USAID KENYA AFYA HALISI QUARTERLY PROGRESS REPORT
Young Mothers Dialogue session at Katito Health Centre, Nyakach Sub-County
Photo 1 CME on use of Partograph and EmONC Signal functions at St. Josephs Mission Rapogi in Uriri Sub-county, Migori County. APRIL 2019 OCTOBER 2017 This publication was produced byfor Afyareview Halisi by thefor reviewUnited byStates the AgencyUnited Statesfor International Agency for Development. International ItDevelopment. was prepared by Dr. Gathari Ndirangu and the team of MCSP Kenya Technical Advisors
USAID KENYA AFYA HALISI PROJECT FY 2019 Q2 PROGRESS REPORT
January 1 – March 31, 2019
Award No: AID-615-A-17-00004
Prepared for Lillian Mutea United States Agency for International Development/Kenya C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya
Prepared by Jhpiego Jhpiego offices, 2nd Floor, Arlington Block, 14 Riverside, off Riverside Drive, P.O Box 66119-00800 Nairobi Office tel: +254 732 134 000
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.
I. AFYA HALISI EXECUTIVE SUMMARY ...... 1
II. KEY ACHIEVEMENTS (Qualitative Impact) ...... 7
III. ACTIVITY PROGRESS (Quantitative Impact) ...... 60
IV. CONSTRAINTS AND OPPORTUNITIES ...... 60
V. PERFORMANCE MONITORING ...... 61
VI. PROGRESS ON GENDER STRATEGY ...... 63
VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 63
VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 63
IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 64
X. PROGRESS ON USAID FORWARD ...... 65
XI. SUSTAINABILITY AND EXIT STRATEGY ...... 65
XII. GLOBAL DEVELOPMENT ALLIANCE ...... 66
XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 66
XIV. FINANCIAL INFORMATION ...... 70
XV. ACTIVITY ADMINISTRATION ...... 73
XVII. GPS INFORMATION ...... 73
XVIII. SUCCESS STORIES ...... 74
In Kitui County, there is increased productivity in the facilities where the HRH staff are deployed. Some of the sites have been able to initiate 24 hour services and seen an increase in the number of skilled birth attendance, reduced waiting time and improved quality of services...... 76
ANNEXES & ATTACHMENTS ...... 82
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 i
ACRONYMS AND ABBREVIATIONS
AEFI Adverse Events Following CMSG Community Mother Support Immunization Group AFP Advanced Family Planning CMTC County Medicines and AMTSL Active Management of Third Therapeutics Committee Stage of Labor COCs Combined Oral Contraceptive ANC Antenatal Care CPR Contraceptive Prevalence Rate AWP Annual Work Plan CQI Continuous Quality AYP Adolescent and Young People Improvement AYSRH Adolescent and Youth Sexual CSO Civil Society Organizations and Reproductive Health CYP Couple years of protection BCS+ Basic Counseling Skills plus DFH Division of Family Health BEmONC Basic Emergency Obstetric and DHIS District Health Information Newborn Care Software BFCI Baby friendly community initiative DMPA Depot Medroxyprogesterone BFHI Baby-friendly Hospital Initiative Acetate BP Blood Pressure DO2 Development Objective 2 BTL bilateral tubal ligation DQAs Data Quality Audits/Assessments C4C Counseling for Continuation DTC Decentralized Training Center CAC Community Action Cycle EBF Exclusive Breastfeeding CBD Community-based distribution ECD Early childhood development CBHIS Community Based Health ECSB Essential Care for the Small Information System Babies CBMNC Community-based maternal and EHA Essential hygiene action newborn care EMMP Environmental Mitigation and CBO Community based Organization Monitoring Plan CBRM Community Based Referral EmONC Emergency Obstetric and Mechanisms Newborn Care CCA Clean Clinic Approach EPI Expanded Program on CCC Comprehensive Care Center Immunization CEC County Executive Committee ETAT Emergency Triage Assessment CEMD Confidential Enquiry into Maternal and Treatment Deaths ETL Extract Transform Load CEmONC Comprehensive Emergency FACES Family AIDS Care and Education Obstetric and Newborn Care Services CH Child Health FANC Focused Antenatal Care CHA Community Health Assistant FGM Female Genital Mutilation CHAI Clinton Health Access Initiative FHOK Family Health Options of Kenya CHC Community Health Committee FIC Fully Immunized Child CHEW Community Health Extension FP Family Planning Worker G-ANC Group Antenatal Care CHMT County Health Management GBV Gender Based Violence Team GIC Generic Instructor Course CHSSIP County Health Sector Strategic GMP Growth Monitoring Promotion and Investment Plan GoK Government of Kenya CHU Community Health Unit GREAT Gender Roles, Equality and CHV Community Health Volunteer Transformation CHX Chlorhexidine HCD Human Centered Design CICA County Institutional Capacity HCP Health Care Provider Assessment HCW Health Care Worker CLTS Community Led Total Sanitation HFs Health facilities CME Continuous Medical Education HH Household CMMB Catholic Medical Mission Board HINI High Impact Nutrition Intervention
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 1
HMIS health management information LAPM Long Acting Permanent Method systems LARC Long-Acting and Reversible HPAC Health Promotion Advisory Contraceptives Committee LCHV Lead CHV HRH Human Resource for Health LDHF Low dose high frequency HRIO Health Records Information LNG-IUS Levonorgestrel intrauterine Officer system HSS Health System Strengthening LOA Letters of Agreement HWTSS Household water treatment and LQAS Lot Quality Assurance Sampling safe storage M2MSG Mother to Mother Support Group ICC inter-agency coordination MCA Member of County Assembly committees MCH Maternal Child Health iCCM Integrated Community Case mCPR Modern contraceptive prevalence Management rate ID Identification details MCSP Maternal and Child Survival IEC Information Education Program Communication MCSP Maternal and Child Survival IFAS Iron and folic acid Program supplementation MEDS Mission for Essential Drugs and IGA Income Generating Activities Supplies IGWG Interagency Gender Working MEL Monitoring Evaluation and Group Learning iHRIS Integrated Human Resource MFL Master Facility List Information System MIYCN Maternal, Infant, and Young Child IMAM Integrated Management of Acute Nutrition Malnutrition MLM Middle Level Managers IMCI Integrated Management of MNCH Maternal, Newborn and Child Childhood Illness Health IPC Infection prevention and control MNH Maternal and Newborn Health IUCD Intrauterine contraceptive devices MNP Multiple Micronutrient Powder IYCF Infant and young child feeding MOE Ministry of Education JOOTRH Jaramogi Oginga Odinga MOH Ministry of Health Teaching and Referral Hospital MOU Memorandum of Understanding KANCO Kenya AIDS NGOs Consortium MPDSR Maternal and Perinatal Death KAPPd Kenya Action Plan for the Surveillance and Response Prevention and Control of MR Measles Rubella Pneumonia and Diarrhea MTC Medicines and Therapeutic KCGTRH Kakamega County Government Committee Teaching and Referral Hospital MUAC Mid Upper Arm Circumference K-CHIC Kitui County Health Insurance MVA Manual Vacuum Aspiration Cover NACS Nutrition Assessment Counseling KDHS Kenya Demographic Health and Support Survey NCAHU Neonatal, Child, and Adolescent KEMSA Kenya Medical Supplies Authority Health Unit KEPI Kenya Expanded Program for NHIF National Hospital Insurance Fund Immunization NHPplus Nutrition Health Program plus KESH Kenya Environmental Sanitation ODF Open Defecation Free and Hygiene OJT On job training KIWASH Kenya Integrated Water, OPV Oral Polio Vaccine Sanitation, and Hygiene ORS Oral rehydration salts KMC Kangaroo Mother Care ORT Oral rehydration therapy KMET Kisumu Medical and Education OVC Orphans and Vulnerable Children Trust PAFP Post Abortion Family Planning KPA Kenya Pediatric Association PBCC Provider based behavior change KQMH Kenya Quality Model for Health PET Pre-Eclampsia Treatment KSG Kenya School of Government PHO Public Health Officer
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 2
PIFP Provider Initiated Family Planning SDA Service Delivery Advisor PLGHA Protecting Life in Global Health SDO Service Delivery Officer Assistance SDPs Service Delivery Points PMP Performance monitoring plan SGBV Sexual and Gender Based PNC Post Natal Care Violence POP Progestin only pills SGS Small Group Sessions PPFP Post-Partum Family Planning SRH Sexual Reproductive Health PPH Postpartum hemorrhage STI Sexually Transmitted Infection PPIUCD Postpartum intrauterine TA Technical Assistance contraceptive devices TBA Traditional Birth Attendant PPR Performance Planning and ToR Terms of reference Review TOTs Training of Trainers PSK Population Services Kenya TWG Thematic Working Group PTBI Preterm Birth Initiative UBT Uterine balloon tamponade PWD Persons living with a Disability UHC Universal Health Coverage PY Planning Year UNICEF United Nations International QIT Quality Improvement Team Children's Emergency Fund RBF Results Based Financing USAID United States Agency for REC Reach Every Child International Development RED Reach Every District USG United State Government RH Reproductive Health VAS Vitamin A supplementation RMC Respectful maternity care VCAT Value Clarification and Attitude RMHSU Reproductive Maternal Health Transformation Service Unit VSC Voluntary Surgical Contraception RMNCAH Reproductive Maternal, VSLA Village Savings and Loaning Newborn, Child and Adolescent Activities Health WASH Water Sanitation and Hygiene RRI Rapid Response Initiatives WCD world contraceptive day SBA Skilled Birth Attendant WHO World Health Organization SBCC Social and Behavior Change WIT Work Improvement Team Communication WRA Women of Reproductive Age SCHMT Sub-County Health Management Team
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 3
I. AFYA HALISI EXECUTIVE SUMMARY
Qualitative Impact The US Agency for International Development’s (USAID) Kenya and East Africa awarded the Afya County and National Support Program (Afya Halisi) cooperative agreement in September 2017 to a consortium led by Jhpiego Kenya with partners Save the Children and PS Kenya. The project aims to deliver quality and integrated services in the areas of family planning (FP)/reproductive, maternal, newborn, child and adolescent health (RMNCAH), nutrition, and water, sanitation and hygiene (WASH) to those most in need in the four focus counties of Kitui, Migori, Kakamega and Kisumu (23 sub-counties including Kakamega County Government Teaching and Referral Hospital). The project is designed to strengthen the capacity of national, county and sub-county leaders and systems so they can enhance the efficiency of health systems to increase sustainability, prioritize populations most in need to increase equity, and scale-up high-impact interventions and practices to improve quality. This report highlights Afya Halisi achievements for PY2 Q2 (January – March 2019) building onto the PY1 and P2Q1 achievements. During the quarter under review, the project continued to center itself around the individual (mother and child), using an ecological framework to address the individual, interpersonal, organizational, community, and health system/public policy levels that determine positive health outcomes. Afya Halisi supported 662 health facilities in the twenty four sub counties including Kakamega County Government Teaching and Referral Hospital in Lurambi sub county of Kakamega..
The project’s support to the counties continues to focus on accelerating the reduction of preventable maternal, newborn and child deaths. This will be achieved through strengthening the capacity of county and sub-county leadership and systems in delivering quality, integrated services in the areas of family planning (FP)/reproductive, maternal, newborn, child and adolescent health (FP/RMNCAH), nutrition, and water, sanitation and hygiene (WASH). The project supported demand generation activities aimed at increasing care seeking and health promoting behavior, these activities were customized to sub-county, community and facility level needs for maximum impact.
The project undertook a gender analysis during the reporting period, the draft report was developed and submitted to USAID. The dissemination of the report to USAID and validation of the findings to key stakeholders will be carried out in the next quarter. The project will utilize the findings to implement context-specific activities that address barriers to access to FP/RMNCAH, nutrition and WASH services. The project also implemented the second phase of the Kitui baseline assessment, which included the two Kitui Rural and Kitui West sub-counties that are not supported by the project. The findings were incorporated in the main baseline assessment report, followed by validation meeting at the county level. The baseline assessment report was finalized and a data use workshop will be held in the next reporting quarter to inform key implementation plans based on the findings.
In this reporting period the project received approval to commence national level support. Afya Halisi will be supporting the Division of Family Health, specifically the Reproductive Maternal Health Services Unit (RMHSU) and the Neonatal Child Adolescent Health Unit (NCAHU) in provision of technical and financial support in delivery of their mandate. To kick start the process, Afya Halisi convened a meeting to introduce the project to the leadership at the division. Thereafter, subsequent
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meetings with the respective program managers and officers were done with the aim of identifying the respective priorities for the units.
Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services During the quarter under review, the project supported 662 health facilities. Out of these, the project had 613 health facilities that were providing FP counseling and/or services, an achievement of 93% against the annual target of health facilities providing FP counseling and/or services. The difference of 7% reflects health facilities that are faith based (mainly Catholic based). During the reporting quarter, the project achieved a CYP of 136,255, bringing the total to 301,594 as at SAPR 2019. This reflects an achievement of 51% against the annual target of 593,445. A total of 1,377 CHVs were actively involved in the provision of FP information, referrals and services to community members compared to 772 CHVs in Y2Q1. This reflects an achievement of 52% against the annual target of 2,673. They equally participated in referring community members for various FP services. A total of 6,359 adolescents accessed FP services, bringing the total to 16,105 as at SAPR 2019. This reflects an achievement of 67% against the annual target of 24,189. During the reporting period, 69% of the health facilities experienced a stock out compared to 68% in Y2Q1 period. Male condoms largely contributed to the stock outs in health facilities across the four focus counties. In the next reporting quarter, the project will continue to support monthly review of FP commodity data and provide data bundles to sub-county Pharmacists for timely and complete uploading FP commodity in DHIS2. As at end of the reporting period, 111 health facilities were assessed and found offering emergency obstetric and newborn care services, an achievement of 41% against the annual target of 274. Out of these, 19 health facilities were offering comprehensive emergency obstetric and newborn care. In the quarter under review, 16,767 pregnant women completed 4 ANC visits bringing the total to 34,637 as at SAPR 2019 period. This reflects an achievement of 38% against the annual target of 90,486. A total of 23,912 births were assisted by a skilled attendant in project supported facilities. This brings the total to 48,525 as at SAPR 2019, an achievement of 58% against the annual target of 83,525. A total of 21,969 newborns received post-natal care within two days, bringing the cumulative total to 41,899 as at SAPR 2019 period. This reflects an achievement of 60% against the annual target of 69,605. During the reporting quarter, 7,371 adolescents (10-19 years) presented with pregnancy and received ANC services in project supported health facilities. This brings the total to 15,022 adolescents reached as at SAPR 2019 period, an achievement of 40% against the annual target of 37,723. This is 25% of the total first ANC visits during the reporting period. The project supported the focus counties to reach 25,446 children with full immunization. This brings the total to 47,763 as at SAPR 2019 period, an achievement of 53% against the annual target. The FIC coverage in the four focus counties was 70% as at SAPR 2019. During the quarter, a total of 6,760 children received treatment for pneumonia in project supported sites, bringing the total to 11,246 as at SAPR 2019. This reflects an achievement of 52% against the annual target of 21,710. Overall, 96% of the pneumonia cases were correctly treated during the reporting quarter. A total of 23,793 children received treatment for diarrhea in project supported sites, bringing the total to 41,121 as at SAPR 2019. This reflects an achievement of 55% against the annual target of 75,284. Overall, 89% of the diarrhea cases were correctly treated during the reporting quarter. The project's focus on nutrition is in the counties of Migori and Kakamega. As at SAPR 2019 period, the project reached 222,905 under five children with Vitamin A supplementation, an achievement of 80% of the annual target in both Kakamega and Migori counties. This was achieved mostly through
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 2
supplementation in Early Year Education (EYE) centers. During the reporting period, a total of 10,600 children received treatment for diarrhea in the two counties. This brings the total to 17,160 children reached as at SAPR 2019, an achievement of 62% against the annual target of 27,815. During the reporting quarter, the project reached 14,546 pregnant women with nutrition specific interventions. This brings the total to 27,594 women reached as at SAPR 2019 period, an achievement of 51% against the annual target of 54,217. The project reached mothers through counselling on maternal nutrition or IFAS both in the facility and community. The project had 97 facilities with capacity to implement integrated management of acute malnutrition (IMAM), an achievement of 86% against the project’s PPR target of 113. The project’s WASH focus remains in Kakamega, Migori and Kitui counties. During the quarter under review, the project enabled 44,597 people to gain access to a basic sanitation service, bringing the cumulative total to 55,947 as at SAPR 2019. This reflects an achievement of 116% against the project's PPR target of 48,300. These people were reached as a result of 124 villages being verified ODF as at SAPR 2019 period. Within the quarter, the project invested in training 330 individuals on improved sanitation methods bringing the total to 508 people trained. This reflect an achievement of 54% against the project’s PPR target of 942. During the quarter under review, the project supported 15,980 people to access safe drinking water bringing the total to 23,474 people as at SAPR 2019. This reflects an achievement of 43% against the annual target of 54,633. During the quarter under review, the project supported 37 health facilities to improve basic sanitation facilities bringing the total to 40 facilities as at SAPR 2019. This reflects an achievement of 48% against the project's PPR target of 83. Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH The project continued to support context-specific strategies for healthy behaviors and demand creation. The project carried out one fully-fledged 3D/HCD exercise in Migori exploring the issue of teenage pregnancy (AYSRH) and two mini-HCDs; WASH in Kitui and Nutrition in Kakamega. The AYSRH 3D/HCD exercise carried out in Migori County brought together participants from MOH to interrogate contributing factors to teenage pregnancies and possible solutions/strategies. The WASH mini-HCD carried out in Mwingi West (Kitui) targeted artisans, community members, CHVs and hardware store owners in a bid to develop a SBC strategy for implementation of sustainable post- ODF activities.
The project conducted the first C4C and ETL cascade ToT training targeting MOH and Afya Halisi staff and CHVs attached to private facilities. The participants are expected to cascade the techniques down to fellow HCWs. The participants were also trained on ETL - a participatory community facilitation technique that seeks to identify the health barriers to service uptake and subsequently come up with solutions and action plans to address the said barriers.
Other demand creation activities conducted during the reporting period included community dialogue sessions on all the project thematic areas, including men only dialogue sessions.
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Sub-purpose 3: Increased MOH stewardship of key health program service delivery Building on the gains made in PY1 and PY2Q1, the project continued to implement activities in the approved PY2 work plan to address the unique county/sub-county needs. The project provided technical support at various county level TWGs. Constraints and Opportunities The constraints and opportunities that affected activity implementation during the quarter under review is as detailed below:
• Health care financing: The rebates from NHIF and Linda Mama program are not ploughed back into service delivery, instead going into settling recurrent expenditures. The project will continue to advocate for rational use and allocation of resources to improve quality of care in the focus counties. • Inadequate supply of primary data collection tools (Facility and CHS): The tools have been under revision and the final version is yet to be shared by MoH. As a stop gap measure, the project facilitated photocopying of tools that were out of stock. The project is in the process of procuring maternity clinical files. • Inadequate supply of blood and blood products: The project in collaboration of Rotary Club of Kisumu conducted a blood drive harnessing 85 units of blood. Through advocacy, the county holds quarterly blood drives. • Inappropriate deployment of service providers leading to artificial staff shortages: The project continues to advocate for reorganization of staffing rosters to match client needs. • Inadequate number of providers trained to proficiently offer voluntary surgical contraception (BTLs and vasectomy) and LARC. • High staff turnovers more so in the private sector and staff shortages affecting service delivery especially provision of 24 hour services in the lower level sites and missed opportunities for skilled birth attendance. • Lack of a stable community health system in Kitui County: The project held discussions with the Ministry of Health to MoH approve the project’s support to 94 CUs in the county, as part of strengthening community health systems for demand creation and delivery of FP/RMNCAH, nutrition and WASH services. • Low utilization of high volume health facilities supported by faith based organisations: The project continues to advocate for the use of K-CHIC scheme to cover costs in faith based facilities.
Subsequent Quarter’s Work Plan The project held joint planning sessions with the CHMTs, SCHMTs and high volume sites, placing emphasis on aligning investments with the current health system needs, pivoting support based on a revised PY2 prioritization matrix. With a needs based lens, interwoven strategies were used to address data driven and context specific programmatic issues identified during supportive supervision site visits. The findings from the Kitui baseline assessment and the gender study will be used to inform programmatic needs. The project will continue to advocate the four focus county governments and CHMTs to lay out plans for transition of the 95 health care workers employed through the project. The project supported the sub-county and county AWP 2019/2020 development and consolidation process in the focus counties. During the process, the project’s technical approaches were embedded in the AWPs. These are key initial steps in strengthening health systems and placing the counties in the driver’s seat towards the journey to self-reliance.
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Quantitative Impact During the reporting period, the project achieved 136,255 couple-years of protection (CYP), bringing the total CYP achieved as at SAPR 2019 period to 301,594. This achievement translates to 86,859 unintended pregnancies averted per CYP as shown in Figure 1 below. Migori had the highest unintended pregnancies averted at 38,078 during the SAPR 2019 period.
Unintended pregnancies averted CY P Pregnancies Averted 38,998 Kakamega 11,231 60,008 Kis umu 17,282 70,374 Kitui 20,268 132,214 Migori 38,078 301,594 Total 86,859
Figure 1. Unintended pregnancies averted in project supported health facilities in Y2Q1 and Y2Q2 During the SAPR 2019 period, the project achieved 1st ANC visit coverage of 75% out of the expected pregnant women in the period, 4th ANC visit coverage was 45%, skilled birth attendance coverage was 64% and coverage for post-natal care for infants was 56% as shown in Table 1 below. During the quarter under review, the project continued mapping pregnant women through community structures and actively linking them to health facilities for ANC and other related services. Table 1. MNH coverage in project supported health facilities, Y2Q1 to Y2Q2 Indicator County/coverage Project Kakamega Kisumu Kitui Migori Estimated pregnant women 76,170 9,537 24,494 16,976 25,163 1st ANC Y2Q1-Y2Q2 Achievement 57,070 7,287 16,503 12,990 20,290 Y2Q1-Y2Q2 Coverage 75% 76% 67% 77% 81% 4th ANC Y2Q1-Y2Q2 Achievement 34,637 4,506 10,952 6,768 12,411 Y2Q1-Y2Q2 Coverage 45% 47% 45% 40% 49% Skilled birth attendance Y2Q1-Y2Q2 Achievement 48,525 7,255 14,175 9,077 18,018 Y2Q1-Y2Q2 Coverage 64% 76% 58% 53% 72% PNC - infants Y2Q1-Y2Q2 Achievement 41,899 5,773 13,235 8,092 14,799 Y2Q1-Y2Q2 Coverage 56% 62% 56% 46% 61%
In 2018/19, the average institutional maternal mortality rate in project supported health facilities was 124/100,000 deliveries as shown in Figure 2 below. According to KDHS 2014, the national maternal mortality ratio was 362 maternal deaths per 100,000 live births.
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200 145 151 150 119 94 124 100 109 50
0 Year 1 Q2 Year 1 Q3 Year 1 Q4 Year 2 Q1 Year 2 Q2 MD per 100,000 Deliveries 2018/19 Average MD per 100,000 Deliveries 2018/19
Figure 2. Institutional maternal mortality rate in project supported health facilities, 2018/19
The county level average institutional MMR in project supported health facilities in 2018/19 is shown in Figure 3 below. Kakamega and Kisumu counties had the highest institutional MMR mainly contributed by Kakamega County Government Teaching and Referral Hospital and Jaramogi Oginga Odinga Teaching and Referral Hospital. The two facilities receive referrals from all the neighboring counties and sub counties
Kakamega County 199
Kisumu County 165
Kitui County 79
Migori County 84
Project 124
Figure 3. County level average institutional MMR in project supported health facilities, 2018 During the SAPR 2019 period, the project achieved DPT1 coverage of 78% out of the estimated children under one year old in the period, DPT3 coverage was 75%, measles coverage was 72% and FIC coverage 70% as shown in Table 2 below. Table 2. Immunization coverage in project supported health facilities, Y2Q1 – Y2Q2 Indicator Project Kakamega Kisumu Kitui Migori Estimated under 1 children 68,697 9,292 20,282 15,504 23,619 DPT 1 Y2Q1-Y2Q2 Achievement 53,552 7,196 15,333 10,729 20,294 Y2Q1-Y2Q2 Coverage 78% 77% 76% 69% 86% DPT 3 Y2Q1-Y2Q2 Achievement 51,223 6,759 14,583 10,379 19,502 Y2Q1-Y2Q2 Coverage 75% 73% 72% 67% 83% Measles Y2Q1-Y2Q2 Achievement 49,219 6,193 14,180 10,530 18,316 Y2Q1-Y2Q2 Coverage 72% 67% 70% 68% 78% FIC Y2Q1-Y2Q2 Achievement 47,763 6,050 14,155 9,592 17,966 Y2Q1-Y2Q2 Coverage 70% 65% 70% 62% 76%
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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)
Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services
Output 1.1.: Strengthened FP/RMNCAH, nutrition and WASH service delivery at health facilities, including referral from lower level facilities and communities. Activity 1.1.1. Strengthen facility service readiness, quality of care and measurement to increase effective coverage of FP/RMNCAH, nutrition and WASH services
Family Planning During the reporting period, the project continued to focus on high impact family planning interventions with focus on scaling up access to family planning service and improving quality of care and competency of HCWs. During the reporting period, the project supported 613 out of 662 health facilities to provide FP counseling and/or services. This is an achievement of 93% against the annual target of health facilities providing FP counseling and/or services. The achievement was an increase of 7 health facilities from 606 health facilities in Y2Q1 period. The difference of 7% reflects health facilities that are faith based (mainly Catholic based). During the reporting quarter, the project achieved a CYP of 136,255, bringing the total to 301,594 as at SAPR 2019. This reflects an achievement of 51% against the annual target of 593,445 as shown in Figure 4 below. The contribution of the counties as at SAPR 2019 was as follows: Kakamega - 38,998 (49% against the annual target), Kisumu - 60,008 (53%), 70,374 (57%) and Migori - 132,214 (48%).
700,000 70% 600,000 60% 57% 500,000 53% 51% 49% 48% 50% 400,000 40%
CYP 300,000 30% 200,000 20% 100,000 10% - 0% Kakamega Kisumu Kitui Migori Project Y2 target 78,878 113,390 123,049 278,128 593,445 SAPR 2019 achievement 38,998 60,008 70,374 132,214 301,594 % achievement 49% 53% 57% 48% 51%
Figure 4. CYP achievement by County, Y2Q1-Y2Q2 The activities implemented during the quarter included capacity building of HCWs in LARC, PPFP and FP counselling through central trainings, CMEs and on-site mentorships; targeted outreaches, in- reaches and FP camps; and FP integration into other service delivery points. In the private sector health facilities, the total CYP achievement during the reporting quarter was 23,730 bringing the total
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achievement as at SAPR 2019 to 48,039 for private health facilities. This reflects a contribution of 17% to the project’s overall CYP during the reporting quarter.
160,000 30% 140,000 25% 25% 120,000 20% 100,000 17% 80,000 15% 13% 60,000 11% 10% 40,000 8% 5% 20,000 - 0% Kakamega Kisumu Kitui Migori Project
Project Y2Q2 results Private sector Y2Q2 results % Private sector contribution
Figure 5. CYP Performance in Private sector facilities and contribution to project performance in Y2Q2 All project staff undertook the 2019 FP compliance training course and the certificates were submitted to USAID. During the quarter, the project continued to monitor FP compliance in all the supported health facilities.
The county specific activities were as detailed below.
Kakamega County Scale up of PPFP: The project supported scale up of PPFP to 26 sites, 11 additional more sites from 15 in Y2Q1. During the reporting period, a total of 433 women received immediate PPFP within 48 hours where 93% opted for implants, 3% took up IUCD, 2% received BTL and the rest received condoms. The project also conducted facility based mentorships to strengthen documentation and reporting of FP data in nine high volume health facilities.
Scale up of LARC: The project continued to support health facilities in the focus counties to have high uptake of implants as a family planning method preferred by many clients. The project supported training of 6 HCWs drawn from 6 private sector facilities on LARC. In the next quarter, the project will strengthen skills for implant removal through intense mentorship sessions.
Scale up of VSC: During the reporting period, two FP outreaches were conducted to enhance access to permanent family planning services resulting to 76 clients taking up various methods, with 17 receiving permanent methods (16 BTL and one vasectomy). Cumulatively, Kakamega County has reached 30 women with BTL and 2 men with Vasectomy.
Strengthening of BCS+: The project continued to strengthen provision of quality FP services through orientation sessions for 72 HCWs (43 female, 29 male) on integrated BCS+ and C4C. Strengthening of BCS+ helped to improve method satisfaction among the clients and reduced method discontinuation.
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Strengthen FP integration in other service delivery points: During the reporting period, the project oriented 115 HCWs (68 female and 47 male) from 11 facilities on provider initiated family planning to reduce missed opportunities and maximize on bridging the unmet need. Kisumu County Scale up of LARCs: During the quarter, the project supported training of 17 HCWs (4 female, 13 male) from 16 private facilities on LARC. In addition, 37 HCWs (26 female, 11 male) underwent on- site mentorship on LARC. The project also supported FP in-reaches and outreaches in target sub- counties where clients received the following FP methods: Implants 163, Depo 136, BTL 17, IUCD 12 and pills 28.
Scale up of PPFP: The project supported scale up of PPFP to 19 additional health facilities up from 17 in Y2Q1, bringing the total to 36 health facilities. A total of 66 HCWs (34 female, 32 male) were mentored on PPFP. During the reporting period, 250 women from the 36 facilities received immediate PPFP within 48 hours with 80% receiving implants, 12% took up IUCD (both copper and LNG-IUS), 7.5% took BTL and the rest took condoms. The project also supported facility based mentorship to strengthen documentation and reporting in 21 high volume health facilities.
Scale up of VSC: During the reporting period, the project supported the county to provide a total of 41 BTLs through reverse referral approach, an increase of 78% compared to 9 BTLs that was achieved in the previous quarter. The project supported mentorship of a team of one surgeon and 3 nurses on permanent methods by experts from JOOTRH. The HCWs underwent a three-day training where there was observed practice while conducting BTL. As a result, 17 women received BTL services, 23 IUCDs,101 implants and 56 short term methods.
Strengthening of BCS+: The project supported orientation sessions for a total of 292 HCWs (205 female, 87 male) from 75 health facilities on integrated BCS+ and C4C in the two quarters in Y2, an increase of 49% from the previous quarter.
Compliance to USG: The project supported orientation and monitoring of FP compliance during routine mentorships to HCWs. The orientations on FP compliance were also done during the facility in-charges meetings reaching a total of 439 HCWs (327 female, 112 male) from 56 health facilities.
Kitui Scale up of LARCs: During the reporting period, the project in collaboration with the national RMHSU supported a TOT training for 26 HCWs on the new FP training curriculum (Module I LARC and Module II PPFP). The TOTs are expected to roll out the training to 400 service providers using county THS funding from April 2019. The project also supported sensitization of 196 (135 female, 61 male) CHVs in Kitui South and Kitui East sub-counties on FP.
Scale up of PPFP: The project continued to support PPFP service delivery in the county. All the 6 hospitals and health centers and dispensaries are providing PPFP services. During the quarter under review, a total of 699 clients received FP in the immediate postpartum period as follows: 642 implants, 15 IUCDs and 42 BTLs. The project supported whole site orientation on PPFP reaching 77 HCWs (49 female, 25 male). Out of these, 7 HCWs (5 female, 2 male) were from private sector health
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 9
facilities. The project also supported demonstration on PPIUD insertion to 29 HCWs (17 female, 12 male) to improve staff confidence in PPIUCD provision.
Scale up of VSC: The project supported procurement and distribution of BTL and implants removal sets to health facilities. This was to bridge the gap in equipment identified during routine FP targeted in reaches and outreaches. The project also supported 28 family planning focused in-reaches, 28 outreaches and 5 camps across the county. The uptake of services was as follows: implant insertion 356, implant removals 30, IUCD insertion 14, Depo 268, pills 35, and BTLs 69. Through the project’s support, 10 medical doctors, 37 nurses and 9 registered clinical officers were trained on various LAPM methods. The medical doctors are now able to conduct BTLs though they will continue to be receive mentorships to achieve proficiency.
Strengthening of BCS+: To enhance FP service delivery, the project supported C4C training for 18 HCWs (14 female, 4 male) from 6 health facilities, aimed at enhancing their skills in counselling for choice in FP. The trained HCWs will cascade the training through on-site mentorships and OJT. In the next reporting quarter, the project will distribute the C4C job aids to complement use of BCS+ in improving counselling for FP and reducing FP discontinuation.
FP Compliance to USG: During the reporting quarter, the project sensitized 17 HRH staff (10 female, 7 male)) in the county were sensitized on FP compliance and underwent the 2019 e-learning course on FP compliance. The project also continued to monitor FP compliance in all the supported health facilities and no violation was observed.
Print and disseminate Job Aids and Guidelines: During the quarter under review, the project supported printing and distribution of Global Hand Book on family planning to 13 private health facilities providing FP services. This was aimed at strengthening quality care and capacity of the HCWs in provision of FP services to clients.
Migori Scale up of LARCs: During the quarter under review, the project supported a total of 27 outreaches mainly focusing in the high priority sub-counties of Kuria East, Kuria West and Nyatike. A total of 877 women were reached with modern contraceptive methods as follows; pills 42 (5%), DMPA 83 (10%), Implants 661 (75%) and IUCDs 91 (10%). In addition, the project supported capacity building of 46 HCWs (33 female, 13 male) on LARC through formal training and mentorships. Of these, 25 (19 female, 6 male) were from the private sector. The project supported distribution of 30 IUCD insertion sets and 15 gynecological examination lamps procured by USAID to supported health facilities.
Scale up of PPFP: The project supported training of 32 HCWs (21 female, 11 male) from 14 health facilities on PPFP through whole-site orientation and low dose high frequency capacity building approaches. A total of 69 health facilities offered immediate PPFP services during the quarter under review reaching 577 clients as follows: 461 (80%) received implants, 99 (18%) received IUCD including LNG-IUS, and 2 received (1%) BTL. In the next reporting quarter, the project will aim at addressing missed opportunities to PPFP including strengthening of counseling at ANC, re- organization of health facilities to improve privacy in addition and continue to provide mentorships on PPFP.
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Strengthening of BCS+: To strengthen quality of FP counseling, FP acceptance and method continuation, a total of 62 HCWs (37 female, 25 male) were oriented on BCS+, 43 HCWs (25 female, 18 male) and 19 HCWs (12 female, 7 male) on C4C. In addition, 5 facilities that had recorded high implant removal were visited to understand the main causes of removals. Removals were mainly attributed to expiry of the period of use and partner resistance. Most of those who were removing on expiry, took up a similar method. Removals due to side effects were minimal. The project is undertaking a FP discontinuation study in Migori county, which will shed more light on the issue.
Scale up of VSC: During the quarter under review, the project supported FP camps in 2 sub counties reaching total of 14 women with BTL services.
Compliance to USG: During the quarter, a total of 45 HCWs were sensitized on FP compliance. All project staff in the county undertook the mandatory 2019 FP compliance training course.
Maternal and Newborn Health During the reporting period, the project continued to build on the efforts and gains made from Year 1 and Year 2 Quarter 1. The project’s focus was aimed at ensuring increased access to emergency maternal newborn services, promotion of health behaviors and preventive action at home and in the community and work with county governments in ensuring effective referral pathways. The project also used data to guide the implementation of existing, low-cost and effective interventions at community and health facility levels and working with county governments and collaborate with other stakeholders to reduce duplication of resources. During the reporting period, 111 health facilities (17% of all supported sites that offer delivery services) were found to have the requisite capacity to offer emergency obstetric and newborn care. out of these, 19 health facilities had the capacity to provide comprehensive emergency obstetric and neonatal care (CEmONC) services. Significantly, two new CEmONC sites were operationalized in Kisumu with the project’s support. The addition of Muhoroni and Kombewa county hospitals as CEmONC sites will help in decongesting the two main referral hospitals in the county and reduce the delays that often arise during the referral process. The project is at advanced stage to support Kitui and Migori counties increase the number of CEmONC sites to reduce patient waiting times in the existing emergency care sites. Provision of medical equipment procured with support from USAID continued having started in Y2Q1. The project continued to support capacity strengthening of HCWs and CHVs reaching 448 HCWs with different modules in maternal and newborn care during the reporting quarter. This brings to total 1,328 HCWs trained by SAPR 2019, an achievement of 111% against the annual target of 1,200. The trainings were conducted in the first half of SAPR 2019 period, which will give room to more focus on mentorship and on-site post-training follow-ups in the next two reporting quarters. In addition, a total of 769 CHVs were trained on MNH technical module during the reporting quarter, bringing the cumulative total as at SAPR 2019 to 870. This reflects an achievement of 22% against the annual target of 3,900. The project completed the process of CU selection during the reporting quarter and targets to conduct and complete training of additional CHVs on MNH technical module in the next reporting quarter.
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Improving access to quality FANC including 4 ANC visits: In the quarter under review, 16,767 pregnant women completed 4 ANC visits bringing the total to 34,637 as at SAPR 2019 period, a 38% achievement against the annual target of 90,486 as shown in Figure 6. At county level, Migori county had the highest contribution at 6,262 during the reporting quarter, while Kisumu had 5,191, Kitui 3,163 and Kakamega had 2,151 women completing 4 ANC visits.
100,000 50% 44% 80,000 41% 40% 38% 33% 60,000 32% 30%
40,000 20%
20,000 10%
- 0% Kakamega Kisumu Kitui Migori Project Y2 Target 14,285 25,033 20,641 30,527 90,486 SAPR 2019 Achievement 4,506 10,952 6,768 12,411 34,637 % Achievement 32% 44% 33% 41% 38% Figure 6. 4th ANC visit achievement against PPR target, Y2Q1 –Y2Q2
The 4th ANC coverage against the population estimates was 45% for project supported sites as at SAPR 2019. Migori county had the highest 4th ANC coverage at 49%, Kakamega – 47%, Kisumu – 45% and Kitui had the lowest coverage of 40% as shown in Figure 7. The project recognizes the need for early initiation of ANC to improve on this performance.
80,000 60% 70,000 50% 47% 49% 60,000 45% 45% 40% 40% 50,000 40,000 30% 30,000 20% 20,000 10% 10,000 - 0% Kakamega Kisumu Kitui Migori Project
Estimated pregnant women ANC 4 Clients 4th ANC Coverage
Figure 7. 4th ANC visit coverage in project sites, Y2Q1 – Y2Q2
The private sector remains an important contributor to this performance with 19% of the 4 ANC visits conducted in the project's supported private health facilities as shown in Figure 8 below.
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 12
18,000 30% 16,000 27% 25% 14,000 12,000 20% 19% 10,000 17% 15% 8,000 14% 6,000 10% 8% 4,000 5% 2,000 - 0% Kakamega Kisumu Kitui Migori Project
Project Y2Q2 results Private sector Y2Q2 results % Private sector contribution
Figure 8. Private sector contribution to 4th ANC performance in Year 2 Quarter 2
The contribution of the private sector health facilities was critical during the HCWs strike in February 2019, with the project pre-positioning the support to the private sector to mitigate the effects of the strike. The county specific activities were as detailed below.
In Migori, the project supported an orientation on FANC and management of anemia in pregnancy to 53 HCW in Nyatike sub-county targeting wards with low 4th ANC coverage. Group-ANC is being implemented in 11 health facilities from 3 sub counties. In the reporting period, the project supported 27 integrated outreaches reaching 366 pregnant women with 59 attending their 4th ante-natal visit during the outreaches. In the reporting quarter, maternity open days were held in 21 facilities, 15 in Migori and 2 each for Kisumu, Kakamega and Kitui. Kisumu. The haemoglobin testing equipment distributed in Y2Q1 in Migori and Kakamega were all in use during the reporting period.
In Kitui, the project supported laboratory networking services to improve access to routine and essential laboratory services. The support reached 96 pregnant women in the hard-to-reach areas of Mwingi West sub-county and will be continued in subsequent quarters.
While medical sonography has been a preserve of trained sonographers, access to routine and diagnostic obstetric ultra sound is limited due to inadequate sonographers in the country and the prohibitive costs of the service. In Kisumu, this role shifted with procurement of portable ultra-sound machines through World Bank support to select facilities. In the reporting period, Afya Halisi built on this support by conducting refresher training to 32 HCWs (28 nurses and 4 medical engineers) on use of the machines. These are the same staff who had been trained in Y2Q1 and the refresher was aimed at maintaining the skills and review progress on the practice. Consequently, while the majority of the 189 scans conducted by the nurses revealed normal fetal conditions, 13 case diagnosis led to surgical interventions resulting to better maternal and fetal outcomes. This will be an important aspect of ante natal care as per WHO’s recommendation of one ultra-sound before the 24 weeks’ gestation to detect any fetal anomalies. During the reporting quarter, the project supported community level activities riding on existing structures in Kisumu, Migori and Kakamega. Discussions were on-going in Kitui on the project’s
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 13
support for community health systems in the absence of a formal structure. However, the project continued to utilize identified active community resources people to support home and community level interventions. During the quarter, the CHVs continued to identify and map pregnant women and newborns as well as other priority groups of interest. The number of pregnant mothers mapped in the reporting period was 1,938 compared to 237 mapped in Y2Q1. The mapped pregnant mothers were tracked to ensure they attend ANC as required, and delivery under skilled birth attendants. Through the community outreaches, 2,262 pregnant women were registered on Linda Mama, a government medical insurance scheme aimed at removing financial barriers and increasing access to pregnancy care, childbirth and post-delivery health services. Scale up of EMONC and SBA: During the reporting quarter, 23,912 births were assisted by a skilled attendant in 509 project supported facilities offering delivery services. This brings the total to 48,525 as at SAPR 2019, an achievement of 58% against the annual target of 83,525. At county level, Migori had the highest contribution with 8,802; Kisumu with 6,900 while Kitui and Kakamega had 4,731 and 3,479 deliveries under skilled care.
90,000 70% 80,000 61% 64% 58% 60% 70,000 55% 50% 60,000 48% 50,000 40% 40,000 30% 30,000 20% 20,000 10,000 10% - 0% Kakamega Kisumu Kitui Migori Project Y2 Target 13,185 23,108 19,054 28,178 83,525 SAPR 2019 Achievement 7,255 14,175 9,077 18,018 48,525 % Achievement 55% 61% 48% 64% 58% Figure 9. Skilled birth attendance achievement against target, Y2Q1 –Y2Q2
The private sector played a key role during the days of the health care workers strike remains an important contributor to this performance with 24% of the facility deliveries conducted in the project's supported private health facilities.
At the end of the reporting period, delivery by skilled personnel coverage was at 64% for the whole project as shown in Figure 10, the highest being in Migori at 72% and lowest in Kitui at 53%. Despite the low coverage in Kitui, it is a marked improvement from 44% recorded at the same period in Year 1. However, access by community to EmONC facilities is still a major infrastructural challenge for the county.
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 14
80,000 80% 76% 70,000 72% 70% 64% 60,000 60% 58% 53% 50,000 50%
40,000 40%
30,000 30%
20,000 20%
10,000 10%
- 0% Kakamega Kisumu Kitui Migori Project
Estimated pregnant women SBA Achievement SBA coverage
Figure 10. Skilled birth attendance coverage, Year 2 Quarter 1
During the reporting period, 448 HCWs were reached with various trainings in maternal and newborn care. In Kitui, the project and MOH are in the process of instituting and initializing 8 maternity shelters in hard to reach areas in the county. For instance, in Ikutha sub-county hospital of Kitui county, 35 of the 132 deliveries conducted during the quarter were from the facility’s maternal waiting home. Similar shelters are in Mikuyuni, Nyaani, Nzawa, Winzyeei and Mikuyuni. During the reporting quarter, the project conducted a standardization of EmONC mentorship to 28 EmONC from the county. The goal of the activity was to standardize mentorship approaches of trainers and service providers with the appropriate skills. The project shifted towards application of evidence-based low-dose high frequency (LDHF) learning approach in the roll-out of Helping Mothers Survive module. In Migori, targeted CMEs on emergency response was conducted in 24 facilities focusing on management of bleeding during and after birth, hypertensive disorders in pregnancy and active management of intra-partum care. In Kisumu, the project supported on-site CMEs on management of maternal and newborn complications in all the six supported sub-counties reaching 536 HCWs. As highlighted in earlier sections of this report, there were two additional CEmONC sites in Kisumu and the county now has a geographically even distribution of CEmONC facilities. In addition to equipment support, Afya Halisi provided 6 nurses on short-term hire with 3 of them deployed to surgical operating theatre at Muhoroni county hospital. In one month of its operation, Muhoroni county hospital had conducted 13 caesarian sections, 9 of which were emergencies. Bleeding after birth remains the leading cause of maternal mortalities. Use of prophylactic uterotonics during the third stage of labour and timely and appropriate management of birth process is a key element in reducing these deaths. In the reporting period, 75% of the assessed case files had recorded provision of uterotonics immediately after delivery. While there were no reported stock-outs of the commodity, correct documentation of this service is still a challenge and a focus for the project. In Kakamega, documented provision of uterotonics was at 83%, Kisumu at 76% while proper documentation of the service in Migori and Kitui at 74% and 70% respectively. Besides mentorship
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 15
on maternal and newborn care skills, EmONC mentors in all the counties are now addressing documentation of vital intra-partum and post-partum care processes. PNC for mothers, newborns and Kangaroo Care: During the reporting period, 22,919 newborns received post-natal care within two days, a 10% increase from Y2Q1, bringing the total to 41,899 as at SAPR 2019. Considering that there were 23,570 live births in the reporting period, access to PNC was at 97%. In the counties, Migori was at 90% and Kakamega with 97%. Performance of the same in Kisumu and Kitui surpassed the 100% mark and this may be attributed to the babies born at home or out of the catchment population but still receive PNC in the project’s supported sites. The project supported the counties to avail the necessary reporting tools with continuous on-site mentorship on the correct reporting for this activity.
In Kisumu, the project supported sensitization on Essential Newborn Care, including application of Kangaroo Care (KMC) in small babies to 126 HCWs. In Migori, the project supported an orientation on PNC in Uriri sub-county targeting 5 health facilities reaching 54 HCWs, sensitization on KMC to 31 HCWs and post-natal care support supervision conducted in 83 health care facilities. Still in Migori, trainings on Helping Babies Breath (HBB) and essential newborn care were conducted in 8 facilities spread in three sub-counties – Rongo, Uriri and Nyatike – reaching 78 HCWs. Continuous mentorship sessions were held reaching 101 HCWs from 6 high volume sites in the county. Similar sessions were held in Kakamega and Kitui, targeting the high volume sites.
The challenge with availability of Chlorhexidine for cord care still remains in the four counties. Assessment conducted in the reporting period showed that most of the private facilities did not have the commodity.
Previous project efforts have been predominantly on essential newborn care and prevention and management of birth asphyxia. This is mainly because of the relatively manageable systems around these two components. The project recognizes the congestion in the 16 facilities with critical care facilities for the small babies. Afya Halisi will provide support for a learning visit to address the third element, Essential Care for the Small Babies (ECSB), in the trio of Helping Babies Survive. ECSB provides the special care needed for small or premature babies, including alternative breast milk feeding options, thermal regulation, infection prevention, stabilization of baby for transport and home or community level care. Afya Halisi has the expansion or the relocation of the Kitui newborn unit as a rolling advocacy agenda with the county government. In the reporting period, the project supported sensitization and refresher sessions on KMC to HCWs as part of the essential newborn care package, building on trainings done in Year 1. Subsequently, tracking of the preterm survival rates will be undertaken by the project as an important outcome indicator. Scaling up Maternal Perinatal Death and Surveillance Response (MPDSR): During the reporting period, all the 23 sub-counties held quarterly MPDSR meetings with the county referral hospitals having monthly audit meetings. However, only two (Kisumu and Migori) of the four counties held a county-level MPDSR committee meeting. There were 36 maternal deaths and 471 perinatal deaths in the quarter, giving an institutional maternal mortality ratio of 151 in 100,000 facility deliveries. This is an increase in mortalities compared to Y2Q1 that had 27 maternal mortalities.
The project noted that despite an increase in CEmONC facilities by two in Kisumu, the county still had the highest (15) number of maternal mortalities and 9 each in Migori and Kakamega during the
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 16
reporting quarter. There were 3 maternal deaths reported in Kitui. There has been an improvement in perinatal death audits from 66% in the previous quarter to 75% in PY2Q2 (see Figure 11). Thirty of the maternal deaths occurred in government facilities with six recorded from private facilities.
100% 100% 100% 100% 94% 100% 83% 80% 88% 82% 60% 72% 68% 70% 40% 45% 20%
0% Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Proportion of maternal deaths audited Proportion of perinatal deaths audited
Figure 11. Proportion of maternal deaths and perinatal deaths audited, Y2Q1 – Y2Q2
Immediate post-partum bleeding was the main cause of the maternal deaths (23), while complications from eclampsia resulted to 6 deaths. Five other deaths were due to post-surgery sepsis. There was a case of domestic violence where a pregnant woman in Kitui succumbed to self-inflicted injuries sustained through poisoning. The county specific activities are detailed below: Kakamega County In the previous quarter, there were 6 maternal deaths reported in facilities in the county and were attributed to delayed referrals and quality of care. A one-month nurses’ strike, poor referral procedures and sub-optimal quality at point of care could have contributed to the 9 maternal deaths in the reporting period. Due to management changes at the department of health, Kakamega did not hold a county level MPDSR meeting. Seven (78%) of the maternal deaths were due to PPH, 1 (11%) due to eclampsia, 1 (11%) due to sepsis. There were total of 103 perinatal deaths with 65% of these audited. Prematurity as the leading cause followed by asphyxia, sepsis and other causes. In the reporting quarter, the project supported continuous session on management of maternal emergencies in Khwisero, Matungu and KCGTRH. Kisumu County Despite improvements in institutional maternal mortality ratios over the past 5 years, maternal deaths still remain high. In the previous quarter, there were 13 maternal deaths reported in facilities in the county and attributed to delayed referrals and quality of care. In this quarter, there were 15 maternal deaths reported with 100% audit, 8 (53%) were due to PPH, 3 (20%) due to eclampsia, 3 (20%) attributed to intra-operative anesthesia complications and 1 (7%) due to sepsis. A total of 185 perinatal deaths with 93% audit, asphyxia being the leading cause, followed by prematurity and sepsis. Five near miss cases of three undiagnosed eclampsia and two ruptured uterus in Muhoroni, Ahero and Nightingale were discussed. The project also supported one simulation on management of
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 17
PPH at JOOTRH. Gaps in emergency preparedness and response were identified and mitigation measures discussed. Afya Halisi supported a stakeholder review meeting on the referral pathways. A county referral protocol is under discussion that will include an ambulance command centre. Other mitigation measures is continuous updates on emergency response in all the EmONC facilities, the county to procure or re-distribute the correct delivery beds to EmONC sites and advocacy on implementation of the enacted county bill that now allows for monthly payment of CHV remuneration. Afya Halisi recognizes that the roll-out of universal health coverage in the county may not achieve the anticipated goals without an effective quality of care management. The project has revitalized quality of care as started by a QOC by GIZ/Amref in 2017 and held a refresher to 20 Quality of Care mentors during the reporting period. Kitui County All the three maternal deaths – two in Mwingi and one at the Kitui county referral hospital (KCRH) – were audited and reported. One occurred at KRCH due to acid poisoning and the other two occurred at Mwingi hospital as a result of PPH. Post-partum hemorrhage was cause of the the two maternal deaths that occurred in Mwingi hospital as facility didn’t have blood in the two events. The resolve was to update staff on management of PPH, update medical officers on safe surgery skills, a refresher on BEmONC trained staff and availing of blood for emergency. However, third delay has been outlined as a major issue in the poor maternal and perinatal outcomes. Consequently, the project trained 23 HCWs from Mwingi central on preparation for and management of PPH. The training encompassed training on skills using the helping mothers survive and helping babies survive modules. The project supported a one-day refresher on management of pre-eclampsia and eclampsia targeting the same participants. These support structures will continue in subsequent quarters. In response to the high perinatal deaths at KCRH, the facility initiated weekly skill drills and coaching on proper scoring of the babies at birth, comprehensive resuscitation of the babies, strict monitoring and documentation of labour using partograph to reduce delays in decision making. The project supported on-site updates to 26 HCWs on newborn resuscitation, assisted vaginal delivery and emergency response in maternal and newborn care. Migori County In the reporting period, Afya Halisi worked to strengthen MPDSR committees at the county, sub- county and facility level. All the 8 sub-counties and county quarterly MPDSR meetings were held. In the reporting period, 11 maternal deaths were reported due to the following causes; PPH 6 (55%), Eclampsia 2 (18%), Anemia 1 (9%), post CS complications 1 (9%), unknown 1(9%). 9 (82%) of these maternal deaths occurred at the health facility while 2 (18%) occurred in the community. Poor staff attitude and poor care processes were reported as the causes of maternal deaths at the Migori county referral hospital (MCRH). To respond to the causes of maternal deaths, Afya Halisi supported a one-day county-wide blood donor drive and held advocacy meetings with the county management to address the quality of care gaps at MCRH. A total of 85 units of blood were collected in the exercise. Through advocacy, staff transfers were effected at MCRH that have resulted in reduction of maternal deaths over the period. This was necessitated by slow or lack of improvements in patient care despite capacity strengthening efforts by Afya Halisi and other stakeholders.
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Immunization Afya Halisi supported the four focus counties to improve access to immunization services. During the reporting period, the project supported the focus counties to reach 25,446 children with full immunization. This brings the total to 47,763 as at SAPR 2019 period, an achievement of 53% against the annual target as shown in Figure 12 below. The FIC coverage in the four focus counties was 70% as at SAPR 2019, a 2% increase compared to Y2Q1 performance. The project contributed to the achievements by ensuring health facilities developed micro plans and had clear targets for the year, low dose high frequency mentorships, supported collection and redistribution of vaccines to ensure an un-interrupted supply of antigens thus reducing missed opportunities, and intensified defaulter tracing. This was additionally support by organizing outreach and targeting efforts in hard to reach areas that had low immunization coverage. Afya Halisi also supported EPI technicians to repair faulty fridges to minimize disruption of immunization services because of broken cold chain management. The private sector contributed 15% to the FIC performance during the reporting period.
100,000 70% 90,000 60% 80,000 57% 57% 53% 70,000 51% 50% 60,000 39% 40% 50,000 FIC 40,000 30% 30,000 20% 20,000 10,000 10% - 0% Kakameg Kisumu Kitui Migori Project a Y2 Target 15,393 24,884 18,732 31,397 90,406 SAPR 2019 Achievement 6,050 14,155 9,592 17,966 47,763 % Achievement 39% 57% 51% 57% 53%
Figure 12. FIC achievement against target, Y2Q1 – Y2Q2
The county specific activities are detailed below: Kitui County In Kitui County, 5276 children were fully immunized and 5172 children received DPT3 vaccine. The coverage for project-supported sites in the county stood at 67% for DPT3 and 62% for FIC.
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 19
REC Microplanning: The project supported sub-county teams to set immunization targets for health facilities and prepare micro-plans. A total of 178 HCWs (96 female, REC Microplanning 82 male) have been mentored on microplanning. The project supported a follow up meeting for 14 HCWs (10 female, 4 male) Afya Halisi supported from wards that had low immunization coverage. Key issues microplanning in Kakamega, Kisumu and Kitui County. A large affecting immunization coverage included: immunization proportion of immunizing health happening on specific days instead of daily, inadequate staffing, facilities (82%) have already distance to health facilities, inadequate information on completed their micro plans. immunization at community level, inadequate information provided Health facilities in wards that had to caregivers on return dates for immunization, stock out of low immunization coverage had an additional half-day meeting to vaccines especially Measles/Rubella in January 2019, and the identify root causes of low presence of non-immunizing MOH health facilities. Health coverage. facilities then came up with context specific strategies for improving immunization coverage in their areas.
EPI mentorships: The project trained eight EPI mentors to provide facility level mentorship to HCWs on EPI operations and REC. Mentors supported 53 health facilities, 21% of which had sub-optimal cold chain maintenance. Following this, 105 HCWs (74 female, 31 male) benefitted from EPI mentorship sessions. Immunization mentors covered topics such as use of fridge tags, vaccine monitoring, and defaulter tracing, and complete and accurate documentation in the permanent register and monitor chart.
Repair of EPI fridges: Fourteen health facilities had faulty EPI fridges; the project supported the repair of nine fridges by facilitating the movement of sub-county EPI technicians. The main challenges experienced during the quarter was the Figure 13. EPI mentorship at Nzalae frequent breakdown of EPI fridges even after dispensary Kitui County repairs and the lack of spare parts. The project will work with the county to address these challenges by supporting collection of spare parts from the National Vaccines and Immunization Program, as well as supporting county technicians to mentor the sub-county counterparts on fridge maintenance and repairs.
Migori County EPI review and planning meeting: During the reporting quarter, the project supported an EPI performance review and planning meeting that brought together 17 (8 female, 7 male) county and sub-county EPI logisticians, community strategy focal persons, maintenance/biomedical and disease surveillance teams. The project linked the Migori county team to the Kakamega regional EPI depot as the Kisumu depot was still being renovated. This was to help prevent any stock out of vaccines.
REC microplanning: Afya Halisi supported sub-county teams to set immunization targets for health facilities and prepare micro plans. The project supported 298 HCWs (146 female, 132 male) comprising of frontline HCWs, ward/facility CHAs (and the SCHMT) from all the 188 immunizing
AFYA HALISI PROGRESS REPORT FOR Q2 FY 2019 20
health facilities. During the review of microplans, rationalized immunization targets/catchment populations for 2019 were given to all the immunizing health facilities and vaccine forecasting was conducted. Hard to reach areas were mapped out for targeted REC strategies to improve immunization coverage including the mining zones, fishing communities, and religious sects. Micro plans for 2019 were generated and pockets of zones with high dropout rates for Penta 1 – Penta 3, Penta 1 – MR1 and MR2 mapped for targeted RRI/defaulter tracing and immunization.
EPI mentorship: The project supported EPI mentorships in 42 health facilities. Only three (7.1%) of the health facilities mentored had sub-optimal cold chain maintenance.
Vaccines collection: To strengthen immunization service readiness in the county and minimize missed opportunities for immunization in health facilities, the project trained the sub-county EPI coordinators to collect all antigens and diluents from the regional EPI depot in Kakamega (Kisumu depot still under renovation). However, sporadic stock-outs of MR, BCG and Polio antigens at the regional depot/facilities during the quarter contributed to multiple collections at the depot (Jan, Feb and March 2019). As a result, facilities continued to operate below the minimum stock levels for key antigens hindering daily immunization services and contributing to missed opportunities. The project engaged teams from CHAI who had been supporting national mechanisms to help in following up the issue of vaccine stock outs.
Facility assessments and installation of EPI fridges: The project supported the county’s biomedical department to conduct facility assessments and installation of solar-powered fridges donated by UNICEF/GOK in order to improve the proportion of health facilities providing daily immunization services from 158 (88%) to 185 (100%). After the installation of 40 EPI fridges in Y1, the county requested Afya Halisi to support the installation of an additional 12 EPI fridges, as they had not yet received any support for installation. Moreover, the county EPI logistics department is also coordinating the redistribution of EPI fridges to non-immunizing health facilities to ensure that all facilities provide daily immunization.
Immunization monitoring: To improve immunization services, data for decision-making is key. The project supported the county through the supply of 185-immunization monitoring charts (v2017) to all the facilities. This will help monitor the monthly performance progress and achievement of immunization services through close monitoring of dropout rates for DPT1 – DPT3 and DPT 1 – MR1 at the facility level. The project mentored healthcare providers on completing and interpreting the monitoring charts during the microplanning sessions.
EPI targeted supportive supervision: The project supported the sub-county teams in conducting the EPI supportive supervision in priority and poorly performing wards with over 10% of un-immunized children in 2018 in the county. Twenty-one out of the 41 wards were identified. This was aimed at improving the quality of integrated immunization services in the facilities. Key challenges observed included: incomplete micro plans and catchment maps (finalized in March 2019), defaulter tracking lists generation “know-do” gaps among both healthcare providers and the community health strategy workforce, inconsistent documentation and updating in the MOH immunization registers. Eighty- three healthcare providers and community health teams present during the supportive supervision visits were mentored/oriented on proper documentation in the relevant MOH EPI registers, generation of defaulters' lists, tracking and updating of the relevant registers. The project will continue to monitor
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and review the performance of the target priority wards/facilities in order to improve immunization performance.
Immunization defaulter tracing: During the reporting quarter, the project supported in tracing and linking 1,353 immunization defaulters to services, out of the 4,358 defaulters line listed. The challenge of documentation of immunization services offered at the health facility was noted, as some children line listed as defaulters in Kakamega had actually received the service though the permanent register was not updated. The project will strengthen mentoring of MCH staff on complete and accurate documentation.
Kisumu County Collection of vaccine from regional depot: This quarter, Kenya experienced a shortage of BCG antigens. The project supported the county to collect vaccines from Kakamega depot.
Immunization defaulter tracing: During household registration for Universal Health Coverage (UHC) in Kisumu, the project supported 96 CHVs linked to nine community units in Muhoroni sub- county to track immunization defaulters. This exercise was conducted during the UHC door-to-door mobilization activity. Following this exercise, 471 children were tracked by CHVs, 11 true defaulters referred for DPT1, 45 for DPT3 and 33 for Measles/Rubella vaccine.
Muhoroni, Nyakach and Kisumu East sub-counties had low immunization coverage in PY1. Therefore, in Y2Q2, the project strategized to facilitate the sub counties to increase immunization uptake in health facilities. The project identified ten high volume health facilities in Muhoroni and seven in Nyakach, ten of which had a high number of defaulters. Health facility staff generated line lists of defaulters and shared with CHVs. In Kisumu East, six facilities were identified based on the number of defaulters. Their contact information was retrieved and the defaulters contacted via telephone. CHVs traced 185 defaulters in Muhoroni and 205 in Nyakach.
Cold chain maintenance: Cold chain management is an integral part of immunization services. Afya Halisi supported routine servicing of fridges in four facilities in Kisumu East. In Kisumu West, two faulty fridges were repaired in Lwala Kadawa. In the Abuoge dispensary, a solar powered fridge was installed. During the exercise, healthcare providers were updated on modern methods of cold chain management for example use of FT2 tools and new refrigerators like the MK 144, VLS 200A and the solar TCW15 SDD.
Facility Rapid Assessment in sub counties with low immunization coverage: The project supported sub-county managers to establish drivers and hindrances for immunization services in the sub counties. Thirty facilities (five per Sub-county) were assessed. Challenges identified in the facilities included documentation gaps, cold chain management and a high number of defaulters. Based on findings from this assessment, the following activities were undertaken during this reporting quarter: repair of and servicing of fridges; rigorous defaulter tracing through home visits by CHVs and telephone calls; improved documentation of information in the immunization registers, tally sheets and monthly summaries and support for immunization outreaches.
REC microplanning: During the reporting quarter, the project supported six sub-counties to conduct target setting for immunization. During the target setting, sub county health management teams and
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health facility staff reviewed the 2018 sub-county immunization performance and provided health facilities with new 2019 population estimates and immunization targets. Moreover, health facilities identified root causes of low immunization coverage and came up with strategies to address these causes. The project worked with facilities to generate micro plans for 2019. Each facility was able to forecast on their vaccine requirements and estimate population of children under one year. They also mapped hard to reach areas with high number of immunization defaulters that were targeted with outreaches.
EPI mentorship and on-the-job training: During this reporting period, the project supported EPI mentorships in Kisumu Central, Kisumu West, Muhoroni and Nyakach Sub counties. Mentors identified the following gaps: non-documentation on immunization registers which contributes to the perception of high immunization defaulters, no clear records of missed appointments and defaulters, no usage of tally sheets and some facilities scheduling certain antigens with inadequate follow up mechanisms in place.
The project supported mentorship of 53 HCWs (37 female, 16 male) with focus on improving documentation and harmony across related registers and summary tools, cold chain maintenance, defaulter tracing mechanisms, building capacity on vaccine forecasting and facility community linkage. During mentorship sessions, EPI mentors identified eight of the 36 (22%) health facilities that had sub optimal cold chain performance and provided mentorship.
Kakamega County REC microplanning: Afya Halisi supported all the 54 health facilities to set their annual immunization targets and to review their micro plans. The project also supported a half-day meeting with health facility staff in wards with low immunization coverage. Health facility staff identified the main reasons for low coverage and came up with the following solutions: promote use of correct tools to capture data, proper forecasting to avoid vaccine stock outs, periodic data review to monitor performance, increase number of outreach sites and targeted support supervision.
EPI mentorships: To improve the immunization coverage as well as quality of service being offered, Afya Halisi supported EPI mentorship in seven health facilities in Khwisero sub-county and mentored 12 (6 male, 6 female) health care providers. Human resources is a major challenge in facilities as this delays service delivery especially in private health facilities where there is a high rate of staff turnover.
CME on immunization: The project supported CMEs in nine health facilities, reaching 58 (49 female, male 9) healthcare providers. The CMEs focused on vaccine management, documentation, and defaulter tracing. This was to ensure quality of immunization services was not compromised following mass transfer in January of healthcare providers by the county government.
Immunization focused dialogues: To improve healthy behaviors at community level, the project supported five Small Group dialogue Sessions (SGS) in Kakamega. Sixty-five caregivers attended the sessions. They raised the following issues as some of the factors that hindered uptake of immunization services: distance to health facility, lack of knowledge on importance of immunization and long waiting time in understaffed health facilities. After the sessions, 17 children under two years who had defaulted on various antigens were identified, referred and received immunization services.
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Immunization defaulter tracing: At the community level, the project supported active defaulter in project sites. As a result, 836 children were traced and referred, 111 (13.2%) were found to be true defaulters. The rest had documentation errors or the documentation was incomplete in the permanent registers. Healthcare providers updated permanent registers using mother baby booklets.
Child Health In project-supported sub-counties, the proportion of children under five with diarrhea who received oral rehydration therapy increased from 74% in Y2Q1 to 89% in Y2Q2 and those with pneumonia who received recommended treatment increased from 84% to 96% as shown in Figure 14 below.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Kakamega Kisumu Kitui Migori Project
Proportion of diarrhea cases treated Y2Q1 Proportion of diarrhea cases treated Y2Q2 Proportion of pneumonia cases treated Y2Q1 Proportion of pneumonia cases treated Y2Q2
Figure 14. Proportion of diarrhea cases and pneumonia cases treated, Y2Q1-Y2Q2 During the reporting period, the project supported low dose high frequency mentorships on Integrated Management of Newborn and Childhood Illnesses (IMNCI), continuous medical education of health workers on diarrhea and pneumonia case management, and improved availability of ORS, Zinc and Amoxil. The project also supported health facilities with pneumonia and diarrhea management monitoring charts and the health facilities are now able to monitor their performance on a monthly basis.
In the private sector, 1,537 children under five were treated with antibiotics, a contribution of 22% to the project’s performance while 2,837 children with diarrhoea were treated with ORS and Zinc, a contribution of 11% to the project’s performance. The county level activities are detailed below.
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Kakamega County IMNCI training: To improve the capacity of service providers on management of under-five illnesses, the project trained 29 HCWs (16 female, 13 male) on IMNCI. Proper documentation was emphasized and the participants were walked through the reporting tools, MoH 204A, MoH 705A and the ORT register. The average pre- and post-test scores for the participants were 68% and 81% respectively.
Mentorship on IMNCI: Afya Halisi supported mentorship of staff on IMNCI. Of the 30 health facilities mentored on IMNCI, 15 started using sick child recording forms during the reporting quarter. Figure 15. Participants doing a role play during IMNCI training in Kakamega During the reporting quarter, Afya Halisi sensitized of healthcare workers on establishment of ORT corners in 10 private health facilities. This was in response to gaps identified in the management of diarrhoea during support supervision. The project advocated for acquisition of the ORT equipment by the private facilities. In the next quarter, the project will provide ORT equipment to some of the needy private facilities to address the gaps and the county to technically support the facilities to improve the functionality of the ORT corners.
The project also carried out quarterly quality of care IMNCI assessments in 2 high volume health private health facilities in the county. In the two facilities, it was noted that sick children weren’t being seen in a specific area in the hospital, there was no functional ORT corner, IMNCI chart booklet was not in use, there was no job aid for triaging, poor documentation in registers leaving out IMNCI classifications, there were no resuscitation equipment/drugs checklist and no warming device. Additional there was no lockable cabinet in the ward and there was no blood in the laboratory. The project advocated for attendance of sick children in the appropriate area i.e. MCH; In-charges to allocate area for ORT corner; IMNCI booklet to be placed at the clinical area where children are seen; avail job aid for triaging; improve documentation of IMNCI classifications in registers as per standard operating procedure (SOP) and creating a checklist to ensure all resuscitation equipment are available.
Disseminate IEC materials for IMNCI: To improve case management of children under five, the project procured and disseminated 180 copies of scanned sick child recording forms and 30 copies of IMNCI flipbooks. In order to avail convenient access to reference materials and to serve as job aids to build capacity of the health providers, Afya Halisi disseminated the 2018 IMNCI guidelines to 8 private facilities. The guidelines will also guide healthcare workers in conducting CMEs.
Kisumu County Quality of Care Assessments: During the quarter under review, the project supported six child health mentors in performing a QoC assessment in three high volume facilities per sub-county. Eighteen facilities were reached. Health facilities were evaluated for readiness to manage pneumonia and diarrhea. Gaps identified included: 1) knowledge gaps on IMNCI specifically on classification and treatment of diarrhea and pneumonia in accordance to the national guidelines, 2) documentation errors, especially on presence or absence of danger signs, 3) erratic supply of commodities and
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occasional absence of equipment especially ORT corner equipment and 4) understaffed facilities forcing students with little knowledge to do triaging. Because of the above findings, the project in coordination with the sub-county CH mentors rolled out CMEs on child health in order to improve knowledge. To address occasional ORS/Zinc erratic supply, the project worked with the sub-county pharmacists to redistribute the commodities.
Child Health CMEs: The project supported CMEs in Nyando, Kisumu East and Kisumu West sub- counties during reporting quarter. Cumulatively, during the quarter, 14 facilities were visited and 151 HCWs (77 female, 74 male) were given education on IMNCI. IEC materials and job aids were also distributed.
Dissemination of guidelines and reporting tools: The project also procured and disseminated 20 ORT registers, 49 ORT corner guidelines and 49 IMNCH chart booklets during the reporting [eriod.
During the quarter under review, the project sensitized HCWs in 27 private health facilities recruited in PY2 on establishment of ORT corners. This was as a result of supportive supervision that was carried out and identified a number of private facilities lacking ORT corner equipment and ORT registers. The project also mentored 11 private facilities on ORT corner operationalization during support supervision.
Kitui County Mentorships on IMNCI: During the reporting period, the project-supported mentorship sessions in the county, as these are key in child health service delivery. During the reporting quarter, 112 HCWs (62 female, 50 male) were mentored on management of neonatal and childhood illnesses using IMNCI approach. Of the 71 health facilities mentored on IMNCI, four started using sick child recording forms in during the reporting quarter. The project will work with IMNCI mentors to address the huge know-do gap and focus on high volume health facilities before scaling up.
The project conducted CMEs and mentorships in 13 private facilities reaching 16 HCWs. The main topics covered included IMNCI classification and treatment of diarrhea cases with ORS and Zinc sulphate; and pneumonia with antibiotics.
Continuing medical education (CME): The project supported continuing medical education on child health topics, which include management of diarrhea in children under five years, diagnosis and treatment of pneumonia, skills training on newborn resuscitation and essential newborn care. A total of 272 HCWs (150 female, 122 male) attended these CMEs.
ORT corners: Through ongoing mentorships on diarrhea case management, 43 health facilities have set up ORT corners using facility improvement funds. So far, 62 health facilities have fully functional ORT corners.
Dissemination of guidelines: Availability of child health guidelines is key in provision of real time quality management of newborn and childhood illnesses. The project supported dissemination of IMNCI flipbooks (v2018), ORT corner operational guidelines and policy guideline for management of diarrhea in children under five years. As a result, 46 HCWs (30 female, 16 male) in 29 health facilities attended the dissemination sessions.
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Migori County Child Health Mentors Review/ Planning Meeting: The project supported the initial review and planning meeting to guide the implementation of child health activities in PY2 including capacity building of HCWs in diagnosing and correctly treating diarrhea and pneumonia in children under five. Twenty-three (16 female, 7 male) mentors (including sub-county child health coordinators) participated. Key priorities for the quarter included capacity building of healthcare workers in diarrhea and pneumonia management to improve clinical management of cases; reporting of childhood illnesses in the relevant MOH registers; support with the provision of the current guidelines/protocols on case management and equipping all the ORT corners with basic equipment and supplies.
The supply of ORS/Zinc has been erratic at the health facilities and county-level. Chronic stock outs of basic essential drugs in the facilities is a major hindrance to correct treatment of childhood cases as per the national guidelines. The Afya Halisi team engaged the county director of health and county child health focal person in these discussions. The county procured some stock of ORS/Zinc (plus Amoxicillin DTs in addition to other essential tracer drugs as per the pediatric essential medical list) that were supplied to stocked out facilities. The project will continue to support the health facilities on commodity management sensitizations including feasible forecasting and ordering of adequate stocks of ORS and Zinc sulphate to avoid sporadic stock outs experienced in almost all facilities in the previous quarters/PY1.
IMNCI Quality of Care Assessments: The project supported the IMNCI QoC assessment by the IMNCI ToTs to assess the facilities readiness in provision of IMNCI services (management of diarrhea, pneumonia and malnutrition) in four priority high volume facilities. These assessments focused on the structural and process domains in the correct management of clinical cases in children under five. Key findings from the assessments included: 1) ORT corners were well equipped in the target facilities, 2) some of the key staffs providing clinical services in MCH were not trained on IMNCI, 3) sick children are seen at the OPD with adults compromising the targeted triaging and integration of services required for pediatric cases, 4) stock outs of Amoxyl DT, and ORS/Zinc hinder the functionality of ORT corners, 5) MCH booklets are not used by clinicians therefore immunization missed opportunities not addressed. The project will continue to support the IMNCI QoC assessments to achieve the IMNCI centers of excellence in the county.
The IMNCI QoC assessment findings from facilities showed knowledge gaps among HCWs in the classification and treatment of diarrhoea and pneumonia as per the recommended national paediatric/IMNCI guidelines. To improve the QoC, the project supported the sub-county child health coordinators and mentors to conduct facility level orientations/CMEs and mentorship sessions at high volume facilities, targeting triage of all the sick children, correct classification and treatment of diarrhoea and pneumonia as per the recommended national guidelines. This was also aimed at improving the management of ORT corners through collaborative efforts between the HCWs and CHVs. Four hundred and eighty HCWs (274 female, 206 male) including CHVs in 23 priority high volume facilities were reached. The project will continue to support targeted mentorships for the clinical staffs managing the sick children under five in order to improve the quality of clinical care and reporting in the relevant MOH registers.
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Furthermore, Afya Halisi supported a CME on pneumonia in under-fives in one of the private facilities reaching 6 healthcare workers (4 female, 2 male) attended. The basis of this was gaps identified on management of pneumonia noted during support supervision to facilities. The project also supported targeted support supervision in 11 facilities. Meeting with the Clinton Health Access Initiative (CHAI): Clinton Health Access Initiative (CHAI) is an implementing partner in child health in Migori County. The county organized a joint meeting between Afya Halisi and CHAI to help coordinate implementation of child health activities in the county and prevent duplication of activities. CHAI will be supporting ETAT+ trainings, IMNCI trainings, support procurement of child health equipment and do advocacy on commodities.
Dissemination of IMNCI Guidelines and Kenya Pediatric Protocols: In order to improve the quality of care in diagnosis and treatment of under-five illnesses in the health facilities (with a focus on diarrhea and pneumonia), the project procured and disseminated 90 IMNCI guidelines (v2018), 90 ORT corner operational guidelines (v2013) and Kenya Pediatric Protocols (v2016) based on the reported findings from the facility assessments and technical support visits by the project. The project will continue to monitor the documentation of the correct cases and treatment at the facility level and mentor health care workers on addressing any emerging gaps.
Distribution of Basic ORT Equipment: To revitalize the operations of ORT corners in the management of dehydration (diarrhea) cases in children, the project procured and distributed basic ORT equipment to additional seven health facilities in the county.
Nutrition In the two project supported counties, 32,006 children under five received Vitamin A supplementation in during the reporting quarter bringing the total performance at six months to 222,905 children, a 80% achievement of the annual target. During the reporting quarter, 10,600 children with diarrhea received zinc supplementation bringing the total achievement to 17,160, a 62% achievement of the annual target. In the two counties, 15,977 children aged 0-23 months were reached with nutrition interventions at community level, an increase of 76% compared to Y2Q1.
The county level activities are detailed below.
Kakamega County Strengthen capacity for Baby Friendly Hospital Initiative (BFHI): The project supported Matungu sub-county hospital to implement a breastfeeding workplace policy by establishing a lactation room for staff. The room was identified by the nursing officer in charge who also found equipment while the medical officer of health sought out a fridge for storing of milk. The pro advocated for the establishment of the room, issued handwashing facilities and IEC materials. This is part of the initiative the project supported towards making the hospital baby friendly and supporting staff and their patients to breastfeed exclusively. Figure 16. A staff in Matungu in the lactation room preparing to breastfeed
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In Y1, the project supported the training of two hospitals (Navakholo and Matungu) on BFHI. Thirty- three percent of the trained HCWs in the two hospitals were transferred out after training. To bridge this gap and build capacity of all staff within the facility, the project supported CMEs (30 non- technical and 45 technical staff in Matungu; 15 non-technical and 30 technical in Navakholo). Consequently, the project supported a facility self-assessment for Matungu on the ten steps to breastfeeding, which showed that the facility scored well on only two steps. Though the project supported whole site CMEs, it was realized that maternity staff were not being reached due to shifts and the high number of deliveries. The project therefore organized for a one-day sensitization meeting for maternity staff that was conducted within the maternity ward to ensure that even those on night duty could attend. In the coming quarter, the project will print and disseminate the revised MIYCN policy (2019), conduct self-assessments and build on identified gaps in readiness for external certification. The projected conducted one CME in Navakholo during the reporting quarter and will complete the required sessions in the next reporting quarter.
Based on data from KHIS, initiation of breastfeeding within one hour and exclusive breastfeeding are at 87% and 78% respectively. However, county coverage is 67% (based on facility live births) and 78% for exclusive breastfeeding.
Maternal nutrition: The number of pregnant women reached with messages on Infant and Young Child Feeding (IYCF) and maternal nutrition during ANC was 7,287 (42%). Those supplemented with combined IFAS was 15,252 (60%) while 14% received separate IFAS. The county faced stock outs of IFAS that resulted in a 5% reduction in pregnant women supplementing with combined IFAS from PY2Q2 compared to PY2Q1. The project supported the county in borrowing 200 tins from Bungoma and Vihiga counties. These were then redistributed within the county. The private sector contributed greatly to this coverage due to the stock outs in the MOH health facilities. The pregnant women supplementing with combined IFAS from the private sector was 27% (4,148). Overall, for the entire county, uptake of combined IFAS among pregnant women was 60% against the annual target. Additionally, the project reached 225 pregnant women at household level with messages on maternal nutrition through BFCI implementing CUs.
Strengthened capacity for integrated management of malnutrition (IMAM): The project started mentorship in an additional three facilities to scale up IMAM sites within the county, bringing the total from 31 to 34. This included one facility in Matungu and two in Khwisero. Follow up is being done to ensure that the three facilities are given access on KHIS to enter IMAM data. The project also supported IMAM mentorship in health facilities that scored yellow or red during IMAM assessment in year one. Twenty-one facilities were mentored, of which 14% were private. Staff transfers were found to have impacted implementation as most of those who had been mentored had been transferred out. There was also stock out of IMAM commodities for which the project continued advocating for supplies. Community linkages and referrals was an area of focus during the mentorship to help strengthen the weak linkages. In the coming quarter, the project will continue with IMAM mentorship and work with the commodity focal person to quantify IMAM commodities to support the county project their needs.
The project reached 54,878 children aged 6 – 59 months, 58% of the annual target with Vitamin A supplementation to which the private sector contributed 5%. The county coverage for the eligible
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population was 59%. In the same period 2% (1,999) of children under 5 years were detected to be underweight.
Migori County Strengthen capacity for Baby Friendly Hospital Initiative: Based on data from the KHIS, initiation of breastfeeding and exclusive breastfeeding are at 97% and 86% respectively. Private sector contributed 21% of the total number of women who initiated breastfeeding within one hour and 19% of women who exclusively breastfed. The project supported CMEs, HINI mentorship, integrated supportive supervision and DQAs. The coverages for the entire county based on facility data are 72% and 86% for initiation of breastfeeding and exclusive breastfeeding respectively.
In Y1, the project trained staff from eight hospitals on BFHI. Subsequently, the project supported CMEs in these health facilities. During the quarter under review, the project intensified efforts in two health facilities (Lwala and Kegonga) by supporting CMEs on a weekly basis for all staff within the facility, both technical and non-technical. Consequently, the project supported a facility self- assessment for Lwala, which scored three of the ten steps and failed in meeting criteria for mother friendly care. Knowledge and skill gaps were observed among mothers, technical and non-technical staff on positioning, attachment and expressing breastmilk. Initiation of breastfeeding with sustained skin-to-skin contact was also not well done. The project summarized key messages and disseminated to the CHVs during their monthly meeting to build their capacity in delivering messages to mothers during home visits in addition to information given at the health care facility. Lwala has designated a breastfeeding corner in the MCH and is in the process of setting up a lactating room for staff at the facility. In the next quarter, the project will conduct self-assessments and support CMEs based on the gaps identified in readiness towards being baby friendly.
Strengthened capacity for High Impact Nutrition Interventions (HINI): At the onset of the project, a HINI assessment was conducted to highlight gaps in implementation to determine areas of mentorship specific to facilities. During the reporting period, the project reached 15 health facilities across Migori County with HINI mentorship. Challenges noted include task shifting by the health care workers to CHVs without orientation and inadequate/faulty anthropometric equipment. All fifteen facilities visited were mentored on growth monitoring. The project will support repair of weighing scales in the subsequent quarter as well as continue with HINI mentorship based on gaps identified and support other facilities that suffered due to a number of staff transfers.
The number of children 6-59 months who were supplemented with Vitamin A was 168,027 (91% of the annual target) of which 20,008 (12%) were reached through the private sector. Based on the eligible population for Vitamin A supplementation, the county coverage was 88%.
Maternal nutrition: The number of pregnant women reached with messages on IYCF and maternal nutrition during ANC was 20,290. The pregnant women supplemented with combined IFAS were 57,797 (85%), while 9% and 7% were supplemented with separate iron and folic acid. Coverage for combined IFAS uptake was similar among the project sites and the entire county. The pregnant women supplemented with combined IFAS through the private sector were 7,118 (12%). Additionally, the project reached 381 pregnant women at the household level with messages on maternal nutrition through BFCI implementing CUs.
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Strengthened capacity for Integrated Management of Acute Malnutrition (IMAM): Mentorship for scale up of IMAM was started in four health facilities to offer IMAM services, bringing the total number of IMAM sites to 78. Sub-counties are working to ensure that these new sites are issued with data sets. As a follow up to the IMAM health facility assessment conducted in Y1 that sought to identify the gaps with IMAM implementation, the project reached 34 health facilities with IMAM mentorship. Some of the gaps with IMAM implementation included inadequate health worker knowledge and skill, incomplete documentation and poor reporting which subsequently affects the status of nutrition commodities in the facilities. The areas of mentorship included the use of the mother child booklet to determine the nutrition status of children through proper plotting and interpretation as well as Figure 17. IMAM mentorship sessions on documentation in the CWC, CHANIS and other registers used identification and classification of to document management of malnutrition as well as focusing malnutrition in Migori County on the IMAM component that scored yellow on red during the assessment. The project will continue with IMAM mentorships in the subsequent quarter to continue capacity building of the new sites as well as follow up existing sites.
The project, in conjunction with NHP Plus, supported a review meeting on IMAM. The meeting highlighted the challenges with IMAM implementation as similar to those encountered during mentorship. The consensus from the meeting was that the sub counties would submit all reports in KHIS and send hard copies of the registers to NHP as the project continues to support mentorship to address capacity gaps.
WASH During the reporting period, the project continued to support various water, sanitation and hygiene (WASH) activities both in community and health facilities in Kakamega, Migori and Kitui counties. These included triggering villages for community-led total sanitation (CLTS), follow up and verification as open defecation free (ODF); improving access to basic sanitation and basic drinking water services; and building health care worker and community capacity in WASH. The project’s performance is summarized in Table 3 below.
Table 3: Summary of WASH achievements in Y2Q1 –Y2Q2 Indicator County/ Kakamega Kisumu Kitui Migori Project Achievement Villages verified as ODF Y2 Target 51 110 161 Y2Q1 Achievement 22 0 22 Y2Q2 Achievement 37 65 102 SAPR Achievement 59 65 124 % Achievement 116% 59% 77% Number of people gaining Y2 Target 15,300 33,000 48,300 access to a basic Y2Q1 Achievement 11,350 0 11,350 sanitation service Y2Q2 Achievement 25,139 19,458 44,597 SAPR Achievement 36,489 19,458 55,947 % Achievement 238% 59% 116% Y2 Target 11,082 19,265 24,286 54,633
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People gaining access to Y2Q1 Achievement 0 0 7,494 7,494 basic drinking water Y2Q2 Achievement 0 10,880 5,100 15,980 services SAPR Achievement 0 10,880 12,594 23,474 % Achievement 0% 56% 52% 43% Individuals trained to Y2 Target 377 314 251 942 implement improved Y2Q1 Achievement 70 25 83 178 sanitation methods Y2Q2 Achievement 237 73 20 330 SAPR Achievement 307 98 103 508 % Achievement 81% 31% 41% 54% Number of basic Y2 Target 10 43 30 83 sanitation facilities Y2Q1 Achievement 2 1 0 3 provided in institutional Y2Q2 Achievement 3 22 12 37 settings as a result of SAPR Achievement 5 23 12 40 USG assistance % Achievement 50% 53% 40% 48%
WASH in healthcare facilities: The project facilitated Sub-County Health Management Committees (S/CHMTs) to give WASH specific supervision to various health facilities, as this area that has long been neglected. The team also mentored the S/CHMT on waste disposal and infection prevention and control (IPC). Further, the project disseminated IPC guidelines as reference materials, and oriented 158 (53 female, 105 male) HCWs in 31 health facilities on IPC. For sustainability, the project will advocate facility management committees and S/CHMTs to allocate resources to purchase WASH supplies using the available county and facility resources.
Health care waste management: The project is supporting Kakamega, Migori and Kitui Counties to develop long-term solutions to poor healthcare waste management (HWCM) practices that challenge public health. Building on work done in PY2Q1, the project assisted the three counties to develop comprehensive HCWM plans that direct counties to properly manage and dispose of medical and hazardous waste. In Kakamega, Afya Halisi supported the county to review the draft HCWM plan, which now awaits finalization. In Migori, the CHMT appointed a 13-member committee (3 female, 10 male) to spearhead development of the county HCWM plan. Afya Halisi supported the first meeting to draft terms of reference for developing the plan. In Kitui, the project met with the CHMT to discuss healthcare waste management challenges and developing a comprehensive plan to provide strategic direction for managing healthcare waste in the county. The project will continue supporting this process across the three counties in the next reporting quarter.
Improving sanitation facilities in healthcare facilities: During the reporting period, the project continued to support the county health and education departments to improve the basic sanitation facilities in early year education (EYE) schools and healthcare facilities. The project improved 36 facilities to provide sanitation facilities with safe access and adequate privacy. The minor improvements included unblocking clogged sewer lines (both open and closed), fixing doors on latrine structures, fixing tower bolts on latrine doors, repairing bathrooms and water systems to facilitate proper drainage in facilities. For EYEs, the project in consultation with the Departments of Education identified five schools needing to improve sanitation facilities for support in PY2Q3. The selected EYEs have dilapidated, non-functional sanitation units for EYE children. For sustainability, the project will continue to advocate to the County MoH departments and facility health management committees to allocate resources to improve sanitation facilities.
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Clean Clinic Approach (CCA): Afya Halisi, working closely with the CHMTs in the three priority counties, identified one sub-county in each county to roll out CCA using a phased approach. The project and each CHMT identified the BEmONC sites in the identified sub-county where CCA will begin. Roll out will continue to additional counties in PY2Q3 based on lessons learned.
The county specific activities are detailed below.
Kakamega County During the reporting quarter, the project conducted WASH assessment in 15 health facilities to understand better the extent of WASH needs. The assessment found that health facilities needed waste bins and bin liners. Afya Halisi provided these health facilities with 32 sets of waste bins and 60 bin liners, as a WASH start up pack. The project also conducted whole site IPC orientations with 140 HCWs (73 female, 67 male) that included clinicians, nurses, support staff, CHVs and cleaners. The project disseminated 26 IPC guidelines.
The project also supported sanitation improvement in three facilities. This brings the current PY2 achievement to five, or 50% achievement of Kakamega’s target. The improvement ranged from fixing tower bolts and door handles to tightening loose latrine doors.
Figure 17. Fixing waste management bins (Left) and Improved sanitation facility at Mundobelwa Health Centre, Khwisero sub-County, Kakamega (Right).
Kitui County To strengthen skills and practices among HCWs, the project conducted whole site IPC orientations at Mwingi West sub-county hospital reaching 74 (44 female, 30 male) people in different MOH cadres. Following the orientation, the facility observed IPC practices and has reported several other achievements that include improved hand hygiene infrastructure and commodities, continuous supply of piped water, functional water taps, liquid soap in every handwashing station and adequate hand sanitizers, all procured using hospital resources. The hospital reports marked improved hand hygiene practices among the staff and visitors. Additionally, the hospital has improved the availability and use of Personal Protective Equipment (PPEs).
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The project also conducted supportive supervision targeting water, sanitation and hygiene in private facilities. The findings ranged from absent facility IPC committees, poor waste segregation in service delivery points and poor waste disposal. To address these gaps, Afya Halisi supported 5 CMEs reaching 32 HCWs in 4 private health facilities. The areas of focus were hand washing, decontamination of instruments with use of enzymatic solution and waste management. Follow up on formation of IPC committees and action points in improvement of sanitation facilities will be done routinely in the subsequent quarter. Based on the findings of support supervision that included absence of facility IPC committees, poor waste segregation, poor or no fencing of waste pits and poor handling of sharps containers, the project supported dissemination of IPC guidelines to five facilities in Mwingi North while two facilities in Kitui Central and Mwingi North received bin liners from the project.
To improve sanitation access in health facilities, the project supported a sanitation assessment and undertook minor renovations of sanitation facilities in 22 facilities. This constitutes 51% of the targeted 43 health facilities for Kitui in Y2. Through the project’s advocacy efforts and to ensure sustainability of the WASH investment in health facilities, five health facilities used their own resources to renovate sanitation services. Some of the minor renovation works included: unblocking clogged open and closed sewer lines, fixing doors on latrine structures, fixing tower bolts on latrine doors, and repairing of bathrooms and water systems to facilitate proper drainage in facilities. During the same quarter, Afya Halisi advocated for repair of a broken patient toilet door in AIC Zombe Heath centre. The facility repaired this to allow access to good sanitation facilities for their clients.
Migori County In Migori, the project supported whole site IPC orientation in four health facilities reaching 52 HCWs (25 female, 27 male) during the reporting period. These orientations improved knowledge and influenced HCW positive behavior on sanitation, handwashing, IPC and waste management in HCFs. Following the orientation, beneficiary HCFs formed IPC committees to guide IPC and WASH issues at the facilities. To improve HCWM in the county, the project distributed 4,500 bin liners and 30 sets of waste management bins to 24 different facilities across the county. Afya Halisi is currently assisting the county to develop a HCWM plan.
During the quarter, Afya Halisi sensitized 11 HCWs (4 female, 7male) on importance of proper waste management including waste segregation, proper disposal of sharps in one of the private facilities. During support supervision, the facility was noted to have few waste bins and no stands. All HCPs were equipped with knowledge on proper waste disposal. In the next quarter, the project will procure more waste bins for facilities with the same challenges.
During the quarter under review, the project carried out minor improvements on existing basic sanitation facilities in 12 HCFs. The main improvements done included fixing missing and loose latrine/toilet doors, tower bolts, and door handles, installing placenta covers and improving drainage at the maternity wards. These health facilities are now more inviting for clients, especially the mothers delivering at the facilities as patients and caregivers have easy access to clean sanitation and handwashing facilities with adequate privacy.
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Figure 18. Patient latrines before and after repair in Sibuoche Health Centre
Activity 1.1.3. Quality improvement approaches to strengthen facility services The project recognizes that multi-sectoral approaches have been instituted to improve access to maternal, newborn and child health services. Afya Halisi invested in institutionalization of quality improvement approaches in PY1 and linking MPDSR with QI. The project has established a collaborative of 18 facilities where more than 90% of the maternal and perinatal mortalities occur. These facilities are either actively implementing quality improvement initiatives, re-organizing their teams or have successful improvement to share with stakeholders. The project will have a learning forum in this project year. Here are specific county efforts in the reporting period: Kakamega Through on-going project support, the quality improvement team (QIT) at the KCGTRH has been able to successfully reactivate Work Improvement Teams (WIT) or impress upon the various departments to constitute the teams where they were nonexistent. The project did support the orientation of the FP/MCH department and Maternity Unit WITs using the site-based mentors. A total of 14 members (9 females; 5 males) were oriented. Reports in subsequent periods will provide progress on various improvement initiatives by these WITs. ETAT+ assessment in high volume sites: The project conducted IMNCI assessment to improve quality of under-five case management at in 10 health facilities in Kakamega. Triaging was noted to be a challenge in the health facilities. The Khwisero Health Centre is planning to have a locum clinician to clerk under-five children in a separate room as opposed to clerking them together with adults.
Kisumu In the reporting period, Afya Halisi continued to strengthen quality improvement approaches in line with the KQMH strategy. QI mentorship was done in 9 health facilities and this entailed supporting the health facilities to revitalize WITs and identify projects for improvement. A total of 30 (25M 5F) HCWs members were trained. WITs have been revitalized at the following departments within the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) hospital; labour, postnatal, pediatric and OBGYN wards, NBU, MCH/FP and theatre. Progress on QI initiatives will be shared in subsequent reports.
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Kitui The three main referral facilities in Kitui – Mwingi hospital, KCRH and Mutomo mission hospital – have quality improvement teams at various stages of maturity. During the quarter, Afya Halisi sensitized the QIT comprised of 5 staff at Zombe AIC health centre on process of quality improvement and check lists for quality assessments. The project is also working with the management at KRCH to institute quality improvement processes to reduce the high rates of sepsis and improve quality of care to address gaps in the third delay. In the reporting quarter, the project supported sensitization on MPDSR guidelines to three high volume hospitals – Neema, Mutomo Catholic and Zombe AIC – reaching 22 HCWs. The QITs in the private facilities will be oriented on KQMH process for QI and will be trained and supported to carry out self-assessment of their facility in the subsequent quarter. The project conducted a focused dialogue session in the Mutha Health Centre with pregnant women, mothers with newborns and TBAs on cord care. The dialogue brought on board these groups to get an understanding of current cord care practices at community level. Through the discussion with participants and HCWs including the SCHMT, cord care practices in the past and current practices at community level were identified. It was noted that poor cord care practices are being used in care of newborns including use of soot and ash. The facilitators demystified various myths around cord care and community members were given clear messages on how to use chlorhexidine for cord care. The participants were encouraged to share with other community members information on CHX including preparing for skilled delivery. More targeted dialogue sessions will be supported in the next reporting quarter.
Migori In the reporting period, Afya Halisi continued to support QA/QI interventions aimed at improving the capacity of WITS/QITs to identify, design and implement quality improvement initiatives. The project continued to build on the WITs established during the previous quarter where a total of 16 WIT meetings were held. The project supported a sensitization meeting on KQMH at MCRH where 29 HCWs participated. This was as result of increasing poor maternal outcomes at the facility. Site improvement assessments were conducted in 4 facilities in Uriri sub-county where a second chart abstraction was done. Tracked indictors included documentation, partograph use, BP monitoring and PPFP which demonstrated improvement compared to the previous period. A team maturity index assessment was conducted in 4 facilities with an average maturity of 2.5 out 5. However, one facility (God Kwer) had a team maturity index of 4.5, an indication of active high performance. Output 1.2: Strengthened delivery of targeted FP/RMNCAH, nutrition and WASH services at community level, including effective referral to mobile and/or static facilities Activity 1.2.1. Strengthen Community Health Platform During the quarter, the project supported delivery of health services at the community level and carried out activities to strengthen the functionality of community units. CHVs were empowered to provide services at household level and facilitate dialogue sessions which influenced uptake of health services.
Finalization of CU selection The project finalized identification of the 220 community units (CUs) to be supported in Y2. The CUs were selected based on ward level performance on key indicators – Penta 1 and 3, FIC, ANC 1
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and 4 visits, and SBA. Any ward with low coverage for both Penta 1 and 1st ANC visit was considered to have low access and was prioritized. Other factors considered was the presence of partner support to the CUs, qualitative data, teenage pregnancy, family planning uptake or un-met need as well baseline assessment findings in Kitui. Final CUs selected for support were distributed as follows: Migori-32, Kisumu-60, Kakamega- 34 and Kitui 94 CUs. Afya Halisi successfully held consultative discussions with the S/CHMT for buy-in on the CUs prioritization and selection process. In the next reporting quarter, the project will carry out CU functionality assessment then roll out various capacity strengthening activities among them training based on knowledge and skills gaps identified in the functionality assessment.
Capacity building of CHVs
Training on FP and MNH technical modules: As at SAPR 2019, the project supported training of 870 CHVs on the MNH technical module, an achievement of 22% against annual target as shown in Table 4 below. The training equipped the CHVs with technical knowledge and skills to enhance their capacity in supporting community MNH services delivery, especially in providing information on pregnancy related risk, birth planning, pregnancy related complication, danger signs, importance of ANC among others. As a result, CHVs have intensified health talks and dissemination of information to women of reproductive age on ANC, importance of skilled birth attendance and PNC. In addition, they now monitor pregnant mothers and newborn in their villages and refer those who have missed essential services. Further, the project supported training of 424 CHVs on FP technical modules. The CHVs were trained on various methods of family planning, benefits of family planning and healthy timing, spacing of pregnancy, family planning counselling and family planning compliance. The training sought to improve the knowledge and skills of the CHVs on providing various FP services at community level such as providing family planning information, counseling and community level services.
Table 4: CHVs trained on MNH and FP Technical Modules, Y2Q1 – Y2Q2 County Technical module Male Female Total Kakamega MNH 31 114 145 FP 38 78 116 Kisumu MNH 50 131 181 FP 26 86 112 Migori MNH 25 103 128 Kitui MNH 124 292 416 FP 61 135 196
The project further supported CUs (66 CUs supported in Year 1) to convene monthly review meetings during which CHAs reviewed reporting, documentation, and use of data to inform CU level actions that enhance service up take.
The county level activities are detailed below.
Kakamega County Apart from training of 145 CHVs (114 female, 31 male) on MNH and 116 (78 female, 38 male) on family planning, 17 CHVs (10 female, 7 male) in two CUs (Shinoyi A and Khalaba B CUs) benefitted from community data quality (CDQ) review supported by Afya Halisi and the MOH Health Records
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and Information teams. Various gaps in documentation, interpretation of indicators and use of the community data were identified. The CDQ team then mentored on accurate and complete reporting in all the community MPH tools, indicator definitions, interpretation of data and its use.
Kitui County The project supported refresher training on the MNH module reaching 416 CHVs (292 female, 124 male). The CHVs had previously been on MNH technical module. Focus topics included communication and counseling skills, focused ANC, skilled birth attendance, PNC, cord-care practices including use of CHX and child immunization. The project further provided an FP orientation to 196 CHVs (135 female, 61 male) in Kitui South and Kitui East that focused on improving their knowledge on the various methods, side effects, myths and misconceptions, FP compliance, and communication and counselling skills. It is expected that CHVs will provide various FP and MNH services at community level following the training.
Migori County In addition to 128 CHVs (103 female, 24 male) trained on the MNH technical module, the project conducted a training for 59 CHVs (39 female, 20 male) and four CHAs (2 female, 2 male) on adolescent youth sexual and reproductive health in Kuria West and Uriri sub-counties. The CHVs were drawn from wards with the highest rates of teenage pregnancy as per the sub-county score card for October-December 2018. The trained CHVs have since mapped adolescents and are providing counselling to them during household visits. The CHVs also hold dialogue sessions with parents of adolescents on prevention of teenage pregnancies.
Training CHVs on WASH technical modules Kakamega County During the reporting quarter, the project trained 30 CHVs (21 female, 9 male) from Navakholo sub- county, Kakamega County on WASH technical module. The CHVs were equipped with skills to support community WASH implementation activities, CLTS follow-up, and to promote household water treatment, safe storage and improved handwashing with soap.
Migori County During the quarter under review, the project trained 94 CHVs (65 female, 29 male) in Migori on the WASH technical module and essential nutrition and hygiene actions. The training provided the CHVs with skills and knowledge to negotiate improved WASH practices with households and community members that should affect nutrition and health outcomes positively. In addition to promoting improved sanitation methods, the training also strengthened the CHV capacity to educate communities on household water treatment and to report effectively on WASH parameters.
Supportive Supervision for CUs During the quarter, the project facilitated S/CHMT and CHAs to conduct supportive supervision for the 66 CUs selected in Year one to strengthen delivery of health services at the community level. The supervision revealed gaps in documentation, reporting and interpretation of the mother-baby booklet. As a result, the supervisory team mentored CHVs on proper documentation and reporting, indicator definition, and use of data to inform various community level actions.
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In Kakamega County, members of the CHMT, SCHMT and CHAs provided supportive supervision to the 19 CUs (four CUs above the supported 15) reaching 190 CHVs in Matungu, Khwisero and Navakholo Sub-counties. The team observed that CHVs household visits were irregular and thus encouraged the CHVs encouraged to visit households consistently to provide various health services. The team also mentored CHVs on proper documentation and reporting.
In Kisumu County, the project supported sub-county focal persons to provide supervision to 17 CUs. The visits identified gaps in documenting feedback in the referral note at the facility level. Mentorship was provided for CHVs and CHAs on filling and interpreting key indicators on the chalkboard, identifying, capturing and notifying key health issues at household level, and interpreting mother baby booklet.
In Migori County, during the quarter, the project facilitated 28 CHAs (9 female, 19 male) to conduct supportive supervision across the eight sub-counties. The CHAs mentored CHVs on data quality management, documentation of referrals and defaulter tracing outcomes.
A meeting with CHAs and lead CHVs Migori County: CHAs discussing Khwisero SCFP Oluoch visiting and CHC members from in Kuria west with CHVs how to use MNH diary one of the HHs in Mundaha CU sub and Kuria east counties respectively to book clients as a first step in during household supportive reducing piled up defaulters supervision by CHAs
Figure 19. Community Activities
Defaulter tracing During the quarter, the project supported defaulter tracing across the four counties as part of increasing utilization of immunization and ANC services at community level. Health facilities line listed defaulters then assigned CHVs for tracking and tracing. The total number of defaulters who were successfully traced back and received missed services this quarter was 1324 (ANC, PNC and immunization) compared to 1072 in previous quarter. A uniform default-tracing tool was used across the project area to ensure accountability of the process. Because of the tracing activities, performance of some health facilities against targets improved. In Rabour Health Centre, Kisumu County for example, more than 80% of the 98 identified defaulters were traced, leading to the number of fully immunized (FIC) children rising from 64% to in the month of January to 103% in the month March 2019.
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Table 5: Defaulter tracing outcomes Mapping of pregnant women and new born in hard to reach areas to identify defaulters
County Service Listed Traced & referred Provided with service Received service in another facility Had received antigens listed but Relocated Not known Tracing in progress Kakamega Immunization 2,587 113 113 0 725 0 0 1751 Kisumu ANC 29 29 29 0 0 0 0 0 PNC 0 0 0 0 0 0 0 0 Immunization 477 477 477 0 0 0 0 0 Migori ANC 192 186 182 0 0 6 0 0 PNC 71 66 66 0 0 5 0 0 Immunization 319 308 308 0 0 0 11 0 Kitui Immunization 683 149 149 481 6 47 0 0 Total 4,358 1,328 1,324 481 731 58 11 1751
To further enhance continued use of immunization, ANC and SBA services through providing targeted messages, the project supported CHVs to provide targeted messages and focused small group dialogue sessions in areas with poor performing indicators to allow the community members discuss the importance of immunization, ANC and SBA; identify possible barriers to service utilization, and proposes mitigation measures.
Kakamega County Kakamega County had the highest number of listed immunization defaulters 2,587. However, only 113 were traced, referred and received required services. It was observed that 725 of the listed defaulters had already received antigens though the permanent registers were not updated. Efforts to trace the unreached defaulters are ongoing. Further, the project will work with the EPI coordinators to mentor MCH staff on proper documentation of children who have been immunized.
Kisumu County CHVs traced 29 ANC and 477 immunization defaulters and referred them for services to nearby health facilities. It was noted weak coordination between the CHAs and MCH staff was hindering defaulter-tracing efforts. The facilities resolved to have the CHAs and CHVs assist the MCH staff in line listing of defaulters and follow up. Kitui County During the quarter, CHVs traced 683 defaulters who had been identified in different facilities. Of these, 47 out of the 683 had relocated, 481 of the children had received the missed antigens in other facilities and 149 were confirmed as true defaulters and referred for services. Tracing outcomes were used to update permanent register in the MCH.
Migori County Listing, tracing and referral of defaulters was done weekly as defaulter tracing was prioritized in Migori County. CHVs provided information to the defaulters on the importance of attending ANC and having children fully immunized. Only four ANC defaulters who were traced did not visit the facility as expected. Follow up is being done to ensure they also receive services as required.
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Mapping for priority target populations at community unit level During the quarter, the CHVs continued to identify and map pregnant women, newborns and other priority groups. The number of pregnant mothers mapped was 1,938 compared to 237 mapped in quarter one. The mapped pregnant mothers were tracked to ensure they attend ANC as required, and deliver under skilled birth attendants. Pregnant mothers were sensitized on danger signs during pregnancy and benefits of skilled birth attendance while 2,828 of them were registered on Linda Mama.
In Kakamega County, 380 pregnant mothers were mapped, and 1,312 mothers enrolled for Linda Mama. In Kisumu County, CHVs mapped 571 new pregnant mothers, 932 children under one, and 327 new immunization clients. They referred the new immunization clients to the nearby facilities for various services. Furthermore, the CHVs assisted the pregnant mothers in preparing individual birth plans.
In Kitui County, the project collaborated with World Vision during household mapping for BFCI in Kyangwithya East Ward, and used the opportunity to track immunization status for children under two in the ward. Three-hundred and eighteen children under two were mapped; 13 were identified as defaulters and were referred for immunization. About 232 children under two years in Migwani Itoloni, Kyamboo and Kea CUs were mapped, eight of whom were defaulters and referred for immunization. In addition, 38 pregnant women were mapped. Among them, eight were teenagers. Six of the pregnant women had not attended ANC despite them being at average gestation of five months. This was mostly because of positive outcomes of previous home deliveries, influence of mother in-laws and TBAs. Immunization defaulting was attributed to religion, distance/cost of transport to the link facility, and stock outs.
In Migori County, during the quarter, CHVs identified and mapped 437 new pregnant women and 182 newborns were referred to nearby health facilities for various services. CHVs linked 48 first-time pregnant teenage women to the Young Mothers Clubs (YMC). CHVs sensitized the mapped mothers danger signs during pregnancy and benefits of skilled birth attendance. Of the mapped pregnant mothers, 97 delivered under skilled attendants. During the reporting period, 203 pregnant mothers were successfully registered in the Linda Mama initiative.
Previously trained TBAs (148) continued to serve as a birth companion, referring and accompanying pregnant women to nearby facilities. In Suna West sub-county, the TBAs referred and accompanied 83 pregnant mothers for ANC and 64 pregnant mothers for skilled childbirths at God Kwer Health Center and Arombe Dispensary. They have also worked closely with CHVs in community level health promotion activities to provide focused on messages on identifying and responding to danger signs during pregnancy, childbirth preparedness and postnatal care.
Activity 1.2.2. Support community health service delivery Activity 1.2.2.1. Conduct integrated outreaches, including outreaches targeted at hard-to-reach populations
Community Maternal and Perinatal Death Surveillance and Response The CHVs supported verbal autopsies for maternal and perinatal deaths that occurred in the community. Three maternal deaths (Kakamega-1; Migori-2) and four perinatal deaths (Kitui- 1;
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Kisumu-3) were reported. In Kakamega, the maternal death occurred within the community only one day after the mother was discharged from hospital after delivery. The verbal autopsy revealed she died of excessive post-partum bleeding. In Migori, one maternal death was suspected to result from obstructed labour, while the probable cause for the second maternal death could not be ascertained. In Kisumu, verbal autopsies for the three perinatal deaths will be carried out in the coming quarter. In Kitui, the newborn who died had developed possible sepsis (fever and refusal to feed) five days after delivery. To address some of the possible risk factors contributing to the deaths, CHVs were encouraged to empower pregnant women to be able to identify danger signs during pregnancy and postnatal period, and on the need to seek urgent medical services should they identify any such sign.
Strengthened Integrated Community Case Management (iCCM) Supportive Supervision
During the quarter under review, the project continued to support iCCM in nine priority CUs (five in Migori and four in Kakamega) that are in wards with high diarrhea burden. The project facilitated CHAs to conduct supportive supervision and mentor CHVs on areas with skills and knowledge gaps as well as reporting.
In Migori County, access to quality healthcare in hard-to-reach areas is the main challenge hindering quality treatment and care for diarrhea and pneumonia, common childhood illnesses preventable at the community level. The project (in collaboration with the community and facility CHEWs) conducted the quarterly supportive supervision to the five trained community units on iCCM within Y1. 60 CHVs and CHEWs (22 female, 38 male) were reached. Key challenges observed included: knowledge and skills gaps on correctly diagnosing fast breathing in children using the respiratory timers and chronic stock outs of ORS/Zinc at the link facilities. On job mentorship on correct diagnosis of fast breathing in children, using the respiratory timers was conducted and ORS/Zinc stocks issued to the CHVs. The project will continue to support the ICCM implementation in the target community units.
In Kakamega County, during the reporting period, the 40 trained CHV on ICCM managed children with diarrhea using ORS and Zinc at home and referred others with fast breathing and malnutrition for further management at link health facilities.
Immunization outreaches
In Kitui County, the geography is vast with hard to reach areas where access to immunization and other health services is still low. Therefore, sites that were not supported by other immunization partner NGO were identified. Immunization outreaches were conducted reaching under 1 children with various immunization vaccines.
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Figure 20. Immunization outreaches in Katoto village and among nomadic communities in Yanguli, Mwingi North
In Kisumu County, the project supported the private and faith based facilities to conduct immunization outreaches during the nurse’s industrial action. The following facilities were targeted Disciples of Mercy, St Elizabeth Chiga, Rabuor Riat and Kochieng health facilities. The number of children reached with specific antigens is summarized in the table below.
In Kakamega County, the project supported 20 health facilities to conduct outreaches in the hard to reach areas. This was achieved through integrated outreaches, reaching 112 under 1 children with Penta 1, 122 with Penta 3, 148 with measles, 138 with FIC, 144 with measles 2 at 18 months and 124 with FIC at 2 years.
Activity 1.2.2.2. Scale-up Community Based Distribution
During the reporting quarter, the number of CHVs providing various FP services increased from 772 in Y2Q1 to 1,377 in Y2Q2. The FP services they provided included targeted FP messages at household level and in dialogue sessions on various FP options; addressing myths and misconceptions on FP; Community Based Distribution (CBD) and referring clients that needed further guidance from HCWs to nearby health facilities. Table 5 below shows a summary of the FP services provided by CHVs.
Table 5: FP services provided by CHVs County # of CUs CHVs providing #s reached with Condoms Cycles of Pills providing CBD FP messages FP messages Distributed distributed Kakamega 0 307 423 8 0 Kisumu 24 626 1,524 5,107 157 Migori 7 444 122,359 1,345 113 Kitui 0 0 404 0 0 Total 31 1,377 124,710 6,460 270
In Kakamega County, 307 CHVs disseminated FP messages and distribution of male condoms. Preliminary discussions were held with the County RH Coordinator and Community Strategy focal persons on the roll out of CBD by CHVs who were previously trained on FP technical modules. This is scheduled for next reporting quarter.
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In Kisumu County, the number of CUs undertaking CBD of FP commodities increased from 9 in Y2Q1 to 24 CUs in Y2Q2. The CHVs in these CUs reached 1,524 people with FP messages, and distributed 5,107 condoms and 157 cycles of pills.
In Kitui County, 23 CHVs were involved in mobilization for FP camps and outreaches. The total number of community members reached with FP services during camps and outreaches was 187. During these camps, 60 mothers received ANC information, 43 young women received information on menstrual hygiene and 21 young women were provided information on FANC.
In Migori County, 42 CHVs in six CUs in Uriri Sub-county and one CU in Suna west CHVs were involved in CBD of commodities. This focused on FP commodities such as pills beyond condoms provision. During the quarter, 1345 condoms were distributed by the CHVs for dual protection. One hundred and thirteen women of reproductive age received pills at the community level. However, most clients in the county prefer long-term methods by most of the targeted clients.
During the reporting period, the CHVs reached 122,359 (73,993 female, 48,366 male) for community level sensitization on the various methods of family planning, benefits of family planning and healthy timing and spacing of pregnancy including post-partum family planning. Because of the continuous sensitization by the CHVs on FP, an increased demand for information and services on FP has been witnessed. For instance, Arombe CU in Suna West sub-county recorded an improved uptake of FP services by the women of reproductive age in the community unit.
Activity 1.2.2.3. Strengthen community-facility linkages, referral mechanisms, and accountability
During the quarter under review, the project supported establishment and use of CHV desks and convening of CU monthly feedback meetings at the health facility as some of the mechanisms for strengthening community facility linkages.
Strengthened use of CHV desks in CU link health facilities: Building on the support to establish CHV link desks for 66 supported CUs in Year 1, the project worked closely with CHAs to mentor CHVs on coordinating defaulter tracing and referrals, provision of services such as registering patients, providing health education in the morning, and filing referral forms. They also ensured the CHVs have a duty roster to guide them in serving the link health facilities on a rotational basis.
Monthly CU data review and feedback meetings at CU link health facility staff: The project continued to support monthly meetings at the link facility (for 66 supported CUs in Year 1) to further strengthen linkage between the community and health facility, and enhance accountability for the work done by CHVs. The meetings brought together CHAs, CHEWs, CHVs and other facility staff to review CU performance as well as identify areas for improvement.
In Kakamega County, all the 15 CUs held monthly reporting meetings to review performance and quality of activities done at the community level. During the quarter, the project ensured the CHVs use the files issued at the link desk for referrals as required. All documents are now filed and kept safely at the facility. Some of the community units are using desks and chairs given by other partners.
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In Kisumu County, the CUs held their monthly meetings at the link health facility to review their performance. CHVs at link facilities continued to receive community referral forms, registered patients, line listed defaulters and provided morning health education sessions. Gaps in reporting, defaulter tracing and inconsistent household visits were identified. The CHAs committed to closely monitor the CHV work to ensure they deliver the desired services to the community.
In Migori County, the project supported CHVs monthly data review and feedback meetings in 34 CUs which were conducted at the CU link health facilities. In these meetings, the CHAs assessed the levels of knowledge, understanding and interpretation of the required health indicators collected by the CHVs. These meetings were attended by 402 CHVs (293 female, 109 male) and 56 CHAs (25 female, 31 male). During the feedback meetings, the project mentored the CHAs and CHVs on definition of community health indicators, referral strategies, and identified villages having many defaulters for planned outreaches. Through these meetings, the CHVs have reported improved efforts in defaulter tracing especially for ANC, post-natal care and immunization.
In Kitui County, the project supported the MOH in holding a meeting with relevant stakeholders. Participants included six male village elders, one male village administrator, one male Assistant Chief, two PHOs (one male, one female), one SPHO, one Medical Engineer, and one Afya Halisi SBCC staff. The community identified six (4 female, 2 male) Community Owned Resource Persons (Corps) who would be engaged in disseminating health information. The sub-county PHO was tasked to advocate for community choice to be considered in the next recruitment to reduce resistance. Output 1.3: Strengthened county health systems for delivery of FP/RMNCAH, nutrition and WASH services Activity 1.3.1. Assess and improve Leadership and Governance capacity of CHMTs and SCHMTs
In Kakamega County, the project supported integrated support supervision in 3 sub-counties reaching 53 health facilities. Key findings included stock out of MNCAH commodities, inadequate FCDRR forms, lack of penile models for demonstration in FP rooms, poor documentation especially in family planning and PNC services. These issues were addressed through focused and structured mentorship.
In Kisumu County, the project supported integrated support supervision in 6 sub-counties reaching 123 health facilities. Key findings included poor infection prevention practices; stock outs of MNCAH commodities and supplies and poor documentation and remedial measures taken by the MoH mentorship teams. As a result of the UHC initiative in the county, there was observed increase in OPD and inpatient work load in the county during the reporting period.
In Kitui County, the SCHMTs and the project teams conducted integrated supportive supervision in all the focus sub counties reaching 75 health facilities. The Key findings were, lack of Implanon NXT (national issue) and documentation challenges. The project supported redistribution of NXT and mentored the staff on documentation with emphasis on integration of services.
In Migori County, the project supported integrated county and sub county level support supervision where a total of 123 health facilities were visited across 5 sub counties. The exercise was aimed at
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assessing the human resource capacity, quality of FP/MNCAH services and identifying service delivery gaps. The key findings included lack of emergency preparedness, lack of maternity files, poor utilization of Linda Mama funds and weak community to facility linkage and referrals as a result of lack of community referral tools. These challenges were discussed with the CHMT for action. The follow on module II and III training on Leadership, Management and Governance, jointly supported by Afya Halisi and Tupime Kaunti, for Migori CHMT is slated for next quarter with facilitation from the Kenya School of Government. Activity 1.3.2. Strengthen Health Workforce
During the period under review, the project continued to work with the CHMTs to support health workforce activities across the four focus counties aimed at optimizing performance, improving the quality of care and impact of the health workforce. In Migori County, the project in conjunction with the CHMT and County Public Service Board hired an additional 16 HRH staff in Migori, bringing the total HRH support to Migori county to 20. The staff were deployed to high volume and needy facilities, following a one-day induction process and their personal data entered into iHRIS. In Kisumu County, the project in conjunction with the CHMT and County Public Service Board hired an additional 13 HRH (2 HRIOs and 12 Nurses) bringing the total HRH support to Kisumu County to 20. The HRH staff came in handy in mitigating the effects of the nurses strike that affected the county during the reporting quarter. In Kitui County, a total of 51 HRH staff (8 RCO, 5 HRIOs and 38 nurses) continued to be supported by the project. The staff are placed in 34 key health facilities including 6 hospitals, 17 health centers and 6 dispensaries). Four of the staff during the reporting quarter. The replacement process is ongoing and will be finalized in the next reporting quarter.
On staff transition, it is expected that 30% of these staff are transitioned to the county payroll by the end of PY2. None has been transitioned across the four counties. The project will strengthen advocacy to the county governments for transition of the staff as per the letters of agreement.
Activity 1.3.3. Health Management Information Systems for effective use of data
This has been reported under the Performance monitoring section.
Activity 1.3.4. Access to Essential Medicines and Other Health Commodities at county and sub-county level
Stock management, inventory, forecasting and ordering for quality health: The project continued to support supply chain management activities aimed at ensuring commodity security and rational use of drugs at all levels of service delivery. During the period under review, the percentage of USG supported facilities that experienced stock out of any commodity in the 5 categories (COCs or POPs, IUDs, DMPA, Male condoms and Implants) was 69% up from 68% in PY2Q1 against PY2 target of 15% as shown in Figure 21 below.
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100%
80%
60%
40%
20%
0% Kakamega Kisumu Kitui Migori Project
Percent of SDPs that report a stock out Y2Q1 Percent of SDPs that report a stock out Y2Q2 Average stock out rate Y2Q1 Average stock out rate Y2Q2
Figure 21. Percent of SDPs that reported stock and average stock out rate – Y2Q1 – Y2Q2 The high levels of stock out across the counties, were primarily due to stock out of the male condom. In the month of March 2019 alone, 91 health facilities reported stock out of male condoms in Migori county; 116 in Kisumu county; 30 facilities in Kakamega and 276 sites in Kitui county. The male condoms were however available in the CCCs for HIV prevention purposes. The project will continue to support integration of services across the service delivery points. The average stock out rate of contraceptive commodities at Family Planning (FP) service delivery points using DMPA as the tracer commodity was 26% against a PY2 target of 15%. The project will continue to address the stock out challenges and streamline forecasting and quantification for all commodities to inform future orders from KEMSA. The project will also enhance re-distribution of commodities as guided by the FP dashboard. Commodity and supply chain management at county and sub-county level: To ensure that there is improved commodity management practices and enhanced commodity security across board, and using lessons learned from previous programs, the integrated commodity management model (iSCM) is being piloted in Kakamega and Kisumu counties. Kisumu county was selected because of its unique position in the UHC pilot process while Kakamega was selected because there is a wide range of USAID supported programs including HIV, MNH and malaria. A series of preparatory meeting were held between USAID implementing partners (AMPATH Plus, Afya Ugavi, Afya Ziwani, Afya Halisi) and the CHMTs in Kakamega and Kisumu to map out the sub-counties by partner for support. The following key considerations were made in the partner mapping exercise: Afya Ugavi provides support at sub-county and county levels in Kisumu, AMPATHPlus has presence in Western region and only supports one site in Kisumu County (Chulaimbo SCH in Kisumu West sub county); Afya Halisi is in all the sub-counties in Kisumu county except Seme (facility level support) and in three out the 12 sub counties in Kakamega while Afya Ziwani supports 17 health facilities in 6 sub counties in Kisumu county. Under this model, Afya Halisi is responsible for 158 facilities; Afya Ugavi – 192; Afya Ziwani – 17 and AMPATH Plus – 51. The model will initially address 21 tracer commodities; with a possible expansion to 51 commodities once a consensus is reached at the RMNCH TWG and the National government to conform with the UHC 301/2/3 reporting data set form reported monthly in the KHIS2
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aggregate. Table 6 below summarizes the key achievements in tracking and reporting on 21 tracer commodities during the reporting period: Table 6. iSCM Indicator Performance – Y2Q2 TA Package Indicator PY2Q2 Achievement
Support to county # of integrated commodity 1. 2 meetings were supported in Kisumu and Kakamega departments of health to management working bringing together Sub County Pharmacist, County strengthen oversight for groups supported at county Nutritionist, CRH coordinators, County Laboratory supply chain and sub-county level coordinator, County Malaria Coordinators, CASCOs, and TB Coordinator to agree on the iSCM adoption and operationalization 2. One meeting was supported in Migori to review data for all program commodities supported by KARP, Afya Halisi, Afya Ziwani, Afya Ugavi, University of Maryland (CDC donor-funded) 3. One meeting supported in Migori for county commodity security committee to plan on disposal of pharmaceutical waste and integration of supply chain activities. The meeting was co-hosted and supported by Afya Halisi, Afya Ziwani, Afya Ugavi and AMPATH plus 4. Redistribution of RMCH commodities (IFAS and Vitamin A) in Kakamega county borrowed from neighboring Vihiga and Bungoma counties # of program-specific No commodity management TWG supported for specific commodity management program area since the adoption of integrated model working groups supported except in Kitui where the TWG was integrated in the Afya at county and sub-county Halisi progress review meeting level
Capacity Building # of CME’s in commodity None Initiatives in Commodity management best practices Management
Improve inventory % improvement in facilities Using DMPA as proxy, % improvements as at the end of management practices where commodities are December 2018 and end of March 2019 were as follows: - stocked according to plan 1. Kakamega: 8 HFs (12%) - 6HFs (9%) drop 2. Kitui: 34 HFs (9%) - 39HFs (10%) Increase 3. Kisumu: 16 HFs (7%) - 24HFs (11%) increase 4. Migori: 34HFs (13%) - 33HFs (12%) drop Commodity data % improvement in DHIS2 Matungu sub county performance was 100% at position 5 acquisition, reporting commodity reporting rates countrywide. In the county ranking, Migori at position 5 and use (national and county levels) (98.1%), Kakamega at position 13 (96.2%), Kisumu 17 (94.7%) and Kitui 19(93.4%). Kakamega’s ranking is for the county with 12 sub counties and not only Afya Halisi supported.
Pharmacovigilance # of reports submitted to No adverse events reported quality assurance and the national PV system on use suspected poor-quality medicine and adverse drug reactions
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Monitoring Tracer Reporting rate in DHIS2 Aggregate reporting rate 98.3 up from 98.0% in Y2Q2; Commodities with Kakamega reporting 100% and Kisumu reporting the lowest at 95.3%. On-time reporting rate in Aggregate reporting timeliness 94.85% up from 94.1% in DHIS2 Q2Y2, with Kakamega reporting 100 % and Kisumu reporting lowest at 90.2% but which is an improvement from 87% in Y2Q1
% of observations where Using DMPA for monthly reporting of stocks between 3-6 commodities are stocked months within recommended stock levels 1. Kakamega: 8 HFs (12%) 2. Kitui: 34 HFs (9%) 3. Kisumu: 16 HFs (7%) 4. Migori: 34HFs (13%) % of observations where Using DMPA as proxy for monthly reporting of stock outs commodities are stocked out 1. Kakamega: 11 HFs (16%) 2. Kitui: 27 HFs (7%) 3. Kisumu: 10 HFs (5%) 4. Migori: 10 HFs (4%)
Supportive Supervision: During the reporting quarter, the project facilitated integrated supportive supervision involving all USAID implementing partners in Kakamega county reaching 30 health facilities including KCGTRH and 35 health facilities in 7 sub-counties in Kisumu County. Key findings from the support supervision were: discrepancies in DAR, FCCRR and MOH 711, physical stock-taking not done monthly, facilities have small or no stores to hold stocks for 3 to 6 months, distribution of job aids, monthly data verification in target facilities, mentorship on tools for collection and aggregation and quarterly data review. The project also supported the operationalization of medicines and therapeutic committee (MTC) meetings in KCGTRH where an annual work plan was developed. In Migori County, supportive supervision covered 3 sub-counties in Suna East, Kuria West and Rongo while the rest of the sub-counties were supported by NASCOP.
Improving storage conditions: To improve storage conditions, the project procured 45 pallets for Migori County. The project also supported the transportation of 150 pallets from KEMSA to Kakamega County and distribution to the sub-county level stores.
Activity 1.3.5. Health System Financing During the reporting period, the project continued to engage the CHMTs/SCHMTs in collaboration with the NHIF county officers to sensitize the communities and CHAs on the Linda Mama program. Table 7 below summarizes achievements of the mobilization processes:
Table 7. Achievements in healthcare financing – Y2Q2 Indicator Kisumu Kakamega Migori Kitui Total Was this facility accredited by NHIF or a health 3 13 165 21 202 insurance company to provide services during the reporting period? People enrolled into NHIF, Linda Mama program or 784 698 4,695 378 6,555 other health insurance cover through Afya Halisi initiatives.
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People utilizing NHIF, Linda Mama program or other 733 568 7,831 438 9,570 health insurance cover through Afya Halisi initiatives.
In Migori County, the project continued to ride on various platforms to support community sensitization and mobilization for Linda Mama enrollment. A total of 4,695 mothers were enrolled during the quarter under review. Stock out of NHIF enrollment forms at facility level, lack of NHIF codes and the needed infrastructure to support enrollment of mothers including computers and poor internet connectivity remained a challenge during the reporting period.
In Kitui County, the project continued to advocate for increased budgetary allocation for health service delivery (FP/RMNCAH, WASH, Nutrition) in the county as a key strategy on the journey to self-reliance. In collaboration with the Advance Family Planning Program (AFP), the project supported the review of the FP costed implementation plan 2014/2018. Plans are underway to develop the next 5-year (2018/2022) strategic plan for the county. To enhance partner coordination, the project supported mapping of key stakeholders in the county. This was a forum for sharing partner work plans and strategies and identifying areas of synergy and collaboration to avoid duplication of effort. The project continued to advocate and mobilize mothers for Linda Mama, NHIF and K-CHIC enrollment aimed at eliminating out of pocket expenditure on health care and improve access to service. A total of 378 mothers were enrolled.
In Kisumu County, the project supported 3 meetings for UHC coordinators reaching 357 HCWs, to assess UHC implementation progress, sensitize HCWs on UHC and address challenges around reimbursements for private sector facilities. During project supported events including maternity open days, household registration for UHC were conducted reaching 34,840 households during the mop up registration exercise. Delayed Linda Mama reimbursements for private sector facilities; non- inclusion of the private sector sites in the UHC platform; stock out of NHIF enrollment forms; lack of NHIF codes for private facilities, lack of computers and poor network coverage were key challenges that slowed down the registration process in the County. A total of 784 mothers were enrolled on Linda Mama program through the project’s support.
Figure 22 below shows an increase in clients seeking OPD services in Kisumu county following the launch of UHC in the county.
140000 Kisumu county (excluding Seme) 120000 Jan to Mar 2018 – 324,969 Jan to Mar 2019 – 385,259 (18.5% increase) 100000 80000 60000 40000 20000 0 Kisumu Central Kisumu East Kisumu West Muhoroni Nyakach Nyando Jan to Mar 2018 Jan to Mar 2019 Figure 22. Comparison of OPD visits in Jan to March 2018 and Jan to Mar 2019 in Kisumu County
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In Kakamega County, a total of 101 HCWs (76 female, 25 male) were oriented on the NHIF facility accreditation, coding and reimbursement process; registration of Linda Mama, as well as prudent use of resources. A total of 9 new sites were accredited bringing the cumulative total of Afya Halisi supported sites to 36 in the three project supported sub counties. A total of 698 mothers were enrolled on Linda Mama through the project’s support.
Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH
Output 2.1: Increased knowledge of and demand for FP/RMNCAH, nutrition and WASH services Activity 2.1.1 Identify and support context-specific strategies for healthy behaviors
TOT trainings for counselling for choice (C4C) and education through listening (ETL): The project conducted the first C4C and ETL cascade training targeting Afya Halisi and MOH staff and CHVs attached to private facilities. A total of 67 participants were taken through the two-day TOT training. The TOTs are expected to cascade the techniques down to their fellow HCWs. The participants were also trained on ETL - a participatory community facilitation technique that seeks to identify the health barriers to service uptake and subsequently come up with solutions and action plans to address the said barriers. Figure 23. Participants having group-work discussion during a recent C4C training Capacity-building CHVs: As part of the second cascade for C4C and ETL, the project trained 63 CHVs in the ground-breaking facilitation techniques and the Basic Health Modules for FP/RMNCAH. The CHVs are expected drive SBC and carry out interactive interpersonal communication (IPC) community sessions such as Small Group Sessions (SGS), Household visits, Community Dialogue Days & targeted events. CHVs have also been equipped with non-monetary coupons to aid in the closing of the referral loop. Development of context specific SBC strategies: The project carried out one fully-fledged 3D/HCD exercise in Migori exploring the issue of teenage pregnancy (AYSRH) and two mini-HCDs; WASH in Kitui and Nutrition in Kakamega. The AYSRH 3D/HCD exercise carried out in Migori County brought together participants from MOH to interrogate contributing factors to teenage pregnancies and possible solutions/strategies. The WASH mini-HCD carried out in Mwingi West (Kitui) targeted artisans, community members, CHVs and hardware store owners in a bid to develop a SBC strategy for implementation of sustainable post-ODF activities. Inter-denominational meeting: In follow-up of recommendations from the MNH HCD carried out in Kitui in PY1, the project brought together 48 religious leaders, MOH and MOE staff and partners to discuss poor health indicators, healthcare challenges and the role of faith based organisations in reversing the negative indicators in the county. The meeting agreed on the following: conduct similar
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(inter-denominational) meetings at sub-county and ward level with the support of the project, work with the project to disseminate health information to the congregations, and play a leading role in guidance and Counselling sessions targeting adolescents and youth. Activity 2.1.2 Create demand for services During the reporting period, community mobilizers conducted health education sessions through small group sessions, household visits, youth forums, club meetings and community dialogue days under the project health areas. There was also intensified mobilization for services in underserved communities leading to outreaches/in-reaches where integrated services were offered to the target audience.
Community dialogue sessions for all thematic areas: During the reporting quarter, the project conducted community dialogues in different thematic areas: MNH (ANC, cord care), FP, child health and immunization, AYSRH and gender. The location of dialogue sessions was informed by data with priority given to villages with poor performance in key indicators.
In Kakamega County, the project supported three immunization focused small dialogue reaching 101 mothers and a village elder. The session focused on giving the community opportunity to discuss through barriers to utilization of immunization services and emphasize the importance of a child getting all the antigens. During the session, 17 defaulters were identified and referred to the facility for required antigens. Furthermore, the project supported youths’ and adolescents’ parents and caregivers with dialogue sessions reaching 95 community members (62 female, 33 male). The sessions provided an opportunity to the participants to appreciate the adolescent and youth health needs and how they can be involved in supporting them.
Kisumu County, the project supported 11 focused dialogue sessions: three on MNCH, three on immunization and four on AYSRH and two on family planning, reaching 257 people (200 female, 57 male). During the FP dialogue day, the community men and women expressed fears about side effects and community propagated myths and misconceptions as the main reasons for FP methods discontinuation. Because of the dialogue, three men took their women to the FP clinic and clients in the area attending a FP camp in Kisumu Central booked long-term FP services.
In Migori County, the project conducted seven focused community dialogue meetings reaching 257 (121 female, 136 male) participants. The key issues discussed were derived from data from the community and link health facilities and focused on unskilled birth attendance, teenage pregnancies and maternal deaths. Each dialogue session developed action points with a six-month timeline for implementation and review.
In Kitui County, the project carried out 22 focused dialogues this quarter reaching 378 people (284 female, 94 male). A cord care-focused dialogue revealed that community members use different methods to care for the cord of their children some of which could have negative consequences such as soot. Information on chlorhexidine (CHX) gel for cord care in neonates was shared during the discussions and participants are expected to share information with community members. Dialogues on skilled delivery across the sub counties shows that distance is key impendent to skilled delivery. There was agreement that it would be necessary that pregnant mothers form groups and have a revolving fund to enable them access skilled delivery as required. Suggestions included involving mother in laws who were identified as key influencers of reproductive health services utilization as
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well as reaching community members with messages in public barazas, water points, matatu/ boda terminus, engaging heads of households for non-users who mostly do not attend public forums.
Immunization focused dialogues identified home deliveries, distance to the facility, poor ANC attendance due to fear of HIV testing and too many questions at the health facility as the main reasons for poor immunization uptake. TBAs agreed to accompany mothers to delivery in the facilities and to refer pregnant mothers for ANC.
Men only focused dialogue In the four counties, men influence the uptake of FP services for they are the main decision makers at the household level. The project seeks to engage them in an effort to increase uptake of FP services. During the quarter, four sessions (reaching 74 men) were held with men in Ngatie, Township, Nzawa and Kiluluni villages in Kitui which had low uptake of FP services. Service providers had shared information that male spouses forcefully remove implants from their partners if they are not consulted prior to use. The participants said they feared reduced fertility when the couple finally plan to have a baby. They also feared that their manhood would not work well when their partners were using an FP method. Health workers present clarified facts about family planning. The men appreciated the need for family planning and requested for a follow up dialogue so as to reach more men within the catchment area of Ngatie sub-location.
In Migori, Afya Halisi supported male only dialogue days. During the session, men were challenged to support their partner to attend ANC and the health facilities.
Output 2.2: Improved gender norms and sociocultural practices Activity 2.2.1. Conduct a gender analysis and develop gender strategy During the reporting quarter, the project completed the transcription of qualitative data for the gender analysis. The gender analysis findings will be disseminated to USAID and at county level in the next quarter. The project will utilize the findings to implement context-specific activities that address barriers to access to FP/RMNCAH, nutrition and WASH services.
Activity 2.2.2. Identify community platforms to promote positive gender and sociocultural norms and practices, including equitable decision-making In order to on-board Community-Based Organizations (CBOs) to support in implementation of gender activities, the project developed a Terms of reference for use in identifying suitable local organizations. The organizations will be involved in implementing activities geared towards addressing harmful socio-cultural practices, negative gender norms resulting in behaviour change. The RFA was advertised in one of the local dailies during the reporting period. In the next reporting period, the project will review the bids to identify a maximum of two CBOs per county to be engaged by the project. The representatives from these organizations will in Y2Q3 be trained on gender transformative programming. Community scorecard processes were rolled out in Khwisero sub-county in Kakamega and in Muhoroni sub-county in Kisumu. Meetings were held at the sub-county level with the SCMOH, SCRHC, SCPHN and Sub-county community health strategy focal persons to agree on the facilities where the scorecard processes would be undertaken. The project will in Y2Q3 roll out the community
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scorecard meetings which will bring together community members, service providers, and facility management to identify service utilization and provision challenges, and to mutually generate solutions, and an implementation action plan with the aim of enhancing the quality of services. Activity 2.2.3. Build capacity of HCWs, CHVs and champions to discuss gender norms and sociocultural beliefs and provide gender responsive services
Sensitization of WASH committee members in Kakamega county: During the reporting period, the project conducted a water point users Management committee sensitization. The sessions were aimed to equip the learners with knowledge on gender mainstreaming with a focus on their role in water source management, leadership, conflict management. A total of 67 (37 female, 30 male) were sensitized.
In an effort to understand the underlying reasons why community members in Kakamega opt for home deliveries, the project conducted a one-day sensitization for TBAs in Navakholo (16 TBAs) and Khwisero (12 TBAs). Some of the reasons given for home deliveries include delayed referral of women and girls to health facilities as most of them opt to access services once the pregnancy is advanced and confirmed through baby kicks; Some of the pregnant women and girls do not have birth certificates or national IDs which are necessary for registration under Linda Mama and/or NHIF; Religious beliefs that prohibit the use of facility related delivery services; Free services offered by the TBAs; negative provider attitude mostly towards pregnant women and girls who show up at the facility after 5 pm; Transport-related challenges with a focus on the distance to the facilities; Providers do not support pregnant women and girls during the labor process; Some TBAs administer herbs to hasten the labour and delivery processes among others. The TBAs cited the following as barriers to EBF – the belief that an infant should be given water to open their digestive tract; Cultural taboos around breastfeeding during pregnancy; The perception that it is not culturally acceptable to breastfeed multiple births; If male partners suckle the breasts of the pregnant mothers; and If another man and not the spouse is responsible for the pregnancy. In such instances, the woman/girl has to have her breasts and thighs cleansed using herbs. The project will use these findings to strengthen provision of skilled birth attendance services.
AYSRH sensitization in Kitui: Adolescents and youth were sensitized on harmful gender norms and subsequently guidance on how to develop strategies for reinforcing healthy norm amongst their peers. These sessions were conducted by a County Gender Officer from Kitui South. A total of 58 adolescents and youth (36 female, 22 male) from Ikutha (Kyoani), Ikanga (Tuvila) and Mutumo (Mwengea) were reached. The topics covered included developing their understanding of gender and related concepts, GBV, gender roles and effects of harmful, socio-cultural practices on SRH outcomes.
Activity 2.2.4. Strengthen county forums to improve gender equity and response to gender discrimination in relation to RMNCAH, Nutrition and WASH During the reporting period, the review of the Migori county SGBV policy was undertaken. The
project also contributed to the county level county participation forum that was convened to review the draft SGBV policy. The project participated in a planning meeting for a 6 year (2018-2023) Ministry of Health project funded by the World Bank in line with the Kenya Country Partnership Strategy (CPS, 2014–2018) with focus on building human capital through education and training.
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Output 2.3: Increased practice of key nutrition and WASH behaviors in target communities Activity 2.3.1. Promote and support key nutrition and WASH behaviors in target communities
Strengthen capacity for Baby Friendly Community Initiative (BFCI) In Migori County, the project reached 6,614 children aged 0 – 23 months through BFCI. An additional 3,131 newborns were reached through BFHI and other project CU sites bringing the total children 0- 23 months reached to 9,745. The newborns were reached with messages on exclusive breastfeeding while the other children were reached with messages and offered practical support on infant and young child nutrition. The project also supported integrated monthly review meetings for the CHVs.
Towards end of the reporting quarter, the project scaled up BFCI in Migori County by training 24 HCWs (9 female, 16 male) drawn from 12 health facilities in five sub counties namely Awendo, Rongo, Kuria East, Suna East and Suna West. In the subsequent quarter, the project will support community sensitization meetings, training of community mother support group and CHVs from 17 CUs linked to the 12 trained facilities. In the other BFCI-implementing CUs, the project will continue supporting CMEs and self-assessments towards being baby friendly.
120 97 96 95 95 100 88 86 82 81 80 60 40
20 9 3 0 Initiation of Pre lacteal feeding Exclusive Introduction of Intake of animal breastfeeding breastfeeding complementary source foods
feeding
Jan - Mar 18 Jan - Mar 19
Figure 24: Performance on BFCI indicators in Migori, Y2Q1-Y2Q2
From BFCI implementation and scale up, there has been progress in indicators: initiation of breastfeeding increased from 86% to 97%; pre-lacteal feeding decreased by 6%, exclusive breastfeeding increased by 8%, introduction of complementary foods increased by 135 while intake of animal source foods increased by 14%.
In Kakamega county, the project reached 6,232 children aged 0 – 23 months. A total of 4,328 children aged 0 -23 months were reached through BFCI, while 1,904 newborns were reached through BFHI and other project CU sites respectively. The newborns were reached with messages on exclusive breastfeeding while the other children were reached with messages and offered practical support on infant and young child nutrition.
Initiation of breastfeeding has increased in the previous three quarters from 88% to 95% while exclusive breastfeeding and introduction of semi-sold foods was not significantly different at 88%
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and 87% respectively as shown in Figure 25 below. There was also an increase in intake of animal source foods among children older than six months from 78% to 90%.
120
100 92 95 88 90 87 88 88 91 87 90 78 80 80
60
40 20
0 Initiation of breastfeeding Exclusive breastfeeding Semi solid foods intake Animal source foods intake Jul - Sep Oct - Dec Jan - Mar
Figure 25: Performance on BFCI indicators in Kakamega, Y1Q4 – Y2Q2
The total health facilities implementing BFCI within project sites in Kakamega County are 18 of which 17% are private. The project conducted spot checks in some households selected randomly to determine the messaging on breastfeeding at community level. Despite having been trained on BFCI, CHVs were found to have knowledge and skills gap. The project therefore supported CMEs in the three sub counties for all staff and CHVs reaching 434 participants (321 female, 113 male) with a focus on the various aspects of supporting and ensuring exclusive breastfeeding. The project also supported integrated monthly review meetings for CUs to strengthen documentation and reporting of BFCI data.
Mass Screening: In Migori County, the project analyzed data for children under five who were underweight in 2018. Overall, prevalence of underweight was at 2% for the county. However, there were greater differences among facilities ranging from 0% to 13% underweight. The project organized for mass screening in the catchment areas of four health facilities that had recorded underweights greater than 10%. The total children screened in these sites using MUAC was 2,417.
Training of EYE teachers: In Kakamega County, the project sensitized 89 EYE teachers (84 female, 5 male) on how to screen using MUAC, Vitamin A supplementation and WASH. The project issued the teachers with MUAC tapes to screen children and refer those at risk of malnutrition to the nearest health facility. In the next reporting quarter, the EYE teachers will mobilize support for vitamin A and malnutrition screening during Malezi bora weeks.
WASH: The project demand for services through sanitation marketing of products that will assist communities climb the sanitation ladder. Kitui County advocated for communities to install Satopans and Satostools to improve existing latrines and make them more sustainable. Afya Halisi’s WASH and SBC teams undertook a mini human-centered design assessment to ascertain the acceptability of Satopans and to better understand barriers and solutions that may exist for ODF sustainability in Mwingi West Sub-County.
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Activity 2.3.2. Improve Water Sanitation and Hygiene practices During the quarter under review, the project enabled 44,597 people to gain access to a basic sanitation service, bringing the cumulative total to 55,947 as at SAPR 2019. This reflects an achievement of 116% against the project's PPR target of 48,300. These people were reached as a result of 124 villages being verified ODF as at SAPR 2019 period. Within the quarter, the project invested in training 330 individuals on improved sanitation methods bringing the total to 508 people trained. This reflect an achievement of 54% against the project’s PPR target of 942. During the quarter under review, the project supported 15,980 people to access safe drinking water bringing the total to 23,474 people as at SAPR 2019. This reflects an achievement of 43% against the annual target of 54,633. During the quarter under review, the project supported 37 health facilities to improve basic sanitation facilities bringing the total to 40 facilities as at SAPR 2019. This reflects an achievement of 48% against the project's PPR target of 83.
Figure 26. Mukuyu spring before and after improvement, Migori County
In Kitui, the county rolled out three key pillars for post ODF sustainability: 1) skills upgrading 2) social norms training for local leaders and 3) sanitation marketing. During the quarter under review, the project working in partnership with Department of Health, identified and upgraded the skills of 21 (3 female, 18 male) local artisans to adopt and install an improved sanitation facility. To support Kitui County’s post-ODF plan to upgrade skills, the project trained artisans to install Satopans and to line latrines to prevent them from collapsing.
Activity 2.3.3 Support County WASH and Nutrition forums and link with partner projects
In Migori County, the project supported one CLTS review forum for Migori County that brought together all partners involved in CLTS. During the meeting, the MOH revised the ODF declaration date from March to May 2019 because about 20% of ODF certifications were take place in April 2019. In Kakamega County, the project supported a County WASH stakeholders’ forum for all WASH partners. The 25 participants resolved to meet next quarter to form a TWG to discuss WASH issues affecting the county, promote synergy and avoid any duplication of effort. In Kitui County, the project supported the County Department of Health to convene a WASH stakeholder’s forum. The meeting identified the need to establish a WASH TWG to coordinate WASH activities across the county, promote synergy and avoid any duplication of effort. The participants discussed merging two separate WASH stakeholder forums that, to date, have been organized separately by the Departments of Water and Health.
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Sub-purpose 3: Increased MOH stewardship of key health program service delivery
Output 3.1: Strengthened coordination, M&E capacity Activity 3.1.1. Support MOH to convene coordination structures including TWGs and interagency coordinating committees In this reporting quarter, the project provided technical support in FP and MNH TWGs. Key deliberations include; Family Planning During the TWG, key issues discussed were the commodity security. In this current year, only $9.1m has been secured creating a deficit of $15.1. The counties are well stocked with all commodities, however, as at 1st March, only 2 commodities (POPs and COCs) were within the ideal stock level at the central level. UNFPA is in the process of procuring some additional commodities with a bias on implants. In preparation for the release of the ECHO study findings, a task force was established comprising of key stakeholders from the family planning and HIV communities. Thematic subcommittees including media, advocacy, technical will be formed once the task force is operationalized. Maternal and Newborn Health MPDSR is still not fully functional in all counties. Data quality remains a key challenge after a review of DHIS entries on maternal deaths revealed discrepancies with information from the county RH coordinators. The Ministry hopes to provide technical support in establishment and revamping the functionality of the committees across the country.
The program intends to conduct an RRI on improving MNH indicators across some focus counties with poor performances. A working team was established to spearhead the development of the implementation plan for the RRI
Activity 3.1.2. Build M&E capacity and strengthen strategic information for evidence-based policy planning HMIS revision of tools During this quarter, the project in collaboration with Jhpiego’s Advanced Family Planning project provided technical and financial support in reviewing FP/MNH/AYSRH/SGBV indicators and data elements that are currently collected within the HMIS. Following the meeting, a proposed list of indicators and data elements were finalized and presented to HMIS for consideration. In line with the proposed revisions, the registers and reporting tools were revised to reflect the proposed changes. In the subsequent quarter, the HMIS division will convene a stakeholder meeting to ratify and adopt the changes before printing and dissemination of the tools.
Output 3.2: Strengthened capacity to develop evidence-based policies, strategies and guidelines Activity 3.2.1. Provide technical support for the development, review and dissemination of national policies, guidelines and technical briefs
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During the quarter under review, the project supported the Newborn Child Adolescent Health Unit (NCAHU) to finalize neonatal guideline for hospitals. The guidelines are important in informing neonatal care in hospitals. Dissemination of the guidelines will be completed in the next reporting quarter. Activity 3.2.2. Revitalize the DFH research agenda The project engaged the head of Division of family health in identifying a focal point who will spearhead the revitalization of the research agenda. In this reporting period, the project in collaboration with DFH developed a survey monkey that was aimed at establishing current RMNCAH research priorities in institutions including the various units in DFH, KEMRI, APHRC, AFIDEP, partner organizations. This is the first step in collecting baseline information and thereafter a smaller working group comprising of MoH and research stakeholders will be established to develop the research agenda.
Lessons learned
The lessons learned during the reporting period included; • Data driven outreaches and in-reaches is an effective and efficient model of reaching the underserved and marginalized populations. • Coupling youth events with activities such as ball games is an effective and efficient mobilization strategy for the youth. • The low dose high frequency mode of couching has helped build staff confidence in addressing MNH emergencies at Migwani sub-county hospital in Kitui among other facilities. • Structured onsite mentorship and iterative planning sessions, fosters proper implementation of high impact program intervention. • Empowering the community with the right information, dispelling myths and misconceptions, goes a long way in influencing behavior change and improving service uptake. • To achieve a desired program outcome, supply side and demand creation interventions should match. There should be enough capacity at facility level to fulfil the needs of the community that is so mobilized. • Small group sessions in the community bring out a lot more issues with suggestions for solutions • Use of CHVs in the management of ORT corners in health facilities improves care for children who require rehydration and overall documentation in the relevant MOH registers as evidenced at Giribe dispensary, Suna West Sub-county.
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III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT)
Refer to attachment
IV. CONSTRAINTS AND OPPORTUNITIES
The constraints and opportunities that affected activity implementation during the quarter under review is as detailed below:
• Health Care Financing: The rebates from NHIF and Linda Mama program are not ploughed back into service delivery, instead going into settling recurrent expenditure. The project will continue to advocate for rational use/ allocation of resources to improve quality of care. • Inadequate supply of primary data collection tools (Facility and CHS): The tools have been under revision and the final version is yet to be shared by MoH. As a stop gap measure, the project has been facilitating by photocopying. The project is in the process of procuring maternity clinical files • Inadequate supply of blood and blood products: The project in collaboration with Rotary Club of Kisumu conducted a blood drive harnessing 85 units of blood in Migori. Through advocacy, the county holds quarterly of blood donation drives. • Inappropriate deployment of service providers leading to artificial staff shortages: The project continues to advocate for reorganization of staffing rosters to match client needs. • Inadequate number of providers trained to proficiency to offer voluntary surgical contraception (BTLs and vasectomy) and LARC. • High staff turnovers more so in the private sector and staff shortages affecting service delivery especially provision of 24 hour services in the lower level sites and missed opportunities for skilled birth attendance. • Low utilization of high volume FBO facilities: The project team continues to advocate for the use of K-CHIC scheme to cover costs in FBO facilities. • Potential for leverage between CHAI, GAVI and LVCT activities will be helpful in increasing immunization coverage for Kitui County. • Partnership with Catholic Medical Mission Board (CMMB) CHAMPs project in Kitui South is an opportunity in conducting immunization outreaches and child health continuous medical education.
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V. PERFORMANCE MONITORING
Support for development of AWP 2019/2020 The project supported the development of the 2019/2020 annual work plan in Migori, Kisumu, Kakamega and Kitui counties. The project facilitated the activity through convening planning meetings at sub county, ward and facility level. The completed sub- county AWPs were submitted for compilation at the county level. Target setting and EPI microplanning for 2019 The project supported the process of setting EPI programmatic targets across the four counties. The process was guided by Reach Every Child (REC) strategy to identify unvaccinated and under vaccinated children in the supported counties. These forums Figure 27. AWP meeting in Mwingi West sub- provided a platform for capacity building of the new county facility in-charges and SCHRIOs to enhance skills on planning and monitoring of child health indicators. Conduct Kitui baseline assessment During the reporting period, the project implemented the second phase of the Kitui baseline assessment, which included the two Kitui Rural and Kitui West sub-counties, that are not supported by the project. Data was collected, analyzed and preliminary findings shared with the CHMT together with SCHMTs from the two sub-counties. The findings were incorporated in the main baseline assessment report, followed by validation meeting at the county level. Strengthen capacity of MOH systems, structures and personnel on data collection and use Train SCHMT and CHMT on data for decision making: In Kisumu County, the project together with Tupime County supported a data analytic training for 40 SCHMT (21 Female, 19 Male) members. The training focused on elements of data demand and use, data extraction and DHIS2 navigation, dashboard development and indicator definition. The training will enable HCWs to conduct data abstraction and use in health care service provision moving forward. Mentorship to HRIOs and facility in charges on data collection and reporting tools: In Kisumu County, the project conducted mentorship on child health data capture and reporting tools in 38 facilities reaching a total of 168 HCWs (100 female, 68 male). The data mentors developed in Y2Q1 were utilized during the mentorship process. In Migori County, a total of 16 HMIS/Data mentors (9 female, 7 male) were identified across Migori county awaiting orientation on mentorship skills. The mentors comprising of 12 Nurses and 4 HRIOs are drawn from different facilities. The mentors will help improve data capture, indicator definition, reporting and overall data quality aspects. In Kitui County, the project worked with MOH to conduct on-site mentorships in 75 health facilities during the reporting period. A total of 136 HCWs (83 female, 53 male) were mentored on documentation process. Key findings during the exercise included; availability of good data management practices and update of progress charts. Besides, documentation challenges, poor
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AYSRH indicator definitions and lack of updated version of MOH tools was noted. Action plans were developed to address the gaps. Improving data quality Quarterly sub-county RDQA and feedback meetings During the reporting quarter, the project supported SCHMTs in the four focus counties to conduct RDQA on FP/RMNCAH and nutrition indicators in 88 facilities and 2 CUs. For example in Kuria West sub-county in Migori County maintained good performance recording 95% in data accuracy, 94% completeness and 96% in precision. Feedback meetings were held to share the findings and action plans developed to address the gaps. In addition, the project undertook a DQA exercise in 2 community units in Kakamega. The findings showed lack of reporting tools for the CHVs as a major gap, hence posing a challenge during mapping and household visits. It also emerged that the CHVs had inadequate knowledge on proper use of registers. As a stop gap measure, on job training was conducted in the 2 CUs with plans underway to scale up capacity building of CHVs in other supported CUs, through mentorship and OJTs. Strengthening HMIS During the quarter, Kisumu, Kakamega, Migori and Kitui counties registered over 95% reporting rates in the major reports that include MoH 711, 710 and 711. The project contributed to the achievement through verification and validation of data reported in DHIS2, triangulation of data for various indicators to check for accuracy and consistency, and support of airtime to SCHRIOs for uploading data into DHIS2. Identified inconsistencies were shared with the SCHRIOs and corrections were done in DHIS2. Strengthen data use for decision making
QGIS orientation training During the reporting quarter, the project supported training of 16 SCHRIOs from Migori County and project staff from Kitui on QGIS. During the orientation, the team developed QGIS maps using mined data in DHIS2. The project will continue to champion data demand and use through application of QGIS as one of the key data visualization tools. Quarterly sub-county data review meetings During the reporting quarter, the project supported monitoring of monthly facility progress through quarterly sub-county data review meetings which also used the RMNCAH scorecard to review sub- county and ward level performances. At facility level, the project continued to strengthen use of the “talking walls” to review performance and develop action plans for implementation. In Kitui, a total of 241 HCWs (132 female, 109 male) from 127 facilities and 3 sub counties attended the sub county data review meetings. The RMNCAH score card revealed wards within the region that had unvaccinated children leading to low coverage. Some of the action plans developed included need for immunization microplanning meeting to strategize on reaching every child with immunization services as well as robust community mobilization services to improve SBA coverage. In Kisumu county, low performance in 4th ANC visit and immunization indicators was noted. The team developed performance implementation plan to be tracked for the next 3 months to reverse the trend. In Kakamega county, the review meeting focused on high volume facilities. The forum
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provided an opportunity for various stakeholders to review their performance and plan effectively based on informed decisions. In Migori County, ward level performance reviews using QGIS map outputs and scorecard were conducted in the eight sub-counties. The purpose of the ward performance reviews was to have an in-depth understanding of RMNCAH performance, challenges and best practices. Most of facilities in Awendo sub county recording impressive performance i.e. above 70% in Penta 1 and Penta 3 coverage respectively. Ward administrators and representatives of the wards promised to work with the poor performing health facilities to improve service provision and uptake.
VI. PROGRESS ON GENDER STRATEGY During the reporting period, the project intensified community-level efforts to identify and address some of the harmful socio-cultural practices that act as barriers to service access and utilization. Small group sessions were held to identify opportunities the project can use to reach the unreached with immunization services and accurate information on FP, SBA and ANC. Male-focused group sessions were held with boda-boda riders, young men and religious leaders in an effort to enhance their participation and involvement in FP/RMNCAH, WASH and nutrition. The project will in the next reporting period utilize findings of the gender analysis to develop a gender strategy and targeted interventions to address gender related barriers and opportunities to service utilization and adaption of healthy WASH and nutrition behaviors. The project will in Q3 implement GBV activities once approval is obtained from USAID.
VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING The project continued to support the implementation of the Environmental Mitigation and Monitoring Plan (EMMP) that was developed and submitted to USAID to guide environmental mitigation measures. Details on the progress in implementing the project’s EMMP for Year 2 are included in the EMMP progress report. The project continues to engage the CHMTs/ SCHMTs on health care waste management having developed Waste Management Plans the previous quarter. The construction works, funded by JICA, for modern microwave incinerators at KCGTRH and JOOTRH are ongoing. Asbestos roofing materials, remains a wide spread problem in Kakamega county. The affected health facilities are at different stages of replacing the asbestos material from the roofs.
VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS During the quarter under review, Afya Halisi project continued to collaborate with USAID funded mechanisms as well as other funding agencies to share information, leverage resources and avoid duplication of effort. The collaborative activities accomplished through such linkages are as detailed in Table 8 below:
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Table 8 Linkages with other partners National Mechanism/ Other Activity/Achievement USAID partner Afya Ziwani Linking of adolescent girls to funding opportunities provided by Afya Ziwani at Nyakuru dispensary in Awendo. Integration of AYSRH services in 4 safe spaces established by Afya Ziwani
UNICEF /GAVI Growth monitoring and immunization services support KEYOP Linking the youth to economic opportunities
HRH Kenya HRH TWG and Stakeholder meetings in Migori County for the Lake Basin Cluster TCI FP activities in Migori County LVCT SQUALE Community level quality improvement initiatives for Community Health services in Kitui and Migori counties. Training of CHVs on MNH technical modules. Blood donation campaign in Migori county , a total of 250 units of blood collected Rotary Club of Kisumu from donors over the two-day event.
Pronto simulation ToT training at St Joseph Ombo Mission Hospital PTBi. Tupime Kaunti (Palladium) Collaborated during sub-county data review / planning meetings and joint county level MPDSR meetings Amref Health Africa Strengthening of WITS /QITS at the level 4 and 5 health facilities using the KQMH model. WASH program / Support for outreach activities KMET Supported the scale up of UBT in the management of Post –Partum Hemorrhage in Kakamega and Kisumu counties Pharm - Access / NHIF Accelerate UHC registration in Kisumu County Afya Ugavi / Afya Ziwani / World Integrated supply chain management model roll-out planning meetings / Bank/ AMPATH Plus strengthening supply chain mechanisms / support for County integrated TWG meeting for Migori. NHP+ Addressing the management of malnutrition in Migori County. Supply of documentation tools and food commodities for health facilities managing malnutrition. Review IMAM implementation and progress and sensitization of new HRIOs on IMAM. Support for outreach activities in Kitui County
Feed the Future BFCI Trainings in Kakamega County (Kitchen gardening)
World Bank - Multi Donor Trust Supporting 4 hospitals (Kitui County Referral, Mwingi, Kauwi and Kanyangi) to Fund- ( MDTF) strengthen the MPDSR process; updating the committees on the new guidelines / tools.
The project will continue to strengthen county level stakeholder meeting to enhance collaboration, synergy and leveraging resources.
IX. PROGRESS ON LINKS WITH GOK AGENCIES The key achievements during the quarter under review included: • Ministry of Education: Vitamin A supplementation in ECD centers/ trained teachers on AYSRH and roll out of the School Health Program.
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• Ministry of Agriculture: Roll out of BFCI at Community level, teaching the CUs on how to set up an ideal kitchen gardens • NHIF: Strengthening NHIF and Linda mama enrollments. • KEMSA and MEDS: KEMSA continued to avail essential MNH commodities to the counties based on the pull system. MEDS supplied subsidized commodities mainly to the private sector facilities. • Ministry of Education: Development of AYSRH curriculum for teachers • Ministry of Gender and Youth Affairs: Providing TA during TWG meetings / Collaborated on AYSRH and SGBV programming. • Ministry of Youth (National Council): Supported in mobilizing youth for dialogue sessions • National and County Government (Kitui): Mobilization of communities during baseline survey/ Mobilization of men only dialogues including boda-boda riders. • KMTC: Formation of ASRH groups to steer youth activities inside and outside KMTC
X. PROGRESS ON USAID FORWARD To deliver results on a meaningful scale in gender sensitive programming, the Project is at an advanced stage of engaging eight CBOs to handle specific scope of work on gender. The sub-county and county level AWP development process incorporates Afya Halisi strategies and approaches and therefore a significant number of the project approaches can be funded using local budgets since they are embedded in the County AWPs. This will promote sustainable implementation through high- impact partnerships and local solutions and identify and scale up innovative, breakthrough solutions to intractable service delivery challenges.
The project continues to improve on service focus and selectivity, having gone through a data driven CU selection process. More emphasis will be placed on support for Community Health Services given that facility level performance is relatively better. The project continues to engage the private sector as a key stakeholder in service delivery and leveraging resources with other USAID funded programs. The project continues to foster the development of innovations improving the lives of mothers and children across the four focus counties. Some of the local solutions to health financing challenge that the project has been working closely with include: The Oparanya Care / Imarisha Afya ya Mama na Mtoto program; K-CHIC; NHIF; Linda Mama program; KMET and FACES.
XI. SUSTAINABILITY AND EXIT STRATEGY The vision of program sustainability for Afya Halisi is infused into the implementation approaches designed to help counties and facilities to operationalize existing Government of Kenya policies and programs. At the sub county level AWP development stage, Afya Halisi activities are included and therefore a significant number of the project approaches can therefore be funded using local budgets since they are embedded in the County AWPs. These are key initial steps in strengthening the systems and placing the counties in the driver’s seat in the journey to self-reliance.
The project, through county level stakeholder meetings, endeavors to bring public and private investments together with committed Ministry of Health (MoH), national, and county leaders to address maternal mortality. The MPDSR committees are able to count, analyze, and report all maternal and perinatal deaths along with the cause of death; improve completion of facility records
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and registries; institutionalize maternal and perinatal death surveillance and response (MPDSR) in each sub-county and foster high-level awareness of these reviews among traditional, religious, and political leadership to learn from each preventable death and promote necessary health system and cultural changes.
The project continued to promote capacity strengthening of the MoH mentors in the various service delivery technical areas, to provide mentorship to service providers at facility level. During the quarter under, Advocacy, Technical Working Groups (TWG) and quality improvement teams, joint work planning, mentorship teams, and working off the existing community level platforms, supported by the counties, were key sustainability strategies.
XII. GLOBAL DEVELOPMENT ALLIANCE Not Applicable
XIII. SUBSEQUENT QUARTER’S WORK PLAN
Table 9. Subsequent quarter’s work plan Planned Actions from Previous Quarter Action Status Explanations for this Quarter Deviation Management activities On boarding of 8 CBOs to support gender mainstreaming activities On course Nil deviation Conduct a gender analysis and develop gender strategy Complete Nil deviation Quarterly Review Meetings with USAID On course Nil deviation Acquire a spacious office for Kisumu based staff Complete Nil deviation PY2 Work plan unpacking for project staff Complete Nil deviation PY2 Work plan unpacking meetings with the CHMTs/ Sub County Complete Nil deviation HMTs Procure essential office equipment and supplies Complete Nil deviation Development of joint work plans (county/sub county and high Complete Nil deviation volume health facilities (30) HRH staff hires Complete Nil deviations Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services Output 1.1.: Strengthened FP/RMNCAH, nutrition and WASH service delivery at health facilities, including referral from lower level facilities and communities. Family Planning Establishment of master trainers and mentors on LARCs Complete Nil deviation Standardization training of mentors on LARCs Complete Nil deviation Training of frontline HCWs on LARCs Ongoing Nil deviation Whole site orientation of service providers on Ongoing Nil deviation LARCs/PPFP/BCs/PIFP Conduct CMEs/Orientation of HCWs on LARCs in high volume sites Ongoing Nil deviation Mentorship of HCWs on LARCs Ongoing Nil deviation Print and disseminate job aids and guidelines Ongoing Nil deviation Strengthen inter-facility referral networks for FP in mission facilities Ongoing Nil deviation Training of HCWs on PPFP Ongoing Nil deviation Conduct mentorship on PPFP Ongoing Nil deviation Conduct whole site orientation on PPFP Ongoing Nil deviation
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Establish VSC teams at Sub-county level Ongoing Nil deviation Training of 4 VSC providers per sub-county Ongoing Nil deviation Conduct mentorship of VSC providers Ongoing Nil deviation Conduct BTL/VSC In reaches in Level 3 and 2 facilities Ongoing Nil deviation Conduct training of HCWs on implant removal Ongoing Nil deviation Conduct mentorship of HCWs implant removal Ongoing Nil deviation Strengthen referrals and linkage for difficult implant removals Ongoing Nil deviation Capacity building of HCWs on C4C and BCS+ Ongoing Nil deviation Sensitize HCP on FP compliance Ongoing Nil deviation Orient HCWs at the PIFP Ongoing Nil deviation Strengthen integration at MCH and CCC/PSC with a focus on HIV, Ongoing Nil deviation immunization and Child health Support FP stakeholder meetings and RH TWGs Ongoing Nil deviation Conduct FP sub-committee TWG meetings Ongoing Nil deviation Support supervision for FP&AYSRH Ongoing Nil deviation Conduct client exit interviews and mystery client interview Ongoing Nil deviation Procure and distribute non consumables for LARCs Ongoing Nil deviation Support FP camps and integrated outreaches in hard to reach areas Ongoing Nil deviation Train CHVs and CHAs on DMPA-SC Ongoing Nil deviation Conduct advocacy meetings at the county on the scale up of CBD Ongoing Nil deviation DMPA-SC Provide CBD kits Ongoing Nil deviation Conduct support supervision for community based distributors Ongoing Nil deviation AYSRH Ongoing Nil deviation Develop county specific AYSRH master mentors Complete Nil deviation Hold sub-county youth camps/symposium during school holidays Ongoing Nil deviation Training Youth Champions on AYSRH & life planning Ongoing Nil deviation Training CHVs on AYSRH & life planning Ongoing Nil deviation Conduct sensitization during PTA meetings Ongoing Nil deviation Hold community dialogue with Key behavior influencers e.g. boda- Ongoing Nil deviation boda, cane cutters, gold miners, fisher fork, practice of ong'ora, migrant population & truck drivers. Conduct community action cycle events on harmful cultural practices Ongoing Nil deviation Develop AYSRH appropriate IEC materials (flyers, posters, Ongoing Nil deviation brochures, banners including promotional materials) Train teachers to provide health education talks for students focusing Ongoing Nil deviation on AYSRH information and life skills/life planning Support teachers to provide health education talks for students Ongoing Nil deviation focusing on AYSRH information and life skills/life planning Form and facilitate clubs for out of school young adolescents and Ongoing Nil deviation youth Whole site sensitization on AYSRH, provider initiated PPFP ,VCAT Ongoing Nil deviation and gender norms ,respectful care Establish and conduct young mothers clubs sessions at facility level Ongoing Nil deviation and community level Standardization of AYSRH implementation packages ( Instructional Ongoing Nil deviation workshop on AYSRH Participate in Health days ( National /international days) Ongoing Nil deviation Establish and support formation of interagency coordinating Ongoing Nil deviation committees at the county level .Support service extension and weekend service provision for Ongoing Nil deviation AYSRH services
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Support AYSRH stakeholder meetings. At the county and sub-county Ongoing Nil deviation levels Create a network of Adolescents through county hotline groups a Ongoing Nil deviation forum to ask questions on AYSRH/FP FP Compliance Ongoing Routine systematic monitoring Maternal and Newborn Health Kangaroo Mother Care Training Ongoing Nil deviation Respectful Maternity Care Ongoing Nil deviation Focus Antenatal Care Ongoing Nil deviation Essential Newborn Care Ongoing Nil deviation Infection Prevention and Control Ongoing Nil deviation Hemorrhage Ante/Post -Partum Hemorrhage Ongoing Nil deviation CME on Pregnancy care, Intrapartum Care, PNC, ENC,PPFP,FANC Ongoing Nil deviation MPDSR Quarterly County Meetings Ongoing Nil deviation Support Monthly Sub-County MPDSR Meetings Ongoing Nil deviation Support QI mentorship forums Ongoing Nil deviation Establish a collaborative of facilities in each sub-county Ongoing Nil deviation Support cross learning forums Ongoing Nil deviation Support external assessment on quality of care at facilities Ongoing Nil deviation Establish learning corners on newborn care: bi-monthly sessions on Ongoing Nil deviation newborn resuscitation (HBB) Design a minimum package of support for the CoL Ongoing Nil deviation Support referral meetings at County level Ongoing Nil deviation Increase number of EmONC ready facilities through routine Monthly Ongoing Nil deviation assessments. Support county EmONC wave assessment Ongoing Nil deviation Establishment of EmONC Mentors Ongoing Nil deviation Collaboration with other existing stakeholders Ongoing Nil deviation Maternity Open Day incorporate RMC Ongoing Nil deviation Child Health Child health CMEs Ongoing No deviation Defaulter tracing for immunization services Ongoing No deviation Post training follow up for IMNCI, ETAT+, EPI plus Mentorships Ongoing None and OJT Cold chain maintenance/Fridge repairs Ongoing None Immunization and child health mentorship Ongoing No deviation Nutrition VAS in EYE On course Nil deviation BFHI CMEs On course Nil deviation HINI mentorship On course Nil deviation IMAM mentorship Complete Started with screening WASH Training of CCA ToTs in Kitui Done Nil deviation Provision of IPC whole site orientations Done Nil deviation Training water point committee management on operation, On course Nil deviation maintenance and management Output 1.2: Strengthened delivery of targeted FP/RMNCAH, nutrition and WASH services at community level, including effective referral to mobile and/or static facilities
Community health services
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Capacity building On course Awaiting completion of CU selection CU motivation – VSLAs, badges, certificates; CHV bags On course To be complete by end of the quarter Strengthening CBHIS and data demand/ use On course Continuous activity Support establishment of community-facility referral and linkage Done Nil of deviation mechanisms Strengthening CBHIS and data demand/ use Done Nil of deviation Support/ advocacy for restructuring of PATUMA in Kitui Done Nil of deviation
Support monthly review meetings On course Nil of deviation
Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH Output 2.1: Increased knowledge of and demand for FP/RMNCAH, nutrition and WASH services Output 2.2: Improved gender norms and sociocultural practices Develop and Print Gender Strategy & County Briefs Ongoing Nil deviation Instructional Design Workshop for Adaptation of Gender Ongoing Nil deviation Curriculum Pilot Gender Transformative Support Supervision Module Ongoing Nil deviation Conduct Client Feedback Exit interviews & Check point meetings Ongoing Nil deviation Conduct training for one CBO Ongoing Nil deviation Conduct Mentorship & Supervision for CBOs Ongoing Nil deviation Develop & Print teaching Aids for the CBO Ongoing Nil deviation Capacity Building of County Level Mentors in Gender Responsive & Ongoing Nil deviation Quality Care Sensitization of Male & Female Champions on Gender Norms Ongoing Nil deviation Capacity Building of SC/CHMT Leadership on Gender Equity Ongoing Nil deviation Facilitate County Gender Department involvement in RH TWGs Ongoing Nil deviation Output 2.3: Increased practice of key nutrition and WASH behaviors in target communities ECD training on Nutrition Complete Nil deviation BFCI CMEs On course Nil deviation BFCI review meetings On course Nil deviation Sub-purpose 3: Increased MOH stewardship of key health program service delivery Output 3.1: Strengthened coordination, M&E capacity Train SCHMT, CHMT and Staff on DHIS2, QGIS and dashboard Complete Nil deviation for improved data use for decision making Support workshops for generation of County information products Ongoing Nil deviation (Bulletins, Factsheets, scorecards ) Train SCHMT and CHMT on RMNCAH score card Ongoing Nil deviation Identify and develop HMIS mentors to mentor HCWs on registers Ongoing Nil deviation and reporting tools Conduct quarterly county and sub county prioritization meeting Ongoing Nil deviation (Score card, QGIS and dash board) Conduct quarterly data review meetings at sub-county levels. Ongoing Nil deviation
Conduct quarterly CHV data review meetings Ongoing Nil deviation Conduct biannual county data review meetings with stakeholders To be done in Q3 Preparations started in Q2
Collaborate with Tupime Kaunti to hold quarterly M&E TWG Ongoing Nil deviation meetings at the county level. Conduct quarterly data quality assessments. Ongoing Nil deviation
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Data corrections with SCHRIOs Ongoing Nil deviation Conduct collection, photocopy of DHIS and Non DHIS tools into Ongoing Nil deviation project data base Support sub-counties, Health facilities and community unit in Ongoing Nil deviation sensitization and consolidation of AWPs for 2019/2020. Provide airtime support to SC/HRIOs in project supported sub- Ongoing Nil deviation counties for use in uploading data in DHIS2.
XIV. FINANCIAL INFORMATION
Cash Flow Report and Financial Projections (Pipeline Expenditure Rate)
Projected Expenses 30,000,000 expenditure quarter July- September 2019 25,000,000 Projected Expenses 20,000,000 expenditure quarter April- June 2019 15,000,000 Actual Expenses 10,000,000 expenditure quarter January-March 2018 5,000,000
0 Obligations Expenditures
Figure 26: Obligations vs. Current and Projected Expenditures - $Millions
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Table 9: Budget Details T.E.C: $66,336,770 Cumulative Obligations: $25,791,049 Cumulative Actual Expenditures: $9,065,076
Obligations 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Actual Actual Projected Projected Expenditures Expenditures Expenditures Expenditures 25,791,049 5,166,744 3,898,332 4,639,115 4,690,299
Personnel 604,098 796,107 615,896 615,896 Fringe Benefits 234,972 311,726 240,960 240,960 Travel 1,082,301 437,199 264,481 264,481 Equipment 271,788 Supplies 208,437 52,455 210,000 82,228 Contractual 2,072,125 1,280,365 1,930,232 2,190,179 Construction Other Direct Costs 484,348 354,144 791,517 791,517 Total Direct Costs 4,686,280 3,503,784 4,053,086 4,185,261 Total Indirect Costs 480,464 394,548 586,029 505,039 Total Estimated Costs 5,166,744 3,898,332 4,639,115 4,690,299
Budget Notes Salary and wages Salaries and wages are in line with Jhpiego's Human Resource policies. Fringe Benefits Calculated as per Awards conditions and prevailing Jhpiego approved NICRA rates. Travel costs are in relation to Project staff. Participant travel is generally charged Travel to Programmatic Costs. Equipment Equipment costs relate to procurement of project vehicles, copiers and a generator. Contractual The contractual are consistent with agreements signed with PS Kenya and Save the Children Other Direct Costs Other direct costs include programmatic activities aligned to the detailed implementation plan and general office operating costs. Total Indirect Costs Calculated as per award conditions. Total Estimated Cost Total of all costs
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TABLE: NEW SUB-AWARD DETAILS Total Amount in the approved budget for sub-awards: $4,757,416 Total Amount sub-awarded to date: $4,197,416 For each sub-award made in this reporting period, please include the following:
DO Title:
Name of Sub-Awardee: Population Services Kenya
Activity Title: Afya County & National Support Program (Afya CNSP)
Agreement Performance Period: Jan 1st, 2018 to June 24th, 2022
Agreement Amount (Total Estimated Cost): $1,133,231
Geographic Locations for Implementation: (As defined in Section XIII.D.) Kakamega, Kitui, Kisumu and Migori Counties
Activity Description: Sub-purpose 1: Increased availability of quality delivery of FP/RMNCAH, nutrition and WASH services though outputs 1.1and 1.3: Output 1.1 Strengthened FP/RMNCAH, nutrition and WASH services at private health facilities including referral from lower level facilities and communities. Output 1.3 Strengthened county health systems delivery of FP/RMNCAH, nutrition and WASH services in the private sector. Sub-purpose 2: Increased care seeking and health promotion behavior for FP/RMNCAH, ensuring consistency across the project though Output 2.1, 2.2 and 2.3, Output 2.1 Increased knowledge of and demand for FP/RMNCAH, ensuring consistency across the project. Output 2.2 Improved gender norms and social-cultural practices, leading interventions in the private sector. Output 2.3-Increased practice of key nutrition and WASH behaviors in target communities and Sub-purpose 3, increased MOH stewardship of key health program service delivery through Output 3.1 and 3.2, Output 3.1 Strengthened coordination, monitoring and evaluation capacity.
DO Title:
Name of Sub-Awardee: Save The Children Federation, Inc.
Activity Title: Afya County & National Support Program (Afya CNSP)
Agreement Performance Period: Jan 1st, 2018 to June 24th, 2022
Agreement Amount (Total Estimated Cost): $3,064,185 Geographic Locations for Implementation: (As defined in Section XIII.D.) Kakamega, Kitui, Kisumu and Migori Counties Activity Description: Save The Children will contribute to Sub purpose 1: Increase availability and quality delivery of FP/RMNCAH, nutrition and WASH services through Output 1.1, 1.2, 2.1, 2.3, 3.1 and 3.2.
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XV. ACTIVITY ADMINISTRATION The Mission Director visited Chiga Mission Hospital and Chulaimbo SCH in Kisumu county on a routine program supervision in March 2019, cohosted by Afya Halisi and AMPATH Plus. Discussions centered around the journey to self-reliance. The embargo on national level support was lifted in the quarter under review. The project held consultative meetings with the national team to chat a way forward and develop a supplemental work plan for national support. The work plan was submitted to USAID for review.
The project relocated to a more spacious new office block in Kisumu county on the 21st of February 2019, hosting other Jhpiego programs including Impact Malaria Program.
Personnel The recruitment process of the second DCOP was initiated in the quarter under review and the DCOP came on board effective 1st April 2019.
Contract, Award or Cooperative Agreement Modifications and Amendments
No cooperative modification or amendment was done during the quarter under review.
During the quarter under review, the project issued a call for applications for Community-Based Organizations (CBOs) interested in collaborating with the project to address harmful gender norms and socio-cultural practices in line with the USAID/Kenya Gender Equality and Female Empowerment Action Plan (2016). A technical proposal review committee was set up to review the technical applications.
XVII. GPS INFORMATION
Refer to attachment
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XVIII. SUCCESS STORIES
Improved health workforce productivity: The human resources for health pillar
Success story 1: By Hudson Inyangala
As Migori county struggled with strategies to expand and realign their health workforce in the long term, health system performance at Maeta dispensary was maximized in the short term through efficiency of service delivery and improved productivity of the only nurse and 10 CHVs at the facility for the last three years. Afya Halisi in collaboration with the County, recruited and deployed one nurse in the month of June 2018 to support the team at Maeta dispensary- Kuria West Sub county, Migori County. “In health systems, workers function as gatekeepers and navigators for the effective, or wasteful, application of all other resources, such as drugs, vaccines, and supplies. Human resources are often viewed as the most significant input since health care remains a very labor intensive industry with wages accounting for the largest component of health sector spending in both low and high-income countries" (Vujicic et al. 2009). It is reasonable therefore, to focus on improving health workforce productivity as an integral part of improving the workings of the larger health system. How effectively the health workforce performs and how effectively health workers use other health system inputs will contribute to improving health outcomes (Vujicic et al. 2009). A well- performing workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances" (WHO 2006). This is the situation. Acute staff shortages, a cross many sites in Kitui, Migori and Kisumu counties. It was against this backdrop that Afya Halisi engaged a total of 95 HRH staff on contract basis to augment the staffing levels in selected sites in Migori, Kisumu and Kitui counties. Working closely with the County Public Service Boards and Human Resources Office and with support from IntraHealth, the staff personal details have been uploaded into the iHRIS system. A clear transition process was agreed upon with the three county governments. Health workforce performance is critical because it has an immediate impact on health service delivery and ultimately on population health. Given the acute staff shortages, there is a critical need to improve the productivity of the existing lean health workforce and maximize service delivery efficiencies to ensure quality FP/RH/MNH/ Child Health / Nutrition and WASH service delivery, as well as further progress towards universal health coverage. Health workforce productivity measures the amount of health services produced by health workers in a given period of time. The productivity improvement process, at the selected sites is a journey that Afya Halisi project is taking with the facility teams. “At Maeta dispensary, the work load has doubled, the waiting time has reduced by almost half, skilled deliveries have gone up, thanks to the extra skilled pair hands that Afya Halisi has given us. We can now have flexible facility opening times to suit the needs of the community. I can now be able to comfortably take leave and not worry about my clients “Explained Archimedes on being asked about the benefits of the HRH staff posted at Maeta. “Reaching out to those within the facility’s catchment area is important to understand community attitudes towards our facility and reasons for multiple types of productivity problems. At Maeta dispensary, we hold monthly community feedback meetings that have greatly contributed to quality improvement and improved productivity” Added Archimedes. Alex (HRH nurse at Maeta) is a young and dynamic nurse, he was my college mate and
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we have blended quite well to provide services to the community. I have noted a skills gap in PP-FP and specifically IUCD insertion that I will be mentoring him on the job. This is a situation that is replicated across 6 sites in Kisumu, 4 sites in Migori and over 30 sites in Kitui where Afya Halisi has deployed HRH contracted staff across the four counties. Interventions put in place to improve productivity at Maeta dispensary include, providing mobile outreaches to bring health services to the population, thus increasing the number of patients served (and thus the number of health service outputs produced). Partnerships with transportation providers can improve patient demand when physical access to health facilities is difficult or expensive, Ksh. 50 is given to a boda-boda rider who brings clients to the facility. The Maeta dispensary team has also been innovative enough to align facility schedule (shifting regular hours of operation accordingly) with patient demand, offering services at times that are convenient to the clients including the adolescents and youth. Ensuring respectful care and supporting CHVs to engage in positive interactions with the clients has also improved the effectiveness and perceived quality of health services. At Muhoroni SCH, the operating theatre was complete but nonfunctional. The main challenge being staffing. Afya Halisi is supporting a total of 5 nurses at the site, supplied 8 caesarian section sets procured by USAID, 2 BTL sets and a vasectomy set. “The five HRH staff at the facility have been deployed in theatre and Maternity unit. This has seen the skilled deliveries increase from an average of 50 to 75 per month. Although there’s is increased work load as a result of UHC, waiting time has significantly been reduced” Explained the nursing officer in charge. To date a total of 13 caesarian sections have been successfully performed at this facility since February 2019. “We needed to have the theatre functional to minimize on the unnecessary, time wasting referrals to Kisumu. Thanks to Afya Halisi for supporting us with the staff and the equipment procured by USAID that has gone a long way to operationalize the theatre. The staff had to go through refresher theatre trainings / orientations supported by Afya Halisi and conducted by the gynecologist from JOOTRH. The 1st CS was done at the facility on …. Feb 2019 to Mrs. T A, 23-year-old, para 2 + 0, gravida 3, presented with labour pains in breech presentation and non-reassuring fetal status. A subarachnoid block done with Marcaine 10 mgs, a male living infant, APGAR score 7/1, 9/5, 10/10, with a birth weight of 2750 gm, extracted via a Pfannenstiel incision” Added the Nursing officer in Charge with a sense of satisfaction. This has greatly addressed the 3rd delay in the continuum of care for our mothers and expanded ground for CEmONC services. “Explained the Nursing officer in charge. “ At Ahero SCH, Afya Halisi posted a total of 7 nurses and the facility received 8 caesarian section sets to initiate theater services. The theater staff were taken through an orientation process as well by the gynecologist from JOOTRH. An average of 40 CSs are done every month with an average of 200 deliveries per month this facility. A gynecologist has been posted to the facility to support the team and handle obstetric complications. The opening up of the theatre at Muhoroni and Ahero has increased the government run CEmONC sites in Kisumu county to 5 thus improving access to CEmONC services. “The doctors and anesthetists were sitting idle, very unproductive, dissatisfied, demotivated, underutilized because of the nonfunctional theatres at Ahero and Muhoroni occasioned by acute staffing shortage we had. We want to thank Afya Halisi for supporting the county with a total of 18 nurses, 2 HRHIOs, and equipment, that has actualized this course that was initiated a few years back. This will go a long way in making mothers easily access CEmONC services as we work towards universal health coverage” added the Nursing Director Kisumu County. The current challenge at Ahero SCH, that the facility is working on is the need for a rest room for doctors/ anesthetists on call. Currently they take calls from their residences in Kisumu, which significantly
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contributes to the 3rd delay. “We thank Afya Halisi for supporting a similar course at Kombewa SCH (Seme Sub-county) for the official launch of the theatre. The 1st caesarian section was done on Tuesday February 19th, 2019 at 9:06 am. The first baby born via Caesarian section at this facility was named after the Governor HE Peter Anyang Ngong’o. The young Excellency is doing well and attending PNC / immunizations”. Added the Nursing Director. In Kitui County, there is increased productivity in the facilities where the HRH staff are deployed. Some of the sites have been able to initiate 24 hour services and seen an increase in the number of skilled birth attendance, reduced waiting time and improved quality of services. Productivity analysis can help inform if the level of outputs is acceptable given the present input use. If productivity is low, the analysis can help managers and supervisors identify what they can do to enhance productivity at their health facilities. The productivity measure used here is relative, the project is in the process of establishing a benchmark for the various levels of care. The project will continue to work closely with the facility management teams to address inefficient organization of services and work processes that contribute to health facility inefficiencies to optimize resources. The signs of poor organization include long patient waiting times, inadequate or inappropriate staff scheduling, lack of health worker accountability, and poor management. Poor organization can lead to a need for more resources to attend to a given number of patients or can lower patient demand due to a perception of poor quality. Either way, productivity is reduced. The sites where the HRH staff are deployed have sufficient equipment, supplies, and infrastructure to support service delivery. Missing or broken medical equipment, supply or drug stock outs, or lack of water/electricity/utilities may prevent health facilities from providing their usual services, even with adequate staffing. This typically leads to fewer patients and hence reduced productivity The project will continuously advocate with the county governments to have these amenities in place to enhance productivity. “The HRH team engaged by Afya Halisi has injected into the system a skills mix increasing efficiency at facility level. Even the walking style of our nurses has changed, the nurses walk briskly and attend to issues with the urgency desired” Explained the nursing officer I/C Chulaimbo SCH. The project will on a quarterly basis support CHMT to conduct supportive supervision, create a space for performance improvement, address issues of indiscipline, lateness, absenteeism (both unexcused and excused) which can result in the interruption of health service delivery and lower productivity. As a requirement for HRH staff payment, the project implements paper time cards that are signed by the facility in charge. This has helped engender an environment where the HRH staff are held accountable. To help communities hold health workers accountable to be present, facility hours and/or staffing schedules are posted publicly on the facility notice boards / service charters. To address health system inefficiencies, the facilities are encouraged to embrace task shifting -rational redistribution of tasks among health workforce teams. The Project will continue to advocate with the county governments to provide conducive working environments where health workers are able to deliver services with total efficiency. The HRH support however is not sustainable. This is a stop gap measure to mitigate staff shortages as the county governments put in place mechanisms to make decisions that effectively and efficiently utilize their own resources to plan and deliver coordinated quality health services that are acceptable and responsive to empowered communities. “The purpose of foreign assistance must be to end the need for its existence” – to make the counties at the end of the day, self-reliant. The systems and processes leading to self-reliance is a journey that the project has started taking baby steps with the counties.
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Obstetric Ultrasonography by Nurses: Kisumu County Experience
Success story 2: By Alinda Ndenga and Hudson Inyangala
“This is Adelaide, 28-Year-old, Para 2+ 0 Gravida 3 at 38 weeks’ gestation. She has had one caesarian section 3-years ago due to prolapsed cord and was hoping to deliver her third child normally – spontaneous vaginal delivery (SVD). But her baby’s presentation is not clear from the abdominal palpitation. Vaginal birth would put both the mother and the baby’s life in danger. Adelaide therefore needs an urgent obstetric ultrasound to confirm the presentation and help us decide the line of management” - Said Nurse Night as part of her handing over report to Nurse Day. “My gaze swiveled over the waiting room, looking for a place for Mkunga (my birth companion) and I to sit. A TV played quietly in one corner, a distraction that helped me to ponder on my next steps. Two seats, sandwiched between two sweating and shivering women were empty. One of the women leaned forward and filled the air with harsh, hacking, rusty coughs that reverberated in the waiting bay. It dawned on me why no other mother had jumped to take up a seat at the prime location next to these two mothers. I steered Mkunga to the other side of the waiting bay, the bland walls and tableful of plastic cups suddenly much more appealing- the ORT Corner – it was labeled”- This is what was going on in Adelaide’s woolly thinking mind occasioned by the need for an urgent Ultra-sound.
Kisumu county has only two government radiologists stationed at JOOTRH and KCH respectively serving the entire population and referrals from the neighboring counties. Only two out of 18 CEmONC sites in Kisumu county have the prerequisite expertize to offer obstetric ultrasonography further hampering scale up and scale out efforts. The other available radiologists, are in private practice where it costs an arm and a leg to have a scan done. This situation is limiting and most of the ANC mothers were going without this important scan early in pregnancy. Obstetric ultrasonography is increasingly used in monitoring pregnancy. This has had a great impact on the way in which women and societies at large conceptualize and experience pregnancy and childbirth. As a standard, WHO recommends one ultrasound scan before 24 weeks’ gestation to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce induction of labour for post-term pregnancy, checking the continuation of a pregnancy if there has been bleeding ; checking the position of the placenta; checking the amount of amniotic fluid; checking the physical development of the fetus; and diagnosing birth defects and/or hereditary conditions and generally improve a woman’s pregnancy experience.
Having observed this gap, Afya Halisi, the CHMT Kisumu County and the World Bank conducted a 10-day training in September 2018, for 28 nurses and 4 biomedical engineers, drawn from 6 strategically selected high volume health facilities to specifically conduct obstetric ultrasonography. A monitoring framework was established to assess the impact and accuracy of the scanning reports. The 6 facilities were supplied with Ultrasound machines procured through World Bank funds together with necessary consumables. The biomedical engineers were engaged to support maintenance. Afya Halisi supported the training sessions, facilitated the radiologist to conduct supportive supervision and conduct mentorship for the trained nurses and supplied the necessary consumables. Mothers start ANC late (about 48% complete 4 ANC visits), missing out on the recommended scan before 24 weeks. Adelaide was no exception; she was presenting for the first time at ANC at 38 weeks. Nurse D is one of the nurses who had gone through this training and Nurse N being fairly new at the facility wasn’t aware that there was an Ultrasonography expert right in their facility. “As I was
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contemplating on my next steps, Nurse D approached me and heartily greeted me and asked me to follow her to a secluded room. Mkunga tugged along. She explained to me what she wanted to do and that I will not need to travel all the way to Kisumu to have the scan done. I gathered myself onto the couch and after draping and applying some jelly on my abdomen, she placed a probe and I could see images of my baby on a TV screen in the corner of the room. This is the heart beating, the baby is term and in breach presentation she explained to me. I was amazed at this technology! I asked her whether the baby was a boy or a girl? She giggled and told me we would discuss later. Given that your baby is in breech presentation and you have a previous scar, it would be dangerous for both you and the baby to have a normal vaginal delivery – explained Nurse D. It will be safe for you and the baby to have an elective caesarian section. Adelaide was adequately prepared and referred for an elective caesarian section delivering a baby boy that she had always wanted.” Nurse D at PNC explained to me that she did not want to discuss the issue of the sex of the baby just in case it wasn’t the sex I desired.” To date, a total of 1855 ultrasound scans (154 - high risk pregnancy; 1,630 – routine scans; 53- Trauma related; 18 – obstetric emergencies) have been conducted by the trained nurses. About 72% of the scans were carried out at the 4th ANC visit; 68% were rated as normal scans. The common abnormalities detected so far have been breech presentation (10%); low lying placenta (5%); Placenta Praevia (3%); Multiple gestation (7%); polyhydramnios (2%), IUFD (4%) and pelvic inflammatory disease (4%). About 7% (13 cases) of the abnormal scans had a CS done; 23% (43 cases) had normal deliveries; while 4% (7 cases) had a macerated still birth. The radiological diagnosis by the nurses was 98% congruent with the clinical findings. There was no maternal death reported. “This was a great pregnancy experience for me. From the pre-diagnosis - I was quite anxious to know why Nurse D had said it wasn’t safe for me to deliver normally; learning the diagnosis, and living with the diagnosis – that the baby was breech and I needed a caesarian section. There were themes of optimistic expectation, hearing bad news, need to know, and time with baby was great on the TV screen”. Explained Adelaide when asked about her experience in the ultras sound room.
With the appropriate training, mentorship and close follow up, and as a task shifting strategy, nurses can proficiently provide obstetric ultrasonography services. This will augment clinical diagnosis and improve the quality of care and promote integration of services. Decentralization of obstetric ultrasonography services to the lower levels of care will enhance universal access to care. The 28 nurses trained on ultrasound combine the midwifery skills and ultrasonography to offer high quality maternity care.” We thank Afya Halisi and the World Bank team for training us and giving us the necessary equipment. We thank USAID for supplying us with equipment, caesarian section sets, FP sets and many other point of care equipment. Capacity building the nurses in ultrasonography is a great systems strengthening strategy to broaden ground and improve access to this service. This has enhanced our quality of care and improved client satisfaction”- concluded Nurse Day.
The Journey towards Baby Friendly Hospital –Breastfeeding Matters at Matungu SCH Success Story 3: By Nancy Muchuta (Sub County Nutritionist, Matungu); Brenda Ahoya and Hudson Inyangala. The Woman- Kora, “whose only sin was motherhood”, was in distress. She swooned in pathetic despair as all her efforts to console her crying newborn baby were fruitless. Ramadhan, the 50-year- old cook and breastfeeding champion at Matungu SCH, could hear the loud whaling sound piercing through the walls, only getting hasher and louder. It was hard to believe it came from such a tiny
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little baby. As the baby cried, Ramadhan couldn’t help but admire the soft cackling and gasping sounds, suffocating with each breath. Ramadhan watched the mother struggling to breastfeed. Distressed – the mothers’ first tear broke free, the rest followed in an unbroken stream leaving a trace - like rain on a dusty window pane. What’s the problem? Ramadhan inquired. The baby is hungry and I have no milk – replied Kora. Afya Halisi project identified 10 health facilities (2 in Kakamega and 8 in Migori) and initiated the journey towards baby friendly hospital initiative, with each facility taking their own baby steps towards that goal. Matungu SCH in Kakamega county, is one such facility. The project trained 13 health care workers, using the BFHI curriculum, at the facility and supported whole site orientation for all staff (both technical and nontechnical) including support staff and CHVs on baby friendly hospital initiative (BFHI). To further engender the practice, 15 continuous medical education sessions (CMEs) involving all the staff have been supported by the project, with the content tailored to suit the technical and non-technical staff (cooks, cleaners, watchmen and women, clerks). Given the skilled human resource challenge and high workload at the facility, the nontechnical staff are expected to support, educate, counsel and guide mothers on breastfeeding in the course of discharging their duties. Breastfeeding is a vital component of realizing every child’s right to the highest attainable standard of health, while respecting every mother’s right to make an informed decision about how to feed her baby, based on complete, evidence-based information, free from commercial interests, and the necessary support to enable her to carry out her decision (WHO / UNICEF). The first few hours and days of a newborn’s life are a critical window for establishing lactation and providing mothers with the support they need to breastfeed successfully and that the “core purpose of the Baby-Friendly Hospital Initiative (BFHI) is to ensure that mothers and newborns receive timely and appropriate care before and during their stay in a facility providing maternity and newborn services, to enable the establishment of optimal feeding of newborns, which promotes their health and development( WHO/UNICEF). Matungu sub county hospital has taken up this initiative, and has been taking steps towards achieving this WHO/ UNICEF recommendation. It is against this backdrop that the project took up this initiative and identified 10 facilities in Migori and Kakamega based on the criteria that they are sub county referral hospitals with a high number of deliveries. Ramadhan the cook, is one such support staff that has with great aplomb taken up the trainings. On hearing the baby cry, he decided to put his knowledge on breastfeeding acquired through CMEs at the facility into practice. He requested Kora to put the baby on the breast and he immediately noted that the baby was not attaching well. He applied the 4 key points of positioning and attachment as taught at the CMEs, guiding the mother accordingly, but realized that there was still a problem with attachment. In the process of supporting the mother to ensure the baby attaches correctly, Ramadhan noticed that the mother had inverted nipples. He advised the mother to continue putting the baby to the breast to allow the nipple to come out by itself, but that did not work immediately. Feeling beaten, Ramadhan scratched his head, and decided to call in the nutritionist for support. After a quick assessment, the nutritionist got a 20 cc syringe and explained to the mother how she intended to use the syringe on the breast to help the baby attach. Using the syringe, the nutritionist pulled out the nipple and supported the mother to attach the baby and immediately the baby started suckling well. “I watched in awe as the newborn peered through brand new eyes at what must be such a strange world after life in the womb, galloping down the breast milk ferociously”- said Kora feeling a sense of relief. The nutritionist congratulated Ramadhan and left him to continue serving food to the patients. “I always try to put into practice what we learn during CMEs and whole site orientations supported by Afya Halisi project. As I serve the mothers with food, I watch the babies looking out for
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positioning and attachment, and hunger cues, teaching mothers how to tell when their babies are hungry and showing them the IEC materials on the walls. The ten steps to successful breastfeeding are now at my fingertips and I apply them everywhere. At my age and being a man, I am able to support because I have learned so many things that I had not known before. Now I preach breastfeeding and can support mothers to breastfeed for six months and assist them when they have problems with breastfeeding,” Ramadhan said with a sense of pride on being asked what motivated him. “They say charity begins at home, and as health care workers, we are supposed to be the mirror / role models for the society. We needed to put in place systems that support workplace breastfeeding for our own staff. With guidance and support from Afya Halisi, the facility put in place structures for workplace support for staff with children below six months of age to support them to practice exclusive breastfeeding after completion of maternity leave”- Explained Mr. Hilary Nandasaba the Nursing Officer in charge. Hillary is a BFHI committee member and chair and has been very active and instrumental in supporting the facility progress towards being baby friendly. He set aside a room that can be used by staff and also mobilized some equipment from within the facility to equip the room. The room currently has seats, handwashing station, two cupboards with a surface to act as a table, and two couches. The medical officer in charge of the sub county has been quite supportive, issuing a fridge from his office that staff can use to keep expressed breastmilk. Afya Halisi project supported the process by advocating for setting up of the room, ensuring that staff utilize it and availed IEC materials on breastfeeding. The first beneficiary of the structural improvements at Matungu SCH to accommodate a lactating room was Edelinda Lisutsa, a nutrition officer. “Given the nature of my contract, I had to go back to work after a few weeks break after delivery. Being a nutritionist myself, I understand the importance of exclusive breastfeeding and I was determined to exclusively breastfeed my baby for the first six months without giving her any other foods or even water. The room is clean, private and safe for my baby. I commute to work daily from Bungoma town 26 Km away. I bought containers that I use to keep the expressed breastmilk in the fridge at the lactation room and carry it home after duty. Currently, I have expressed so much that I have more than enough breastmilk. This keeps up my milk supply and ensures that my child has enough to feed. I currently have less than 150 days to achieve the six months exclusive breastfeeding goal and the facility has provided an enabling environment that has helped guide my journey to continued breastfeeding success. Thanks to Afya Halisi and the USAID team for the support” Explained Edelinda. Lydia Khalayi, a Pharmacist at Matungu SCH, reported back to work two months into her maternity leave due to service need following the demise of the sub county Pharmacist. Since her house help was not so reliable, she opted to bring her baby along to work with her niece to attend to the baby as she worked. Edelinda talked to her about the lactation room. Initially hesitant, she was convinced that the room is ideal and safe for her baby. She is currently using the room and intends to continue to use it to express her milk when she officially resumes duty. Martha, a nurse in the maternity unit, always comes on duty with her child when on night duty after the lactation room was set up. Since the lactation room has a couch, she is able to put the baby to sleep in the room as she performs her duties, taking periodic breaks to breastfeed. “The room is secure, clean, has comfortable seats and adequate privacy (thanks to curtains supplied by Afya Halisi) to promote breastfeeding for staff at the facility. This gives us a sense of security and reassurance that the baby is safe as we discharge our duties” -added Martha.
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The baby-friendly hospital initiative (BFHI) is a concept to motivate facilities providing maternity and newborn services to implement the ten steps to successful breastfeeding for the best start in life. The ten steps summarize a package of policies and procedures that facilities providing maternity and newborn services should implement to support breastfeeding. The facility team is working overdrive to scale up to universal coverage and ensure sustainability over time focusing on integrating services. The Project is in the process of replicating the Matungu setup in 9 selected facilities in Migori and Kakamega county in a step wise approach, with advocacy initiatives for the counties to scale up / scale out to other facilities. The facility is continuing with implementation and also conducts periodic self-assessments. When the facility meets the criteria set for the ten steps of successful breastfeeding, the county will invite an independent assessment team from national level to conduct external assessment and certify the facility as baby friendly.
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ANNEXES & ATTACHMENTS
Annex 1: Afya Halisi - From Commitment to Action: Framework for Action by Migori, Kisumu and Kakamega on Adolescents and Youth Sensitive Services Activity 1.1.2. Strengthen adolescent and youth-friendly services at health facilities
During the quarter under review, the project continued to support implementation of high impact AYSRH activities. The aim is to increase access to information and services in order to prevent or delay first pregnancy (primary prevention) and linking pregnant adolescents and youth to ANC services, skilled delivery, PNC, family planning, income generating activities and opportunities to return to school (secondary prevention). The activities supported by the project included capacity building of HCWs, CHVs and youth champions in AYSRH, youth focused outreaches and in-reaches, dialogue sessions for adolescents and youth and, and meetings with influencers.
Table 10 and 11 below shows the project’s performance AYSRH in Y2Q1 to Y2Q2 periods.
Table 10. Adolescents (10-19 years) presenting with pregnancy – Y2Q1 – Y2Q2 County PPR Target Y2Q1 Y2Q2 SAPR 2019 % achievement achievement Kakamega 5,054 992 1,147 2,139 42% Kisumu 10,622 2,080 1,588 3,668 35% Kitui 9,382 1,844 1,931 3,775 40% Migori 12,665 2,735 2,705 5,440 43% Project 37,723 7,651 7,371 15,022 40%
Table 11. Adolescent 10-19 years receiving FP services County PPR Target Y2Q1 Y2Q2 SAPR 2019 % achievement achievement Kakamega 1,568 874 638 1,512 96% Kisumu 5,855 3,048 1,350 4,398 75% Kitui 3,365 1,280 812 2,092 62% Migori 13,401 4,544 3,559 8,103 60% Project 24,189 9,746 6,359 16,105 67% The county specific activities were as detailed below.
Kakamega County
Primary prevention
School health interventions: During the reporting period, the project supported the Ministry of Health led by Navakholo RH Coordinator to provide SRH information to two primary schools in
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Navakholo sub county. A total of 718 students (351 female, 367 male) were reached. The topics covered included risky behaviour and the consequences of teenage pregnancy.
Targeted adolescent and youth in-reaches and outreaches: The project supported 3 in-reaches during the quarter under review. The FP uptake was as follows: COCs 2, Depo 17, implants 28, and IUCD 3. Parents and guardians dialogue sessions: The project supported two sessions in Navakholo and Matungu sub counties where 127 parents (66 female, 61 male) attended. The issues discussed included: challenges parents face in talking to adolescents and young people about sex and sexuality, socio-economic situations heavily contributing to transactional sex among adolescents and youths and parents understanding their role in the growth and development of adolescents. Secondary prevention
Training CHVs on AYSRH: The project supported training of 74 CHVs (47 female, 27 male) on AYSRH from Parents and Guardians during the Parental the three sub-counties in the county. The CHVs were dialogue session in Matungu Sub County trained on how to share information to the youth and link those in need of services to care. Training youth champions on AYSRH and life skills: A total of 57 (M- 27, F-30) youth champions were trained on AYSRH to equip them with knowledge and skill to share SRH information with their peers. Adolescent and young mothers clubs: During the reporting quarter, the project supported 10 health facilities to hold young mothers club meetings. The topics discussed included importance of ANC attendance and skilled delivery. Kisumu County
Primary prevention Targeted adolescent and youth in-reaches and outreaches: A total of 7 In reaches were conducted that resulted in a total of 104 new acceptors taking up FP services as follows: COCs 14, POPs 9, Depo 21 Implants 57 and IUCD. Youth Centers/Corners: The project in collaboration with MOH identified areas frequented by adolescents and youths, including university and college students as well as out of school youths and adolescents. These places provide safe spaces where the youth informally share on sex sexuality and access condoms for prevention purposes.
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Parents and guardians dialogue sessions on AYSRH: Through the project’s support, parents and guardians dialogue sessions on AYSRH were carried out during the reporting period. A total of 116 parents (64 female, 52 male) were reached. These were parents that had the highest level of teen pregnancies in 2018. The sessions focused on understanding the root causes of teen pregnancies, challenges parents face in talking to their adolescents, and possible solutions.
Community Strategy focal Person in Kisumu West facilitating a session for Parents and Care Givers on AYSRH, addressing teen pregnancies.
Secondary prevention Training of CHVs on AYSRH and Life Skills: A total of 50 CHVs (40 female, 10 male) from two sub-counties, Nyakach and Nyando, with high burden of teenage pregnancies were oriented on SRH to enhance their knowledge and skills in handling adolescents and youths. They will also help in identification and linkage to care of pregnant adolescents and youth. Training youth champions on AYSRH and life skills: A total of 30 peers (16 female, 14 male) from Nyando and Nyakach were trained on life skills with a view of formalizing and centering conversations amongst peers around health promoting and risk reducing actions programs attempt to empower youth to attain healthy lifestyles. Adolescent and young mothers clubs: A total of 195 pregnant teens who are 10-19 years old and 249 teen mothers with children were linked to various services. So far, 26 clubs have been formed in the county.
Kitui County Primary prevention interventions
Sensitization of teachers on AYSRH: The project supported one meeting for 55 key officers (34 female, 21 male) from MOH and MOE to strategize on how to reach adolescents and youth in schools with SRH messages. During the meeting, key messages were identified including: Age appropriate messaging on sex and sexuality, puberty and adolescent, menstrual hygiene and WASH, drug and substance abuse, teenage pregnancy, GBV and life skills. The teachers were to lead the process of sensitization in selected schools whereas the MOH team was to offer expertise on RH issues.
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Engagement of out of school adolescents and youth AYSRH dialogue sessions for out of school youth forums: The project in collaboration with the Ministry of Health, Gender and Youth services together with the national and county governments conducted dialogue meetings with youth and opinion leaders in four wards in Kitui South that were leading in teenage pregnancy. The aim of the meetings was to help in contextualization of the existing challenges at community level. The main causes of teenage pregnancy were attributed to poverty, irresponsible parenthood and weak legal system at sub-county level. Formation of AYSRH out of school groups: Three youth clubs consisting of 84 young people (51 female, 33 male) out of Adolescents giving input during out of school were formed in Kitui South where teenage pregnancies school club formation in Kawelu are high. The groups meet monthly to discuss pertinent life issues including sex and sexuality and other reproductive health topics with support from a trained HCW. Engaging adolescents and youth in schools and colleges School health life skills forums: In an effort to reach adolescents and youth in schools, the project supported life skills forums for 502 students (229 female, 273 male) from three schools in Mwingi Central. The young people highlighted the issue of peer pressure, influence of social media and high demand by older men as some of the biggest challenges that they face. Sensitization for adolescents in schools and churches: The project supported two mentorship sessions in Kitui East reaching a total of 298 students(255 female, 43 male). Areas of discussion revolved around delaying of sexual debut, setting of life goals, effects of early teenage pregnancy and menstrual hygiene management. Sensitization of adolescents and youth in colleges on AYSRH: A total of 99 adolescents and youth (42 female, 57 male) in colleges were sensitized on AYSRH. Out of these, 17 adolescents and youth (11 female, 6 male) were from Mutomo School of Nursing and 82 adolescents and youth (36 female, 46 male) were from Mwingi KMTC. AYSRH sensitization meeting for parents: A total of 113 parents (90 female, 23 male) from the 3 wards with high teenage pregnancy in Kitui South were sensitized on SRH. The discussions were focused on adolescent growth and developmental changes, understanding and supporting adolescents and supporting youth to access health and social services. The project aims to support these forums twice in a year. Meeting with opinion leaders on AYSRH: The project supported a sensitization meeting for 45 opinion leaders and administrators (19 female, 26 male) in Kitui South. Topics discussed included prevalence of teenage pregnancies and gender based violence. The opinion leaders promised to sensitize the community on AYSRH issues during barazas and to refer the young people for SRH services.
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Meeting with boda boda riders: A sensitization meeting was held for 29 men doing boda boda businesses in Kitui town on SRH. This cohort has been identified as key behavior influencers of teenage pregnancies in the county. They also received information on the importance of family planning. Secondary prevention Boda boda chairman giving a vote of thanks after Capacity building in AYSRH AYSRH sensitization meeting at Kitui Stadium.
Whole site sensitization meetings: The project supported whole site sensitization meetings in 3 hospitals (Mwingi, Ikutha and Kitui) reaching 138 HCWs (76 female, 62 male) to improve on referrals and positive response to health needs of the adolescents and young people. AYSRH youth champions training: A total of 24 youth champions (9 female, 15 male) in Kitui South were trained on AYSRH with an aim of equipping them with knowledge and skills so that they reach the youth, principally out of school, with the right messages to reduce bad health outcomes like teenage pregnancy. After the training, they are expected to champion and assist in making referrals and offering psycho-education to the other young people in the community. Pregnant adolescents’ clubs: Three adolescent young mother’s clubs were supported in Mwingi North, Mwingi West, Kitui Central and Mwingi Central reaching a total of 108 young mothers aged between 15-24 years. Three girls from Katulani were linked back to school. At Migwani, the young mothers have a merry go round where each contributes 50 Kenya shillings each for self-development and care or the baby. Migori County
AYSRH stock-taking workshop: In the reporting period, the project jointly with other stakeholders supported a two day stock-taking workshop for 35 participants (20 female, 15 male), drawn from key adolescent and youth stakeholders in Migori county, to review progress of implementation of the AYSRH Multi-sectoral plan that has been in operation for six months. During the meeting, a plan was developed for accelerated interventions. The project also supported a stakeholder meeting and utilized the forum to share Afya Halisi AYSRH activities for Year 2. A total of 37 stakeholders (14 females, 23 male) attended the meeting.
Interventions for primary prevention
Establishment of adolescents clubs for out of school adolescents and youth: The project supported establishment of two groups for adolescents out of school reaching a total of 236 (178 female, 68 male) adolescents and youth. The primary prevention interventions focused on providing messages and information on SRH and family planning. In the next reporting quarter, the project will utilize these forums to engage parents to address parenting issues. Support the AYSRH human centered design (HCD) on teenage pregnancies in Migori: The project supported a 5-day 3D HCD workshop on teenage pregnancies to identify factors influencing teen
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pregnancies and strategies to address barriers to adolescents and youth accessing health services. In attendance were 34 participants (22 female, 12 male) that included county and sub-county RH coordinators, youth focal persons, and selected youth from each sub county. The adolescents suggested the need to strengthen avenues of access to SRH information, skills on how to cope with transition during adolescence and, sensitization of parents on AYSRH. School health program: As part of preparation for roll out of the draft school health package that is being supported by Afya Halisi, the MOH and MOE conducted a baseline assessment on prevalence of teenage pregnancies in schools in Uriri sub-county – which has the highest number of teenage pregnancies in Migori county. In the 67 schools visited, 97 pupils aged between 10 and 19 years old were reported to be pregnant or had delivered with 41 (42.3%) in the age bracket 10-14 years and 56 (57.7%) in the age bracket 15-19 years. This information will help to guide the team in selecting priority schools for roll out of the school health package. Youth event: The project partnered with Migori TTC during the institution’s health week to provide SRH services to students. During the 2-day event, 238 students (196 female, 42 male) were reached with SRH information including life planning sessions. A total of 74 students accessed FP services for the first time. Interventions for Secondary prevention
Young married adolescents club and first time mum clubs: During the reporting period, Afya Halisi supported the formation of young married adolescent clubs in Kuria East and Kuria West sub- counties. The two sub-counties have recorded the highest burden of teenage pregnancies in the county. A total of 62 adolescent mothers were enrolled in the 2 sub-counties including 20 that were parents to twins. In addition, the project continued to strengthen young mothers’ clubs (YMC) that were established in Y2Q1. During the reporting period, a total of 268 young mothers were reached, out of which 104 took up family planning services and nine had skilled delivery. Provision of AYSRH services through extended hours: Afya Halisi supported service extension in 9 health facilities across five sub-counties. The facilities were providing services during weekends. A total of 288 adolescents and youth (207 female, 81 male) received information and services. In addition, 351 adolescents were reached with information. The services offered included family planning (117 adolescents), ANC 16, immunization 8 and STI screening 31. Building the capacity of HCWs and CHVs to offer and mobilize for YFS: The project supported whole-site orientation sessions on VCAT in 13 health facilities reaching 191 HCWs (105 female, 86 male) in 5 sub-counties. Reaching out to key influencers for the adolescents and youth to access AYSRH services: The project supported the community action cycle for 48 community leaders (30 female, 18 male) from Uriri and Kuria west. The main aim of the session was to review the current norms, beliefs and practices that influence teenage pregnancy and develop action plans aimed at mitigating the problem. The project will follow up on the action plans in the subsequent quarter and review the progress of implementation. with the aim of fostering more equitable gender norms and discussing ways of reducing teenage pregnancy among adolescents and youth.
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Annex 2: Schedule of Future Events
The scheduled activities for Quarter 3 of 2019 are included in the Table 12 below. Table 12. Schedule of upcoming events in Y2Q3 Date Location Activity 2nd April 2019 Migori, Kitui , Kisumu and World Autism Awareness Day Kakamega 7th April 2019 Migori, Kitui , Kisumu and World Health Day Kakamega 24th April 2019 Migori, Kitui , Kisumu and World Immunization Week Kakamega April – May 2019 Migori County Development of the County CHS Bill 14th - 16th May 2019 Kisumu UHC Conference- Theme: Revitalizing Primary Health Care (PHC) for sustainable Universal Health Coverage 31st May 2019 Migori, Kitui , Kisumu and World No Tobacco Day Kakamega 14th June 2019 Migori, Kitui , Kisumu and World Blood Donor Day Kakamega 17th May 2019 Migori, Kitui , Kisumu and World Hypertension Day Kakamega May 2019 Migori, Kitui , Kisumu and International Nurses Week Kakamega May 2019 Migori, Kitui , Kisumu and Malezi Bora Activities Kakamega May Nyatike Sub-county / Migori 1st Ladies Marathon County June 2019 Siaya Lake- Basin Inter-Country HRH Stakeholders Meeting
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Annex III. Afya Halisi Year 2 Quarter 2 performance
Indicator FY19 Y2Q1 Y2Q2 Y2Q3 Y2Q4 Total % target Achievement FP/RH HL.CUST FP 14.0 Number of Health 330 0 175 175 53% Workers trained in commodity management through USG supported programs CUST Number of men 126 0 73 73 58% CUST Number of women 204 0 102 102 50% HL.CUST FP 15.0 Total number of 1,408 381 288 669 48% Health Workers trained in FP/RH through in-service training CUST Number of men 531 119 100 219 41% CUST Number of women 877 262 188 450 51% HL.CUST FP 16.0 Percent of USG- 15% 68% 69% 69% 69% assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide CUST Denominator 662 606 613 613 CUST Numerator 97 413 426 426 HL.7.1-3 Average stock out rate of 15% 29% 0 26% 26% contraceptive commodities at Family Planning (FP) service delivery points CUST Denominator 662 606 613 613 CUST Numerator 97 177 157 157 HL.7.1-1 Couple Years protection in 593,445 165,339 136,25 301,594 51% USG supported programs 5 HL.7.1-1-a Urban HL.7.1-1-b Rural 593,445 165,339 136,25 301,594 51% 5 HL.7.1-2 Percent of USG-assisted 100% 92% 93% 93% 93% service delivery sites providing family planning counseling and/or services HL.7.1-2-a Numerator 662 606 613 613 HL.7.1-2-b Denominator 662 662 662 662 HL.7.2-2 Number of USG-assisted 2,673 772 1,377 1,377 52% community health workers (CHWs) providing Family Planning (FP) information, referrals, and/or services during the year HL.7.2-2-a Number of men 1,013 221 322 322 HL.7.2-2-b Number of women 1,660 551 1,055 1,055 HL. CUST FP 18.0 Total adolescent 24,189 9,746 6,359 16,105 67% clients (10-19) receiving FP services
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Maternal Health HL.CUST MCH 6.0 Number of 274 98 111 111 41% USG-supported facilities that provide appropriate life-saving maternity care (this will be defined as seven signal functions for BEmONC and nine signal functions for CEmONC) BEmONC 252 75 92 92 CEmONC 22 23 19 19 HL.CUST MCH 7.0 Number of 90,486 17,870 16,767 34,637 38% women who received at least 4 ANC visits during the latest pregnancy HL.CUST MCH 8.0 Total number of 3,900 101 769 870 22% Community Health Workers (CHWs) trained in maternal and/or newborn health through USG supported programs. CUST Number of Female 2,419 82 558 640 26% CUST Number of Male 1,481 19 211 230 16% HL.CUST MCH 9.0 Number of 1,200 880 448 1382 111% Health care workers trained in maternal and/or newborn health care through USG supported programs CUST Number of Female 457 354 224 578 126% CUST Number of Male 743 526 178 704 95% HL.6.2-1 Number of women giving 83,525 19,411 17,983 37,394 45% birth who received uterotonics in the third stage of labor (or immediately after birth) through USG-supported programs HL.CUST MCH 10.0 Number of 83,525 24,613 23,912 48,525 58% births in a given year attended by a skilled birth attendant (SBA) such as doctor, nurse, or midwife HL. CUST MCH 17.0 Total 37,723 7,651 7,371 15,022 40% adolescent clients (10-19) receiving ANC Child Health HL.CUST MCH 4.0 Number of 96,863 25,688 25,535 51,223 53% children who received DPT3 by 12 months of age in USG-assisted programs
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HL.CUST MCH 5.0 Children who 23,156 26,063 49,219 received measles vaccine by the time they were 12 months of age HL.CUST MCH 11.0 Number of 90,406 22,317 25,446 47,763 53% children under one fully immunized HL.6.3-2 Number of newborns who 69,605 19,930 21,969 41,899 60% received postnatal care within two days of childbirth in USG-supported programs HL.6.6-2 Number of cases of 21,710 4,486 6,760 11,246 52% childhood pneumonia treated in USG-assisted programs HL.6.6-1 Number of cases of child 75,284 17,328 23,793 41,121 55% diarrhea treated in USG-assisted programs Nutrition HL.9-1 Number of children under 279,625 190,899 32,006 222,905 80% five (0-59 months) reached by nutrition-specific interventions through USG-supported programs HL.9-1-a Number of children whose 54,217 13,048 14,546 27,594 51% parents/caretakers received behavior change communication interventions that promote essential infant and young child feeding behaviors HL.9-1-b Number of children 6 - 59 279,625 190,899 32,006 222,905 80% months who received vitamin A supplementation in the past 6 months HL.9-1-c Number of children under 27,815 6,560 10,600 17,160 62% five who received zinc supplementation during an episode of diarrhea HL.9-1-d Number of children under five who received Multiple Micronutrient Powder (MNP) supplementation HL.9-1-e Number of children under five who received treatment for severe acute malnutrition HL.9-1-f Number of children under five who were admitted for treatment of moderate acute malnutrition HL.9-1-g Number of children under five who received direct food assistance HL.9-1-h Number of male children 137,016 93,540 15,683 109,223 80% under five reached by USG- supported nutrition programs HL.9-1-i Number of female children 142,609 97,359 16,323 113,682 80% under five reached by USG- supported nutrition programs HL.9-2 Number of children under 32,714 9,083 15,977 25,060 77% two (0-23 months) reached with
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community-level nutrition interventions through USG- supported programs HL.9-2-a Number of male children 16,029 3,053 7,672 10,725 67% under two (0-23 months) reached with community-level nutrition interventions through USG- supported programs HL.9-2-b Number of female children 16,685 3,188 8,305 11,493 69% under two (0-23 months) reached with community-level nutrition interventions through USG- supported programs HL.9-3 Number of pregnant women 54,217 13,048 14,546 27,594 51% reached by nutrition-specific interventions through USG- supported programs HL.9-3-a Number of women 54,217 13,048 14,546 27,594 51% receiving iron and folic acid supplementation HL.9-3-b Number of women 54,217 13,048 14,546 27,594 51% receiving counseling on maternal and/or child nutrition HL.9-3-c Number of women receiving calcium supplementation HL.9-3-d Number of women receiving multiple micronutrient supplementation HL.9-3-e Number of women receiving direct food assistance of fortified/specialized food product HL.9-3-f Number of women < 19 4,878 3,727 7,371 11,098 228% years of age HL.9-3-g Number of women > or = 49,339 9,318 7,175 16,493 33% 19 years of age HL.9-4 Number of individuals 238 0 155 155 65% receiving nutrition-related professional training through USG- supported programs HL.9-4-a Number of non-degree 238 0 155 155 65% seeking trainees HL.9-4-b Number of degree seeking trainees HL.9-4-c Number of new degree seeking trainees HL.9-4-d Number of continuing degree seeking trainees HL.9-4-e Number of men 74 0 62 62 84% HL.9-4-f Number of women 164 0 93 93 57% HL. CUST N1.0 Number of health 113 97 97 97 86% facilities with established capacity to manage acute under-nutrition HL. CUST N2.0 Number of Children 3,116 3,001 6,117 under five who are underweight
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HL. CUST 2.0-a Male 1,337 1,232 2,569 HL. CUST 2.0-b Female 1,779 1,769 3,548 HL. CUST N3.0 Total Number of 328,970 328,970 328,970 children under five years HL. CUST 3.0-a Male 161,196 161,196 161,196 HL. CUST 3.0-b Female 167,774 167,774 167,774 WASH Number of people gaining access to 48,300 11,350 44,597 55,947 116% a basic sanitation service as a result of USG assistance Male 23,184 5,448 21,382 26,830 116% Female 25,116 5,902 23,215 29,117 116% Urban Rural 48,300 11,350 44,597 55,947 116% Number of communities verified as 161 22 102 124 77% “open defecation free” as a result of USG assistance Number of individuals trained to 942 178 330 508 54% implement improved sanitation methods Male 453 83 163 246 54% Female 489 95 167 262 54% HL.81.1 Number of people gaining 54,633 7,494 15,980 23,474 43% access to basic drinking water services as a result of USG assistance HL.8.1-1.a Number of Men 26,224 3,451 7,669 11,120 42% HL.8.1-1.b Number of Women 28,409 4,043 8,311 12,354 43% HL.8.1-1.c Urban HL.8.1-1.d Rural 54,633 7,494 15,980 23,474 43% HL.8.2-4 Number of basic sanitation 83 3 37 40 48% facilities provided in institutional settings as a result of USG assistance Institution Type (School/Health 83 3 37 40 48% Facility) School Health Facility 83 3 37 40 48%
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