification exercise which took place during the quarter, was also an opportunity to orientate new facility staff on HIV indicator reporting as part of efforts to improve the quality of HIV data collection, entry and reporting.

viii) Supporting M & E Technical Working Group

For effective management and utilization of information, Afya Pwani supported the institutionalization and revitalization of M&E TWGs for project supported sites during the July-September 2017 reporting period. By supporting these TWGs, project staff are working to strengthening County M&E systems and promotion of a culture of evidence based decision making, that will help with the following: ensure functional county monitoring and evaluation system including advocacy for HIS resource allocation; strengthen the county’s capacity in health information generation (incl. EMR), validation, analysis, dissemination and use; and facilitate platforms/mechanisms for stakeholder engagement for monitoring and evaluating health sector performance, sharing best practice, innovation and lessons learnt. ix) Availability & Utilization of Documentation and Reporting Tools Cognizant that the Kenya National AIDS and STI Control Program (NASCOP) revised the mainstream documentation (registers) and reporting (summary forms) tools in 2016, since the revisions, the Afya Pwani team have been supporting the training of health care workers on the revised tools. During the quarter under review, Afya Pwani ensured that all the revised data capture tools were available in all the health facilities and the MOH reporting tools and continued its TA mission on ensuring that there was proper utilization of the tools considering all the dimensions of the data quality. Efforts have been fruitful as they made it easy for the successful collection of quality data for reporting through DATIM platform (Kwale 2017). In addition to the routine paper based registers and reporting forms, the team has supported implementation and actualization of EMR-IQ Care. As of now, good progress has been made towards paperless documentation and reporting through the EMR platform, and in Kwale County for example, there are 12 health facilities running on IQ Care at various stages with 4 of them being at the point of care. The Project has also continued to mentor, health care workers (various cadres) on the utilization of EMR in day to day management of patient data and making use of the patient information for decision making. The team has empowered the health care workers to run line lists that can inform the facility in the quality management of the patients e.g. line listing all clients due for viral load thus creating demand for data use. Figure 31 below provides more information on EMR uptake in Kwale County for the FY 2017.

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Figure 31 Kwale County EMR Uptake August 2017

VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH

Gender i) Refresher Training for Mombasa CHVs

During the quarter Afya Pwani a two-day refresher training for 45 CHVs on their roles in helping to support community-facility linkages in Mombasa County and Sub-County AIDS and STI Coordinators (SCASCOs). Training topics included but were not limited to: basic information about the CHV Code of Ethics and their roles in gender mainstreaming; HTS; new testers identification and linkage to care and treatment; 90:90:90 strategy; differentiated care; eMTCT; formation and monitoring of client support groups; defaulter tracing, provider attitudes and values clarification during client interactions for HIV, FP and MNCH services. Emphasis was also placed on the importance of client’s receiving quality services with unconditional positive regard, confidentiality and respect. Once trained the CHVs are attached to 20 Afya Pwani supported health facilities providing ART services.66 One outcome from the training has been that Project sensitized CHVs in Mombasa County linked to Afya Pwani affiliated health facilities, have already succeeded in enhancing Young People Living with AIDS (YPLHA) client retention. Additionally, these trained CHVs have also helped nine adolescent and youth (AY) support groups in Mombasa remain actively engaged with Project supported health facilities -- despite ongoing national health workers strikes – in seven sites (see the AY Support Group section below).

ii) SGBV Survivors Support Group Afya Pwani also supported a meeting with staff from the Gender Based Violence Recovery (GBVR) Centre to identify areas of collaboration; the following areas where included; starting a support group for survivors of sexual violence, provision of Post-Rape Care (PRC) forms, support of awareness creation in the community and provision of dignity kits (containing sanitary towels, underwear, sandals, towels,

66 Miritini, Bokole, Chaani, Port Reitz, Mbuta, Likoni, Shika Adabu, Jomvu, CPGH, Tudor, Ganjoni, Mvita, Railways, Kongowea, Mlaleo, Bamburi, Kisauni, Utange, Magongo, and Mrima.

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toothbrush and toothpaste, comb, Leso and bucket). Moving forward, Afya Pwani pledged to support the establishment of the survivors’ support group which is to run weekly for a duration of 10 weeks; so far, 1 support group meeting has been held for 15 survivors. Project staff will continue to build on these gains in the next quarter as part of efforts to improving gender norms and retrogressive socio-cultural practices that are perpetuating SGBV in communities across Afya Pwani supported Counties.

iii) SGBV Inter-agency meeting Project staff also participated in a SGBV inter-agency meeting at Vipingo Health Center during the quarter under review; a total of 19 Participants attended the meeting which included but was not limited to; the police, health facility staff, school head-teachers, ward administrators, paralegal staff, and Orphan and Vulnerable Children (OVC) focal persons, Community Health Committee (CHC) members and representatives from the children’s department. The main objective of the meeting was to discuss trends in SGBV cases around Vipingo Health Centre and determine how stakeholder involvement in SGBV referrals and management as well as reporting for legal redress. The main barriers to reporting of SGBV cases around Vipingo were identified as; intimidation of survivors, preference for settlement out of court, lengthy protocol for reporting to the police, social issues like single parenting and poverty. In light of these challenges and issues, the inter-agency team recommended that more needs to be done to create awareness of SGBV in the community and schools, and that all cases need to be re reported and followed- up, and lastly, forums that encourage immoral behavior e.g. “siniriche” (overnight funeral discos) should be discouraged and banned altogether.

ii) CHV SGBV Network Meeting In the quarter under review, Afya Pwani facilitated and supported 3 CHV SGBV Network meetings were held in Malindi Sub-County; a total of 78 participants attended in July, 83 participants attended in August, and 68 participants attended in September. During the meetings, the CHVs discussed SGBV case identification, referral and follow-up. In this network, the members share their experiences and debrief other participants based on experiences. During the meeting, nine survivors have been identified and linked to care and support; one girl was defiled and the CHVs who were linked to the case have ensured that it was adequately followed up as per protocol. The perpetrator has since been jailed for 15 years. Moving forward, Afya Pwani project staff will continue to build on these successes and will support more meetings in the next quarter. Additionally, project staff will also work to strengthen the documentation of success stories and follow-up of survivors in the next quarter as part of the Project’s mandate to improve gender norms and address retrogressive sociocultural practices in Afya Pwani counties.

Youth

i) AYPLHIV support and age-appropriate Positive Health Dignity & Prevention (PHDP)/Health Literacy Sessions.

Project supported interventions to facilitate adolescents and young people living with HIV and AIDS (AYPLHIV) to disclose, improve adherence, self-esteem, and address myths and misconceptions on living with HIV targeted empowerment sessions were held for AYPLHIV during school holidays and over weekends. Project efforts to enhance AYPLHIV client retention, quality of care and suppression included support for PHDP/health literacy sessions for in and out-of-school AY clients conducted by CPGH Youth Zone using NASCOP’s PHDP curriculum. During these sessions, AYPLHIV interact with age-mates and share their challenges, which they are assisted to address by adolescent competent teams comprised of skilled adult facilitators working with AY divided in age appropriate groups (i.e. 10-14, 15-19, 20-24 years) and trained youth peer educators who tackle individual issues. AYPLHIV with personal or outstanding issues

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are booked for further counselling. Caregivers are also involved in problem sharing sessions to improve the quality of support to the AYPLHIV. This quarter, Afya Pwani support to CPGH Youth Zone included PHDP/Health literacy messages reaching 20 AYPLHIV care givers (6 males and 14 females). Project support enabled care givers to provide for AYPLHIV in terms of counselling, nutrition and disclosure processes and its benefits including improved adherence and viral load suppression. As a result of targeted caregiver interventions, the number of in- school AYPLHIV reached during school holidays this quarter increased from 167 in the previous quarter, to 200 in August 2017; with almost equal numbers of males and females attending CPGH Youth Zone PHDP/Health literacy sessions: • April 2017 holidays-167 (81 females and 86 males) attended PHDP/Health literacy sessions; • August 2017 school holidays-200 young people attended (100 males and 100 females).

The age ranges of AY attendees, including youth peer educators/mentors of other YPLHAs to enhance linkages to care, treatment and support at CPGH Youth Zone were as follows:

• 10-14 years (37 males and 35 females); • 15-19 years (34 males, 38 females); • 20-24 years (29 males; 27 females).

Project staff noted that the number of AY reached at PHDP/Health Literacy sessions for ages 10 – 19 years was 144, far exceeding young adult participation by 56, 20 -24-year old’s. Among the post PHDP/Health Literacy sensitization findings shared by AY with facilitators at CPGH Youth Zone, were concerns about some adult care-givers, such as school teachers, whose insensitivity causes stigma leading to non- adherence to ART by AYPLHIV in-school.

ii) Adolescent Support Groups (Kwale, Taita Taveta, Kilifi and Mombasa counties)

Afya Pwani also provided TA to Kwale county Adolescent Support Groups through Project affiliated health facilities in the following 7 sites, each of which hosts one support group: Tiwi; Kikoneni; Mazeras; Msambweni; Lunga Lunga, Kinango and Diani. In order to ensure continuity, adolescent support groups are facilitated by peer educators funded by the project in collaboration with health facility management. Peer educators have continued holding monthly adolescent support group meetings despite the ongoing health workers strike. In Taita Taveta county, there are two adolescent support groups i.e. one each in Sagalla Health Center and the Moi -Voi Hospital respectively. Kilifi county hosts six adolescent support groups affiliated with the following health facilities i.e. Mariakani, Ganze, Vipingo, Chasimba, Gede and Kilifi County Hospital. Mombasa County has nine adolescent support groups located as follows: Coast Provincial General Hospital (CPGH) has 3 AY support groups; Ganjoni (1), Kongowea (1), Likoni (1), Utange (1), Port Reitz (1) and Kisauni young mothers support group (1). In Mombasa and Likoni Hospital’s Nutrition section, two youthful CHVs have been extremely vocal about addressing adolescent and youth HIV/AIDS, SRH and malnutrition issues at CPGH Youth Zone, an indication of the potential that this strategy in terms of reaching AY with positive health information. These CHVs have successfully linked YPLHA clients to care and facilitated their referral for health services both within, and outside of facilities. iii) Mariakani Teens group Afya Pwani project staff also continued to work with the Tumaini teens group in Mariakani, which is made up of 80 members (and their caregivers) who are aged between 2 and 18 years that was established in 2006. These children and adolescents are HIV positive and meet on a weekly basis at the facility, where

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they offer peer support for one another through experience sharing and are empowered with life skills; they also bond with each over food prepared by some of their parents. Caregivers have also been empowered on how to disclose the children’s status to their children and Afya Pwani has continued to support this group’s meetings by providing milk and other refreshments as and when needed. During this reporting period, further support has been provided through provision of toys to provide the necessary incentives to keep the teen group members coming to their meetings as part of broader efforts to support adherence and PHDP for these clients.

iv) Kilifi County Referral Hospital Teen Mothers Support Group Between July and September 2017, the Project also supported one meeting with the teen mothers group, which was attended by a total of 12 teenage mothers. During this meeting, participants discussed and addressed the adherence challenges they were facing. They also discussed ways of generating income as part of economic empowerment efforts, with some participants deciding to engage in mat weaving as one of the IGAs. During the meeting, it was also agreed that subsequent meetings will be structured using existing guidelines to allow for better use of the participant’s time and to ensure that all necessary information was shared and that these young mothers received the full PDHP package as per the national guidelines. Moving forward into the next quarter, Project staff will continue to work with this groups, building on the gains already made this quarter in terms of promoting economic empowerment of the group.

v) Kilifi Youth Group Support ‘Friends for life’ is a group of young professional and business women from Kilifi County who address social and contemporary issues in society through advocacy and edutainment. In light of the General Elections that were due to take place on the 8th of August 2017, the Project supported this group to carry out a peace campaign on 29th July 2017 in Mariakani, Mazeras, Rabai, Kaloleni, Dzitsoni, Mavueni, Mtwapa, Vipingo, Tezo, Chumani, Matsangoni, Gede, Watamu, Msabaha, Malindi to Gongoni areas; a caravan was used to transverse through the different areas where messaging on peace was delivered. Aside from the peace campaign, this group also made use of this platform to share positive health information messages for the communities in these areas.

Youth performing edutainment skits during the peace campaign

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vi) Kwale County collaboration with Kenya Youth Employment Skills (K-YES) Project67

A joint meeting by K-YES, Afya Pwani project staff and the County Director of Health of Kwale County (represented by Kwale County’s Pharmacist) took place on 7th September 2017 as a follow up of three previous meetings with the Afya Pwani team. The meeting’s main aim was for Afya Pwani to introduce K- YES to the County Director of Health and discuss roles/responsibilities of the three development partners present in Kwale county community-facility HTS and SRHS linkage. Both Afya Pwani and USAID K-YES Projects are already working in Kwale county through existing county structures, where K-YES’s Kwale County Bunge Network’s mandate is to mobilize and share information through a network of 220 youth village bunges/groups across the county. The Youth Bunge targets youth aged 18-35 years, whose education level is below the final year of high school (i.e. Form Four), to mobilize AY for community-facility health services through their networks, and simultaneously advocate with facility-based health service providers not to discriminate against, but ensure SRHS service delivery to community AY clients including adolescent parents. It was noted that health services were essential for Kwale youth due to high rates of school drop-outs (44% – especially by adolescent girls and young women (AGYW)), as a result of early, unplanned or unintended pregnancies. The County Pharmacist pointed out that 2017 Kwale County April-June data revealed that 88% of pregnancies attended to in county facilities were attributed to 10-19-year-old AGYW. The meeting delineated roles and responsibilities as follows: The role of the County Health Director’s office was to work within existing management structures to facilitate: • demand creation for AYSRHS; coupled with, • access to twelve (12) Kwale county health facilities selected in previous meetings i.e.: Kinondo Kwetu, Kinango Hospital, Msambweni Hospital, Kwale Hospital, Diani Health center, Tiwi Health Center Model site, Kikoneni Health Center, Mazeras Health Center, Mkonagini, Lunga Lunga, Samburu and Vitsangalaweni Health Center - to enable provision of AYFS including: • Youth Friendly Health services (YFHS), • HIV Testing Services (HTS), • Reproductive Health/Family Planning (RH/FP) services, and; • HIV care and treatment (HCT) services.

The Role of USAID K-YES was to mobilize youth for health services at the 12 designated Kwale county facilities through twelve USAID K-YES mobilizers. Ultimately, the intention is to ensure effective community AY referral links with K-YES peer educators attached to the twelve designated Afya Pwani supported health facilities for AYFS especially HIV Testing Services, RH/FP and HIV Care and Treatment. USAID K-YES will also mobilize outreaches planned by the twelve/other facilities to enable adolescents and youth access to AYSRHS.

67 Kenya Youth Employment and Skills Program (K-YES) is a five-year activity funded by USAID and implemented by RTI International and its consortium partners that aims to enhance the employability of Kenyan youth (ages 18-35 years) with primary/secondary education for increased wage and self-employment. The Program focuses on 9 counties, including Kwale, a USAID Afya Pwani Program implementation site. K-YES activities are expected to result in increased youth workforce competitiveness and employment in the county where the Program facilitated formation of the Kwale County Youth Employment Compact. The latter stakeholder forum engages training institutions, hotels/hospitality industry, government departments, CSOs/NGOs, companies, financial institutions and entities interested in youth development.

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The Role of USAID AFYA Pwani is to: • facilitate health education to youth mobilized by K-YES on various health topics including HIV/AIDS integrated in RH/FP, • support K-YES in-reaches to selected vocational institutions by facilitating HTS counsellors to provide HIV testing services. • At the request of USAID K-YES, Afya Pwani to mobilize youth aged 18-35 years with incomplete ordinary Level (O-level) education who have not cleared form four education and require skills building through contact with health providers at health facilities. The health providers will be expected to refer youth meeting the referenced criteria to the K-YES team to facilitate the skills-building process. A more detailed pre-qualification criteria for the selection of the youth will be shared by K-YES. This collaboration will ensure that Afya Pwani affiliated youth in Kwale county receive a comprehensive package of services in terms of i) access to health services and ii) economic empowerment.

Moving forward, K-YES and Afya Pwani will meet with the SCHMTs to inform them of this tripartite collaboration, and later, with health facility In-charges and K-YES mobilizers and peer educators, to create demand and ensure access to health services. vii) Male Engagement in eMTCT

During this quarter under review, Afya Pwani also supported the formation of two couples support groups as part of efforts to enhance eMTCT outcomes through male engagement in PHDP discussions during facilitated support group meetings. The support groups were formed at Magongo Health Center and CPGH. This is a good practice and the benefits can be observed over time as the complexities involved in the formation of couple’s groups are known to the mentor mothers such as power imbalances and poor health seeking behavior by the husbands of HIV positive mothers. During these Afya Pwani support groups sessions family testing and disclosure is discussed extensively and encouraged; this initiaitve is in its nascent stages and membership and impact is expected to increase over the next quarters. viii) USAID Afya Pwani Gender and Youth Officer’s participation in the 3rd annual AYFHS Summer Institute at Pathfinder International HQ, Boston, USA (July 2017)

Pathfinder sponsored participation one of its Afya Pwani Gender and Youth staff to its annual summer institute from July-18-28, 2017 held at Pathfinder International’s Headquarters in Boston, Massachusetts, USA. The focus was on advancing AYSRH programming within projects. Representatives from nine Pathfinder field offices were in attendance (Kenya, Burkina Faso, Cote d’Ivoire, Democratic Republic of Congo, Haiti, Ethiopia, Mozambique, Nigeria and Tanzania). Sessions entailed discussions on various aspects of AYSRH programming ranging from the global Youth and AYSRH Landscape to case studies in AYSRH programming and youth –responsive health systems among other relevant topics. Post training, participants are expected to liaise with program teams and implement feasible/relevant approaches in AYSRH programming to increase positive health outcomes for adolescents and youth in various projects. Implementation learning was encouraged during to keep track of lessons learned and opportunities. Post- training, Afya Pwani’s Gender and Youth teams plan to share and infuse learning from the summer institute in Afya Pwani Project through two AYFHS sessions with program staff (October 18 and 23, 2017).

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Afya Pwani project staff facilitating a Gender Network meeting in Malindi. Planned Activities for Next Quarter 1. USAID RMNCAH/FP/Nutrition Implementing Partners (IP) Meeting in Kilifi (Nov 13-17, 2017). Theme: Delivering for Youth through multi-sectoral investments in Health, Education, Economic Empowerment, Innovation and social protection. USAID AFYA Pwani project is assisting USAID KEA Office of health, Population and Nutrition with the logistics and related preparations for this annual RMNCAH/FP implementing partners meeting in collaboration with the host county and Afya Pwani’s Kilifi cluster team including assessment of potential sites to be visited on November 15th, 2017. 2. Collaboration with the DREAMS project in Mombasa county to support AYSRH outcomes for AGYW ages 10-24 in selected sites. 3. Support Afya Pwani Grants and Program Team efforts to on-board grantees engaged in gender and youth. 4. Care givers training for guardians of children living with HIV on adherence, age appropriate disclosure, treatment and viral load monitoring 5. Dialogues sessions with teachers and matrons to promote adherence among AYLHIV in learning institutions and enacted stigma reduction 6. Support groups sessions/teen club meetings for AYLHIV to provide psychosocial support. 7. Leveraging social media platforms to enhance sharing of information among AYLHIV 8. Implementation of process indicators that will contribute to positive health outcomes in Year two: i. Conduct joint supportive supervision with CHMT/SCHMT to ensure provision of adolescent friendly HIV services in high volume facilities ii. Train, mentor or conduct CMEs to health workers on the adolescent package of care (APOC). iii. Train providers on integration of GBV case management in health service provision in all facilities

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iv. Work with local administration, County Depts. & NGOs to establish safe spaces for GBV survivors and networks for prevention and management of GBV against PLHIV/women/Minors and other vulnerable population groups v. Support legal redress and provide PSS to GBV Survivors vi. Design a community-facility SGBV management and referral system to facilitate SGBV survivors access to health and support services vii. Train Community-facility linked CHVs on GBV referrals and support viii. Train, update, mentor providers on HIV post-exposure prophylaxis among survivors of sexual violence and vulnerable populations at the health facilities. ix. Support forums to create awareness on HIV post-exposure prophylaxis to vulnerable populations. x. Initiate monthly youth days for adolescents to access ART services in selected very high volume facilities xi. Mentor providers on HIV post-exposure prophylaxis among survivors of sexual violence and vulnerable population at the health facilities xii. Support integration of FP services, TB screening, GBV screening, PREP, PEP, nutrition, and prevention of substance and drug abuse services into adolescent friendly clinics.

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

Please see Appendix I which contains the detailed Environmental Mitigation and Monitoring report for the July-September 2017 quarter. VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS During the July-September 2017 quarter under review, Afya Pwani staff continued to work closely with other USAID supported implementing partners. During this quarter, Afya Pwani participated in the USAID Coast Implementing Partners Meeting which took place on the 18th of September 2017 at the Afya Pwani Training Center in Mombasa. During the meeting, the following issues were discussed: Afya Pwani will conduct an index analysis of all stakeholders in the counties to identify where and what type of capacity to be strengthened. The team also highlighted that health departments are accessing/disbursement of funds from respective county treasuries are not cascading down to the lower levels, as envisaged by the constitution which is negatively affecting implementation of some activities.

In terms of the USAID HRH program, they highlighted that they are developing an integrated Human Resources Information System (iHRIS), a software resource that is used to track HR data of health workers. The software is web-based and is open to all USAID funded organizations to access and used to gauge HR needs of staff. Kilifi Medical Training College (MTC) and Pwani University, are part of their capacity building, have access to the software and use it to store data on HR status of health workers. The iHRIS dashboard is still under development and is slated to go live for all counties by end of June 2017. The project is working with Kilifi MTC and Pwani University as the institutes of tertiary education in Coast region to conduct pre-services and in-service capacity building sessions and educations to health workers in the region. There is already a HRH TWGs for all the counties in the region. The next TWG meetings to be held for all counties between 12th and 13th of July 2017.

In terms of collaboration with PS Kenya- it was noted that there is no training or mentorships being conducted on cryotherapy. This is an area that partners like PS Kenya and Afya Pwani and other relevant

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partners and agencies can address. It was also agreed that for any training, mentorship and capacity building sessions should also consider clinicians from staff in USAID-LINKAGES Drop-In Centers (DICs). All partners can access PS Kenya’s condoms supply. The plenary also realized that there is no partner who provides systematic logistic support to KEMSA. Most logistic support to KEMSA is ad hoc.

It was also noted that Health Policy Plus- a new project, is building up on the successes of the Health Policy Plan project. Objective of the project is investing in structural capacities to mitigate catastrophic health expenditures by individual households. The Project will work towards “Sector Working Groups”, which are required by law to be convened by county treasurers in their respective counties to interrogate county expenditure. Working to build capacities of Counties to inculcate program-based budgeting rather than itemized line-based budgeting and is proving a challenge. HPP to provide updates on its social protections plans including National Health Insurance Fund (NHIF) support in the next meeting. Afya Pwani also continued to work with the Nilinde Project where there is a need for collaboration among the partners to conduct client testing and targeted HTS among targeted populations. Other areas collaboration includes working with children of women who inject drugs and female sex workers. The NHIF household beneficiary is currently limited to households that have registered to participate under the USAID-NILINDE project with project beneficiaries residing in the households. Afya Pwani is also planning to pilot a NHIF support initiative for vulnerable families and will collaborate with partners on the same. In the next meeting, Nilinde will provide updates on their social protection interventions. Lastly, in terms of collaboration with the United Nations Office on Drugs and Crime (UNODC) will with Afya Pwani and follow up on how to report and handle (S)GBV. It was also highlighted that the current location of Medication Assisted Treatment (MAT) clinics in Mombasa and Kilifi Counties are not optimal as is the case in Malindi where the Malindi MAT is next to the Malindi CCC which has been negatively affecting CCC clients; while in Kisauni, communities are complaining insecurity caused by People Who Inject Drugs (PWIDs) who visit the Kisauni MAT clinic.

IX. PROGRESS ON LINKS WITH GOK AGENCIES During the quarter under review, Afya Pwani staff continued to work closely in partnership with the CHMTs from all five counties, as they Project works towards increasing access and utilization of HIV, MNCH, RH/FP, WASH and Nutrition health services, and health systems strengthening. A has been mentioned in the previous sections, Project staff partnered closely with the County teams to successfully support World Contraception Day activities as well as the Malezi Bora week which saw several communities and marginalized groups get access to high quality MNCH health services and positive health information. In terms of supporting Health Systems Strengthening, the Afya Pwani team actively engaged all the five counties-Kilifi, Mombasa, Kwale, Taita-Taveta at the level of County Health Executive, Chief Officer of Health County Director of Health and all the county public services board to work out on finalizing MOUs for the contracted facility based staff which the Project will be supporting for the counties. Several MOUs have already been signed and recruitment and deployment of some of these facilities based staff has already begun. Between July and September, Afya Pwani staff and USAID also met with CHMT members during the SIMS exercises where discussion had on the effects of the industrial action on service delivery across all support sub-purpose areas and the way forward.

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X. PROGRESS ON USAID FORWARD During the quarter, Afya Pwani received approval from USAID to engage 20 local organizations to implement demand creation activities and outreaches at community level ultimately contributing to the overall project goals and targets. To facilitate formal contracting, the project held a one day work planning meeting with the approved grantees to share highlights of the approved Year 2 Afya Pwani work plan with the grantees. Grantees were supported to prepare work plans and budgets that are aligned to the approved Year 2 workplan and Afya Pwani results framework. The project has also initiated formal engagement processes to contract the grantees in the next quarter. An orientation meeting will also be held in the next quarter, where Grantees will be taken through key compliance and reporting requirements as they commence implementation of their activities in the next quarter. This orientation session will also provide a benchmark on the different capacities and capabilities of each of these grantees in terms of finance, reporting, programming as well as communications. The Afya Pwani team will endeavor to build the capacity of these organizations for each of these areas throughout the implementation period of the Project. During the quarter Afya Pwani staff utilized innovative strategies using Geographic Information Systems (GIS) to implement targeted innovations for HTS to maximize on the gains made for the ‘1st 90’. This quarter also contracted Provider Initiated Testing and Counselling (PITC) counselors and encouraged the existing Voluntary Counselling and Testing (VCT) counselors to target testing in the out-patient, in- patients, pediatric, MNCH, and TB wards and clinic where the results are giving a high yield. For the ‘2nd 90’, the team is also building the capacity of CHVs and peer educators linked to project supported sites to ensure HIV clients are Linked and retained in the program; equipping them with the skills to continue providing these services even beyond the life of the Project. These CHVs have also been doing home visits for those clients who have missed their appointments. To address the challenges associated with the ‘3rd 90’ for viral load suppression among adolescents and youth, cohort specific support groups have been established for different age groups and PHDP mentorship done to support them as they encourage and inform clients on the importance of ensuring they take their medication daily.

Project staff are also looking at ensuring all the high volume CCCs are providing quality services and are client friendly if the Project is to achieve its set targets. Moving forward, the Project is looking to engage the private sector to support the operationalization of minor renovations at some of the CCCs to improve not only the work environment for health care workers but also for clients.

Lastly, during the quarter, Afya Pwani staff have worked towards implementing strategies for DDIU at the facility, sub-county and county levels respectively. This is a practice that should be institutionalized and leveraged to be able to provide AY, and mother friendly services in terms of respectful maternity care. IN the next quarter, the Project will also work to strengthen the provision of Youth Friendly Services and linkages for school going children and adolescent undergoing treatment; by building the capacity of health workers to provide these services, it is hoped that the positive outcomes supported by the Project will extend beyond the life of the Project.

XI. SUSTAINABILITY AND EXIT STRATEGY To ensure sustainable impact and continued improvement of high quality HIV, MNCH, RH/FP, WASH and nutrition health service delivery in the five coastal counties, Afya Pwani has begun to implement its HSS component and has finished the process of the grantee selection awaiting approval from USAID so the project can proceed to the next step to engage the sub-grantees. During the quarter, project staff have worked towards ensuring that all activities implemented have been in: 1) Full alignment with national policies and guidelines; 2) Focused on supporting the implementation of targeted and tailored TA, OJT

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and mentorship to address the specific needs of health workers, CHVs and S/CHMTS to ensure that the Project is providing tangible and measurable value addition, 3) Strengthen community networks for service delivery through CHVs and facility referral networks to ensure a continuum of service delivery for vulnerable and marginalized clients living in hard to reach areas. Whilst focusing on strengthening referral systems and linkages between health facilities and surrounding communities and vice versa. This has enabled Afya Pwani to reduce the risk and numbers of loss to follow‐ up and defaulting clients. Significant improvements have been achieved to the laboratories across the coastal counties subsequently improving viral load testing as per the project’s mandate. Afya Pwani continues to partner with all key actors and stakeholders including collaborating with other USAID funded mechanisms like Nilinde and Linkages, strengthened partnerships with all five CHMTs by developing MOUs for facility staff that will be absorbed by the counties at the end of their contracts, ensuring that there are no gaps in service delivery for clients- an apt illustration of how Afya Pwani has been able to put sustainability at the core of how it does business. In the next quarter, all grantees will have been oriented and implementing activities aimed at creating demand and increasing uptake of services at the community level for the betterment of all the Kenyan living in Afya Pwani supported counties and facilities. Project staff have focused on building the capacity of health workers, CHVs and the S/CHMTs in terms of service delivery as well as health systems strengthening as part of efforts that al the positive outcomes that have and will be reported in this and the subsequent quarters are maintained beyond th life of the Project. Lastly, Project staff have also placed significant focus on institutionalizing quality assurance (QA)/quality improvement (QI) at the facility level in line with national standards, guidelines all of which are vital for ensuring sustainability of delivery of quality health services in the long term.

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XIV. ACTIVITY ADMINISTRATION

Serenics navigator not changed so far. In terms of staff, there have been a change in Key Personnel in terms of the M&E Specialist position, the team is currently working on looking for a replacement for the position.

XV. SUCCESS STORIES

I DID IT! NOW I MENTOR OTHER HIV+ MOTHERS TO HAVE HEALTHY BABIES When Evalyne Akoth first found out she was HIV positive more than seven years ago, “her life exploded like a ‘bomb blast’” she says. The 40-year-old wife and mother of one was attending her first ANC visit when she found out about her status. At first, she could not believe it, for her HIV was a condition for certain people and not people like her. Unlike most partners, Evalyne was quick to disclose her status to her husband by going forth to accuse him for infecting her with HIV. Although he stood accused Evalyne’s husband welcomed the idea of getting tested so as to reassure his wife that they would still live a normal life even if they were both HIV positive. Her husband tested HIV negative this should have provided relief to her but in turn thrusted Evalyne into confusion. It took consistent counseling and her husband’s support for her to accept her status and adhere to medication. “My husband and I managed to protect our child from HIV infection. My family is proof that HIV positive mothers can have healthy babies and live happy lives with their discordant partners. I am using our experience to give other families hope,” Evalyne remarked. Looking back, Evalyne acknowledges that her experience as a HIV positive mother prepared her to be a mentor mother, a career she has dedicated herself to since her training in 2011. She takes pride in herself as one who has mentored more than 500 HIV positive mothers, encouraged their partners to get tested for HIV and supported discordant couples and HIV positive children to live normal healthy lives. She continues to also use her knowledge to help mothers in Mombasa County to protect their children from HIV infection during and after pregnancy. Evalyne has been working in Port Reitz Sub-County Hospital since 2013, which was initially supported by the USAID AIDS, Population and Health Integrated Assistance (APHIAplus) Nairobi-Coast project and now Afya Pwani. Acknowledging the role of donor support in her work, Evalyne notes that USAID through APHIAplus Nairobi-Coast and Afya Pwani projects they have given her the skills and platform to give back to her community. Afya Pwani project is currently supporting two monthly PMTCT support group meetings and tracing of defaulters and clients who miss appointments at the Port Reitz Sub-County Hospital, some of the key contributors Evalyne attributes the success of her work to. She adds that the support is having a direct impact on adherence, viral suppression and prevention of HIV infections to babies and partners in discordant couples. Evalyne Akoth (R) and Stacy Anyango (seated) reviewing a client’s file at the Port Reitz Sub-County Hospital

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“I encourage mothers to find out their HIV status but I don’t just stop there. I also champion for partner testing because I now understand that discordant partners do exist. Getting both partners involved in Prevention of Mother to Child Transmission (PMTCT) makes me particularly excited because it eases the burden for the mother,” she noted.

BRINGING BACK HOPE - CRUSADING FOR POSITIVE LIVING ONE YOUTH AT A TIME Nicholas Mulwa’s (Nico) account of his life is a good reminder of the very essence of bouncing back. The 24-year-old HIV positive orphan and breadwinner in his family has been fighting for his survival for as long as he can remember. “I was very sickly as a child. I remember the multiple times I was forced to skip school because I was either down with a cough or my skin covered with sores.” Nicholas says. He and his younger brothers were orphaned at a very young age after their widowed mother succumbed to HIV-related illnesses. They were left under the care of their grandmother, who already had four orphans under her care. For his grandmother, ‘Nico’s’ constant illnesses were nothing out of the ordinary until one of the members of their community who advised her to have him tested which she did when he was 13 years-old. Like most caregivers, ‘Nico’s’ grandmother did not disclose his status to him but had him enrolled into care. “My grandmother was keen about my appointment days but I didn’t really understand why I had to take the drugs. She was however not very keen on monitoring my adherence so I would only take the drugs when my health deteriorated.” Nicholas reminisces. Having counted more bad health days than good ones growing up, Nico had become accustomed to hearing that he was suffering from ‘ule ugonjwa’ (that disease). This statement did not have any weight for him until he turned 17 years. “I remember that is the time nyanya stopped accompanying me to the clinic. It hit me that I was now fully responsible for the quality of my life.” With a ‘new’ responsibility, uncontrolled past and a sponsor to support his high school education, Nicholas gathered his courage and made a conscious decision to adhere to his medication. He notes that previous health challenges motivated him to get serious. In addition, Nico had consistent support from Lilian Muange, a HIV counselor at the Malindi sub-County Hospital CCC. “Lilian ni kama mama yetu (Lilian is like our mother). I have known her since I was 13 years and she has been a pillar in my life.” Even with great support, Nico faced numerous challenges including fear of discrimination. He says it was particularly difficult to explain ‘his sunken eyes’ or ‘rashes’ to his peers in school. High school became a major blow to the progress he had made with self-acceptance and adherence. Self-isolation was his solace. The death of his grandmother made coping even harder as he was now in denial again and this time angry at his parents.

In 2015, Nico’s life took an interesting turn. This was after Nicholas discussing the importance of ARVs Malindi Sub-County Hospital through the CCC and the Sub- County AIDS Control office invited and requested him to mobilize YPLHIV to attend a teen meeting supported by the APHIAplus Nairobi-Coast program. It was interesting to him because prior to that he always felt alone in this struggle. During the meeting, he shared his experience publicly for the first time with his peers. That is how I began to see the potential I had to reach out to other young people.

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With continued counselling and support from the CCC, Nico regained his confidence but this time, he gained enough courage to reach others. From the quarterly meeting, he identified and established a support group in Kisumu Ndogo, Malindi. The group which meets bi-monthly receives support from the USAID Afya Pwani project which took over supporting the CCC at Malindi Sub-County Hospital after the APHIAplus Nairobi-Coast project ended in June 2016. Lilian comes to our meetings to offer guidance but the members take charge of the discussions. We encourage and educate each other especially on taking drugs at the right time, negative peer pressure, balanced diet and adolescence among other issues. According to Dr. Godfrey Njoroge the Sub-County AIDS Control for Malindi, such youth-led initiatives have been well received by County and Sub-County Health Management Teams and hospital management. In addition to empowering youth like Nico to become champions for positive living, they are increasing demand for and responsiveness for the interventions provided by health workers. It may have taken him too long, but Nico admits that sharing his experience has and continues to give hope to many young people in Malindi including his younger brothers who have always supported him. He hopes to scale to bigger platforms to empower more young people globally. “All I wish for is a world where all Young People Living with HIV (YPLHIV) enjoy normal lives without stigma or AIDS-related deaths. I also wish to get a job and a family. I will personally take the necessary precautions to ensure my wife and/or my children do not get infected. This way, I will be able to demonstrate to many who have lost hope that HIV is not the end of life!”

USING TECHNOLOGY TO PREVENT STOCK OUTS: WHATSAPP TO THE RESCUE Limited or no access to health commodities undermines service delivery and impacts negatively on those seeking health services. Commodity stock outs, limited skills on inventory management, storage, commodity reporting and drug administration among health care workers and their managers further undermines service delivery efforts. To address some of these gaps, the USAID Afya Pwani project has established a networking platform for commodity managers in Mombasa, Kilifi, Kwale, Taita Taveta and Lamu Counties. ‘Pwani Commodity Managers’ WhatsApp group has over 85 members mainly pharmacists, pharmaceutical technologists from the five Counties as well as program supply chain advisors from Afya Pwani and other partners in the region. The group was formed in November 2016 by the Afya Pwani Commodity Management Advisor, Antony Mwangi with all the County Pharmacists as group administrators so that they could add their colleagues. As a first of its kind for the five Counties, the WhatsApp group provides seamless access to information to its members. More importantly, the forum provides the County commodity managers with a real-time platform to identify challenges and implement solutions.

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The Pwani Commodity Managers group has significantly simplified inter and intra-County redistribution of short dated expiries and excesses as members list commodities for offer or exchange thus promoting optimal use and reducing wastages. as well as raise concerns of commodity shortages for guidance on their availability thus preventing stock-outs. The forum aims to build the capacity of health care workers as they share amongst them knowledge and skills they require to deliver their mandates as well as introduction to new solutions and emerging innovations thus driving demand specifically IQ care. Sharing of ART guidelines, Ministry of Health Sample conversations from the Commodity WhatsApp circulars, guidelines for appropriate medicines use Group. and Kenya Essential Medicines Lists among others has enabled members to build each other’s capacities and enhance knowledge of basic practices including storage and drugs administration. Although still new, this forum has cultivated ownership of challenges and processes in the five Counties as well as improving the speed at which they are resolved or escalated for resolution from the facilities to Sub-County and County levels. Further on, the engagements on the group have improved understanding of commodities security thus improving access to quality health commodities. Apart from partnering with commodity managers, Afya Pwani is also working with the County Health Management Teams (CHMT) through commodity security Technical Working Groups (TWG) to strengthen mechanisms for commodities disposal, storage, forecasting and quantification, reporting and redistribution.

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