Afya Uzazi Program

USAID KENYA/EAST AFRICA Afya Uzazi Program

QUARTERLY PROGRESS REPORT: APRIL 1ST ― JUNE 30TH 2017

A nurse attends to a mother and her child during an integrated outreach in Loberer, Baringo County. JUNE 2017

This publication was produced for review by the United States Agency for International

USAID KENYA AND EAST AFRICA

AFYA UZAZI - FY 2017 Q3 PROGRESS REPORT

01 April 2017 – 30 June 2017

Award No: AID -615-A-16-00011

Prepared for Lilian 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 Family Health International (FHI 360) 359 BLACKWELL STREET, SUITE 200 DURHAM, NC 27701 USA PHONE +1.919-544-7040 Email: [email protected] WWW.FHI360.ORG

DISCLAIMER The authors’ views expressed in this report do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

I. EXECUTIVE SUMMARY ...... 2 Quantitative Impact ...... 4 Constraints and Opportunities ...... 5 II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 6 III. KEY ACHIEVEMENTS (QUANTITATIVE) ...... 33 IV. CONSTRAINTS AND OPPORTUNITIES ...... 36 V. MONITORING EVALUATION AND LEARNING ...... 38 VI. PROGRESS ON GENDER STRATEGY ...... 42 VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 42 VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 43 IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 44 X. PROGRESS ON USAID FORWARD ...... 44 XI: SUSTAINABILITY AND EXIT STRATEGY ...... 45 XII: GLOBAL DEVELOPMENT ALLIANCE ...... 45 XIV. FINANCIAL INFORMATION ...... 50 XV. ACTIVITY ADMINISTRATION ...... 52

List of tables

Table 1: Supportive supervision and action plans ...... 7 Table 2: Community health volunteer reporting rates ...... 28 Table 3: Common and preferred communication channels from the assessment ...... 31 Table 4: Key achievements from Oct 2016 – June 2017 ...... 33 Table 5: DHIS 2 Reporting rates ...... 41 Table 6: Budget Details ...... 51

List of Figures

Figure 1: Number of clients reached during outreaches ...... 7 Figure 2: Comparison of IUCD & Implants Uptake between Q2 and Q3 in Nakuru, Baringo ...... 10 Figure 3: Trends in FP uptake for all methods over the last two quarters...... 10 Figure 4: Completion of 4 ANC visits by sub-county, by quarter...... 11 Figure 5: Trends in SBA for Nakuru and Baringo, by quarter ...... 12 Figure 6: Trends in SBA for Nakuru and Baringo ...... 13 Figure 7: Pre-and post-training level of skills on neonatal resuscitation in Nakuru ...... 13 Figure 8: Monthly coverage on immunization coverage in Baringo focus sub-counties ...... 15 Figure 9: Availability of RMNCH commodities, Nakuru County ...... 24 Figure 10: Availability of RMNCH commodities, Mogotio Sub-County, Baringo County ...... 25 Figure 11: Uptake of FP and Teen Pregnancy in Q2 and Q3 by focus sub county ...... 28 Figure 12: Number of people reached through IPC ...... 32 Figure 13. DQA output at 50 facilities within the focused sub counties ...... 38 Figure 14: DQA output in Baringo County ...... 39

Annexes

Annex 1: Afya Uzazi Integrated Outreach Model of Implementation

Annex II: Concept Note on Centres of Exchange Learning

Annex III: Report of Exposure Visit to PHE Mt Elgon, Uganda

Annex IV: Report of Population, Health and Environment (PHE) Stakeholders Meeting, Wednesday 7th June 2017, Waterbuck Hotel, Nakuru

ACRONYMS AND ABBREVIATIONS ACRONYMS AND ABBREVIATIONS

AIDS: Acquired Immunodeficiency Syndrome AMREF: Africa Medical and Research Foundation ANC: Ante-Natal Care APHIA: Aids, Population and Health Integrated Assistance ASSIST: Applying Science to Strengthen and Improve Systems AYSRH: Adolescent and Youth Sexual Reproductive Health BEmONC: Basic Emergency Obstetric and Newborn Care BFCI: Baby Friendly Community Initiative CBO: Community Based Organization CDH: County Director of Health CDHS: County Department of Health Services CEL: Centers of Exchange Learning CEmONC: Comprehensive Emergency Obstetric and Newborn Care CFA: Community Forest Association CHC: Community Health Committee CHEW: Community Health Extension Worker CHMT: County Health Management Team CHRIO: County Health Records and Information Officer CHU: Community Health Unit CHV: Community Health Volunteer CHX: Chlorhexidine CME: Continuous Medical Education COC: Combined Oral Contraceptive COP: Chief of Party CQI: Continuous Quality Improvement CSE: Comprehensive Sexuality Education CU: Community Unit CYP: Couple Years Protection DCOP: Deputy Chief of Party DHIS: District Health Information System DMA: Data Management Assistant DMPA: Depo Medroxyprogesterone Acetate DPT: Diphtheria, Pertussis, Tetanus DQA: Data Quality Audit DQIP: Data Quality improvement plan DVI: Division of Vaccination and Immunization ECD: Early childhood development EMR: Electronic Medical Records EMONC: Emergency obstetric and newborn care ENC: Essential Newborn Care EPI: Expanded Program on Immunization FANC: Focused Ante-Natal Care FCDRR: Facility Consumption Data Report and Request FGD: Focused Group Discussion FHI: Family Health International FHOK: Family Health Options Kenya FIC: Fully Immunized Child

6 FP: Family Planning GoK: Government of Kenya GBV: Gender Based Violence HCM: Health Communication and Marketing HCW: Health Care Worker HF: Health Facility HIV: Human Immunodeficiency Virus HMIS: Health Management Information System HRH: Human Resources for Health HRIS: Human Resource Information System HSS: Health Systems Strengthening IEC: Information, Education and communication IHRIS: Integrated Human Resource Information System IMCI: Integrated Management of Child Illness IPC: Infection Prevention and Control IUCD: Intra-Uterine Contraceptive Device KCSEED: Keringet Community Socio-Economic Empowerment and Development KEMRI: Kenya Medical Research Institute KEMSA: Kenya Medical Supplies Agency KEPH: Kenya Essential Package for Health KEPI: Kenya Expanded Program on Immunization KFA: Kenya Forestry Association KMET: Kisumu Medical and Education Trust KSCSS: Kenya Supply Chain System Strengthening KFS: Kenya Forestry Service LARC: Long-Acting Reversible Contraceptives LAPM: Long acting and permanent methods LOP: Letter of Permission LBVC: Lake Victoria Basin Commission LDP: Leadership Development Program MCH: Maternal Child Health MEC: Medical Eligibility Criteria MEL: Monitoring, Evaluation and Learning MIYCN: Maternal, Infant and Young Child Nutrition MNH: Maternal and Newborn Health MNCH: Maternal, Newborn and Child Health MOE: Ministry of Education MOH: Ministry of Health MPDSR: Maternal and Perinatal Death Surveillance and Response MSH: Management Science for Health MVA: Manual Vacuum Aspiration NACS: Nutrition Assessment, Counseling and Support NCAHU: Neonatal, Child and Adolescent Health Unit NCPD: National Council for Population and Development NHIF: National Hospital Insurance Fund NHP: Nutrition and Health Program OJT: On-Job Training

OPV: Oral Polio Vaccine ORS: Oral Rehydration Solution ORT: Oral Rehydration Therapy PAC: Post Abortion Care PACE: Policy, Advocacy & Communication Enhanced PATH: Program for Appropriate Technology in Health PET: Pre-Eclampsia Treatment PHE: Population, Health & Environment PHES: Partner Health Environmental System PLWHA: People Living with HIV/AIDS PMTCT: Prevention of Mother to Child Transmission of HIV POP: Progestogen Only Pill PNC: Post-Natal Care PPB: Pharmacy and Poisons Board PRC: Post Rape Care PRB: Population Reference Bureau PS-K: Populations Services Kenya PY: Program year QA: Quality Assurance QI: Quality Improvement RBF: Resource Based Financing RH: Reproductive Health RMC: Respective Maternity Care RMHSU: Reproductive and Maternal Health Services Unit RMNCAH: Reproductive, Maternal, Neonatal Child and Adolescent Health SBA: Skilled Birth Attendants SBCC: Social Behavior Change Communication SCHMT: Sub County Health Management Team SDP: Service Delivery Points SGBV: Sexual and Gender Based Violence SOPs: Standard Operating Procedures SRH: Sexual Reproductive Health STI: Sexually Transmitted Infection TA: Technical Assistance TBA: Traditional Birth Attendants ToT: Trainers of Trainers TWGs: Technical Working Groups USAID: United States Agency for International Development WASH: Water and Sanitation Hygiene WRA: Women of Reproductive Age YFS: Youth Friendly Services

I. EXECUTIVE SUMMARY

Afya Uzazi, meaning healthy parenthood in Kiswahili, is a five-year project funded by USAID East Africa (AID-615-A-16-0011). Afya Uzazi aims to increase Family Planning/Reproductive, Maternal, Neonatal, Child, and Adolescent Health (FP/RMNCAH) impact through improving quality FP/RMNCAH demand generation activities and care provision in the focus sub-counties of Baringo North, East Pokot, Marigat, and Mogotio in Baringo County and Kuresoi North and Kuresoi South in Nakuru County. Afya Uzazi builds on lessons and achievements from APHIAplus Nuru ya Bonde project and other projects. Specifically, the project aims to achieve: 1. Increased availability and quality delivery of FP/RMNCAH and 2. Increased care seeking and health promotion behavior for FP/RMNCAH.

During the third quarter of Program Year (PY) 1, the Afya Uzazi, in partnership with the county governments of Nakuru and Baringo made substantial achievements towards increasing access, availability and demand for high quality, equitable, gender sensitive reproductive, maternal, newborn, child and adolescent health (RMNCAH) services. The project has been working to increase the capacity of the healthcare workers and managers to ensure provision of high quality FP/RMNCAH services in the focus sub counties. However, the project has not been able to operate in East Pokot sub county of Baringo due to insecurity that has persisted in the area since late 2016.

The following text highlights high level achievements of Afya Uzazi project from April 1, 2017- June 30, 2017.

Cross cutting Interventions: The project supported CHMTs in conducting integrated supportive supervision through development of a standard checklist, training and mentorship. Identified gaps were addressed through training, mentorship, provision of job aids and advocacy for issues that need intervention of high level management. The project assessed three potential facilities for use as centers of exchange learning (CEL). These include Marigat Sub County hospital, Olenguruone Sub County Hospital and Kabartonjo Sub County Hospital. In the Marigat Sub County hospital and Olenguruone County hospital CEL, which met the criterial of suitability as CEL, relevant equipment, models, supplies and job-aids were identified for procurement and placement. To augment facility based services, alleviate the effect of health workers strike on the provision of services and access hard to reach populations, Afya Uzazi conducted 34 integrated outreaches, reaching a total of 6131 mothers and children with various health and nutrition services. The project also supported the counties’ Malezi Bora campaigns, reaching a total of 48,799 children and 726 lactating women with vitamin A and deworming.

Family Planning and Reproductive Health: Following the Long Acting Reversible Contraceptive (LARCs) Methods training conducted in quarter 1, the project followed up 6 of 19 trainees to assess application of skills in service provision and provide necessary mentorship. Notably, there was an improved uptake of LARCs with a 286% increase in IUCD (from 14 to 54 insertions) in the visited facilities.

Maternal Newborn Health: To bridge gaps in HCW capacity to provide MNCH services, the project supported training of 57 HCW: 30 on Emergency Obstetric and Newborn Care (EmONC) and 27 on Essential Newborn Care (ENC). The project also supported facilities with Basic EmONC job aids. The project adopted a clustered approach to CME to reach more HCWs more efficiently and cost effectively. Through this approach, 107 HCW (54 in Baringo and 53 in Nakuru) received CME on EmONC and

newborn care. As a result, service providers in tier two facilities have shown improvement in monitoring women in labor using partograph, newborn resuscitation and emergency preparedness to handle obstetric and newborn emergencies. To update and gain the support of managers on Respectful Maternity Care (RMC), the project team collaborated with County Department of Health Services and Reproductive, Maternal Health Services to orient of 51 CHMT/SCHMT members and selected health facility managers on respectful maternity care using the national RMC guidelines. In preparation for the roll out of chlorhexidine (CHX) use for cord care, the project provided orientation to 51 HCW on CHX use as a module under ENC training. Afya Uzazi project supported a 3-day workshop for 34 HCW from Baringo on the revised Maternal and Perinatal Death Surveillance and Response (MPDSR) to equip them with necessary skills and tools to undertake maternal and perinatal deaths reviews and audits

Child Health: To bridge the gaps in knowledge and skills in cold chain management, lack of EPI micro plans at facilities, and improve use immunization monitoring using charts observed in previous support supervision, the project supported EPI training for 20 service providers drawn from tier 2 and 3 facilities. Twenty-nine more service providers (19 in Nakuru and 10 in Baringo) were mentored on EPI with the support of the EPI focal persons at the sub county level. Further, the project team helped identify 21 nonfunctional cold chain equipment and will work with DVI technicians at national and county level to repair the equipment, and facilitate scale up of immunization sites. Twenty (20) health facilities have now developed comprehensive and up to date micro plans. Follow up to assess service provision will be done in the current quarter. To strengthen management of diarrheal and other common under five-year-old diseases, the project supported implementation of the IMCI standards in Baringo County through training of 30 HCW on IMCI. A further 54 service providers were reached through cluster mentorship and CMEs at the facility level.

Nutrition and WASH: Through collaboration with NHP-Plus and nationally accredited trainers, the project trained 28 HCWs on Maternal, Infant and Young Child Nutrition (MIYCN) in Nakuru county to promote and support optimal infant and maternal nutrition through the Baby Friendly Community Initiative (BFCI). This will be followed by establishment of mother to mother support groups at the community levels to promote exclusive breastfeeding and optimal complementary feeding in quarter 4.

Social and Behavior Change Communications: To inform the process of SBCC strategy development, the project conducted a SBCC formative assessment in focus sub-counties in partnership with PSK-HCM and CHMTs. The project also supported capacity building of the service providers and CHVs on nutrition and WASH as well as incorporating all RMNCAH service indictors to ensure quality service provision and messaging at the household and community levels. Additionally, the program supported monthly data review meetings among the CHEWs and CHVs to enhance timely and quality reporting, thus the reporting rates by CHVs have improved whereby up to 48 Community Units (CUs) are currently reporting with reports available in DHIS2. To ensure that the CUs and beneficiaries appreciate data use for decision making purposes, the program supported community dialogue days and health action days in the 48 CUs. The project also supported CHVs supportive supervision, which led to improved quality of messaging at the household level.

To reach the larger communities beyond the CUs, the program engaged the women and men with interpersonal dialogue at their respective social networks where targeted messages on ANC, skilled delivery, FP and PNC were delivered. To alleviate HCW shortages, the project trained and collocated CHVs in some high-volume facilities with staffing constraints to support nutrition service provision, as well as manning the ORT corners.

Health Systems Strengthening: In collaboration with USAID|ASSIST project, Afya Uzazi project supported training of 25 staff from Baringo CHMT, SCHMT & selected facilities on QA/QI based on the KQMH

framework. Afya Uzazi also supported rapid Human Resources for Health (HRH) capacity assessments and established HRH Coordinating Committees in both Nakuru and Baringo Counties. In Baringo county, the project also spearheaded the establishment of HRH unit and appointment of a HRH focal point. The project also supported training 30 staff from Baringo on HRH Management skills. To strengthen commodity and supply chain management, the project spearheaded the re-establishment of Baringo County Commodity TWG and reactivation of the Nakuru County Commodity TWG. The project also supported training of 35 staff from the CHMT, SCHMT and selected facilities in Baringo as commodity management ToT, conducted supply chain mapping and support supervision in 33 facilities in Kuresoi North, Kuresoi South and Mogotio sub-counties. The project facilitated donation of 4800 bottles of CHX solution for cord care from Turkana county and distributed to facilities within the program’s focus sub-counties except East Pokot.

Adolescent and Youth Sexual Reproductive Health: In recognition of the importance of integrated youth SRH services and to increase the availability of and access to quality services to young people, the project trained 27 HCWs from Baringo County on AYSRH and 55 Youth Champions from Nakuru and Baringo counties on Comprehensive Sexuality Education (CSE) using Family Health Options Kenya Comprehensive Sexuality Curriculum to reach out of school youth. The youth champions conducted 70 community CSE sessions, reaching 1061 youth, distributed 17,280 condoms and referred 51 clients for HTS, ANC and FP services. The project also spearheaded the formation of AYSRH TWG to spearhead the coordination of AYSRH activities. Potentially due to the AYSRH activities, the project saw an increase in FP uptake among youth aged 15-19 and a corresponding decrease in the number of pregnant teens.

Gender Interventions: To build the capacity of HCWs to provide comprehensive post violence care services and ensure availability of post violence care services, Afya Uzazi project supported training of 14 HCWs on Post-rape Care (PRC) from Marigat sub county. In the subsequent quarter, the project will ensure comprehensive services to SGBV survivors by supporting and strengthening of linkage to other community support services through establishing multisector networks. The project will also initiate GBV screening as well as strengthen documentation of other forms GBV through training and mentorship of HCW.

Population Health and Environment: Afya Uzazi aims to integrate population, health and environment (PHE) activities as a vehicle to improve FP/RMNCAH services while simultaneously promoting environmental conservation in Kuresoi North and Kuresoi South sub counties. The two sub counties have experienced unprecedented environmental degradation, coupled with poor FP/RMNCAH indicators. To inform development of PHE strategy, Afya Uzazi project conducted a formative PHE assessment, coordinated an exposure visit to the LVBC PHE site in Mt Elgon region and convened a PHE Stakeholders Workshop. The PHE strategy will be finalized in quarter 4.

Monitoring, Evaluation and Learning: Afya Uzazi MEL team conducted an M&E systems assessment to determine the status of the M&E practices and gaps in the two counties. Based on the assessment, the team developed SOPs to support data verification at facility and sub county levels. The team facilitated monthly facility and sub-county data verification as well as quarterly sub county data review and planning meetings in the focus sub counties except East Pokot. Based on the M&E systems assessment, the team procured and distributed necessary tools to facilities and CUs. To coordinate M&E activities, the Afya Uzazi MEL team, in consultation with the CHRIO, established the Baringo County TWG.

Quantitative Impact During the reporting quarter, the program continued to make tremendous progress towards achieving the PY1 targets. Vitamin A supplementation among children under the age of 5 years increased from 8, 652 in Q2 to

49,643 in Q3, thereby improving cumulative achievement of PY1 targets from 8% in Q2 to 55% in Q3. An additional 3,242 children under 1 year of age were fully immunized, cumulatively improving performance against the annual target to 47%. Completion of from ANC visits increased to 19% up from 10% in Q2. Concurrently, the skilled birth attendance rates increased to 22% from 11% in Q2.

The HCW training is on target as 89%; 70%, and 100% of training targets on maternal/newborn health and nutrition, child health care and nutrition, and community maternal/newborn health and nutrition, respectively, have been met. During this quarter, 30% of performance indicators were below 50%, 58% were above 50%, and, of these, 36% were above 75% of the annual targets.

Constraints and Opportunities During this quarter, there was a strike by nurses and midwives that hampered access to services. Insecurity persisted in East Pokot sub county which prevented project operation in that sub county. In addition, the project experienced high levels of bureaucracy with ministry of education and interior ministry, delaying the roll out of in-school youth sexual and reproductive health and sensitization of police officers on post gender violence interventions. On a positive note, high levels of cooperation from the CHMTs and county governments has continued. The existence of World Banks Results Based Financing, Free Maternity Care and the National Hospital Insurance fund provide an opportunity to break financial barriers to service access. The existence of other USAID funded mechanisms has provided a forum for collaboration and leveraging for technical expertise and resources.

II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

CROSS CUTTING INTERVENTIONS

Integrated Outreaches An integrated outreach is a planned, scheduled single-day visit by qualified staff from a health facility to populations located in hard-to-reach and underserved areas. Outreaches play an important role in systematically delivering essential maternal and child health services to underserved and hard-to-reach populations. This approach, coupled with an effective community health strategy, has proven to be effective even though a permanent solution to this challenge lies with mobilization of resources for medical infrastructure and human resources. In the five accessible sub counties, immunization coverage in most facilities is below 80% with a high (>10%) dropout rate. The rate of completing 4 ANC visits is less than 25%. Contraceptive prevalence rate for modern methods in Baringo county is 33% and Nakuru is 54% (KDHS 2014).

Using the s-curve for FP in Kenya, Baringo is in the rapid acceleration phase while Nakuru is in the plateau phase. However, Kuresoi North and South sub counties are likely to be in the rapid acceleration phase given their unique characteristics. The recommended interventions for rapid acceleration counties includes targeted outreaches and community-based distribution. To address poorly performing FP/RMNCAH indicators, the project, in collaboration with SCHMTs and health staff, mapped out priority outreach posts based on the following criteria: low Pentavalent 1 antigen coverage, high dropout rate of more than 10 % and high number of unvaccinated children. The project team and SCHMT further developed standard operating procedures to ensure standardization and quality services in all the outreaches (Annex 1).

Twenty-two (22) outreach sites (Baringo-14, Nakuru-8) were selected based on the above criteria and the project supported implementation of monthly comprehensive and integrated outreaches. An integrated package of essential promotive and preventive services including FP, ANC, PNC, immunization, nutrition, and management of common childhood illnesses were offered during the outreaches. The Ministry of Health provided staff, equipment and supplies while the project provided technical and logistical support. In PY1 Q3, 61 outreaches were conducted reaching different beneficiaries with services as shown in chart below:

Integrated Supportive Supervision Supportive supervision is a quality improvement intervention. The process entails mapping of poorly performing facilities based on RMNCAH indicators, scheduling a visit by SCHMT together with facility HCW, and reviewing actions taken to address gaps with an objective of ensuring adherence to standards and quality improvement. Using a standardized checklist, facilities are assessed for quality of service, documentation and capacity of health care providers. In PY1 Q3, the project supported the SCHMTs of focus sub counties in Baringo and Nakuru to conduct supportive supervision in 42 health facilities.

Figure 1: Number of clients reached during outreaches

Numbers reached during outreaches Proportion of New 1600 & Revisit FP Clients 1387 1400 Revisit 1200 1000 850 800 726 560 600 423 400 258 208 169 205 200 78 85 28 0 New Baringo Nakuru 82% Immunization VAS ANC FP ORS/Zn Dewormed New Revisit

Table 1: Supportive supervision and action plans

Findings Action Taken No documentation of PNC services due to Mentorship done on use of PNC register during inadequate capacity and registers supervision. Orientation on targeted PNC conducted reaching 74 health care workers. In liaison with SCHRIO, the project distributed postnatal register. Nonfunctional ORT corners in some facilities and Mentorship done on establishment of ORT corners. lack of documentation of ORT services Trained 27 providers on IMCI in Baringo. The IMCI training is planned for subsequent quarter in Nakuru. Improvised ORT register and disseminated. Service providers had inadequate knowledge on Orientation conducted for HCWs on use of CHX current updates on cord care for cord care at facilities Knowledge gaps in KEPI operational level EPI training conducted. Follow up of trainees to be implementation (cold chain maintenance) and conducted in the current quarter. plotting on the immunization monitor charts Poor newborn resuscitation skills and equipment OJT conducted at facilities. EmONC and ENC training conducted with target for facilities identified during supervision. A rapid equipment assessment was done in quarter 2 and procurement process is ongoing Inadequate monitoring of labor using partograph Supported CMEs on use of partograph reaching 37 due to limited supply of partographs and inadequate health care workers. Photocopies of partograph skills done and supplied to health facilities. Knowledge and practice gaps in implementing CMEs on IPC were conducted at facilities. infection prevention and control (IPC), coupled by Training on EmONC and LARC incorporated IPC

inadequate supply of IPC equipment’s, color coded modules. A rapid equipment assessment was done bins and liners and autoclave in quarter 2 and procurement process is ongoing. Inadequate staffing in tier one facilities Advocacy to the CHMT for staff rationalization between facilities. The CHMT has plans to employ more nurses for new facilities in Baringo. As a stop- gap measure, the project is piloting the engagement of CHVs on a rotational basis to provide basic nutrition and WASH services. This is to be implemented as documented in PY1 Q4 work plan. Inadequate nutrition assessment, counseling & Trained 28 health care providers on MIYCN/BFCI support at MCH, maternity and postnatal clinic due in Nakuru. In Baringo, the training is scheduled for to lack of capacity PY1 Q4. The project oriented service providers on use of MUAC tapes (Children and Adult) and supplied to facilities. Non-implementation of Respectful Maternity Care The project, in collaboration with RMHSU, concept in health facilities supported sensitization of 51 health managers in Baringo and Nakuru. Service providers will be oriented in subsequent quarter. Nonexistent or nonfunctional MPDSR committee Trained 34 health care providers on MPDSR in at health facilities Nakuru. In Baringo the training is planned for PY1 Q4.

Center of Exchange Learning (CEL) The Center of Exchange Learning (CEL) is an innovative approach for onsite capacity building of frontline health care providers as compared to the traditional offsite, hotel based trainings that require movement of staff from their workplace. The focus sub counties have a shortage of health workers and most primary health care facilities in the sub counties are staffed by one provider. To improve health care provider capacity to deliver quality services, the project is in the process establishing three CELs with a goal of ensuring that health workers continuously gain and apply requisite competencies necessary to successfully deliver essential package of FP/RMNCAH services. A concept paper detailing the CEL model is attached (annex 2). The key processes in establishing a CEL include pre-assessment, infrastructure support (minor refurbishment), equipment, supplies and development of trainers. The project, in collaboration with CHMTs, conducted assessment for CEL in Olenguruone SCH (Nakuru County) and Marigat SCH (Baringo). The project, in collaboration with CHMTs, has refurbished the identified rooms to be used for lecture and as a skills lab, selected services providers to be developed as trainers and initiated the procurement process of models and relevant equipment.

Sub purpose 1: Increased availability and quality delivery of FP/RMNCAH services

Family Planning and Reproductive Health

• LARC Service Provision One of the major barriers to provision of LARC services is attributed to inadequate skills by service providers and lack of requisite job aids. To address this gap, the project supported the training of healthcare providers on LARC methods to promote access to quality FP services. This was done in PY1 Q2 (19 HCWs in Nakuru and 18 HCWs in Baringo) and additional 25 HCWs during this reporting period in Baringo. In this quarter, trainee follow up was conducted to assess skills application and knowledge retention in Nakuru. This was done in collaboration with CHMT using the trainee follow-up tool developed by the Reproductive and Maternal Health Services Unit (RMHSU) for specific skills and competency assessment. During the follow up, 32% (6 of 19) of trainees from four health facilities in Nakuru were reached. The facilities were Mau Summit Medical Center, Neema Highway Medical Home, Tonymed Medical Clinic and Keringet Sub County Hospital. The health facilities visited were mainly private facilities as most HCWs in public facilities were unavailable due to labor disputes between nurses’ unions and the county and central governments. The project also supported facility based mentorships in various FP methods during this reporting period. A total of 54 healthcare workers were mentored on postpartum FP and revised 2015 WHO medical eligibility criteria. In Baringo, trainee follow up will be done in the subsequent quarter and more HCWs will be trained through on-the-job training. Implementation of facility-specific action plans has been initiated in facilities with trained service providers. Some facilities have procured basic FP supplies including chlorine for decontamination. Need for IPC measures, such as instrument processing (decontamination) and waste segregation bins, was identified at most facilities, as was the need for updated job aids to support optimal FP service delivery and IPC. The project is in the process of procuring jobs aids (including revised MEC wheel (2015), BCS+ cards, FP checklist and waste bins), currently not available with MOH to be disseminated in quarter PY1 Q4. To strengthen commodity security for FP methods, the project supported the re-distribution to facilities with stock outs.

As a result of the above interventions, there was an increased uptake of FP services in the reporting period. For example, in Nakuru sub counties, IUCD insertions increased from 207 to 293 from the period January to March and April to June respectively. Implant insertions increased from 745 to 876 during the same period (Source- DHIS2). Similarly, during this reporting quarter the project witnessed a 56% increase in CYP (2874 compared to 1881 in Q2). The contribution of LAPM to CYP in Kuresoi North was 83% in Q3 compared to 73% in Q2. In Kuresoi South sub county, there was an increase in the CYP from 3102 to 3252 representing a 5% increase during the same period. The contribution of LAPM to CYP in Q3 was 84% as compared to 80% in Q2. It is worth noting that the effects of the ongoing nurses strike have been mitigated by continued service provision in the high-volume private for profit and faith-based facilities.

In Baringo county, there was a marginal increase in IUCD insertions from 110 to 120 from the previous reporting period. It was noted that most facilities did not report any service data in the month of June as a result of the nurses strike as most facilities are served by nurses. Consequently, only 13 of 110 facilities reported service data for the month of June, representing a 12% reporting rate. There was also a drop in the CYP from

a previous of 3721 in Q2 to 2465 in Q3.

The charts below demonstrate the trends in uptake of long acting methods over the last two quarters.

Figure 2: Comparison of IUCD & Implants Uptake between Q2 and Q3 in Nakuru, Baringo

Comparison of IUCD & Implants Uptake between Q2 and Q3 in Nakuru Comparison of IUCD & Implants Uptake between Q2 and Q3 in Baringo

1000 876 700 745 600 800 IUCD IUCD 500 600 400 Implants Implants 300 400 293 207 200 200 Linear Linear (Implants) 100 (Implants) 0 0 Jan-Mar Apr-Jun Jan-Mar Apr-Jun

Figure 3: Trends in FP uptake for all methods over the last two quarters.

Trends in FP uptake for all methods in Nakuru Trends in FP uptake for all methods in Baringo 2000 2000

1500 1500

1000 1000

500 500

0 0 Jan Feb Mar Apr May Jun Jan Feb Mar Apr May Jun

Kuresoi North Kuresoi South Baringo North Marigat Mogotio

Maternal & Newborn Health

• Emergency Obstetric and Newborn Care (EmONC) During initial facility assessments and ongoing supportive supervision, the project staff and SCHMTs identified gaps in the implementation of EmONC signal functions in tier two facilities in Baringo and Nakuru. Some of the gaps identified included inadequate skills for service providers and lack of equipment and supplies. To address these gaps, the project supported trainings on EmONC PY1 Q2 (23 HCWs in Nakuru and 25 HCWs in Baringo). An additional 30 HCWs were trained in Baringo county in PY1 Q3. These providers were drawn from Mogotio, Marigat, Baringo North and East Pokot sub-counties.

To reach more service providers in a cost-effective way, the project supported CMEs and facility based mentorship on EmONC in focus sub counties. For CMEs, a clustered approach was employed, which entailed pooling between 10 and 15 health workers from nearby facilities to a central site to reach more providers. Various MNH topics were covered including; partograph use, ANC, PNC as well as obstetric emergencies and their management (post-partum hemorrhage, preeclampsia and eclampsia, puerperal and

neonatal sepsis, maternal and newborn resuscitation). A total of 107 HCWs (54 in Baringo and 53 in Nakuru) were reached.

Following the training of health care providers on emergency obstetric and neonatal care, Afya Uzazi team, in collaboration with CHMTs, conducted trainee follow up to assess skills application at four BeMONC health facilities. Six of 23 (26%) HCWs trained in Nakuru were reached at visits to Mau Summit Medical Center, Neema Highway Medical Home, Tonymed Medical Clinic and Keringet Sub County Hospital. The process was hindered by the nurses’ strike. In Baringo county, four HCWs were reached for post-training follow up at Marigat PHC, Kamar Dispensary, Sirwa Health Center and Molo Sirwe Health Center. Key observations included: institutionalization of correct partograph use; procurement of EmONC equipment and supplies including ambu bags by some facilities; use of chlorine for decontamination; and set up resuscitation station and emergency trays. The project also supported facilities with Basic EmONC job aids including those for active management of third stage of labor (AMTSL), assisted vaginal delivery, newborn resuscitation, warm chain, kangaroo mother care, newborn examination and use of magnesium sulphate for management of eclampsia. In general, there was a marginal increase in the number of women completing 4 ANC visits in Q3 as compared to Q2. The increase was more pronounced in Kuresoi North and Kuresoi South possibly due to presence of contracted nurses in some public facilities to mitigate effects of the strike. In Baringo North and Mogotio sub counties, there was a reduction in ANC 4 completion possibly attributed to the strike but without any mitigation measures. The chart below illustrates the actual ANC 4 completion per sub county.

Figure 4: Completion of 4 ANC visits by sub-county, by quarter.

Number of women completing 4 ANC visits by sub county; a comparisson between Q2 and Q3 450 400 350 300 250 200 150 100 50 0 Marigat Mogotio Baringo North Kuresoi North Kuresoi South Jan - Mar 371 362 272 159 237 Apr - Jun 387 311 218 235 271

Jan - Mar Apr - Jun

The chart below shows the trends in skilled deliveries from January to June. The upward progress from the month of March to April/May was not sustained and in fact reversed in June and is attributed to the ongoing nurses strike.

Figure 5: Trends in SBA for Nakuru and Baringo, by quarter

Trends in SBA for Nakuru and Baringo for the last two quarters 450

400

350

300

250 Nakuru (Kuresoi North and South) 200 Baringo (Marigat, 150 Mogotio, Baringo North)

100

0 Jan Feb Mar Apr May Jun

In May 2017, the project initiated support for routine monthly EmONC assessments in Baringo North sub county EmONC supported facilities. Common gaps identified during monthly assessments include stock outs of oxytocin, magnesium sulfate and calcium gluconate. To mitigate the commodity stock outs, the project supported redistribution of these essential commodities. Facilities are now able to budget and buy some essential equipment necessary for EmONC service readiness, e.g. purchase of MVA kits. The graph below illustrates the results of the monthly assessments. Monthly EmONC assessments will be initiated in other sub counties in the subsequent quarter.

Figure 6: Trends in SBA for Nakuru and Baringo

Facility EmONC Service Readiness per Signal Function (SF) in Baringo North (n = 4)

120 100 80 60 40 20 0 SF1 SF2 SF3 SF4 SF5 SF6 SF7 May-17 75 75 75 50 50 100 100 Jun-17 100 100 100 100 75 100 100

May-17 Jun-17

• Essential Newborn care To strengthen skills required for provision of essential package for newborn care and ensure quality of care especially during the golden minute of life, the project supported training of HCWs on ENC. This was done in collaboration with the CHMT and national trainers from the Neonatal, Child and Adolescent Health Unit (NCAHU). A total of 48 HCWs were trained; 21 in Nakuru and 27 in Baringo. The mean pretest scores for knowledge and skills for participants were 54% and 25%, respectively while the mean post-test scores increased to 75% and 86%, respectively. The acquired skills will improve availability and quality of life-saving interventions at primary health facilities. Trainee follow-up to assess translation of skills into practice will be conducted in Q4.

Figure 7: Pre-and post-training level of skills on neonatal resuscitation in Nakuru

Level of Skills on Neonatal Resuscitation During ENC Training in Nakuru 120%

100%

80%

60%

40%

20%

0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

% PreTest Score % Post Test Score Linear (% Post Test Score)

• Chlorhexidine for cord care Compared to dry cord care that is currently widely practiced, CHX use for cord care reduces newborn deaths by 24% while reducing severe omphalitis by 75% (Lancet 2006: 367(9514): 910 - 918). Based on the evidence, the MoH Kenya developed “A guideline for the use of chlorhexidine for newborn umbilical cord care in Kenya ”. Despite dissemination of the guidelines in April 2016, the use of CHX for cord care has remained low in public health facilities. According to a commodity assessment conducted by the project in Q3, no facility had CHX stocks. In preparation for the roll out of CHX use for cord care, the project supported orientation of 48 HCWs (27 in Baringo and 21 in Nakuru) on use of CHX for cord care as a module under ENC training. An additional 15 HCWs were oriented through CME on cord care in Mogotio sub County. The project sourced for and received a donation of 4480 doses of CHX digluconate 7.1% from Turkana County. These have been distributed to the health facilities in the focus sub counties and are already in use.

• Respectful maternity care (RMC) According to the HESHIMA project (2010), disrespect and abuse was found to be widespread amongst the public health facilities in Kenya. This poses a barrier towards utilization of services including maternity services. RMC refers to respectful and dignified maternity care. The RMC approach addresses the common types of disrespect and abuse. This approach aligns itself to the project’s guiding principle emphasizing on services being client-centered and rights-based. The concept of RMC has not been implemented in the focus sub-counties. During the reporting period the project, in collaboration with CHMT and RMHSU, supported orientation of 51 CHMT/SCHMT members and selected facility managers (35 in Baringo and 16 in Nakuru) on RMC using the national RMC guidelines. Subsequently, Afya Uzazi in collaboration with CHMT and RHMSU will train ToTs who will eventually cascade service providers to implement RMC measures.

• Maternal and Perinatal Death Surveillance & Response (MPDSR) MPDSR is a systematic process for active identification and review of causes of maternal and perinatal deaths with the objective of making appropriate responses to avert subsequent maternal and perinatal mortality and morbidities. In the project focus sub-counties, the audit process is nonexistent in the lower level facilities and nonfunctional in the higher level facilities. In cases where audits are conducted, there is more emphasis on the maternal than the perinatal component and more focus on the surveillance than response. In this quarter, the project supported a 3-day workshop on the revised MPDSR guidelines 2016 in Nakuru (Kuresoi North and Kuresoi South) for 34 participants. These included participants from CHMT, SCHMTs, and healthcare workers. The objective was to equip them with necessary skills and supply them with requisite tools (MoH 369, MoH 370, MoH 371, MoH 372 and 519) to undertake maternal and perinatal death reviews and audits. Currently, two sub county MPDSR committees have been established in Kuresoi North and Kuresoi South. In the subsequent quarter, a similar training will be conducted in Baringo county. Additionally, the project will support establishment of six MPDSR facility based committees in high delivery volume facilities through onsite training and provision of tools.

Child Health

• EPI operational level training In the focus sub counties, similar infrastructural, capacity and documentation challenges are present with regard to immunization. In these sub counties, the last KEPI operational level training was conducted over

ten years ago. Coupled with high staff turnover in some facilities, the quality of immunization services have been negatively impacted. In addition, multiple gaps in immunization services were noted during integrated supportive supervision in the previous quarter, including limited knowledge on cold chain management, lack of EPI micro plans at facilities, and poor immunization monitoring using charts. To address these gaps, the project supported EPI training for 20 service providers drawn from tier 2 and 3 facilities in Baringo county. In addition, 29 (10 in Baringo and 19 in Nakuru) service providers from 19 health facilities were mentored. Afya Uzazi project, in collaboration with the respective County Division of Vaccines and Immunization (DVI) services coordinator and sub county teams, further identified 21 non-functional cold chain equipment for repair. The project will work with DVI technicians at national and county level to repair this cold chain equipment to facilitate scale up of immunization sites and increase of fully immunized child coverage (FIC). Twenty health facilities have now developed comprehensive updated micro plans. Follow up to assess service provision following these changes will be done in Q4.

The graph below shows the monthly performance of three antigens (Penta 1, Penta 3 and measles) as well as the percentage of fully immunized children in the last two quarters. In the month of June, service provision was reduced by the nurse’s strike. In Q4, the project will continue to work with facility and community teams to place CHVs at facility level (MCH) to support growth monitoring, client education and vaccination defaulter tracing.

Figure 8: Monthly coverage on immunization coverage in Baringo focus sub-counties

Monthly coverage on immunization coverage in Baringo focus sub counties 120 100 80 60 40 20 0 Jan Feb Mar Apr May Jun Penta 1 91.4 85.2 86.3 73.8 86.8 17.5 Penta 3 85.4 84.6 76.8 79.6 81.7 14.4 Measles 104.3 92.6 84 77.5 86.4 14.1 FIC 104 92.6 83.9 81.2 84.4 14.2

Penta 1 Penta 3 Measles FIC

• Integrated Management of Childhood Illnesses (IMCI) The integrated management of childhood illness (IMCI) approach aims to improve the case management and prevention of five leading causes of childhood mortality (pneumonia, diarrhea, malaria, malnutrition and HIV/AIDS). To strengthen management of these conditions, the project supported implementation of the IMCI standards in Baringo County. This was done through support for training of 30 healthcare workers on the IMCI package. A further 16 service providers were reached through cluster mentorship and CMEs at the facility level. Trainee follow-up is scheduled and similar training is planned for Nakuru sub counties in PY1Q4.

• Oral Rehydration Therapy Prevalence of diarrheal diseases in children under five is high across the focus sub counties. Management and prevention of childhood diarrhea is inadequate and most facilities have inadequate capacity to manage dehydration. The project supported HCWs training and mentorship on IMCI. In Q3, the number of children treated for diarrhea with ORS/Zinc were 1097 cases in Kuresoi North as compared to 1411 cases in Q2. In Kuresoi South, 1718 cases of childhood diarrhea were treated with ORS/Zinc as compared to 1526. In Baringo, 2993 cases of childhood diarrhea were managed in Q3 as compared to 4132 in Q2. The decline in diarrhea cases is attributed to sustained messaging on water, sanitation, and hygiene (WASH) by CHVs at the household level. In Q4, the project will support establishment of functional ORT corners and provide ORT registers. The project has developed a plan to embed CHVs on a rotational basis to support growth monitoring and ORT at HRH-constrained health facilities, as a stop-gap measure. The CHVs will work under close supervision of the trained health care workers. Nutrition and WASH

• Support to Malezi Bora campaigns Malezi Bora is a Ministry of Health initiative started in 2007 with the aim of increasing uptake of Maternal and Child Health services in an effort to increase the coverage of MNCH indicators such as immunization, ANC and skilled delivery among pregnant women, Vitamin A supplementation for children below 5 years of age and lactating mothers, and PMTCT and de-worming. The Malezi Bora objectives are similar to the project goals. Furthermore, Malezi Bora aims to sensitize and educate the community on importance of promotive and preventive health and nutrition services available to infants, children, expectant women and breastfeeding mothers.

During Q3, the project supported the Malezi Bora campaign through accelerated Vitamin A supplementation and deworming, targeting children under five years and breastfeeding mothers through community outreaches and at early childhood development (ECD) centers. The project facilitated the preparation, logistics and review of Malezi Bora data by the SCHMTs. The chart below illustrates Vitamin A supplementations by sub county.

Figure 8: Monthly coverage on immunization coverage in Baringo focus sub-counties

Malezi Bora Vitamin A Supplementation for focus sub counties 14000 11743 12066 12000 10637 10000 7875 8000 6864 6000 4000 2000 0 Vitamin A

Marigat Mogotio Baringo North Kuresoi North Kuresoi South

Baby Friendly Community Initiative

Exclusive breastfeeding rates according DHIS2 in 2015 for focus sub-counties are quite low: Baringo North is 12.5%, Marigat is 51.3%, Mogotio is 43.1%, Kuresoi North is 25.2% and Kuresoi South is 32.5%. To improve breastfeeding practices, the project is supporting implementation of the Baby Friendly Community Initiative (BFCI). In Q3, the project trained 28 HCWs on BFCI in Nakuru to promote and support optimal infant and maternal nutrition at community, dispensary and health centers. This was done through collaboration with NHP-Plus and nationally accredited trainers. The participants were drawn from both the community and facilities. At the health facility level, HCWs will promote and support early initiation of breastfeeding, exclusive breastfeeding for the first 6 months, optimal complementary feeding and maternal nutrition through targeted health education and counselling. In subsequent quarter, BFCI training is planned for HCWs in Baringo focus sub counties.

Assessment and reactivation of community health units to facilitate community to facility referrals

Community Health Units (CHUs) are the first level of care as outlined in Kenya 17 essential elements for CU functionality score card health policy framework 2015-2020. A CHU serves a population of CHEWs trained, CHC trained, CHVs trained, CHVs approximately 50,000 people which is equivalent to 1000 households. The supplied with CHV kits, all trained CHVs have MoH community-based workforce providing key health services to those households 514, CHV reporting rate above 80%, CHU has a are well trained CHVs, with the support of CHEWs who are government chalkboard, all trained CHVs have referral booklets, CHU action plan developed, Quarterly CHC Meeting employees. The CHV are expected to provide quality health services at held, CHVs monthly Meetings, All reporting CHVs household including referrals for skilled delivery, immunization, FP and ANC, (MoH 514) receiving stipend, Monthly dialogue days among other services. A CHV is required to work in a functional CHU to held, Quarterly Health Action Days held, SCHMT supervisory visit conducted, CHU has bicycles for provide optimal services at the community level. To establish functionality of use by CHVs and CHU having a sustainable initiative the CUs, the project conducted functionality assessments in 42 units in all the (IGAs). project focus areas during the reporting period to establish the status of the Source: Amref CU functionality assessment tool units prior to engagement with them. The project adopted the Amref functionality scorecard tool which has been tested and used in all CHUs in Kenya. The assessment found that most of the CUs were established in 2012 and a few in 2014. However, none were functional at the time the assessment were conducted, which was attributed to the sponsoring partner withdrawal. Specifically, it was found that most CUs lacked reporting and referral tools, did not hold regular meetings, did not conduct quarterly dialogue and action days and lacked CHV kits. These were areas that needed action from the CHEWs and CHVs to ensure CU functionality. During Q3, the project supported CHUs to reactivate through monthly meetings, dialogue and action days, photocopying of referrals and reporting tools and refresher training for both CHVs and CHEWs. This has resulted to improvement in documentation, reporting, referrals and coordination by CHEWs and CHS focal persons

Health Systems Strengthening Interventions

1. Quality Assurance/ Quality Improvement (QA/QI) interventions

As part of the initiative to build capacity for QA/QI, the project, in collaboration with the USAID|ASSIST project, conducted a 3-day QA/QI training in Baringo. A total of 25 participants drawn from the CHMT, SCHMT and health facilities attended the training, which covered key principles of continuous quality improvement (QI). At the conclusion of the training, participants developed action plans to guide their subsequent activities in QA/QI at their respective facilities. The project will support the facilities to establish the necessary structures for implementation of QA/QI activities as well as providing TA in the implementation of CQI interventions and follow up activities as well as providing TA in the implementation of CQI interventions and follow up. County QA/QI Training HRH Interventions

1. Assessment of HRH needs to develop and implement worker recruitment, retention and incentive interventions To initiate the project’s Human Resources for Health (HRH) activities in Nakuru and Baringo counties and adequately respond to the needs, the project convened one-day meeting with each county to introduce the projects’ HRH interventions. A consensus from the Participants in the QA/QI training at the Baringo meeting was the need for conducting an urgent rapid assessment to identify the HRH strengths and gaps in a most cost effective and efficient manner using existing tools. This would enable prioritization of interventions that adequately respond to the specific needs of each county in line with the project’s mandate. Due to the urgency of the baseline information describing the status of HRH in the counties and time constraints, the project adapted MSH’s HRH rapid assessment tool, which is already endorsed by WHO as a standard tool for rapid comprehensive HRH assessments. The tool consists of a matrix that includes twenty- one human resource components that fall within six broad areas of human resource management. It also describes four stages of development of the HR systems with characteristics that describe each component at each stage of development. The tool has proven capacity to provide governments and other stakeholders with information about HRH capacities to help identify areas for further investigation and intervention with the longer-term objectives of prescribing context based interventions on HRH issues such as ensuring adequate staffing levels, optimizing efficient utilization of health workers, identifying HRH barriers to quality service delivery and collecting specific HRH data to inform program planning and transition.

Nakuru County: Arising from the initial meeting with the CHMT on the need for the HRH assessment, a county comprehensive HRH rapid assessment was conducted in a one-day meeting held on 17th May 2017 at Chester Hotel in Nakuru with 30 participants drawn from the CHMTs, SCHMTs, and various health departments. Key findings of the assessment highlighted the county’s strengths and weaknesses on the HRH practices. Strengths:

• Existence of a semi functional HRH unit with a focal person • Availability of skilled health professionals in the establishment • Existence of supportive county government management structures

Weaknesses: • Inadequacies of the HRH unit in terms of skills and competencies of the personnel deployed to the unit • Inadequate financial flows and budgets allocated for HRH activities beyond salaries • Weak HRH planning due to inadequate HRH information and unresponsive recruitment and deployment processes and practices that are not proportional to service needs • Health worker maldistribution in Kuresoi North and South with most of the facilities managed by one health worker • Weak coordination of stakeholder efforts • Weak performance management and supportive supervision systems

Some key recommendations from the assessment included the need for: • An orientation program for the CHMT and the members of the County Public Service Board to appreciate the need for supporting the HRH unit under the Directorate of Planning and Administration. • Institutionalization of staff orientation or onboarding program for all newly recruited staff and those appointed in new positions • Training a pool of officers to manage the Human Resources Information system installed by IntraHealth to replace the staff who were trained earlier and have since left the service. • Capacity building of the CHMT and SCHMT on leadership and governance skills for improved HRH management in the county • The need for developing a context-based attraction and retention strategy for Kuresoi North and South that were classified as hard to staff areas of the county.

The draft report is awaiting a stakeholder endorsement in Q4 before embarking on step by step implementation of the recommendations.

Baringo County

Based on the project’s preliminary consultation with the CHMT on 22nd May 2017 that discussed the HRH status and the need for rapid HRH assessment, a county HRH rapid comprehensive assessment was conducted on 7th June 2017. The meeting had 40 participants drawn from the County Health Department and relevant stakeholders including representation from health worker associations and unions, training institutions, UNICEF, World Vision and the Fred Hollows Foundation.

Key finding from the initial meeting and assessment identified the absence of a HRH unit with a HRH focal person and thus the weak governance structure to manage HRH issues. Other issues raised included the fact that some parts of Baringo County suffer from acute HRH shortages fueled by attraction, recruitment and retention challenges especially in the security compromised and hardship areas which in turn influence the number of health workers willing to work in such places. Health workers recruited in the hardship areas join

the service on the basis that after a specified period of service, they will be transferred to other, more resourced areas. The lack of specific health worker recruitment and retention strategies that offer incentives that can only be accessed by health workers serving in such identified areas. The low literacy levels and lack of interest in admission to medical training institutions is also a factor, meaning that low numbers of health workers who are from hardship areas are not produced and thus low attraction and retention rates. Further, distribution of health workers in the sub counties is disproportionate to population ratios and Kenya Essential Package of Health (KEPH) Levels which is characterized by low workforce-to population ratio.

The following recommendations for immediate implementation by the County and the stakeholders included:

• The need for adopting a systematic methodology for planning of health workers for improved staff deployment, recruitment and redistribution of the maldistributed health workers. • Development and institutionalization of a staff orientation/onboarding program for all the new health workers in the system as a retention strategy. • The need for orienting all the county management especially the CHMT, SCHMT, Health administrators, County Public Service Board and the Health Committee members of the County Assembly on HRH practices. The administrators were specifically trained because they are the ones who perform the HRH functions at the sub county level and facility levels. • Strengthening of the quarterly supportive supervision of the health workers in the facilities • Strengthening of the HRH stakeholder coordination meeting to improve partnership and resource mobilization for HRH activities in the county • The need for reactivation of the HRIS that was established by Intrahealth in 2014 and has not been in use. This will enable staff data cleansing and harmonization of the sources of staff information for planning and timely decision making in the county • The need for a five-year HRH Strategic Plan for the county to improve HRH practices. The draft report is awaiting validation in Q4 to be followed by the development of attraction and retention strategy based on the recommendations of the assessment.

Afya Uzazi’s first step to addressing the HRH gaps involved advocacy to the CHMT to establish and institutionalize the HRH unit. This was done and an office space allocated in the Directorate of Administration and Planning. The CHMT appointed a HRH focal person with clear roles and responsibilities and endorsed by the County Public Service Board. The project provided technical support for the development of the officer’s job profile as per the national guidelines.

Participants HRH for Health Rapid Assessment- Baringo County (l) and Nakuru County (r)

2. Strengthening health workforce management skills in Nakuru and Baringo Counties From the rapid assessments of the two counties, it was evident that the counties lacked adequate capacities in terms of skills and competencies to effectively manage the health workforce. This compromises health service delivery at the facilities. In addition, there is weak HRH partner coordination within counties. Investments made by the county governments and development partners on health inputs were not bearing much fruit without concomitant efforts from the managers charged with translating the investments into positive health outcomes. The project therefore conducted a 5-day orientation workshop for 30 participants from Baringo County using the Health Systems Strengthening training materials developed by the MOH, MSH and AMREF Health Africa. Participants consisted of members of the CHMTs, SCHMTs, County Public Service Board, the newly appointed HRH officer and health administrators. The skills will enable the managers to improve work force management and scale up health services provided in the county. The outcomes of the orientation included the identification of weak HRH practices for support in the county, building a strong case for CHVs to be incorporated in the mainstream health workforce at the primary level with a monthly stipend from the county government, the need for developing clear job descriptions and strengthening of the CHV performance management systems. The Nakuru orientation is planned for Q4, PY1.

Baringo Participants during the HRH orientation at Midland Hotel-Nakuru

To support the weak coordination of the diverse HRH stakeholders in Baringo and Nakuru counties, the project advocated for the formation and institutionalization of the HRH coordination committee which is a national requirement for all counties. The CHMTs acknowledged the importance of the committee as a strategy to address the HRH challenges locally. This will be done by coordinating and harnessing the diverse stakeholders’ efforts to respond to HRH issues and challenges and defining roles and responsibilities of each partner. This is because solutions to HRH issues and challenges are multidimensional and many inputs are outside the control of the department of health. The project provided technical support to the CHMTs for the formation of the committees by mapping HRH stakeholders and developing the terms of references indicating the roles, mandates and frequency of meetings for the committees as provided for in the 2009 National Coordinating Guidelines of the Country.

The key stakeholders identified to form the membership of the committees include: representation from the CHMTs, SCHMTs, the county directors of human resources, selected heads of programs from the county health departments, health training institutions in the counties, union representatives of the health workers, representatives of the health regulatory bodies or councils, professional associations, implementing partners in

the counties supporting health related activities, representatives of County Public Service Boards and relevant county departments that have direct impact on health namely education, environment and finance.

As described by the terms of references developed with the help of the project, the HRH CC meetings will be convened by the directors of administration and planning of both counties in collaboration with the county- specific HRH partners on a quarterly basis. The secretariats will be the HRH units of the counties. The committees’ main mandate will be to support the counties to identify, prioritize and address challenges of HRH, and mobilize resources and provide oversight for HRH collaborative efforts in the counties. The products from the County HRH CC meetings are then presented and showcased in the inter cluster HRH fora which is a laid down national coordinating mechanism which serves as a platform for HRH best practices knowledge sharing. Nakuru belongs to the South Rift cluster team while Baringo belongs to the North Rift cluster. In support of the HRH national coordination mechanisms, Afya Uzazi project supported a team of six officers comprising representatives from Baringo County Assembly, County Public Service Board and the CHMT to attend the institutionalized quarterly HRH inter cluster meeting for North Rift Cluster held in Sirikwa Hotel in Eldoret from 14th to 15th June 2017. The meeting provided Baringo County an opportunity to share and showcase the HRH achievements of the county during the quarter which included the creation of a HRH unit and directorate, appointment of a HRH focal person with a clear job description to steer the HRH function, establishment of a County HRH Coordination Committee with terms of reference, the recruitment of 56 new health workers in some facilities that had shortages, the introduction of mobile clinic using the “ Beyond Zero” campaign infrastructure to reach out to the security compromised areas of East Pokot, the institutionalization of the client satisfaction survey in all the county health facilities and the monthly health worker meetings to discuss HRH challenges and proactively mitigate them. The newly appointed HRH focal point person was officially introduced during the meeting and officially admitted to the cluster membership.

3. Development of leadership and management skills of frontline health workers and managers

A priority of the Afya Uzazi project is to develop leadership and management skills of frontline health workers and managers based on MSH’s Leadership Development Program (LDP). The LDP model is carefully embedded as a key model for strengthening frontline health worker’s leadership and management capacities to improve the FP/RMNCAH services. LDP is a six to eight months’ team-based experiential learning and performance improvement process. The teams comprise 3-6 members from the various front line health workers and managers in a facility. The training empowers health workers and managers at all levels to learn leadership, management and governing practices, face challenges, and achieve measurable results. This model is based on a county-led process for focusing health teams on priority health results which in the case of Afya Uzazi is FP/RMNCAH. The training content empowers teams to be able to focus on results they care about and adds ownership for finding solutions to challenges identified by teams. A meeting with the Baringo CHMT was convened on 22nd June 2017 to create awareness on the LDP model. The project solicited the county’s top level management commitment for the subsequent planned trainings aimed to develop leaders at all levels of health care to face challenges and achieve results in the project’s priority health area. The CHMT, in harmonizing HRH interventions with the project’s main mandate of improving FP/RMNCAH, backed the need for strengthening FP/RMCAH specific interventions in the LDP trainings. Based on the orientation, the CHMT identified five teams from the four focus sub counties and the CHMT making 25 participants for the first cohort. The initial two-day training is scheduled for Q4.

4. Implementation of the Integrated Human Resource Information System (IHRIS) for Baringo and Nakuru Counties The attainment of improved FP/RMNCAH services relies on the two counties having adequate numbers of HRH and their appropriate distribution. Understanding of the systems used to generate information for monitoring HRH stock and flows known as human resources information systems (HRIS) is minimal in the two counties. While HRIS is increasingly recognized as integral to health system performance assessment, baseline information regarding its scope, capability and usage is limited as highlighted in the findings of the rapid assessment. Towards ensuring the functionality of the County HRIS, Afya Uzazi project supported health workforce data cleaning and updating for both Baringo and Nakuru Counties. The cleaning of the data is aimed at ensuring a match between employee data in the personnel files, staff returns and the payroll. The cleaned staff data has been uploaded in the HRIS that was established by IntraHealth through USAID support and has not been in use. Currently, Baringo has uploaded 79% of staff data into the HRIS (999 of 1258) while Nakuru County has uploaded 54% (1022 of 1899). Once data cleaning is completed in Q4, staff will be trained to generate quarterly HRH reports for sound health workforce planning and decision making. In addition, linking HRIS data with broader health information such as disease burden, health services utilization for FP/RMCAH services and patient outcomes will be a powerful tool in prioritizing resource allocation for health worker training and deployment to meet health system goals.

Commodity Management and Supply Chain

1. Strengthening Commodity Security Committee County commodity security committees are expected to provide stewardship for commodity management and security thus ensuring continuous access to required health commodities to adequately support delivery of health services at all levels of care including FP/RMNCH. However, across many counties, these committees have either not been established or are weak, hence affecting their ability to deliver on their mandates.

Following initial engagement in Q3, consensus was reached with both Nakuru and Baringo Counties to establish (Baringo) and reactivate (Nakuru) commodity TWGs.

Baringo County: During Q3, Afya Uzazi project, in collaboration with the USAID-funded KSCSS project, supported Baringo County to reactivate the County Commodity Technical Working Group which had been dormant for more than one year. An initial planning meeting was held on 6th April 2017 with the County Pharmacist, sub-county pharmacists, RH coordinators and others to strategize and plan the way forward with regard to the operations of the commodity TWG and overall commodity management support. This was followed by the inaugural meeting of the of the TWG on the 7th April 2017 where the ToRs were reviewed and a calendar of activities for the quarter agreed upon. Prioritized activities were:

• Commodity management training for ToTs • Commodity supply chain mapping/supervision • Commodity data review meeting (s)

Nakuru County: The program collaborated with APHIAplus Nuru ya Bonde to support the quarterly commodity TWG meeting on 27th April 2017. A total of 14 members who included the County Pharmacist, County RH coordinator, the County HIV/AIDS and STI coordinator and the County Medical Laboratory

Technologist attended the meeting chaired by the Deputy County Director of Medical Services. Membership of this committee include CHMT members in charge of departments and/or programs which manage or require access to specific health commodities to deliver services. Also in attendance was the KEMSA liaison officer for South Rift region. Although this TWG has been in existence, the last meeting was held in March 2016 as the committee has lacked consistent technical assistance and resources to support its operations

During the meeting, the TWG reviewed its work plan and developed a schedule of activities for the quarter. Key FP/RMNCAH commodity related issues discussed included advocacy to KEMSA to stock CHX for cord care and procurement and supply of IPC items such as disinfectants, detergents and fungicides which has previously not been factored in the health commodity budget, especially for health centers and dispensaries. The program also supported a follow-up meeting of sub-county pharmacists to track implementation of activities and address emergent issues in commodity management/supply chain in the county.

2. Commodity supply chain mapping exercise/supportive supervision In collaboration with the CHMTs and county commodity TWGs, the project conducted commodity supply chain mapping exercise/supportive supervision in Baringo (Mogotio Sub County) and Nakuru (Kuresoi North and Kuresoi South sub counties). The purpose of this activity was to evaluate commodity management practices and supply chain for FP/RMNCAH commodities to identify gaps and provide support by recommending corrective action to address the key challenges at each of the supported counties. The set of tracer commodities assessed include: Depot medroxyprogesterone acetate (DMPA), Combined Oral Contraceptives (CoC), Intrauterine Contraceptive Devices (IUCD), Progesterone only Pills (POP), Oral Rehydration Salt ORS/Zinc Co-packs, Oxytocin, Magnesium Sulphate and Tetracycline Eye Ointment (TEO)

A total of 9, 10 and 13 facilities in Mogotio, Kuresoi North and Kuresoi South, respectively, were assessed. Key findings are shown in the figures below:

Figure 9: Availability of RMNCH commodities, Nakuru County

FP/RMNCH COMMODITY AVAILABILITY Availability of FP Methods 120 95.7 ALL TRACER ITEMS 4.3 100 78.3 78.3 80 60 43.5 39.1 ALL FP METHODS 26.1 40 20 commodities Percent (Facilities) Percent 0 80% OF TRACER ITEMS 30.4

0 10 20 30 40 Facilities (%) FP Method

Availability of MNCH Commodities MoS FP/RMNCAH Commodities 120 100 100 91.3 TEO

80 60.9 ORS Zinc 60 35.7 Oxytocin 40 28.6

% (Facilities) % IUCD 20 0 POP Amoxy ORS ZN TEO Oxytocin MgSo4 DMPA Commodity 0 50 100 150 200

Baringo County: Supply chain mapping was conducted in collaboration with the KSCSS project in three of the focus sub-counties, with the exception of East Pokot. Afya Uzazi supported the activity in Mogotio sub- county where 10 facilities were visited. None of the assessed facilities either had all the tracer items or all FP methods, and only two facilities had 80% of all tracer items. Availability of FP methods ranged from 88.9% for COCs to 0% for 2-ROD implants. Figure xx below shows the availability for the various FP methods in the assessed facilities in Mogotio sub-county

Availability of MNCH commodities ranged from 88.9% for Oxytocin injection and zinc tablets to 0% for ORS (single) sachets, with the ORS Zinc Co-packs available in 22.2% of the facilities. This implies that although zinc tablets were available in most facilities, ORS to be used with these tablets for management of acute diarrhea was not available and facilities in the sub-county would need to order for the ability to provide ORS and zinc as individual commodities, assuming the co-pack is not available.

Figure 10: Availability of RMNCH commodities, Mogotio Sub-County, Baringo County

Availability of FP Methods Availability of MNCH Commodities

TWO ROD 0 Chlorhexidine 0

ONE ROD 55.6 Zinc Tabs 88.9

POP 55.6 ORS 0

IUCD 77.8 ORS Zinc 22.2 FP Mehtods DMPA 77.8 MgSO4 77.8 MNCH Commodity COC 88.9 Oxytocin 88.9

0 20 40 60 80 100 0 20 40 60 80 100 % Facilities Percent

Contrasting storage and arrangement of Health Commodities in facilities in Baringo

Overall, availability of FP/RMNCH commodities was inconsistent across the facilities in the two counties. In Q4, Afya Uzazi will continue implementing interventions including redistribution, capacity building of staff as well as improving overall storage and stocking practices at the facilities to remedy challenges detected by the mapping exercises.

To alleviate the non-availability of CHX for cord care across all the facilities in the two counties, the project secured a donation of 4800 CHX bottles from Turkana County, which was part of the stock that had been procured for the county by UNICEF. To achieve this, the project worked with the county pharmacists for Baringo and Nakuru Counties to generate official requests for this donation and facilitated transportation following information shared on the county pharmacists Google group on availability of this commodity for donation/redistribution. These supplies will be distributed to facilities in both counties in Q4 in collaboration with the county and sub-county teams to support the growing demand for the commodity following on-going sensitization of health care workers on CHX use in ensuring optimal cord care at birth and during the first week of life.

In collaboration with the KSCSS project, Afya Uzazi team conducted a 4-day ToT training on commodity management with participants drawn from the four focus sub-counties in Baringo County. A total of 35 participants attended the training which covered inventory management, FP/RMNCH commodity reporting/LMIS as well as a practicum on support supervision using a scored checklist. These ToTs will subsequently support other facilities to improve commodity management practices through CMEs and OJT.

Participants at the Baringo County Commodity management TOT

To support FP/RMNCH product QA and client safety, Afya Uzazi requested and received reporting tools and job aids from the Pharmacy and Poisons Board. The materials included yellow forms for reporting suspected adverse drug reactions and pink forms for reporting suspected poor quality medicinal products (10 booklets of each) and 10 sets of Pharmacovigilance (PV) job aids. These will be disseminated to HCWs and facilities to support reporting. In addition, a one-hour sensitization session was conducted for 30 HCWs from facilities in Kuresoi North and Kuresoi South focusing on the basics and importance of PV, tools and reporting.

Sub Purpose 2: Increased care seeking and health promotion behavior for FP/RMNCAH

AYSRH Interventions Afya Uzazi project recognizes that young people have the right to live healthy sexual and reproductive lives. Yet, adolescents and youth (those between the ages of 10 and 24 years) often face social, cultural, economic, and structural barriers to accessing sexual and reproductive health information and services at a time when they need these services the most, making them vulnerable to poor health outcomes. The project focus sub counties have an approximate total population of 94,895 females aged between 15 -24 years with an unmet need for FP of 41% (KDHS 2014) among the same age group. This equates to 38,907 young people who require a FP method. The project implemented the following set of activities to address the structures and norms that impact AYSRH as an important aspect in improving access to, availability and utilization of SRH services by young people.

Out-of-school Youth Intervention: The project recognizes that young people’s behavior is strongly influenced by their environment, including the attitudes and actions of their family, friends, community and cultural norms. The CSE as implemented by Afya Uzazi is an evidence based approach, adapted from the Family Health Options Kenya (FHOK) curriculum, to increase youth access to SRH information and services. The strategy empowers youth to champion and promote healthy sexual behaviors leading to delays in onset of teenage pregnancies and healthy spacing among teenagers with children. This provides the young people with life skills to help them navigate difficult issues and make healthy choices surrounding SRH.

To initiate youth engagement activities, a total of 55 Youth Champions from Nakuru and Baringo County were trained on CSE. In the month of June, the youth champions conducted 70 community CSE sessions (36 in Nakuru and 34 in Baringo), covering human sexuality, teenage pregnancies, contraception, HIV and AIDS, drugs and substance abuse. In Nakuru County, four of the sessions were organized and supported by the community. In Baringo County, 551 young people (247M, 304F), were reached with SRH information, while in Nakuru County, 510 young people (70M, 240F) were reached with SRH information. While MOE approval is still pending and the Youth Champions cannot conduct CSE sessions within schools, the Youth Champions were still able to reach some in-school youth and adolescents during weekends and midterm school break. This was made possible by some Champions engaging in targeted mobilization, specifically for in-school youth and adolescents for weekend sessions.

AYSRH HCWs Training: In recognition of the importance of comprehensive youth and adolescent responsive services, and to increase the availability of and access to quality services to young people, the project trained an additional 27 HCWs from Baringo County on AYSRH using the national curriculum during the reporting quarter. This complements the already project established community-based activities as implemented

by the Youth Champions to foster an enabling environment and to create demand for AYSRH services.

Adolescents & Youth Access to Services: During the reporting quarter, 51 referrals for HIV Testing Services (HTS), ANC and FP services were made by Youth Champions; 20 and 31 within Marigat and Kuresoi South Sub Counties respectively. A total of 17,280 male condoms were distributed by Youth Champions in Marigat Sub County, during the community CSE sessions. The project also created a community-facility linkage mechanism via directories linking the Youth Champions with CUs and health facilities to enhance effective referrals. This directory is a paper-based system detailing contacts of HCWs and CHVs attached to a given health facility and CU, respectively, as a process of increasing youth and adolescents access to both community and health facility services available to them.

The project provided 587 adolescents aged 15 – 19 years with FP in Q3, up from 415 in Q2. This is the age group among which girls have the highest teen pregnancy incidence. The increase in FP uptake among adolescents may be attributable to the introduction of Youth Champions and training of HCWs in AYSRH which imparted the HCWs with the knowledge on adolescent and youth focused service provision practices. The project also observed a corresponding decrease in teen pregnancies from 271 in Q2 to 183 in Q3, representing a 12% decrease across project focus sub-counties, as shown in figure 11 below. Even though FP uptake in Marigat slightly declined in Q3 as compared to the other sub-counties, where the FP uptake increased, teen pregnancy cases reported still showed a significant drop. The general trend in FP uptake vis a vis teen pregnancies in this case can also be potentially attributed to the increased capacity of HCWs to provide adolescent and youth focused services and youth champions providing CSE sessions at the community, despite the nurses’ strike affecting service access especially in the month of June.

Figure 11: Uptake of FP and Teen Pregnancy in Q2 and Q3 by focus sub county

FP Uptake vs. Pregancies amoung Adolescents age 15-19 Years 100%

80%

60%

40%

20%

0% Marigat Mogotio B. North K. North K. South TOTALS

FP Uptake Q2 FP Uptake Q3 Pregnancies Q2 Pregnancies Q3

Coordination of AYSRH Activities: The MOH coordinates AYSRH activities through a multi-sectoral approach. The AYSRH TWG, which is the coordinating body, has a membership which consists of relevant government and development partners, with a responsibility of providing oversight on adolescent and youth programming in line with the national guidelines.

During the reporting quarter, Afya Uzazi supported the establishment of the Baringo County AYSRH TWG for better coordination of AYSRH activities by different stakeholders in the county. This was followed by engagements with the county leadership on the integration of SRH into the county-led school health program. The project acknowledged this as an opportunity to leverage on an existing County School Health Program to offer age appropriate CSE integrated with existing WASH and nutrition messaging. Succeeding this realization, and considering that the program has not been active, consultative meetings with county and sub county school health program focal persons have been planned for both Nakuru and Baringo counties to discuss areas of support and existing opportunities for synergy. The project will also facilitate the counties to reactivate the defunct school health program.

Gender Interventions

Gender discrimination and inequities are known to limit women’s and men’s access to good-quality FP/RH services. They also hinder women’s ability to negotiate FP and use contraception effectively, with traditional gender roles, further placing greater constraints on women’s access to FP/RH. In Baringo and Nakuru counties, gender inequality and GBV are widespread, thus increasing the vulnerability of women to SRH related problems. The project also considers addressing gender-related barriers and making services gender responsive as key approach in activities. During the quarter under review, the project implemented the following activities to address the gender inequalities as identified in the project sites.

Post Rape Care (PRC) Training: GBV results in physical, sexual, and psychological harm to women and men and subsequently negatively impacts women’s reproductive health. Fear of GBV may also prevent people from accessing FP and reproductive health services, thereby increasing the risk of unintended pregnancy. To identify the level of support required in responding to GBV, the project conducted a facility based assessment in Q2 that revealed the gap in both HCW’s capacity and availability of services at the facility level. The analysis also highlighted East Pokot and Marigat as focus sub-counties for GBV intervention in Baringo County. Particularly, East Pokot currently has no HFs offering PRC and there is a critical demand for these services due to periodic conflict from cattle rustling and accompanying violence. To address the project identified gaps in capacity and service availability, the project trained 14 health HCWs on PRC from Marigat sub-county. Unfortunately, due to the mentioned security issues, the project was not able to train any HCWs from East Pokot sub county.

During the Marigat training, the following gaps were further identified through service provider experiences, as pertains comprehensive post violence care services:

• Lack of evidence collection bags • Lack of dedicated EC pills at the facility • HCWs updates on other existing types of oral contraceptive pills to perform the same function as EC pills. • Linkage to non-clinical support services for SGBV survivors.

Q4 activities will focus on remediating these identified gaps through the following activities. To ensure comprehensive services to GBV survivors, the project will support strengthening of linkage to other community support services, such as legal aid and psychosocial support services (PSS); and establishment of multisectoral networks. Considering that the current training focuses mainly on sexual violence, in the subsequent quarter, the project will initiate GBV screening as well as strengthen documentation of other forms GBV. To initiate early diagnosis and response to GBV, the project will utilize the East Central and Southern Africa-Health Community (ECSA-HC) trainers guide for routine screening for IPV to conduct orientations to CHMT, SCHMT and HCWs on GBV screening. A draft screening tool developed from the trainer’s guide will also be tested during the orientation sessions and adopted for use at health facilities. The actual screening will be done at different key service delivery points within the health facilities such as the OPD, ANC/PNC and CCC.

Gender Analysis: Afya Uzazi recognizes that pervasive gender inequality and inequity undermine women’s ability to access information, care, and the effective interventions to improve health outcome. Conducting a detailed gender analysis before initiating any intervention is therefore critical to effectively addressing the needs of both men and women in each setting. To conduct a robust gender analysis, the project developed a gender analysis protocol in Q2 and submitted for FHI 360 ethical review. During the reporting quarter, the protocol was approved by the FHI 360 PHSC and subsequently submitted to KEMRI-SERU for local review. The gender analysis will be used to identify differences between women’s and men’s lives, including gender roles, access to resources, and structural factors, and subsequently, to apply this understanding to gender integration. Developing a deeper understanding of gender-based differences among women and men related to FP/RH behaviors will therefore aid Afya Uzazi in developing more effective gender-integrated interventions and anticipate direct and indirect impacts of the interventions on beneficiaries.

Community Partnerships: To initiate community level collaborations, the project held consultative meetings with Dandelion Africa, a local NGO in Mogotio sub-county, with community presence on RH/FP, gender, youth and PHE interventions, targeting;

• Women and girls of reproductive age because they are mainly affected by the burden of raising a large family and cultural practices such as female genital cutting (FGC); • Children who need immunization and deworming; and • Teenage girls and boys who need SRH education and services Following these meetings, the project will foster collaborations and move forward with implementation in subsequent quarters to undertake targeted community level gender and youth activities, especially where there are functional CUs, to leverage on their already established community networks for effective service delivery.

Population Health and Environment

The integrated population-health-environment (PHE) approach to development recognizes the interconnectedness between people and their environment and supports cross-sectoral collaboration and coordination. Afya Uzazi seeks to leverage on this opportunity to deliver an integrated FP/RMNCAH/PHE approach, to link the three components of PHE in areas where one or two components are already present. At the same time, there is an untapped opportunity in the project’s focus sub-counties to expand access to quality FP/RMNCAH services for underserved communities while simultaneously conserving the environment and stabilizing household economies through innovative and sustainable livelihood initiatives. To address the poor health indicators and the ongoing deforestation and environmental degradation in Kuresoi North and South sub-counties, and building on the successes seen in previous PHE efforts deployed in Kenya, Afya Uzazi has conducted essential landscape assessments and stakeholder engagement to inform PHE design and

implementation.

Key Achievements:

• Stakeholder forum to share findings from the assessment and exposure visit, eliciting key stakeholder views for the intervention design • Fostered engagement with NCPD to leverage on the existing resource base for advocacy on FP/RMNCAH towards visibility and appropriate budget allocations at county level

PHE Participatory Assessment: The project successfully conducted the formative PHE assessment, involving data collection, analysis and report writing in Q3. Some of the key themes derived from the assessment results included the following;

• Top health issues: WASH (namely, typhoid), alcohol abuse, FP/early pregnancy/large families and HIV/AIDS • Top environment issues: deforestation, climate change, environmentally harmful farming practices • Top livelihood issues: agricultural decline, limited non-agricultural job opportunities • Other: trash/litter, time poverty for women and girls

PHE Exposure Visit: The project team, accompanied by representatives from Ministry of Health, Ministry of Environment, National Council for Population and Development (NCPD), and KUWORA (a local CBO), visited the Mt. Elgon PHE site in Uganda. All selected stakeholders are from Nakuru county and are considered as the potential key implementing partners in the forthcoming proposed integrated PHE intervention. Representatives from Lake Victoria Basin Commission (LVBC) also participated in the PHE exposure visit as the hosts to LBVC PHE site.

The purpose of the four-day PHE exposure visit was to enable the Afya Uzazi team and the accompanying key stakeholders, to learn from the PHE initiatives supported by the LVBC and gather ideas to be incorporated in the proposed Afya Uzazi PHE intervention design for Kuresoi North and Kuresoi South sub-counties. The visit also provided an opportunity for the Kenyan PHE stakeholders to network with implementers of a successful PHE program for future collaboration and experience sharing. The LVBC PHE model showed a clear linkage between PHE, health and socio-economic indicators as illustrated below:

• Improved relations with national park authorities: The PHE initiative has promoted co-existence between community members and the park management. Through the CBOs, the community also gets a share of park revenues from the government agency. CBOs have also been equally allowed to sustainably utilize forest resources. • Improved linkages to health facilities: PHE champions educate and refer clients to health facilities and health workers use the champions to access communities. • Health indicators have improved: The PHE initiative has enhanced latrine coverage, immunization, antenatal visits and hospital deliveries, FP uptake, use of mosquito nets, safe male circumcision, treatment of drinking water, and handwashing practices. • Adoption of clean energy: improved stoves and bio-gas • Agroforestry and linkages to carbon credit schemes (through an organization called EcoTrust) has been established to benefit community • Diversified livelihood options, including beekeeping, horticulture, agroforestry and dairy farming (zero-grazing) have been promoted by the implemented PHE initiatives.

PHE Stakeholders forum: The project supported a stakeholder forum to disseminate the findings of the PHE participatory assessment and the exposure visit to LVBC PHE site, obtain stakeholder feedback and to synthesize the findings and lesson learnt into a PHE intervention design for Kuresoi South and North sub Counties. Key design issues discussed at the stakeholder workshop included:

• Need to expand youth empowerment interventions to include PHE • Consideration to leverage on the current project activities to integrate PHE prior to the intervention design • Concerns around PHE indicators to be addressed as part of the intervention design and within the scheduled IBTCI baseline survey with more emphasis on quantitative measures. The project should ensure defining the PHE needs into the larger project baseline survey. • Drawing from the PHE exposure visit findings, there is need to adapt an in-country PHE model, contextualized to the local implementation site • Consideration and emphasis to work with existing CBOs where CUs don’t exist or are not fully functional • To ensure effective implementation and coordination of the proposed PHE activities, there is great need to establish governance structures at the various levels – county, sub-county and community • Strengthen linkages with national mechanism on PHE advocacy efforts in collaboration with PACE/PRB • The project should explore working in collaboration with Living Goods on integrating livelihoods activities into the PHE intervention design • The intervention design should articulate clearly the outcomes and the expected results from the proposed PHE activities. • The design should also address water safety under WASH/PHE integration • The Afya Uzazi PHE intervention will be anchored on the health platform and not designed as a stand alone • There is need to explicitly show the value addition of integrating PHE in the RMNCAH activities

The project also embarked on the development of a PHE intervention design that incorporates the findings from the PHE assessment, exposure visit and discussions from the stakeholder meeting. PHE will be integrated into the ongoing Afya Uzazi project and it will incorporate operations research to measure the contribution of the integrated model on key project indicators.

Social Behavioral Change Interventions Social and Behavior Change Communication (SBCC) interventions for Afya Uzazi program are a consultative process that use communication to promote and facilitate health-seeking behavior and address the requisite societal constructs to improve health outcomes through targeted demand generation. The project plans to employ multifaceted approaches to community engagement based on needs identified through participatory ethnographic surveys (formative assessment), completed in Q3. Afya Uzazi SBCC approach is anchored on the socio-ecological model and plans to use CHVs, community groups dialogue (men, women, youth, religious leaders and chiefs), community theatre and mass media to engage different sub-populations with appropriate messaging on FP/RMNCAH and provision of basic commodities at household and community level and providing effective referral for facility based services.

Innovative approaches to extend services to hard-to-reach communities

The Living Goods (LG) model has been adopted by the project to be rolled out in Kuresoi South Sub-county through implementation of a modified version using trained CHVs to provide community-based FP/RMNCAH, nutrition, and WASH behavior promotion and care in homes. LG will absorb and train existing certified CHVs as community health promoters using the GoK approved modules including ICCM and entrepreneurial skills. These trained CHVs will continue to distribute products from the GoK Community Health Strategy program at no cost, such as specific FP commodities, but will also sell commodities that do not overlap in purpose, such as solar lights and energy saving woodstoves to generate income. In Q3, the project held sensitization meetings with the Nakuru County CHMT and Kuresoi South and North SCHMTs to introduce the LG model. This was followed by community mapping and identification of 17 CUs in Kuresoi South and three new sub-locations for the first phase of implementation of the LG model. The project identified the warehouse for LG merchandise storage which will be operational in the next quarter. This will be the model’s administrative center and where restocking of medicine and products will take place. The model will be rolled out in phases beginning with eight CUs in the first cohort and in a period of 6-8 months train another cohort until the project eventually covers the entire Kuresoi South sub-county.

To ensure CHMT, SCHMT and community leadership buy in and support, the project held a stakeholders’ forum with 71 participants of SCHMTs, CHEWs, and local administrators and community representatives who were sensitized on the model. The participants unanimously endorsed the model and agreed to sensitize their respective communities on the model.

• Training of CHEWs and CHVs on WASH and Nutrition CHEWs and CHVs are key services providers at level one of the service delivery. CHEWs are the primary designated officers to provide technical support and supervision to the CHVs. During the functionality assessment that was conducted, it was noted that a majority of CHEWS and CHVs were not trained on the aspects of community strategy, WASH and nutrition and or did not have up to date information on nutrition and WASH since some of them were trained on basic CHS dating back to 2012. This necessitated reorientation to enable them to conduct growth monitoring at households and facilities for children under five and pregnant women and provide messages on WASH activities at the household level. The SCHMT and the project supported a 2-day refresher training for the CHEWs as TOTs and CHVs on nutrition and WASH modules. A total of 75 CHEWs (36 males and 39 females) and 786 CHVs (324 males and 462 females) were trained. The training aimed at equipping CHVs with knowledge and skills to provide key messages at the household and community level to address immediate drivers of sub-optimal household nutrition such as inadequate dietary intake, poor access to sufficient safe and nutritious food, safe drinking water, hygiene and sanitation. During the training, the CHVs were also provided with information on PNC, ANC, FP and immunization to ensure that they provide holistic and quality messages during their household visits. Further, to facilitate quality documentation and reporting, the CHVs were oriented on the relevant monitoring and evaluation tools i.e. MoH 513, 514,516, and referral forms (MOH 100). This led to improved referrals and reporting on various indicators, compared to the previous reporting period, as shown in the following table:

Table 2: Community health volunteer reporting rates Sub # of Children of # of # of children 6-59 County 0-11 months Defaulter # of Defaulter months referred # of Referred referred for referred for referred for for Vitamin A for Skilled immunization ANC Immunization supplementation Delivery Q2 Q3 Q2 Q3 Q2 Q3 Q2 Q3 Q2 Q3 Baringo N 114 - 18 - 49 - 302 - 115 Marigat 56 - 1 - - - 145 - 71 Mogotio 67 142 - 32 1 34 - 239 33 64 Kuresoi N 56 - 4 - 16 - 49 - 28 Kuresoi S 168 - 14 - 80 - 112 - 45 Source: DHIS2 QTR3 2017

• CHVs co-location in facilities with staffing constraints During the nutrition and WASH training, one of the action points included attaching CHVs to health facilities by developing a duty roster for the CHVs to support link facilities on a rotational basis. CHVs will support nutrition services (growth monitoring) and provision of ORS and zinc to children under 5 years presenting with diarrhea as well as conducting health education sessions at the waiting bay. CHVs will be provided with transport and lunch when they are on rotation (approximately USD $ 10). There will be no other compensation. This task-shifting provides an opportunity for the CHVs to build their A community volunteer weighs a baby for growth capacity while working under supervision of the monitoring at Mogotio Health Centre service providers. This activity has already started in all facilities linked to the nine CUs in Mogotio and will be rolled out to all 48 linked facilities in the next quarter. This has led to improved HRH coverage in the link facilities and hence integration of services. However, the industrial action (nurses strike) adversely affected this innovation as nurses were not available in most cases to supervise the CHVs.

• CHV Monthly data review meeting One of the parameters of functionality of the CUs is to conduct monthly data review meetings with CHVs to improve knowledge management and use of data for decision making at all levels. The meetings provide opportunity to interrogate individual CHV reports at the point of submission to the CHEWs prior to collation to MOH515. The meetings help in correction on the entry errors from the source documents and preparation for the transcription of summaries on the MOH 516 (Community chalk boards).

During the reporting period, monthly data review meetings were conducted in all 48 CHUs in Baringo and Nakuru counties. These meetings were facilitated by the CHEWs and were meant to improve the quality of data generated by CHVs and CHEWs by identifying errors, inconsistencies, and any other data anomalies as well as improving timely reporting. The meetings also provided an A monthly data review meeting in Marigat CU opportunity for the team to review their own data with support of the Sub County Health Record Officer and project team. The data reviewed were collated in MOH515 and forwarded to DHIROs for upload into the DHIS2 and also transcribed onto the chalkboards for discussion during the dialogue days.

• Household supportive supervision by CHEWs Supportive supervision conducted by the CHEWs and CHS focal persons center on meeting the needs of CHVs within the CUs so that they can effectively provide quality services at the household and community level. The supportive supervision conducted was to assess CHV performance on providing key health messages at the household level on importance of immunization, ANC, skilled delivery, PNC checkups, FP, nutrition, EBF, nutrition and WASH and supports them by providing feedback on critical areas of their work, which will help them A CHV during household visit in Baringo North identify specific areas for improvement and demonstrates their improvement over time. The supportive supervision makes the CHVs feel part of the health system and hence motivates them to rededicate themselves to achieving the desired health outcome in addressing behavioral interventions at households. During the reporting period, the project supported CHEWs and sub county focal persons to conduct supportive supervision to the CHVs at the household level. During Q3, the project supported 20 CUs whereby CHEWs walked with 58 CHVs to visit 115 households. Some of the identified gaps included poor documentation and preference to discuss hygiene issues over other RMNCAH indicators. These issues were addressed on the spot as well as during the monthly review meeting.

• Community dialogue days Community dialogue days are community forums conducted within the CU each quarter to discuss the data reported by CHVs from their daily activities. At the forum, data track various health indicators are relayed to the CHEWs, who summarize them in the MOH515 and subsequently transcribing them to MOH516 (Community chalk board). The community data presented on the chalk board is interrogated and key concerns affecting that community are identified and local solutions proposed for action.

Afya Uzazi team supported the counties to update all the chalkboards with the new version including construction of the chalkboard stand in 54 CUs. The chalk boards were used to facilitate community dialogue sessions held in 48 CHUs. Dialogue days were aimed to increase first and fourth ANC visit completion, skilled deliveries, PNC visits, immunization coverage among under one year and Afya Uzazi DCOP Dr Marsden Solomon attends a dialogue day children under five, community referrals, in Kuresoi North Sub county FP uptake among women of reproductive age, improved latrine coverage, use of safe drinking water, and hand washing facilities at household level. The sessions were attended by community members, CHVs and members of community health committees. The sessions provided opportunities for improvement, especially on reporting and provision of feedback to facility in charges, increased communication, and helped identify community health problems and data use difficulties. The sessions also enhanced positive relationships among the members of each CU, the link facility, and the community administration. The meetings were facilitated by CHEWs, who led participants through the community quarter data as displayed on the community chalkboard (MOH 516). Data generated discussions, with emphasis on poorly performing indicators. The total number of participants was 5755 (2991 Female and 2764 Male). The actions during the community dialogue sessions included identification of a poorly performing indicator and collaborative development of corrective actions that are demonstrated during the community action days. The dates and venues of the community days are set by members during the community dialogue days. • Community action days Community action days are open forums where communities interact and share their experiences in supporting community work and where high-performance CUs and individuals receive government or host agency recognition.

Community action days enhance participation, leading to behavior change. During Q3, the project supported 11 community action days. The activity comes after the community dialogue day where the participants identify a poor performing indicator and generate actions to improve the indicator(s). The CHEWs and CHVs take the lead in this activity and various service indicators were demonstrated during the action days. Low latrine coverage was pointed out in most of the CUs. This resulted in five CUs constructing latrines in some of the villages using locally available resources for the community members to emulate. Some of the CUs, like Kaboskei, engaged in rubbish collection and Community members construct a low-cost pit latrine burning at a nearby shopping center. during health action day in Emining, Mogotio sub- county

• County specific SBCC strategy development process

The national RH communication strategy 2016-2021 posits that developing county-specific SBCC strategies could improve coordination of contextualized messaging at the community level and sustained demand creation activities for health services over time, due to ownership and grassroots support by the target communities. Developing a good SBCC strategy requires a thorough understanding of the community structures, beliefs, general ideation and key barriers, which calls for ethnographic survey through a structured formative assessment.

During the reporting period, the project worked closely with the PSK-HCM national mechanism and MoH RMHSU to plan and execute SBCC formative assessment in Baringo and Nakuru counties to inform development of Nakuru and Baringo County specific SBCC strategies. PSK is implementing the Health Communication and Marketing project and is mandated by USAID to provide support to partners on development of SBCC strategies as a national mechanism and works through RMHSU. Some of the highlights from SBCC formative assessment Two consultative meetings were held with the HCM in Nairobi and Nakuru to share the tools and harmonize • Meaningfully involve the public formative assessment approaches. The meetings administration to engage with men resolved that the formative assessment be conducted • Consistent messaging on FP with men and women at HH jointly to avoid confusing the county and community • Simplify advocacy messages and members and harness resources. Subsequently, the communication packs project conducted assessments in all the focus sub- • Use bottom up approach to message and counties except East Pokot. The assessment process materials development involved tools development, consultation with the • Ensure couple based approach in FP CHMTs and SCHMTs, research assistant recruitment messaging • Use verbal IPC for migratory men and training, and field data collection, which involved • Door to door FP campaign recorded in-depth interviews with the HCWs; and Key • Develop community activity/seasons informant interview and FGDs with the youth, WRAs, calendars religious leaders, cultural leaders, male sexual partners • CHVs to provide FP and other basic aged above 25 years, TBAs, CHVs and CHMTs and MNCAH services • Use visual messaging eg Videos and Pictures political leaders. Data collected were analyzed and • Use community theatre to trigger dialogue report writing is underway. Notes from the preliminary • Use mobile van to mobilize the communities report are being used to inform the development of the for services PY2 SBCC work plan.

Table 3: Common and preferred communication channels from the assessment Group Women Youth Men Service Policy Gate Opinion Providers Makers Keepers Leaders

Channel C P C P C P C P C P C P C P

Facility Health Talks        

PHA Outreach Activity     

PAVS & Edutainment     

WST              

Phone Calls/Texts     

Social Media         

Television          

Radios, Main & Vernacular          

Close Family and Friends Networks  

Partners   

Social Interactions /Groups &          Professional Networks

IEC Materials       

Health Talks in Church     

Community Dialogue – Baraza’s       

Social Mobilization/ Rallies   

PHA Door to Door/Word of Mouth      

Learning Institution/Schools    

Magazines & Videos   

Institutional Structure /Memos/Letters   

OJT  

Documents & Reports 

Field Assessments/ Visits  

Public Participation  

Role Modeling/ Mentors  

• Community groups IPC sessions with men and women in their social networks During Q2, the project worked with SCHMTs and mapped out various social networks for men, women and youth in the focus sub-counties for effective engagement to promote FP/RMNCAH.

During the Q3 reporting period, the project supported CHEWs and CHVs to reach these groups in their settings with key messages on importance of ANC attendance, skilled delivery, PNC, initiation of breast feeding immediately after birth and importance of EBF for six months. Additional topics covered included importance of immunization for under-five children, FP, and nutrition and WASH. The project supported CHEWs reaching men in men social network in Baringo CHEWs to facilitate social networks of women’s North groups reaching women and men with FPRMNCAH messages. To reach more beneficiaries, public meetings were conducted in Baringo North and Marigat sub-counties.

The chart below summarizes the number of people reached by different activities during Q3 with key FP/RMNCAH, nutrition and WASH messages through dialogue days, health action days, social networks and data review meetings

Figure 12: Number of people reached through IPC

Number reached through IPC

Social network

Dialogue day Data review Dialogue day Health action day Social network meetings Female 2991 436 258 764 Male 2764 331 52 464

Female Male

III. KEY ACHIEVEMENTS (QUANTITATIVE)

During the period under review, Afya Uzazi made significant progress towards achieving project targets for the key service areas. Table 4 shows 36 selected indicators from the USAID target matrix and JPHES program custom indicators vs PY1 targets.

Table 4: Key achievements from Oct 2016 – June 2017

Achievements (OCT 2016- Total June 2017) Achieved OCT- JAN- (OCT Progress DEC MAR APR-JUN 2016-JUN APR to APR Key indicators 2016 2017 2017 2017 Targets (%) Standard: 3.1.9-15 Number of children (under 5 yrs) reached by USG-supported nutrition programs: 8652 49643 58295 106866 55% Custom: Number of children under five who are Underweight 1076 855 1931 11642 17% Standard: 3.1.9.2-2 Number of health facilities with established capacity to manage acute under-nutrition 0 153 153 156 98% Standard: 3.1.9.2-3 Number of children under 5 years of age who received Vitamin A from USG-supported programs: 8652 49643 58295 106866 55% Number of pregnant women reached with nutrition interventions through USG- supported programs 5478 5413 10891 14705 74% Custom: Number of women who received at least 4 ANC visits during the latest pregnancy during a specified time period (year) 1401 1424 2825 14705 19% Custom: Number of births in a given year attended by a skilled birth attendant (SBA) such as a doctor, nurse, or midwife 1877 1789 3666 16353 22% Custom: Number of women who had a live birth in the same specified period 1837 1755 3592 21216 17% Custom: Number of children 12-23 months of age who received measles vaccine by the time they were 12 months of age: 4769 3442 8211 15752 52% Custom: Number of children age 12-23 months of age who received third does of DPT (Diptheria, Pertussis, Tetanus) vaccine: 4694 3409 8103 15752 51% Custom: Number of children who have received the third dose of pneumococcal conjugate vaccine by 12 months of age: 4665 3427 8092 15752 51% Number of children under one fully immunized 4189 3242 7431 15752 47% Custom: Number of children under one year who receive three doses of OPV excluding birth polio 4656 4519 9175 15752 58% Custom: Number of children under five years of age who were ill with diarrhea : 7069 4808 11877 11642 102%

HL.6.6-1-Number of cases of child diarrhea treated in USG-assisted programs 7069 4808 11877 11642 102% Custom: Number of children under five years old with diarrhea who received Oral Rehydration Therapy (ORT), defined as receiving Oral Rehydration Salt (ORS) solution: 7069 4808 11877 11642 102% Custom: Number of 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): 22 24 24 25 96% Custom: Number of babies who received postnatal care within two days of childbirth in USG-supported programs : 2618 2091 4709 14898 32% HL.6.2-1-Number of women giving birth who received uterotonics in the third stage of labor (or immediately after birth) through USG-supported programs 1877 1789 3666 3666 100% HL.6.3-1-% of newborns not breathing at birth who were resuscitated in USG- supported programs 18 19 37 37 100% Standard: 3.1.7.1-1 Couple-years of protection (CYP) in USG-supported programs 8705 8590.93333 17295.525 41608 42% Standard: 3.1.7.1-2 Number of service delivery points (SDP) that experience stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide: 156 144 300 98 307% Standard: 3.1.7.1-4 Number of additional USG-assisted community health workers (CHWs) providing family planning (FP) information: 0 806 806 412 196% Custom: Number of facility reporting on contraceptive commodity. 156 156 156 156 100% Number of people trained in FP/RH with USG funds 38 858 896 1288 70% Number of people trained in Family Planning and Reproductive Health monitoring and evaluation with USG assistance 0 0 0 242 0% Custom: Total number of CHWs trained in family planning counselling services through USG supported programs 0 806 806 804 100% FPRH-Custom: Total number of health workers trained in FP/RH through in- service training 38 52 90 242 37% Custom: Total number of health workers trained in commodity management through USG supported programs 0 35 35 217 16% Number of people trained in maternal and/or newborn health and nutrition care through USG-supported program 23 174 197 1049 19% Number of people trained in child health care and nutrition through USG- supported health area programs 23 174 197 1291 15% Number of people trained in Maternal and Child Health monitoring and 0 0 0 242 0%

evaluation with USG assistance MCH-Custom: Number of health service providers trained in maternal and/or newborn health and nutrition care through USG supported program 23 174 197 245 80% MCH-Custom: Total number of Community Health Workers (CHWs) trained in maternal and/or newborn health through USG supported programs 0 0 0 804 0% Nutrition: Number of Community health workers trained in child health and/or nutrition 0 806 806 804 100% Nutrition-Custom: Number of individuals receiving nutrition-related professional training through USG-supported programs 69 1328 1397 3389 41%

Lessons Learned

The project team learned some vital lessons during this reporting quarter. Key among them include:

• With the severe heath worker shortage in our focus sub-counties in Baringo and Nakuru Counties, implementing onsite TA/ capacity-building provides an avenue for training and skills transfer that does not affect service delivery compared to offsite trainings/workshops • Targeted and sustained community mobilization for health services has improved demand creation during integrated outreaches. Inclusion of the local administration (chief) in social mobilization improves outcomes for health services. • By use of adapted standardized tools (supportive supervision and outreaches), the SCHMTs are more focused and objective in identifying the opportunities and areas for improvement which are region-specific. • Participation of community members in strengthening health systems elicits grass root acceptance, support and a sense of ownership. This resulted in increased demand for health services at level 1, thereby improving health of the target population. • Creating community demand for health services must be matched with the availability of improved services within health facilities since the larger community members depend on the feedback from the early adopters. • Absolute volunteerism is still a challenge unless a well-defined incentive package is put in place for community-level services.

IV. CONSTRAINTS AND OPPORTUNITIES

Constraints Insecurity affecting East Pokot and parts of Marigat and Baringo North sub-counties persisted in this reporting quarter. As a result, Afya Uzazi could not support service delivery in the East Pokot sub- county during the entire quarter, impacting performance. Because insecurity in East Pokot may not be resolved soon, Afya Uzazi has requested to be allowed to support Baringo Central Sub County so as to meet the set targets and improve the relatively poor FP/RMNCAH indicators in that sub county. Once approval is granted, the project will roll out the support in Baringo Central in the first quarter of PY2.

During Q3, the program leveraged on the existing structures of the MoH and the existence of the CUs in the sub county, and goodwill from the CHMTs, thus enabling a rapid startup of community based activities. However, the nurses/midwives strike that started in the month of June 2017 affected service provision in all areas of FP/RMNCAH and trainee follow up as over 90% of the facilities are staffed by nurses. The project is liaising with private facilities and has increased the number of outreaches to alleviate the effect of the HCW strike on service access and uptake.

Gender interventions experienced setbacks during Q3 due to the requirement for national authorization from the National Police Service to allow training of police officers on their role in SGBV prevention and response. Waiting for this authorization has delayed the sensitization of police on SGBV as key actors in SGBV prevention and response. To mitigate this delay, the project will work with the existing county GTWGs to advocate for the need to address the knowledge and attitude gaps on SGBV prevention and response among of police officers.

In general, inadequacy of Human Resources for Health (HRH) continues to negatively impact access and availability of promotive and preventive health services. Most facilities are staffed by one health personnel. In addition, inadequate infrastructure in facilities poses a challenge for effective and quality service provision. Some facilities lack electricity or water sources, making it difficult to maintain hygiene, equipment safety and to provide room warmers and instant showers for maternities. Facilities also lack space to set up rooms for additional essential services such as nutrition and ORT corners. The project is addressing the human resource shortage through use of CHVs to augment existing health facility personnel by providing basic nutritional and WASH services and health education, increased outreaches, and working with private providers, while engaging the county leadership on implementation of long term attraction and retention schemes. The project has also partnered with Project CURE for donation of basic MNCH equipment.

Shortage of MOH recording tools is a major constraint for reporting. In some cases, Afya Uzazi project has procured tools as a temporary measure to enable documentation and reporting. But this is not adequate or sustainable in the long term. The project will continue to lobby the county to print and photocopy tools to increase availability of data tools to all facilities and include funding for this purpose in their annual budget request projections.

Opportunities

There are other national mechanisms working in the project area of coverage. These include APHIAplus Nuru ya Bonde, KSCSS, ASSIST, HRH-Kenya, HCM/PSK and Palladium- implemented HIS support project. Afya Uzazi will maintain collaboration with these existing mechanisms as well as those that will be funded in future.

Afya Uzazi has continued to enjoy good will from members of county and sub-county health management teams (CHMT, SCHMT), who see the project as filling an important gap in the provision of RMNCAH services.

The focus counties have strong collaborations with other counties (Bomet, Kericho) and at the national level. These linkages have enabled the Afya Uzazi Program focus counties to draw technical recourses such as trainers and training equipment from the other counties and nationally and to cross-refer patients across counties.

Baringo county is implementing the World Bank-funded Resource-Based Financing (RBF) for Health scheme through which facilities are compensated in monetary terms for meeting targets. Part (40%) of the funds are used to improve facility operations; for instance, purchasing consumables, and the remaining 60% is paid to facility staff. This incentive motivates health care providers to improve the quality of services to meet their targets. Afya Uzazi will leverage this opportunity to increase uptake and quality of services.

The national government is implementing the free maternity program through which facilities are compensated Ksh 2,500 ($25) for every facility-based delivery. Mothers are not charged for delivery services. The money received from the national government is used to improve the facility and motivate staff. The free maternity scheme is meant to eliminate financial barriers to service access and motivate staff to promote facility-based delivery and offer other quality services. Potentially, the funds could also be used to motivate CHVs and birth companions (former TBAs) for promoting facility based delivery. Afya Uzazi will work with CHVs and HCWs to promote ANC mothers’ enrollment in the free maternity program and encourage them to register for the National Health Insurance Fund (which is free for expectant mothers). In addition, Nakuru County government has recruited nurses on contract. These contracted staff are working despite the strike. Further, the existing private and faith- based health facilities can be used to augment service provision by public facilities, especially during industrial strikes.

Another important opportunity for rapid scale up of services is the existence of community and civil society groups engaged in community activities. Groups such as Dandelion Africa in Marigat and Baringo Gender Network Groups are involved in youth and gender interventions. In Kuresoi, groups such as KUWORA, KSCEED and KFAs are involved in different components of PHE interventions. In Baringo County, there is already a school health intervention. The project will collaborate and integrate activities alongside these existing structures, thus presenting an opportunity to leverage resources while strengthening service delivery.

Finally, the baseline evaluation planned by IBTCI has delayed and the project implementation is ongoing with no concrete baseline values. Even if the evaluation is conducted in quarter 4 or PY2, estimating the true effect of program activities will be difficult since a lot of effort is already being made. Afya Uzazi team has proposed a rapid baseline evaluation in Q1 of PY2, should the baseline evaluation planned by IBTIC delay further.

V. MONITORING EVALUATION AND LEARNING

Description of work plan status

During the reporting period, the project implemented activities in line with the M&E plans which was drawn after joint baseline DQAs with USAID team. The team focused on:

• Improving data quality at health facility, community and local implementing partner’s levels, • Improving documentation of program activities for greater accountability, to promote data dissemination and use for evidence-based decision making, • Building the capacity of program and MOH staff through mentorship.

In the reporting period, the team conducted OJT for 20 HCW on data capture and generation of monthly summaries and Routine Data Quality Audits (RDQA) coupled with DHIS2 mentorship. Afya Uzazi MEL team also facilitated provision of recommended data capture and summary tools especially for CUs (MOH 516, MOH 515, MOH 514, MOH 513, and MOH 100). The team also supported sub counties to conduct quarterly data reviews and monthly data review verification in five focus sub counties (Kuresoi South, Kuresoi North in Nakuru Countries, Baringo North, Marigat and Mogotio sub counties) and implemented a performance recognition plan to strengthen data quality and reporting rates in DHIS2. The team also conducted a participatory M&E assessment jointly with CHMT and SCHMTs in the same five sub countries (please see annex). a) Activities to improve data quality at all levels of Health Service Delivery

Routine Data Quality Audits During Q3, the program, in conjunction with Baringo and Nakuru CHMTs and focus SCHMTs, conducted DQAs in 50 facilities; 10 in each focus sub county to enhance data quality in RH/FP, immunization and nutrition services. From the assessment results, the counties had overall performance of 58% data recording completeness. This level is attributed to use of outdated and missing registers. Nearly all (99%) facilities assessed were level 2 and 3 that do not have HRIOs. The score on M&E functions and responsibilities were rather low in most facilities.

Figure 13. DQA output at 50 facilities within the focused sub counties

Data Management assessment

Documentation

Links with National Reporting 58% 98% Data variance System 27% 23%

Data Management Processes 54% M&E Capacities, roles and 39% and Data Quality Controls responsibilities

Training

Figure 14: DQA output in Baringo County

Score Component # Max % Expected Documentation 181 300 60% 100% Data variance 50 110 45% 100% M&E Capacities, roles and responsibilities 104 180 58% 100% Training 74 120 62% 100% Data Management Processes and Data Quality Controls 109 540 20% 100% Links with National Reporting System 60 60 100% 100%

Total 578 1310 44% 100%

Figure 15: DQA output in Nakuru County

Score Component # Max % Expected Documentation 108 200 54% 100% Data variance 50 100 50% 100% M&E Capacities, roles and responsibilities 59 120 49% 100% Training 3 80 4% 100% Data Management Processes and Data Quality Controls 99 360 28% 100% Links with National Reporting System 38 40 95% 100%

Total 357 900 40% 100%

Participatory assessment of MOH M&E systems May 2017

The low score on M&E functions and responsibilities resulted because most HCWs reported that they have not received any training on data recording, management and reporting. In response, Afya Uzazi MEL team has scheduled a training on data collection and reporting for 80 HCWs (20 in Nakuru and 60 in Baringo). Further, the project will implement a sub county mentorship program where HRIOs from sub counties will conduct mentorship and help facilities conduct data review meetings and reporting. In addition, the project team, jointly with facility and sub county teams, have developed specific data verification SOPs that will be disseminated in Q4.

There were discrepancies between monthly reports submitted by health facilities and what was recounted in the source documents, mainly affecting FP uptake among adolescent and youth and immunization indicators. A corrective measure work plan was developed and the facilities continue to be mentored on report generation and verification before submission to SCHRIO. In addition, SOPs were developed to assist facilities to conduct their own facility-based data verification to improve data quality.

At the community level, data validation was done in 12 CUs where data in the MOH 515 report was compared with data in the source documents (MOH 513) and chalkboard (MOH 516) for completeness and consistency. Any inconsistencies were corrected and CHVs mentored on proper data recording.

b) Activities to improve documentation of program activities for greater accountability To improve EMR database, the project, in collaboration with MOH through the Baringo TWG, embarked on implementation of one EMR for the county. During Q3, the project conducted an EMR assessment to identify strengths and weaknesses of each EMR and find ways to use them for managing outpatient data to improve data quality and quality of care.

Provision of Health Management and Information System (HMIS) Tools

To improve availability of tools, the program photocopied 6844 of community tools and 189 ORT registers and assisted the sub counties to distribute tools from the county headquarters to facilities. However, M& E tools shortage has persisted, especially for community tools and data reporting tools. Afya Uzazi team will continue to lobby counties to print tools and distribute to facilities. As a temporary measure, Afya Uzazi project will support photocopying of tools on a case by case basis to ensure availability of tools in facilities.

The project will continue developing customized tools, which will add value to service provision and capture emerging data elements required by program and donor.

Data Dissemination and Use for Evidence-Based Decision Making

• Quarterly SCMT – Performance Review Forum

In collaboration with SCHMTs, the project supported sub counties data performance review meetings in five focus sub countries, where workplan and performance of Q2 were reviewed and workplan for Q3 jointly developed. This activity involved all SCHMT and facility in-charges. During this forum, facilities whose performance was below par were identified and enlisted for supportive supervision and mentorship.

• Data Management, Analysis and Reporting The project continued with tracking of FPRMNCH indicators to improve reporting rates in DHIS 2, in collaboration with APHIA PLUS Nuru ya Bonde. This is done through a performance recognition plan with sub county Health Records and Information officers. All reports are weighted to ascertain timeliness and completeness and facility teams are rewarded with data bundle as per performance. In the next quarter, the project will increase focus on data quality, timely reporting and feedback.

The project also introduced performance monitoring charts to facilities for tracking indicators and a data use hand book to document performance and develop a corrective plan to achieve targets.

Table 5: DHIS 2 Reporting rates

Data Marigat Jan to Mar Ma Mo Mo Bar Bar Ku Ku Ku Ku 2017 rig got got ing ing res res res res at io io o o oi oi oi oi Ap Jan Ap No No No No So So r to to r to rth rth rth rth uth uth Jun Ma Jun Jan Ap Jan Ap Jan Ap 201 r 201 to r to to r to to r to 7 201 7 Ma Jun Ma Jun Ma Jun 7 r 201 r 201 r 201 201 7 201 7 201 7 7 7 7 Facility Contraceptives Consumption 93.8 61. 87. 66. 80. 48. 94. 73 101 97. Report and Request 5 5 7 4 2 1 .4 1

MOH 515 Community Health Extension 66.7 91. 100 88. 41. 91. 100 25 100 Worker Summary 7 9 7 7

MOH 705 A Outpatient summary < 5 97.8 68. 100 79. 98. 72. 96. 95. 100 100 years 8 6 4 7 1 2

MOH 705 B Outpatient summary > 5 95.7 68. 100 78. 99. 69. 94. 96. 100 100 years 8 5 2 7 1 8

MOH 710 Vaccines and Immunization 95.2 69 100 74. 94. 71. 100 100 100 98. 2 4 3 5

MOH 711 Integrated Summary Report: 92.2 73. 100 76. 100 93. 90. 90. 95. 100 Reproductive & Child Health, Medical & 3 3 2 2 5 7 Rehabilitation Services

MOH 713 Nutrition Monthly 86.9 67. 97. 71. 66. 52. 44. 33. 9 6 4 7 9 4 3

MOH 734 F-CDRR for Nutrition 3.1 39. 1 11. 4.8 12. 29. 16. 13 Commodities 6 1 5 6 7

MOH 733B Nutrition services Summary 58.3 58. 33. 100 100 100 33. 77. 100 77. Tool Revision 2016 3 3 3 8 8

During Q3, there was improvement in community reporting rates. This is attributed to the monthly data review meetings with CHVs. However, due to the HCW strike, most of the facilities didn’t report in June, leading to drop in reporting rate in facility-based reports this reporting quarter. Afya Uzazi team will continue to support SCHRIO to validate paper based reports through the SOPs developed, support sub county mentorship program and monthly validation meetings to correct discrepancies before data entry in DHIS2.

• Monthly facility data validation meeting During Q3, the project participated in monthly in-charge meetings. Working with the facility in- charges and members of the SCHMT, data were reviewed for accuracy, completeness, timeliness and reliability using a data verification SOP developed by the project team in collaboration with SCHMT. During those meetings, errors attributed to arithmetic or addition and variance in common data elements reported in different reports were identified and corrected; programmatic errors and missed opportunities were identified and corrective measures planned.

• Building the capacity of project and GOK partners The M&E held a project quarterly review meeting where planned activities (Jan-Mar 2017) were reviewed and the Apr-June 2017 quarterly implementation plan generated. Through brown bag sessions, the MEL team mentored project staff on writing of concept note, abstracts, and operations research writing to enable program document best practices and learning products in the coming quarters.

• Establishment of Baringo M&E TWG To create a forum on which to anchor M&E support, Afya Uzazi MEL team spearheaded the formation of the first Baringo County M&E TWG. The first meeting of the TWG took place on 31st May 2017 with participation of 16 participants from CHMT and partners including Afya Uzazi team. The team agreed on draft TOR, membership and frequency of meetings. The next meeting of the TWG will happen in Q4 where the TOR will be discussed in detail with participation of more members and the work plan agreed.

• Participation in National meetings The MEL staff attended JPHEs new indicators reporting guidelines workshop in Nairobi where the reporting guideline for this quarter was discussed and mapping of new indicators outlined. Representatives of all non-HIV USAID-supported programs attended the meeting. The project also supported 9 public health officers from Kuresoi South and Kuresoi North to attend and participate in a web-based M&E reporting training in Nakuru which will enable them to report in real time on Open Defecation.

VI. PROGRESS ON GENDER STRATEGY

During the reporting quarter, the project developed a gender intervention description, with due consideration of the gender equality continuum tool, outlining the gender integration and mainstreaming approaches and describing the key activities towards achieving gender integration across program interventions. The same will be updated with recommendations from the gender analysis results for a more comprehensive gender strategy ideally leading to more targeted outcomes.

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

No specific environmental mitigation and monitoring was done during this quarter. However, as explained above, the project implemented a PHE baseline assessment this quarter and analysis is ongoing. This will inform the development of a specific PHE strategy. Afya Uzazi has also continued to provide mentorship to facility-based HCW on infection prevention including waste disposal.

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

Afya Uzazi Program has continued to leverage on the work of USAID’s APHIAplus Nuru ya Bonde. The project has hosted the Afya Uzazi teams in the Nakuru and Kabarnet and provided administrative and logistical support as well as financial services. In all the facilities supported by Afya Uzazi, APHIAplus established a good foundation of program and data quality, on which Afya Uzazi is building. Where possible, joint activities have been implemented; for example, collaboration with APHIA Plus Nuru ya Bonde to support the quarterly Nakuru County commodity TWG meeting held on 27th April 2017 and a follow up meeting held on 15th June 2017 to plan and review the implementation of commodity management activities in the county, and in the implementation of integrated outreaches in Kuresoi North and South Sub Counties. The project also collaborated with NHP-Plus to deliver training on the BFCI.

Afya Uzazi project team worked closely with the PSK-HCM national mechanism to plan for SBCC formative assessment for Nakuru and Baringo Counties. This involved joint review of the protocol and audience segmentation, tools development, research assistants’ recruitment and training, data collection and analysis and report writing.

Afya Uzazi also collaborated with the USAID/ASSIST project implemented by URC to conduct a 3- day training on QA/QI for Baringo County held from 27th -29th June 2017. The ASSIST project provided overall TA in the training where 25 participants from the Baringo sub-counties were trained.

The project collaborated with the USAID Kenya Supply Chain Systems Strengthening (KSCSS) Activity in the following ways: Support for the quarterly Baringo County Commodity Technical Working Group Meeting held on 6th April 2017; support a 4-day Commodity Management Training for 35 participants from Baringo county from 15th -18th May 2017 and; conducting Supply Chain Mapping/Supervision from 12th - 16th June 2017 in 3 sub-counties (Mogotio, Kuresoi North and Kuresoi South).

In addition, Afya Uzazi project collaborated with HRH Kenya to: support operationalization and functionality of the Integrated Human Resources Information System in Nakuru County including support for data cleaning and uploading and; support for participants from Baringo County to attend the HRH inter-cluster meeting for North Rift held on 14-15 June 2017 in Eldoret

Further, the project collaborated with USAID PIMA project to support the process of developing Nakuru County Referral Guidelines. Specifically, PIMA provided TA during the inaugural meeting of the Nakuru County Referral Guidelines TWG held on 31st May 2017.

The project also had discussions with IBTIC regarding planning for baseline assessment. Afya Uzazi team provided input on the baseline assessment protocol and tools and suggested additional indicators. Afya Uzazi also supported logistical planning for the baseline assessment.

IX. PROGRESS ON LINKS WITH GOK AGENCIES

Afya Uzazi has maintained a close working relationship with the Nakuru and Baringo CHMTs and county government. In Marigat, Chemolingot and Keringet, the CHMTs have allocated Afya Uzazi project offices as part of their contribution. Afya Uzazi will undertake renovation work in these offices and then co-locate with MOH counterparts.

The project collaborated with the key government implementing ministries and other partners in the GoK-led TWGs for both gender (GTWGs) and AYSRH. Other links include collaboration with the Ministry of Education and Ministry of Gender and Youth Affairs on implementation of in and out of school adolescent and youth interventions, respectively. The project also collaborated with NCPD, Ministry of Environment and Natural Resources with regards to the planned PHE intervention. These platforms facilitate the effective coordination and implementation of youth and gender interventions and inform planned PHE activities in a collaborative process.

The project had consultative meetings with County Directors of Health-Public Health for Nakuru and Baringo as well as other members of the CHMT/SCHMT. The project worked with the RMHSU to identify, collect and distribute various facility and community-based job aids and IEC materials from the RMHSU repository. The project also participated in the national SBCC materials review meetings held in Mombasa and organized by the RMHSU where further audit and new directives were given on the co-branding of the nationally developed IEC materials and HCW trainings on RMC and MPDSR.

Additionally, the project held a consultative meeting with the NCPD regional coordinator to identify areas of collaboration and mutual support as far as FP and population advocacy is concerned. Some of the opportunities identified were to jointly engage with the administrative arm of the national government at county and sub-county levels to sensitize them on the FP and populations issues. This has been factored into the Q4 work plan where the project would participate in the World Population Day and mobilize and sensitize chiefs and assistant chiefs in all the sub-counties, to reach men with FP messages during the barazas and other community forums. The project also continues to engage with NCPD, as the organization taking the lead in coordinating the national PHE network, to leverage on the existing resource base for advocacy on FP/RMNCAH towards visibility and appropriate budget allocations at county level.

As mentioned previously, Afya Uzazi collaborated with the Pharmacy and Poisons Board (PPB) to support Pharmacovigilance activities in the two counties. Specifically, PPB supplied Afya Uzazi with Pharmacovigilance reporting tools and jobs aid which will be disseminated to facilities in the two counties to boost reporting of suspected medicine related adverse drug reactions and poor quality medicinal products. The project also collaborated with Kenya Medicines Supply Agency (KEMSA) during the Nakuru County commodity TWG meeting by supporting the attendance of the KEMSA regional liaison person at the meeting to address KEMSA-related queries from the county.

The project further collaborated with the project-held HCWs’ trainings on RMC and MPDSR in collaboration with Reproductive and Maternal Health Support Unit (RMHSU) of Ministry of Health, Kenya.

X. PROGRESS ON USAID FORWARD

The project also engaged local organizations such as Keringet Community Socio-Economic Empowerment and Development (KCSEED) and KUWORA, and several CFA in planning for implementation of PHE interventions.

XI: SUSTAINABILITY AND EXIT STRATEGY

Not applicable this quarter.

XII: GLOBAL DEVELOPMENT ALLIANCE

XIII: SUBSEQUENT QUARTERS’ WORK PLAN

Program Management

i. Complete recruitment of additional key staff; PHE Technical Officer, Learning Technical Officer and Data/Systems Manager ii. Complete purchase of vehicles iii. Sign MOU and complete the process of signing Local Purchase Order with CURE for provision of donated equipment and training of facility staff

Sub purpose 1: Increased availability and quality delivery of FP/RMNCAH services

QA/QI Interventions

i. Conduct QA/QI training based on the KQMH framework for CHMT/SCHMT and staff from selected high-volume facilities in Kuresoi North and South ii. Support a total of 20 facilities in Baringo and Nakuru sub-counties to establish QITs and develop initial work plans iii. Support monthly meetings of QITs/WITs from the selected facilities to review progress and data on selected indicators HRH Interventions

i. HRH orientation program for Nakuru County Health Management Team ii. Validation of the HRH rapid assessment results for Baringo and Nakuru Counties with the stakeholders for adoption and implementation iii. The development of the specific HRH attraction and retention strategies for the selected sub counties in the two counties iv. Health workforce data cleansing and update in the Human Resources for Health information system(HRIS). Commodity Management/Supply Chain

i. Support quarterly commodity TWG meetings in Baringo and Nakuru Counties ii. Conduct 2-day commodity management training for 60 HCWs from selected facilities in Kuresoi North and South

iii. Conduct Commodity management OJT in selected facilities in Nakuru and Baringo Counties for capacity-building in commodity management iv. Conduct 1-day training on FP/RMNCH commodity reporting for in-charges from facilities in Kuresoi North and South v. Conduct 2-day training on Pharmacovigilance for HCWs from Baringo and Nakuru Counties

Facility Team

i. Training of TOTs for CEL; operationalization of CEL to build capacity of HCWs ii. Conduct trainee follow-up of the rest of BeMONC trainees iii. Continue targeted mentorship, orientation, CMEs and OJT on FANC, ORT, Immunization, LARCs, PNC, IPC, EmONC iv. Conduct trainee follow-up and establish MPDSR committees. Conduct onsite CMEs and orientation on MPDSR & RMC. v. Establish Mother to Mother Support groups to implement BFCI vi. Conduct quarterly integrated SCHMT support supervision vii. Continue supporting integrated outreaches and increase outreaches posts viii. Conduct HCWs trainings on Post Abortion Care (PAC) and Integrate Management of Childhood Illnesses (IMCI) and Maternal, Infant and Young Child Nutrition; RMC and KEPI ix. Facilitate attachment of CHVs at HRH-constrained facilities to conduct growth monitoring and assist at ORT corners x. Conduct orientation of birth Companions in Marigat sub county, xi. Conduct TOTs training and Trainee follow up, KEPI training at operational level,

Sub purpose 2: Increased care seeking and health promotion behavior for FP/RMNCAH

Social Behavior change communications

i. Convened participatory workshop with the target audience and their influencers to inform the development of county specific SBCC strategy ii. Establishment 6 verbal autopsy committees as well as sensitization of the committee on revised MPDSR guideline. iii. Support community quarterly dialogue and action days to ensure community understanding and appreciating their data. iv. Continue building capacity of the CHEWs and CHVs through mentorship v. Continue to support CHEWs to leverage on the meetings and conduct sensitization on the RMNCAH messages, vi. Sensitize chiefs and sub-chiefs on the RMNCAH indicators as an entry point for their buy in and mobilization of men during the chiefs barazas to embrace Family Planning and other RMNCAH services. vii. Support the county and sub-county to discuss FP and skilled delivery through the local radio, which will also be used to mobilize the community for the integrated outreaches. viii. Map kiosk/pharmacy/chemist /outlets that sell ORS to be sensitized on standard management of diarrhea as well as provision of SOP.

Youth

i. Conduct HCWs trainee follow up and supportive supervision ii. Support Baringo and Nakuru Counties AYSRH TWGs quarterly meeting iii. Support integration of SRH/WASH into school health program iv. Support the trained youth champions hold community level CSE sessions v. Conduct quarterly review and update meeting with youth champions

vi. Support youth engagement workshops to explore mHealth platforms for virtual support to pregnant teens

Gender

i. Conduct data collection for the Gender Analysis ii. Introduce GBV screening at health facility level iii. HCWs trainee follow up and supportive supervision on post violence service provision and documentation iv. Support Nakuru and Baringo Counties SBCC and Gender Integration networks v. Engage with local leaders, community groups and CSOs on gender norm change and GBV prevention vi. Engage males in the community and galvanize male partners and fathers through facility based activities

PHE

i. Establish a county based PHE network for Nakuru County ii. Sensitization of CBO members on FP and MNCH issues and service demand generation.

Monitoring Evaluation and Learning

i. Routine data quality assessment at facility, community level. ii. Roll out of Sub County Mentorship program iii. Convene a learning conference iv. Build capacity of HCW on data recording, reporting and DHIS2 v. Prepare analysis/feedback charts for quarterly sub county performance review meetings vi. Continue to support TWG meeting in Baringo county and participate in Nakuru county TWG. Photocopy, distribute and lobby for printing of national M&E tools.

XVIII. SUCCESS STORY

Outreaches bring health care closer to underserved communities

Loberer is a dusty outpost in Marigat sub-county, Baringo County. Three small kiosks stand dominant in the vast open space in this area close to the border with Baringo North sub-county, where health services have been disrupted by violent conflicts in some areas.

But despite its harsh environment, Loberer is an important center for the local population because it has a water point where women, children and herders congregate. The center is also a safe haven for families recently displaced by the conflict in the north, where the government is currently running a military operation to restore security.

The nearest health facilities are Marigat sub-county, over seven kilometers away over very rough terrain and Kampi ya Samaki, 12 kilometres away. There is virtually no public transport and before outreach clinics were introduced here, people walked the long distances to seek services. Many cannot make the trip and go without essential services, including check-ups for pregnant women that save lives or care for new mothers and their babies.

USAID’s Afya Uzazi project organizes integrated outreaches to the area to bring health services closer to the people, many of who would otherwise not get health care. The outreaches are designed to increase access to a wide range of services to women, children and other community members in hard- to-reach areas in four sub-counties in Baringo and two in Nakuru covered by the project.

In Loberer, the outreaches have come as a big relief not only to the displaced families, mainly women and children, but also to the local community.

“Our main aim is to reach women and young children who are not able to go to clinics because of the long distances,” said Samson Kipruto Moek, the local public health officer in charge of three administrative wards.

Samson works closely with the Afya Uzazi project and sub-county health management team to plan and run the outreaches. Once all plans are in place, Samson mobilizes people to attend the outreaches, held at the water point where a store is temporarily converted into an examination room.

On the day of the outreach, Afya Uzazi provides fuel for the government vehicle to transport a multidisciplinary team to the site and cater for lunch. Besides the public health officer, the team includes a clinical officer, nurses, a nutritionist and a pharmaceutical technologist.

The team provides services such as family planning, immunization, Vitamin A supplementation, nutritional assessment and counselling. Other services include antenatal care for pregnant women. Breastfeeding mothers and their babies benefit from health checks and health education.

Although the outreaches mainly target women and children, other community members also benefit from treatment for common illnesses.

“To ensure the outreaches are well-coordinated and targeted, standardized and cost-efficient, we have worked with the county health management teams to develop standard operating procedures,” says Dr. Marsden Solomon, Afya Uzazi Project Deputy Chief of Party. “The SOPs also ensure outreach sites are selected to cover underserved areas with the greatest need in respect to maternal, newborn and child health.”

Between March and June 2017, Afya Uzazi has supported integrated outreaches to 16 sites in Baringo and Nakuru Counties, reaching almost 300 women with antenatal care and 42 with postnatal care.

Over 1,000 children received Vitamin A supplements, 660 were immunized and over 800 treated for various illnesses. Thousands of others received health messages.

Women, children and men queue for services during an integrated outreach to Loberer, Marigat. Photo: E.Ouma/Afya Uzazi