USAID AFYA PWANI QUARTERLY PROGRESS REPORT

JANUARY-MARCH 2020 This publication was produced for review by the United States Agency for International Development. It was prepared by Dr EileenJULY Mokaya,- SEPTEMBER Chief of party, 2018Afya Pwani . 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.

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USAID AFYA PWANI

FY20 Q2 PROGRESS REPORT

1st January – 31st March 2020

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

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

Prepared by Pathfinder International-Kenya Lavington, James Gichuru Road, Hse # 158 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.

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TABLE OF CONTENTS

II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 19

SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES ...... 19 Output 1.1: Elimination of Mother to Child Transmission (eMTCT): ...... 19 Output 1.2: HIV Care and Support Services ...... 26 Output 1.3 HIV Treatment Services...... 33 Output 1.4 HIV Prevention and HIV Testing and Counseling ...... 44 Output 1.5: Tuberculosis/HIV Co-infection Services...... 49 Output 1.6: Key Populations ...... 52 Output 1.7: Determined, Resilient, Empowered, AIDS Free, Mentored and Safe (DREAMS) Initiative ...... 61

SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH AND FP, WASH AND NUTRITION ...... 71 Output 2.1: Maternal, Newborn and Child Health Services ...... 71 Output 2.3 Family Planning Services and Reproductive Health (FP and RH) ...... 91 Output 2.4 Water, Sanitation and Hygiene (WASH) ...... 102 Output 2.5 Nutrition ...... 105

SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS ...... 110 Output 3.1 Partnerships for Governance and Strategic Planning...... 110 Output 3.2: Human Resources for Health (HRH) ...... 111 Output 3.3: Health Products and Technologies (HPT) ...... 113 Output 3.4: Strategic Information and Monitoring and Evaluation Systems ...... 116

IV. CONSTRAINTS AND OPPORTUNITIES ...... 117

V. PERFORMANCE MONITORING ...... 117

VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH ...... 121

VII. GRANTS ...... 122

VIII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 123

IX. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 124

XII. SUSTAINABILITY AND EXIT STRATEGY ...... 125

XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 125

XIV. FINANCIAL INFORMATION ...... ERROR! BOOKMARK NOT DEFINED.

BUDGET DETAILS ...... ERROR! BOOKMARK NOT DEFINED.

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OBLIGATIONS VS EXPENDISTURES ...... ERROR! BOOKMARK NOT DEFINED.

COUNTY ANALYSIS ...... ERROR! BOOKMARK NOT DEFINED.

DISAGGREGATED BY EARMARKS ...... ERROR! BOOKMARK NOT DEFINED.

XV. ACTIVITY ADMINISTRATION ...... ERROR! BOOKMARK NOT DEFINED.

XVI. SUCCESS STORIES ...... 127

LIST OF ANNEXES & ATTACHMENTS ...... 132

LIST OF TABLES Table 1:Afya Pwani Performance Q1 and Q2 FY20 ...... 14 Table 2: Afya Pwani Summary HIV Performance Q2 FY20 ...... 19 Table 3: PMTCT Achievements Jan-Mar 2020 ...... 19 Table 4: Taveta SC Hospital PMTCT CQI project findings ...... 21 Table 5: PHDP services beneficiaries in support groups Jan-Mar 2020 ...... 26 Table 6: OTZ outcomes as at March 2020 ...... 29 Table 7: Retention per County Q2 FY20 ...... 30 Table 8:Defaulter tracing outcomes Jan-Mar 2020 ...... 30 Table 9: Linkage by gender Jan-Mar 2020 ...... 34 Table 10:Explanations for unlinked clients by County Jan-Mar 2020 ...... 35 Table 11: Facility based staff supported by Afya Pwani ...... 37 Table 12: ART optimization as at March 2020 ...... 38 Table 13: EID tests done in Q2 FY20 ...... 38 Table 14:Viral load tests done during Q2 FY20 ...... 39 Table 15: Viral Load uptake as at March 2020 ...... 39 Table 16: Viral load uptake April 2019-March 2020 ...... 40 Table 17: Suppression by gender ...... 40 Table 18: HTS performance across counties Jan-Mar 2020 ...... 44 Table 19: Yields by modality Jan-Mar 2020 ...... 45 Table 20: Yields by age group Jan-Mar 2020 ...... 45 Table 21: HIV self-testing kits distributed Jan-Mar 2020 ...... 47 Table 22: Coupling testing at maternity of SCH in ...... 48 Table 23: Gene Xpert tests utilization Jan-Mar 2020 ...... 50 Table 24: HIV/TB Integration ...... 50 Table 25: IPT uptake Jan-Mar 2020 ...... 50 Table 26: DR TB patients in Afya Pwani supported facilities as at Mar 2020 ...... 51 Table 27:KP served in Jan-Mar 2020 ...... 53 Table 28: Summary of KP tested and provided with ARVs by Typology ...... 53 Table 29: Uptake of Prevention Interventions among KP Jan-Mar 2020 ...... 53 Table 30: Summary of other prevention services ...... 54 Table 31: PrEP Uptake among KP Jan-Mar 2020 ...... 54 Table 32: Identification of KP LHIV compared to annual target Oct'19-Mar 20 ...... 55 Table 33: Identification of Positives Jan-Mar 2020 ...... 55 Table 34: 1st time testing among KP Jan-Mar 2020 ...... 56

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Table 35: DIC and outreaches testing for KP Jan-Mar 2020 ...... 56 Table 36: PNS cascade Jan 2020 ...... 57 Table 37: KP on ART Jan-Mar 2020 ...... 58 Table 38: VL uptake and suppression among KP in 12 months ending Mar'20 ...... 60 Table 39: Number of Active and inactive AGYW as at the end of Q2 FY20 ...... 61 Table 40: Number of AGYW layered in the project as at Q2 FY20 ...... 62 Table 41: Number of community members reached with SASA! as at Q2 FY20 ...... 64 Table 42: Number of young women reached with information on condoms as at FY20 ...... 64 Table 43: Young women reached with contraceptives services as at Q2 FY20 ...... 65 Table 44: Commodities distributed by CBDs in Q2 FY20 ...... 96 Table 45: Tabulation of Facility Based staff by cadre ...... 112 Table 46: EMR support to health facilities ...... 117 Table 47: Budget details ...... Error! Bookmark not defined. Table 48:Obligations vs Expenditures (I) ...... Error! Bookmark not defined. Table 49:Obligations vs Expenditures (II) ...... Error! Bookmark not defined. Table 50:Budget Notes ...... Error! Bookmark not defined. Table 51: New Awards ...... Error! Bookmark not defined. Table 52:County Analysis ...... Error! Bookmark not defined. Table 53:Disaggregated by Earmarks ...... Error! Bookmark not defined.

LIST OF FIGURES Figure 1: HEI cohort analysis findings at 1st and 2nd reviews for 16 HVFs ...... 24 Figure 2: Causes of mortality among PLHIV ...... 31 Figure 3: DSD uptake as at Feb 2020 ...... 32 Figure 4: DSD outcomes in 17 facilities in County ...... 32 Figure 5: Linkage Jan-Mar 2020 ...... 33 Figure 6: Linkage by age band Jan-Mar 2020...... 34 Figure 7: Explanations for unlinked clients Q2 FY20 ...... 35 Figure 8:High VL cascade above 15 years ...... 41 Figure 9: High VL cascade less than 15 years ...... 41 Figure 10: Afya Pwani HTS performance as at SAPR FY20 ...... 44 Figure 11: HTS yields per County Jan-Mar 2020 ...... 45 Figure 12: PNS performance Oct'19-Mar'20 ...... 47 Figure 13:Linkage to ART among KP identified ...... 58 Figure 14: Explanation for inactive AGYW ...... 61 Figure 16: MNH Cascade in Afya Pwani supported sites ...... 72 Figure 15: MNH Cascade in Afya Pwani supported sites ...... 72 Figure 17: Graph depicting BEmONC sites in ...... 78 Figure 18: FP method mix in Afya Pwani supported sites in Kilifi County ...... 92 Figure 19:Distribution of gaps amongst targeted mentees and facilities ...... 98 Figure 20: Distribution of gaps amongst targeted mentees and facilities ...... 98 Figure 22: Percentage FP commodity stock outs by sub counties Q1&Q2 ...... 100 Figure 21: Average FP commodity stock outs in Afya Pwani supported sites Q1 and Q2 ...... 100 Figure 23:Binti Wa Kisasa Call log Numbers Oct 2019 to Mar 2020 ...... 102 Figure 24: Frequency of contraceptive information requested by method ...... 102 Figure 25: HIV Rapid Test Kits Reporting Rates-HCMP ...... 113 Figure 26: ART FCDRR Reporting Rates-KHIS ...... 114 Figure 27: Kilifi County FP Commodity Reporting Rates for January to March 2020 (KHIS...... 114 Figure 28: Obligations vs. Current and Projected Expenditure ...... Error! Bookmark not defined.

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ACRONYMS AND ABBREVIATIONS

ADR Adverse Drug Reactions AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care APH Antepartum Hemorrhage 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 BFCI Baby Friendly Community Initiative BMI Body Mass Index CASCO County AIDS and STI Control Officer CBD Community Based Distributor CBP Community Based Promoter CCC Comprehensive Care Center CEmONC Comprehensive Emergency Obstetric and Newborn Care CHEW Community Health Extension Worker CHMT County Health Management Team CHV Community Health Volunteer CLTC County Leprosy and Tuberculosis Coordinator CLTS Community Led Total Sanitation CME Continuing Medical Education CPGH Coast Provincial General Hospital CSB Corn Soy Blend CQI Continuous Quality Improvement CU Community Unit CWC Child Welfare Clinic CYP Couple Years Protection 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 FCDRR Facility Consumption Data Report and Request Form F&Q Forecasting and Qualification FP Family Planning

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GBV Gender-Based Violence GOK Government of Kenya HAART Highly Active Antiretroviral Therapy HCW Health Care Worker HEI HIV Exposed Infant 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 IFAS Iron and Folic Acid Supplementation IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IPC Infection Prevention Control IPT Isoniazid Preventive Therapy KEMSA Kenya Medical Supplies Agency KEPI Kenya Extended Programme on Immunization KP Key Populations KQMH Kenya Quality Model for Health LTFU Lost to Follow Up MAM Moderate Acute Malnutrition MCH Maternal and Child Health M&E Monitoring & Evaluation MNCH Maternal, Newborn and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Surveillance and Review NACS Nutritional Assessment Counselling and Support NASCOP National AIDS and STI Control Program NCD Non-Communicable Disease NDMA National Drought Management Authority ODF Open Defecation Free OJT On Job Training ORT Oral Rehydration Therapy OTP Outpatient Therapeutic Therapy OVC Orphans and Vulnerable Children PAC Post-Abortion Care

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PEP Post Exposure Prophylaxis PITC Provider Initiated Testing and Counseling PLHIV People Living with HIV PMP Performance Monitoring Plan PMTCT Prevention of Mother to Child Transmission PNC Post-Natal Care PNS Partner Notification Services POC Point of Care PRC Post-Rape Care PrEP Pre-exposure Prophylaxis QA Quality Assurance QI Quality Improvement RH Reproductive Health RTK Rapid Test Kits RUTF Ready to Use Therapeutic Food 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 SLTS School Led Total Sanitation 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 TWG Technical Working Group USAID United States Agency for International Development USG United States Government VCT Voluntary Counseling and Testing VL Viral Load WASH Water, Sanitation and Hygiene WHO World Health Organization WRA Women of Reproductive Age YLHIV Youth Living with HIV

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EXECUTIVE SUMMARY The United States Agency for International Development (USAID) MER Pwani Project, hereby referred to as Afya Pwani is a health project that is being implemented to achieve the USAID/Kenya Country Development Cooperation Strategy (CDCS) Development Objective 2 “Health and Human Capacity Strengthened” and Intermediate Result (IR) 2.2 “Increased use of quality health services” by improving County-level accountability, institutional capacity, leadership, and management of health service delivery”. The project was specifically designed to improve access and utilization of quality health services through strengthened service delivery and institutional capacity of health systems in the coastal namely; Mombasa, Kilifi, , and Taita Taveta.

This report covers the period January-March 2020. During the period, the project anchored its implementation of interventions in line with the guiding principles of journey to self-reliance. The project empowered and allowed Counties to take lead in many activities. To this end, counties analyzed their program data across the service areas to inform programmatic decisions related to quality improvement and financial investments. The project offered comprehensive services targeted at preventing HIV infection among vulnerable populations like AGYW and key populations, identifying people living with HIV, linking them to ART, retaining those on ART including supporting them to achieve viral suppression while preventing transmission of HIV from HIV infected mothers to their children. Additionally, Afya Pwani worked towards its goal of increasing access and utilization of high-quality Maternal, newborn and child health (MNCH), Family Planning (FP), WASH and Nutrition services.

During the reporting period, the project performance increased across the various service areas compared to the Q1 FY20. This was however, impacted negatively following the outbreak of COVID-19 pandemic in March 2020. The president’s declaration on a country-wide curfew and other COVID- 19 precautionary measures, the project documented a decrease in workload and service uptake in most project supported facilities. This was mainly due to misinformation and fear of the pandemic by health care providers and the community. Additionally, lack of personal protective equipment (PPE) for the frontline health care providers compounded this fear. Moreover, government ban on meetings and public gatherings also led to cancellation of demand creation and capacity building sessions. Besides, the Counties shifted their priority to COVID-19 response.

Despite the aforementioned challenges, the project successfully advocated the department of health to continue offering essential services, which had stalled in some facilities. The project also, in consultation with Counties developed a mitigation plan to ensure minimal disruption of services during the period. Measures put in place include; innovatively using the digital platform for information and demand creation, engaging the already established workforce and networks of community resource persons for demand creation activities and service provision, while observing COVID-19 precautionary guidelines.

The following text highlights key achievements made during the reporting period January-March 2020.

Qualitative Impact

As at SAPR FY20, Afya Pwani had identified 4,066 new PLHIV against an annual target of 10,543, an achievement of 39%. In Q2 FY20, the project achieved 80% of its quarterly targets (2,105/2,636). Kilifi County achieved 78% (730/934), Kwale 82% (458/557), Mombasa 109% (702/646) and 43% (215/499) in Taita Taveta. This was achieved through strengthening of index testing by increasing facility level investments as well as engaging more HTS providers, HTS screening and improving the capacity of health care workers to provide quality HTS services.

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During the period, the project started 1,805 newly identified PLHIV on treatment compared to the 2,105 identified, a proxy linkage of 86% with Kilifi County linking 83% (606/730), 86% (395/458), 85%(595/702) and Taita Taveta County 97% (209/215). The project is on overdrive to characterize, trace and link the unlinked clients to ART by working with existing facility and community health structures.

As at the end of Q2, Afya Pwani had achieved 34%(3,371/9,955) of the APR target for new on ART and 84% (53,082/62,882) of its target for current on ART for the same period. This was achieved through retention strategies including case management, psychosocial support groups, OTZ clubs, special clinics for pediatric and adolescents among others. Differentiated care service delivery was implemented as one of the retention as well as quality of care strategies. As at February 2020, the uptake of multi-month scripting among stable patients was at 75% (20,686/27,512) in 67 sampled facilities.

In the previous 12 months, viral load tests were done for 50,352 unique clients giving a Viral Load uptake of over 95% and suppression rate of 88% (44,032/49,996), highest being Mombasa County at 90% (18,636/20,800) followed by Kilifi County at 88% (14,613/16,699), Kwale and Taita Taveta County at 84% each. To improve the suppression rates, Afya Pwani prioritized Viremia Clinics, Unsuppressed Clients Psychosocial groups, Multi-Disciplinary Teams and the Case Management Approach.

Afya Pwani supported the counties to offer a comprehensive eMTCT package focused on improving early antenatal care (ANC) coverage, strengthening ART integration into maternal child health (MCH) clinics, early identification of HIV and Syphilis-infected pregnant and lactating women, prompt provision of HAART for HIV infected mother baby pairs (MBPs) and infant prophylaxis as well as strengthening retention among maternal and HIV-exposed infant cohorts. During this period, the project supported eMTCT services in 213 facilities across Mombasa, Kwale, Kilifi and Taita Taveta Counties.

In the reporting period, PMTCT performance was suboptimal in most indicators owing to the effects of protracted RCO strikes early in the year. Further, the outbreak of COVID-19 and mitigation measures put in place in March 2020 slowed down most of the planned activities. To this end, PMTCT STAT, the project achieved 24% (with 26, 034 women knowing their HIV status out of an annual target of 108,319). Despite the project being on course to achieve its PMTCT STAT targets, identification of HIV infected pregnant and lactating women remained low with a 21% achievement in Q2 (829 women identified HIV infected PBW identified out of an annual target of 3,965). In the same period, the project reported a 5% improvement (80% EID uptake at 2 months from 75% reported in Q1) in EID tests done among HEIs before 2 months of age this despite the persistent overall low uptake of EID of 14% (540 initial PCRs done against an annual target of 3,771).

Regarding Key Populations (KPs), Afya Pwani served 15,448 KPs clients among these 12,868 FSW, 2,426 MSM and 154 TG. To improve coordination, accountability and quality of services, the project supported 3 TWG meetings in Kilifi and Mombasa counties where key concerns were discussed and partners sensitized on accountability.

Through DREAMS initiative, the project accelerated its efforts towards provision of basic minimum primary package (Layering). Over 99% of those layered received services beyond the primary package (the extra services that are need based and include; education subsidy, vocational trainings, entrepreneurship training, economic strengthening interventions).Community mobilization programs that target caregivers, male sexual partners and the general community were well received leading to buy in of program interventions and behavior change thus reducing the risk and vulnerability of AGYW to HIV

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 10 infection. The project also collaborated with various government departments such as the Ministry of Health and Ministry of Education, Local Administration including village elders to ensure sustainability of the services provided.

In RMNCH/FP/WASH and Nutrition, the project scaled up low-cost, high impact interventions aimed at building the capacity of the County, Sub-counties, Health facilities, and Community while aligning its activities to Journey to self-reliance. The project consolidated its community strategies, service delivery initiatives leveraging on each thematic area of the integrated project and putting the client at the center of its implementation. Despite the decrease, the performance across the MNH cascade in supported facilities increased in most indicators. The number of new antenatal clients increased to 13,359 new antenatal clients in Q2, an increase from 11,143 reached in Q1, cumulatively reaching 24,502 pregnant women, attaining 61% of the annual target. The project also made strides in the number of women delivered by skilled birth attendants. There was an increase from 8,561 women in Q1 to 9,702 women in Q2. Cumulatively 18,263 women were delivered by skilled birth attendants attaining 56% of the annual target. This achievement is attributed to intensified community mobilization strategies like universal early ANC referrals, Maternity Open Days, community dialogues, and sensitizations on the importance of Antenatal and hospital delivery services. Besides, the project continued to support retention strategies like Mama Kwa Mama and Binti Kwa Binti groups while supporting the capacity building of health care providers.

During the reporting period, Kilifi County experienced immunization vaccine stockout from Q1 through to Q2 as a result of a national stock out for the measles-rubella vaccine. Despite these challenges, the number of children under 1 year fully immunized increased from 8,445 in Q1 to 10,034 during the period, cumulatively reaching 18,479 children attaining 48% of the annual target. However, the number of children reached with DPT3 immunization by 12 months of age slightly decreased from 9,244 in Q1 to 8,497 in Q2, cumulatively reaching 17,741 children attaining 46% of the annual target. These achievements are attributed to strengthening of defaulter tracking and mop-up activities.

In the reporting period, Family Planning activities were also implemented in Kilifi County through partnership, networking, and collaboration with the MoH, RMNCAH implementing partners and community members in line with the J2SR strategy. The project strengthened the core capacities of service providers, Community-Based Distributors (CBDs), and other community resource persons. It also accelerated access and awareness to quality comprehensive family planning services through targeted community interventions, cumulatively serving 35,850 women of reproductive age, and 12,246 adolescents. The project also realized a drop in FP commodities percentage stock out rates at service delivery points from 54% in Q1 to 44% in Q2. The Average stock out also decreased from 7% in Q1 to 5% in Q2. In Q3, the project shall scale up mentorship on documentation, forecasting, and quantification targeting facilities with gaps.

Through Water, Sanitation and Hygiene (WASH) interventions, Afya Pwani constructed and installed water tanks for rainwater harvesting in one primary school. Besides, the project also supported post- triggering Community-Led Total Sanitation (CLTS) follow up, sanitation marketing, and refresher training of community resource persons (CORPS) on sanitation and hygiene improvement at the community level. In the same period, the project supported the Department of Health to validate County Nutrition Action Plan 2 (CNAP2) as well as supervision to stream IMAM services in 17 facilities. Besides, the project supported the BFHI review meeting in 17 facilities and conducted one PD hearth session in Kaloleni Sub- county and targeted cooking demonstration at the community level reaching 570 women.

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As a cross cutting intervention, Afya Pwani strengthened its advocacy efforts for gender integration into health facilities as well as build the capacity of health care workers to provide care to victims of gender based violence. Partnerships with the Youth Advisory Councils were established which ensured ownership and sustainability of interventions implemented which are guided by the County SRH and HIV strategy.

Through its Health Systems Strengthening (HSS) efforts, the project worked to address capacity gaps within the health system through targeted technical assistance and other support. The project emphasized on deepening and institutionalization of health systems interventions in line with the projects J2SR approach which aims at building the capacities of Kilifi, Kwale, Mombasa and Taita Taveta counties to plan, finance, and implement sustainable, quality health solutions. There were sustained efforts in strengthening partnerships for Governance and Strategic planning; Human Resource for Health (HRH); Health Products and Technologies; Strategic Monitoring and Evaluation and Quality Improvement. The project continued to participate in DOH annual performance reviews in the implementation of annual workplans and the S/CHMT’s cascade of planning to health facilities. Also, implementation of HRH staffing plans and employee performance management process strengthening received targeted TA and other support. County Commodity Security TWG’s and technical staff handling commodities received targeted support. High volume facilities also continued to receive on-site EMR support to institutionalize EMR use for improved data quality demand and information use.

Afya Pwani has continuously supported initiatives that encourage good data management practices, evidence-based decision making and learning. In this last quarter, several activities took place to sustain the project strategic information investments. The specific activities included routine site visits, mentorship, joint data review and gap analysis meetings at all levels of service delivery, data quality assessments, dissemination of reporting tools and performance monitoring charts (PMC). The program continued to track reporting rates and data accuracy metrics across facilities and acted accordingly where facilities did not achieve 90%. As a program, we use the results of these monitoring activities to measure improvements, identify areas that need strengthening and form the basis for technical support and mentorship.”

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Quantitative Impact

Table 1 below is the detailed quantitative program performance for the period Q1 and Q2 FY2

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Table 1:Afya Pwani Performance Q1 and Q2 FY20

Afya Pwani Performance FY20 Q1 and Q2( Annex 1) Y4 (COP 19 FY 20) Target

Indicator Area Technical Age Cascade bands Q1 Achiev'd % Q2 Achiev'd % achiev'd Total FY20 Achiev'd % FY20 Kilifi Kwale Mombasa Taveta Taita Pwani Afya

<15 (Coarse) 6,484 19% 4,724 14% 11,208 33% 12,996 8,716 7,008 5,496 34,216 # of individuals who received HIV Testing Services HTS_TST (HTS) and received their test results. >=15 (Coarse) 93,318 29% 94,893 29% 188,211 58% 122,174 76,143 67,077 58,899 324,293

Total 99,802 28% 99,617 28% 199,419 56% 135,170 84,859 74,085 64,395 358,509

<15 (Coarse) 148 17% 117 14% 265 31% 326 216 173 144 859 # of individuals who received HIV Testing Services HTS_TST_POS (HTS) and received their test results (Positive). >=15 (Coarse) 1,821 19% 1,991 21% 3,812 39% 3,411 2,011 2,411 1,851 9,684

Total 1,969 19% 2,108 20% 4,077 39% 3,737 2,227 2,584 1,995 10,543 Positivity <15 2.3% 2.5% 2.4% Computed Indic 1 Positivity >=15 2.0% 2.1% 2.0% Positivity Total 2.0% 2.1% 2.0%

<15 (Coarse) 112 14% 100 13% 212 27% 276 197 197 111 781 # of adults and children newly enrolled on TX_NEW antiretroviral therapy (ART) >=15 (Coarse) 1,455 16% 1,704 19% 3,159 34% 3,197 1,895 2,208 1,874 9,174

Total 1,567 16% 1,804 18% 3,371 34% 3,473 2,092 2,405 1,985 9,955 Linkage <15 76% 85% 80% Computed Indic 2 (Target: Linkage >=15 80% 86% 83% Linkage>95%) Linkage Total 80% 86% 83%

<15 (Coarse) 3,501 3,576 70% 3,576 70% 1,914 1,276 1,456 484 5,130 # of adults and children with HIV infection receiving TX_CURR antiretroviral therapy (ART). >=15 (Coarse) 48,431 49,506 86% 49,506 86% 19,916 11,337 19,480 7,019 57,752

Total 51,932 53,082 84% 53,082 84% 21,830 12,613 20,936 7,503 62,882

Denominator 22,303 21% 26,041 24% 48,344 45% 42,641 26,322 30,067 9,289 108,319

Numerator: # of pregnant women with known HIV Numerator 22,233 22% 26,034 25% 48,267 47% 40,436 25,009 28,533 8,837 102,815 status at first antenatal care visit (ANC1) (includes those who already knew their HIV status prior to PMTCT_STAT Known Positives 410 14% 541 18% 951 32% 975 569 1,213 216 2,973 ANC1). Denom: # of new ANC clients in reporting period New Positives 236 24% 288 29% 524 53% 305 223 397 67 992

Total Positive 646 16% 829 21% 1,475 37% 1,280 792 1,610 283 3,965

PMTCT_ART Already on ART 405 14% 541 19% 946 33% 928 555 1,140 208 2,831

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# of HIV-positive pregnant women who received ART New on ART 229 25% 282 30% 511 55% 293 218 357 64 932 to reduce the risk of mother-to-child-transmission during pregnancy. Total on ART 634 17% 823 22% 1,457 39% 1,221 773 1,497 272 3,763 PMTCT Positivity 2.9% 3.2% 3.1% Computed Indic 3 (Target: ART ART Uptake - New Pos 97% 98% 98% uptake=100%) ART Uptake - All Pos 98% 99% 99%

0<=2 Months 338 10% 431 13% 769 23% 1,091 674 1,365 244 3,374 # of infants who had a virologic HIV test within 12 PMTCT_EID months of birth during the reporting period 2<12 Months 90 23% 109 27% 199 50% 129 83 157 28 397

Total Tested 428 11% 540 14% 968 26% 1,220 757 1,522 272 3,771

0<=2 Months 11 1 12 _ # of HIV-infected infants identified in the reporting period, whose diagnostic sample was collected by 12 PMTCT_HEI_POS 2<12 Months 5 6 11 _ months of age. Excludes confirmatory testing

Total Positive 16 14% 7 6% 23 20% 38 23 43 10 113

0<=2 Months 10 1 11 _

ART initiation and age at virologic sample collection. PMTCT_HEI_POS_Initiated_ART 2<12 Months 3 5 8 _

Total Initiated ART 13 11% 3 3% 16 14% 38 23 43 10 113 Computed indic 4 (Target: HEI Positivity 3.7% 1.3% 2.4% Positivity<5%; ART uptake=100%) HEI ART Uptake 81% 43% 70% Computed indic 5: % EID <2months % EID <2months 79% 80% 79%

<15 (Coarse) 2,513 53% 2,425 51% 2,425 51% 1,837 1,127 1,286 467 4,718

TX_PVLS (N) Suppressed >=15 (Coarse) 41,719 82% 41,476 82% 41,476 82% 17,497 9,880 17,333 5,951 50,661 % of ART patients with a suppressed viral load (VL) result (<1000 copies/ml) documented in the medical Total 44,232 80% 43,901 79% 43,901 79% 19,334 11,007 18,619 6,418 55,378 or laboratory records/laboratory information systems (LIS) within the past 12 months <15 (Coarse) 3,723 75% 3,530 71% 3,530 71% 1,934 1,186 1,354 492 4,966

TX_PVLS(D) VL done >=15 (Coarse) 46,616 87% 46,394 87% 46,394 87% 18,418 10,400 18,245 6,264 53,327

Total 50,339 86% 49,924 86% 49,924 86% 20,352 11,586 19,599 6,756 58,293 % Suppression <15 67% 69% 69% Computed indic 6 (Target: % Suppression >=15 89% 89% 89% Suppression >90%) % Suppression Total 88% 88% 88% RMNCAH RMNCAH #DIV/0!

4th ANC 4th ANC 6,681 7,556 22% 14,237 41% 34,554 34,554

Skilled Birth Attendance SBA 8,561 9,702 30% 18,263 56% 32,827 32,827

Fully Immunized Children < 1 year FIC 8,445 10,034 26% 18,479 48% 38,871 38,871

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PNC Infants receiving Postpartum care within 2-3 days PNC within 2-3 days 7,002 8,276 27% 15,278 49% 31,185 31,185

Performance FY20 Q1 and Q2 (Annex 2) Kilifi Kwale Mombasa Taita Afya Pwani Y4 (COP 19 FY 20) Target

Indicator Technical Area Age Cascade bands Achiev'd FY20 % Achiev'FY20 Achiev'd FY20 % Achiev'FY20 Achiev'd FY20 % Achiev'FY20 Achiev'd FY20 % Achiev'FY20 Total achiev'd FY20 Achiev'd % FY20 Kilifi Kwale Mombasa Taveta Taita Pwani Afya

34, <15 (Coarse) 4,394 34% 3,058 35% 2,590 37% 1,166 21% 11,208 33% 12,996 8,716 7,008 5,496 216

324 # of individuals who received HIV Testing Services HTS_TST ,29 (HTS) and received their test results. >=15 (Coarse) 74,146 61% 42,312 56% 48,605 72% 23,148 39% 188,211 58% 122,174 76,143 67,077 58,899 3

358 ,50 Total 78,540 58% 45,370 53% 51,195 69% 24,314 38% 199,419 56% 135,170 84,859 74,085 64,395 9

<15 (Coarse) 81 25% 85 39% 79 46% 20 14% 265 31% 326 216 173 144 859

# of individuals who received HIV Testing Services 9,6 HTS_TST_POS (HTS) and received their test results (Positive). >=15 (Coarse) 1,347 39% 790 39% 1,304 54% 371 20% 3,812 39% 3,411 2,011 2,411 1,851 84

10, Total 1,428 38% 875 39% 1,383 54% 391 20% 4,077 39% 3,737 2,227 2,584 1,995 543 Positivity <15 2% 3% 3% 2% 2% Computed Indic 1 Positivity >=15 2% 2% 3% 2% 2% Positivity Total 2% 2% 3% 2% 2%

<15 (Coarse) 65 24% 72 37% 57 29% 18 16% 212 27% 276 197 197 111 781

# of adults and children newly enrolled on 9,1 TX_NEW antiretroviral therapy (ART) >=15 (Coarse) 1,083 34% 664 35% 1,062 48% 350 19% 3,159 34% 3,197 1,895 2,208 1,874 74

9,9 Total 1,148 33% 736 35% 1,119 47% 368 19% 3,371 34% 3,473 2,092 2,405 1,985 55 Linkage <15 80% 85% 72% 90% 80% Computed Indic 2 Linkage >=15 80% 84% 81% 94% 83% (Target: Linkage>95%) Linkage Total 80% 84% 81% 94% 83%

5,1 <15 (Coarse) 1,564 82% 891 70% 803 55% 318 66% 3,576 70% 1,914 1,276 1,456 484 30

# of adults and children with HIV infection receiving TX_CURR 57, antiretroviral therapy (ART). >=15 (Coarse) 17,459 88% 9,158 81% 17,772 91% 5,117 73% 49,506 86% 19,916 11,337 19,480 7,019 752

62, Total 19,023 87% 10,049 80% 18,575 89% 5,435 72% 53,082 84% 21,830 12,613 20,936 7,503 882

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108 ,31 Denominator 19,766 46% 11,222 43% 12,935 43% 4,421 48% 48,344 45% 42,641 26,322 30,067 9,289 9

102 Numerator: # of pregnant women with known HIV ,81 status at first antenatal care visit (ANC1) (includes Numerator 19,705 49% 11,216 45% 12,935 45% 4,411 50% 48,267 47% 40,436 25,009 28,533 8,837 5 those who already knew their HIV status prior to PMTCT_STAT

ANC1). Denom: # of new ANC clients in reporting Known 2,9 period Positives 347 36% 206 36% 327 27% 71 33% 951 32% 975 569 1,213 216 73

New Positives 167 55% 101 45% 210 53% 46 69% 524 53% 305 223 397 67 992

3,9 Total Positive 514 40% 307 39% 537 33% 117 41% 1,475 37% 1,280 792 1,610 283 65

2,8 Already on ART 344 37% 204 37% 327 29% 71 34% 946 33% 928 555 1,140 208 31 # of HIV-positive pregnant women who received ART to reduce the risk of mother-to-child-transmission PMTCT_ART New on ART 158 54% 98 45% 210 59% 45 70% 511 55% 293 218 357 64 932 during pregnancy.

3,7 Total on ART 502 41% 302 39% 537 36% 116 43% 1,457 39% 1,221 773 1,497 272 63 PMTCT Positivity 3% 3% 4% 3% 3% Computed Indic 3 ART Uptake - (Target: ART New Pos 95% 97% 100% 98% 98% uptake=100%) ART Uptake - All Pos 98% 98% 100% 99% 99%

3,3 0<=2 Months 256 23% 127 19% 306 22% 80 33% 769 23% 1,091 674 1,365 244 74 # of infants who had a virologic HIV test within 12 PMTCT_EID months of birth during the reporting period 2<12 Months 71 55% 50 60% 62 39% 16 57% 199 50% 129 83 157 28 397

3,7 Total Tested 327 34% 177 23% 368 24% 96 35% 968 26% 1,220 757 1,522 272 71

0<=2 Months 5 _ 1 _ 3 _ 3 _ 12 _ # of HIV-infected infants identified in the reporting period, whose diagnostic sample was collected by 12 PMTCT_HEI_POS 2<12 Months 5 _ 1 _ 4 _ 1 _ 11 _ months of age. Excludes confirmatory testing 1 1 Total Positive 10 26% 2 9% 7 16% 4 39% 23 20% 38 23 43 10 3

0<=2 Months 4 _ 1 _ 3 _ 3 _ 11 _ PMTCT_HEI_POS_Initiat ART initiation and age at virologic sample collection. ed_ART 2<12 Months 4 _ - _ 3 _ 1 _ 8 _ Total Initiated ART 8 21% 1 4% 3 7% 4 39% 16 14% 38 23 43 10 113 HEI Positivity 3% 1% 2% 4% 2%

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Computed indic 4 (Target: Positivity<5%; HEI ART ART uptake=100%) Uptake 80% 50% 43% 100% 70% Computed indic 5: % EID % EID <2months <2months 78% 72% 83% 83% 79%

<15 (Coarse) 4,7 988 54% 398 35% 840 65% 199 43% 2,425 51% 1,837 1,127 1,286 467 18

>=15 (Coarse) 50, 13,625 78% 6,646 67% 17,796 103% 3,409 57% 41,476 82% 17,497 9,880 17,333 5,951 661

% of ART patients with a suppressed viral load (VL) Total 55, result (<1000 copies/ml) documented in the medical TX_PVLS (N) Suppressed 14,613 76% 7,044 64% 18,636 100% 3,608 56% 43,901 79% 19,334 11,007 18,619 6,418 378 or laboratory records/laboratory information systems (LIS) within the past 12 months <15 (Coarse) 4,9 1,527 79% 589 50% 1,121 83% 293 60% 3,530 71% 1,934 1,186 1,354 492 66

TX_PVLS(D) VL done >=15 (Coarse) 53, 15,172 82% 7,588 73% 19,679 108% 3,955 63% 46,394 87% 18,418 10,400 18,245 6,264 327

Total 58, 16,699 82% 8,177 71% 20,800 106% 4,248 63% 49,924 86% 20,352 11,586 19,599 6,756 293 % Suppression <15 65% 68% 75% 68% 69% Computed indic 6 % Suppression (Target: Suppression >=15 90% 88% 90% 86% 89% >90%) % Suppression Total 88% 86% 90% 85% 88% RMNCAH

4th ANC 4th ANC 34, 14,237 41% 14,237 41% 34,554 554

Skilled Birth Attendance SBA 32, 18,263 56% 18,263 56% 32,827 827

Fully Immunized Children < 1 year FIC 38, 18,479 48% 18,479 48% 38,871 871

PNC Infants receiving Postpartum care within 2-3 days PNC within 2-3 days 31, 15,278 49% 15,278 49% 31,185 185

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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES In the reporting, Afya Pwani partnered with CHMTs in the Counties of Kilifi, Kwale, Mombasa and Taita Taveta to increase access and utilization of HIV services. As at SAPR, the project achieved 56% (199,419 /358,509) of its testing targets, 39% ( 4,077 /10,543) of the targets for identification and 34% (3,371/9,955) of newly initiated on ART as shown in the table 2 below. Th project provided ART to 53,082 PLHIV against an annual target of 62,882 with a viral load suppression of 88%. In the same period, 1,475 HIV infected pregnant women were identified compared to an annual target of 3,965, a 37% achievement with 99% (1,457/1,475) of those identified linked to ART. The details are covered in the specific sub- sections as indicated below.

Table 2: Afya Pwani Summary HIV Performance Q2 FY20 Indicator Annual Target # Achieved % Performance HTS_TST 358,509 199,419 56% HTS_ TST_POS 10,543 4,077 39% TX_NEW 9,955 3,371 34% TX_CURR 62,882 53,082 84% VL Uptake 58,293 50,457 87% VL Suppression 49,996 44,032 88% PMTCT_STAT_POS 3,965 1,475 37% PMTCT_ART 3,763 1,457 39%

Output 1.1: Elimination of Mother to Child Transmission (eMTCT): In the reporting period, Afya Pwani offered comprehensive eMTCT package focused on improving early antenatal care (ANC) coverage, strengthening ART integration into maternal child health (MCH) clinics, early identification of HIV and Syphilis-infected pregnant and lactating women, prompt provision of HAART for HIV infected mother baby pairs (MBPs) and infant prophylaxis as well as strengthening retention among maternal and HIV-exposed infant cohorts. During this period, the project supported eMTCT services in 241 facilities across the four Afya Pwani supported counties. The table below summarizes the PMTCT achievements for the period January-March 2020.

Table 3: PMTCT Achievements Jan-Mar 2020 Indicator Quarterly Jan - % Target Mar Achieved 2020 Number of PMTCT sites supported 241 241 100 Number of pregnant women with known status 27,080 26,034 96% Number of HIV positive pregnant women identified 991 829 84% Number of pregnant women known to be HIV positive (known 541 positives) 743 73% Number of newly identified HIV positive pregnant women (new 288 positives) 248 116% Number of HIV infected pregnant women on HAART 941 823 87%

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Overall, despite the project having been on a recovery trajectory following a slow start in Q1. PMTCT performance in Q2 was suboptimal owing to the effects of protracted RCO strikes affecting the initial parts of the reporting period and slowed activity due to the outbreak of COVID-19 and mitigation measures put in place as at the end of March. The following are some of the activities conducted during the period.

i. Utilizing CORPs for demand creation In Q2 FY20 , Afya Pwani worked through grants in-kind in Kilifi, Kwale, Mombasa and Taita Taveta Counties to mobilize communities for early ANC attendance and skilled delivery. Through this partnership, 246 community health volunteers (CHVs) in Taita Taveta, Kwale and Mombasa were sensitized on the early signs of pregnancy, importance of early ANC, danger signs in pregnancy, importance of skilled delivery and essential MNCH services including PMTCT and immunization. The sensitized community units agreed to incorporate ANC, PMTCT and postnatal health messaging at household level during COVID-19 response activities. This has seen continuity Ndilidau Community Unit Sensitization on ANC of services despite the current pandemic situation. In the demand creation supported counties, CORPS mobilized and effectively referred 1,309 women for early 1st ANC. Towards the end of the reporting period, the project closely worked with County community focal persons to leverage on the community COVID-19 response to ensure pregnant women attend 1st ANC and are not deterred by negative messaging that health facilities are closed down and are only accepting COVID-19 patients.

ii. Scale up of PNS through HIVST among sexual partners of PMTCT clients To eliminate vertical HIV transmissions in the Counties, Afya Pwani strengthened index testing as one of the key modalities to identify HIV infected sexual partners of PMTCT clients and untested children including HEIs. Obstetrical population is a group of people who are in constant risk of getting infected hence the need for proper continuous and longitudinal follow up including their partners. In the reporting period, the project scaled up self-testing among sexual partners of PMTCT clients reaching 86 sexual partners of PMTCT women in 11 HVFs to add up to the other previous index clients tested. Out of the 79 tested, a total of 25 were newly identified HIV positive and all initiated on HAART. The discordant couples were given health messages of positive living and prevention of HIV to the negative partner as well as PrEP. Besides, Afya Pwani supported 2 inter facility PNS learning and sharing forum for and Taveta sub counties. This saw 10 HTS counselors from 10 facilities supported and sensitized on aPNS, including on how to elicit and deal with reserved clients, community aPNS follow up and reporting. The training was also an introductory meeting for 5 newly recruited HTS counselors in aPNS.

iii. Human Resources for Health (HRH) The project strengthened health systems in supported Counties through human resources for health (HRH) especially in high-volume public facilities that were identified to have serious HRH gaps. To this end, 23 nurses and 10 HTS providers were engaged and placed in the MCH clinics in 23 facilities1 in Mombasa, Taita Taveta, Kwale and Kilifi respectively. This was done to improve quality of PMTCT services offered to clients in various facilities which also enabled the project to mitigate staff shortage and ensure Counties

1 CPGH, HC, Portreitz SCH, Matsangoni health center, Vipingo health center, Muyeye health center, Ganze health center, Vitengeni health center, Kiwandani dispensary, Moi Voi, Taveta hospital, sub county, Gombato HC, Diani HC, Shimoni HC, Vanga HC, Mkongani HC, Mwaluphamba HC, Taru HC, Mackinon HC, Shimba Hills HC and Vitsangalaweni HC

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optimally utilize the available staff. Based on this, it is expected the HTS providers in the MCH setting will reduce the number of missed opportunities for testing among mothers both in ANC and postnatal, increase couple testing among the ANC clients and ensure same day linkage for clients who test positive in the facilities. Further, the project supported ad hoc placement of roving laboratory technicians in Kwale County to ensure all pregnant women received a HIV test during their 1st ANC visit. Additionally, in an effort to saturate PMTCT facilities with case managers, the project recruited and deployed an additional 19 peer mothers bringing the total number to from 37 in the quarter from 18. The peer mentors have ensured that all PBW identified to be HIV infected are immediately and successfully started on HAART thereby reducing the number of missed opportunities of antiretroviral therapy and HTS testing hence our 100% achievement in the quarter. They have also acted as patient escorts to ensure all clients were linked to treatment while also ensuring longitudinal follow up of PBW to ensure better retention and PMTCT outcomes. iv. Facility PMTCT continuous quality improvement projects During the reporting period, Taita Taveta County selected viral load suppression as an indicator of focus for all the supported sub counties with special follow up for the high-volume facilities. Taveta hospital did an unmatched logistical model to identify root causes/reasons of high viral loads among the PBW on ART which worryingly stood at 27% as at December 2019. The cases (unsuppressed PBW on ART) and controls (suppressed PBW on ART) shared their experiences while on ART and bottlenecks associated with viral suppression. The findings showed that 82% of the cases had missed medication in the last 6 months, 41% of them also had no consistent condom use and for both cases and controls, 16% of the cases were in stressful situations compared to the 58% of the unsuppressed. Thirty three percent (33.3%) of the cases reported low risk perception claiming nothing will happen to them if the viral load is high while 41.7% ascertained that it will lead to poor health. About 8.3% claimed that high viral load may progress to AIDS and die and 16.7% didn’t know what happens when the viral load shoots. In the other case 45.5% and 18.2% of the controls claimed high viral may lead to poor health state and may progress to AIDS and die respectively. Slightly more than a third (36.4%) of the controls (suppressed mothers) didn’t know what high viral load can lead to as shown in the table below.

Table 4: Taveta SC Hospital PMTCT CQI project findings Either a case or a control * Do you know why you are taking HAART (By own assessment) Do you know why you are taking HAART (By own Total assessment) Don't know knows very well others Either a case case 2.00 10.00 0.00 12.00 or a control 16.70% 83.30% 0.00% 100.00% control 3.00 7.00 1.00 11.00 27.30% 63.60% 9.10% 100.00% Total 5.00 17.00 1.00 23.00 21.70% 73.90% 4.30% 100.00% Based on these baseline findings, facilities have had good indication of areas to focus on during support group sessions and individual counselling as their CQI project. It also indicates a strong case for the continuous need to case manage all new positive pregnant women and the unsuppressed. In the month of March 2020, a preliminary review was done and out of the 14 unsuppressed clients (27%), 8 had re- suppressed (57%), 4 are awaiting viral load results (29%) while 2 are still unsuppressed (14%).

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Further, 222 facilities from Mombasa, Kilifi and Kwale counties were supported to participate in monthly collaborative learning sessions on CQI. Each facility had a QI project that they have followed up key among them improving uptake of EID services, reduction of infant sero-conversions among others and improving early ANC attendance. Kenya quality model for health (KQMH) indicators and improvement of quality of care featured as key discussions in the learning sessions. Follow up actions that were not yielding were abolished while actions that were giving positive outcomes were strengthened. v. Real time EID data clean up in Mombasa County Overall in the reporting period, the project conducted a total of 540 initial PCR tests of which 431 were done by 2 months of the infants age representing an 80% uptake by 2 months of age. A total of 7 infants sero-converted in the quarter representing a 1.3% positivity. As part of project’s efforts to ensure a clean EID database, continuous and real time clean up and monitoring of the EID dashboard was initiated. Facility level EID data was downloaded and shared with all Sub Counties and facilities on a weekly basis. This prompted facilities and sub counties to review and critique their own data on EID and strategize on ways to institute remedial actions. Subsequently, EID database cleanup was done taking into consideration findings and feedback from the facilities hence ensuring availability of quality and credible data on the EID website. The project continued to further support the roll out of facility remote log in into the NASCOP EID website enabling HCWs to directly utilize EID data in the platform. Point of care (POC) sites such as Mariakani, Taveta and Hospitals were facilitated with internet bundles and technical support to ensure there was minimal possibility of errors or missing EID data in the database. This has led to an improvement in the project’s EID tests within 2 months from 76% in Q1 to 80% overall as at the end of Q2.

vi. PMTCT specific Viremia clinics and multidisciplinary teams Afya Pwani supported PMTCT sites to run PMTCT specific viremia clinics reaching 222 unsuppressed and low level viremic clients PMTC clients. The clinics offered highly targeted and individualized enhanced adherence sessions and were supported to make individual care plans which were used for close follow up and adherence support. The Viremia clinics were also an avenue of psychosocial support to unsuppressed clients in facilities. The project further supported quarterly multi-disciplinary meetings at subcounty level to discuss any difficult cases emanating from the facility PMTCT viremia clinics. Each facility summarized their cases using a standardized SOP and tool before presenting the cases to the team for deliberations and proposals for improved management. Any improvements from this strategy will be reported in the subsequent quarters.

2 Msambweni Hospital, Kwale Sub county hospital, Lungalunga Hospital, Kinango Hospital, Samburu HC, Mazeras HC, Tiwi HC, Mkongani HC, Kikoneni, Taru Dispensary, VItsangalaweni Dispensary, Mwangulu Dispensary, Gombato Dispensary, Ng’ombeni Dispensary, Mnyenzeni, Kinondo Kwetu Health services, Kilimangodo, Mackinon Dispensary, Mwaluphamba Dispensary, Kilifi sub county hospital, Malindi hospital and hospital

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vii. Institutionalized case management of mother baby pairs To promote individualized quality PMTCT services that are based on needs of individual clients, Afya Pwani continued to support Mentor mothers act as the engagement, training and deployment of mentor mothers in non-technical members of PMTCT settings during the reporting period. As such 35 mentor the PMTCT team who mothers in the supported facilities. Towards J2SR, the project work to reduce stigma, supported Kwale County to sign an MoU with Base Titanium to increase community further support an additional 27 mentor mothers. The project communication and supported the mentor mothers with maternal infant pair (MIP) registers to track their follow ups and airtime to aid in defaulter mobilize demand for tracing and appointment reminders. During the reporting period, services, follow up PBW a joint County level mentor mother and peer educators meeting and their infants up to 24 was held in Mombasa, Kilifi and Taita Taveta Counties was months postnatally.. reaching a total of 42 participants from 18 facilities. viii. Strengthened longitudinal follow up of MIPs To increase the retention of HIV positive pregnant and breastfeeding women and their HEIs in care, Afya Pwani supported mentorship of mentor mothers and MCH nurses on the importance of mother-baby pair follow up for 24 months well as the feeding options for infants. The Project also conducted OJT and targeted mentorships for health care providers on cohort enrollment and importance of retention of all HIV positive pregnant and lactating women, strengthening defaulter tracing mechanisms as well as proper documentation of HEI registers and cards. By equipping health service providers with knowledge on the above and the necessary skills sets to be able to provide these services the project has seen an improved follow up and retention of MBPs for the initial 6 months following initiation on ART. During the quarter, HEI cohort analysis of 163 high volume facilities that represented 80% PMTCT workload was conducted. In the first review (12-month retention), 81% of MBPs were still active on follow up while 13% of then had transferred out to other facilities with 2% of the MBPs missing their initial follow up. In the 2nd review (at 24 months), 73% of the MBPs were still active at 2 years, 12% had transferred out and 6% LTFU as shown in the charts below. The project working closely with S/CHMTs is aiming at institutionalizing the HCA and MCA on a quarterly basis to ensure sustained better HEI and maternal outcomes in the long run.

3 Moi Voi referral hospital, Taveta sub county hospital, Mwatate sub county hospital, Ndovu health center, Wesu sub county hospital, Bura health center

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Figure 1: HEI cohort analysis findings at 1st and 2nd reviews for 16 HVFs

ix. Promoting facility based HEI graduations Afya Pwani supported S/CHMTs to conduct HEI graduation ceremonies in Kilifi and Kwale Counties with a total 322 HEIs graduating and their guardians appreciated for their continued efforts and dedication towards achieving negative HIV status outcome for their infants as well as encouraging good retention in care and celebrating the maternal and infants’ milestones. The HEI graduations have been used to motivate other PMTCT clients still on care to be dedicated to their clinic appointments and adhere to ART. In the J2SR, the two Counties set aside more that half of the HEI Graduation ceremonies held during the quarter

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total budgets for the graduation ceremonies and led in the planning, mobilization partner coordination for the exercise.

x. Targeted S/CHMTs led PMTCT Joint Supportive Supervisions In the J2SR, the project supported respective S/CHMTs to organize, lead and conduct targeted joint supportive supervisions to high volume PMTCT facilities. This was done to ensure they complete integration of PMTCT into MNCH, improve uptake of ART among HIV positive pregnant and breastfeeding mothers as well as good retention and MBP outcomes. These supervisions were A Joint supportive supervision by the CHMT, SCHMT and Afya complemented with appropriate HCWs to Pwani staff provide quality, integrated and updated PMTCT care as per the revised 2018 ART and PMTCT guidelines where gaps were noted. During the period, Afya Pwani supported MOH led joint support supervision visits to 55 PMTCT sites in Mombasa, Kilifi and 21 Kwale Counties4. During the visits, capacity and knowledge gaps identified especially among new HCWs those newly deployed to MCH settings were addressed with appropriate follow up remedial plans and sensitizations.

Key Challenges and mitigation strategies What were the challenges encountered during the How were these challenges addressed? quarter? Slow real-time uploading of EID results from local • On job training and support supervision for the hubs/POC sites into NASCOP EID website affecting local hubs to ensure continuity of work and the overall TAT and reporting provision of quality services to clients supplemented with internet support PMTCT knowledge and capacity gaps on DTG • Afya Pwani supported targeted sensitizations optimization among women of reproductive health and CMEs by the S/CHMTs for facilities in preparation of optimizing women with DTG

Stock outs and erratic supply of HIV-Syphilis Duo • Lab HRH support and strengthened lab test kits especially affecting facilities without networking for 1st ANC in the affected facilities laboratories. This affected VDRL/RPR reporting in to complete ANC profiling and offer Syphilis the quarter testing HEI graduations planned for March 2020 in Kwale • Individualized graduations ceremonies and Kilifi Counties affected by the COVID-19 performed with HEIs and their mothers getting prevention measures prohibiting group gatherings recognition and awarded as they visited the facility for their usually clinic visits

4 Coast Provincial General Hospital (PGH), Port Reitz District Hospital, Tudor District Hospital (Mombasa), Sub-District Hospital, Kongowea Health Center, Kisauni Dispensary, Bamburi Dispensary, Mikindani (MCM) Health Center, Magongo (MCM) Dispensary, Cowdray dispensary, Mnarani dispensary, Kilifi County referral hospital, Vishakani dispensary, Jibana Sub county Hospital, Tsangatsini dispensary, Bamba health center, Ganze health center, Mambrui dispensary, Marereni health center, Gongoni health center, Mariakani sub county hospital, Vitengeni health center, Matsangoni health center, Ganda dispensary, Kakuyuni dispensary, Madunguni dispensary, Gede health center, Vipingo health center, Mtwapa health center, Chasimba dispensary, Pingilikani dispensary, Baolala health center, Gahaleni dispensary, Kiwandani dispensary, Muyeye health center, Malindi sub county hospital, SDA, Watamu dispensary, Mtondia Dispensary, Takaungu dispensary, Konjora Dispensary, Oasis medical center, Bomani dispensary, Mtepeni dispensary, Jilore dispensary, Kakoneni dispensary, Matuga, Msambweni, Kinango and Lungalunga

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Output 1.2: HIV Care and Support Services

i. Provision of the standard package of care Provision of ART and PHDP services: Afya Pwani supported the provision of Positive Health Dignity Prevention (PHDP) messages and services to PLHIV in the project focus Counties. In Taita Taveta County, 487(194M,293F) PLHIV were reached with PHDP services in 47 health talk sessions and 793 (166M,627F) reached in 42 support group sessions. In Mombasa County, support groups and health talks were supported in 21 facilities5 reaching a total of 4,967 (1,745M,3,222F) and 7,526 (2,954M, 4,572F) respectively while in Kwale County, 188 support groups facilitated by 68 peer mentors were supported reaching 3,344(1,668M, 1,676F) PLHIV. In Kilifi County, the project worked with 36 peer educators, 30 adherence counselors and 30 Linkage navigators based in 40 health facilities6 to provide PHDP services to 6,209(2,080 M,4129F). The Table 5 below summarizes the number of PLHIVs who benefitted from PHDP services in various types of support groups.

Table 5: PHDP services beneficiaries in support groups Jan-Mar 2020 PLHIV received PHDP services Jan-March 2020 in Support Groups. Type of Support Group Mombasa Kilifi Kwale Taita Total Male Female Male Female Male Female Male Female Virally Unsuppressed/ 266 624 377 760 210 487 22 54 2800 PMTCT Mothers 2 411 1194 781 0 27 2415 AYLHIV- (OTZ Clubs) 328 268 444 569 206 293 36 43 2187 Newly enrolled Clients 210 362 572 Couples 0 0 15 15 30 CLHIV Caregiver groups 229 785 112 491 301 583 13 121 2635 Children 133 261 315 355 1 4 1069 Male Only 256 455 81 792 General and mixed 321 511 377 760 90 295 2354 Total 1,745 3,222 2,080 4,129 813 2,159 162 544 14,854 Specific opportunistic infection screening and prevention : As part of the standard package of care for PLHIV, Afya Pwani supported health facilities to prevent and screen for opportunistic infection . In the reporting period, 103 (43M,60F) health care workers from 40 heath facilities 7 in Kilifi County, 12(7M, 5F) from 8 facilities8 in Mombasa County and 32(20M, 12F) health care workers from 15 facilities9 in Kwale County were mentored on the provision of CTX, STI screening, TB screening using ICF Cards and provision

5 Coast PGH, Tudor SCH, Portreitz SCH, Likoni SCH, Kongowea HC, Kisauni Dispensary, Bamburi HC, Mikindani MCM, Magongo MCM and Mlaleo CDF HC and Jomvu Model HC, Mvita Clinic, Railways Disp, Clinic, Chaani-CPGH Outreach, Bokole CDF, Mrima Hospital, Likoni Catholic, Utange Disp, and Mbuta CDF HC 6 ; Matsangoni, Ngerenya, Mtondia, Takaungu, Vipingo, KCH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Vitengeni, Malindi, Muyeye, Ganda, Kakuyuni, Marafa, Gongoni, Marereni, Dida, Vitengeni, AIC Malanga, Kiwandani, Mambrui, Gahaleni, Marikebuni ,Bomani, Jilore, Garashi, Baolala, Kakoneni, Mtepeni, Madunguni, Bwagamoyo and Ngomeni 7 Matsangoni, Ngerenya, Mtondia, Takaungu, Vipingo, KCH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Vitengeni, Malindi, Muyeye, Ganda, Kakuyuni, Marafa, Gongoni, Marereni, Dida, Vitengeni, AIC Malanga, Kiwandani, Mambrui, Gahaleni, Marikebuni, ,Bomani, Jilore, Garashi, Baolala, Kakoneni, Mtepeni, Madunguni, Bwagamoyo , Ngomeni 8 Mvita, Chaani, Railways, Shika Adabu, Likoni Catholic, Miritini, Magongo, Portreitz 9 Msambweni, Lungalunga, Kwale , Kinango Hospitals, Samburu, Diani, Mazeras, Kikoneni, Tiwi, Mkongani Health centers , Mackinon, Taru, Mwaluphamba, Mwangulu, Kilimangodo dispensaries

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 26

of IPT during joint support supervision. A total of 1,000 copies of TB ICF cards were distributed in Mombasa County. In Taita Taveta County, 39 PLHIV from 8 health facilities10 were tested using crag test with 2 testing positive and treated for Cryptococcal meningitis. Reproductive Health Services and NCD screening and management : The project supported capacity building sessions for health workers in the four Counties to provide modern contraceptive methods to all female PLHIV in the reproductive age as well as integration of family planning services in to CCCs. In Taita Taveta County,1,017 clients received modern contraceptive method in 24 health facilities11 while 128 female PLHIV were screened for cancer of cervix in 6 health facilities12 where they all turned negative.

Nutritional services, Mental Health Screening and Management and preventing other infections:

Considering the relationship between HIV Poor Nutrition and nutrition, where nutrition can affect the rate of HIV progression to

AIDS and HIV/AIDS worsen Increased

nutritional needs, Poor ability to the nutritional status of an reduced food intake HIV fight HIV and and increased loss other infections individual as illustrated in of nutrients the figure below i, the

project supported the DoH in Kilifi, Kwale, Mombasa Increased vulnerability to infections, poor health, earlier and Taita Taveta Counties and faster progression to the to ensure PLHIV maintain end-stage of AIDS good nutrition status through strengthening access to quality nutrition services. In addition, the project in collaboration with other partners supported PLHIV to access relief food programs and empowerment projects. During the reporting period, the project supported Kwale and Kilifi CHMT to conduct nutrition data review meetings at County level where a total of 34 (13F,21M) health workers participated in Kwale County and 30(11F,19M) in Kilifi County. The review meetings focused on reporting on DHIS (MoH 733B) where challenges related to stock outs in updated version of the reporting tools, inconsistent reporting and late reporting were noted. The action points from the meetings included mentorship sessions for targeted health facilities, CHRIO to source for reporting tools and support supervision to targeted health facilities on NACs. The graph below shows the number of PLHIV who accessed food by prescription program during the reporting period. There is a significant drop in the numbers attributed to a nationwide stock out of commodities.

10 Moi CRH, Taveta SCH, Njukini HC, Ndovu HC, Mgange Nyika HC, Wundanyi SCH, Buguta HC and Mwatate SCH 11 Buguta HC, Bura HC, Challa Disp, Kimorigho Disp, Kishushe Disp, Kitobo Disp, Kwamnengwa Disp, Mahandakini Disp, Marungu HC, Mata Disp, Maungu Model HC, Mgange Nyika HC, Modambogho Disp, Moi CRH, Msau Disp, Mwatate SCH, Ndilidau Disp, Ndovu HC, Njukini HC, Rekeke HC, Tausa HC, Taveta SCH, Wesu SCH , Wundanyi SCH 12 Buguta HC, Kasigau HC, Ndovu HC, Tausa HC, Mwatate SCH and Taveta SCH.

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Figure 2: Food by prescription for HIV/TB patients

Food by prescription for HIV/TB patients 6000 5687 5687 4862 5000 4761

4000

3000 2368 1836 2001 2000 1131 1000

0 Kilifi Kwale Mombasa Taita Taveta

Food by prescription for HIV/TB patients January Food by prescription for HIV/TB patients February

During the reporting period, the project supported the DoH in Kwale County through the CNTF to advocate for prioritization of CCC clients in general food distribution (GFD) from the office of the Deputy County Commissioners (DCC). To this end, Lunga lunga Sub-County received GFD ration for 42(28F, 14M) targeted CCC clients. In Kilifi County, Magarini Sub-county Gongoni health centre, a support group of 32(22F, 10M) were supported to maintain a shade net in collaboration with the WASH department and the Ministry of Agriculture. This group has made progress through sell of produce thus earning them income. Out of the 10(6F,4M) members have replicated the farms in their homes.

ii. Addressing specific needs of children, adolescents and young people living with HIV CLHIV and care givers support groups: Afya Pwani supported facilities in Kilifi, Mombasa, Kwale and Taita Taveta Counties to conduct support group sessions and trainings to parents and guardians of children and adolescents living with HIV. Various topics were covered including assisted disclosure of HIV status to adolescents, adherence to treatment, nutrition, stigma, discrimination and how to effectively cope with psychosocial dynamics that caregivers face. In Kilifi County, support groups were facilitated in 34 health facilities13 reaching a total of 603(112M,491F) caregivers. One care givers training was also supported at Matsangoni Health center where 18 female caregivers participated. In Kwale County, 4 caregivers’ trainings were conducted in Lungalunga, Kikoneni, Vigurungani and Kinondo benefiting 142(87F,55M) caregivers with 67 monthly caregivers ‘sessions conducted by 26 caregivers support groups reaching 884(583F,301M) caregivers from 2514 facilities. In Taita Taveta County, 7 caregivers’ meetings were conducted in 3 facilities15 reaching 134 (13M, 121F) caregivers . In addition, a special clinic for CLHIV was conducted at Moi CRH reaching 37 (20M, 17F) children. In Mombasa County , 14 caregivers group sensitization forums were also conducted reaching 1,014 (229M, 785F). The key activity outputs from these forums were centered on viral load suppression, assisted disclosure among children, and support to children for effective adherence.

13 Kilifi, Ngerenya ,Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni,Mariakani,Bamba,Baolala,Takaungu,Vipingo,Dida,Ganda,Mariekebuni,Gede,Gotani,Oasis,Ngomeni,Mtepeni,Mtondia,Kakuyuni,Vitengeni, Marafa,Marereni,Kiwandani,Matsangoni,Gongoni,Ganze,Malindi,Rabai, Mtwapa. 14 Kwale, Mkongani, Mwaluphamba, Tiwi, Ng’ombeni, Diani, Msambweni-2 ,Kinondo, Lungalunga, Kikoneni, Vitsangalaweni, Vanga, Mwangulu, Kinango, Samburu, Vigurungani, Mazeras ,Taru, Mackinon, Ndavaya, Mnyenzeni, Kizibe, Shimoni, Gombato ,Shimba-hills. 15 Mwatate SCH, Moi CRH and Wundanyi SCH

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Weekend Clinics: The support group sessions, which are mostly conducted on Saturdays, were integrated in ART clinic days for the children and adolescents to enable school going children access treatment. During the period, 760(315M,355) children in Kilifi County were served on Saturdays. In Taita Taveta County, weekend clinics were conducted in Moi CRH, Taveta SCH and Mwatate SCH with 79 (36M, 43F) adolescents and children benefiting while in Mombasa County, 394( 133M, 261F) children were served at CPGH, Likoni Catholic Dispensary, Portreitz SCH, Bokole Health Center, Mlaleo CDF Health Center and Likoni SCH.

OTZ Clubs, Youth Zone, Teen Clubs: OTZ clubs have been instrumental in reaching and addressing the needs of AYLHIV. The club provides a forum for youth to get information, share experiences and challenge one another to attain a zero viral load count, LDL. In Kilifi County, OTZ clubs were supported in 24 facilities16 reaching a total of 1,013(444m, 569F) young people living with HIV. Twenty three OTZ Champions were facilitated to spearhead the implementation of OTZ clubs. The champions motivate and encourage other adolescents regarding adherence, stigma related issues and sexual reproductive Health sessions. In Taita Taveta County, 4 OTZ clubs were supported in 4 health facilities17 reaching 166 (82M, 84F) ALHIV and 1 adolescent clinic session supported at Taveta SCH, reaching 47 (20M, 27F) adolescents. In Mombasa County , 16 OTZ clubs were supported in 11 facilities18 reaching 596 (328M, 268 F)ALHIV whereas in Kwale County, 13 OTZ clubs of 998 (412M ,586F) members were started in 1319 facilities in the quarter. CLHIV and AYLHIV have shown great improvement in the last three months ranging from BMI and confidence attributed to improved self-esteem.

Table 6: OTZ outcomes as at March 2020 OTZ outcomes as at March 2020 AYLHIV enrolled in No# active in % retention No# virally % viral County OTZ club OTZ clubs suppressed suppression Mombasa 641 596 93% 512 86% Kilifi 1127 1013 90% 750 74% Kwale 998 968 97% 687 71% Taita-Taveta 166 156 94% 133 85% Afya Pwani 2932 2733 93% 2082 76%

iii. Retention Strategies As at the end of March 2020, Afya Pwani had 53,054 PLHIV who were on ART in 208 sites ( 79-Kilifi, 65- Kwale, 25-Mombasa and 49 in Taita Taveta) which is 84% of the APR target of 62,882. The proxy retention for the period was 99% for Kilifi, 99% for Kwale, 100% for Taita Taveta and 98% for Mombasa as shown in the table below with details on retention.

16 Malindi District Hospital, Kilifi District Hospital, Mtwapa Health Center, Mariakani District Hospital, Oasis Medical Clinic, Muyeye, Gede Health Center, Vipingo Health Center, Gongoni Health Center, Rabai Health Center, Marereni Dispensary, Bamba Sub-District Hospital, Matsangoni Health Center, Chasimba Health Center, Ganze Health Center, Gotani Dispensary, Mtondia Dispensary, Mambrui Dispensary, Kakuyuni Dispensary ,Takaungu, Ngerenya, Marafa, Jibana and Vitengeni 17 Moi CRH, Taveta SCH, Wundanyi SCH and Mwatate SCH 18 CPGH-Youth Zone, Tudor SCH, Portreitz, Likoni SCH, Kongowea HC, Kisauni Dispensary, Magongo HC, Mrima HC, Mikindani, Mvita Clinic and Bokole CDF HC 19 Kinondo, Msambweni, Diani, Lungalunga, Kikoneni, iwi, Kwale, Mwaluphamba, Mkongani, Kinango, Samburu, Mazeras and Shimba-hills.

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Table 7: Retention per County Q2 FY20 Retention per County FY20 Q2 County TX_CURR TX_NEW Expected TX_CURR TX_Net Net Proxy (FY20 Q1) (FY20 Q2) TX_CURR (FY20 Q2) new gain/loss retention (FY20 Q2) Kilifi 18,500 583 19,083 18,968 468 -115 99% Kwale 9,758 395 10,153 10,047 289 -106 99% Mombasa 18,404 571 18,975 18,575 171 -400 98% Taita 5,278 206 5,484 5,464 186 -20 100% Taveta Grand Total 51,940 1,755 53,695 53,054 1,114 -641 99% In the spirit of J2SR, Afya Pwani supported health facilities to strengthen and institutionalize sustainable retention strategies to ensure clients remain active on care across the supported counties. To this end, facility peer mentors, adherence counselors, linkage navigators and CCC volunteers were trained and provided with logistics to implement the appointment keeping and defaulter tracing protocols effectively and efficiently. This move has contributed to an efficient identification of clients missing appointments, accurate documentation and follow up of clients. With the use of appointment diaries and Facility Missed Appointment Tracking Tool (FMATT), facilities have reported significant improvement in tracing back the missed appointments and defaulters. The Table 8 below shows high success rates of defaulter tracing of 91% in Kilifi and Kwale Counties.

Table 8:Defaulter tracing outcomes Jan-Mar 2020 Defaulter Tracing Jan- March 2020 County Total missed Traced/returned to Success rate in Deaths Transfer Still on appointments care tracing back out follow up Mombasa 3257 2855 88% 33 291 317 Kilifi 5198 4746 91% 59 151 242

Kwale 2825 2575 91 38 71 160 Taita Taveta 683 485 71% 11 29 209 Afya Pwani 11963 10661 89% 141 542 928 To improve quality of service and reduce mortality among PLHIV, the project supported facilities to conduct audits for 103 deaths that had occurred from January to March 2020. Most of the deaths occurred among unsuppressed clients with TB and other opportunistic infections as shown in the pier chart below.

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 30

Figure 2: Causes of mortality among PLHIV

Causes of deaths among PLHIV (n=103)

Unkown causes TB, 19, 18% of deaths, HIV related cancers, 8, Non-causes e.g. 19, 18% accidents, 9, 9% 8%

HIV related Ois, 31, 30%

NCD and infections not directly related to HIV., 17, 17%

Case management: The project supports the implementation of case management in health facilities across the four supported counties of Kilifi, Mombasa, Kwale and Taita Taveta. Peer educators, adherence counselors , linkage navigators, expert clients and health care providers act as case managers providing clients centered services to ensure all clients enrolled in care are retained and achieve viral load suppression. In Kilifi County , 1,137 (377M, 760F) unsuppressed PLHIV were supported through case management in 34 facilities20 while in Mombasa County, 192 (48M, 144F)unsuppressed clients were provided with enhanced adherence counselling in their homes within the quarter. The same care was also given to 211 PMTCT mothers and 394(133M 261F) CLHIV from 19 facilities21 in the same county. These individuals were closely monitored and followed up through home visits, assessing their living conditions, ascertain how drugs are stored, assessing adherence concerns, disclosure status, nutrition issues and providing PHDP messages. More case managers continued receive orientation on the concept and reports reviewed during routine facility visits and monthly feedback meetings.

Home visits: In the reporting period, Mombasa County, supported home visits reaching 226 clients (56M,170F) clients. In Kilifi County, home visits were supported in 34 health facilities22 reaching a total of 83 defaulters (35f,50M),56 unsuppressed adults(14F,43M), 34 unsuppressed CLHIV (14 F,20M) and 123 PMTCT mothers.

iv. Differentiated care service delivery As at the end of February 2020, the project had provided differentiated care to 75% of stable PLHIV in 69 sampled facilities as shown in the chart below.

20 Kilifi, Ngerenya ,Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni,Mariakani,Bamba,Baolala,Takaungu,Vipingo,Dida,Ganda,Mariekebuni,Gede,Gotani,Oasis,Ngomeni,Mtepeni,Mtondia,Kakuyuni,Vitengeni, Marafa,Marereni,Kiwandani,Matsangoni,Gongoni,Ganze,Malindi,Rabai, Mtwapa 21 Coast PGH, Tudor SCH, Portreitz SCH, Likoni SCH, Kongowea HC, Kisauni Dispensary, Bamburi HC, Mikindani MCM, Magongo MCM, Mlaleo CDF HC, Jomvu Model HC, Mvita Clinic, Ganjoni Clinic, Chaani-CPGH Outreach, Bokole CDF, Mrima Hospital, Miritini CDF HC, Likoni Catholic Clinic, Utange Dispensary, Railways Disp and Mbuta CDF 22 Kilifi, Ngerenya ,Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni,Mariakani,Bamba,Baolala,Takaungu,Vipingo,Dida,Ganda,Mariekebuni,Gede,Gotani,Oasis,Ngomeni,Mtepeni,Mtondia,Kakuyuni,Vitengeni, Marafa,Marereni,Kiwandani,Matsangoni,Gongoni,Ganze,Malindi,Rabai, Mtwapa.

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Figure 3: DSD uptake as at Feb 2020 DSD uptake among ART clients As at Feb 2020 n=69 facilities

CARGs On DCM Fast track 19842 844

Stable Stable on DSD 20686 3259 <12 months on ART Unstable

Current on ART Stable 27512 10954

0 5000 10000 15000 20000 25000 30000 35000 40000 45000

Community DSD: Afya Pwani has continued to support establishment and functionality of Community ART Groups (CAGs) as one of the strategies adopted to improve retention of clients on ART into care. Stable clients on ART receive ARV refills in the community reducing frequency of visiting health facilities thereby reducing facility workload and creating time for clinicians to attend to the unstable clients .In Taita Taveta County , 96 CAGs were formed reaching a total of 452(136 M,316 F) PLWHIV. In Kilifi County, 9 CAGs were established reaching a total of 157(61M,96 F) PLHIV while in Kwale County 166 health care workers and 417 clients were sensitized on Community DSD resulting to formation of 49 Community ART groups. Besides, the project has provided TA to facilities to longitudinally follow up DSD clients to assess their retention and viral load suppression over time. The chart below shows the outcomes for 513 clients started on DSD in September 2018 in 17 facilities in Kilifi County with a retention of 93% on DSD 18 months later. This analysis will be scaled up to cover more facilities to inform quality improvement initiatives.

Figure 4: DSD outcomes in 17 facilities in Kilifi County DSD Outcomes Sept 2018 Cohort (n=17 HF)

520 513 510 96% 93% 92% 503 501 505 93% 91% 91% 510 498 494 495 500 487 490 490 481 478 481 479 480 474 471 471 471 471 470 460

450

# on DSD # on DSD # on DSD # on DSD # on DSD # on DSD #

# Suppressed # Suppressed # Suppressed # Suppressed # Suppressed # Suppressed #

Sept 2018 Sept

# active on ART on active # # active on ART active # on ART active # on ART active # on ART active # on ART active # # enrolled in DSD enrolled # Sep- As at Dec 2018 As at March 2019 As at June 2019 As at Sept 2019 As at Dec 2019 As at March 2020 18

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 32

Key Challenges and mitigation strategies What were the challenges encountered during How were these challenges addressed? the quarter? Poor documentation processes on client files • Regular support supervision and mentorship and tracking registers continue to build health care workers capacity on HMIS tools.

Competing priorities and challenges caused by • Continue to work with facility staff and the COVID 19 pandemic. adhering to government guidelines, prioritizing telephonic support and social distancing. Human resource shortage (Clinicians, Nurses, • The project hired Roving clinicians to Adherence Counselors) have challenged the provide care and treatment services in Quality of Care clients are getting facilities with inadequate staff e.g. Gotani Health Center, Oasis, Mtondia, Bamba, Ganda, Ngerenya, Kiwandani, Baolala, AIC malanga and Matsangoni

Lessons learnt

• Continuous OJT and mentorship are key to improving knowledge and skills • Regular support supervision plays an important role in improving quality of HIV services offered in facilities

Output 1.3 HIV Treatment Services

i. Linkage to ART In the reporting period, 86% (1,805/2,105) of newly identified PLHIV were linked to ART, with Taita Taveta linking 97% (209/215), Kwale 86% (395/458), Mombasa 85% (595/702) and Kilifi 83% (606/730) as shown in the Figure 5 below.

Figure 5: Linkage Jan-Mar 2020 Linkage Jan-March 2020

Afya Pwani 1805 300

Taita Taveta 209 6

Mombasa 595 107

Kwale 395 63

Kilifi 606 124

0 500 1000 1500 2000 2500

Linked Not linked

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Linkage by gender: The linkage among females was 87% compared to 82% among males in the reporting period as shown in the table below.

Table 9: Linkage by gender Jan-Mar 2020 HTS Pos TX_NEW % Linkage Overall linkage Male Female Male Female Male Female Kilifi 196 534 157 449 80% 84% 83% Kwale 145 313 130 265 90% 85% 86% Mombasa 251 451 190 405 76% 90% 85% Taita Taveta 67 148 63 146 94% 99% 97% Afya Pwani 659 1,446 540 1,265 82% 87% 86%

Linkage by age groups: The older age groups of above 45 years had better linkage rates with the 25-29 years old having poor linkage rates as shown in the figure below.

Figure 6: Linkage by age band Jan-Mar 2020

Explanations for unlinked clients Afya Pwani followed up unlinked clients closely to ascertain why they were not linked and provided support to them to start ART. As a result of this support, 44 PLHIV started ART after the reporting period with 98 still being on follow up by HTS providers, adherence counsellors and linkage navigators. The chart below shows the reasons for not linked clients as at end of March 2020 with the following table giving the

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 34

Figure 7: Explanations for unlinked clients Q2 FY20 Explanations for unlinked PLHIV Jan-March 2020 Linked in April 2020, Other reasons, 72, 44, 12% 20%

Linked in another facility with CCC number Declined , 36, 10% documented, 81, 22%

Died before linkage, Still on follow up, 98, 35, 9% 27%

Table 10:Explanations for unlinked clients by County Jan-Mar 2020 Explanations for unlinked clients by county Jan-March 2020 County Not Linked in April Linked in another Died Still on Decli Other linked 2020 facility with CCC before follow up ned reasons number documented linkage Kilifi 151 26 36 15 34 16 24 Kwale 83 14 22 7 20 12 8 Mombasa 110 4 13 13 40 2 38 Taita 22 0 10 0 4 6 2 Taveta Afya Pwani 366 44 81 35 98 36 72 ii. Quality improvement for adult treatment The project supported quality improvement initiatives in 60 facilities (1923 in Kwale, 9 in Taita Taveta24, 9 in Mombasa25 and 23 in Kilifi26) focusing on identification of PLHIV, improving uptake of differentiated care services, improving viral load suppression, improving retention, bringing back the lost to follow up PLHIV and improving linkage of new PLHIV on treatment. In Mombasa County, Afya Pwani collaborated with AHF to conduct client exit interviews with data from the 427 facilities indicating that clients were

23 Msambweni referral, Kwale, Kinango and Lungalunga Hospitals, Diani, Kikoneni, Mkongani, Samburu and Mnyenzeni, Taru health centers, Gombato, Ng’ombeni, Mwaluphamba, Mazeras, Mackinon road, Vitsangalaweni, Mwangulu Dispensaries and Kinondo Kwetu. 24 Moi CRH, Mwatate SCH, Taveta SCH, Wesu SCH, Wundanyi SCH, Njukini HC, Ndovu HC, Buguta HC and Maungu HC 25 CPGH, Jomvu Model, Mikindani, Likoni SCH, Bamburi, Kongowea, PRDH, Ganjoni, Magongo, Mlaleo 26 Matsangoni HC, Ngerenya Disp, Mtondia Disp, Vipingo HC, Kilifi CH, Gede HC, Mtwapa HC, Oasis Medical Center, Chasimba HC, Ganze HC, Bamba SCH, Gotani HC, Jibana SCH, Mariakani SCH, Rabai HC, Malindi SCH, Muyeye HC, Ganda Disp, Omar project, Kakuyuni Disp, Marafa HC, Gongoni HC and Marereni Disp. 27 Portreitz, Bamburi, Likoni SCH, Kongowea.

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satisfied with services in 95% of the cases. The two major concerns raised by clients were; the time taken during enhanced adherence sessions and accessing lab services. To this end, the “Nashukuru kwa huduma respective WITs in the 4 facilities have developed corrective zote nilizopata leo, mbali actions to address the concerns. ningeomba kama mda iii. Capacity building among health care workers tunaochukuwa hapa kwa Supervision, mentorship and OJT: Afya Pwani supported CHMTs mahabara uwe mdogo, to take lead in ensuring that support supervision was conducted sababu tunapoteza in their counties in line with the spirit of journey to self-reliance. wakati sana, hata These supervisions reached 109(59M,50F) health care workers in Kwale County from 25 health facilities, 103 (43M,60 F) in Kilifi nikija mapema.. 28 Client M.A.B, 38yrs old male from from 41 facilities, 101 (32M, 69F) in Taita Taveta from 27 Portreitz SCH reported that in the exit facilities and 46(18M,28F) from 1629 facilities in Mombasa. interview In addition, 30(12M,18F) and 17 (5M,12F) newly deployed staff in Kilifi and Kwale counties respectively were trained on standard package of care especially treatment optimization for children and adults, viral load monitoring and documentation of services offered to clients among others. In Mombasa County, the project collaborated with S/CHMT to conduct 7 CMEs to 49 (21M,28F) health care providers in 7 facilities30 on transition to TLD and TLE and for women of reproductive age who opted not to go on TLD. iv. Performance review meetings Under the leadership of SCHMT, the project supported performance review meeting in Kilifi North Sub- County where 35(12M,23F) health care workers (mostly clinical officers, nursing officers, health records and information officers and HTS providers) from 16 facilities31 participated. Issues identified and discussed ranged from identification of positive and early linkage to ART to identified PLHIV, retention strategies, intensified adherence sessions for clients and ways of improving viral load suppression among PLHIV. In Kwale county, one sub county review meeting was supported in Matuga sub county with 43 (29M, 17F)health workers participating while 4 reviews were held in Voi, Mwatate, Wundanyi and Taveta sub-counties in Taita Taveta county with 140 (48M,92F) health care workers participating. v. Facility based staff To ensure continued provision of quality service delivery in high volume facilities with dire shortage of staff, the project continued to partner with the counties in the deployment of the following facility-based staff as shown in the table below.

28 Taveta SCH, Moi CRH, Wundanyi SCH, Mwatate SCH, Ndovu HC, Bura HC, Modambogho Disp, Challa Disp, Njukini HC, Chumvini Disp, Rekeke HC, Ndilidau Disp, Kitobo Disp, Kimorigo Disp, Eldoro Disp, Kiwalwa Disp, Maungu Model HC, Ndome Disp, Ghazi Disp, Kasigau HC, Buguta HC, Marungu HC, Sagalla HC, Tausa HC, Nyache HC, Mbale HC, Mgange Nyika HC, Werugha HC, Wesu SCH 29 Miritini, Mikindani, Jomvu, Chaani, Magongo, Portreitz, Ganjoni, Mvita, Cpgh, Tudor, Likoni, Likoni Catholic, Shika Adabu, Mrima, Kongowea 30 GH, Mvita, Likoni SCH, Mrima, Ganjoni, Portreitz, Shika Adabu 31 Kilifi County Hospital, Mnarani, Takaungu, Kiwandani, Mtondia, Ngerenya, Roka Maweni, Matsangoni, Gede Health Center, Cowdry ,Mijomboni, Watamu dispensary, Konjora Watamu SDA, Watamu Timboni Community

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Table 11: Facility based staff supported by Afya Pwani Facility based staff engaged Cadres Kilifi Kwale Mombasa Taita Taveta HTS providers 47 33 39 23 Medical officers 0 0 1 0 Clinical officers 10 7 7 0 Pharmaceutical technologists. 2 1 1 0 Asst. HRIOs. 7 4 6 2 Lab technicians 1 1 1 0 Nursing officer 8 10 9 4 Social worker 0 0 1 0 Adherence Counselors 30 10 2 5 vi. Treatment for Children Supporting treatment adherence among children: Afya Pwani supported interventions to ensure that children adhere to their treatment. To this end, care givers and pediatric support groups were conducted benefiting in 25 facilities in Kwale32 County 884 (,301M,583F) CLHIV, 2333 facilities reaching 88 (13M, 121F) CLHIV, 489 (M 133M,356F) in Mombasa county from 18 facilities34 and Kilifi county reaching 760(315M,355) CLHIV from 34 facilities35. Adherence counselors hired by the project supported the participants in the support groups to discuss among other issues: enhanced adherence especially for those suspected to be failing treatment, treatment literacy, exploration of possible reasons for non-adherence, disclosure and its importance in treatment and challenges faced by caregivers. vii. ART Optimization Afya Pwani partnered with the S/CHMT to ensure PLHIV on non-standard and failing regime were transitioned to more infectious regimen as recommended by NASCOP. Through joint supervision and mentorship visits, facilities were mentored on transitioning all those with NVP based regimen while adopting the use of DTG for children with 20 Kgs and adults. In Mombasa County, the mentorship visits reached 15(7M, 8F) in 6 facilities36, 12 (5M, 7F) in 6 facilities37 in Kwale County, 101 (32M, 69F) health workers from 29 facilities38 in Taita Taveta and 103 (43M,60F) from 4039 health facilities in Kilifi who were

32 Kwale, Mkongani, Mwaluphamba, Tiwi, Ng’ombeni, Diani, Msambweni, Kinondo, Lungalunga, Kikoneni, Vitsangalaweni, Vanga, Mwangulu, Kinango, Samburu, Vigurungani, Mazeras, Taru, Mackinon, Ndavaya, Mnyenzeni, Kizibe, Shimoni, Gombato, Shimba- hills 33 Taveta SCH, Moi CRH, Wundanyi SCH, Mwatate SCH, Ndovu HC, Bura HC, Modambogho Disp, Challa Disp, Njukini HC, Ndilidau Disp, Kitobo Disp, Eldoro Disp, , Maungu Model HC, Kasigau HC, Buguta HC, Marungu HC, Sagalla HC, Tausa HC, Nyache HC, Mbale HC, Mgange Nyika HC, Werugha HC, Wesu SCH 34 Coast PGH, Tudor SCH, Portreitz SCH, Likoni SCH, Kongowea HC, Kisauni Dispensary, Bamburi HC, Mikindani MCM, Magongo MCM, Mlaleo CDF HC, Jomvu Model HC, Mvita Clinic, Ganjoni Clinic, Chaani-CPGH Outreach, Bokole CDF, Mrima Hospital and Miritini CDF HC 35Ngerenya, Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni, Mariakani, Bamba, Baolala, Takaungu, Vipingo, Dida, Ganda, Marikebuni, Gede, Gotani ,Oasis, Ngomeni, Mtepeni, Mtondia, Kakuyuni, Vitengeni, Marafa, Marereni, Kiwandani ,Matsangoni, Gongoni, Ganze, Malindi, Rabai, Mtwapa and Kilifi CH. 36 Mvita, Ganjoni, Mrima, Likoni Catholic, Mikindani, Chaani 37 Silaloni, Kizibe, Msulwa, Kinango and Ng’athini and Eshu dispensary 38 Taveta SCH, Moi CRH, Wundanyi SCH, Mwatate SCH, Ndovu HC, Bura HC, Modambogho Disp, Challa Disp, Njukini HC, Chumvini Disp, Rekeke HC, Ndilidau Disp, Kitobo Disp, Kimorigo Disp, Eldoro Disp, Kiwalwa Disp, Maungu Model HC, Ndome Disp, Ghazi Disp, Kasigau HC, Buguta HC, Marungu HC, Sagalla HC, Tausa HC, Nyache HC, Mbale HC, Mgange Nyika HC, Werugha HC, Wesu SCH 39 Matsangoni, Ngerenya, Mtondia, Takaungu, Vipingo, Kilifi CH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Vitengeni, Malindi, Muyeye, Ganda, Kakuyuni, Marafa, Gongoni, Marereni, Dida, Vitengeni, AIC Malanga,

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 37

also encouraged to use stickers to flag out children files who are on a non-standard for easy identification and optimization. As at the end of March, 100% of CLHIV in Mombasa, Kwale and Taita Taveta that were NVP based regimen as shown in the table below. Two children are still being followed up in Kilifi county.

Table 12: ART optimization as at March 2020 KILIFI KWALE MOMBASA TAITA TAVETA TX_Curr >15 Years 17277 8994 17733 5073 On TLD 8339 3114 8245 1976 On TLE 7151 4150 8180 1879 % on TLE or TLD 90% 81% 93% 76% TX_Curr <15 Years 1523 835 791 321 On NVP Based Regimen 2 0 0 0 % Optimized 99.9% 100% 100% 100% viii. Strengthened laboratory services Lab networking: Afya Pwani continued to support laboratory network optimization for Viral load, EID and GeneXpert to ensure samples reach the 19 hubs40 and CPGH molecular Laboratory for testing in good time. All the lab managers in the hubs were supported with airtime to facilitate logging in of samples remotely to bring the TAT down as well as ensure faster results and better management of clients. Printing of the clients results for health facilities has been going on in the hubs and then results dispatched to the health facilities. To ensure samples meet the required standards, 14 (9M,5F) health workers from 14 facilities in Kwale County, 66 (23M,43F) from 25 health facilities in Taita Taveta County and 97 (43M,54F) health care workers from 33 health facilities in Kilifi County were trained on the job on sample harvesting, packaging, labeling and transportation to eliminate the rejection rates for these samples.

In Mombasa County, there was sustained efficiency of the Coast Molecular Laboratory through continued support of human resource, stable internet connectivity, and sample networking to be able to support other county as a testing facility.

To improve on commodity reporting, quantification and reporting including ensure availability of vacutainers in the facilities, the project supported meetings with sub-county lab coordinators to review their consumption data and make correct orders for lab commodities.

In Q2, the CPGH laboratory analyzed 2,118 EID tests and 21,847 Viral load tests as tabulated in the tables below:

Table 13: EID tests done in Q2 FY20 Month Samples Received Rejected Tested Valid Results Positive Negative January 768 8 704 673 13 660 February 697 2 878 836 13 823 March 754 2 682 653 18 635 TOTAL 2,219 12 2,264 2,162 44 2,118

Kiwandani, Mambrui, Gahaleni, Marikebuni, ,Bomani, Jilore, Garashi, Baolala, Kakoneni, Mtepeni, Madunguni, Bwagamoyo and Ngomeni. 40 Kwale SCH, Msambweni CRH, Lungalunga SCH, Kinango SCH, Kikoneni HC, Diani HC, Tiwi HC, Samburu HC, Moi CRH, Mwatate SCH, Taveta SCH, Wundanyi SCH, Njukini HC, Buguta HC, Malindi SCH, Gongoni HC, Kilifi CRH, Mariakani SCH and Mtwapa HC.

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Table 14:Viral load tests done during Q2 FY20 Month Received Rejected Non-suppressed Suppressed Repeats Total Done January 7,955 39 947 6,279 398 7,624 February 7,029 26 799 6,080 329 7,208 March 9,243 24 709 5,930 376 7,015 Total 24,227 89 2,455 18,289 1,103 21,847 ix. Viral Load Monitoring Viral Load Uptake: The project Viral load uptake for the past 12 months was 96% compared to those who were on ART in Q1 FY20 as shown in the table below.

Table 15: Viral Load uptake as at March 2020 County TX_CURR FY20 Q1 # VL Tests % uptake Kilifi 18,500 16,699 90%

Kwale 9,758 8,263 85% Mombasa 18,404 20,782 113% Taita Taveta 5,278 4,252 81% Afya Pwani 51,940 49,996 96%

To maintain good uptake for viral load, the project sustained efforts in demand creation through health education to clients, support groups and sending reminders to those who are due for viral load. Monthly line listing of clients due for VL was also done with color coded stickers placed on their files to remind health care workers to take samples when they come for their clinical visits.

Furthermore, the project provided mentorship to 103 (43M,60F) health care workers mostly clinical officers and nurses in 40 facilities41during joint support supervision on how to monitor clients with viral load. Similarly, 53 (18M, 35F) from 21 health facilities42 in Taveta and 17 (5M, 12F) from 13 facilities43 in Mombasa were mentored on ART treatment monitoring. In Kwale County 4 facilities (Eshu, Mwaluvanga, Ndavaya and Vigurungani dispensaries) were supported with a lab technologist to harvest viral samples after clients were mobilized as these facilities do not have laboratory facilities.

Viral Load Suppression The viral load suppression among PLHIV was 88%, 87%, 90% and 85% for Kilifi, Kwale, Mombasa and Taita Taveta respectively as shown in Table 16 below.

41 Matsangoni, Ngerenya, Mtondia, Takaungu, Vipingo, Kilifi CH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Vitengeni, Malindi, Muyeye, Ganda, Kakuyuni, Marafa, Gongoni, Marereni, Dida, Vitengeni, AIC Malanga, Kiwandani, Mambrui, Gahaleni, Marikebuni, ,Bomani, Jilore, Garashi, Baolala, Kakoneni, Mtepeni, Madunguni, Bwagamoyo and Ngomeni 42 Marungu HC, Maungu HC, Kasigau HC Wundanyi HC, Wesu HC, Mwatate SCH, Modambogho Disp, Taveta SCH, Moi CRH, Njukini HC, Kimorigo Disp, Eldoro Disp, Kitobo Disp, Tausa HC, Ndovu HC, Nyache HC, Bura HC, Marungu HC, Maungu HC, Kasigau HC, and Mgange Nyika HC 43 CPGH, Tudor, Portreitz, Likoni, Ganjoni, Mvita, Likoni Catholic, Mrima, Shika Adabu, Utange, Bamburi, Chaani, Magongo and Mikindani

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Table 16: Viral load uptake April 2019-March 2020 VL uptake and suppression as at March 2020 County # VL Tests # Suppressed % Suppressed Kilifi 16,699 14,616 88% Kwale 8,263 7,169 87% Mombasa 20,782 18,636 90% Taita Taveta 4,252 3,611 85% Afya Pwani 49,996 44,032 88%

The viral load suppression by gender was comparable across all the counties as shown in table 16 below. Table 17: Suppression by gender Suppression by Gender as at March 2020 County Gender Tested Suppressed Suppression Kilifi Female 12121 10667 88% Male 4578 3949 86% Kwale Female 6114 5344 87% Male 2149 1825 85% Mombasa Female 14164 12689 90% Male 6618 5947 90% Taita Taveta Female 2992 2547 85% Male 1260 1064 84% Afya Pwani Female 35391 31247 88% Male 14605 12785 88%

x. Management of Unsuppressed Clients In line with the J2SR agenda, the project collaborated with CHMTs to have the SCASCOs and facilities in charges take lead in the functioning of Viremia clinics, unsuppressed support groups, multidisciplinary team meetings and capacity building of health care workers in the management of suspected treatment failure clients. As shown in the charts below for Kilifi county, 70% (174/249) of <15-year-old who had high viral loads in the period of March to September 2019 had received enhanced adherence support with good adherence reported while 80% was achieved for the >15 year old in the same period.

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 40

Figure 8:High VL cascade above 15 years Kilifi County High VL Cascade < 15 Years March -Sept 2019 Cohort

249 241 241

174 171 170

91 83 82 59 17 5 0

Figure 9: High VL cascade less than 15 years Kilifi County High VL Cascade > 15 Years March-Sept 2019 Cohort

1000 897 890 888 900 800 709 695 673 700 600 500 370 400 303 283 300 201 200 100 41 14 2 0

Capacity building for the management of unsuppressed clients: To ensure health care providers offer quality services to suspected treatment failure PLHIV, the project supported SCASCOs in Taita Taveta County to mentor 61 (28M,33F) health workers from 24 facilities44 on the management of unsuppressed clients while CMEs on the same reached 60(21M,39F) health workers in 23 health facilities45.

44 David Kayanda Disp, Werugha HC, Shelemba Disp, Danson Mwanyumba Disp, Kimorigho Disp, Mgange Nyika HC, Nyache HC, Challa Disp, Ndome Disp, Ghazi Disp, Kasigau HC, Taveta SCH, Ndilidau Disp, Moi CRH, Kitobo Disp, Marungu HC, Njukini HC, Ndovu HC, Maungu Model HC, Tausa HC, Modambogho Disp, Rekeke Model HC, Mwatate SCH and Kishushe Disp. 45 Mwatate SCH, Modambogho Disp, Taveta SCH, Moi CRH, Njukini HC, Kiwalwa Disp, Eldoro Disp, Kitobo Disp, Ghazi Disp, Ndome Disp, Tausa HC, Ndovu HC, Mbale HC, Nyache HC, Bura HC, Dawson Mwanyumba Disp, Buguta HC, Marungu HC, Maungu HC, Kasigau HC, Wundanyi HC, Wesu HC and Mgange Nyika HC

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Viremia Clinics: Afya Pwani continued to support Viremia clinics in 23 facilities in Kilifi46 24 facilities in Kwale47, 22 facilities48 in Taita Taveta and 12 facilities in Mombasa49 County by proving SOPs, unsuppressed registers, Job Aids and continuous mentorship for health workers to ensure unsuppressed clients are managed according to the standard ART guidelines. This support was enhanced further through engagement of 200 peer educators (36 Kilifi, 68 Kwale, 42 Taita Taveta and 54 in Mombasa County) and 46 adherence counselors (11 Kwale, 30 Kilifi, and 5 in Taita Taveta County) as case workers to provide enhanced adherence counselling to clients with high viral loads.

Unsuppressed support groups: Unsuppressed support groups were conducted in 27 facilities50 in Kwale County, reaching 697 (487F,210M) clients, 3451 in Kilifi County with 1,137(377M,760F) clients, 1952 facilities in Mombasa County with 529 (M 203, F326) clients reached and in 4 facilities (Ndovu HC, Moi CRH, Wundanyi SCH and Wesu SCH) in Taita Taveta reaching 79 (22M, 57F) clients.

MDT meeting: The project facilitated and supported MDT meetings in 1053 facilities in Kwale where 66 (25M,42F) suspected treatment failure clients were discussed, in 1154 facilities in Mombasa discussing 69(34F,35M) clients, in 2355 in Kilifi discussing 145(68m,77f) clients and in 1956 facilities in Taita Taveta discussing 113 (46M,67F) clients .

Case Management: Case managers who include adherence counselors, nurses and clinicians were attached to clients with unsuppressed viral load for close follow up including conducting home visits, assessing the living conditions of unsuppressed PLHIV, establish how drugs are stored, assessing adherence, disclosure status, nutrition issues and providing PHDP messages. For instance, in Kilifi County, 1,137 (377M, 760F) unsuppressed PLHIV from 2357 facilities were enrolled, 776 (281M,495F) PLHIV from

46 Matsangoni, Ngerenya, Mtondia, Vipingo, KCH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Malindi, Muyeye, Ganda, Omar project, Kakuyuni, Marafa, Gongoni, Marereni) 47 Kwale, Msambweni, Kinango and Lungalunga hospitals, Mkongani, Tiwi, Diani, Samburu, Mnyenzeni, Mazeras, Kikoneni health centers, Mwaluphamba, Ng’ombeni, , Kinondo, Vitsangalaweni, Vanga, Mwangulu, Vigurungani, Taru, Mackinon, Ndavaya, , Kizibe, Gombato and Shimba hills 48 Moi CRH, Mwatate SCH, Wundanyi SCH, Wesu SCH, Taveta SCH, Ndovu HC, Njukini HC, Kasigau HC, Mbale HC, Bura HC, Rekeke HC, Marungu HC, Kitobo Disp, Challa Disp, Eldoro Disp, Ndilidau Disp, Kiwalwa Disp, Tausa HC, Modambogho Disp, Sagalla HC, Buguta HC, Mata Disp 49 CPGH, Ganjoni, Kongowea, Mlaleo, Kisauni, Bamburi, Port Reitz, Magongo, Likoni SCH and Likoni Catholic, Jomvu Model, Chaani, Shika Adabu 50 Mkongani, Mwaluphamba, Tiwi, Ng’ombeni, Diani, Msambweni-2, Kinondo, Lungalunga, Kikoneni, Vitsangalaweni, Vanga, Mwangulu, Kinango, Samburu, Vigurungani, Mazeras, Taru, Mackinon, Ndavaya, Mnyenzeni, Kizibe, Shimoni, Gombato ,Shimba- hills 51 Kilifi CH, Ngerenya, Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni, Mariakani, Bamba, Baolala, Takaungu, Vipingo, Dida, Ganda, Marekebuni, Gede, Gotani, Oasis, Ngomeni, Mtepeni, Mtondia, Kakuyuni, Vitengeni, Marafa, Marereni, Kiwandani, Matsangoni, Gongoni, Ganze, Malindi, Rabai and Mtwapa 52 Coast PGH, Tudor SCH, Portreitz SCH, Likoni SCH, Kongowea HC, Kisauni Dispensary, Bamburi HC, Mikindani MCM, Magongo MCM, Mlaleo CDF HC, Jomvu Model HC, Mvita Clinic, Ganjoni Clinic, Chaani-CPGH Outreach, Bokole CDF, Mrima Hospital, Miritini CDF HC, Likoni Catholic Clinic, and Mbuta CDF 53 Mkongani, Tiwi, Diani, Msambweni, Kinondo Kwetu, Lungalunga, Kikoneni, Vitsangalaweni, Kinango, Samburu, Mazeras 54 CPGH, Likoni, Tudor, Chaani Disp, Kisauni, Portreitz, Mikindani, Bamburi, Ganjoni; Jomvu, Mvita 55 Matsangoni, Ngerenya, Mtondia, Vipingo, KCH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Malindi, Muyeye, Ganda, Omar project, Kakuyuni, Marafa, Gongoni, Marereni 56 Moi CRH, Mwatate SCH, Wundanyi SCH, Wesu SCH, Taveta SCH, Ndovu HC, Njukini HC, Bura HC, Kitobo Disp, Challa Disp, Ndilidau Disp, Eldoro Disp, Mwashuma Disp, Modambogho Disp, Kasigau HC, Maungu HC, Marungu HC, Sagalla HC and Buguta HC 57 Kilifi, Ngerenya ,Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni, Mariakani, Bamba, Baolala, Takaungu, Vipingo, Dida, Ganda, Marekebuni, Gede, Gotani, Oasis, Ngomeni, Mtepeni, Mtondia, Kakuyuni, Vitengeni, Marafa, Marereni, Kiwandani, Matsangoni, Gongoni, Ganze, Malindi, Rabai, Mtwapa

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 42

2158 facilities in Mombasa County reaching 776 (495F,281M) and 51 (7M, 44F) from 1259 facilities in Taita Taveta County and 697(487F,210M) from 27 groups in 2560 facilities in Kwale county.

Home visits: This quarter unsuppressed client’s home-visits were prioritized for those clients discussed in MDTs. Suspected treatment failure clients benefited from household visits conducted by CHVs and Peer educators and other health workers. In Kwale County, 67 (47F,20M) suspected treatment failure clients from 14 facilities, 226 (170F,56M) in Kilifi county, 226 (170F, 56M) in Mombasa county and 133 (40M, 93M) from Taita Taveta county were visited. The essence of the home visits was to establish whether there are other causes hindering suppression and help establish areas of support.

Challenges

Challenges How you overcame them Human resource shortage (especially clinical The project hired roving clinicians to provide care officers, nurses and counselors) impacted the and treatment services in facilities with quality of services negatively. inadequate staff. Corona pandemic led to disruption and Provided site level mentorship and on job training postponement of key activities i.e. ART guideline and telephonic TA. training

Lessons learnt

1. Multidisciplinary teams need consistent support for them to be effective. 2. Immediate training of health care workers posted to HIV service delivery points from non-HIV service delivery areas should be trained immediately otherwise they will negatively impact the quality of ART services. 3. Regular support supervision plays an important role in improving quality of HIV services offered in facilities

58 Coast PGH, Tudor SCH, Portreitz SCH, Likoni SCH, Kongowea HC, Kisauni Dispensary, Bamburi HC, Mikindani MCM, Magongo MCM, Mlaleo CDF HC, Jomvu Model HC, Mvita Clinic, Ganjoni Clinic, Chaani-CPGH Outreach, Bokole CDF, Mrima Hospital, Miritini CDF HC, Likoni Catholic Clinic, Utange Dispensary, Railways Disp and Mbuta CDF 59 Taveta SCH, Kitobo Disp, Moi CRH, Kiwalwa Disp, Kimorigo Disp, Mata Disp, Divine Mercy Disp, Njukini HC, Challa Disp, Chumvini Disp, Ndovu HC, and Mwatate SCH 60 Kwale, Mkongani, Mwaluphamba, Tiwi,Ngombeni,Diani,Msambweni-2,Kinondo, Lungalunga, Kikoneni, Vitsangalaweni, Vanga, Mwangulu, Kinango, Samburu, Vigurungani, Mazeras, Taru, Mackinon, Ndavaya, Mnyenzeni, Kizibe, Shimoni, Gombato, Shimba- hills

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Output 1.4 HIV Prevention and HIV Testing and Counseling

At SAPR FY20, Afya Pwani had identified 4,066 new PLHIV against an annual target of 10,543, an achievement of 38.5%. Facility level strategies to improve identification have been strengthened and adopted to cover the unidentified PLHIVs in the supported counties moving forward.

Figure 10: Afya Pwani HTS performance as at SAPR FY20 Afya Pwani Identification Perfoemance as at SAPR 100% 90% 80% 158,990 70% 6,477 6,583 60% 50% 40% 30% 199,519 20% 4,066 3372 10% 0% Testing Identification Linked to ART

Achievement Gap

In Q2 FY20, 2,105 were identified against a quarterly target of 2,636, a performance of 80%. Mombasa County exceeded its identification target for the quarter, identifying 702 PLHIV out of a target of 646. Kwale and Kilifi reached 82%(730/934) and 78% (458/557) respectively while Taita Taveta achieved 43%(215/499).

Table 18: HTS performance across counties Jan-Mar 2020 HTS Performance per county Jan-Mar 2020 HTS_TST HTS_POS Linkage County Quarterly # % Quarterly # % % % target Tested performance target Identified Achieved achievement Linkage Kilifi 33,793 38,963 115% 934 730 78% 606 83% Kwale 21,215 21,589 102% 557 458 82% 395 86% Mombasa 18,521 26,268 142% 646 702 109% 595 85% Taita 16,099 12,935 80% 499 215 43% 209 97% Taveta Afya 89,627 99,755 111% 2636 2,105 80% 1,805 86% Pwani

The yields per County are as shown in the chart below with Mombasa having the highest yield at 2.7% and Taita Taveta lowest at 1.7%.

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 44

Figure 11: HTS yields per County Jan-Mar 2020 HTS yields per county Jan-Mar 2020

2.7%

2.1% 2.1% 1.9%

1.7% Yields Yields

Kilifi Kwale Mombasa Taita Taveta Afya Pwani

The highest yielding modality in the quarter was Index testing (including PNS) at 15 % closely followed by TB at 12% with the least being malnutrition clinic at 0% shown in the tables below. In terms of absolute numbers PITC and VCT continue to lead, the project is continuing to strengthen screening at these service delivery points to improve yield and minimize over-testing.

Table 19: Yields by modality Jan-Mar 2020 Testing Other POST Pediatric VCT ANC TB Clinic Index Modality Inpatient PITC ANC 1 Testing Number tested 2,125 44,802 3,420 236 19,268 25,431 1,026 3,417 Number Positive 66 676 29 5 417 290 125 504 Yield 3.1% 1.5% 0.8% 2.1% 2.2% 1.1% 12.2% 14.7%

The yields among the age groups were highest among the older than 50 years and as shown in the table below. There is need to improve the yield in the 15-19 and 20 -24 age bands, the project is strengthening PNS amongst those identified positive in these two age bands.

Table 20: Yields by age group Jan-Mar 2020 Yields by age groups Jan-March 2020 Age 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ band Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Tested 1,68 1,56 1,518 9,159 20,997 20,604 15,954 11,441 7,051 4,569 5,208 3 0 Positiv 47 42 28 50 232 400 415 324 234 146 191 e Yields 2.8% 2.7% 1.8% 0.5% 1.1% 1.9% 2.6% 2.8% 3.3% 3.2% 3.7%

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 45

i. Testing Strategies

To achieve the above described testing and identification results, Afya Pwani created demand for HTS, employed high yielding modalities like index testing including PNS, offered HIV self-testing, employed strategies to reach men and adolescents, and ensured that quality of HTS met the national standards.

Demand creation and awareness for HIV testing services: To increase uptake of HTS services, HTS providers continued to offer HIV testing education to outpatient clients waiting to be seen by clinicians. The health facilities provided HTS screening at triage and in clinical rooms to identify and recommend HTS to eligible clients. The project also worked with CHVs at community and health facility level trained at the beginning and during the period of project implementation to sensitize, screen and refer eligible clients including pregnant mothers for HTS in all the supported counties. Peer outreach workers and peer educators also continue to reach out to FWS, MSMs and their partners at hotspots in Mombasa and Kilifi counties with HTS and condoms promotional messages, distribution of HIV self- test kits and condoms.

In Kwale County, 287 community owned resource persons (CORPs) from 19 facilities61 were sensitized on the importance of ANC testing and are actively involved in referral of clients for testing. The CORPs who include peer educators, CHVs, male champions, ANC champions and TBAS continue to offer health talks at the waiting bays in the facilities and communities utilizing existing community platforms. In FY20 Q2, the CHVs reached 1,809 (1,240F and 569M) with messages on importance of HIV testing, PNS, disclosure, adherence to ART in the 19 facilities mentioned above. In Taita Taveta county, health education sessions creating demand for HTS were conducted in 15 health facilities62 where 487 (194M, 293F) were reached.

Partner Notification Services: Afya Pwani scaled up the provision of index client testing services in all the four counties to fast track on the achievement of the identification targets by engaging 142 HTS counselors to focus on index client testing in health facilities. Newly recruited HTS counselors in Kwale were trained in PNS to equip them with skills for implementation prioritizing confidentiality and rights of clients. Kilifi, Mombasa, and Taita Taveta counties trainings were postponed because of the COVID 19 pandemic restrictions. The project is exploring innovative approaches to ensure these trainings are done as soon as possible.

To ensure quality of PNS, the project supported CMEs in all the four counties to re-sensitize HTS providers on PNS reaching 38 (5M, 33F) HTS counselors in Mombasa, 33 in Kwale (4M,29F) ,31 in Kilifi (7M,24F) and 33(10M, 23F) in Taita Taveta HTS. The project continued to support HTS providers with transport and airtime to facilitate tracking of sexual partners. To encourage peer learning as a strategy to improve performance of PNS among HTS providers, the project supported review meetings reaching 38(5M,33F) HTS providers in Mombasa, 37 in Kwale (7M,30F), 60 in Kilifi (M13 F47), and 37 (12M, 25F) in Taita Taveta. During these review meetings, in addition to review of data, role plays were also held to help HTS counselors improve on partner elicitation and follow up of sexual contacts for testing.

61 Kwale hospital, Mwaluphamba, Mkongani, Kizibe, Vyongwani, Mbuguni, Msulwa, Magodzoni, Shimba Hills, Lukore, Matuga, Waa, Ng’ombeni, Tiwi, Gombato, Eshu, Msambweni and Diani 62 Moi CRH, Ndovu HC, Tausa HC, Sagalla HC, Modambogho Disp, Mwatate SCH, Bura HC, Wundanyi SCH, Wesu SCH, Ndilidau Disp, Rekeke HC, Kiwalwa Disp, Challa Disp, Njukini HC and Taveta SCH.

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The projected supported selection of PNS champions in all the four counties to help mentor counselors struggling with partner elicitation and follow up of contacts for testing. A total of 12 PNS champions were identified and facilitated to offer peer mentorship to their colleagues on elicitation of sexual contacts.

As a result of these efforts, the project offered PNS to 7,151 index clients in the 1st half of the financial year, 11,045 contacts elicited and 72% (6960/9628) of eligible contacts tested, and 1024 positives identified, giving a yield of 15%.

Figure 12: PNS performance Oct'19-Mar'20

HIV Self-Testing: In the reporting period, the project supported distribution of 688 HIV self-testing kits to men in informal employments, boda boda riders, small-scale traders and index clients for testing of sexual contacts. The table below shows HIVST kits distribution by county which was low due to stock outs of the kits in the quarter.

Table 21: HIV self-testing kits distributed Jan-Mar 2020 HIV self-testing kits distributed Jan-Mar 2020 County 15-19 20-24 25-29 30-34 35-39 40-49 50+ Total Kilifi 7 64 81 60 40 53 23 328 Kwale 0 0 0 0 0 0 0 0 Mombasa 33 142 136 122 75 77 11 596 Taita Taveta 4 19 32 26 20 12 0 113 Afya Pwani 44 225 249 208 135 142 34 1037

Targeted Provider Initiated HIV testing and Counseling: In Q2 FY20, PITC continued to contribute the highest number of HIV positive clients identified due to the high absolute numbers of positive identified at 676, representing 32% of all positives . HTS screening was applied at outpatient based on test re-test screening tools informed by 2016 HIV Counselling and Testing guidelines. On top of sensitizing HTS

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 47

providers on screening, in Taita Taveta county, the project sensitized 21 (14M, 11F) clinical officers from Moi CRH and Taveta SCH on use of HIV testing screening tools.

Couple testing: The project continued to support facilities to implement couple testing as a strategy to reach men with HTS services. For example, the table below shows uptake of couple testing among women delivering at Port Reitz Sub-County Hospital.

Table 22: Coupling testing at maternity of Port Reitz SCH in Mombasa Couple testing at maternity; January to March 2020 No of deliveries Couples tested % uptake of couple testing January 129 84 65 February 129 91 71 March 190 162 85 Total 448 337 75

HIV testing at universities and colleges: To reach young adults, Afya Pwani sensitized college students from Pwani University and ICS college on HIV testing, with 303 clients (122M,185F) tested for HIV( 262 (112M,150F) Pwani university and 45(10M,35F) in ICS) 2 were identified positive and linked to ART. In the same setting, 150 HIV self-test kits were also issued to students at Pwani University.

Testing of AGYW: The project supported HIV testing of 3,048 AGYW aged between 9 and 24 years enrolled in the DREAMS project in Mombasa County during the reporting period. The numbers tested per Sub County are as follows: Likoni SC (1319), Kisauni Nyali (859) and Jomvu (870) . In the reporting period, one HIV positive adolescent girl aged 15 years was identified in Jomvu SC and linked to Miritini HC for treatment. ii. Improving the quality of HIV testing services

Capacity Building: The project supported 11 CMEs to 11 facilities63 in Kilifi county to equip 57(19M,438F) health care workers with skills on identification strategies, communication skills, assisted disclosure and linking unsuppressed clients to PNS. In Mombasa county, OJT was offered to 29 (12M,17F) HTS providers from 10 facilities64 which included distribution of HTS screening tools and HIVST guidelines.

Counselors Support Supervision: Afya Pwani partnered with the counties to conduct supervision for counselors reaching 44 (16M,28F) in Kilifi, 27 (12 M, 15F) in Kwale, 42 (13M,29F) in Mombasa and 23 (10M, 13F) in Taita Taveta county. Action plans on addressing identified gaps were done that included some of the mentorship and CME sessions done in the quarter.

Regular Performance Review: The project supported facilities to conduct regular performance reviews to identify performance gaps and develop change ideas on how they will improve services in their facilities. County level performance reviews with counselors and S/CHMTs were done in Kilifi and Kwale counties with 60 (48F, 12M) and 62(40F,22M) health care providers participating respectively.

63 Kilifi CH, Malindi, Rabai, Mariakani, Mtwapa, Oasis, Vipingo , Chasimba, St Luke, Muyeye, Gede, Matsangoni, Vitengeni, 64 Tudor, Jomvu Model, Mikindani, Likoni SCH, Bamburi, Kongowea, PRDH, Ganjoni, Magongo, and Kisauni.

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Lessons learnt

• Facility ownership is key to improving identification and linkage to ART. • PNS requires continued mentorship and supervision of HTS providers.

Challenges

• Partner elicitation and follow up index partners for testing is still low at 1: 1 (versus a target of 1:3 ); Afya Pwani will work with the county to ensure scale-up of the LRRR strategy (Line-listing of newly identified positive clients, clients with HVL, PMTCT mothers, widows and widowers, defaulters traced back ;Rescreening index clients with no elicited sexual contacts, one sexual contact and sexual contacts who have tested ; R Rebooking contacts who missed appointments during convenient hours ;Review the completeness of the PNS register, review the individual counselor performance and difficult clients during weekly MDT meetings and Reporting weekly to the project, county and subcounty.)

• Testing of elicited contacts is still low at 74% (>80% target), Afya Pwani will work with other IPs outside the coast region to ensure elicited contacts outside the region are linked for testing in the regions the clients reside in.

Output 1.5: Tuberculosis/HIV Co-infection Services

i. The 5I’s Intensified case finding: Under the leadership of the CHMTs, the project provided health education to PLHIV in facility waiting bays and in support group sessions on the benefits of TB screening and early treatment for those with active TB. Cough monitors, peer educators and CHVs were utilized to create more demand for TB screening during their interactions with clients as well as during home visits.

To ensure all PLHIV are screened for TB during every clinical visit, health care workers were reminded and mentored on the utilization of the pediatric and adult intensified case finding tools. Forty six (13M, 33F) health care workers from 14 health facilities65 in Taita Taveta ,103(43M,60F) from 40 facilities66 in Kilifi, 26(9M,16F) from 13 facilities67 in Kwale and 46(17M,29F) from 13 facilities68 in Mombasa benefitted. In addition, the project continued to support sputum collection and transportation to the various testing labs with gene Xpert machines using motorbike riders and reimbursement of transport thus reducing the turnaround time for GeneXpert tests. The Table 23 below show the number of gene Xpert tests conducted during the period from 12 supported labs69 in the four counties.

65 Bura HC, Mwatate SCH, Njukini HC, Ndilidau Disp, Kitobo Disp, Taveta SCH, Maungu Model HC, Buguta HC, Sagalla HC, Ndovu HC, Moi CRH, Werugha HC, Wesu SCH, Wundanyi SCH 66 Matsangoni, Ngerenya, Mtondia, Takaungu, Vipingo, KCH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Vitengeni, Malindi, Muyeye, Ganda, Kakuyuni, Marafa, Gongoni, Marereni, Dida, Vitengeni, AIC Malanga, Kiwandani, Mambrui, Gahaleni, Marikebuni, ,Bomani, Jilore, Garashi, Baolala, Kakoneni, Mtepeni, Madunguni, Bwagamoyo and Ngomeni 67 Eshu, Mbuwani, Ng’athini, , Mrima, Mwangulu, Kilimangodo, Mkangombe, Vigurungani, Ndavaya, Makamini, Mtaa, Mwanda and Silaloni. 68 Miritini, Magongo, Chaani, Magongo, Mvita, Ganjoni, Likoni Catholic, Shika Adabu, Mrima, Kisauni, Utange, Bamburi, Mlaleo 69 Taita Taveta county -Moi CRH, Taveta SCH; Kwale county-Msambweni CRH ,Kwale SCH ,Kinango SCH; Kilifi county -Kilifi County Hospital, Malindi SCH, Mariakani SCH; Mombasa county- Likoni SCH, Coast General Hosp, Ganjoni HC, Portreitz SCH.

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Table 23: Gene Xpert tests utilization Jan-Mar 2020 Total tested TB positive Rifampicin resistance Taita Taveta 1,352 84 2 Kwale 674 78 6 Kilifi 1,657 186 1 Mombasa 4,770 671 17 Afya Pwani 8,453 1,019 26 In the same reporting period, a TB/HIV national stakeholder meeting co-chaired by NASCOP and NTLD-P was held in Mombasa County. The County was selected to pilot TB LAM testing as a method of TB diagnosis. To this end, the project supported 2 CMEs on TB diagnosis including TB LAM to both laboratory technologists and clinicians at CPGH and Portreitz SCH reaching 30(18M,12F) health workers.

Integration of HIV/TB services and immediate ART initiation for HIV/TB co-infected persons: The project ensured that all TB patients were tested for HIV and those infected were initiated on ART. Of the 1,167 TB patients seen in the quarter, 1,078(92%) were tested for HIV, 205(19%) were positive and 192 (94%) linked to ART as shown in the table below. Those not linked had severe disease and are on follow up for start of ART one they are stable. Table 24: HIV/TB Integration No of No % Tested No HIV % TB/HIV No % linkage New TB Tested for HIV Positive Co Started to ART Clients for HIV infected ART Taita Taveta 157 153 97% 28 18% 27 96% Kwale 118 107 91% 40 37% 37 93% Kilifi 356 347 97% 81 23% 77 95% Mombasa 536 471 88% 56 12% 51 91% Afya Pwani 1,167 1,078 92% 205 19% 192 94% As a result of regular support supervision and mentorship, health care workers have now gained the necessary capacity to provide ART services according to 2018 ART guidelines.

IPT coverage: As per the national guidelines, Afya Pwani has continually ensured that all eligible PLHIV are offered TB preventive therapy and followed up to complete the 6 months of treatment. As shown in the table below, 1,188 PLHIV were started on IPT during the reporting period. Besides, health care providers were guided on documentation of IPT in the IPT register as well as on regular follow up of clients to check on adherence, side effects and provide necessary support. In addition, the health care providers were advised to conduct line lists of all clients eligible for IPT, order enough stock for IPT and initiate all clients according to the standard guidelines.

Table 25: IPT uptake Jan-Mar 2020 IPT Uptake Jan-March 2020 County < 15Yrs. > 15Yrs. Total Taita Taveta 9 123 132 Kwale 9 170 179 Kilifi 32 403 435 Mombasa 31 411 442 Afya Pwani 81 1,107 1,188

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Infection prevention and control: To minimize the risk of TB infection among health care workers and PLHIV, the project supported facilities to strengthen the institutionalization of IPC measures. As a result of this, facilities have strengthened triaging of coughing clients as well as promoted coughing etiquette and social distancing. Client flows have been redesigned to allow for scheduling of clients’ appointments thus reducing crowding when health care workers are attending to them. Further, those handling TB samples were provided with protective equipment as per biosafety guidelines. To ensure sustainability, Afya Pwani conducted joint support supervision with the county and sub county TB coordinators in Kwale and Kilifi reaching 12(6M,6F) health care workers from 3 facilities70 and 48(23M,25F) from 39 facilities71 respectively which reinforced IPC among health care providers. Additionally, 40 copies of waste segregation job aids were distributed to health care providers. In Taita Taveta county, the TB coordinators sensitized 72(22M,50F) health care providers on IPC from 4272 health facilities to promoted implementation of IPC plans. ii. Surveillance for Drug Resistant Tuberculosis

During the reporting period, Afya Pwani supported counties to strengthen their surveillance for drug resistant TB through joint support supervision and use of data to make decisions. For instance, in Mombasa County, the project facilitated the screening for DR TB among health care workers as one of the most at-risk population of contracting and spreading TB with 45 health workers being screened, 6 presumed to have TB, 6 samples were sent for Gene Xpert, none were diagnosed for TB. To ensure management of MDR cases meets the MOH standards, the project supported 3 clinical review meetings at Samburu Health Center, Waa and Vigurungani dispensaries in Kwale County and in Kilifi CH, Malindi SCH and Vipingo Health Center in Kilifi county reaching 48 (30M, 18F) health care providers. The table below show the number of drug resistant TB cases in supported facilities as at the end the quarter.

Table 26: DR TB patients in Afya Pwani supported facilities as at Mar 2020 County Intensive phase Continuation phase Total Kilifi 1 2 3 Kwale 7 4 11 Mombasa 26 13 39 Taita Taveta 2 4 6 Afya Pwani 36 23 59

Lessons learnt • Continuous OJT and mentorship improve knowledge and skills for TB diagnosis and treatment. • Lab networking has greatly improved the diagnosis of TB among PLHIV through faster transportation of sample to the testing labs.

70 Msambweni, Vitsangalaweni and Mazeras dispensary 71 Matsangoni, Ngerenya, Mtondia, Takaungu, Vipingo, KCH, Gede, Mtwapa, Oasis, Chasimba, Ganze, Bamba, Gotani, Jibana, Mariakani, Rabai, Vitengeni, Malindi, Muyeye, Ganda, Kakuyuni, Marafa, Gongoni, Marereni, Dida, Vitengeni, AIC Malanga, Kiwandani, Mambrui, Gahaleni, Marikebuni, ,Bomani, Jilore, Garashi, Baolala, Kakoneni, Mtepeni, Madunguni, Bwagamoyo and Ngomeni 72 Mwatate SCH, Bura HC, Modambogho Disp, Maktau HC, Kwamnengwa Disp, Mwambirwa HC, Challa Disp, Njukini HC, Mahandakini Disp, Chumvini Disp, Rekeke HC, Mata Disp, Ndilidau Disp, Kitobo Disp, Kimorigo Disp, Eldoro Disp, Kiwalwa Disp, Taveta SCH, Miasenyi Disp, Kajire Disp, Makwasinyi Disp, David Kayanda Disp, Maungu Model HC, Ndome Disp, Ghazi Disp, Kasigau HC, Buguta HC, Marungu HC, Sagalla HC, Ndovu HC, Tausa HC, Moi CRH, Nyache HC, Mbale HC, Kishushe Disp, Sangeroko Disp, Mgange Nyika HC, Mgange Dawida HC, Werugha HC, Mwanda HC, Wesu SCH and Wundanyi SCH.

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• Joint supervision build ownership within the MOH structures for sustainability of programming. Challenges Challenges How you overcame them GeneXpert machine for Msambweni • Samples taken to Kinango and Kwale hospital for hospital is broken down testing Inadequate supply of ICF tools for • Printing and distribution of the screening tools adults and children in facilities from NASCOP. Low utilization of the gene Xpert • CHMT and Afya Pwani staff continue to sensitize machine despite availability of lab health care workers during project supported support networking support in Kilifi County supervision and meetings on the importance of gene Xpert test and encourage staff to collect samples for testing

Output 1.6: Key Populations

In Q2 FY20, Afya Pwani scaled up service delivery as well as improved quality of services offered to KP clients among other interventions. This involved routine on job mentorship targeting health care workers in Drop in Service Centre’s (DICES) to address identified knowledge and skills gaps noted in the previous reporting period. In addition, the project supported a M&E training in collaboration with “Meeting and Maintaining Epidemic Control (EpiC)” program. The monitoring and evaluation training equipped the staff with skills to ensure adequate corrective and concise reporting. The training was also prepared the two counties for DHISII reporting as reporting remained low in the mainstream government system.

To strengthen coordination with government and improvement of accountability the project supported three County stakeholder forums (technical working groups- 2 in Kilifi and 1 in Mombasa). The project staff also took part in two national forums which were convened by NASCOP in Mombasa and the National transgender guideline development workshop in Nairobi.

In order to strengthen implementation of transgender populations the project commenced a process to engage a local Community based organization (CBO) named Pwani transgender initiative. Under a partnership arrangement called Partner Implemented Program (PIP) in Mombasa73. This will enable the project to mobilize transgender populations to access services in the mainstream heath facilities and in all the drop incentres serving other KP sub-types.

During the reporting period, the project provided KP services to MSMs, FSWs and transgender persons. In Mombasa County, this represents a cumulative achievement of 92% for FSW (n = 6,127/6,664), 62% for MSM (n = 1,207/1,933) and 64% for TG (n = 154/240) for the period Oct to Mar 2020 against the annual KP PREV targets by end of quarter 2. In Kilifi County, this represents a cumulative achievement of 101% for FSW (n = 6,741/6,696) against the annual KP PREV targets by end of quarter 2 while for the MSM program in Kilifi County attained a reach of 40% of the annual target (n=1219/3038).

73 a set of activities will be implemented with costs paid directly

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Table 27:KP served in Jan-Mar 2020

KP's served Jan-Mar 2020 Total KP served in Q2 Annual target Cumulative %Achieved against achievement(Q1+Q2) target by county MSM FSW TG MS FSW TG MS FSW TG MS FSW TG M M M Kilifi 694 5001 3038 6696 0 1219 6741 40% 101 % Mombas 375 2066 148 1933 6664 240 1207 6127 154 62% 92% 64 a % AFYA 1069 7067 148 4971 13360 240 2426 12868 154 49% 96% 64 Pwani % During the quarter a total of 2,641 FSW; 875 MSM and 94 Transgender persons were tested for HIV; A total of 225;76 MSM and 11 Transgender continued to take PrEP n while a total of 629 FSW, 157 MSM and 57 Transgender persons continued to take their ARVS medications. For viral suppression 93% of the FSW were virally suppressed all MSM were virally suppressed while the project is following up to get the VL for transgender when the clients are due, and the information is made available. Details of the summary table below is available in specific sections below.

Table 28: Summary of KP tested and provided with ARVs by Typology KP Type PrEP # Tested for HIV # on ART % VL suppression FSW 225 2641 629 93% MSM 76 875 157 100% TG 11 94 57 Not Due for VL

i. HIV prevention interventions During the reporting period, the project offered HIV prevention services to 11,656 KPs (9,884 FSW, 1,618 MSM and 154TG); with 6,779 (6,305 FSW, 366 MSM and 113TG) having been either tested or referred for HTS services. During the reporting period, demand creation for HIV prevention interventions was done through targeted micro education sessions to 11,646 KPs in 7 DICEs and hotspots. Mobile technologies, particularly WhatsApp and “UJUMBE” SMS platforms were used to broadcast messages targeted for KPs and mobilize for other prevention services.

Table 29: Uptake of Prevention Interventions among KP Jan-Mar 2020

# Of KP who received prevention interventions Jan-Mar 2020 Afya Pwani KP type No. of KPs newly tested and/or referred Total no. of KPs reached with HIV prevention for HTS services services during the reporting period (New + Revisits) FSW 6,305 9,884 MSM 366 1,618 TG 113 154 Total 6,779 11,656

ii. Other prevention services summary

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To ensure prevention against new infections the project distributed a total of 1,225,713 (735,871 Mombasa; 489,842 Kilifi) male condoms; 27,174 lubricants were distributed (25,491 in Mombasa and 1,683 in Kilifi); A total of 3639 KP were screened for STI among these 129 were offered treatment. A total of 270 were screened for Cancer 86 in Kilifi and 184 In Mombasa. NASCOP has assured the KP organizations that the country has enough stocks of commodities which will ensure that prevention is maintained.

Table 30: Summary of other prevention services Commodities and services Mombasa Kilifi Total Male Condoms 735,871 489,842 1,225,713 Female Condoms 0 72 72 Lubes 1,683 25,491 27,174 FP 108 134 242 STI screening 1,630 2,009 3,639 Treated for STI 11 118 129 Cervical cancer screening 86 184 270

iii. PrEP interventions The project offered Pre-exposure Prophylaxis (PrEP) to KPs as part of the high impact prevention interventions in the supported DICES and facilities. To this end, 3,383 KPs (2,458 FSW, 845 MSM and 80TG) tested HIV negative, 3311 (2404FSW, 845 MSM and 62TG) of them were screened for PrEP eligibility with 2960 (2,141 FSW, 757 MSM and 62 TG) found to be eligible for PrEP. Among those eligible, 288 (225FSW, 52 MSM and 11TG) were initiated on PrEP as shown in the table 5 below. Those eligible but were not willing to be started on PrEP were linked to “PrEP champion’s for further follow and counselling on the benefits of PrEP.

Table 31: PrEP Uptake among KP Jan-Mar 2020 PrEP Uptake Jan-Mar 2020 FSW MSM TG Total Number tested HIV negative during the reporting period 2458 845 80 3383 Number screened for PrEP eligibility 2404 845 62 3311 Number eligible for PrEP 2141 757 62 2960 Number Offered PrEP 1410 383 53 1846 Number referred for PrEP enrolment 532 25 40 597 Number NEWLY initiated PrEP at the DIC during the 225 52 11 288 reporting period Number reinitiated PrEP during the reporting period 37 44 0 81 Number initiated PrEP returning for PrEP refill one Month 111 45 9 165 after initiation Number initiated PrEP returning for PrEP refill three 67 11 0 78 Months after initiation Number initiated PrEP returning for PrEP refill six Month 20 2 0 22 after initiation Number current on PrEP at the DIC. (PrEP_CURR) Include 210 84 10 304 Newly initiated, reinitiated and return clients)

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To improve knowledge on adherence to PrEP, 14 PrEP champions were engaged to conduct health talks in KP hotspots, provide peer support for KPs enrolled on PrEP and follow up on PrEP defaulters. A total of 81 PrEP defaulters (37 FSW, 44 MSM) were reinitiated on PrEP. To retain KPs on PrEP, 18 PrEP clubs were conducted through which 290 KPs (245 FSW, 84 MSM and 11 TG) on PrEP met regularly to provide psychosocial support to one another. SMS reminders were also utilized to remind clients on their appointments and time for taking PrEP.

iv. Identification of KP living with HIV The project offered HTS to KPs as part of the high impact prevention interventions reaching 3,104 KPs (2641 FSW, 369 MSM and 113 TG) in both Mombasa and Kilifi counties as shown in the table below. As at the end of Q2, Mombasa county had provided HTS to 58% (1959/3398) of its annual target for FSW, 32% (613/1933) for MSM and 51% (122/240) for the transgender group while Kilifi achieved 64% for FSW (2123/3327) and tested a total of 506 identifying a total of 21 which is 4% (21/500) of the identification target for MSM.

Table 32: Identification of KP LHIV compared to annual target Oct'19-Mar 20 Identification of KP LHIV compared to annual target Oct' 19-Mar 20 Kilifi Mombasa Afya Pwani MSM FSW MSM FSW TG MSM FSW TG Total Annual testing target 3,038 3,227 1,933 3398 240 4971 6625 240 11,836

Number tested 1028 2,123 613 1,959 119 613 4,082 119 4,814 Q1+Q2 % Achieved 33% 66% 32% 58% 50% 12% 62% 50% 41% Target for newly 597 1716 339 910 48 339 2626 48 3013 identified KP positive Identified KP positive 21 138 51 148 20 51 286 20 357 % Achieved 4% 8% 15% 16% 42% 15% 11% 42% 12% In the concluded quarter, 226 KPs (183 FSW, 23 MSM and 20 TG) were newly diagnosed HIV positive in both Mombasa and Kilifi counties as shown in the table below with HTS yields being 6% for MSM, 7% for FSW and 18% for the transgender.

Table 33: Identification of Positives Jan-Mar 2020 Identification of KP Positives Jan-Mar 2020 Kilifi Mombasa Afya Pwani MSM FSW MSM FSW TG MSM FSW TG Total KP Tested 506 1486 369 1155 113 369 2641 113 3104 KP newly diagnosed as 11 91 23 92 20 23 183 20 226 Pos Yield 2% 6% 6% 8% 18% 6% 7% 18% 7% As shown in the Table 34 below, the yields among 1st time testers were higher than the overall yields especially among FSW in Mombasa and Kilifi counties. This was attributed to the fact that will utilize the FSW social network in both counties to reach more FSW as well as scale up risk network referrals and Expanded Peer Outreach Approach (EPOA) to reach social networks of the newly identified KPLHIV.

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Table 34: 1st time testing among KP Jan-Mar 2020 1st time testing among KP Jan-Mar 2020 County Kilifi Mombasa Afya Pwani KP Type MSM FSW MSM FSW TG MSM FSW TG Total KP tested for 1st time 154 47 29 157 4 29 204 4 237 ever KP testing for 1st time 0 23 2 34 0 2 57 0 59 ever testing positive Yields among 1st time 0% 49% 7% 22% 0% 7% 28% 0% 25% testers The testing yield at the DICEs and outreaches was 7% and 14% in Partner Notification Service (PNS) testing (before USAID moratorium) modalities as shown in the tables below.

Going forward and based on the above data, the project will focus on strengthening targeted testing through HTS screening by scaling up risk network referrals and Expanded Peer Outreach Approach (EPOA) to reach social networks of HIV positive KPs to improve on identification of positives.

The project will also sensitize KPLHIV on the importance of bringing their sexual partners for HTS through passive PNS. In collaboration with peer educators and outreach workers, the Staff undergoing a mentorship at Likoni project also identified hotspots with KPs. These are at a higher DIC during a support supervision visit. risk of HIV infection using a risk assessment tool based on behavioral characteristics and the number of STI cases reported in the hotspots. This strategy had similar yields to that of outreaches as shown below.

Table 35: DIC and outreaches testing for KP Jan-Mar 2020 TESTING STRATEGIES Testing at DIC County Kilifi Mombasa AFYA Pwani KP Type MSM FSW MSM FSW TG MSM FSW TG Total KP tested at DIC 23 812 302 654 110 302 1466 110 1878 KP positives identified at DIC 0 42 19 56 18 19 98 18 133 Yield 0% 5% 6% 9% 16% 6% 7% 16% 7% Testing in Outreaches County Kilifi Mombasa AFYA Pwani KP Type MSM FSW MS FSW TG MSM FSW TG TOTAL M KP tested in outreaches 484 67 67 501 3 67 1,175 3 1245 4 KP positives identified in 11 49 4 36 2 4 85 2 91 outreaches Yield 1.45% 7% 6% 7% 67% 6% 7% 67% 7%

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Following a USAID directive on temporary suspension of active PNS with contact elicitation for KPs in Kenya due to breach in confidentiality and increased risk of intimate partner violence, the project held a CME with service providers to discuss the Moratorium and additional case finding strategies. Only passive PNS was encouraged. The figures outlined below were achieved prior to the Moratorium.

Table 36: PNS cascade Jan 2020 PNS CASCADE JAN 2020) County Kilifi Mombasa Afya Pwani KP Type MSM FSW MSM FSW MSM FSW Total New positives offered Index testing 4 91 23 92 23 183 206 Known Positives offered index testing (for 1st 2 15 24 47 24 62 86 time) Number accepting Index testing services 2 91 25 53 25 144 169 Contacts elicited 5 134 115 90 115 224 339 Elicitation ratio 1:3 1:1 1:4 1:1 1:4 1:1.5 2 Contacts Known Positive 0 7 15 9 15 16 31 Contacts Tested 02 120 89 77 89 197 286 % contacts tested 40% 94% 89% 95% 89% 88% 84% Contacts Tested HIV positive 4 6 10 24 10 30 40 Yield 80% 5% 11% 31% 11% 15% 14% Linked to treatment 4 6 10 24 10 30 40 % Linked to ART 100% 100% 100% 100% 100% 100% 100%

v. Linkage to ART Out of the 226 KPs (183 FSW, 23 MSM and 20 TG) identified in the quarter, 93% of them were linked to ART as shown in the chart 11 below with 66% (150) being linked to DIC while 27% (61) were started on ART in nearby link facilities. The linkage among FSW was 92% (169/183), MSM was 100% (23/23) while TG was 95% (19/20).Apart from strengthening pre-and post-test counseling by building the capacity of the engaged service providers, the project also worked with 11 peer navigators to provide peer psychosocial support to newly identified positives to encourage them to start ART as well as facilitate follow ups for those who were not linked immediately. Consenting newly diagnosed positives were escorted by peer navigators to link facilities for same day ART initiation and attached the KP desk (mostly virtual) in the linking facility.

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Figure 13:Linkage to ART among KP identified 200 92% 14 Linkage to ART among KP Jan-Mar 2020 150 60 85% 100 100% 14 11

50 49 109 81 100% 95% 100% 95% 1 1 1 1 28 22 19 22 19 0 FSW FSW MSM TG FSW MSM TG Kilifi Mombasa Afya Pwani ICRH

TX_CURR @ DIC Linked to nearby facility Unlinked

vi. Adherence and Retention to ART In the second quarter of FY20, the project provided ART services to 817 KP (629 FSW, 131 MSM and 57 TG). The caseload is divided into 52 % (421/817) of KP were receiving ART from DICs while 48% (396/817) received ART from link facilities. To help KPs navigate link facilities, the project established virtual link desks to link KPs with clinician or peer navigator for express services. The project is currently working on strengthening the relationship with the mainstream health facilities in abide to mainstream the quality of care in all health care facilities as an effort to ensure that the journey to self-reliance(J2SR) remains on course. Table 37: KP on ART Jan-Mar 2020

KP on ART Jan-Mar 2020 County Kilifi Mombasa Afya Pwani KP type MSM FSW MSM FSW TG MSM FSW TG Total % receiving ART at facility( Link& DIC) # on ART in 0 92 71 240 18 71 332 18 421 52% DIC # on ART in 26 132 60 165 39 86 297 39 396 48% link facilities Total on ART 26 224 131 405 57 157 629 57 817 Target for KP 597 1636 322 866 46 891 2502 46 3439 on ART % 4.4% 13.6% 40.6% 46% 123% 17.6 25% 123% 55% Achievement

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Defaulter tracing: In the reporting period, 58 KPs on ART missed their appointments and were followed up. Out of the 58 KPs, 49 were traced back as shown in the table below.

Table 36: 12 KP defaulter tracing Jan-Mar 2020 KP Defaulter tracing Jan-Mar 2020 County Kilifi Mombasa Afya Pwani KP type MSM FSW MSM FSW MSM FSW Total #missed 00 2 21 35 21 37 58 appointments # followed up 00 2 21 35 21 37 58 Number brought back 00 2 18 29 18 31 49 to care % Success rate 0% 100% 86% 83% 86% 84% 84%

Afya Pwani utilized the services of peer navigators to trace defaulting KPLHIV, including following them up in hotspots or at home if other efforts were unsuccessful. Psychosocial support group meetings: During the reporting quarter, Afya Pwani held 19 support groups reaching 31 MSM in Mombasa, 245 FSW, 15 MSM in Kilifi (147 in Kilifi and 143 in Mombasa) and 18 TG in Mombasa. Differentiated care model: The project has embraced Multi Month Scripting for stable KPs with 76 FSWs and 23 MSM currently on MMS (Multi Month Scripting) in Mombasa and Kilifi counties. With the current COVI9-19 pandemic, guidance from NASCOP is that PLHIVs should be offered Differentiated Service Delivery (DSD) irrespective of age or viral load status. In the next quarter, clinicians will be mentored to scale up the uptake of DSD among KPs. The project will also explore starting community ART groups among KPs by utilizing their peer networks with the peer navigators being the link between the facility and the KPLHIV in the community ART group. Mental Health Support: There has been continuous sensitization of peers on the dangers of drug abuse especially those on ART including patients on PrEP. Through the 21 Psychosocial Support Groups (PSGs) and 18 PrEP clubs, drug and substance abuse issues are commonly discussed as these have a huge impact on adherence and subsequently viral suppression of the clients. In addition, service providers use the Patient Health Questionnaire (PHQ) to screen for depression and substance use disorders among sex workers. Those with moderately severe depression requiring pharmacotherapy are referred to mental health experts. No KP was diagnosed with severe depression during this reporting period. vii. Viral Load Monitoring In the previous 12 months, 416 KPs were offered VL test with 393 of them suppressed, giving a suppression rate of 96.5 % as shown in the table 38 below.

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Table 38: VL uptake and suppression among KP in 12 months ending Mar'20 Viral Load Uptake and Suppression among KP in 12 months ending Mar 2020 Kilifi Mombasa Afya Pwani MSM FSW MSM FSW MSM FSW Total TX_CURR 26 224 131 405 131 629 760 # with VL done in last 12 months with results in file 5 146 65 200 65 346 411 % Viral Load Uptake 50% 65% 50% 49% 50% 55% 54% # Suppressed 5 135 65 188 65 323 388 % Suppression 100% 92% 100% 94% 100% 93% 96.5% The suppression among MSM was 100% while that of FSW was 93%. The project offered enhanced adherence counselling to KPs suspected of treatment failure focusing on likely barriers to suppression such as drug abuse and alcoholism. viii. Violence, stigma and discrimination The project has continued to support gender-based violence response and reporting systems in KP service delivery areas. In the reporting period, 140 cases of physical/emotional violence (134 FSW, 6 MSM) were reported and 2 sexual violence cases involving two female sex workers were reported. The 2 FSW were offered post-exposure prophylaxis and emergency contraceptive as part of the package of post-rape care. The project also engaged six paralegals through its Amplify Change program to assist in follow up of GBV cases.

Challenges and Mitigation Challenges Mitigation factors Low uptake of services due • The project has embarked on using social media including to various restrictions put in WhatsApp groups, Facebook and bulk SMS platforms to reach place by the county clients. government and National • The Drop in Centers are on operation with clinical teams and Government to contain the Program teams working half day on rotational basis to provide spread of Covid-19. services to the clients. • Complete referrals are made to various primary healthcare facilities for the clients from far areas. • Testing and screening of clients are done at the designated places within the county. • The posters shared by MOH warning on covid-19 symptoms and posters on personal hygiene are displayed prominently in public areas within the DICs, offices and others also shared in the hotspots. • The DIC has running water and sanitizers at the entrance for washing and cleaning hands. Laxity among the MSM to • Adopting flexible testing hours and strengthening the social take up on HIV testing networks for mobilization. services. Low PrEP uptake • Continuous PrEP Education and distribution of Prep IEC materials Low reporting on Violence • Education on violence identification and reporting procedures. cases

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Output 1.7: Determined, Resilient, Empowered, AIDS Free, Mentored and Safe (DREAMS) Initiative

i. Coverage and reach of DREAMS interventions

During the reporting period, Afya Pwani enrolled and offered HIV prevention services to 9-24-year-old AGYW in 10 wards74 within Mombasa County. The focus of the program has been to accelerate provision of quality high impact combination interventions to address the risks of HIV infections among the targeted 12,883 adolescent girls and young women (AGYW).

As at end of Q2, the project had enrolled 13259 out of the 12883 targeted in FY20, an achievement of 103%. A total of 12414 (96%) of the 12883 targeted AGYW have so far completed at least one DREAMS intervention incorporating 572 young women who transitioned into 25-26-year-old band in FY20.

Table 39: Number of Active and inactive AGYW as at the end of Q2 FY20 Age (in years) Active inactive 9-14y 3179 352 15-17y 3223 210 18-19y 1863 76 20-24y 3566 176 25-26y 583 31 Total 12414 845 The table above shows the breakdown of the 845 AGYW documented as inactive as at end of Q2. The project worked with mentors to continually trace inactive AGYW and initiate them into DREAMS interventions. In that process, 100 of the 276 girls previously lost to follow up were identified and brought back into the program. In the next reporting period, the project will undertake exit interviews with AGYW who opted out of the program voluntary to understand their reasons for exit and use this to further improve retention in the program. Also, 447 AGYW were identified and are currently being mobilized for services for Q3. Majority of these are AGYW in upcountry secondary schools and who are mainly available during long holidays.

Figure 14: Explanation for inactive AGYW Relocated out Barred from of county (98) participating by 11% care givers (23) 3%

Lost to follow up (176) 21% Identified but yet to be served (447) 53% Opted out voluntarily (101) 12%

74 Mtongwe, Shika Adabu, Bofu, Likoni, Timbwani, Kongowea, Ziwa la N’gombe, Kadzandani, Jomvu Kuu and Mikindani wards

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ii. Accelerated service provision geared towards service layering

As the project matures, the focus has been to accelerate service delivery to ensure AGYW are layered based on the minimum package of DREAMS interventions. To this end, 84% (10,373) of the AGYW active as at the end of the reporting period were layered. This is 80% of the targeted 12,883 program beneficiaries. In terms of layering per age group, 15-17-year active AGYW were the least proportion layered at 78% while 9-14 year were the highest proportion layered at 88%. Based on the duration in the program, 10,669 AGYW have been active in the program for more than 18 months. Of these, 9,326 (87%) have been layered. Overall, nearly all layered AGYW (99%) have received at least a contextual service in addition to the primary package of services. While there has been good progress towards layering, vulnerability continues to change for every girl. This reality has significantly slowed down the process of graduating AGYW out of the program as expected. However, the project has identified and is following up some beneficiaries for graduation to give room for enrollment of additional more vulnerable AGYW. Moving into Q3 and Q4, the project will focus on layering the unlayered AGYW while accelerating the uptake of secondary and contextual interventions, active follow up and service provision to the AGYW based on their emerging risk profiles.

Table 40: Number of AGYW layered in the project as at Q2 FY20 Layering Duration in 9-14y 15-17y 18-19y 20-24y 25-26y Total Status: DREAMS: (3179) (3223) (1863) (3566) (583) Completed 1. 0-6M 47 105 50 45 247 more than 2. 7-12M 15 11 9 8 43 primary 3. 13-18M 66 233 186 263 5 753 package 4. 19-24M 2584 2152 1324 2824 370 9254 Total 2712 2501 1569 3140 375 10297 % of AGYW Active 85% 78% 84% 88% 64% 83%

Fully 1. 0-6M 49 105 50 45 249 layered 2. 7-12M 15 11 9 8 43 3. 13-18M 68 233 186 263 5 755 4. 19-24M 2656 2152 1324 2824 370 9326 Total 2788 2501 1569 3140 375 10373 % of AGYW Active 88% 78% 84% 88% 64% 84%

Not fully 1. 0-6M 200 320 96 58 674

Layered 2. 7-12M 3 2 3 8

3. 13-18M 9 35 30 18 92 4. 19-24M 255 365 168 347 208 1343 Total 467 722 294 426 208 2117 % of AGYW Active 15% 22% 16% 12% 36% 17%

iii. Empowerment of AGYW to increase risk perception and protection against HIV infection

a. In and out of School-Based HIV and Violence Prevention

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Evidence Based HIV Prevention interventions : In Q2, Afya Pwani partnered with schools to promote healthy sexual behaviors through school-based programs. AGYW were empowered to make informed choices about their own sexual reproductive health by avoiding early and unprotected sexual activity that increases their risks to unwanted pregnancies, STIs and HIV infections. Out of school sessions were also offered in community safe spaces. The EBIs offered in the program include; Healthy Choices for a Better Future (HCBF)75, My Health, My Choice (MHMC)76, Shuga II77 and Respect-K78. In FY20, 847 girls, 1792, 2056 and 1359 AGYW have been reached with HCBF, MHMC, Shuga II and Respect K respectively. Cumulatively, 11,513 (89%) of the targeted 12,883 girls and young women were reached with at least one priority population (PP-PREV) behavioral intervention.

From the Focus Group Discussion (FGDs) with the “You can also avoid the [boys] and avoid using drugs. program beneficiaries, the impact of the EBIs They can give you drugs, you use the drugs and then among young people across different ages are they misuse you. When you use the drugs, you lose clear. Older AGYW are now able to make consciousness and you start doing things you are not supposed to be doing.” 9-14-year-old girl, Likoni informed choices about their sexual reproductive health including negotiating for and demanding “It has helped us prevent pregnancies [and] getting for condom use with their sexual partners. They HIV by knowing how to protect ourselves.” 9-14-year- old girl, Kongowea are also confident to talk to other girls about Question: Let’s talk about those [EBIs] that you have behavior that increase their risk of HIV infection received first… and how best to mitigate such risks, as well as “The ones I have received have made me change…to aware of the availability and the required know many things that have helped me stop those bad things…” response to different HIV prevention options such Question: For example? as abstinence, HTS, condoms, PrEP and PEP with “Things like sex, smoking cigarettes, chewing [miraa]. some feeling comfortable to report use. For the Since I started coming for the lessons, I have at least younger age categories, the beneficiaries stopped them…”18-24-year-old, Mikindani mentioned the importance of avoiding negative peer groups, maintaining healthy relationships with boys/men, avoiding drugs and substance use and remaining sexually pure until marriage as some of the lessons they have learnt and are practicing as a result of the EBIs.

iv. SASA!

DREAMS uses SASA! model to address key drivers of violence against women and HIV infections at the community level. It does this by addressing the imbalance of power between women and men, girls and boys. Violence against women/girls reduces their power to negotiate for safe sex thereby increasing their risk to HIV infections. In Q2 FY20, SASA! was implemented through partnerships with community leaders and groups in whose forums the sensitizations were conducted. To this end, 5,526 community members were reached with SASA! interventions offered across different community forums by trained community volunteers. These were distributed across gender and age groups as shown in table 3. In Q3, the project

75 Offered to 10-14-year-old boys and girls in seven (7) weekly sessions in school 76 Offered to 13-17-year-old young boys and girls in four (4) weekly sessions in community setting 77 Offered to 15-24-year-old young women in five sessions in a community setting. 78 Offered to 15-24-year-old young women during HTS.

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intends to assess the impact of the SASA! interventions on the rate of GBV reporting and cases at the community through FGDs.

Table 41: Number of community members reached with SASA! as at Q2 FY20 Age Group (in years) Male Female Total 15-19 151 178 329 20-24 329 262 591 25+ 2,599 2,007 4,606 Total 3,079 2,447 5,526

b. Promotion and provision of male and female condoms To promote access and utilization of male and female condoms as a HIV prevention strategy, the program offers information on condoms as a primary service to the 15-24-year-old AGYW. This is offered by trained mentors during SAB activities, HTS providers in the context of risk reduction counselling and as part of Shuga II and MHMC curriculum. The goal is to promote correct and consistent use of condoms for those that are sexually active. To project addresses condom access barriers by stocking condom dispensers at the safe spaces as well as on demand access through mentors.

As at Q2, 8,512 (92%) of the active young women above 15 years in the program were reached with information on condoms. Regarding uptake of condoms, 2,578 AGYW were provided with male condoms directly by the mentors at the safe spaces while 9,431 male condoms and 1,362 female condoms were distributed through the condom dispensers. In the same period, feedback was received through mentors on their preference for Icon© compared to Sure© condoms. The Icon© condoms were sourced and made available through Family Health program in Kilifi. The project has also noted increased demand for female condoms suggesting the growing preference and use of the same.

Table 42: Number of young women reached with information on condoms as at FY20 Age (in years): Targets - FY20 # reached - FY20 # reached - Cumulative % Active 2. 15-17y 3223 1376 2740 85% 3. 18-19y 1863 561 1809 97% 4. 20-24y 3566 1368 3455 97% 5. 25-26y 583 179 508 87% Total 9235 3484 8512 92% To understand young people’s knowledge and perceptions and obtain recommendations on availability, access and use of condoms, the project conducted FGDs with young women during the reporting period. The project noted that information on condoms has significantly changed young women’s perceptions on condom use. Young women demonstrated knowledge of the importance of correct and consistent use of condoms in the prevention of HIV infections, STIs and unwanted pregnancies; were able to demonstrate correct use of condoms; were able share how condom use is currently at the centre of their sexual relationships and attribute all these to the EBI sessions on Shuga II, MHMC and respect K.

c. HIV testing services (HTS) and linkage to care and treatment In Q2 FY20, the project identified and offered HTS to AGYW with unknown HIV status. Onboarding of full time HTS providers enabled closer follow up to those who were reluctant to test since enrollment to the program. During the reporting period, 3,048 AGYW were tested and given their results bringing the cumulative number tested to 11,490 (93%) of the 12,214 active AGYW. This is 89% of the targeted 12,883

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AGYW in FY20. Only one (1) AGYW was found positive and linked to HIV care and treatment. The impact of EBIs on HTS appears to be significant as confirmed from the FGDs in Q2 where majority of the beneficiaries reported having tested because they now understood the importance of knowing their HIV status as well as that of their partners. For majority, it was no-longer possible to engage in sex with someone whose status they didn’t know. In fact, some young women reported having insisted on testing with their partners and where they could not get their partner to test, condom use was indispensable. Knowing one’s status was also seen by majority of the girls as a step towards planning for a better future. Comparing experiences between testing at the health facility and at the safe spaces, it emerged that the young people prefer the safe spaces because other girls would be testing with them at the same time and that no one will be able to judge them like they would if you were seen at the comprehensive care unit in a health facility. From this feedback, in Q2 the project will work with HTS counsellors and MOH to provide self-test kits for the AGYW who still fear testing at the facility and at the safe spaces to enable them test by themselves and their partners at their convenience. This will be preceded with counselling and demonstration of use.

d. Expanded and Improved Contraceptive Method Mix (CMM) information Continued empowerment of young people with information on available contraceptive method option helps to address unwanted and unplanned pregnancies among young women due to early sexual debut which increases the risk of AGYW to HIV infection as well as increasing chance of dropping out of school and getting married early. In Q2 FY20, the project engaged a roving nurse to accelerate provision of family planning information and commodities to the 15-24-year-old while at the same time facilitated effective referrals for the same services from Afya Pwani linked health facilities. In the same period, 4,251 young women aged 15-26 years were reached with this intervention. Cumulatively, 8,297 (90%) of the active young women in the same age category were reached with information on CMM. Regarding uptake of contraceptive commodities, 17 young women were counselled and offered various contraceptives (implant – 10; injectables – 12 and Pills/oral - 31). Increase in the uptake of the contraceptives, though marginal, is attributable to the efforts of roving nurse who has helped address access issues at the facility. Meanwhile, the project jointly with MOH is currently at an advance stage of rolling out a teenage pregnancy survey among the project beneficiaries across all project sites. The survey will assess the teenage pregnancy prevalence, risk factors, access to reproductive health information and services as well as ambition and desire post -delivery. Understanding these will enable the project contextualize interventions target this segment of beneficiaries as well as improve interventions to enable their integration back into the society.

Table 43: Young women reached with contraceptives services as at Q2 FY20 Age (in years): Contraception Education and Services Target # reached in # reached % reached # who received FP Q2 cumulative cumulative commodities 15-17y 3223 1629 2705 84% 3 18-19y 1863 713 1774 95% 12 20-24y 3566 1702 3380 95% 48 25-26y 583 207 438 75% 10 Total 9235 4251 8297 90% 73

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e. Provision of information on PrEP and Oral PrEP for treatment as prevention for most at risk AGYW Oral PrEP has been proved to be an effective way of preventing HIV infection among those in a continuous risk of HIV infections when used together with other interventions such as condoms. In Q2 FY20, the project continued to provide information and IEC on oral PrEP to young women aged 18-24 years to address myths and misconceptions around PrEP while creating demand for oral PrEP for those eligible as per the PrEP guidelines. As such, 2,626 young women above 18 years were offered PrEP education bringing the total to 54,264 (91%) of the 6,012 active young women in that age category. The nurse working with the mentors conducted targeted screening for PrEP eligibility. Those eligible are then referred and followed up for the service. In FY20, 113 young women were screened and 19 found eligible. Out of these 14 gave been enrolled while 5 are still on active follow up and counselling to explore other suitable preventive options.

Currently on PrEP (82) Discontinued Voluntarily (19) Total Ever Enrolled on PrEP (158) Reduced Risk (29)

Drop out of PrEP Relocated (16) (76)

Pregnant (2)

Adverse Side Effects (10)

Knowledge and perceptions regarding PrEP was also confirmed to have improved “Right now I know PrEP. I never used to know what PrEP significantly due to sessions conducted at is…” 18-24-year-old, Mikindani the safe spaces. Young people confirmed “For me regarding PrEP and PEP, I didn’t know whether that they understood the context in which those things existed but being taught and being provided PrEP was provided, knew what do to incase that information…I am not saying it should happen but if they found themselves in such context and it happens accidentally, I know how to deal with it…” 18- understood where to obtain PrEP when they 24-year-old, Likoni need it. Those on PrEP encouraged others at risk to take it without feeling prejudiced in any way. f. Social Asset Building (SAB) In Q2 FY20, the program continued to use social asset building session to provide an opportunity for girls to interact and make friends, provide financial and entrepreneurship literacy as well as promote sexual and reproductive health information. Mentors used these sessions to provide different life skills such as talent identification and goal setting. Through safe space attendance, the mentors responded to other social needs and questions around biomedical and behavioral interventions. Young women were also able to use the safe spaces and social networks built during the SAB activities to engage in socio economic

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activities like savings groups. These were further confirmed by the participants in the FGDs conducted within the quarter. According to majority of the beneficiaries, social asset building has helped them make

“How to interact and stay with people…previously, I never used to be where people were…I liked being alone…but since I came here, I have gotten friends, I talk a lot…” 15-17-year-old, Likoni

“We didn’t have much to do like now we have when we come here. It is not like in the past.” 9-14-year-old, Likoni

“For me I can say that it has helped me pass time. For example, you can sit idle at home then you start walking with this wrong groups and certain boys…so you could find that when I come here, I am coming to do many things.” 18-24-year-old, Mikindani

“It has helped me especially that one on how to achieve our goals, it has helped me concentrate on my studies. It was never easy for me to read but after learning about that, I wake up early in the morning and read first before I do anything else.” 9-14-year-old, Ziwa la N’gombe new friends and social networks, pursue their childhood dreams, discuss with other girls their social and economic challenges, play while providing a serene environment for the girls to unwind. The outcome of this was that the girls, both the young and the old, were able to report improved confidence and self- esteem and empowerment through peer to peer positive influence.

v. Mobilizing Communities for Norms Change

a. Strengthening Families Parenting/caregiver programs are designed to improve family ties and morals, by increasing communication between caregivers and their adolescents on sexuality and shaping their children’s values. In FY20, 887 parents to 9-14-year old age group (69% of 1,288) and 1488 parents to 15-19-year old age group (101% of 1,468) were reached with FMP I and FMP II respectively. Though no assessment has been conducted to quantify the effects of parental/care giver program, remarked improvement and concern has been reported by mentors from caregivers interested on the progress of their children in the program. Caregivers have also made occasional visits to the safe spaces to learn what their children learn from the program.

b. Social Protection Combined Social-Economic Approaches (CSEA): During the reporting period, the project continued to empower young women through CSEA interventions such as Financial Capabilities (FC), entrepreneurship skills, vocational skills trainings while taking advantage of strong partnerships. The following interventions were offered under CSEA during the period: Financial Capability Training: A total of 3,480 AGYW were reached with FC training translating to 11,619 (94%) of the active AGYW and 90% of the FY20 targets reached with the intervention. The impact of this intervention is manifested in the continued enrollment and the growing number of VSLA groups for the older beneficiaries as well as reported savings among younger groups. Majority of the younger girls have reported using the skills to save their lunch money which they have used to help their family members when in need.

Entrepreneurship Skills training: This intervention addresses direct and indirect structural barriers such as poverty, gender inequality, sexual violence and lack of education. It provides skills to enable them start

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and run their own businesses as a way of addressing vulnerabilities brought about by these barriers. It targets 18-24-year old in the program. During the reporting period, 1,648 (85%) of the 1932 young women targeted were reached. Cumulatively, the project reached 3,571 young women with this intervention. Some AGYW who underwent financial and entrepreneurship literacy trainings have already started or improved their businesses (those who had already existing business). For instance, 2 AGYW from Mikindani ward have since started baking business where they sell within their locality with a plan to register, brand and expand their business. Besides, they “We were also taught about savings…that when train other AGYW who have shown interests in baking at you get 20 shillings, use 10 and keep the other 10 the safe spaces. The program has already kicked off the so that if for example your family lacks food and process of supporting those with viable business plans you have reached say 1000 shillings, you give out and help…so that is savings…so we are supposed with startup kits. They were taken through the business to save.” 9-14 year old, Kongowea plan application process and some of them have already submitted the applications. “You save so that one day when you want to buy something and your parents don’t have money, Vocational Skills Training: The project leveraged on the you can buy for yourself.” 9-14-year-old, Bofu ongoing partnerships with Generations Kenya (GK), an “Personally, it has helped me. I still save the way NGO that targets young out of school youth aged 20-35 we were told by [the facilitator]. If you save and years with short course trainings and placement. Under there is an emergency, you are supposed to help. this partnership, six (6) young women successful When my cousin died, we were supposed to raise 600 [shillings] and my parents did not have underwent a 5 weeks training on financial services sales money and I had 600 in my account, so I raised it and were successfully placed in a relevant institution for for them.” 9-14-year-old, Ziwa la N’gombe their attachment. Currently, two (2) young women undergoing a 5 weeks training on Food and Beverages within the same partnership arrangement. Some of the beneficiaries trained have formed saving groups and are at different stages of starting and running individual and partnership business. Those that have acquired skills in areas such as baking, and pastry have started using the safe spaces to teach others who are willing to learn as part of the SAB activities. This helps them polish their skills while empowering others in their cohort.

Targeting Male Sexual Partners (MSPs) with HIV Risk Reduction Interventions

During the reporting period, Afya Pwani accelerated the implementation of this intervention through outreach services by mentors, HTS providers and SASA! facilitators. The targeted MSPs were mainly Boda boda riders, matatu drivers/conductors, young men in video hang out dens, the long-distance truck drivers and the police. During the MSP outreach services, 454 men aged between 15 and 64 years were reached with a total of 480 HIV self-test kits and 824 male and 20 female condoms issued.

Collaborations, Partnerships and Engagement with Stakeholders

i. Co-enrollment and service provision for co-enrolled orphaned and vulnerable girls from OVC program

The project continued to work with Mwendo OVC program to co-enroll and serve OVC girls in the target wards of Mombasa County. Through this partnership, Afya Pwani supported Mwendo OVC project with

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technical inputs on how to best accelerate layering for the co-enrolled AGYW after the two programs agreed on how to serve them. The project also supported the enrollment and documentation of services for the co-enrolled girls through the joint implementation arrangement. In the same period, joint technical review meetings were conducted between Afya Pwani and Mwendo OVC program to accelerate implementation of services. As such the project co-enrolled 864 girls from the OVC program. Of these, 64% (556) are active out of whom 60% (334) are already layered.

ii. Program Advisory Committee (PAC) Meetings

PAC are ward level committees that bring together community gate keepers and stakeholders on a quarterly basis. The committees are constituted to conduct their affairs as per prescribed Standard Operating Procedures key among their roles being receiving reports on behalf of the community on milestones achieved. They also help the program navigate challenges with penetration of the community with DREAMS interventions. In Q2, PACs from 8 of the 10 wards met. The issues discussed included; education subsidy program, vocational skills training and the uptake of biomedical interventions. Challenge of inadequate safe spaces which is the DREAMs program’s preferred service delivery points and the impact of this on access to services was discussed at length with the members committing to support the program identify some within their communities. Also raised was the issue of lack of a certification process for the beneficiaries to which the project has undertaken to work around.

iii. Partnerships and Collaborations

In Q2, the project partnered with Stanbic Bank Limited for a half day training of 45 young women in the program who were at different stages of starting and running various forms of business. The training focused on developing their business management skills, support business plan development, cash management tips, cash flow management and savings. Three (3) young women opened business accounts during the session. As part of this ongoing partnership, Stanbic Bank will follow up and support the young women through business registration, open accounts and provide them with more opportunities to learn through invitation into other forums as they grow in business.

The project also continued working with Nyali, Likoni and Jomvu Kuu SCHMTs to offer biomedical services through health facilities under their management. The services include provision of HTS providers, HIV Test Kits, contraceptive methods, STI treatment services, GBV clinical care and oral PrEP. Some health facilities have also provided rooms that the AGYW can use as safe spaces. In the subsequent quarters, the

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project will work with the SCHMT to conduct joint support supervision to the service providers at the facility as well as provide inputs on how best to improve service delivery at the safe spaces.

Lessons Learnt and Best Practices

• Introduction of the roving nurse has accelerated the uptake of biomedical services. This is due to improved appointment schedules for services, improved mobilization, reduced turnaround time at the facility and improved confidentiality. With these efficiencies, feedback from the beneficiaries and consultation with the SCHMT and health facility management, the project will start piloting provision of additional biomedical services such as contraceptive commodities from the safe space.

• There is need for more active follow up and support for the AGYW in developing business plans so that can secure resources. This is to ensure that the interested AGYW come up with coherent and realistic business plans.

• PAC meetings are critical in addressing challenges of access to social norm change programs at the community level. It is also a platform for empowering the community through their representatives on the available biomedical interventions such as HTS, STI screening and treatment as well as clinical interventions around SGBV.

• Continuous feedback sessions with the beneficiaries on their experiences on various interventions is critical in improving their perceptions about the program while improving their experiences on the same services. For instance, based on the feedback on the preference of young people of ICON as opposed to SURE male condoms, the program availed the ICON condoms which were out of stock within a very short time.

• Allowing care givers access to the safe spaces by occasionally inviting them to accompany the AGYW for SAB activities at the safe spaces helps to address their concerns about the project while increasing their perceptions about the program. This together with the engagement of PAC leadership and community gate keepers has increased reach with caregiver programs.

Challenges

1. Inadequate supply of the condom brand preferred by young people. Sexually active young women prefer ICON condoms as opposed to Sure condom that in excess supply.

2. Closure of satellite safe spaces and schools interfering with the delivery of in school and out of school evidence based intervention as well as access to SAB activities as a result of the closure of school and the presidential directive on social distancing as a response to the outbreak of COVID- 19 pandemic towards the end of the quarter.

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

Output 2.1: Maternal, Newborn and Child Health Services

During the reporting period, the project continued to work towards its goal of increasing access and utilization of high-quality MNCH services while strengthening Kilifi County Health through partnership, networking, and collaboration with the MoH, RMNCAH implementing partners, community members, and key decision-makers. In an effort to sustain the gains, improve the status of Maternal and Neonatal Health indicators and address the challenges faced in the previous reporting period, the project in Q2 FY20 continued to scale up low-cost, high impact interventions aimed at building the capacity of the County, Sub-counties, health facilities, and community while aligning its activities to Journey to self-reliance. The project consolidated its community strategies, service delivery initiatives leveraging on other thematic areas of the integrated project and putting the client at the center of its implementation. During the reporting period, the project improved its performance across the MNH cascade in supported facilities. The number of new antenatal clients increased to 13,359 new antenatal clients in Q2, an increase from 11,143 reached in Q1, cumulatively reaching 24,502 pregnant women, attaining 61% of the annual target. The number of pregnant women who completed at least 4 ANC visits increased from 6,681 in Q1 to 7,556 in Q2, cumulatively reaching 14,237, attaining 41% of the annual target. The project also made strides in the number of women delivered by skilled birth attendants. There was an increase from 8561 women in Q1 to 9702 women in Q2, cumulatively 18,263 women were delivered by skilled birth attendants attaining 56% of the annual target. The number of newborns given postnatal care within two days of delivery increased from 7002 in Q1 to 8276 in Q2, cumulatively achieving 49% of the annual target. This achievement is attributed to intensified community mobilization strategies like Universal ANC referrals, Maternity open days, referrals for pregnant women for SBA, community dialogues, and sensitizations on the importance of Antenatal and hospital delivery services. Besides, the project continued to support Mama Kwa Mama and Binti Kwa Binti groups as a retention strategy in MNCH, supported facilities to provide quality ANC services through the purchase of HB meters and ANC profile laboratory networking support and supported capacity building of health care providers in MNCH. To further strengthen MNCH service delivery, the project continued to support capacity building sessions, supervision, audits for Maternal and perinatal reviews, and advocated for increased funding for MNCH services through FIF actualization and the development of SOPs to streamline Linda Mama funds utilization. a) Increasing ANC Service Uptake

Antenatal care offers an excellent opportunity to prevent and manage existing and potential causes of maternal and neonatal morbidity and mortality, and a is a vital point of entry for most high-impact interventions targeting the pregnant mother. During the reporting period, the project supported CHVs to conduct door to door household sensitization on the importance of early initiation of ANC, adhering to ANC schedule, pregnancy screening, and referral for pregnant women for ANC services. Besides, the project supported Laboratory networking for ANC profile in 13 facilities (acquisition of Hemoglobin meters) and provided technical assistance for laboratory networking in 43 facilities during Maternity Open Days. The project also used community resource persons such as male champions, religious leaders, and community leaders to address socio-cultural barriers and increase utilization of maternal and newborn health services. Cumulatively, 24,502 women received 1st ANC services (11,143 in Q1 and 13,359 in Q2), achieving 61% of the annual target for 1st ANC as at SAPR.

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The retention strategies like the group ANC (Mama Kwa Mama and Binti Kwa Binti groups) and sensitization of the communities on the importance of ANC resulted in 7,556 pregnant women completing 4 ANC visits in Q2 and cumulatively 14,273 as at SAPR, achieving 41% of the annual target. In Q3, the project will strengthen defaulter tracing by supporting appointment keeping strategy by use of appointment diary and defaulter tracing to enhance retention in the ANC cascade. In line with J2SR, the project will advocate for increased financing for maternal and neonatal health. Besides supporting the County to streamline utilization of Linda mama funds to enhance the sustainability of the gains. b) Increasing uptake of skilled birth attendance and Postnatal care

Afya Pwani has continued to support the DOH to improve Figure 16: MNH Cascade in Afya Pwani supported sites quality of care during labor, delivery, and 24 hours after delivery through competency-based onsite clinical 18,263 mentorship to reduce maternal and newborn morbidity and mortality. The project has also supported SCHMT to conduct Women delivered using skilled support supervision in SBA and PNC. In Q1 FY20, the project birth attendants supported sensitization of 153 health care providers on respectful maternity care while in Q2 FY20, conducted client exit interviews, a central aspect of quality improvement and capacity strengthening of health facilities to offer /BEmONC services. To increase demand for SBA services, the project supported community engagement, social accountability through the "Utawala na Afya" forums, referral of pregnant women by reformed TBAs and CHVs, and community dialogues, and advocacy forums. Cumulatively, 18,263 women (8,561 in Q1 and 9,702 in Q2) delivered under the care of a skilled birth attendants achieving 56% of the annual target. In the same period, the project sensitized health care workers on the PNC indicator definition, integrated postnatal package of care including the use of chlorhexidine for cord care. Moreover, the project supported clinical mentorship on newborn resuscitation. These efforts resulted to 8,276 newborns receiving PNC services within two days of birth during the reporting period translating to cumulative achievement of 49% of the annual targets. Figure 15: MNH Cascade in Afya Pwani supported sites

MNH Cascade in Afya Pwani supported sites fron Oct. 2019 to Mar. 2020

15000 13359 11143 9702 10000 8561 8276 7556 6681 7002

5000

0 ANC1 4ANC SBA PNC

OCT to DEC 2019 JAN to MAR 2020

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c) Addressing socio-cultural barriers to utilization of Maternal and Neonatal Health (MNH) services

i. Community leaders promoting appropriate MNCH practices

Increasing the involvement local leaders in MNCH has been a critical component of Afya Pwani’s demand creation efforts. The project has continuously leveraged on the influence of 97 reformed Kaya leaders linked to the Magarini Cultural Centre to shift social norms that impede utilization of MNCH services. Over time, the project has empowered Kaya elders with facts on reproductive health to enable them debunk culturally inclined myths and demystify reproductive health services.

During the reporting period (Jan-March), the elders conducted 18 community sensitization sessions, reaching 3,670 community members with MNCH information. They used song, dance, and dialogue to educate communities while challenging retrogressive practices. These sessions have been effective in creating an enabling social environment and encouraging behavior change among community members. A case in point: In Shomela, a village in Magarini Sub County, the elders identified a family, where a man and his three wives, perennially sought services of traditional birth attendants, because he believed in Chinga79 a traditional practice conducted by TBAs to protect the fetus and the mother during pregnancy. The Kaya leaders successfully persuaded him to embrace skilled antenatal and delivery services for his youngest wife, who is currently expectant. With the continuous follow-up and education by the elders and CHVs, the reformed man accompanied his wife for 2 ANC visits and committed to ensure she delivers in the Health facility. This shall be the first of his 22 children to be delivered by a skilled health care provider. Through such efforts, 853 women were referred for ANC services, 948 children for immunization services, and 62 women for family planning services.

ii. Reformed TBAs championing safer births In a bid to end preventable pregnancy-related deaths at community level, 306 TBAs previously sensitized by the project have continued to champion skilled deliveries among their peers and communities. In Q2 FY20, the project worked with TBAs in Gongoni and Jimba areas to map out their peers who are still conducting home deliveries. As a result, 28 TBAs were identified and sensitized on the importance of skilled delivery, with emphasis on the risks associated with home deliveries. The TBAs agreed to work together to promote skilled delivery. Further, the TBAs proactively engaged in the referral of all clients who sought their services and accompanied them to health facilities whenever possible. For instance, in Mwarakaya area of Kilifi South Sub County, the reformed TBAs led 3 dialogue sessions, where they informed community members of their decision to stop home deliveries, among other harmful services they performed on their clients. They encouraged skilled ANC and delivery services. As such, the TBAs referred to the link facilities 736 ANC and 602 SBA clients.

iii. Encouraging Male Involvement in Maternal Health

During the reporting period, 278 male champions previously trained by the project, were engaged in community sensitization efforts to promote acceptance of maternal, neonatal, and child health services among their fellow men. The male champions were at the forefront in addressing issues of male chauvinism across all the 7 sub-counties of Kilifi County. Besides, the male champions took lead in organizing community dialogues in their respective community units, referred clients to access family

79 Chinga involves consumption of traditional herbs by the mother to cleanse evil spirits that may be cast on her, and there after the mother is given a charm to protect her and her baby during and after pregnancy. Once a woman goes through this then they do not need to skilled ANC, SBA or even immunization services, because they believe in the power of the process.

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planning services, identified and referred immunization defaulters, and clients who had not started antenatal clinics. Strategies deployed to reach clients include: door to door sensitization of clients; some leveraged on opportunities to speak during organized community meetings ( ‘Barazas’), while some took advantage of men gatherings in the evening, especially at drinking dens while others co-opted their wives to reach out to their fellow women. Through these efforts, the male champions reached 8,643 clients with MNCH information. In addition, 272 men from these sessions invited the male champions to their homes for more personalized counseling, consequently referring to the link facilities 1018 clients for ANC services.

iv. Client tracing and referral for MNH services

Leveraging on its robust community networks, Afya Pwani has continued engaging diverse community resource persons (CORPs) as referral agents for ANC and SBA services. The project has partnered with the community resource persons who include TBAs, CHVs, male champions, and other natural leaders to identify and refer pregnant women who have not started their ANC clinic. During this process, the CORPs screen all women on reproductive age within their localities, asking a set of questions to establish if they are pregnant and if they have started ANC. Additionally, the CORPs educate community members on pre- conception care, positive pregnancy, and postpartum care, as well as nutrition support and counsel. The project has adopted a performance-based remuneration system to rewards the CORPs for every new ANC client-initiated into care and referrals for skilled delivery. As a result of these interventions, a total of 6,249 ANC, and 2259 SBA clients were referred for services.

v. Scaling up Maternity Open Day

Maternity Open Days80 have increased the uptake and utilization of MNH services in Kilifi County. Building on the gains made in Q1 FY20, Afya Pwani continued to support this intervention to address barriers to uptake and utilization of MNH services, demystify myths and misconceptions surrounding pregnancy and childbirth. The open days are also an entry point into the provision of longitudinal MNCHFP services through the formation of cohorts ANC groups81. In Q2 FY20,the project supported 1382 Maternity Open Days , reaching 826 pregnant women (512-1st ANC and 351 ANC revisits). These resulted in the formation of an additional 13 Mama kwa Mama groups and 10 Binti kwa Binti groups. During the Maternity Open Days, the projected provided technical assistance for laboratory networking for the lower level facilities resulting in 672 women receiving ANC profile. As a result, 32 women with low HB (less than 7g/dl) received prompt management. During the forums, the project also supported capacity building of health facilities on the Linda Mama83 claiming process resulting in all 1st ANC clients enrolled for Linda Mama services.

80 Pregnant women only dialogue sessions 81 Mama group for women over 24 years of age and Binti kwa Binti groups for women aged 24 years or less 82 Mtwapa HC, Gotani HC, Mwangatini Dispensary, Chumani Dispensary, Cowdray dispensary, Kamale dispensary, Jimba Dispensary, Takaungu Dispensary, Kinarani Dispensary, Dungicha Dispensary, Garashi Dispensary 83 A publicly funded health care scheme under the National Hospital Insurance funds for basic health care package. It targets expectant mothers and infants improving access to MNH services

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The dialogue sessions during MODs elicited gaps in respectful maternity care (RMC) such as the inappropriate location of the delivery room in Dungicha dispensary, resulting in a lack of privacy. The facility relocated the delivery room and is now reporting an increase in the number of deliveries. The dialogue sessions were also successful at the Gotani Health center. The facility had documented a decrease in the utilization of delivery services due to maternal mortality in the facility. Following dialogue sessions held with the pregnant women, the SCHMT supported the facility to address the gaps in service delivery through mentorship, training, and supervision. Besides, the SCHMT posted an experienced midwife to the facility as the facility in charge. Due to these interventions, the facility has seen a steady increase in the utilization of maternity services. Soap making session during Mama group session at Mnarani Dispensary vi) Mama and Binti Kwa Binti groups Antenatal and postnatal care conventionally takes the form of a one-on-one consultation between a pregnant woman and her healthcare provider. On the other hand, Group ANC (GANC) and Group PNC integrates the healthy individual pregnancy and post-pregnancy health assessment with tailored group educational activities and peer support, to motivate behavior change among pregnant women, improving pregnancy outcomes, and increasing women's satisfaction. Afya Pwani implements this model through its legacy project; the Mama Kwa Mama (MKM) and Binti Kwa Binti (BKB) groups. Mama Kwa Mama84 and Binti Kwa Binti85 groups are vital avenues that have boosted retention in the MNCHFP care cascade. During the reporting period, the project supported 101 MKM groups with a membership of 2,958 and 79 BKB groups with a membership of 1,887 by offering both clinical services and auxiliary services86. Besides, the project focused on building the capacity of women to attain economic freedom through entrepreneurship skills-building sessions. For instance, the project supported health care providers to sensitize clients on liquid soap making across 1287 facilities in Kilifi North Sub County, reaching 218 clients. The women pledged to use the soap in their homes and sell the surplus for improved household income.

84 Mama group is a peer support structure, made up of different cohorts of pregnant women (both HIV positive and negative; both first-time mothers and non-first-time mothers). Each group consists of 2 to 30 women, who are grouped based on their ANC visit, I.e., All women attending their first ANC visit at a given time (i.e., Month) or those who deliver (Postnatal) at a given time (i.e. Month) form one group. Once grouped in the same cohort, all members have their revisit scheduled on the same day where they receive a comprehensive package of integrated services and information, including but not limited to Maternal, Newborn and Child Health, Family Planning (FP), Water, Sanitation and Hygiene (WASH), Nutrition health services and other auxiliary services 85 Binti Kwa Binti are a subset of the Mama group, comprising of young girls and women below 24 years focused on ensuring quality integrated services for adolescent girls and young women either pregnant or breastfeeding. The BKB offers a targeted approach that puts adolescent and youth-friendly services at the core of the initiative. 86 Telephone Support Interventions, Peer to peer support group, Income generating activities

87 Mnarani disp, Ngerenya disp, Mtondia disp, Kiwandani disp, Mavueni dispensary, Takaungu disp, Konjora, Kadzinuni disp, Matsangoni HC, Gede HC, Jimba Disp, Cowdry disp,

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In the same period, Afya Pwani supported exit sessions for 16 Mama and 12 Binti Kwa Binti groups in 1688 Health facilities in Kilifi County, with a total of 631 clients exiting. These exit sessions89 provided an opportunity to celebrate and showcase the women who successfully went through the MNCHFP cascade. During the sessions, facilities invited current Mama and Binti Kwa Binti group members, local administration, community leaders, and SCHMTs to enhance facility and community ownership. The groups' mandate after graduation changed from Facility based (Clinical) management groups to community entrepreneur/ empowerment groups. The women traced their journey and involvement in the groups and reiterated the benefits of attending the group meetings, which included creating new friendships and bonds, which positively altered their attitudes and behavior towards Hospital deliveries, good breastfeeding practices, and ultimately improved their maternal and child health outcomes. The graduates affirmed their commitment to being role models90 and agents of change in MNCHFP. Further, the group members received sensitization on entrepreneurship for small businesses. Besides, 491 Mama groups were registered and certified by the social services department. In the next reporting period, the project will have lined up 12 groups with all the prerequisite documents for registration. Registration for the BKB groups has been challenging because most of them do not have birth certificates and identification cards. However, through the various facility in charges and community health extension workers (CHEWS), the project invited area Chiefs in the group meetings to educate the young women on the requirements for registration for the birth certificates and ID cards. d) Improve access to quality MNH services by optimizing functional existing County health services

i. Supporting RH Consultative meetings for differently-abled persons.

Women who are differently abled often have difficulty with physical access to health services92 and are generally among the more vulnerable and marginalized in society. Differently abled persons have the same sexual reproductive health needs, just like the general population. However, more often, they face barriers to information and access to services owing to ignorance, societal attitudes, and individuals, including health care providers. In the reporting period, the project supported CHMT to convene a Reproductive Health Stakeholders consultative meeting for people with different abilities to foster equity and equality in service provision. The meeting provided a forum for the DOH to understand the challenges and barriers faced by them. As a result of this, the team developed an action plan to address these barriers. Besides, codesigning a transport voucher system for people living with different abilities, they also shared the challenges they face when seeking reproductive health services. The main challenges enumerated include; stigma and discrimination, physical access to service delivery points, lack of sign language interpreters, myths, misconceptions, and the knowledge gap among health providers on different disabilities after deliberations on the cause of these barriers and possible interventions. The team resolved to form a County People with Disability (PWD) task force to; develop a Sexual reproductive Health Strategic Plan for differently abled persons, mobilize and coordinate partners supporting services for the differently-abled persons, and support the implementation of action points from the consultative forum. The Strategic Plan will be anchored in the Kilifi County RMNCAH Strategic Framework, which is in the process of development. Further, through coordination and support from Afya Pwani, the DOH

88 Zowerani Disp, Ngerenya Disp, Mijomboni dispensary, Vipingo HC, Mrya Chakwe dispensary, Pingilikani dispensary, Pala Kumi dispensary, Bomani dispensary, Malanga dispensary, Mtwapa health center, Kiwandani dispensary, Rabai HC, Chasimba HC, Vitengeni HC, Madamani Disensary, Mtepeni Dispensary 89 The exit sessions were held at least 9 months after last baby in the group was delivered and all the babies were fully immunized. 90 Role models in MNCHFP, embracing recommended antenatal and postnatal practices 91 Bomani dispensary, Kiwandani dispensary, Rabai HC, Chasimba HC, 92 World Bank, health, nutrition and population: reproductive health and disability

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 76

convened a task force meeting that spearheaded the development of the work plan. The team deliberated on high impact interventions to drive the agenda. The following activities were prioritized; i) mapping of PWD for targeted interventions, ii) conducting integrated outreaches and in reaches targeting PWD, iii) Community interventions to address social-cultural barriers, iv) sensitization of PWD on SRH/SGBV, v) capacity development for health care workers on disability mainstreaming and addressing stigma and discrimination of PWD, vi) sensitization of PWD champions, and vi) improve the capacity and coordination of sign language interpreters. In Q3 FY20, the project will support the County to implement the work plan.

ii. Supporting laboratory networking for ANC profile targeting lower-level facilities The project supported laboratory networking for ANC profile for facilities in the vast counties of Ganze and Magarini to address the increase in access to comprehensive93 laboratory services for the ANC profile. Following successful registration of facilities with 'Linda Mama and the improvement of the capacity to support lab networking, the project supported the procurement of 7 HB Meters (494 in Magarini SC and 395 in Rabai SC), an addition to 6 HB meters for six facilities supported in Q1 (396 in Magarini and 397 in Ganze Sub County). This led to expanded anemia screening at ANC. All the facilities successfully replenished the HB strips with funds from Linda mama reimbursements. Further, the project provided technical assistance to 4798 health facilities on laboratory networking for ANC services during the reporting period.

iii. Strengthen health facility capacity to offer BEmONC/ CEmONC services

The care women receive during pregnancy, childbirth, and the immediate postnatal period is essential not only to ensure normal, healthy evolution of the pregnancy but also to prevent, detect or predict potential complications during pregnancy, childbirth, and the postpartum period. Thus, quality of care is essential for the survival and well-being of the woman and her newborn. In Q2 FY20, the project supported the DOH to strengthen the facilities' capacity to offer C/BEmONC services through the purchase and distribution of 17 non-pneumatic anti-shock garments in 1099 health facilities and 3100 ambulances, training of 31 health care providers to build on the gains in Q1. The project supported the SCHMTs to conduct onsite clinical mentorship on the PPH bundles, focusing on the use of NASG as a life-saving device reaching 176 health care workers. Further, the project supported the distribution of the 100 pieces USAID procured Assisted Vaginal Delivery kits to 86101 facilities. This quarter saw the County commission an

93 HB measurement, Urine Biochemistry and Blood grouping 94 Marereni Disp, Kambi ya waya disp, Mitzijini disp and Mtoroni disp 95 Bwagamoyo disp, Lenga disp, Kombeni Disp 96 Sabaki disp, Matolani Disp, Mwangatini disp 97 Dida Disp, Ganze HC, Jaribuni Disp 98 Kamale disp, Cowdry disp, Jimba disp, Gotani HC, Mtwapa HC, Takaungu disp, Kinarani disp, Dungicha disp, Mjanaheri disp, Dzikunze disp, Mambrui disp, Mwangatini disp, Marikebuni disp, Garashi HC, Chumani disp, Zowerani disp, Ribe disp, Mshongoleni disp, Kachororni disp, Kombeni disp, Rabai HC, Vitengeni HC, Vishakani disp, Jilore disp, Mkondoni, Mnarani disp, Kokotoni disp, Ndatani disp, Tsangatsini disp, Kijanaheri Marafa, Gahaleni disp, Msumarini disp, Bwagamoyo disp, Kakoneni disp, Mtepeni disp, Mwapula disp, Makanzani disp, Pingilikani disp, Junju disp, Junju disp , Bomani disp. 99 Kilifi county hosp, Mariakani SCH, Malindi SCH, Baolala HC, Gongoni HC, Marafa HC, Gede HC, Gotani HC, Rabai HC, Bamba SCH, Mtwapa HC, 100 Kilifi HC, Mariakani SCH, Malindi SCH 101 Adu disp, Bamba SCH, Baolala HC, Baricho disp, Bombi disp, Chakama disp, Chalani disp, Chamari disp, Chasimba HC, Cowdry disp, Dagamra disp, Gahaleni disp, Ganda disp, Ganze HC, Garashi HC, Gede HC, Gede HC, GK Prison Disp, Gongoni disp, Gotani medical disp, Jibana SCH, Jilore disp, Kakoneni disp, Kakuyuni disp, Kakuyuni disp, Kambi ya waya disp, Kanamai disp, Kijanaheri medical disp, Kilifi CH, Kiwandani disp, Kizingo disp, Kokotoni disp, Konjora disp, Lenga disp, Madunguni disp, Makanzani disp, Malanga AIC, Kaembeni disp, Malindi SCH, Marafa HC, Marereni disp, Mariakani sch, Marikebuni disp, Matsangoni HC, Mephi medical clinic, Mnarani disp, Mshongoleni disp, Mtondia disp, Mtoroni disp, Mtwapa HC, Muyeye disp, Mwangatini disp, Mwapula disp, Ngerenya disp, Ngomeni disp, Oasis medical clinic, Palakumi disp, Rabai HC, Ramada HC, Ribe disp, Roka Maweni disp, Sabaki disp, Sosoni disp, St. Lukes Hosp, Tawfiq disp, Tezo medical clinic, Vipingo HC, Vishakani disp, Vitengeni HC, Dungicha disp, Kachororoni disp, Mrima wa Ndege, Kamkomani disp, Ndatani disp, Madzimbani disp, Mtondia

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additional GOK CEmONC site, the Jibana Sub County hospital, with the support of the project. While the County has made remarkable progress in B/CEmONC signal functions, critical challenges remain in the provision of high-quality B/CEmONC services. These challenges include a shortage of health care workers, frequent staff reshuffles, inadequate capacity of facilities to offer 24-hour maternity services, and inadequate health financing for maternal and newborn health. The project is currently engaging the County to address the issues.

iv. Strengthening EmONC monitoring

Since inception, Afya Pwani has continually supported the DOH in the planning of EmONC activities and strengthening the structures supporting quality EmONC service. During the reporting period, the project supported the DOH to undertake EmONC monitoring in 93 facilities to assess the current situation, to review progress, and identify gaps and needs. The findings from the monitoring are as illustrated in the charts below:

Figure 17: Graph depicting BEmONC sites in Kilifi County % BEmONC SITES WITH 7 SIGNAL FUNCTIONS 50%

84

60

67% 90 72 60 80 85 24 80 % % % % 16 13 % 11 10 11 10 10 8 7 8 6 6 4

Kaloleni Kilifi North Kilifi South Magarini Malindi Ganze Rabai Total

Kilifi AP

medical clinical, Chumani medical clinic, Pingilikani disp, RGC Community clinic, Shakahola disp, Venoma clinic, Sososboara disp, Bwagamoyo disp, Mitsajeni dispensary, Uwanja wa Ndege disp,

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Figure 18: Graph showing appropriate use of partographs

Kilifi County appropriate filling of partographs N=1450

1600 1450 100% 1400 66% 90% 80% 1200 954 70% 1000 60% 800 50% 40% 600 55% 73% 67% 54% 30% 86% 65% 291 400 262 234 237 187 176 202 164 59% 20% 137 106 129 160 200 75 44 10% 0 0% Ganze Kaloleni Kilifi North Kilifi South Magarini Malindi Rabai AP_Kilifi

Total # of files sampled # with partographs filled appropriately % Partographs

Figure 19: Graph showing uterotonic use in the Management of third stage of labor

Kilifi County uterotonic use in AMTSL.N=1450 90% 1600 1450 100% 1400 1302 95% 1200 1000 90% 800 85% 600 84% 84% 87% 94% 94% 93% 291 400 262 220 234 221 237 273 187 162 164 153 199 99% 80% 200 75 74 0 75% Ganze Kaloleni Kilifi North Kilifi South Magarini Malindi Rabai AP_Kilifi

Total # of files sampled # administered oxytocin % administered oxytocin

While there has been significant improvement in the number of facilities with the capacity to offer B/CEmONC services, there are gaps in the process of care. In Q3 FY20, the project shall scale up its capacity-building efforts through mentorship and online job training to address the gaps witnessed in the process of care. Also, the project shall advocate to the County to finalize and commission the CeMONC facilities currently under construction besides advocating for the strengthening of the referral system. e) Capacity building in EMONC Addressing learning needs of health care workers remains a critical component in improving health systems. Afya Pwani has been at the forefront of providing evidence-based technical support to ensure that the health workforce is competent, responsive, and productive in providing EmONC services hence improving the capacity of providers and the health system to reduce the "third delay" in maternal and perinatal deaths. During the reporting period, the project supported onsite clinical mentorship of health care workers in EmONC, cumulatively reaching 257 health care workers. The mentorship sessions focused

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on management of PPH using the PPH bundles, use of AVD, and Neonatal resuscitation. In Q3 FY20, the project shall support the mentors to coordinate audits of near misses in their facilities. f) Strengthen delivery of quality newborn care services Afya Pwani supported the DOH to improve outcomes for newborns with a focus on the promotion of thermal protection, early and exclusively breastfeeding, newborn resuscitation, and infection prevention and treatment, including the use of chlorhexidine in cord care. In Q1 FY20, the project supported the Department of Health to sensitize 31 health care workers on Kangaroo mother care services drawn from 25102 high volume facilities. During this reporting period, the project conducted a post-training follow up in the 25 health facilities. The post-training follow- up sort to ensure capacity building of health care workers working in maternity units through CMEs and setting up of KMC corners in the maternity units. The uptake of Kangaroo's mother care in facilities has been slow because of health care workers and community perception that KMC is not necessary because Kilifi being a coastal region, is warm and humid. To address this gap, the project, through the Sub County Reproductive Health Coordinators, has sensitized HCW s on the additional benefits of KMC besides the region’s weather. Moving forward, the project will further support the DOH to conduct a health facility assessment and supervision to enhance the implementation of this low-cost, high impact intervention.

In the same period, the project conducted a post-training follow-up of 64 health care workers in 48103 facilities trained on Neonatal resuscitation. The follow-up aimed to ascertain whether the HCPs maintained the acquired competence after training. Throughout the follow-up, we ascertained that 100% of the facilities had a functional bag and mask. However, of the newborns that required resuscitation, only 86% had been successfully resuscitated. The gap in successful resuscitation was attributed to a lack of adequate preparation to receive and resuscitate a newborn and not entirely a lack of skill. The project shall continue to support health care workers working in the delivery units to adequately prepare for newborn resuscitation during each delivery and build on their competency through onsite clinical mentorship. g) Strengthening MPDSR Achieving maternal and perinatal mortality reduction as a development goal remains a significant challenge in most low-resource countries, especially in sub-Saharan Africa. Kilifi County, which is a member of one of a low resource country, is not spared either. With a focus on achieving the Sustainable Development Goals, Afya Pwani has continually aimed to support the County Department of Health to accelerate efforts to improve outcomes for women and babies. Since inception, the project has supported the DOH to address barriers towards utilization of MNH services, increasing access, and demand for maternal and newborn health, through the various strategies mentioned in the previous sections. Afya Pwani baseline survey indicated that most maternal mortalities were as a result of delay 1 and 2. The project has continually addressed these gaps through its community interventions which has helped reduce mortality rates in the County. However, the reduction of Maternal and perinatal mortalities

102 Kilifi County Hospital, Malindi SCH, Mariakani SCH, Rabai HC, Bamba SCH, Vipingo HC, Mtwapa HC, Kijanaheri MC, Gotani MHC, Chasimba HC, Matsangoni HC, Gede HC, Muyeye HC, Ganze HC, Vitengeni HC, Baolala HC, Tsangatsini HC, Gongoni HC, Marereni Disp, Jibana SCH, Marafa HC, Sosoni Disp, Garashi Disp, Kinarani Disp., Kizingo HC 103 KCH, Malindi SCH, Mariakani SCH, Mkondoni Disp, Garashi, Jimba, Gongoni, Gede HC, Kijanaheri MC, Soso Bora disp, Baolala HC, M’Mangani Disp, Marereni Disp, Zowerani Disp, Marafa HC, Shakahola Disp, Kambi ya waya Disp, Dagamra Disp, Matolani Disp, Mambrui Disp, Jila HC, Mwapula ,Rabai HC, Mtwapa HC, Kinarani Disp, Lenga disp, Chasimba HC, Ndatani Disp, Chilodi crossfit, Makanzani, Gotani HC, Tsangatsini Disp, Bamba Hosp, Malanga Disp

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reported within the County has been inconsistent. During the period under review, there was a surge in maternal mortalities 12 maternal and 334 perinatal deaths). The Maternal Mortality Audit analysis attributed the deaths to hemorrhage 67%, eclampsia 17%, Infection 8%, and other causes 8%. The spike was due to the enforcement of curfew and travel restrictions due to the COVID-19 pandemic. To address this, the project, in collaboration with the DOH, has engaged communities to strengthen community referral. The table below shows critical challenges and corrective actions.

Key challenges noted during MPDSR audits and mitigation measures Challenges Way forwards The “no name, no blame” dictum in MPDSR – • Sensitization of the health workers on legal Misinterpreted as no accountability by HCWs and ethical issues around MPDSR during audits Inadequate health personnel • Continue to advocate for the hiring of health personnel Lack of timely implementation of • Foster regular sub-county and county recommendations of the MPDSR reports MPDSR meetings • Roll out of MPDSR dashboards Perinatal death audits not considered core and • Enhancing Midwifery-led MPDSR entirely left as a responsibility to the Consultants committees. • Linking MPDSR committees with Civil Registration and Vital Statistics Suboptimal review of the near-miss cases • Including a discussion on near-miss review in the MPDSR committees Lack of consistent MPDSR monitoring and • Advocate for embedding MPDSR supervision by the DOH monitoring in the routine EmONC monitoring and assessment h) Improving the quality of maternal and newborn services Quality improvement

i. Joint support supervision To ensure RMNCAH services meet the minimum standards set by the Ministry of Health, the project collaborated with CHMTs and SCHMTs to conduct integrated quarterly support supervision. Following identification of quality gaps, the joint supervision team offered mentorship and supported facilities to develop action plans for remedial actions. As at SAPR, the project had cumulatively supported supervision in 47 health facilities, with 22 facilities supervised in Q1 and 25 104 health facilities in Q2. Besides, the SCHMTs conducted support supervisions in 19105 health facilities without Afya Pwani support in line with J2SR. The table below shows gaps identified and how the project addressed the gaps.

104 Malindi SC (Kakoneni dispensary, Madunguni dispensary, Malindi SCH), Ganze SC (Jaribuni Dispensary, Mwapula Dispensary, Rima ra Pera dispensary, Ganze HC, Mirihini dispensary, Jila dispensary), Rabai SC (Kokotoni disp, Rabai HC, Ribe dispensary, Kombeni disp, Lenga disp, Kambe disp), Magarini SC (Shakahola disp, Garashi HC, Fundi Issa disp, Chakama disp, Chamari disp, Adu disp, Marikebuni disp, Mwangatini disp, Marafa disp, Dagamra disp 105 Matsangoni HC, Gede HC, Cowdray HC, Takaungu Dispensary, Konjora Dispensary, Kiwandani Dispensary, Mijomboni dispensary, Gotani HC, Jibana SCH, Tsangatsini Dispensary, Mgamboni Dispensary, Kamkomani dispensary, Ndatani Dispensary, Seaside hospital, Vipingo HC, Mtwapa HC, Kizingo HC, Mwembekati dispensary, Chasimba HC

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Gaps identified during support supervision and corrective action Gaps Way forward Inconsistent provision of PNC services resulting in • Supported facilities to develop QI projects missed opportunities in HEI screening in PNC and conducted onsite mentorship and Technical assistance on integrated PNC Some facilities cannot offer comprehensive ANC • Advocate for facilities to utilize Linda profile, i.e., Urine Biochemistry, and Blood Mama funds to support Lab networking grouping for ANC Profiles Delayed Health financing for facilities thus • Advocacy for increased funding for hindering the provision of core services RMNCAH services, currently supporting the development of the Kilifi county RMNCAH strategic and investment plan. Underutilization of the Community functions by • Enhanced joint facility-community the clinical staff meetings Reduced utilization of MNCHFP services due to • Leveraging on project supported activities growing fear among the communities and health to sensitize the communities on the care workers following the confirmed COVID-19 importance of RMNCAH services during cases in Kilifi. the pandemic while ensuring COVID-19 precautionary measures Lack of sustained gains from EmONC mentorship • Advocacy for rationalization of staff due to the frequent staff reshuffles at the Sub- reshuffles. county, facility and departmental levels

ii. Quarterly RMNCAH Data Quality Audit For data to be reliable and used confidently by the intended audience, it should meet all dimensions of data quality. The project during the quarter continued to invest in data quality improvement activities that are simple and sustainable. Leveraging on joint support supervision. The project conducted DQA for MNCH program indicators 27 facilities across Kilifi County during joint support supervision. The project also advocated for and successfully integrated DQA in the RMNCAH support supervision tool. The gaps identified in the DQA included under-reporting in PNC ( data collection in facilities with multiple registers), confusion between Perinatal death notification and audit (where HCP considered notification of perinatal death is equivalent to an audit of the death especially in the lower level facilities) and under-reporting of condoms dispensed. The project, in collaboration with CHMT/SCHMT, provided direction on the correct interpretation of these indicators for HCPs. Besides, the project disseminated data collation SOPs and indicator definitions to the health facilities.

iii. Respectful Maternity Care Promoting respect and dignity is a critical component of providing quality care during facility-based childbirth and is a critical indicator of maternal health care. During the reporting period, the project supported community dialogues, where some clients cited negative health care workers' attitudes as a barrier to utilization of facility-based MNH services. To address this gap, the project supported the DOH to conduct a County-wide health care worker sensitization reaching 153 health care workers drawn from

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52106 health facilities. Following the sensitization, Afya Pwani supported the DOH to conduct 304 maternity client exit interviews in 24107 health facilities. Though most clients were satisfied and recommended the facility, the assessment revealed significant gaps in communication of essential information like return date, lack of food after delivery, and lack of personalized care. Besides, there were some occasions of health care providers disrespecting clients. In Q2, the project supported the County to disseminate and undertake corrective action. The figure below displays the key findings. In Q3, the project shall do a follow-up evaluation to assess the impact of the corrective action.

Figure 18: Graph showing Findings from RMC Client exit interview; Kilifi County

Kilifi County Client Exit interview findings. n=304

97% 96% 90% 85% 81% 85% 85% 85% 64% 48% 38% 39% 29%

3% 6%

i) Address Gender Barriers impeding access to Sexual Reproductive Health services i. Conducting psychosocial support groups meetings for survivors of sexual violence In the previous reporting period, the project supported the running of a psychosocial support group for child and adolescent survivors at Malindi Sub County Hospital. The hospital employed Trauma-Focused Cognitive Behavioral Therapy approach, which targeted children and adolescents aged 10-17 years old as a means of supporting them emotionally and behaviorally. Their caregivers were also counseled as first- line support providers. In this reporting period, follow up was undertaken by health care workers on their progress. While it is acknowledged that healing is a gradual process, preliminary reports indicate positive progress by the young survivors as they continue to interact with others. Follow up shall be undertaken in the April-June 2020 quarter.

106 Kilifi county hospital, Malindi SCH, Mariakani SCH, Rabai HC, Bamba SCH, Vipingo HC, Mtwapa HC, Kijanaheri medical clinic, Gotani HC, Chasimba HC, Matsangoni HC, Gede HC, Muyeye HC, Ganze HC, Vitengeni HC, Baolala HC, Tsangatsini dispensary, Gongoni HC, Marereni Dispensary, Jibana SCH, Marafa HC, Sosoni disp, Garashi Disp, Kinarani Disp, Sabaki disp, Dzikunze disp, Dagamra Dispensary, Kambi ya waya dispensary, Matolani disp, Mambrui disp, Marikebuni disp, Makanzani HC, Kokotoni disp, Ndatani disp, Chakama disp, Bwagamoyo disp, Shakahola disp, Soso Bora disp, Dida disp, Jaribuni dispensary, Kachororoni disp, Mwapula disp, Lenga disp, Uwanja wa Ndege disp, Jila model HC, Mmangani dispensary, Mkondoni Disp, GK Prison, Kaembeni disp, Kaembeni disp, Chilodi Crossfit, Zowerani disp and Jimba dispensary. 107 Kilifi county hospital, Mariakani SCH, Malindi SCH, Gede HC, Matsangoni HC, Mtwapa HC, Vipingo HC, Chasimba HC, Bamba SCH, Rabai HC, Kijanaheri, Gotani HC, Muyeye HC, Ganze HC, Vitengeni HC, Baolala HC, Tsangatsini disp, Gongoni HC, Marereni disp, Jibana SCH, Marafa HC, Sosoni Disp, Garashi disp, Kinarani disp

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ii. Supporting County AYSRH and Gender data review meetings The project supported a gender data review meeting in Q1FY20 attended by health care workers from 14108 health facilities. The meeting discussed the documentation of SGBV data and assessed platforms used by facilities for reporting. It was noted that facilities widely utilized the MOH 711 to report on SGBV data since it has a section of reporting SGBV as opposed to the required MOH 364 summary tool. Other issues included documentation gaps and errors. Representative facilities agreed to rectify the situation by first filling in the MOH 364 summary and submitting it for uploading. As a follow up on the actions, technical assistance was provided to eleven (11) health facilities 109 while an additional 7 110facilities were supported with information via WhatsApp in Q2 FY20. The support was a follow up on documentation of SGBV cases while strengthening documentation for emotional and physical violence that do not have transparent cut documentation systems. From the visits, it was noted that some facilities had started documentation using the correct tool. Other facilities, e.g., Malindi SCH, have documented their SGBV cases, but are yet to upload the same in the appropriate platform. A meeting with the facility HRIO led to a commitment to initiate the uploading of SGBV cases on the right platform. Further discussion with the project M&E focal person has resulted in an agreement on sensitizing the sub-county HRIOs on the same in the April-June 2020 quarter.

Iii Commemorate international gender days During the reporting period, Afya Pwani participated in the International Women’s Day (8th March 2020). The event was held to increase community awareness on gender and also showcase how gender dynamics influence the uptake and use of health services. This include; a focus on women empowerment in the journey towards gender equality because women are disproportionately affected economically and socially. The project teams showcased their work regarding integration in HIV, FP, WASH, and nutrition. Besides, the project showcased Makiga block making by women from Ganze and Kaloleni, and male champions who address harmful gender norms and support increased RH service uptake by their peers. The project participated in the event as a key Kilifi County gender stakeholder providing goods (tents and PA system), SRH services, and edutainment through Magarini Cultural Centers’ Kaya elders.

108 Bamba, Gongoni, Gede, Vipingo, Ganze, Matsangoni, Malindi, Mtwapa, Gotani, Jibana, Rabai, Marafa, Kilifi and Muyeye HC 109 Malindi SCH, Baolala HC, Jaribuni Dispensary, Mjanaheri dispensary, Mariakani SCH, Marafa HC, Bamba SCH Gotani HC, Ganze HC, Vitengeni HC, and Mwapula dispensary 110 Muyeye HC, Rabai HC, Marereni HC, Matsangoni HC, Jibana HC, Gede and KCH

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The event critical activity outputs include; During the event, the project introduced the Community Based Distributors from Kaloleni and Rabai Sub Counties to those in attendance to provide SRH services. Men and women attending the event were informed about the genesis of International Women’s Day and encouraged to reflect on gains made by women in their respective geographic areas. Key speakers during the event emphasized on the need for the citizenry to promote gender equality and realize women’s rights as part of enhancing the County’s social and economic development. The CEC Gender- Ms. Maureen Mwangovya highlighted the achievements made by the department, the key of which was the reduction of teen pregnancies in the county in collaboration with other key stakeholders, including the department of health and education. She also prevailed upon the county assembly to pass the Kilifi gender policy. The chief guest, H.E Governor Amason Kingi, enumerated efforts that his government had put towards advancing gender equality such as 50% gender representation and provision of funds to women for their advancement. He also implored on the women to desist from home deliveries announcing that the county government had built and opened two Kilifi County Governor Amason Kingi (second right in red cap) maternity theatres at Jibana and Rabai joins Magarini Cultural Center dancers during the event Health Center

iv. Community sensitization on SGBV

In Q2 FY20, the project supported a meeting of 15(12M,3F) Community Resource Persons to discuss cases of defilement in Vipingo Ward, a vice that is rife in the area. The team agreed to be proactive in sending out prevention messages and condemning practices such as child marriages and GBV. During the period, CHVs trained on GBV in Malindi continued to integrate GBV in their daily day to day work. The project also supported a feedback meeting of 30 (13M,17F) CHVs to review their progress. Significantly, due to close collaboration with the judiciary a serial pedophile initially set free for lack of evidence was successful prosecuted after the community came forward with evidence. In the coming quarter, the CHVs shall continue to integrate GBV messages as they carry out their day to day activities.

Output 2.2: Child Health Services

The project has continued to support interventions to increase the quality of child health (CH) services and reduce morbidity and mortality among children who are under-five years of age through creating demand for child health services, strengthening immunization and IMNCI services. During the period under review, Kilifi County experienced immunization vaccine stockout from Q1 through to Q2 FY20 following a national stock out for measles Rubella. Besides, there was an interruption of child health services due to the outbreak of COVID-19 pandemic. Despite these challenges, the number of children under 1 year who were fully immunized increased from 8,445 to 10,034, cumulatively reaching 18,479 children attaining 48% of the annual target. However, the number of children reached with DPT3 immunization by 12 months of age slightly decreased from 9,244 in Q1 to 8,497 in Q2, cumulatively reaching 17,741 children attaining 46% of the annual target. These achievements are attributed to the

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 85

strengthening of defaulter tracking and mop-up activities after the vaccines were available. The project recorded a slight decline in the number of cases of child diarrhea diagnosed from 9,667 in Q1 to 9,602 In Q2 due to preventive WASH interventions in place. The number of childhood pneumonia cases who are correctly treated is on the rise due to improved case management. The graphs below depict the trends in child health in Kilifi County.

Figure 21: Graph showing trends in child health Kilifi County

Uptake of DPT3 and FIC in Afya Pwani supported sites from Oct 2019 to Mar 2020 10500 10,034 10000

9500 9244

9000 8497 8445 8500

8000

7500 DPT3 FIC

OCT to DEC 2019 JAN to MAR 2020

Pneumonia and Diarreah cases in Afya Pwani supported sites from Oct 2019 to Mar 2020 12000

9667 9602 9453 10000 8998 9057

8000 5968 6000

4000

2000

0 Number of cases of childhood Number of cases of child Diarreah Number of cases of child diarreah pneumonia treated correctly cases treated correctly

OCT to DEC 2019 JAN to MAR 2020

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a) Increase demand for child health services The following critical interventions to increase demand for child health services were implemented during the reporting period. i. Integrated Community Case Management (ICCM) Afya Pwani has continued to implement ICCM, an equity-focused strategy to enhance access and coverage of life-saving treatment for children under 5 in the vast Magarini Sub County. The project has recruited and built the capacity of 63 community-based case managers in Mulunguni, Mtoroni, and Gandini locations of the Magarini Sub County. The case managers conduct A CHV demonstrating administration of Vitamin A to his fellow case managers continuous mapping of during a review meeting at Mtoroni Dispensary households with children under-5 and follow-up on their wellbeing. During this reporting period, the case managers conducted household visits, whereby they focused on disseminating child health promotion messages aimed at increasing informed demand among caregivers for appropriate treatment-seeking behavior. The case managers also identified and managed mild illnesses within the communities and referred children with acute illnesses or danger signs for clinical management at their link health facilities.

The case managers visited 4,078 households, with 1,745 children under 5 years, sensitizing 1,466 caregiver’s health education on prevention and early diagnosis of pneumonia and diarrhea as well as newborn danger signs. They also emphasized on the need for simple protective measures like sleeping under a mosquito net, minimizing air pollution in the house, preparation of safe drinking water, and the importance of proper nutrition for the community at large. During the household visits, they administered a set of questions to assess the health of all children under 5. Using this tool, they were able to identify and rate illnesses to inform their ability to manage or refer. Consequently, the Case managers identified 852 cases of childhood illnesses: 41 with fast breathing, 16 with chest indrawing,202 with diarrhea, 362 with fever, and 231 malnourished children. From the cases identified: They successfully treated 35 children who had fast breathing with Amoxil and managed 162 children who had diarrhea with ORS and zinc sulfate. They also referred 597 children for further clinical assessment and management. Besides, they managed to track 297 immunization defaulters whom they referred for immunization services.

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The project also supported supportive supervision sessions for 18 case managers in Mulunguni to support them to maintain and improve their skills in managing childhood illnesses. The case managers were accompanied by 2 ICCM trainers of trainers (TOTs) during their household visits to assess their technical capacity in case identification and management. While most of them demonstrated adequate capacity in identifying symptoms and managing the common illness, client follow-up post-treatment was inadequate in some instances. The supervisors advised the case managers to ensure they conduct mandatory follow- up after 3 days for all cases they managed and refer all clients who were not showing signs of improvement. Documentation of their practices was inadequate, and the supervisors recommended that the County develops a simple register to track all procedures. This shall be done in the next quarter. For communities in Sheli village, Magarini Sub County, getting to a health facility to access services means travelling more than 10Km. Many of the residents of this remote location cannot afford transport to the nearest health facility, Mtoroni Dispensary, and therefore have to walk the distance. These challenges have seen majority of the locals turn to traditional treatment from the readily available herbalists and blacksmiths despite their compromised care. During one of the household visits, Domtilla, a trained community case manager and resident of this village, diagnosed a two year old boy with pneumonia and immediately referred the child for specialized care at Mtoroni dispensary. Unfortunately, the parents opted to visit a traditional doctor first despite being told about the urgency and need to seek hospital treatment. At the traditional doctor, the child’s condition worsened despite the treatment which included waving of a dried sheep skin a therapy called “kufukizwa chandani”. Out of despair the parents heeded to Domtilla’s advice and called her to accompany them to the dispensary. The health care provider instituted treatment and referred the child to the sub-county hospital where he was treated and got well soon after. This was a breakthrough for Domtilla. The community started believing her, over the traditional doctors. She has since educated the community on childhood danger signs, and the community members call her for assistance every time they notice an abnormality with their children. Domtilla is always happy to respond to each of these requests. To enhance access to health services, Domtilla collects select medicines and commodities from Mtoroni dispensary. She is therefore able to manage mild cases of pneumonia and diarrhea, which are the most common childhood illnesses in her community. She also liaises with the health facility to conduct outreach services every often.

Additionally, the project supported monthly review meetings where the case managers and their link facility in-charges reviewed data and trends of childhood illnesses, identifying villages with high cases and strategizing how to combat the same. They also shared experience, with a majority reporting that the communities have embraced ICCM, especially in remote and hard to reach locations. This appreciation was due to the reduction in long distances to seeking care, not having to queue, and the availability of accessible free treatment always. ii. Promoting child health services through community mobilization and education In its commitment to protect every child from vaccine-preventable diseases, Afya Pwani has continued to utilize multiple community education platforms to create and sustain demand for immunization services. During the reporting period, 81 community dialogues were conducted reaching 4,595 community members with information on the importance of immunization and other child health services. The project purposed to include all community members, including fathers and mothers with children under

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5 years, to emphasize gender roles in ensuring children’s wellbeing. Local service providers facilitated these sessions, providing factual responses to questions, and observed practices. Influential community- owned resource persons addressed socio-cultural concerns raised by community members, as they could link cultural norms that complemented proposed behaviors. The project also supported 4 radio talk shows in one of the local radio stations, Lulu FM. These educative sessions encouraged communities to adhere to their immunization schedules. Moreover, the platforms were utilized for health promotion, educating communities on how to protect their children from common childhood illnesses like malaria, diarrhea, and pneumonia. The health workers who facilitated the sessions responded to questions sent in, occasionally reminding the clients of the different health services provided in the facilities.

iii. Door to door campaigns to identify and track immunization defaulters

During the reporting period, the project engaged community resource persons to conduct a door to door campaign to trace immunization defaulters whilst enhancing retention and completion of children’s immunization schedules. This process aided in identification, tracing, and referral of children under one who had defaulted from their immunization schedules (verified using the MOH mother-baby booklet). Besides, educating expectant mothers on the importance of ensuring their children are fully immunized. Through this process, the CORPS tracked 5,848 immunization defaulters and accompanied them to health facilities for services. Additionally, one of the project grantees, Pwani University, engaged CHVs in 2 selected facilities: Kilifi County Hospital (KCH) and Ngerenya, to help in clients booking using the appointment diaries and conduct defaulter tracing for clients who missed their appointments. Ngerenya dispensary managed to line list 51 defaulters, traced back 43, 6 clients self-transferred to other facilities, and 2 are still on follow up. At KCH, out of the 496-line listed defaulters, 158 were traced back, 257 clients were confirmed to have self-transferred to other facilities, 85 are still on follow up. b) Improved county coordination in child health service delivery

i. Supportive supervision for quality assurance In Q2 FY20, Afya Pwani supported the Sub County Management Teams (ScHMT) to conduct integrated supportive supervision in 31111 health facilities across the 7 Sub-counties of Kilifi county using a standardized tool. The team noted an improvement in documentation of the permanent register and defaulter register. The ORT corner register was also well documented. The team used the opportunity to explain to the facilities their targets and how to achieve and track performance. The table below depicts the key challenges and corrective action instituted.

Gaps Way forward Vaccine stock-outs in January to mid-February as • Supported facilities to conduct defaulter a result of the National stock out resulting in Low tracking and defaulter line lists. The immunization coverage for DPT3 and FIC vaccines are currently available, and Mop- up exercises ongoing across the County. Laxity in facilities conduct Outreaches due to • Advocate for utilization of Linda mama donor dependency for support and financing of funds for Outreach support. the outreaches resulting in Low immunization • Q.I projects on Immunization coverage coverage for DPT3 and FIC

111 Shomela, Mtoroni, Marereni, Kambi ya waya, Muyeye, Dzikunze, Vitengeni, Chasimba, Zowerani, Gede, Mtondia, Jimba, Ganze, Kombeni, Ribe, Rabai, Bwagamoyo, Mitsajeni, Lenga, Kokotoni, Kambe, Ngerenya, Mtondia medical, Pingilikani, Mtwapa, Mrima wa Ndege, Jaribuni, Mwapula, KCH, Palakumi, Mirihini,

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Underutilization of the Community functions by • Enhanced joint facility-community the clinical staff meetings Staff shortages • The situation was escalated to the CHMT for action • Task shifting in tasks which CHVs can do effectively like documentation, growth monitoring, queue management etc Poor access to some facilities including • New outreach sites were mapped out and Bwagamoyo dispensary population adjustments during microplanning Faulty fridge in Shomela, Pingilikani, Palakumi • KEPI fridge maintenance advocated for dispensaries and done to avoid disruption of immunization services

c) Strengthening the quality of Child Health services

i. Capacity building in child health services- EPI/IMNCI Building on the gains made in Q1 FY20, the project in this reporting period conducted post-training mentorship for 25 (5M, 20F) newly employed HCWs trained in EPI in Q1. The project used the EPI performance monitoring handbook for reference112 to reinforce the trainee's knowledge & skills and to monitor the implementation of action plans developed during the training. The project also offered TA to 22 HFs on how to provide quality service delivery. The facilities were also guided to develop action plans to address the gaps noted. Besides, in Q2, the project supported mentorship in 31 facilities on IMNCI, strengthening case management of diarrhea and pneumonia.

ii. Performance review meetings

During the reporting period, the project supported the SCHMTS of Malindi, Ganze, Magarini, and Kaloleni sub-counties to review their performance in RMNCAH to improve the quality of data and service delivery. The table below shows the highlights during the review meetings per sub-county;

Gaps identified Action was taken Delay in reimbursement of Linda mama funds • The administrator was tasked to do follow up and give in Mariakani Sub-county hospital feedback Late reporting and low FP, FIC, 4th ANC • Facilities to review their data, correct discrepancies, coverage and high perinatal mortalities and continue using their data for decision making. (25FSB, 46MSB) in Malindi sub-county • Defaulter tracking to be strengthened • commodity ordering week to continuous • The orientation of HCWs and DQA support. Staff shortages in facilities in Ganze sub- • Integration of services in all facilities (PMTCT county integration at MCH) Data variance in some indicators in Magarini • Intensify defaulter tracking to get those with missed (SBA more than Birth OPV) opportunities • Operationalize monthly review of data at the facility level

112 EPI performance monitoring handbook

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iii Strengthening commodity supply During the reporting period, ScHMT were supported to conduct child health commodity redistribution coupled with mentorship and OJT on child health commodity management. A total of 56 health facilities across the 7 sub-counties of Kilifi County were supported. Commodity security and equipment availability are vital in the management of the immunization program. Besides, the project distributed immunization tally sheets, defaulter registers, appointment diaries, and Immunization job aids to aid in reducing missed opportunities. The project also supported the County to ensure KEPI equipment functionality through the maintenance of fridges.

Output 2.3 Family Planning Services and Reproductive Health (FP and RH) Family planning (FP) is a critical component of quality of care among the Adolescents, Youths, and Women of Reproductive Age (WRA), when provided during pre-conception, antenatal period, immediately after delivery and during the first year postpartum (WHO 2009). Kilifi County has shown tremendous improvement in WRA accessing family planning services in various health facilities. Round 6 of the Performance Monitoring and Accountability 2020 (PMA2020)113 reported an increase in the use of mCPR to 41% from 33% (KDHS 2014).

Despite having policies, guidelines, protocols, and program in place; many adolescents and young women remain inadequately served, as a result of inadequate youth-friendly facilities Muslim perspective: and providers, lack of clear clarification on the Allah said: Let those (disposing of an estate) have content of comprehensive sexual education, the same fear in their minds as they would for their proxy decisions made on their behalf on SRH own if they had left a helpless family behind: let issues by the guardians, unmet need for them fear Allah and have appropriate words contraceptives, high prevalence of sexual and (Qur’an 4:9). Also, the mother shall give suck to gender-based violence, alcohol and drug their children for two whole years. For those abuse, HIV and teenage pregnancy prevalence. parents who desire to complete the term of suckling, but the father of the child shall bear the As a result of the above gaps in adolescent's cost of food and clothing on reasonable basis" reproductive health, the project, through (Qur’an 2:233). advocacy, enhanced its partnership with the county government and like-minded CSOs to Christian Perspective advocate for acceleration, availability, access, We have a responsibility to take care of our and utilization of services. The project also families, and that means planning the number of made tremendous progress in addressing children we can support, nurture and educate. adolescents and young women SRH challenges “Anyone who does not provide for their relatives, by increasing access, coverage, and quality and especially for their own household, has denied the faith and is worse than an unbeliever” (1 messaging, and services through facility Timothy 5:8) integrated youth-friendly services, school programs, clinic model, and youth-friendly SRH community forums.

In Q2 FY20, the project implemented FP activities in Kilifi County through partnership, networking, and collaboration with the MoH, RMNCAH implementing partners, community members, and key decision-

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makers. The interventions strengthened the core capacities of service providers, Community Based Distributors (CBDs), Community health volunteers (CHVs), youth peer providers (YPPs), community leaders, among others. They also accelerated access and awareness to quality comprehensive family planning services. These efforts targeted key decision-makers in adolescents SRH, including village elders, administrators, teachers, parents, religious leaders, youth leaders, and men, all of whom have been impediments to the uptake of contraceptives services among the adolescents and young women. The meetings addressed the high prevalence of teenage pregnancy within the sub-counties.

The Community Based Distributors (Demand creation team) worked closely with community members on Social behavior change communication activities through sit in sessions, mobilizations, education forums, and community forums to enhance their knowledge on family planning in all the 7 sub- Counties. Within the quarter, the project supported facilities continued with family planning service provision to the adolescents and women of reproductive age through facility health education, in-reaches, outreaches, and youth clinic days. Most of the clients taking up family planning services at the facilities were referrals, with a few being provider-initiated, a clear indication of a working initiative in community facility linkage.

Through the above mention’s interventions, the project supported facilities in Q2 cumulatively served 35,850 women of reproductive age and 12,246 adolescents as depicted in the graphs below.

Figure 18: FP method mix in Afya Pwani supported sites in Kilifi County

FP Method Mix in Afya Pwani supported sites in Kilifi county Condoms, 1,246 , 3% Natural, 1,999 , 5%

Sterilization, 28 , 0% Pills, 3,865 , 10%

Implants, 5,403 , 13%

IUD, 1,101 , 3% Injections, 26,828 , 66%

a) Increased demand access to quality family planning services in the community In its effort to increase and sustain demand for family planning services in Kilifi County, Afya Pwani reinvigorated awareness creation interventions as well as utilized local leaders as FP champions to influence perceptions around contraception. As a result of these, community leaders are now supportive of child spacing. The project has also witnessed growing buy-in by community members, as highlighted in the sections below:

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Figure 19: FP uptake in Afya Pwani supported sites in Kilifi County

i. Normalizing RH discussion in religious platforms Ustadh Khamis Mohammed prides himself on being involved and making appropriate reproductive health decisions for his family. His wife Mariam attended at least 6 ANC visits during her 2 pregnancies; she

Family planning uptake in Afya Pwani supported sites in Kilifi County

10026

8527

Q1 Q2

2509 2030

328 190

Adolescent Family planning uptake Adolescent Family planning uptake Youth Family planning uptake 20-24 10-14 yrs 15-19 yrs yrs delivered in a health facility, and their children, born 3 years apart, were fully immunized. He understands that these are important for the excellent health of his wife and children. The soft-spoken Ustadh represents Kilifi North Sub-County in the Supreme Council of Muslims of Kilifi County. While he appreciates reproductive health and sees a clear connection between the role of religious leaders in spiritual matters and health issues, he attests, many religious leaders are still shy of sharing reproductive health education to their congregations. This he attributes to fear of being blemished by controversy, lack of confidence about the subject matter, and upheld values.

To change these perceptions and fears, Afya Pwani, in collaboration with the Department of Health, KMYDO, Supreme Council of Muslims in Kilifi, and the Christian Pastors Fellowship organized a sensitization forum for 30 religious’ leaders from Kilifi North, representing diverse denominations including Muslim, Pentecostal, and Protestant leaders. The objective of this forum was to transform attitudes, equip the leaders with RH knowledge to enable them, counsel clients, dispel myths, and refer all those who need services as well as establish a partnership between the leaders and the department of health. The discussions led by the County RH Coordinator and Health Promotions focal person revealed that a significant number of community members still don’t utilize these essential RH services. They further explained the potential harm this could have in society, especially maternal, newborn and child morbidity and mortality. The department called for collaborative efforts to ensure every woman and child receives MNCH services.

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While many leaders supported maternal health, immunization, and treatment of childhood illnesses, there were varied opinions about family planning, especially among youth and adolescents. The leaders allied to contraception cited Quran and Bible verses that supported child spacing, indicating that there is no evidence in the holy books castigating family planning and therefore calling upon their fellow leader to remain objective and factual in promoting RH services. It was agreed that no religion is against child spacing and that different faiths are comfortable with different methods and thus should promote what is right for their congregants.

Since the meeting, six of the leaders Kilifi County RH Coordinator sensitizing the religious leaders on vital RH services have reported integrating RH education in their sermons, reaching about 1405 of their congregants with information. In the next quarter, the project shall establish an interfaith network of religious leaders across the seven sub-counties to champion RH and social accountability to demand quality health services.

ii. Strengthening ‘Utawala na Afya’ platform as an avenue for demand creation and social accountability In Q1 (Oct-Dec 2019), Afya Pwani oriented National administrators, including assistant County Commissioners, Chiefs, and assistant chiefs in the 7 Sub-Counties of Kilifi County, on positive RH practices including building their confidence to cascade RH information and implement practical actions in their communities to enhance uptake of RH services. The administrators were also linked to public health and health promotions officers to foster joint efforts in promoting the utilization of RH services by communities. During this quarter (Jan-March 2020), 45 assistant chiefs took a lead role in mobilizing and educating 3601 community members in their sub-locations on the importance of different RH services, calling upon them to take responsibility in ensuring good health for their families. The administrators invited health workers to address questions and concerns raised by community members about different health services. Besides the knowledge gaps, community members complained of frequent commodity stock-outs, long waiting periods, and provider attitude as crucial factors that discourage them from seeking services. Men also complained of being secluded in health discussion by CHVs who only focus on female members of the household. Based on this, health workers utilized the platforms to explain some factors that compromise service delivery such as staff shortage among others. They requested for patience and continued support by the community members.

The CHVs agreed to involve all men and women of reproductive age in health discussions during household visits. The ‘Utawala na Afya’ sessions also initiated community action for improved health services. For instance, in the Mdzongoloni area, of Kilifi North Sub-County, due to long-distance to the nearest health facility, the community members under the leadership of their Chief identified an abandoned building as a possible outreach site. Together they cleaned the building and surrounding areas.

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Subsequently, the area PHO inspected it for the suitability and approved it for health service delivery. Since then, the Chief has worked with health workers at Konjora dispensary to have monthly outreach services at the site. During this quarter, 435 women received FP services, and 1187 children were immunized at this site. iii. Encouraging reproductive health conversation among men Afya Pwani understands that while women in Kilifi County desire to access reproductive health services, often, they depend on their male partners’ support to do so. The project has continued working towards increasing access to RH information among men while challenging social norms to enable informed decision making. Through the project supported male champions and grantees, the Afya Pwani project conducted 108 male-only dialogue forums this reporting period. These RH education sessions were conducted mainly in the evenings and on weekends, at flexible community hangout points where men were likely to be found. These included local drinking dens, Boda Boda stalls, and board games playing points. At the facility, the project supported “male information desks,” in 12114 facilities, where male champions scheduled and conducted sensitization forums on family planning and other RH topics to male clients visiting the facilities. Ignorance and unexplained resistance on reproductive health, especially family planning, was evident at the beginning of these conversations, but later transformed to positivity and acceptance of the same. These sessions reached 9243 men with FP information. Cumulatively during this, reporting period the male champions referred 418 clients for FP services.

A male champion guiding a discussion on reproductive health among fellow men

iv. Increasing access to Family planning services through Community-Based Distribution (CBD) Afya Pwani has continued to support community-based distribution of family planning, to increase access to FP information and quality services. In FY19, the project trained 1,070 CBD agents who are now proactively conducting home visits, one-to-one and group sessions, to provide contraception education as well as select family planning commodities, i.e., pills refill to continuing clients and condoms. They also refer new FP clients to health facilities for other services. During this reporting period, the project supported the CBD agents to conduct 813 community dialogue sessions where they also provided FP information, educated communities on the importance of family planning in improving the health and wellbeing of families, dispelling misconceptions, and gendered barriers to uptake of FP services. The CBDs

114 Sabaki, Gongoni, Marereni, Mambrui, Kizingo, Ziani, Sokoke, Mtoroni, Marikebuni, Malindi, Baolala, Mirihini

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also mapped clients on pills and those who needed condoms, to inform timely refills. They also provided one-on-one counseling sessions during household visits. During the visits, the CBDs endeared to educate women together with their partners to enhance male involvement in FP decision making. Cumulatively during this period, the CBD sensitized 74,419 community members on FP while referring 4549 for family planning services in their link facilities. The table below shows the distribution of clients receiving FP commodities from CBDs.

Table 44: Commodities distributed by CBDs in Q2 FY20 No of clients Condoms Pills No. of clients receiving referred for other commodities (How many Pieces) (How many cycles) FP services from CBDs Male Condoms Female Condoms COCs POPs

24,209 133,756 3516 512 303 4,549

During the reporting period, the project and the Kilifi County leadership commemorated the CBD agents, recognizing their efforts in ensuring every woman of reproductive age can access FP services with ease. As the County celebrated the International Women’s Day, an event that was graced by H.E. Amason Kingi, the Governor of Kilifi County, among other senior County leaders, the CBD agents were lauded for their selflessness and the prowess they showcased while explaining the importance of FP and the broad range of FP methods available. They were encouraged to expand their reach, to help reduce the unmet need of FP in the County. The project leveraged this event to equip the CBD agents with a CBD package, including a bag for carrying commodities, an Umbrella, T-shirt, and a badge for identity.

Ready to work! A group of CBDs setting off for work after receiving their CBD package

v. Community sensitization on family planning

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During the reporting period, various platforms were used to sensitize communities on Family planning. As such, the project conducted 87 community dialogue sessions to educate and get perceptions of community members on family planning. The dialogue catalyzed in-depths analysis of how socio-cultural beliefs and practices restrict family planning acceptability and use. During the dialogues, allied community leaders and satisfied FP users served as local champions, overtly expressing support for family planning and encouraging shared decision-making regarding family planning between spouses.

At the facility level, the project leveraged on different services delivery points such as Child Welfare clinic (CWC) and out- patient departments, integrating family planning health education into the service package provided at these departments. Also, A CHV educating a client on the different family planning methods outside Gongoni Health Centre CWC trained CHVs conducted FP education sessions, alongside health workers who responded to the technical questions raised by the clients. Additionally, the project supported FP education sessions during the Mama Kwa Mama and Binti Kwa Binti group sessions. These served to prepare the women for postpartum FP. Health workers encouraged the women to start early FP discussions with their partners early so that they can have adequate time to negotiate for acceptance, especially where a partner is not keen on FP. These sessions reached 5361 community members with FP information. b) Strengthen the capacity of facilities to deliver Family planning services through training, mentorship, and on-job training

In this reporting period, the project supported the County to roll out a structured Family Planning Clinical Mentorship program. The sub-counties RH-Coordinators identified well-trained service providers on Long- acting Reversible contraceptives (LARC), who had practiced for more than 3 years, passionate in cascading the knowledge and skills to their peers. Each sub-county identified five mentors totaling 35 mentors in Kilifi county. The mentors were subsequently sensitized on FP clinical mentorship and attached to mentees to initiate mentorship. The mentors also conducted a baseline assessment of the assigned mentees and facilities to assess the capacity of service providers, availability of job aids, implants, IUCD insertion, implant removal equipment, infection prevention practice, documentation, integration, and commodity security. The figure below shows the gaps identified during the assessment. To bridge the gaps above, mentors developed a three-month Workplan (Feb- April/2020) with the mentees to improve access, availability of method mix, competency among mentees' quality of care, and utilization of family planning services. The mentors embarked on a rigorous mentorship program. To date, the mentors have

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mentored 170 mentees in 70 facilities reaching a total of 1658 clients with family planning counseling, cervical cancer screening, implant, and IUCD insertion, and removal. Besides, the project collaborated with the county and sub-counties to redistribute equipment from facilities that were having an excess of this equipment's in their stores to facilities with none and reproducing job aids that were missing. So far, improvements have been noted among mentees and facilities.

Figure 20: Distribution of gaps amongst targeted mentees and facilities

Distribution of gaps amongst targeted mentees

600 550

500 450

400 297 300 245 216 200 153

100

0 Total mentees Mentees trained Mentees Mentees Mentees with Infection on FP incompetent in incompetent in inadequate skills prevention Implant insertion IUCD insertion and on counselling practices gaps and removal removal

Figure 19:Distribution of gaps amongst targeted mentees and facilities

Distribution of Gaps amongs Targeted mentorship facilities 160 140 140

120 112

100 84 78 80 56 60

40

20 14 14

0 Total Facilities Lack of IUCD Lack of implant Lack of Tiahart Lack of Lack of cue Lack sample sets insertion and chart Counselling Job cards bags removal kits aids

c) Expanding and Institutionalizing continuous quality improvement in Family Planning

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I Strengthening of facility work improvement teams to utilize data, identify and implement a small test of change to improve MNCHFP outcomes

In the last reporting period, the project trained 79 service providers in Quality Improvement and enhanced the capacity of the quality improvement teams in three high volume facilities (Mariakani Sub- county hospital, Malindi Sub-County hospital, and Kilifi County hospital). The 3 facilities in Q2, identified change projects within their facilities and are currently implementing them. The project also provided family planning Technical Assistance (TA) in 13 facilities in Rabai and Ganze sub-county and initiated quality improvement projects to improve RMNCAH indicators. Besides, the facilities developed a facility work plan and conducted a performance review. The session was an eye-opener to most of the facilities, who acknowledged the importance of having a facility work plan, QIT, and teamwork in the various departments.

Ii Expanding quality Family planning access through integration

The project mentored 60 service providers at the CCC, 30 at the inpatient wards, and 54 at the maternity and postnatal wards on Long-Acting Reversible contraceptive to increase access to comprehensive quality family planning services. However, most of the units lacked a daily activity register and job aids. These challenges are being addressed by the facility in-charges and the Afya Pwani Project to ease the service providers' work.

Iii Expanding quality FP services through outreaches

Evidence demonstrates that mobile outreach services can successfully increase contraceptive use, particularly in areas of low contraceptive prevalence, high unmet need for family planning, and limited access to contraceptives, and where geographic, economic, or social barriers limit service uptake such as Kilifi county. In the reporting period, the project conducted 27 outreaches across the 7 sub-counties reaching a total of 3,465 people with Information on Family planning, 176 Adolescents and 381 WRA with FP services. d) Improving access to quality, sustainable FP and other SHR services through strengthening FP commodity security

During the period, the project conducted several activities to minimize provider bias and enhance method mix among adolescents, youths, and WRA. Besides, minimizing average commodity stockouts through clinical mentorship focusing on documentation, forecasting, and quantification at provider/facility level, engaging sub-counties leadership to critique and verify facilities data and investigating facilities reporting zero on a commodity that is available either in the sub-county stores or in other facilities. Due to the above interventions, the FP commodities percentage stock out rates at service delivery points decreased from 54% in Q1 to 44% in Q2. The Average stock out also decreased from 7% in Q1 to 5% in Q2. Despite the drop, there are some disparities in the sub-counties, as depicted in the graphs below.

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Figure 22: Average FP commodity stock outs in Afya Pwani supported sites Q1 and Q2

AVERAGE STOCK OUTS

55.7%

54.5%

27.5%

23.9%

23.2%

14.5%

13.5%

9.7%

7.6%

6.6%

6.4%

5.1%

4.3% 4.1%

% Av Kilifi County Q1

% Av Kilifi County Q2

Figure 21: Percentage FP commodity stock outs by sub counties Q1&Q2

Percentage Stock Outs

76.9% 68.8% 66.7% 61.5% 57.1% 55.0% 53.8% 53.8% 48.0% 45.0% 45.5% 41.0% 43.5% 37.1% 35.7% 27.3%

Ganze Sub Kaloleni Sub Kilifi North Sub Kilifi South Sub Magarini Sub Malindi Sub Rabai Sub Grand Total County County County County County County County

Q1 Q2

In Q3 FY20, the project shall scale up mentorship on documentation, forecasting, and quantification targeting facilities with gaps.

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e) Strengthening youth-friendly services to increase access and utilization of contraceptives to reduce teenage pregnancy

I Conducting age-appropriate sexuality and contraception education

In Q2 FY20, the project in collaboration with Pathfinder’s Female Condom (FC2) project trained 160 young people from Pwani University and its environs on the use of the Female Condom commonly known as FC2. The 4-day training consisted of different teams: a mixed group of peer educators and students within the institution; expectant mothers/ students and young mothers; female students and male peer educators; young religious leaders from different faiths (SDA, CU, Catholic, and Muslim) and some youth within Pwani University environs. The young people also received contraceptive technology updates (CTUs) from a Pwani University nurse attached to the Afya Pwani project. Following the sensitization, peer educators have distributed 2000 female condoms.

During the reporting period the project Pwani University to create awareness of its SRH the services and provide integrated services that included Family planning, cervical cancer screening, STI screening, GBV screening, blood donation, and HIV testing services. During the drive, the project reached 3011 students with contraception information, referred 139 clients for family services, and distributed 6896 condoms (6479 Male, 417 Female).

The project Sub grantee KMYDO conducted 4 AYSRH sessions to improve access to quality adolescent and young people during the reporting period. The sessions provided information on puberty, menstrual health /hygiene, sexually transmitted infections, and diseases HIV/AIDS reaching 139 Students (84M 55F) aged 10-19 years. Subsequently, 19 adolescents from each madrassa formed peer education clubs, while 43 young people (14-17years) were referred for AYSRH services to nearby health facilities. Besides, the project conducted 12 online campaigns on social media (Facebook, Twitter, and WhatsApp) targeting adolescents and youth on AYSRH/SGBV/FP and RMNCAH. The project leveraged the platform to share and popularized the toll-free telephone line “Binti was Kisasa.” The phone message primes young people to overcome provider bias provides contraceptive information and connects them to the health care provider for further counseling. ii Strengthening Youth networks

The project in Q1 supported the establishment of a youth network of 11 groups in Rabai sub-county in collaboration with the Kilifi youth advisory council. To strengthen the network in Q2 the project further supported the establishment of seven AYSRH ward level networks from each ward in Kilifi North sub- county with a membership of 129 members (58 M and 71 F). Plans are in place to fully capacity build these network members to be able to articulate AYSRH issues while amplifying grassroots health issues fully. iii Addressing provider bias through Binti Wa Kisasa

In the previous quarter, improvements were made on the Binti Wa Kisasa mobile platform to provide contraception information and to connect callers to a service provider. This has improved the service uptake, as seen in the figure below.

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Figure 23:Binti Wa Kisasa Call log Numbers Oct 2019 to Mar 2020

Binti wa Kisasa call log by quarter 550 540 530 520 510 500 490 480 470 460 450 Oct-Dec Jan-Mar

As shown in the figure above, the increase is attributed to numbers are attributed to popularity of the number among peer educators, youth networks, and youth leaders. Data from the platform reveals that most young people want more information on condoms and pills.

Figure 24: Frequency of contraceptive information requested by method

Frequency of contraceptive information requested by method using the Binti wa Kisasa Platform

35 30 30 25 23

20 15 15 10

Percentage 10 8 7 8 5 0 Condoms Oral Depo Inplants IUCD Vasectomy Natural contraceptives

Output 2.4 Water, Sanitation and Hygiene (WASH)

During the period January- March 2020, the project implemented Water, Sanitation and Hygiene (WASH) interventions in close collaboration with the County Departments of Health, Water and Education as well as community and one sub-grantee (USTADI) to enhance access to water, improved sanitation and hygiene practices. The services were aimed at reducing morbidity due to water and sanitation-related ailments and Pneumonia among children under the age of five through supporting targeted activities at Health facilities, schools, and the community levels in Ganze, Kaloleni, Magarini, Kilifi North, Rabai and Kilifi South sub- counties.

The main activities in the period include; construction and installation of water tanks for rainwater harvesting and water shade in one primary school. The project also supported post-triggering Community- Led Total Sanitation (CLTS) follow up and review meetings in 120 villages, of which 32 villages are above

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80% CLTS protocol to attain ODF status. In addition, the project supported refresher training of 146 community resource persons (CORPS), Artisan, and CBPs on sanitation and hygiene improvement at the community level. a) Improved access to water for drinking, domestic and animal use During the reporting period, the project supplied construction materials to finalize the construction of tanks. It also utilized the project locally trained artisans to construct and install one more 5000 liter- capacity plastic water tank for rainwater harvesting in Baraka Jembe primary school in Magarini sub- county bringing to a total of nine water tanks installed in Q1 and Q2. The construction involved casting of tank plinth, plumbing, fixing gutters, and tank shade installations for environmental compliance. The trained artisans shall also support the institution and community on the routine operation and maintenance services of the infrastructure, ensuring project sustainability, and continued utilization. As a result of this investment, 200 students (B-96, G-104) have Installed water tank systems at Baraka Jembe access to safe drinking water Baraka Jembe primary school. In primary school Q3, the project shall finalize the construction and installation of water systems in Chasimba Health center, Dungicha dispensary, and Tsangatsini dispensary. b) Increase access to sanitation services i. Scaling up of Community-led total sanitation (CLTS)

Post -triggering CLTS household follow-ups at different levels of toilet construction Increased access to and use of improved sanitation at community and institutional levels within the project area shall go a long way in contributing to the improved health status of the community members, especially the under-fives. Building on Q1 achievements on sanitation scale up, the project supported the County public health department field staff (PHOs, CHOs, CHVs) to carry out CLTS review meetings and post triggering follow-ups in 12 sub-locations , reaching 120 villages in Ganze, Kilifi south, and Kaloleni Sub-counties. Due to the post CLTS review meetings and follow-up, a total of 35 villages have attained over 80% of the CLTS protocol required to reach ODF status. Additionally, the project encouraged PHOs

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and CBPs to carry out weekly house to house campaigns to promote latrine construction, use, and tippy tap installation to enhance handwashing practices to all communities claiming ODF. As a result of the weekly CLTS follow up, the household heads were able to construct 685 toilets. Some of the households are constructing permanent latrines using Makiga technology, which is appropriate, durable, and affordable. A total of 5233 (m 2355, f 2878) people now have access to improved sanitation within the project area. ii. Sanitation Scale-up In Q2 FY20, the project continued to utilize artisans trained in Q1 for sanitation scale as part of a post- training follow-up to ensure they gain competency in their skills. Besides, the project supported the County Department of Health to conduct refresher training for 146 (66M,80F) Community Based Promoters (CBP) to enhance sanitation and hygiene scale up for demand creation at the community level. The participants were drawn from Ganze, Sokoke, Jaribuni, and Chasimba wards. The refresher training included impacting technical skills for demand creation to enhance improved sanitation and hygiene practices at the household level. It also included construction and use of toilets, handwashing techniques, tippy tap installation, water treatment, sanitation ladder, and CLTS documentation. The trained CORPS consequently supported the community to manufacture Interlocking stabilized blocks (ISSB) for upgrading traditional latrines to permanent toilets. The training empowered more women who volunteered to be trained as artisans after realization of the importance of participating in sanitation and hygiene promotion practices at the household level. Their involvement as artisans in sanitation marketing shall influence many household heads to construct improved latrines and contribute significantly to the improved household economic and health status as well as project maintenance and sustainability. iii. Establishment of self-help support groups During the reporting period, Afya Pwani initiated a process for establishing community-based organizations (CBO) in six sub-locations; Mwahera, Chasimba, Birini Mwamleka, Nyari, Rare and Tsangalaweni to sustain, own and enhance WASH strategies in the target areas. In collaboration with the Department of Social Services and local leaders, the project sensitized the community on the importance of establishing self-help groups. Subsequently, Mwahera sub-location CBPs/CHVs of 24 members registered a CBO, with the Department of Social Services. They included by-laws that safeguard the efforts of the WASH interventions through behavior change among the catchment community members. This includes each household to own a toilet and use it, household members to adopt and maintain handwashing practices and water treatment. They shall also spearhead household environmental sanitation and hygiene practices, including model households as well as energy-saving Stoves (Jikos) and Bio sand filters, scale-up. c) Uptake of desirable Hygiene promotion practices and behaviors for the prevention of childhood diarrhea i. Promote water safety improvement practices The project continued to support point of use water treatment as a critical intervention in ensuring household water quality to prevent diarrheal diseases among household members and children under the age of five. Due to inadequate supply of water treatment products, households not consistently treating water; Afya Pwani in consultation with the County Health Department, will further promote other household water treatment technologies in the coming quarter. The technologies shall include Bio sand

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filters and Solvatten kits for solar water sterilization. The Bio sand filter is appropriate, affordable, accessible, and can be manufactured locally at the community level. The introduction of these technologies shall ensure the continuous use of safe water at the household level. ii. Enhance community engagements on hygiene promotion During the reporting period, the project engaged community members through dialogues on sanitation and hygiene promotion at the household level. A total of 45 community dialogues were held by the PHOs and CHVs who also demonstrated to community members on water treatment at the household level, hand washing, installation of tippy tap, and maintenance/use. A total of WASH coordinator for Ganze looking on as one community member 1,009 (454M, 555F) community do return demonstration on water treatment using PUR during members were reached with hygiene community dialogue. promotion messages. iii. Implementation of school hygiene and sanitation promotion interventions Improved practices among school children have a positive effect on their health and that of their families. School-led total sanitation (SLTS) approach is an effective way of ensuring all school environments and their catchments become safe and clean to minimize disease transmission. It recognizes the school as an entry point and pupils as a change agent that shall contribute to achieving universal toilet coverage and improved hygiene behavior practices at the school level to the community through the CTC and CTP methodology. Due to the busy school schedules during the Q1 and early school closure in Q2 following the outbreak of COVID-19pandemic, school health promotion activities were not conducted during this period. The activities will be conducted when schools resume.

Challenges: Challenges Encountered Corrective action Collapsing pit latrines due to weak soil • Scale-up of Sanitation marketing-use of structure Makiga ISSB blocks Inadequate WASH facilities in health facilities, • Involvement of all partners-parents, community, and schools-latrines/water government, NGOs. • Use of locally available resources-artisans, Makiga blocks Opportunities

The willingness of the community and leaders in supporting the use of locally available resources

Output 2.5 Nutrition Kilifi County is among counties in Kenya that have high rates of chronic malnutrition (Stunting at 39.1% KDHS 2014). The situation is attributed to various issues that affect the most vulnerable population, including women and children below five years of age. These issues include; social-cultural barriers affecting maternal and child health, high rates of teenage pregnancies (30%) leading to maternal

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malnutrition, and high rates of low birth weight. Considering these challenges, Afya Pwani has continued to support the Kilifi County DoH to implement High Impact Nutrition Interventions (HINI) to prevent, treat, and create community awareness on malnutrition. These efforts have contributed to the reduction of stunting to 26% (Kilifi county SMART survey 2016)

The project has adopted three main strategies to reduce malnutrition in the County:

▪ Enhance and sustain coordination mechanisms and capacity to offer quality nutrition services. ▪ Improve community nutrition practice on maternal, infant, and young child feeding. ▪ Improve household food security and nutrition initiatives in target communities. a) Improve coordination and capacity building in nutrition service delivery at three different levels: County/Sub-county, health facility, and community Malnutrition is a multisectoral problem and needs concerted efforts from all sectors to address it. Afya Pwani, through the County Nutrition Technical Forum (CNTF), supports the DoH to coordinate and collaborate with other partners and line ministries, including the Ministry of Education (MoE), Ministry of Agriculture (MoA), Ministry of livestock and, fisheries. Among others to mobilize resources and streamline intervention towards the reduction of malnutrition. During quarter two FY 20, the project supported the DoH to conduct a County Nutrition Technical Forum, where a total of 34 (18M,16F) participants attended. The participants included representatives from the SCHMT, partners, MoA, MoE, and National Drought Management Authority (NDMA). The meeting validated the County Nutrition Action Plan 2(CNAP2), a document that illustrates 14 key result areas to reduce malnutrition in Kilifi County.

The project currently supports 101 health facilities to offer Integrated Management of Acute Malnutrition (IMAM). During the period under review, the project, in partnership with the County and Sub-county health teams, conducted targeted support supervision in 17 health facilities115 that offer IMAM services. The activity identified gaps in the implementation of the Outpatient Therapeutic Program (OTP) and the Supplementary Food Program (SFP) and developed corrective action points together with the health facility staff. The team recommended facilities to strengthen inter-facility mentorship sessions where health workers in best-performing health facilities, mentor health workers in facilities experiencing challenges in specific areas. Also, the team emphasized timely and consistent reporting on DHIS and LMIS systems.

The project will also continue to support the Kilifi County department of health to implement the Baby- Friendly Hospital Initiative (BFHI) in 67 selected health facilities. During quarter 2 FY 0, the project supported a consultative meeting of 46(18M,28F) health workers from 26 facilities116. The meeting

115 , Kizingo Health Center, Mtepeni Dispensary, Chasimba Health Center, Malindi Sub-county hospital, Muyeye health Center, Marafa health Center, Bamba Sub-county hospital, Ganze health Center, Vipingo health Center, Mariakani Sub-county hospital, Rabai Sub-county hospital, Kakuyuni Dispensary, Vitengeni health Center, Gede health Center, Pingilikani Dispensary, Junju Dispensary, Kilifi County Referral Hospital 116 Bwagamoyo Dispensary, Matsangoni Health Center, Gede health Center, Ngerenya Dispensary, Kiwandani Dispensary, Mtondia Dispensary, Kilifi County Referral Hospital, Ganze health Center, Kizingo Dispensary, Vipingo health Center, Chasimba Health Center Mtwapa health Center, Muyeye health Center

Malindi sub county hospital, Kakoneni Dispensary, Kakuyuni Dispensary, Marereni Dispensary, Gongoni health Center, Marekebuni Dispensary, Marafa health Center, Mariakani sub-county hospital, Gotani health Center, Jibana health Center, Lenga Dispensary, Kadzinuni Dispensary, Jaribuni Dispensary, Tsangatsini Dispensary

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provided a forum for health workers to discuss performance and challenges in the implementation of BFHI. Besides, the County nutritionist utilized this meeting to plan for BFHI facility self-assessment in 20 high volume facilities to be done in Q3. The project will continue to strengthen vitamin A supplementation at the facility level and integration of vitamin A supplementation within other community activities. The project reached 30,172 children under 5 years with vitamin A supplementation in Q2.

The project leveraged on open maternity days, Integrated outreaches, and community awareness on IFAS while strengthening Iron and Folic supplementation (IFAS) supplementation at the facility level. Also, the project supported the training of CHVs lead mothers who shall form mother support groups in their CUs to foster good nutrition practices at the community level. A total of 1,118 lead mothers have been sensitized, and 17 mother support groups are currently active. These women forums have been avenues to pass messages on the importance of IFAS. The project has included key messages on IFAS supplementation for pregnant women within all community activities to improve coverage. Afya Pwani supported health facilities to revitalize ORT corners and strengthened case management through capacity building (sensitizations and mentorship sessions). A total of 17 sessions were conducted in quarter 2, reaching 51 (32M, 19) health workers on zinc supplementation). Besides, the project strengthened demand creation at the community level through the inclusion of critical messages on diarrhea prevention and treatment during health talks/dialogue sessions. b) Improve community nutrition practice on maternal, infant, and young child feeding. Afya Pwani supports Kilifi DoH to implement the Baby- Friendly Community Initiative (BFCI) in 50 targeted Community Units to promote Maternal, Infant, and Young Child Nutrition (MIYCN). During the quarter two reporting period, the project supported a sensitization meeting for 44(24M, 20F) local leaders117 in Kilifi North, Ganze, and Kaloleni sub-counties (Villages highlighted to be hot spots for malnutrition). The sensitization forums sought to ensure continuous social behavior BFCI sensitization meeting for local leaders at change communication (SBCC) through BFCI messages Matsangoni during monthly household visits and community dialogue sessions. These forums culminated in a mutual agreement that all the local leaders present would use their power to influence the community to adopt optimal nutrition practices. The project conducted 17 targeted community dialogue in Kilifi South, Kaloleni, Ganze, and Kilifi North Sub- Counties are reaching of 398 (202F,196) community members. The dialogues sessions targeted vital decision influencers in the family; mothers-in-law, Fathers, and

117 8 Lead mothers, 4 Chiefs, 8 Young mothers, 4 Birth companions ,8 Religious leaders, 8 CU representatives

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grandmothers. They enlightened community members on the importance of optimal MIYCN and demystified myths impeding optimal nutrition practices. Further to this, Afya Pwani conducted 8 BFCI review meetings attended by 238(147M,91F) CHVs in Kilifi North, Malindi, Ganze, and Kaloleni Sub- counties. The meeting reviewed BFCI data, discussed their challenges. The project identified documentation as a major gap, in Q2 the project will support peer to peer mentorship for the CHVs on using form 1 tool during household visits.

Afya Pwani supported 15 participatory cooking demonstrations at the community level, reaching a total of 570 women in four sub-counties. The demonstrations aimed at helping families plan and prepare nutritious meals using locally available resources. Cumulatively, during this reporting period, the CHVs reached a total of 1405118 caregivers during their household visits. The number of children under two years whose parents/caretakers received behavior change communication interventions that promote essential infant and young child feeding behaviors decreased slightly from 7696 in Q1 to 7548 in Q2 due to a gap in documentation which has been corrected. c) Improve household food security and nutrition initiatives in target communities. The project supported the Kilifi DoH to promote safe and energy-saving cooking initiatives by training CHVs on energy saving stoves (Jikos). The CHVs further mentored community members on the same as a receding of nutrition interventions at HH level. During the reporting period, 28 mothers who benefited from P D hearth activities in Kaloleni Sub-county, together with the CHVs and the area Chief, identified and formalized a selected area of public land for training and manufacture of energy-saving jikos scheduled for the next quarter. The project shall engage artisans trained in Ganze in the previous reporting period for peer to peer mentorship.

The project supports food security at the household (HH) level through partnerships in agri-business initiatives, including kitchen gardening and poultry keeping. The project supported 10 health facilities to set up demo kitchen gardens for targeted support groups to learn and replicate at the household level. The project also supported a support group of 32(25F, 7M) members in Magarini Sub-county, to maintain a shed net. The group is now able to sell the farm Mothers in Mariakani Ward participating in a cooking demonstration. produce and engage in other IGA.

118 455 in Kilifi North, 705 in Ganze ,245 in Kaloleni

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Challenges and way forward Gap Challenge Opportunities Sustainability for Malezi Bora The DoH fully depends on Advocate for more allocation of activities partner support to conduct funding for nutrition activities Malezi Bora activities Documentation gaps Disseminate data collation tools to ensure accuracy and consistency - ongoing Sub-optimal facility-community Suboptimal defaulter tracing Develop a longitudinal follow up linkage on the IMAM program from growth monitoring to IMAM program Roll out IMAM defaulter tracing register Missed opportunities for zinc Knowledge gap at community Mentorship sessions on supplementation at facility level level on zinc supplementation management of diarrhea-ORS and zinc supplementation at facility level - ongoing

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SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS In the reporting period, Afya Pwani Health Systems Strengthening (HSS) initiatives focused on consolidating gains realized in Q1 in the four target counties as well as remaining true to J2SR approach of building capacities for counties to plan, finance to implement sustainable, quality health solutions. In Q2 FY20, the project sustained its efforts in strengthening partnerships for Governance and Strategic planning; Human Resource for Health (HRH); Health Products and Technologies; Strategic Monitoring and Evaluation and Quality Improvement. The project participated in DOH annual performance reviews and implementation of annual workplans including the S/CHMT’s cascade of planning to health facilities. Besides, the project supported the implementation of HRH staffing plans and employee performance management process. The County Commodity Security TWG’s and technical staff handling commodities continued to receive targeted support. High volume facilities also received on-site EMR support to institutionalize EMR use for improved data quality demand and information use. Output 3.1 Partnerships for Governance and Strategic Planning i. Strengthen the planning and budgeting process in the sector During the reporting period, the project worked with Mombasa, Kilifi and Kwale Counties to conduct the County Annual Performance Reviews in line with the provisions of the County Treasury Annual Budget Circular which contains budget guidelines, timelines and required activities. The Annual Performance Reviews have enabled the Counties to take stock of accomplishments in FY 2019/2020 and begin setting priorities for FY2020/2021. The project in collaboration with HP+ and Thinkwell provided targeted TA in the preparation and dissemination of Kilifi County Annual Performance Review (APR) which brought together key stakeholders in health and the County treasury. The County treasury team was taken through priorities for the health department in readiness for FY20/21 budget preparation and it is expected that the team understands health and priorities for the department. The project also participated in APR of Kwale and Mombasa Counties giving insights to health priorities in each of the counties and helping identify priorities for FY20/21. The Mombasa S/CHMT’s in its quest of delegating and building planning capacities in hospitals and other health facilities allowed Coast General Teaching and Referral Hospital (CGTRH) to review the implementation of the hospital 2013-2017 Strategic Plan. In this review, the hospital received targeted technical support in strategic plan development and review from the project. The hospital for the first time and in line with J2SR strategy put its own financial and logistical resources to have the review conducted. This is a great improvement where we begin to see hospitals appreciating the need to have proper plans to guide their initiatives. After review of the strategic plan CGTRH went further to commence planning for 2020-2024 period anchoring their plans on the past period and recent developments in the reclassification of the hospital as a semi-autonomous government institution. During this planning, the hospital provided more financial and logistical resources for the process while the project provided technical support in the development of the strategic plan. It is anticipated that the plan will be concluded by June 2020. The Hospital Management Team (HMT) and Hospital board have for the first time been the drivers of this planning process which is a great shift from the past. In Kilifi county, the project has initiated discussions with the S/CHMT responsible for Linda mama initiative and plans are underway to deepen the strengthening and management of funds which come through such government initiatives. In this, the project will work with facility management committees and facility in-charges to ensure generated funds are put to the intended use.

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The project is also providing targeted TA and other support to the county RMNCAH stakeholders forum in the development of RMNCAH strategic and investment plan. RMNCAH stakeholders’ meetings have been held with the team assigning roles in the development of the plan. Its projected that the plan will be concluded in Q4. It is believed that the plan will enhance priority setting and advocate for increased resource allocation for health service delivery. Following discussions in the last 3 years with Kilifi County government, County Assembly, civil society, patient representatives, professionals’ forums and other community groups to lobby for assenting of the pending passed bill (Kilifi County Health Services Improvement Fund Act 2016), the County has made recommendations for amendments to the bill and the process is on-going. Similarly beginning March2020 the county treasury has made exemptions and allowed the DOH to begin the implementation of the Health Services Improvement Fund. The fund is administered using guidelines issued by the county treasury and the operations are guided by a board committee. This exception has allowed health facilities address service delivery bottlenecks in a reduced turnaround time. In Q3 and Q4,the project will endeavor to support the County to address emerging operational challenges which will target the functioning of facility management committees to ensure the available resources are put to the intended use. ii. Strengthen stakeholder coordination and collaboration The project worked with Mombasa County DOH in strengthening private sector engagement. The structural and service delivery gaps report for 26 dispensaries in Mombasa County is near finalization and it will be used in the anticipated stakeholders (private partners) meeting to trigger the private players to commit resources to address structural gaps that impede service delivery in dispensaries in the County. The project will continue to provide targeted TA and other support in this process including supporting the private partners mapping process. It is anticipated that in Q3 FY20 a stakeholders meeting will be held, to provide the much-needed opportunity to enhance the engagement, coordination and collaboration between the DOH and stakeholders in the county. This will begin the realization of “adopt a dispensary initiative”. Output 3.2: Human Resources for Health (HRH) i. Performance Management The project continued to work closely with the County Public Service Boards and the CDOH HR units in Kilifi and Mombasa to ensure performance appraisals for FY18/19 for staff in DOH were reviewed as well as fast-track the roll out of FY19/20 appraisals. This effort is aimed at strengthening performance appraisal process that is integral in the realization of improved health service delivery. The process has begun taking shape in the two counties as the County Public Service Boards are now referring to past appraisals while conducting interviews and promotions for internal candidates. As such, this has significantly enforced the need for having a functional performance appraisal process in each of the project focus Counties. For instance, Mombasa CPSB has dedicated an officer (Director) responsible for the process. The project together with the DOH in Mombasa County is working closely with the officer to strengthen further the appraisal process by incorporating performance rewards and sanctions as key elements of the appraisal process. Besides, the two counties (Mombasa and Kilifi) have made provisions for printing and distributing the required appraisal tools (PAS-Forms) which is a significant departure from the past where they relied on partners to provide them with the appraisal tools. Towards J2SR, the project in Q3 FY20, will continue to extend this support to Kwale and Taita Taveta which have had systemic and leadership challenges to commence the process.

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ii. County Human Resource for Health The project has continued to work closely with the DOH HR units offering them targeted TA and building their capacity to manage and address health workers’ routine concerns which have always been a source of grievances. In Q1, Taita Taveta County through project targeted TA enhanced the capacity of the DOH HR unit by recruiting an additional HR Officer. The additional staff to the unit has helped in fast tracking the preparation and processing of health workers annual increments and routine HR support. In Q3 FY20, the new hire will receive coaching through the project TA to enhance her skills. Kilifi County with the support of the project and HRH Kenya Mechanisms trained sub-county HR Assistants in the use of IHRIS and they have taken up the role of periodical update of HRH data in the system. Going forward and in line with the J2SR strategy, the project will offer targeted support to the HR units in the DOH in the target counties to ensure they play fully the supplementary roles to the County Human Resource Departments of providing direct, prompt and comprehensive HR support to health workers. In partnership with HRH Kenya, the HR units will continue to receive support in the use of HRMIS (IHRIS) to enable them generate reports as well as use the system as a decision support tool and a repository of HRH data. In the long run and towards sustainable HRH, target counties will be guided to institutionalize the use of the system as a key HRH planning tool. iii. Facility Based Staff(Contract health workers) Management To respond to the project’s rapid scale up of enhancing identification, linkage to treatment, retention and viral suppression (SURGE), and in line with year 4 work plan facility-based staff requirements, Afya Pwani hired additional HTS Providers, Clinical Officers and Nurses. The placement of the identified candidates was done in Q2 FY20. The project sustained continued engagement with County Public Service Boards and County Department of Health and the County Human Resource Departments in the management of facility-based staff in Mombasa, Kilifi and Kwale counties. In the coordination of routine human resource management issues including payroll and performance management issues were addressed. There has been continued engagement with County Public Service Boards working on the transition modalities for Facility Based Contract Health Workers to County Public Service in Kwale, Kilifi and Mombasa. In the same period, consultative discussions were held between the County Public Service Boards and Departments of Health in Kilifi, Mombasa and Kwale and consensus built on transitioning of the contract health workers. Kwale County has expressed the desire to transition all its contract staff while Kilifi is assessing the possibility of transitioning its contract staff to a three-year renewable contract under the UHC initiative. The transition will enhance the much-needed health workforce for service delivery. As at 1st April 2020 the project had a total of 234 facility-based staff. A detailed breakdown of the staff is as below;

Table 45: Tabulation of Facility Based staff by cadre Number Cadre Total in-post as at 1st April 2020 1 Medical Officer 1 2 Clinical Officer 29 3 Nurse 29 4 Nutrition and Dietetics Assistants 4 5 HTS Providers 145 6 Laboratory Assistant 1 7 Medical Laboratory Technologist 2 8 Health Records Information Assistant 15 9 Social Worker 3 10 Pharmaceutical Technologists 4 11 Phlebotomist 1 TOTAL 234

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iv. Capacity Building of Local Implementing Partners During the reporting period, Afya Pwani provided organizational strengthening support to Mombasa Catholic (a grantee) based on the capacity assessment findings done in the previous year. The support included review of the organization structure to address overlapping functions, revision of management team job descriptions and aligning departmental objectives to the new organization structure. To this end, the grantee HR unit will also continue to receive targeted support from the project through coaching and mentorship of the newly hired HR manager. This process is aimed at strengthening organization structures of the grantee to enhance business processes. In Q3 FY20, the support will be enhanced and target performance management process that is still developing. Kinondo Kwetu hospital has also reached out to the project for organization development support and there will be detailed discussion with its leadership to map out new areas of support. Output 3.3: Health Products and Technologies (HPT) i. To support timely and accurate commodity data reporting through provision of job aids, SOPs, tools and airtime The project continued to ensure timely and accurate reporting for program commodities in the supported Counties during the quarter. ART commodity data collection and reporting tools were photocopied and distributed to all the four counties as per need. The various reporting rates are shown below:

Figure 25: HIV Rapid Test Kits Reporting Rates-HCMP HIV RAPID TEST KITS REPORTING RATES - HCMP 100 90 80 70 60 50 40 Series1 30 20 10 0 JAN FEB MAR JAN FEB MAR JAN FEB MAR JAN FEB MAR JAN FEB MAR MOMBASA KILIFI KWALE TAITA TAVETA AVERAGE

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Figure 26: ART FCDRR Reporting Rates-KHIS ART FCDRR REPORTING RATES - KHIS

97.6 98.4 98.4 100 93.2 91.9 89.2 86.7 86.7 89.0 86.6 88.9 90 82.6 82.6 78.4 80 72.2 70

60

50

40 PERCENTAGE 30

20

10

0 JAN FEB MAR JAN FEB MAR JAN FEB MAR JAN FEB MAR JAN FEB MAR MOMBASA KILIFI KWALE TAITA TAVETA AVERAGE

Figure 27: Kilifi County FP Commodity Reporting Rates for January to March 2020 (KHIS KILIFI COUNTY FP COMMODITY REPORTING RATES - KHIS

98.1 97.6 96.7 100

90

80

70

60

50

40 PERCENTAGE 30

20

10

0 KILIFI COUNTY JAN FEB MAR

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ii. To facilitate counties to conduct accurate forecasting and quantification of Health Products, Vaccines and Technologies (EMMS, Antiretrovirals, OI, FP, RTK, VL, EID, TB, and Nutrition commodities) ART and HIV Test Kits allocation was done in every County using commodities supplied by KEMSA MCP. ART quantification and allocation was done every month while HIV RTK allocation was done once in January 2020 since it’s quarterly. Afya Pwani facilitated the HIV Test Kits allocation meetings in the four counties. There was one meeting sponsored in Mombasa County for ART commodities allocation in January 2020 but then they were weaned off the support in the spirit of Journey to Self-Reliance. Subsequently the Sub County Pharmaceutical Facilitators did the quantification/allocation individually and sent to the County Pharmacist for approval as it has been happening in other counties. iii. To support commodity redistribution to minimize stock outs Commodity redistribution was extensively done for various items in the quarter. 2,000 and 1,800 Determine Test Kits were redistributed respectively to Kwale and Taita Taveta counties .As at the end of Q2, DBS Kits mostly from Mombasa County were taken to Kilifi, Kwale and Taita Taveta Counties to avoid expiry. Antiretrovirals (Zidovudine and Nevirapine liquids) which have been in short supply from KEMSA MCP were redistributed extensively and TDF/FTC availed to various DICES. Lamivudine 150mg tablets were redistributed before they expired at the end of January 2020. There were many instances of mapping different commodities on KHIS using pivot tables to inform other program staff of where there were enough quantities of certain commodities for redistribution. Afya Pwani motor pool was very instrumental in redistribution as they moved from place to place in their normal work and at times, they would dedicate vehicles specifically for redistribution as was the case for Kilifi County in January 2020. Facilities missing FP commodities were mapped and supplied with the missing commodities from the respective Subcounty Stores. This was after some Facility In charges complained on the Kilifi Reproductive Health WhatsApp group that they had constraints ferrying commodities to their facilities due to transport problems as only motorbikes were available in their areas. Chalani and Tsangatsini Dispensaries specifically requested for help to ferry Male Condoms to their facilities from Mariakani SCH. iv. To support Pharmacovigilance reporting to promote patient safety Pharmacovigilance was assessed alongside commodity management in the facilities visited in (e) below. Spontaneous reporting of adverse effects and poor quality medicinal products was also done to the Pharmacy and Poisons Board. v. To facilitate County Commodity Security Technical Working Groups The teams continued to offer leadership in commodity security in the respective counties. In Kilifi, the team held their meeting with funding from Healthstrat and an electronic tool for RMNCAH commodities tracking (Qualipharm) was launched. vi. To attend the National HIV Commodity Security TWG meetings Afya Pwani attended the virtual March 2020 National HIV Commodity Security Meeting. The issue of preparedness in the wake of the COVID-19 pandemic was discussed to ensure clients do not miss commodities thus be exposed to unnecessary risk. Implementing Partners were urged to advise their regions against panic dispensing of too many months of stock as it would put a strain on the national warehouse. For example, if a client had two months of stock at home, they should not be given another three months of stock to have five months of stock at home. The stock status for all commodities was

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discussed including laboratory commodities and the issue of Cotrimoxazole 960mg was clarified by NASCOP. vii. To support commodity support supervision and OJT at facility level to improve inventory management, accountability and good storage practices while streamlining support supervision systems at County level for sustainability. Four facilities were visited for commodity management supportive supervision and were assessed on inventory management, good storage practices, reference materials and management information system tools for commodity management and pharmacovigilance. On the job training on commodity management was done to 21 health workers (14 male and 7 female) in various departments that is Pharmacy, Medical Store, Laboratory, TB Clinic, CCC, Nutrition Clinic and FP Clinic. An additional five facilities were visited for tools distribution or to pick commodities for redistribution and a quick assessment of the commodity status and any constraints they would be having was done. There was also constant follow up with NASCOP and KEMSA A section of a Pharmacy Store at Samburu Health Centre MCP for shipment of commodities to be done (March 2020) when Afya Pwani counties were about to run out of stock for example HIV Test Kits, GeneXpert Viral Load cartridges and single molecule antiretrovirals for example Lamivudine 150mg. There was also follow up with KEMSA on shipments of vaccines that had delayed being supplied leading to stock-outs in Kilifi County for example Measles vaccine. Output 3.4: Strategic Information and Monitoring and Evaluation Systems i. Facility Based EMR support In Q2 FY20, the project upgraded four additional sites’ EMR systems from IQcare version 1.0.0.7 to version 2.1.1. To this end, all sites were running on IQcare version 2.1.1. A newer version has been released (version 2.2) and the project is preparing to begin the upgrade of all EMR sites to the new version in Q3. The project further offered an array of support services ranging from hardware repairs and maintenance, network support and system troubleshoots. Also, during the quarter, the project started setting up EMR infrastructure in 4 new sites (Railways Dispensary, Miritini CDF, Mazeras Health Center and Samburu Dispensary) while Diani and Jomvu Kuu sites got network extension to cover more service points. A detailed breakdown on specific EMR support to health facilities is as depicted below:

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Table 46: EMR support to health facilities # Facility Support 1 Railways Dispensary Set up new IQcare infrastructure, installed version 2.1.1 2 Miritini CDF Set up new IQcare infrastructure, installed version 2.1.1 3 Mazeras Dispensary Already laid network infrastructure to 3 service points, installed IQcare, pending network termination and training 4 Samburu Health Centre Machine setup and IQcare installed, pending training 5 Lungalunga Dispensary IQcare system upgrade from version 1.0.0.7 to version 2.1.1 Hardware maintenance and software support IQCare system support. 6 Mkongani Dispensary IQCare system upgrade from version 1.0.0.6 to version 2.1.1 Operating System update 7 Vanga Health Centre IQCare system upgrade from version 1.0.0.6 to version 2.1.1 Operating System update 8 Vitsangalaweni Health Centre IQCare system upgrade from version 1.0.0.7 to version 2.1.1 9 Kwale Sub District Hospital IQCare system support with update of drugs & Regimens. IQCare management troubleshooting 10 Kikoneni Health Centre IQCare System troubleshooting support.

11 Kinango Hospital IQCare system upgrade from version 1.0.0.7 to version 2.1.1 Network re cabling troubleshooting and maintenance. 12 Kilifi District Hospital Hardware maintenance and software support. IQCare system support 13 Malindi District Hospital IQCare system network troubleshooting and Maintenance 14 Mtwapa Health Centre IQCare system upgrade from version 1.0.0.7 to version 2.1.1 Computer operating system support 15 Oasis Health Centre IQCare system upgrade from version 2.0.0 to version 2.1.1 IQTools troubleshooting and support 16 Waa Health Centre IQCare system upgrade from version 1.0.0.7 to version 2.1.1 and orientation to the new Version. 17 Shika Adabu Dispensary IQCare system upgrade from version 1.0.0.7 to version 2.1.1 and IQManagement troubleshooting

III. ACTIVITY PROGRESS (Quantitative Impact)

Please see Attachment II for the full performance summary tables.

IV. CONSTRAINTS AND OPPORTUNITIES

These have been described under respective output sections.

V. PERFORMANCE MONITORING During the reporting period, the project conducted M&E activities as part of ensuring compliance to donor reporting requirements. The project also sustained weekly performance reporting for SURGE, provided support in KDHIS2 reporting, strengthened Electronic Health Records (EHRs), built capacity and

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provided support supervision on M&E aspects. Additionally, the project conducted data quality improvement activities including data review meetings, targeted On Job Trainings (OJTs), Continuous Medical Education (CMEs), mentorships and Data Quality Audits (DQAs) with an aim of capacity building health facilities on documentation and reporting. Furthermore, whilst ensuring the availability of documentation and reporting tools at facility level, the project purchased and distributed Ministry of Health (MOH) and project specific data reporting tools to Service Delivery Points (SDPs).

Key Achievements i. Compliance to donor Reporting The M&E staff ensured project implementation data was captured at SDPs and summary reports compiled as per USAID and MOH guidelines. In regard to early warning indicator reporting, the project collected, analyzed, consumed and reported data for High Frequency Report (HFR), SURGE, PreP as per the set timelines. Data for other routine reports was also collected and uploaded into the recommended information systems; JPHES, DATIM, DREAMS and Partner Performance Portal (PPP) and KHIS2 on time. ii. Performance monitoring In the reporting period, the project continued with its airtime and data bundles support to county, subcounty and health facilities to access, enter, and use the data in KHIS for informed decision making as well as facilitating follow up on missing reports. This has helped in sustaining reporting rates and timeliness of reports at above 95% and 90% respectively. Further, monthly project data was summarized and analyzed and presented using a standard PMP template with interactive dashboards for all project indicators. Additionally, the project collected and entered program data in DATIM, partner performance portal, and JPHES as a contractual requirement and analyzed the data to track project performance with findings shared on monthly basis for programmatic decision making. iii. Data Quality and Improvement The project sustained efforts to improve the quality of data through a myriad of data quality improvement activities across supported counties. In Taita Taveta County, where documentation in most facilities was affected by the health worker strike, the project supported data cleaning and reconstruction in various affected health facilities . The project also ensured that the Health Care Providers (HCPs) had enough capacity on documentation and reporting through OJTs/mentorship on data capture tools and reporting in 15 targeted sites . In Kilifi County, the project was engaged in deep dives in data analysis with the aim of identifying service delivery and documentation gaps to flash out reporting culprits in FP stock outs, diarrhea and pneumonia and well as inform programing in bid to improve the quality of data. Analysis results were shared, facility and desk reviews of the data conducted, appropriate decisions made and implemented. In addition, more DQA files with customized county DQA protocols were printed and distributed to facilities. In Mombasa County, the project supported routine data verification in selected facilities119 and an internal RDQA in Likoni SCH which yielded the following results:

119 Ganjoni Dispensary, Magongo MCM, Miritini CDF

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Key Findings Recommendations

1. Good documentation of ART • CCC staff to hold own internal reviews, separate register from the facility 2. Inconsistent documentation in the • Institutionalize departmental and facility data MOH 257 reviews 3. Inconsistency in use of ICF cards • Internal OJT for ANC staff 4. Incomplete documentation and • Consistent follow up by facility HRIO to ensure dispensing in IQ care documentation is done well 5. Incomplete documentation in ANC • IQ care data cleaning due to knowledge gap but summaries well done 6. Good documentation in HTS register 7. Data discrepancy between KHIS and IQ tools

iv. Data demand and information use During the quarter ,the project continued to create demand for data use. This was done through generation of periodic program/project performance reports (statistical analysis reports, charts & graphs) from DATIM and KHIS which were discussed in various data review meetings supported by the project. Kwale county supported a county HRIOs meeting whereby an analysis of the HRIOs department was undertaken to identify strengths, weaknesses, opportunities and threats (SWOT) of the department whilst coming up with innovative ways of utilizing these strengths and opportunities while mitigating weaknesses and threats. The HRIOs were engaged in discussions on data management, streamlining data collection, reporting, data capture, reporting tools and capacity building. This was followed by the development of a way forward for the department with a key take-away being the adoption of roving HRIOs. Additionally, Kwale subcounty hospital conducted a data review meeting and highlighted issues including adoption of improved strategies of identification of PLHIV, differentiated service delivery (classification of active clients; well, advanced, stable and unstable), defaulter tracing and suppression rates in the facility. The meeting was aimed at discussing their performance and development, future targets and objectives, considering past performance and recognizing successes and to identify where improvements/changes could be made.

v. Strengthening Electronic Health Records (EHR) use at facility level In collaboration with national MOH, County MOH, County ICT and Health IT team, the project provided technical assistance for a baseline assessment to ascertain the hardware, software and capacity gaps that various counties should address before rollout and scale up of a facility wide EHR system. The assessment results were geared towards informing the County Department of Health on the existing gaps in terms of hardware in the facilities, human resource, the effective EHR system that should be deployed to scale and facilitation of an adequate budget allocation for the agenda. Furthermore, to enable all levels access to quality data for informed decision making that will guide policy formulation, intervention options, programming and effective management of health facilities, the project procured 3 desktops for IQCARE

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scale up in Mazeras, Samburu and Diani PMTCT in Kwale county and Miritini CDF in Mombasa county. Consequently, Miritini CDF was supported with data cleaning and mentorship on EMR documentation and reporting. Other facilities provided with EMR targeted CMEs and mentorship include Tudor SCH and Mvita Clinic in Mombasa County

Other M&E activities • Review of SDPs filing protocol (using CCC numbers in ascending order) of client files with adoption of color-coded stickers to identify unsuppressed individuals. • Refresher training on data collection and summary tools for HRIOs • Orientation of M&E staff on Key populations reporting • Distribution of dashboards to health facilities to enable performance monitoring at SDP level. • Procurement and distribution of appointment, ICF cards and patient files to improve both service delivery and data capture Lessons Learnt • Consistent data sharing using interactive dashboards enhances data use and demand • Close working relationship with the MOH ensures data ownership • Support facilities own internal mechanisms to institutionalize data quality, information use and adoption of data quality improvement strategies. • Joint work planning with the county and other partners greatly improves program interventions. • Adoption of a purely M&E rewards system improves morale of reporting units • Joint supervision enhances learning and identification of challenges Key Challenges and Recommendations • Shortage of HIV documentation and reporting tools. The project plans to photocopy the tools bridge any shortage as NASCOP finalizes printing of the tools. • Corona virus global pandemic is expected to have an impact in project implementation • Adoption and uptake of data quality strategies by the facilities • Adoption and uptake of EMR still a challenge Key Planned Activities • Weekly reporting of SURGE and DATIM • Monthly reporting of HFR to OHA • OJTs and mentorship to facility staff in documentation VL samples in viremia register and NASCOP website • Targeted DQAs for HIV and RMNCAH • Support adoption of data quality improvement plans at facility level • Facility-based data review meetings • EMR support supervision including data cleaning and reconstruction • Support facilities to closely monitor indicators for quality of care • Scale up data review meetings and data use through use of facility dashboards • Support and scale up EMR use to eligible facilities • Scale up use of PrEP and GBV tools and reporting in supported sites

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VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH

In the reporting quarter, Afya Pwani supported intimate partner violence and gender-based violence screening among newly identified HIV clients and unsuppressed clients during support group sessions at 17 health facilities120 in Mombasa county reaching 404 (336F; 68M) PLHIV with 7121 women reporting physical, sexual abuse, discrimination based on their gender and verbal abuse due to their HIV status. Counselling and appropriate support was provided to the 7 clients at both the facility and household level for those who consented. In quarter 3, the project will strengthen IPV screening in ART clinics as per the ART guidelines and institutionalize the use analysis and use of post GBV care services to improve service delivery. To improve the quality of services provided, in partnership with Mombasa CHMT, support supervision was conducted in 28 health facilities122 in the efforts to build their capacity to provide gender based violence recovery services. Most of these facilities referred clients to the Coast General Hospital Gender Based Violence Recovery Center thereby contributing to delays in the initiation of treatment. To further build their confidence and skills, the project will support health care from facilities with gaps to be mentored at the Coast General Hospital Gender Based Violence Recovery Center on rotational basis. In the spirit of journey to self-reliance, the CHMT took lead in conducting 3 CMEs in the county reaching 49 (12M; 37F) health care workers from 7 facilities123 covering topics such as: Gender and GBV concepts, the national policy of free services for all sexual violence survivors, GBV screening at CCC and PMTCT, filling of consent forms by all survivors of sexual violence; filling of PRC forms; filling of the sexual violence register; and filling the summary tool fed into the DHIS for reporting. The project also utilized these CMEs to replenish some tools to the facilities which included: GBV and IPV screening tools, MoH 363 (PRC forms), MoH 365 (Sexual Violence Register), MoH 364 (Sexual Violence Monthly summary), consent forms, patient files and the National Guideline on the management of sexual violence in Kenya. Additionally, OJT on GBV and IPV screening was undertaken for the DREAMs teams serving three safe spaces in Mombasa County (Mtongwe, Kongowea and Likoni – LIKODEP) to improve their capacity to identify cases of gender based violence, provide immediate support and link promptly to appropriate services. DREAMS teams also received IPV/GBV Screening tools and reporting tools. Counselling services will be availed to identified AGYWs post-COVID 19 due to government bans on gatherings to curb its spread. Emphasis has also been placed on confidentiality, respectful care and follow-up for 10-24 year old adolescents. To create awareness and promote uptake of post violence services in the County, health talks on GBV were prioritized at the waiting bays of facilities; for instance, at Mikindani Health Center health talks on GBV services reached 299(32M, 267F) clients . The project also participated in the Likoni Sub County SGBV Response stakeholders meeting to promote county led coordination of SGBV response services and leveraging of resources from other partners in the

120 Tudor SCH, Ganjoni Health Center, Railways Health Center, Mvita Health Center, CPGH and Youth Zone, Likoni SCH, Mrima Health Center, Likoni Catholic Hospital, Shika Adabu, Mbuta Health Center, Portreitz SCH, Chaani Health Center, Magongo Health Center, Bokole Health Center, Mikindani Health Center, Jomvu Model, and Miritini Health Center. 121 2 from Magongo Health Center, 2 from Bokole Health Center, 2 from Likoni SCH and one from Jomvu Model Health Center 122 Likoni SC Hospital, Jomvu Model H/c, Chaani Teaching and Referral Hospital, Bokole Health Center, Miritini CDF, Mikindani Dispensary, Shika Adabu Dispensary, Mbuta Health Center, Mrima Hospital, Kisauni Dispensary, Port Reitz District Hospital, Kongowea Health Center, Mlaleo Dispensary, Coast General Hospital, Mvita Health Center, Tudor Hospital, Railways Dispensary, Ganjoni Dispensary, Mwembe Tayari Clinic, Kaderbouy Dispensary, Junda Health Center, Maungunja, Vikwatani, Bamburi, Marimani, Mtongwe and Mwakirunge Dispensary 123 Likoni Hospital, Mbuta Health Center, Mrima H/c, NYS Dispensary, Mtongwe Dispensary, CGH – Chaani Outreach Center and Mikindani Dispensary

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Sub-county. Emphasis was on the use of data to improve service quality, demand creation for services especially on victims seeking care with 72 hours of violence and linkage to support services. In Taita Taveta County, OJT on IPV screening and management of sexual violence was conducted in 12 health facilities124 reaching 42(23M, 19F) health care providers with IPV screening and post rape care tools (MOH 363, MoH 364 and MOH 365) being distributed. The project takes cognizant of the low reporting rates of post -rape care services and corresponding low uptake of the services in Kwale County compared to other counties. In order to provide contextualized support, the project is working with the CHMT to conduct an assessment and analysis on the utilization of GBV/IPV screening and PRC tools in 3 sub-counties of Msambweni, Matuga and Lungalunga.

VII. GRANTS Grants Award and Management During the reporting period, the project worked with 16 approved grantees. Nine grantees were supported to implement HIV prevention, care and treatment services in Mombasa, Kilifi, Kwale and Taita Taveta counties while the other three grantees supported the program in the implementation of demand creation for FP and MNCH services and 1 grantee supported the program in water, sanitation and hygiene (WASH) and nutritional services in Kilifi County. Three grantees supported the program in implementation of increased availability and utilization of combination prevention services for Key and priority populations in Kilifi, Mombasa and Kwale counties. Afya Pwani issued out close out notices to 5125 grantees and 1 PIP- Kenya Youth Muslim Development Organization-KYMDO due to constraint of resources. Grantee Reporting and Compliance During the quarter ending March 31st, 2020, the project was able to facilitate late disbursements amounting to Ksh. 21,583,017.44 to grantees to enable them conduct planned activities for the quarter. The burn rate against the grantee budget obligation for the financial year is currently at 59%. Tamba Pwani, ICRH and CIPK delayed in submissions of financial reports. Capacity Building of Local Implementing Partners (Grantees) Afya Pwani grants and program team visited Kishushe CU to conduct capacity building in both financial and program implementation. Kishushe had recruited an accountant who was not very familiar with donor requirements. Kishushe had gap in reporting, the exiting accountant exited Kishushe without notice and proper handing over. The new accountant has adopted to the donor requirements and reporting. CIPK had a challenge in reconciling their financial accounts from the previous financial year. Afya Pwani team managed to engage CIPK management and assisted in finalizing the financial reporting. It is still work in progress. Desk reviews have been going on and recommendations shared to grantees on a timely manner. The grants team is currently doing OJT to the accountants to enhance compliance.

124 Moi CRH, Ndovu HC, Taveta SCH, Njukini HC, Challa Dispensary, Ndilidau Dispensary, Rekeke HC, Mwatate SCH, Wesu SCH, Wundanyi SCH, Mbale HC, and Nyache HC 125 The Council of Imams and Preachers of Kenya- CIPK, Moving the Goal Post, Magarini Cultural Center, Pwani University, Ustadh, Reach out Center Trust

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Afya Pwani Partner Implemented Projects (PIPs) Afya Pwani engaged KYMD during the period October 2019 to March 2020 to assist the project in implementing increased demand for access and utilization of focused AYSRH services in Kilifi County. KYMDO spent a total of Kes. 1,955,839.07 in project implementation. The following are the highlights of their accomplishments: • RMNACH interfaith network was established to better promote, generate demand and advocate for RMNCAH information and services. • 75 parents/ guardians/ gatekeepers/ OVC households and religious leaders were sensitized on adolescent and youth sexual and reproductive health where religious leader was able to integrate AYSRH key messages into their sermons. • 33 Amina Ali CBD were trained to disseminate AYSRH/FP information, provide referral for voluntary LARC and provide level contraception during the project they managed to distribute 2340 (condoms). • 2 street events were supported reaching 566 participants (419 males and 147 female), 657 condoms were distributed to sexually active youth, Binti WA Kisasa toll free number was distributed to 566 participants, 14 feedbacks were collected and 17 recommendations on Binti WA Kisasa toll free number were collected. • 8 clubs with a membership of 1241 (498-males and 743-females) adolescents and young people. • Establishment of 8 peer education clubs’ in madrassas and mahads with a membership of 1241 (498- males and 743-females) adolescents and young people and 12 session were supported to orient the members on AYSRH reaching 1380 Students (798 females and 582males). • 7 ward level AYSRH networks have been established with a membership of 129 (58 males and 71 females) whom were taken through one introduction forums in each ward reach the members of the network. • Conducted 12 online campaigns on AYSRH/HIV/SGBV targeted messages. • The projected also supported its staff to offer technical support during the 6 county lead meeting (2 FP TWG – KMYDO took lead in designing the midterm FPCIP review toolkit, 3 RMNCAH thematic group – KMYDO is among the RMNCAH strategy development team, 1 AYSRH meeting where KMYDO took lead in development of the annual review of the AYSRH/HIV strategy response and participated in the development of a primary school AYSRH mentoring guide through the department of gender.

VIII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING Mitigation of adverse effects of Afya Pwani activities on the environment continued during the quarter alongside other activities. The mainstay of the mitigation measures is to ensure that facilities have colour coded bins, bin liners and job aids for proper waste segregation to ensure infectious waste does not end up being disposed alongside uninfectious waste and harm the environment and hence humans and animal life. Mitigation measures were enhanced towards the tail end of the quarter following the outbreak of COVID-19 in Kenya. Facilities were placed on high alert with concerted efforts that included all stakeholders with the leadership of the County Governments. Just like in the pre COVID-19 period, heath care workers in supported facilities were equipped with appropriate personal protection gear for the service area e.g.N-95 masks for TB clinics and labs handling TB samples, gloves, lab coats, etc. These in addition to protecting caregivers from TB and other hospital-based transmissions, they will also protect aginst COVID-19 infections. The enhanced protection added an extra burden of proper disposal of used PPEs which is being managed using existing structures.

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Efforts were also taken to ensure facilities have good commodity management practices including proper inventory management, quantification/ordering and using First Expiry First Out (FEFO) to minimize expiries that would require disposal. Health workers in visited facilities were sensitized on good inventory management and quantification in order to minimize expiry of commodities. There are still small quantities of medicines that do expire and these are mopped up periodically by KEMSA MCP for disposal. See Appendix I which contains the detailed Environmental Mitigation and Monitoring Report (EMMR) for the period Jan-Mar 2020. IX. PROGRESS ON LINKS TO OTHER USAID PROGRAMS Afya Pwani, worked with MWENDO project to link Children Living with HIV, HIV exposed infants, adolescent and young women living with HIV in PMTCT program to socio-economic support to address barriers to ART adherence and retention for better treatment outcomes in Kwale, Mombasa and Kilifi Counties. Additionally, Afya Pwani collaborated with EPIC team to conduct joint support supervision for DICEs and M&E training for HRIOs from Mombasa and Kilifi counties. The project also worked closely with Health IT to build capacity of health care workers on use of EMR Support; KenyaEMR software development and hardware maintenance; Capacity building of county health managers on data analysis and use for decision making. During the reporting period, the project also worked closely with HP+ project in planning and budgeting in Kilifi and Mombasa counties. Specifically, in Kilifi County the two projects collaborated in preparation, review and dissemination of DOH Annual Performance Report. In Mombasa county the two projects collaborated in the DOH Annual Performance Review. In Human Resource for Health (HRH) that has been continued partnership with HRH Kenya in strengthening Kilifi and Mombasa counties in the use of HRMIS (iHRIS). HRH Kenya continues to support county health departments HR units in the use of the system and on trouble shooting and other user support needs. In HPT there were collaborations with KEMSA MCP in coordination of supply of commodities in the four target counties. review and dissemination in Kilifi county X. PROGRESS ON LINKS WITH GOK AGENCIES In the spirit of journey to self-reliance, the project collaborated with all four CHMTs (Kwale, Taita Taveta, Mombasa and Kilifi) to conduct County-led targeted supportive supervision and mentorships for HIV and RMNCAH services. To support children living with HIV who are in school and AGYW in the DREAMS initiative, Afya Pwani liaised with the teachers under the Ministry of Education and the Ministry of Gender and Social Services. Continued collaboration with NASCOP and other national level agencies in the Ministry of Health were sustained through participating in the national TWGs for various thematic areas and activities. In HPT the project engaged directly with KEMSA in addressing vaccine shortages in Kilifi county in January and February. There we continued collaboration with the County Commodity Security TWG’s, and the S/CHMT’s. Similarly, on planning, budgeting and HRH the project engaged with the S/CHMT’s as well as the County Public Service Boards especially in the management of Facility Based Contract workers. There was also direct engagement with CGTRH in the review and development of the hospital strategic plan. XI. PROGRESS ON USAID FORWARD Afya Pwani aligned its implementation to the USAID strategy of Journey to Self-Reliance by sustaininng engagements with all the four CHMTs and sub county teams on J2SR and what is expected of them to have resilient and sustainable county health systems. The J2SR work plan has been implemented thus increasing their capacity and commitment in ensuring strengthened health systems for provision of quality

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health care. The J2SR interventions have been integrated into mainstream service delivery designed in line with the six building blocks of the health system namely Leadership and Governance, Human Resources for Health, Health Products and Technologies, Health Information Systems, Service Delivery and Health Care Financing. Afya Pwani will continue to support counties to implement interventions that will build their capacity to continue taking lead in project interventions in the spirit of J2SR. XII. SUSTAINABILITY AND EXIT STRATEGY In line with the J2SR, Afya Pwani has continued to enhance the capacity of CHMT to ensure that joint Supportive supervisions are conducted and technical assistance provided to health care workers to improve quality of services. Collaborations with other government agencies such as ministries of education and gender were done to support the implementation of the DREAMS interventions. To ensure children living with HIV in schools continue to receive support from teachers beyond the project, Afya Pwani collaborated with KENEPOTE to build their capacity to provide support and guidance to CLHIV in school. In regard to health products and technologies, the sustainability and exit strategy was anchored in the institutionalization of the county commodity security TWG’s in the four counties and they now can receive direct support from NASCOP and other partners. In planning and budgeting, the project continues to support the county to deepen further planning and budgeting and build the relevant skills required for the process. There are also concerted efforts to build performance management capacities among HR officers deployed in the DOH to enhance and institutionalize performance appraisal process in the public sector. Plans are also under way on transition modalities of contract health workers to the county public service to ensure continuity in health service provision. XIII. SUBSEQUENT QUARTER’S WORK PLAN With the ongoing COVID-19 pandemic and the associated preventive restrictions in place, in Q3 FY20, Afya Pwani will adapt implementation of activities to encourage teleworking and social distancing to prevent infections among health care workers and clients. Facilities will be supported to make service delivery organizational changes that will facilitate social distancing including changes in client flows. In the coming quarter, the project will focus on PNS and HTS screening to improve on identification of people living with HIV. Capacity building on HTS providers will be done to improve the quality of pre and post-test counselling. OTZ clubs and other forms of psychosocial support will also be supported to ensure that PLHIV are retained on ART. Defaulter tracing mechanisms will be strengthened to reach clients who were lost to follow up and brought back to ART. Multi-month dispensing of ART will be scaled up to all PLHIV except PMTCT clients as per the national guidelines on mitigation of the effects of the COVID-19 pandemic. Afya Pwani will prioritize viremia clinics, unsuppressed support groups and multi-disciplinary team meetings to improve viral load suppression. In PMTCT, the project will prioritize strategies to counter the effects of COVID-19 which have seen the number of pregnant women attending ANC clients dip. To achieve this Afya Pwani will work closely with the county community focal persons and through its grantees to ramp up demand creation strategies and mop up all pregnant women for ANC services. The project will also prioritize, efforts to mop up all HEIs in communities for HEI EID services. Cognizant of the fact that most women may have missed ANC attendance and also had unskilled deliveries, the project will also strengthen PNC testing of all lactating women and HIV screening at CWC to capture any HEIs that may have been missed during the COVI-19 response period.

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Afya Pwani will also prioritize the provision of the basic package of services for AGYW to achieve 100% layering in the supported wards. Community level interventions will be strengthened to enhance behavior change which will sustainably reduce the risk and vulnerability of AGYW to HIV infection. For Key Populations, Afya Pwani will increase its efforts to identify KPLHIV through intensive case identification strategies such as PNS and working with peer networks. Linkage to ART for newly identified KPLHIV will be strengthened by engaging peer navigators and psychosocial support provided to improve retention on ART. Community and household level delivery of services will also be prioritized as a mitigation measure against COVID-19 infection among KPs. Collaboration with the health facilities will be strengthened to ensure high quality service delivery for KP and reporting of KP data in KHIS 2 by HRIOs. In Q3 FY20, the project will prioritize to implement interventions that mitigate the effects of the COVID- 19 pandemic on service delivery while ensuring continuity of quality services. In MNCH, the project shall bring to scale its demand creation community strategies by Corps, championing early ANC booking, and preconception care. It shall also strengthen retention in the MNCH cascade through scaling up antenatal clinic scheduling, SMS reminders, and defaulter tracking. Besides, bringing to scale high impact cost- effective interventions like Mama Kwa Mama and Binti Kwa Binti groups. The project shall continue capacity building the project supported CHVs, CBDs, and HCWs through low-cost interventions like Structured mentorship and on the job training. In Wash, the project shall continue supporting CLTS and sanitation marketing while increasing access to quality water to vulnerable communities. To ensure sustainability, the project shall support the establishment of self-help groups which shall be spearheading household environmental sanitation and hygiene practices, including model households as well as energy- saving Jikos, Bios, and filters, and sanitation scale up. In nutrition, the project shall prioritize the scale-up of BFCI and BFHI activities. Besides, the project shall scale up IMAM facilities and Vitamin A supplementation at ECD centers. In line with J2SR, the project shall support the DoH to launch CNAP 2 and advocate for resource mobilization towards the implementation of proposed activities. In the next quarter, the project in partnership with other stakeholders will continue to participate in DOH performance reviews in the implementation of annual workplans and support hospitals in development of strategic plans as need arises. Similarly, there will be sustained efforts towards strengthening staff performance management process in the DOH in the target counties. Also, during the quarter, the project will continue support to the DOH HR units in monitoring the implementation of HRH staffing plans and more specifically continued use of HRMIS (iHRIS) as a decision support tool and repository of HRH data. County Commodity Security TWG’s, S/CHMT’s and technical staff handling commodities will continue to receive targeted support in commodity security while High Volume Health Facilities will also continue to receive on-site EMR support to institutionalize EMR use for improved data quality and information use.

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XVI. SUCCESS STORIES

These are outlined below: Giving hope to a teenage pregnant mother

Fifteen-year-old, Winnie Anjila was just about to do her Kenya Certificate of Primary Education (KCPE) when labor pains set in. The 2019 class eight candidate at Mjanaheri primary school had to figure out whether to drop out of school at such a critical time or endure the sharp labor pains.

Her early and unplanned pregnancy stirred shame and stigma from her classmates. She lived a lonely life in school during her last trimester (Sep - Nov 2019) with no interaction from other students.

All was not lost though, Winnie would find solace at Mjanaheri dispensary through Anne Wanjiru, a Nursing Officer working for a USAID Afya Pwani supported facility. Winnie was not the only one faced with this predicament. She was among the 8 out of the 19 members of a Binti Kwa Binti group who were below 19 years, pregnant, and in school. She felt embraced whenever she went for her ANC visits. The nurse continuously encouraged her to do her best and prove her critics wrong. Besides, the officer offered intensive health education on the importance of ANC visits and hospital delivery, individual birth preparedness, and maternal- infant and young child nutrition. Many are the times when the nurse re-scheduled her appointment dates to accommodate her school. This gave Winnie some new impetus to work hard in school. She developed a special relationship with the nurse. Ultimately, the nurse approached Winnie’s mother through the home visits supported by the USAID Afya Pwani project. Luckily, she managed to convince her mother not to send her away from home despite the frustration but instead offer her moral support.

“I was thrilled when the mother decided to take care of Winnie, I knew that the rest would fall in place if she received a strong support system.,” said the warm-hearted nurse. The Nursing officer continuously had sessions with Winnie on school reintegration, life skills, values clarification, and goal setting. These sessions helped Winnie to rebuild her self-confidence and general outlook towards life. Thus, Winnie changed her mentality over how her classmates ridiculed her, and she viewed it as an opportunity to prepare adequately for the exams as she had ample free time by herself. She decided to take the examinations boldly.

Ordinarily, she would have felt overwhelmed during the exam period, abandoned, anxious, and full of regret since her pregnancy was not by choice. Worse still, the boy who had impregnated her was nowhere in the picture. Despite all odds, she didn’t allow the thoughts of the missing father to her unborn child, distract her mind. She did her exams with courage!

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A month later (Dec 2019), after the release of the KCPE, Winnie became a household name in Mjanaheri village of Kilifi County as she emerged as the top student in Mjanaheri primary with 398 marks, listed amongst the top students across Kilifi County. No doubt, Winnie had conquered a lot, if not all, and her future was bright!

The relentless advice offered by the USAID Afya Pwani MNCHFP team who accompanied the nurse to Winnie’s home, coupled along with great news of Winnie’s excellent KCPE performance prompted Winnie’s mum to strengthen the relationship with her daughter.

After that, the mother gave full support to her daughter; she accompanied her to deliver, stood by her, and was her birth companion in labor. It was an answered prayer to the nurse and the Afya Pwani MNCHFP team. “When such things happen, we feel that Afya Pwani’s interventions are helpful to our beneficiaries. We feel accomplished.” Afya Pwani MNCH Manager, reiterated.

Collectively, the chief at Mjanaheri sub-location, Mjanaheri dispensary Nurse, the Public Health Officer together with the MNCH Afya Pwani team, managed to apply for a scholarship with Wings to Fly - Equity bank foundation and Winnie was fortunate enough to qualify. It was such a breakthrough! Winnie joined St. John’s Girls Kaloleni in January 2020, where she is currently studying while her mother back at home is taking care of the baby. She is always punctual and never misses the post-natal clinic. Whenever Winnie is around during midterm, they attend health education sessions together at Mjanaheri dispensary.

As a member of a Binti Kwa Binti group Winnie acquired excellent lessons on quality sexual education that shall enable her to avoid future unwanted pregnancy. Data on teen pregnancies indicated that 22% of girls aged 15-19 years had begun childbearing, higher than the national figure of 18%; KDHS 2014. With Magarini sub-county, where Winnie hails from; in October to December 2019, reporting the highest numbers of 3257 adolescent pregnancies. ( Further, primary school enrollment in Kilifi county was at 84%, with only 26% of these children enrolled in secondary school126. Winnie feels that she can now make informed choices in her life. She received information and counselling on contraception and she is currently on a long term family planning method. She is proud that she can now decide on when to conceive. Her experiences have not deterred her from achieving her dreams.

“I want to complete school and become a nurse, just like my favorite cheerleader, the Nursing officer at Mjanaheri dispensary who ignited my hope when it was diminishing,” she said.

126 The Ministry of Education, Science and Technology (MoEST). 2015. 2014 Basic Education Statistical Booklet.

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Family Planning Efforts Help Teenage Mothers Resume School Anne Wanjiru is a Nursing officer at Mjanaheri dispensary in the Magarini sub-county of Kilifi county. Anne has worked in the facility since its inception in 2016, providing health services. “When I joined Mjanaheri, the facility only offered outpatient services. Six months later, with the support of the USAID Afya Pwani project, we strengthened Maternal, Neonatal, and Child Health services as well as Family planning services.” Says the warm-hearted nurse. Wanjiru has helped hundreds of young mothers deliver healthy babies putting a smile on their faces. “I always feel motivated when I touch people’s souls; to me, it means putting more hearts in my hands. I was taught in college always to go the extra mile in whatever I do, giving my best in all circumstances.” The enthusiastic Anne states.

Because of her passion and dedication in serving women and girls with sexual reproductive health education, the sub-county health management team selected her lead and champion the facility’s Mama Kwa mama (MKM) and Binti Kwa Binti (BKB) groups in 2017. The BKB is a USAID Afya Pwani project initiatives geared towards supporting different cohorts of young pregnant girls and young breastfeeding mothers regardless of their HIV/AIDS status. Each group consists of 20-30 members, who are grouped based on their ANC visit schedules. Throughout the sessions, the groups are encouraged to adhere to antenatal care visits, skilled delivery, and postnatal care services. They also get an opportunity to learn and share experiences, create lifelong bonds, and robust peer support systems. By design, the Mama kwa Mama and Binti kwa groups are tailored to encourage pregnant and postnatal women to look Ann Wanjiru – Nurse, Mjanaheri dispensary forward to meeting again because of the meaningful engagement they are involved in during the sessions. The bonds established by the group members encourage

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retention, as the group members keep reminding each other of their next appointment. The women are retained in these groups up to nine months post- delivery to foster exclusive breast feeding, family planning, ensure the infants and their mothers receive PNC services and immunization services. Through facilitated group discussion, this model builds a supportive community of pregnant women to normalize the pregnancy experience, fosters birth planning, and provides emotional and social support during a stressful, momentous, and often isolating time.

For the four years, Anne has been at Mjanaheri; she has seen it all. She is quick to let us know that through Mama Kwa Mama and Binti Kwa Binti’s intervention that she is currently spearheading, she takes pride to note that she has empowered hundreds of young mothers and expectant girls Selina Samson, 19, who has 2 kids and has gone back overcome the challenges that affect them. These to school challenges include school drop-out, poverty, malnutrition, pregnancy complications and emotional problems e.g. depression.

Notably, she highlights the last cohort, where she had 19 Binti’s. Eight of the girls were below the age of 19 years, and only two out of them were married. “Most of them were disturbed by their early and unplanned pregnancies. Some felt stigmatized by their fellow schoolmates and had low self-esteem. I knew I had to do something to save their lives and that of their unborn babies.” Anne reiterates.

Anne relentlessly encouraged the young girls and counselling them whenever they came for their ANC visits and during the Binti Kwa Binti sessions. Most of them felt safer during the sessions than at their homes. Anne planned antenatal clinics for them according to their school schedules and support them through their teachers, parents, and religious leaders. All the girls did not stop going to school while pregnant . Postnatally lucky enough, they delivered before the long Nov - Dec school holiday, and by February, all the babies were above 3months age, and they could attend school. By the end of March 2020, Anne says that she is super thrilled to note that 6 of the girls in the cohort had already reported back to school.

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Interestingly, she has managed to go beyond her call of duty to convince their parents, and they have pledged to continue providing care and support to the girls. Through the support extended to her by Afya Pwani project team, the facility has conducted home visit follow-ups, defaulter tracing, meetings with the Chief’s and village elders which have yielded excellent results.

“Some of the parents have now adapted the motherly roles, and they even accompany their daughters for health sessions during their visits,” Anne comments.

In situations where the girls experience hostility from the teachers, she reaches out to the teachers and involves religious leaders too. She believes that no girl should be denied a chance to go back to school and brighten her future simply because she got pregnant.

“Such efforts have helped the facility in increasing access, utilization, and retention in the Maternal newborn, child, and family planning services. We have sensitized the facility on Linda mama as well, and they have successfully registered for this service. As a result, its financial base has also improved.” USAID Afya Pwani MNCHFP team reveals.

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LIST OF ANNEXES & ATTACHMENTS

ANNEX I: USAID Afya Pwani Organogram

ANNEX II: List of Activities supported as Partner Implemented Projects (PIPS)

ANNEX III: List of Tracer Commodities in the Supportive Supervision Checklist

ANNEX IV: Grantees specific activities implemented during the quarter

APPENDIX I: USAID Afya Pwani EMMR for Jan-Mar 2020

ATTACHMENT I&II: USAID Afya Pwani Project Monitoring Plan period Q1 and Q2 FY20

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ANNEX I: USAID AFYA PWANI ORGANOGRAM

Chief Of Party Dr Eileen Mokaya

Commodity Mgt HRH Development Program Manager Sr Finance & Admin Head of Human Technical Advisor Internal Audit & Risk Executive Assistant Communications MEL Specialist Technical Advisor Sr Technical Advisor Advisor Advisor Nutrition Director Resource Y&P Compliance Salome Kibuna Manager Stephen Konah C&T PMTCT/QI Dr Antony Jotham Chacha Lindah Khabeko Dennis Ali Pamelah Omondi Pamela Onduso Eric Mugodo Festus Kivindu Dr Victor Rono Solomon Omariba Mwangi Snr Technical Advisor Sr Technical Advisor Comm & Outreach Sr Lab Technologist M&E Officer M&E Technical Nutrition Officer C&T/ Ag.Chief of Clinical Cluster Zebedee Mkala Dishon Olumu Gender & Youth Front Office Asst Sr Technical Adv Kevin Oyugi Advisor Faith Mwangi PMTCT Technical Paryy Manager Officers Asha Wairimu MNCH & FP Francis Muema Advisor Dr Isaac Chome Ahmed Bunu Cynthia Anyango Dr. Charles Ondieki Jane Wangare Lindah Mbeyu

Program Officers- Communication Data Assistants Lab Technologists M&E Assistant Community Officer Esha Khamis Jeremiah Korir Gordon Opiyo Daniel Mudibo Office Assistants Clinical Cluster Arther Waweru Peter Kiondo HTS Linkages Manager Jonathan Mwanake PMTCT Manager Stephen Githaiga Hannington Olang Manager Magdaline Barasa Antonnette Otieno Cleophus Chorongo Stephen Ainley John Karisa Motor Riders – Lab Clinical Cluster M&E Officer M&E Officer Networking M&E Officer Programs Officer – Manager Julius Mwanyalo Cleopatra Dan Omolo Gerald King’ori Comm MNCH/FP Meshack Mwangala Mkanyika Ronald Museni Sharon Atieno Front Office Asst Eddison Hare Charo Head Driver Patricia Mwea Office Asst Coxswains HTS Linkage Officers Samuel Osero Wilson Nyaingo M&E Assistants M&E Assistant Florence Ndii Abubakar Alale Loice Ng’oma Clinical Cluster Rose Getonto Kephas Arende Abubakar Sadat Manager Sammy Rono Francis Mbithi Procurement Officer Jacob Lenjayo Nelly Makena Felix Omollo Joseph Bidivo Data Clerks Sr Driver Kelvin Wahome Loy Tebisigwa Justus Makau

HTS Linkage Officer Elosy Mukiri MNCH FP Sr Admin Asst - Procurement Asst Financial Controller Chief Accountant IT Manager Accountant Managers Logistics Allan Ouma Daniel Akach Edwin Odipo Emmanuel Kwambai Desmond Tirop Damaris Makori WASH Manager Gideon Mwai Anne Kipsuto Caleb Chemirmir Program Manager - HTS Linkage Officer AGYW Admin Asst Logistics Joseph Oreta Irene Makena Ag Grants Specialist ICT Officer Accountant F&A Assistant & Security Fridah Mogeni Valentine Nyamwaro Zadock Itindi Marie Fayemi Moses Kabugi Front Office Asst Wash Officer June Adhiambo Peter Omangi Drivers Program Officer Program officer David Aromba Felix Mogere Irene Mutea Nasibo Diba Accounts Assistant Grants Assistant Joel Agonya William Shena Ali Bahaji Office Asstant John Mwambi Raphael Mutinda Brian Juma Field Assistants Khalfan Mremi Field Assistants Stephen Okwacha Nicholas Okiro Edith Chepkemoi Edgar Machuki Joseph Mwangi Yvonne Alivitza Jimmy Kibungi Data Assistant Leslie Solomon Josephine Marura Dorah Juma

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ANNEX II LIST OF ACTIVITIES SUPPORTED AS ‘PARTNER IMPLEMENTED PROJECTS’ (PIPS)

Output 2.4.1 -Water quality Activity 2.4.1.A: Support PHOs conduct training of Community Based Promotors (CBPs) Improve improvement at groups/CBOs on Household water filtration technology options household level -Selection of CBPs done at sub -A total of 6 -CBPs acquired -Activity access to through locational level through chief’s offices trainings appropriate satisfactorily water for treatment at in liaison with the area PHOs conducted. knowledge for conducted. drinking, point of use. program domestic and -Actual trainings were planned and -146 CBPs trained implementation -Use of animal use conducted at Ward level. in terms key Nyumba Kumi indicator strategy for protocol for enhanced CLTS and other follow up at WASH aspects, village level. documentation and reporting. This was to be applied and contribute significantly to the overall project results Activity 2.4.1.B Support PHOs from 16 sub locations in Ganze, Kaloleni and Kilifi South sub- counties to empower CBP committees/CBOs to initiate and market Household Water Treatment Technology options. -Activity not implemented due to -Nil N/A N/A time constraint and other emerging factors during program implementation e.g. Budget cut, Corona virus pandemic among others Output 2.4.2 Environmental Activity 2.4.2.A: Facilitate 20 sub-locational level Community Based Promotors (CBPs) from Kilifi Increase Sanitation South, Kaloleni and Ganze sub-counties establish self-help structures for sustained WASH access to improvement at interventions. sanitation schools and services community -Identification of sub locations for -6 sub locations The groups were Sensitization level. establishment of self-help structures. identified out of to be taken sessions had the required 16 through the not - Birini Mwamleka group formation commenced -Chasimba and dynamics -Nyari protocol by the -Tsangalaweni social services -Rare officers -Mwahera

Activity 2.4.2.B: Support public health workers to carry out SLTS in 20 primary schools in Ganze, Kaloleni and Kilifi South sub-counties. - Identification of schools was done in - 20 schools The acquired SLTS sessions each target area, whereby identified. knowledge and had just consideration was given to select 4 - A total of 3 skills on hygiene started to take schools in the 5 respective Wards. sessions and sanitation pace and conducted would go handy unfortunately in reinforcing schools were

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- Actual Sessions had started in the reaching over 180 some of the indefinitely schools children. CLTS protocol at closed early as their household a result of the level e.g. hand corona crisis. washing aspect. Activity 2.4.2.C: Support Community Based Promotors (CBPs) conduct CLTS follow ups in triggered villages (post-triggering follow ups) in 120 villages of 16 sub locations in Ganze, Kilifi South and Kaloleni sub-counties. -CLTs sensitization meetings -8 CLTs -Village elders -CLTS progress conducted in at sub locational level sensitization and Nyumba was monitored targeting Village elders & Nyumba meetings done Kumi acquired in all the target Kumi in liaison with chiefs & PHOs. with. appropriate villages. -746 Village knowledge and -Post trigger CLTS follow ups elders/ Nyumba were also able Kumi sensitized on to establish their -CLTS review/Feedback meetings WASH/CLTS village ODF conducted at sub locational level. modalities. status and plan -120 villages for vigorous -CLTS progress tracking followed up CLTS action in -8 review and order to feedback meetings maintain ODF conducted status for those -720 new toilets villages that constructed; 5233 were ODF and individuals declare ODF for accessing these the villages that sanitation had not. facilities. Activity 2.4.2.D: Support SCPHOs conduct sub-county level verification of newly acquired ODF status in 40 villages in Ganze, Kilifi South and Kaloleni sub-counties. -Village self-Claim ODF status Three villages self- The villages - 32 villages are claimed ODF carried out self- above 80% status; Jibidishe, ODF assessment mark of the Koromio and with the CLTS protocol Spaki. CBPs/CHVs to attaining /CHOs. ODF status

Not done -Sub county ODF verification

Output 2.4.3: Environmental Activity 2.4.3.A Support school hygiene and sanitation events (school wide WASH sessions and Improve Sanitation demonstrations to fellow pupils) in 20 primary schools in Ganze, Kilifi South and Kaloleni sub- healthy improvement at counties. hygiene schools and - Identification of schools was done in - 20 schools The acquired SLTS sessions behaviors to community each target area, whereby identified. knowledge and had just prevent level. consideration was given to select 4 skills on hygiene started to take diarrheal schools in the 5 respective Wards. - A total of 3 and sanitation pace and diseases sessions would go handy unfortunately - Actual Sessions had started in the conducted in reinforcing schools were schools some of the indefinitely

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 135

reaching over 180 CLTS protocol at closed early as children. their household a result of the level e.g. hand corona crisis. washing aspect. Activity 2.4.3.B Support hygiene champions to conduct community dialogue on handwashing stations, latrine, water treatment and ORT at health facilities, schools and selected community forums in 120 sub-locations. -Community dialogue meetings -45 community -Community Dialogues conducted at village level on Water, forums conducted dialogue integrated with Sanitation and Hygiene with with 1009 meetings Hand washing emphasis on CLTS community reinforced on and water individuals promoting treatment reached. behavior change demos to amongst enhance skills community and knowledge individuals to of community perform members. promoted practices in relation to CLTS thus contributing towards ODF achievement. Activity 2.4.3.C Facilitate water safety demonstration forums in 120 villages. -Water demos conducted at village -45 sessions Reinforce level conducted in 45 adoption and villages maintenance of promoted behaviors. Activity 2.4.3.D Support County WASH PHO is emergency response in diarrheal diseases outbreak prone sites in Kilifi county, through distribution of water treatment chemicals within project support areas or as may be advised by the WASH technical lead at Afya Pwani. -Distribution of water treatment - 1 distribution -Enhancing Demand for chemicals done in target areas; cycle was done. adoption of the water Kaloleni and Ganze sub counties. water treatment treatment - 17,000 Aqua tabs practices at chemicals is distributed point of use thus very high at the (340,000 liters of improving water community water treated). quality and level. safety for -7200 PUR sachets human distributed (72,000 consumption. Liters of water treated)

Output 2.5.2: Activity 2.5.2.A: Enhance proper nutrition practices by conducting targeted cooking Strengthen demonstrations in select facilities and communities - Prioritize BFCI communities delivery of -Conduct cooking demonstration by -10 cooking demos Promote balance Target quality of targeting Mothers in areas with CHU conducted. dieting among beneficiaries newborn care trained on BFCI. target encouraged to services beneficiaries use locally

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-620 mothers thus improving available food reached the Maternal stuff. and young child health status and therefore curbing related diseases.

Activity 2.5.2.B: Promote EBF activities by identifying and sensitizing lead mothers and support groups (Father & Mother) on BFCI -Engage target beneficiaries on BFCI -18 support groups -Efforts through Integration of initiative supported across support groups Sanitation and Ganze, Kilifi North, break social hygiene during Kilifi South and norm related Nutrition Kaloleni sub barriers and aspects counties. enhance synergy towards BFCI initiatives. Activity 2.5.2.D: Promote good maternal and child nutrition practices by conducting dialogue sessions with targeted cohorts including mother in laws, Adolescents and Young Women AYWG) and engage community leaders and male champions to address retrogressive cultural behaviors that affect MIYCN -Nutrition Dialogue meetings -4 Dialogue Will reinforce -Male conducted targeting specific cohorts. meetings behavior change involvement in conducted. towards the sessions. addressing -116 individuals retrogressive reached cultural behavioral barriers thus improving health nutritional status for the mothers and their children.

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ANNEX III – LIST OF TRACER COMMODITIES IN THE SUPPORTIVE SUPERVISION CHECKLIST

Amoxicillin caps 250mg Cotrimoxazole Susp. 240mg/5ml Sulphadoxine Pyrimethamine tablets Ferrous Sulphate 200mg/FEFOL tablets Vitamin A 20000IU Capsules Oxytocin Injection Magnesium Sulphate Injection Zidovudine/Lamivudine/Nevirapine 60mg/30mg/40mg Paed. FDC

Isoniazid 300mg tabs Ready to Use Therapeutic Food (RUTF) Satchets

Artemether/ Lumefantrine tabs 20mg/120mg (24's)

Cotrimoxazole tabs 960mg Implants 1 Rod Combined Oral Contraceptive pills Depot-medroxyprogesterone acetate injection vials Zinc Tabs/ORS packs Paracetamol tabs 500mg

TB Patient Pack

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ANNEX IV: GRANTEES SPECIFIC ACTIVITIES IMPLEMENTED DURING THE QUARTER

Sub-Purpose 1: Increased Access and Utilization of quality HIV services

Output Activity Achievement

Output 1.1: Early identification of HIV Mombasa County Elimination of & Syphilis positive To improve early identification of HIV positives among pregnant women, the Mother-To-Child pregnant and project supported facilities through the grantees across the four Sub-Counties to Transmission breastfeeding mothers conduct health talks. (eMTCT) Health talks: 127 • In Mombasa County, Afya Pwani supported grantees , engaged peer mothers, peer mentors and other facility health service providers to

conduct health talks every morning, creating awareness on various health concerns and give information on key priority areas like HIV testing, need for quality Reproductive, Maternal newborn child and

adolescent health services /Family Planning, importance of ANC especially early 1st ANC among other topics. The 21 supported facilities conducted up to 83 health talk sessions/ focus group discussions during

clinic days and managed to reach a total number of 7,526 (4,572F & 2,954M) During the same period, peer mothers were supported to carry out EMTCT support groups. These psychosocial support group sessions include need for early infant diagnosis at four to six weeks after birth, testing at particular intervals during breast feeding up to 18 months and/or when breastfeeding ends, and ART initiation as soon as possible

for HIV-exposed infants to prevent HIV transmission . A total of 1236 PMTCT mothers were reached through such sessions. Engagement of community key actors (CHVS, TBAs) and volunteers

Through grantees, the project worked closely with the community health focal persons in engaging CHVs, TBAs, and other community volunteers to support community facility referrals of 1st ANC, pregnant mothers to attend their first clinical visit within the first 16 weeks of pregnancy. • In Mombasa County, 145 community health volunteers were engaged in the identification and referral of pregnant mothers for routine HIV and Syphilis testing. A total of 1,673 pregnant women were identified,

referred and some physically escorted to the health facilities for the first ANC visit in Changamwe, Mvita and Likoni Sub county facilities. To scale up the CHVs referral system and improve on 1st ANC visits and uptake,

the Grantees and Community Focal persons at Sub County level, the grantees have organized to hold meeting with CHVs at Community Unit and engage them in the referral network.

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Output Activity Achievement

Kwale County: Male involvement in PMTCT

• The project through the grantees supported 8 male champions in a bid to improve male involvement and reduce stigma which is still a challenge

in Kwale County. The project engaged 5 new male champions in Silaloni and Mafisini. The male champions are PLHIV who are community champions in various health related issues . Besides, they also work closely with grantees and community health strategists to enhance inter facility referrals and community to facility referrals. During the reporting quarter they sensitized and interacted with 117 men and referred 18.

Psychosocial support services

• The grantees supported 27 EMTCT support groups monthly during the

reporting quarter in the following facilities128 A total of 597 mothers attended the three sessions in the reporting quarter and benefited from health literacy as well as therapeutic group counselling session. In a bid

to enhance male involvement, 7 male support groups of 123 men were formed which have been running monthly since inception. All of them having emanated from PMTCT at Kinango-21, Mazeras-17, Vigurugani-

12, Lungalunga-16, Kikoneni-19 Vitsangalaweni-18 and Kinondo-20.

Defaulter Tracing

• Appointment diaries and defaulter registers were provided in addition to airtime to ensure missed appointments are noted early and traced back. Mentorship and OJT sessions have been ongoing in all the facilities

to enhance clients tracking and appointments dairies keeping. The clients who have a tendency of missing appointments are called prior to their appointment. The clients who have defaulted are traced via phone

in the reporting period 45 out of the 47 defaulters were successfully traced back. The remaining two are still on follow up.27 EMTCT support groups were formed during the reporting period where they have been holding monthly meetings . Mothers are triggered to discuss various issues and empower one another. 129A total of 597 mothers have attended the three sessions in the quarter and benefited from health literacy as well as therapeutic group counselling session.

128 (Mwangulu-1,Kinondo-2,Diani-3,Msambweni-3,Kwale-2,Mkongani-1,Tiwi-1,Kinango-3,Lungalunga-2,Kikoneni-1,Vitsangalaweni-1,Samburu-2,Mazera- 1,Gombato-1,Ngomeni-1,Shimbahills-1,Vigurugani-1) 129 (Mwangulu-1,Kinondo-2,Diani-3,Msambweni-3,Kwale-2,Mkongani-1,Tiwi-1,Kinango-3,Lungalunga-2,Kikoneni-1,Vitsangalaweni-1,Samburu-2,Mazera- 1,Gombato-1,Ngomeni-1,Shimbahills-1,Vigurugani-1)

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Output Activity Achievement

Table on Grantees Contribution in defaulter Tracing at PMTCT: County Total Traced Transf Repor Transfe Still following Back erred ted r In Miss ed out Death s Appo intm ent (PMT CT) Mombasa 208 181 8 0 12 19 Kwale 162 166 2 0 0 4

Taita 2 Taveta 52 48 4 0 3 Kilifi 187 161 1 0 0 25 609 556 15 0 14 51

Taita Taveta Health talks: • In Taita Taveta County, during adherence training session for clinical officers and adherence counsellors, discussions were held and various

health sessions were conducted to empower the clients seeking for services. Various topics were discussed. Among them were sessions on Focused Antenatal Clinic and maternity open days. The need to mobilize

pregnant mothers for the 1st ANC visit within the first 16 weeks of pregnancy and follow them up for subsequent visits. A total of 83192F were reached through the health maternity open days. Four women were enrolled for first ANC during the sessions. Community dialogues and sensitization During the reporting period, the project through grantees supported community dialogues as highlighted on this report.

• Sensitization and engagement of community key actors (CHVS, TBAs)

and volunteers on community PMTCT. Sub-grantees have helped in mobilization for timely PMTCT service uptake through sensitization and facilitation of CHVs, TBAs, and other community volunteers engaged to support community facility referrals of 1st ANC, pregnant mothers to attend their first clinical visit in Kishushe. 6 mothers initiated clinic within the first 16 weeks of pregnancy. Several sensitization sessions were conducted to enable them to achieve this. The community key actors map the number of pregnant women in their villages and have an estimation of the current pregnant women in their manned households. They then conduct routine visits to the households to ensure that the

USAID AFYA PWANI PROGRESS REPORT Q2 JANUARY-MARCH 2020 141

Output Activity Achievement

family members remain healthy and are attending their regular mother and baby follow up appointments. In addition, they ensure that if any

mother is positive, she is linked to a nearby health facility, taken care of and they make follow ups to ensure that they are taking their ARVS as expected. The mothers are offered counselling on nutrition and breastfeeding practices, family planning and birth spacing, danger signs in pregnancy, malaria in pregnancy, mental health, danger signs in labor, neonatal danger signs, HIV testing and Importance of partner and family testing.

Kilifi County: • In the reporting quarter, as part of efforts to increase utilization of

maternal health services for pregnant women and breastfeeding women in Kilifi County, USAID Afya Pwani program worked hand in hand with Mombasa Catholic CBO(grantee) to improve PMTCT services in the

County. Through the partnership, 85 community health volunteers continued to be supported to actively refer pregnant women for early 1st ANC from their households in the villages and ensure that they

continue mother child follow up from the 1st ANC to when the child reaches at least 2years. Through Afya Pwani supported grantee Mombasa Catholic the CORPS were supported to mobilize and refer 1204 1st ANC women during the reporting period Improving retention of PMTCT- Improving Retention of Mother Baby Pair (MBP) mother baby pairs (MBP) • To enhance retention, the project through the grantees supported facility volunteers/peer mothers to play the role of ‘Linkage navigators.’

This was done to ensure that once a new PMTCT mother is identified, she is assigned a peer mother/ case worker to provide treatment literacy sessions, guide the newly enrolled clients to a support group and ensure

that they understand the need to adhere to treatment. In Mombasa county, the grantees supported 18 peer mothers with airtime and were able to reach to about 51 new PMTCT mothers and supporting more than 2000 mothers through health talks. To improve retention of mother baby pairs the grantees also facilitated EMTCT Psychosocial support group sessions- In Mombasa, grantees supported 14 facilities to hold sessions on adherence, treatment literacy and disclosure. 1236

pregnant mothers were reached. The grantees supported retention activities including defaulter tracing of all Missed appointments/ LTFUs to trace and bring them back to care. 18 peer mothers were facilitated

with airtime to send reminders, call and follow up on clients to return them back to care. This is an ongoing process of line listing LTFUs, daily follow up of missed appointments and defaulters.

Kwale County: Health talks:

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Output Activity Achievement

• In Kwale the grantees-(Kwetu and HFG) supported 48 health talk sessions on ANC/PMTCT in 18 facilities 130( offering stigma reduction, PMTCT, demand creation for HTS, partner testing, early ANC and skilled delivery. The daily health talks sessions were conducted during clinic days and managed to reach a total number of 1809(1240F,569M). HEI graduations:

• Most facilities celebrated their HEI graduations in December of the last reporting quarter. In this quarter, however Kinondo-Kwetu hospital celebrated with 52 infants’ graduates. In a bid to encourage more mothers in coming year 22 new mothers were also invited during the occasion courtesy of Kinondo Kwetu, MOH and Afya Pwani. Engagement of community key actors (CHVS, TBAs) and volunteers

• A total of 287 CORPS (CHVs, TBA, local leaders and male champions) were supported through grantees to improve ANC coverage and early ANC in facilities with low uptake in the dispensaries below 131 The targeted numbers were achieved with an average of 94%. Through the support of the project, the grantees supported retention activities including defaulter tracing of all Missed appointments/ LTFUs to trace and bring them back to care. 18 peer mothers were facilitated with airtime to send reminders, call and follow up on clients to return them back to care. This is an ongoing process of line listing LTFUs, daily follow up of missed appointments and defaulters.

Taita Taveta County: PMTCT- Improving Retention of Mother Baby Pair (MBP)

• To enhance retention, the grantees supported facility volunteers/peer mentors to play the role of ‘Linkage navigators’ This was to ensure that once a new PMTCT mother has been identified, she is assigned to a peer mother/ case worker to provide treatment literacy sessions, guide the newly enrolled clients to adherence. Wundanyi SCH held 2 meetings to address stigma, treatment literacy, partner involvement, challenges encountered and possible solutions. They also shared success stories amongst themselves, through this meeting 28F members were reached. Kilifi County:

• During the reporting period Afya Pwani continued to support health facilities in strengthening retention strategies to ensure clients remain active on care. In Kilifi County, Afya Pwani grantee supported PMTCT

130 Kinango, Taru, Vigurungani, Mwangulu, Kilimangodo, Mwaluphamba, Ng’ombeni, Msambweni, Diani, Tiwi, Lungalunga, Vitsangalaweni, Kikoneni, Kwale, Mazeras, Shimba Hills, Kinondo and Samburu) 131 Mtaa,Kafuduni,Kibandaongo,Silaloni,Vigurungani,Majimoto,Mwananyamala CDF,Majoreni,Mamba,Kilimangodo,Godo,Mwapala,Mkundi,Kiteje,Mwaluvanga,Eshu,Muhaka and Mafisini.

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Output Activity Achievement

support groups in 34 facilities 132 where a total of 1194 PMTCT mothers received PHDP services. The grantee engaged CHWs, 36 peer educators,30 Linkage navigators and 30 adherence counselors to provide PHDP (Provision of Positive Health, Dignity and Prevention) services, manage appointment, conduct defaulter tracing including home visits and act as case managers to ensure PMTCT Mothers receive client centered services and remained in care. The minimum package for PHDP services provided to PMTCT mothers during support groups include; Disclosure of HIV status; adherence counseling, Screening and messages on substance abuse, Partner/family testing and engagement; Condom use; Family planning and Sexually Transmitted infections screening. Output 1.2: HIV Enhance the access and Taita Taveta Care and Support utilization of the standard Provision of Positive Health, Dignity and Prevention (PHDP) Services package of care for adults • During the reporting period, Afya Pwani through the Grantees continued to engage facility Peer educators to ensure all patients on ART receive a

minimum package of Provision of Positive Health, Dignity and Prevention . These sessions have demonstrated the effectiveness in retention as clients are provided with information on treatment literacy, adherence training, share feelings and experiences hence helping them in disclosure thereby lessening feelings of isolation and being neglected. During those forums, the PLHIV were given the opportunity to discuss HIV-related issues openly within the support groups, which may otherwise not be available in other contexts of daily life. Through the grantee’s efforts, a session was held reaching 7 EMTCT mothers who attended the RX literacy session as well as therapeutic counselling session. Grantee Male reached Female reached total

Lower Mwachabo 83 350 433

Kishushe 13 41 54

Njukini 5 27 32

132 Kilifi, Ngerenya, Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni, Mariakani,Bamba,Baolala,Takaungu,Vipingo,Dida,Ganda,Mariekebuni,Gede,Gotani,Oasis,Ngomeni,Mtepeni,Mtondia,Kakuyuni,Vitengeni,Marafa,Marereni,Kiwa ndani,Matsangoni,Gongoni,Ganze,Malindi,Rabai,andMtwapa

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Output Activity Achievement

care giver training sessions on PHDP Njukini Addressing specific needs Operation Triple Zero (OTZ CLUBS) of adolescents and young people. Addressing specific needs of adolescents and young people Living with HIV- OTZ Clubs • OTZ clubs have been instrumental in reaching and addressing the needs of AYLHIV. The clubs provide a forum for youths to get information, share experiences and challenge one another to attain a zero viral load count, LDL. • In Mombasa County, 434 (276 M, 158F) young people were reached through the OTZ clubs. The OTZ forum are mostly conducted on Saturday to ensure young people in school get an opportunity to access treatment services. The OTZ club days serve as adolescent friendly clinic day where young people receive treatment services, Family planning and Reproductive health services, adherence, treatment literacy, Condom use, Disclosure, positive living messages, and partner testing messages were provided. • In Kwale County, in collaboration with grantees, 13 OTZ support groups of 998(586F, 412m) were started in 13facilities namely;133 Kids have shown great improvement in the last three months ranging from BMI and confidence attributed to improved self-esteem. In the last third session they were playful and excited to meet again. OTZ are aimed at encouraging the kids to become champions and one another’s keeper as they walk together in a journey of zero missed drugs, zero missed appointments and zero viral load.

133 Kinondo, Msambweni,

Diani,Lungalunga,Kikoneni,Tiwi,Kwale,Mwaluphamba,Mkongani,Kinango,Samburu,Mazeras and Shimba-hills.

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Output Activity Achievement

OTZ sessions in Tiwi and Kinondo, Kwale County. • In Kilifi County, grantees supported OTZ clubs in 24 facilities134 reaching a total of 1013(444m, 569F) ALHIV.b23 OTZ Champions were identified to spearhead the implementation of OTZ Clubs. The champions motivate and encourage other adolescents regarding adherence, stigma related issues and sexual reproductive Health sessions. The clubs are mostly conducted on Saturday to ensure young people in school get an opportunity to access treatment services. The OTZ club days serve as adolescent friendly clinic day where young people receive treatment services, Family planning and Reproductive health services, adherence, treatment literacy, Condom use, Disclosure and positive living messages. • In Taita Taveta County, OTZ clubs have been instrumental in reaching and addressing the needs of AYLHIV. The club provides a forum for youths to get information, share experiences and challenge one another to attain a zero viral load count, LDL. Within Njukini sub-grantee covered facilities, 1 OTZ club support group was held in Njukini health facility during school mid-term. This quarter 1 session was held benefiting 14(3m&11f). The AYLHIV were very happy to have a day on their own and play with their peers. They promised to keep in touch with peer mentors for healthy positive living.

Output 1.3: HIV Enhancing the uptake of Home visits for PLWHIS by peer mentors Treatment Services ART among Adults Living • with HIV During the reporting period , Afya Pwani through the grantees recruited 5 Adherence Counselors who worked closely with CHVs, peer educators to help in tracking defaulters through phones calls and text messages.

This helped to improve uptake and adherence of quality HIV services. Facility Male Female Total

Njukini 9 44 54

Lower Mwachabo 33 45 78

Kishushe 21 30 51

134 Malindi District Hospital, Kilifi District Hospital, Mtwapa Health Center, Mariakani District Hospital, Oasis Medical Clinic, Muyeye, Gede Health Center, Vipingo Health Center, Gongoni Health Center, Rabai Health Center, Marereni Dispensary, Bamba Sub-District Hospital, Matsangoni Health Center, Chasimba Health Center, Ganze Health Center, Gotani Dispensary, Mtondia Dispensary, Mambrui Dispensary, Kakuyuni Dispensary ,Takaungu, Ngerenya, Marafa, Jibana and Vitengeni

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Output Activity Achievement

• The visits reports helped in formulation and development of case plans to address clients felt needs as hindrance to viral suppression.

Community Differentiated Care Services (DSD)

• Community ART Groups (CAGs) have enabled improve retention of clients on ART. This is made easy by reduction of frequency of number of visits to the facilities, as well as ensuring that clinic visits are maintained New CAG members registered in the quarter 31

CAG group dissolved 112

Cumulative CAGS at the county 4

Total clients on CDSD 96

Died 452

Transfer out 100

Returned to care 0

Unsuppressed 0

Received EAC 0

CAG meeting at Chala and Ndilidau

Treatment for • In Kwale County 13 OTZ support groups YPLIHIV were held in seven adolescents and Key facilities135s during school holiday and mid-term. During the reporting populations period, 39 sessions were held benefiting 13 OTZ support groups of 998(586F, 412m) in Kwale county. These are new OTZ concept support groups. The YPLHIV felt accomplished to have a day on their own as they interacted with their fellow peers. They also paired and committed to be one each other’s keeper • In Kilifi County, the grantee supported OTZ clubs in 24 facilities136 reaching a total of 1,013(444m, 569F) ALHIV.

135 Kinondo, Lungalunga, Msambweni, Kinango, Samburu, Kikoneni ,Lungalunga, Kwale, Mkongani, Shimba-hills, Tiwi, Diani and Mwaluphamba 136 Malindi District Hospital, Kilifi District Hospital, Mtwapa Health Center, Mariakani District Hospital, Oasis Medical Clinic, Muyeye, Gede Health Center, Vipingo Health Center, Gongoni Health Center, Rabai Health Center, Marereni Dispensary, Bamba Sub-District Hospital, Matsangoni Health Center, Chasimba Health Center, Ganze Health Center, Gotani Dispensary, Mtondia Dispensary, Mambrui Dispensary, Kakuyuni Dispensary ,Takaungu, Ngerenya, Marafa, Jibana and Vitengeni

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Output Activity Achievement

Output 1.4: HIV HIV Prevention activities Targeted community dialogues for advocacy, information, education on Gender, Prevention and HIV to vulnerable populations Rights and service availability Testing and Counseling • In Mombasa County, NEPHAK, facilitated gender-based violence screening among both newly identified clients, unsuppressed clients and adolescents, and young adults, during support group sessions at the health facilities. 31 females, among 654 clients screened from three different cohorts reported that they have experienced different forms of gender-based violence including, physical and sexual abuse, discrimination based on gender and verbal abuse due to their HIV status. The program supported peer mentors and health care providers to follow up on the clients to provide counselling support. • In Kilifi County, Adherence Counselors supported by Afya Pwani grantee Mombasa Catholic conducted GBV screening to PLHIV in the supported ART facilities. The facility-based staff emphasize on emotional, sexual and physical abuse screening. A total of 408 GBV Cases were reported between January and March 2020. Among the reported cases, it was noted that physical cases were on the rise (193), followed by Emotional abuse (118) and finally sexual abuse (113). In addressing the above cases, home visits were conducted for clients who consented, continued counseling sessions were offered. Some clients were also referred to Kilifi County Hospital for further professional counseling from trauma, Child and Marriage counselors

Improving the uptake and • In Mombasa County, Grantees facilitated facility health talk to create quality of HIV Testing demand for HTS and optimizing PNS, index client testing during clinic Services days and managed to reach a total number of 7,526 (4,572F & 2,954M) through these sessions in 21 facilities. • Afya Pwani grantee facilitated health talks in 34 health facilities137 creating demand for HTS services with emphasis on PNS during clinic days. Output 1.5: Optimize the Afya Pwani None Tuberculosis/HIV six "I"s approach for Co-Infection TB/HIV control Services

Output 1.6: Provision of standard Mombasa County Accelerating HIV package of care for • Grantees facilitated facilities to conduct caregivers’ sessions and Care and Treatment children including trainings to parents or guardians of children and adolescents living with for children provision of ART HIV. Various topics were covered; assisted disclosure of HIV status to

137 Kilifi, Ngerenya ,Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni,Mariakani,Bamba,Baolala,Takaungu,Vipingo,Dida,Ganda,Mariekebuni,Gede,Gotani,Oasis,Ngomeni,Mtepeni,Mtondia,Kakuyuni,Vitengeni,Marafa,Marer eni,Kiwandani,Matsangoni,Gongoni,Ganze,Malindi,Rabai, Mtwapa.

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Output Activity Achievement

adolescents, adherence to treatment, nutrition, stigma, and discrimination and how to effectively cope with psychosocial dynamics that caregivers face. • In Mombasa County, 27 caregivers group sessions were conducted reaching 111 males and 344 females. • Afya Pwani supported grantees were responsible for the implementation of these activities. The facility peer mentors mobilized and facilitated the caregiver’s sessions with support from the nurses and clinicians at the CCC Clinic. The psychosocial group sessions addressed major concerns of viral suppression among pediatrics/adolescents and disclosure process/ challenges. • In Q2, Afya Pwani Grantees continued to work with the OVC implementing partner (MWENDO). Although with numerous challenges, they jointly worked on the enrollment of CLHIVs, 15 years and below into the OVC program. Up to 900 CLHIV have been enrollment out of whom about 700 children have received services from MWENDO. The community team will continue to engage to see that all CLHIVs have been enrolled and continue receiving much needed service hence improving their health outcomes.

Kwale County

• Special clinic days: the following facilities have special clinic day for attending to children up to 24 years on HAART courtesy of grantees support the following facilities; 998(586F, 412m) )clients. Grantees support service providers to do flexy hours and weekends to attend to children.

Caregivers attending a training at Vigurungani on the left; CLHIV enjoying playing with TOYS at a support group

• In a bid to fully equip the caregivers 67 monthly sessions of 26 caregivers support groups were held this quarter benefiting 884(583F,301M) in Kwale, Mkongani, Mwaluphamba, Tiwi, Ng’ombeni, Diani,Msambweni- 2,Kinondo,Lungalunga,Kikoneni,Vitsangalaweni,Vanga,Mwangulu,Kina ngo,Samburu,Vigurugani,Mazeras,Taru,Mackinon,Ndavaya,Mnyenzeni, Kizibe,Shimoni,Gombato,Shimba-hills.138

138 Kinondo, Kinango, Samburu, Tiwi, Vigurungani, Mkongani, Mwaluphamba, Kwale, Vitsangalaweni, Kikoneni, Lungalunga, Diani , Ndavaya, Mnyenzeni, Mazeras, Msambweni, Shimba-hills

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Output Activity Achievement

• Games and art therapy: Children living with HIV have been attending group therapy sessions accompanied by their guardians/caregivers. benefiting 884(583F,301M) clients. • Children in School: The project through the grantee facilitated the Kenya Network of Positive Teachers (KENEPOTE) to conduct health literacy and stigma reduction sessions in schools. This was agreed upon after a successful joint meeting with Kwale education director, SC Kwale and Afya-Pwani service delivery manager. Permission was granted and a sensitization meeting for 25 KENEPOTE teachers ensued which deliberated on the best way to reach schools and key messages for teachers, parents and pupils. During the meeting the priority schools with most CLHIVS were shared. A total of 8 schools were visited reaching a total of 120 teachers, 1686 pupils and 259 Parents who had come for PTA meetings.

Taita Taveta County

• Grantees facilitated facilities to conduct care givers sessions and trainings to parents or guardians of children and adolescents living with HIV. Various topics were covered; assisted disclosure of HIV status to adolescents, adherence to Caregiver’s session at Njukini HC 1 treatment, nutrition, stigma, and discrimination and how to effectively cope with psychosocial dynamics that caregivers face. Caregiver’s session at Njukini HC 2 • The grantees were responsible for the implementation of this activities. The facility peer mentors mobilized and facilitated the caregiver’s session with support from the nurses and clinicians at the HIV Clinic. The psychosocial group sessions addressed major concerns of viral suppression among pediatrics/adolescents and disclosure process/ challenges. Kishushe 43(8m35f) lower Mwachabo 39(3m3f) were reached

Kilifi County:

• Afya Pwani through Mombasa Catholic, supported Support groups in 34 health facilities139reaching a total of 603(112M,491F)caregivers.

139 Kilifi, Ngerenya ,Chasimba, Jibana, Vipingo, Muyeye, Baolala, Mambrui, Gahaleni,Mariakani,Bamba,Baolala,Takaungu,Vipingo,Dida,Ganda,Mariekebuni,Gede,Gotani,Oasis,Ngomeni,Mtepeni,Mtondia,Kakuyuni,Vitengeni,Marafa,Marer eni,Kiwandani,Matsangoni,Gongoni,Ganze,Malindi,Rabai, Mtwapa.

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Output Activity Achievement

Minimum PHDP packages shared during support groups included: assisted disclosure of HIV status to adolescents, adherence to treatment, nutrition, stigma, and discrimination and how to effectively cope with psychosocial dynamics that caregivers face. Support group days serve as special clinic days for children which are mostly conducted on Saturdays to enable school going children access treatment. A total of 760(315M,355) children received ART services on Saturdays. One Care givers training was also supported at Matsangoni Health center where 18 female caregivers participated. • To effectively address Socioeconomic obstacles to treatment among children i.e. poor timing of taking drugs, Lack of transport, lack of stable caregivers or elderly, nutritional issue and poor drug storage, Afya Pwani grantee Mombasa catholic partnered with OVC LIP(MWENDO) where 1531( 724M, 767) CLHIV were enrolled into the OVC program. Some of the services the CLHIV are currently benefiting from MWENDO project are; ➢ Provision of school levies and school fees ➢ Provision of transport to access the clinics. ➢ Provision of pill boxes to facilitate good storage of drugs. ➢ Watches to enable them observe drugs timing ➢ Dignity pack Key Population • In Q2 of FY20, the KP program under USAID Afya Pwani prioritized among other interventions the scale up of service delivery as well as improvement of standards/quality of services offered to clients. This involved routine on job mentorship targeting health care workers in Drop in Service Centers (DICS). The mentorship was designed to address the identified knowledge and skills gaps. In addition, the project supported a monitoring and evaluation (M&E) training in collaboration with Meeting and maintaining epidemic control (EpiC) program. During the same period, the project supported two technical and stakeholder forums in Kilifi and Mombasa and participants in the national Technical Working Group (TWG) meeting that took place in Mombasa. The program also engaged Pwani Transgender Initiative - one of the grantees under the Partner Implemented Program (PIP) in Mombasa140. • In Mombasa and Kilifi counties, a total of 11,656 clients were served in 7 Drop in Service Centers DICS and KP responsive health facilities. Among those served were 9884 FSW; S, 1718 MSM and 154 transgender persons. This population was reached through both DICS and outreaches. Sub-Purpose 2: Increased Access and Utilization of focused MNCH and FP, WASH and Nutrition

140 a set of activities will be implemented with costs paid directly

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Output Activity Achievement

Output 2.1: Addressing barriers to • Afya Pwani engaged 4 sub-grantees141 to enhance demand creation Maternal Newborn utilization of MNH interventions aimed at increasing utilization of quality Maternal, Health Services services through Newborn and Child health services, including family planning. community mobilization • During the reporting quarter, the grantees conducted 7 advocacy and male engagement meetings, targeting community gatekeepers. These were aimed at achieving buy-in for appropriate MNCH practices and to nurture the community leaders to become agents of change. 130 community leaders were sensitized and utilized to conduct community education sessions promoting good MNCH seeking behaviors. • The grantees engaged 120 male champions to champion acceptance of maternal, neonatal and child health - MNCH services among their fellow men. The male champions conducted 108 male only dialogue forums reaching 8643 men with information and referred 418 clients for MNCH services. Increase Demand for • The grantees proactively engaged community health volunteers and MNH services TBAs to map out and identify and refer expectant women in their villages who had not started ANC. Through this approach, 6249 ANC and 2259 SBA clients referred. Besides,4 maternity open days yielding 102 1st ANC clients were conducted. • 102 community dialogue meetings targeting expectant women were conducted to educate them on pregnancy care. 2576 women were reached with information, and during these sessions 629 new ANC clients referred for services. • The grantees also supported 86 mama groups and Binti kwa Binti group to enhance client retention across the MNCH cascade. Though this intervention 2275 women benefited from group ANC and PNC services during this reporting period. Pwani University initiated entrepreneurship skills building in the sessions. 3 groups were taught how to make home-made soap as a source of income for them. Output 2.2: Child Increase demand and • The grantees supported 70 targeted integrated outreaches in the Health Services access for child health supported facilities in Kilifi North. A total of 2213 children were reached services with CH services and 437 immunization defaulters were identified. Other services provided included FP, ANC and HTS for postnatal clients. A total of 495 clients were reached with FP services and 82 clients were provided with the available ANC services and booked for ANC profiling. • The project conducted a total of 81 community dialogue sessions. The meeting targeted the general population with special emphasis on caregivers of children under 5 years. A total of 3992 people were reached with information. Through the community dialogues, a total of 1437 children were referred for pneumonia and 36 children were referred for diarrhea treatment.

141 Moving the goalpost(MTG), Pwani University, Magarini Cultural Center and Kenya Muslim Youth Development Organization (KMYDO)

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Output Activity Achievement

• Pwani University engaged CHVs in 2 selected facilities (KCH and Ngerenya) to help in clients booking using the appointment diaries and conduct defaulter tracing for clients who missed their appointments. Ngerenya dispensary managed to line list 51 defaulters, traced back 43, 6 clients self-transferred to other facilities and 2 are still on follow up. KCH line listed 596 clients; 257 clients were reported to have self- transferred to various facilities, 158 were traced back, 91 were lost to follow up, 1 death was recorded and 89 are still on follow up. 201 clients were traced back for services in the 2 facilities • Magarini cultural center also supported integrated community case management in Magarini subcounty. 68 case managers were engaged. The conducted 4078 household visits, reached 1466 caregivers with education on prevention of childhood illnesses, referred 1745 children for immunization services and managed 1130 cases of diarrhea and pneumonia at household level. Output 2.3 Family Increase demand and • To enhance access to FP services the grantees worked with 749 CBD Planning uptake of FP services agents this quarter. The CBD agents conducted 1190 FP education sessions at community level, reaching up to 36709 people with FP information. The CBD agents also conducted one-on-one counselling to 26632 clients, distributed 84242 male condoms, 2155 female condoms, 303 cycles of contraceptive pills and successfully referred 3153 clients for other FP services • Further the grantees supported 6 FP outreaches. CHVs were engaged as mobilizers to mobilize clients to the facility for services. A total of 214 clients were reached with FP services • Additionally, the grantees conducted 35 Utawala na Afya sessions. These forums served to enlighten communities on reproductive health, while educating them on their rights and responsibilities when seeking health services.

Strengthen youth friendly • Pwani University in collaboration with Pathfinder International services to increase conducted a one-day training on FC2 and capacity building on uptake of FP contraception. A group of 114 peer educators and 39 student mothers from Pwani University attended the training. Pwani University supported a 4-days health drive aimed at increasing utilization of integrated RH services by the student’s population. Services that were offered during the health drive were; Family planning, cervical cancer screening, STI screening, GBV screening, hypertension screening, and HTS. The Table below shows uptake of services during the health drive. The university also conducted a one- day youth/adolescent days activity at Pwani University. The activity was integrated with various services such as STI screening nd treatment, Family Planning and Cervical cancer screening. A total of 50 CBDs were engaged to provide of FP information/Counseling to peers and refer clients for FP, STI screening and cervical cancer screening services, share

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Output Activity Achievement

Binti wa Kisasa number to peers. 1320 student were reached with information and 36 received FP services. • KMYDO supported a sensitization forum for caregivers on AYSRH. This was aimed at bridging the inter-generational gaps that impede acceptance of AYSRH services by their caregivers. 75 caregivers were reached with information.

HEALTH DRIVE SUMMARY REPORT No. of people referred for services Condoms distributed FP Cervical STI Blood HTS Male Female services cancer screening donation screening 102 202 202 308 280 5039 267

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